Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

Abstract

Background:

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

Methods:

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

Results:

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of interagency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

Conclusion:

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

INTRODUCTION

Opioid overdose deaths in the U.S. reached the highest level yet in 2021, with 100,306 fatal overdoses reported, a 28.5% increase from the previous 12-month period.¹ Since 2000, opioid-related overdoses have increased over five-fold in the state of Massachusetts,² with fentanyl driving opioid-related overdose deaths since 2013.^3–5 People who use opioids (PWUO) have a high risk of incarceration⁶ and, in Massachusetts, those with histories of incarceration have a risk of overdose death 120 times higher than that among the adult population without histories of incarceration.^7,8 Carceral settings present key touch points for interventions to prevent overdose.^9–12

Medications for opioid use disorder (MOUD), including methadone, buprenorphine, and naltrexone, are effective in treating OUD,^3–5 with methadone and buprenorphine associated with up to 59% lower risk of fatal overdose.¹³ Previous studies on MOUD treatment among incarcerated populations, largely conducted outside the US, have noted favorable outcomes,^11,14,15 as well as new markers for increased support among MOUD treatment patients following release from corrections settings.¹⁶ Of note, relative to international trends, increases of morbidity and mortality related to OUD in the US is unparalleled.¹⁷ In addition, the US has the second largest known prison population,¹⁸ with close to half of the people incarcerated for drug offenses.¹⁹ Despite MOUD effectiveness and elevated needs among people within carceral settings, MOUD treatment is rarely available in correctional facilities in the US, due to complex historical and political contexts,^20–22 and lags far behind other countries.^23,24 However, this gap has slowly begun closing in recent years, showing promising opportunities to decrease overdose deaths^25,26 and recidivism post-release.²⁷

In 2019, seven county jails and houses of correction (heretofore “jails”) in Massachusetts initiated provision of all Food and Drug Administration (FDA)-approved MOUDs following a state mandate.²⁸ In the US, jails are settings where pre-sentenced detainees and individuals with short sentences are incarcerated. As MOUD treatment within carceral settings becomes more available in the US,²⁹ more attention is needed to ensure adequate linkage to treatment during the risky transition back into communities.^{30 31–36}

The Massachusetts Justice Community Opioid Innovation Network (JCOIN) conducted an implementation study with treatment programs that provided MOUD to individuals post-release.³⁷ The Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework, adapted for work with criminal justice-involved populations,³⁰ guided the study design.³⁷ Qualitative interviews with staff members aimed to better understand the contextual factors that facilitated and impeded linkages to community MOUD treatment following a period of incarceration.

METHODS

Our qualitative findings employed the EPIS implementation science framework, which has been widely utilized to examine the implementation of evidence-based practices adapted in multilevel, context-specific, public-sector settings. In particular, the EPIS framework’s emphasis on the elucidation and interplay between the inner and outer contexts of MOUD treatment, in jails and community-based agencies, and the bridging of care between these contexts, provided a helpful framework for the examination of the relationships and collaborations therein, from the perspective of community-based MOUD treatment staff.³⁸ In this study, the inner context included domains within the jails that were related to MOUD; the outer context included domains within and around local community MOUD treatment programs; bridging factors related to constructs that connected inner to outer contexts (see Figure 1).³⁸ Barriers and facilitators to the implementation of MOUD treatment continuity post-release, captured through the experiences and perspectives of community-based MOUD providers, were explored across these contexts and domains. In this way, we aim to build on the recent utilization of EPIS to examine the implementation of MOUD in prisons and jails.^30,39

Figure 1.

The Inner and Outer Context of the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, as well as modified collaboration or bridging factors that spans the two. Gray boxes represent the domains that informed and guided coding and analysis of our qualitative data.³⁸

Participants

Interviews were conducted with 36 staff from 18 community-based MOUD treatment programs in Massachusetts geographically located across the seven counties where jails were participating in the pilot to provide MOUD. Among the 36 participants, 14 worked within local jails as outside contractors on behalf of their community-based agency. The counties were located in Eastern and Western Massachusetts, in urban and suburban locations. A purposive sampling frame was used to recruit MOUD treatment staff involved with decision-making or knowledgeable about MOUD treatment experiences, including: 1) medical staff, 2) clinical supervisors, and 3) senior administrators. Individuals were recruited via email and phone-based outreach.

Data collection

Individuals or small groups [2–4 participants] from each MOUD program participated in semi-structured interviews via videoconference between March-October 2020. These interviews were completed during the COVID pandemic; we aimed to be flexible and offer individual or small group interviews, to maximize convenience for participants. The EPIS framework and prior research informed the interview guide (Appendix).³⁰

Small groups and interviews lasted approximately 60 minutes. Verbal consent was obtained prior to conducting the interviews and participants were assured that findings would be anonymized, with mentions of agencies or names redacted from final transcripts. Participants were compensated ($100 gift card). Interviews were digitally recorded and professionally transcribed. Interviewers (TS, EP, PF, EE, WF) included female and male epidemiologists, physicians, psychologists, and public health specialists with many years of substance use-focused research experience. All interviewers were doctoral level researchers with extensive prior training and experience with qualitative interviewing. Interviewers introduced themselves as research team members to study participants. The Baystate Health Institutional Review Board approved all study procedures.

Data analysis

Analysts [TS, RR, WF, EP, LDTM, EE] employed deductive and inductive strategies. We developed an initial codebook using both a priori codes and codes based on the interview guide questions, many of which were connected to EPIS constructs. Codes were refined using open coding and constant comparative methods, resulting in a coding tree with seven parent codes and 50 child codes. Once the codebook was finalized, four staff in two dyads coded each transcript independently, and met with their partner to resolve any differences in coding. The full analytical team met regularly to discuss code definitions and applications, as well as discrepancies in coding, until agreement was achieved, and code definitions were refined and finalized. Coded transcripts were uploaded to Dedoose v9 (Los Angeles, CA).⁴⁰³ This manuscript summarizes thematic findings from six codes: community reentry, perception of MOUD, community treatment program and jail collaboration, general MOUD treatment, barriers and facilitators, and perceptions of jails. In the final stage of analysis, emergent themes were derived using a data-driven thematic coding scheme iteratively developed by the analysts in keeping with grounded theory.^41,425 We did not detect any notable deviant cases. Colloquialisms and utterances were removed from quotes to improve readability. We shared a draft manuscript with study participants and asked for their feedback prior to submission. Additional details on the study design and analytical approach are described elsewhere.³⁷

RESULTS

We conducted 11 individual interviews and 9 small group interviews (2–4 participants). Study participants had a mean age of 47.8 years (SD: 10.8) and were predominantly female (79.4%) and White non-Hispanic (82.4%) (Table 1). Participants worked in organizations in local communities that collectively provided three MOUD treatment options: buprenorphine (83.3%), naltrexone (72.2%), and methadone (44.4%), with four agencies providing all three (Table 2).

Table 1.

Demographic characteristics of staff members and leaders at community-based MOUD treatment programs who participated in interviews and focus groups (n=36)

Characteristic	Count (%)
Age, mean (SD)	47.8 (10.8)
	Missing= 10
Female, n (%)	27 (79.4)
	Missing= 2
Race, Hispanic/Latino Ethnicity n (%)
White, Non-Hispanic	28 (82.4)
White, Hispanic	3 (8.8)
More than one race, Non-Hispanic	1 (2.9)
More than one race, Hispanic	1 (2.9)
Asian, Non-Hispanic	1 (2.9)
	Missing=2
Education, n (%)
High school diploma or equivalent	0 (0.0%)
Some college, but no degree	3 (8.8%)
Associate’s degree	3 (8.8%)
Bachelor’s degree	9 (26.5%)
Master’s degree	13 (38.2%)
Doctoral degree or equivalent	6 (17.6%)
Other	Missing=2
Role at MOUD program, n (%)
Senior administrator	9 (25.0%)
Supervisor	3 (8.3%)
Clinical supervisor	9 (25.0%)
Clinical staff	3 (8.3%)
Senior medical staff	6 (16.7%)
Medical staff	Missing=0
Years working in current position, n (%)
<1 year	2 (6.1%)
1–3 years	11 (33.3%)
4–9 years	14 (42.4%)
≥10 years	6 (18.2%)
	Missing= 3
Years working for your current agency, n (%)
<1 year	2 (6.1%)
1–3 years	4 (12.1%)
4–9 years	13 (39.4%)
≥10 years	14 (42.4%)
	Missing=3

Abbreviations: SD=Standard Deviation

Table 2.

Organizational Characteristics of Participating Sites (n=18 sites)

Characteristic	Count (%)
Medication Offered n (%)
Buprenorphine (Suboxone, Subutex, or Sublocade)	15 (83.3%)
Naltrexone (oral naltrexone or Vivitrol)	13 (72.2%)
Methadone	8 (44.4%)
On Site at Jail, n (%)
On Site	6 (33.3%)
Not On Site	12 (66.7%)
Contract with Jail, n (%)
Has Contract	11 (61.1%)
No Contract	7 (38.9%)
Not for Profit Status, n (%)
Not for Profit	12 (66.7%)
For Profit	6 (33.3%)
Organization Type, n (%)
OTP (Certified Opioid Treatment Program)	7 (38.9%)
Community Health Center	4 (22.2%)
Outpatient Clinic	5 (27.8%)
Clinic Within a Hospital	2 (11.1%)

Structured in terms of the EPIS domains (Figure 1), Figure 2 presents a visual representation of the steps from MOUD treatment within the jails (inner context), to MOUD treatment continuation in community-based programs (outer context), highlighting bridging factors and collaborative steps from jail to community, as well as barriers and facilitators to MOUD treatment continuity.

Figure 2.

Medication for opioid use disorder (MOUD) treatment continuum: 1) MOUD provided in the jail to people with opioid use disorder; 2) Prior to and during release, the newly released person is referred to MOUD providers in the community; 3) the community-based MOUD post-release. A number of facilitators and barriers can ease or hinder continuity including: unplanned releases, communication between the jail and CBO, geography, transportation, access to a phone, prescription requirements and challenges, participant MOUD preferences, identification requirements, housing, scheduling.

Inner context

Participants perceived that some jail staff questioned treatment expansion to agonist medications, historically considered contraband in these settings. Participants reflected that some correctional officers who they had encountered viewed MOUD in jails as substitution therapy, while some MOUD counseling staff were more aligned with abstinence only models and did not immediately embrace MOUD treatment:

I think you will always have those select few individuals. I think we see it actually ironically less with security staff, and more with the counseling staff...often times a lot of those individuals [security staff] come with the lived experience of being in recovery themselves and come from more of a 12-step approach, that they necessarily may not support MAT (Medications for Addiction Treatment). [ID19, Senior administrator, Opioid Treatment Program (OTP)]

I’ve spoken with representatives from [MOUD PROVIDER] and, as well as folks that work currently, clinicians and nurse practitioners that work there…even the COs, I think there’s still…stigma for folks starting methadone. [ID15, Clinical supervisor, OTP].

Participants articulated the importance of MOUD education within jails to diminish stigma, increase staff’s understanding of the benefits of MOUD treatment, and increase referrals. MOUD providers also believed it would be important for MOUD programs within carceral settings to provide more than MOUD treatment alone. They valued MOUD programs that also provided group therapy and individual counseling, as they believed these complementary treatment services, above and beyond medication, would help to normalize more comprehensive treatment post-release for patients:

We require a little bit more structure in terms of the weekly requirements for groups and therapy than what they’re facing necessarily inside. So, when they come out, that becomes a barrier for them. In that, ‘Well, I didn’t have to [do] this before. I only just got my medication’. Or ‘I only had to talk to one person.’ Or that type of thing. So, if we could sort of collaborate with what specifically are the requirements for them to be medicating inside the jail, and take a look at that, I think that would be really helpful. [ID2, Clinical supervisor, OTP].

Many study participants valued opportunities to have their staff members working in the jails with which they were collaborating, as this onsite presence was viewed as bolstering trust among patients, treatment continuity, and facilitating planning for post-release treatment:

...we have a contact person, [PROGRAM ADMINISTRATOR]…over at the House of Corrections. And so, my role is that [PROGRAM ADMINISTRATOR] will either call, email and say, ‘Hey, I have a person. They’re going to be released with the suboxone.’ It’s very urgent. So, she calls me the same day, and I really try to get the person in either that day or the next day… [ID22, Medical staff, Community Health Center (CHC)].

Bridging factors

Bridging components to facilitate cooperation between key partners (jails, community-based treatment providers, health centers, courts) were noted as essential to MOUD treatment continuity.

Release planning was a major obstacle to successful continuity of MOUD treatment, especially with the pre-trial population. Resources and efforts available to ensure timely release planning varied across community treatment providers and jails. Unplanned releases, especially from court, often stymied opportunities to implement discharge plans:

When somebody is pre-trial, their release is always so unknown. So, we do oftentimes have individuals who are very unexpectedly released, which puts a huge barrier in terms of discharge planning. So, the individual may say, “Hey, like I’m going to court next week. I’ll definitely be back”. But then for whatever reason, they go to court and they’re released. [ID19, Senior administrator, OTP].

Release or discharge planners can quickly schedule same day appointments with MOUD programs if funding and staffing are available to support their time and effort and they are notified about an impromptu and unexpected release with enough time to make arrangements. In fact, several participants shared the great lengths they went to in order to set up next day appointments to avoid treatment interruptions. However, other agencies that lacked resources and staffing needing several days to ensure continuity of care for impromptu releases:

I think even if we had two- or three-days’ notice so that we could get a clinician to [do] an intake appointment, we’d have the lab work, we’d have everything in place. It’s not that long, but we can’t do it like with a phone call, ‘can you take them in the morning?’ Or ‘they’re getting released from the court at 4:00 o’clock this afternoon, can you take them?’ No, we’re closed… [ID28, Clinical supervisor, OTP].

Participants highlighted gaps in release planning between the jail and the treatment program that hindered a smooth transition to treatment in the community:

It’s really challenging for us to pick up right where they left off because, a) we might not be able to confirm the last dose right away. And b) we’re not getting the paperwork from the institution…[ID13, Senior administrator, OTP].

A lack of geographic proximity between community treatment programs and the jail was another challenge to treatment continuity, particularly when the patient was released to a community far from the jail:

So, I would say that most of the folks that leave [jail name] end up going back to their home program. They don’t necessarily live in this area. So, we take them as sort of like a guest medicator while they’re with us, and then they’re given the information to return to their home program, [ID12, Senior administrator; OTP].

Care coordination

Care coordination centered around three topics: 1) Communication between the jail and the community treatment providers, 2) sharing medical information, and 3) an adequately trained workforce. Participants highlighted variability in communication with jails, which could simplify or hamper care coordination:

[Jail name] does a great job at saying – like, for example, I have patients there that are coming out next week, and we’ve already got that paper on hand. We already have their information, and they already have their appointment. They’re very good at giving us at least a week. Some facilities don’t even call us, and give the patient the phone number, and say, ‘Here. Here’s your prescription. Call them.’ [ID3, Medical staff, CHC].

Respondents suggested that joint partnerships and workflows, especially with information technology and electronic medical record (EMR) solutions, could facilitate information sharing (e.g., dosing level, dosing letter, prescriptions, and clinical notes) to facilitate seamless treatment continuity. They also emphasized the importance of a trained workforce — especially patient navigators, community health workers, and release planners who have the time, lived experience, competence, patience, and diligence to enable smooth transitions through the many steps to ensure treatment continuity. Patient navigators help to guide patients through the healthcare system to overcome barriers to quality care and get financial, legal, clinical, and social support:

Step one is register. Step two is get insurance. Step three is make an appointment. Step four is go to your appointment…People need a little hand holding and a little support and help...I mean, they’re dealing with much more challenging life behavior changes, and they just need that help. So, I love community health workers. I think it’s a great model. I hope that we find a way in our system to pay for them, to reimburse for the time they spend with people because peer support is a big factor in people’s success with reaching their goals, [ID9, Senior administrator, CHC].

MOUD engagement and retention in community settings

Participants also emphasized the importance of program components to facilitate first visits, engagement, and retention in community-based MOUD treatment. Prominent themes in this domain included: patient follow-up and readiness to seek treatment, the importance of the first appointment post-release, transportation to treatment facilities, appointment timing, and expanded hours of service.

Participants also viewed patient follow-up immediately post-release from jail as paramount, because getting the patient to the first appointment sets the stage for trust and rapport building:

…we push that first visit philosophy to just get ‘em in here and realize that…we want to help you, we want to be a part of the solution. …most of the time, I mean…the great majority of the time if someone makes their first visit, they’re in therapy…getting their lives back... [ID7, Senior medical staff, Outpatient clinic].

Communication with patients to facilitate and schedule the first visit post-release may be stymied when patients do not have an active telephone due to substantial systemic barriers patients face upon re-entry. If, for example, a newly released patient misses their first appointment, the clinic has no way to reach them to reschedule and the patient may be lost to follow-up:

Interviewer: If you could wave a magic wand around your relationship with [Jail name] and have them make some changes to improve care coordination, what would you want them to be doing?

Participant: I think for me, as they’re leaving the facility, I would love for them to make sure the patient actually has a phone, or they leave there with a phone on hand, [ID3, Medical staff, CHC].

The timing of appointments can also have a profound impact as most MOUD treatment programs have designated staff on hand only during traditional weekday hours. Treatment staff have limited or no availability evenings and weekends. Patients released from jails on weekends or before holidays would benefit from “bridge prescriptions” to carry them through until full intake, registration, and enrollment:

…the scheduling, and them coming out sometime on a Friday and not having enough for the weekend. Those are the concerning things, and when they started happening, it was like, how are we going to do this? How are we going to manage to make it more than a day’s script? [ID21, Senior medical staff, CHC].

Some community MOUD clinics will seek to accommodate their service hours to adapt to client needs where possible for recently released patients:

If a client will call us and tell us that at quarter of 11:00, ‘I couldn’t get a ride, and I’m trying really hard to get there. I know the doors close at 11:00, but I’m going to be there at 11:00.’ We’ll make every effort that we can to stay open, [ID2, Clinical supervisor, OTP].

Some participants noted the importance of expanded hours of service, beyond morning hours, and including weekends:

“...we have had the experience where they send over the paperwork on a – late on Friday or a holiday weekend, and our Managers – we have an Operations Manager who sees it, and then responds swiftly to be able to do what we’ve got to do to continue their treatment. It’s not in our contract…that we have to respond that quickly. It’s just something that – it’s a best practice, and we do it. Typically, we wouldn’t have to respond until the next business day…our staff go above and beyond and will do whatever work necessary on the weekend to get that person to be able to continue his methadone treatment...” [ID13, Senior administrator, OTP].

But not all treatment programs are able to be as flexible due to funding and staffing limitations. Respondents identified the need for low-barrier (e.g., medication first)^43,44 clinics, open-slots for appointments, and a hotline for released patients as important to facilitating community MOUD engagement and retention:

So, for instance, starting our hotline was really important so that they didn’t have to ever wait… the minute they called us somebody was going to answer the phone and solve their problem, so they trusted us and saw that we were reliable, [ID4, Senior administrator, CHC].

Outer context

Outer context results centered on the experience of community-based MOUD treatment programs, their relationships with jails, and barriers and facilitators experienced by patients. Health insurance (e.g., Medicaid), identification cards (ID), and social determinants of health (SDOH) were particularly important.

Health insurance and IDs

The community-based MOUD treatment providers identified a substantial administrative challenge tied to re-initiation of health insurance. In Massachusetts, when people are in jail, their insurance is suspended, given that their health care is covered by the jail, and patients need to re-initiate insurance upon release. We learned how patient navigators could help to assist in overcoming this challenge, re-connecting recently released patients to insurance. Patient navigators who were able to work with patients before their release from jail reported making extra efforts to prepare insurance documents during the release process.

In addition, programs that acknowledge and address the insurance and cost issues upon release are able to connect patients to safety net pharmacies participating in the 340B Drug Pricing Program, which helps to make drug prescriptions more affordable for patients (https://www.hrsa.gov/opa/index.html). Other agencies were able to financially withstand providing flexible pricing for treatment to those who are uninsured:

It’s not like, ‘Oh, you’re [PUBLIC INSURANCE] isn’t eligible? Can’t see you.’ It’s nothing like that. I’m like, ‘All right, well, let me connect you with somebody that can help. You’re still going to be seen today.’ It’s not going to be like, ‘Oh, I need x amount of dollars beforehand.’ No. ‘If you’re here now, let’s get you seen…” [ID16, Supervisor, Outpatient clinic].

IDs are another barrier. Many patients leave carceral settings without an ID and yet they need one to pick up MOUD prescriptions at local pharmacies:

You need an ID to pick up a federal narcotic at a pharmacy. So, then what happens when they don’t have an ID. So, now they have no money, no ID, and they’ve been given suboxone for today, and they’re really worried and concerned about tomorrow… [ID35, Medical staff, Clinic in hospital].

Social determinants of health (SDOH)

SDOH, including homelessness, unemployment, and transportation, also figure substantively into the outer context that surrounds MOUD treatment continuity. Intertwined SDOH can compound challenges to stability and patients need to focus on getting several key components of life in place, and quickly, during their time post-release to address unmet needs (e.g., work, meals, probation follow-up, mental health care for dual diagnoses, family re-connections, childcare). All of these components can alter patient priorities post-release:

If a patient has an appointment with me on the day of release, a lot of times we lose them on the day of release, and they show up two days later. Because they want – maybe their girl’s picking them, their wife, and their mother. They’ve got to see probation. They’ve got to do – they’ve got to get to welfare to get their cash assistance and food stamps put on immediately [ID32, Senior medical staff, Clinic in hospital].

SDOH pressures tied to re-entry into life on the outside cannot be underestimated. Homelessness looms large as a major barrier to successful transitions and treatment continuity:

...people who have long incarceration stays are actually at a big disadvantage for getting onto housing lists for subsidized housing, which…is something that so many people would like to access. I think treatment program beds having long waitlists is a really big challenge. Halfway houses or like transitional housing having really long waitlists... [ID25, Supervisor, Outpatient clinic].

Further, community-based MOUD treatment providers viewed employment as a high priority and a major challenge:

…if somebody has committed a felony, it’s very difficult to get a job. And I’m always very much pro-employment. I think it’s important for people to feel productive, to work, and this is a big obstacle if they have a felony on their record. So, a counselor can certainly work with them with an employer on how to approach that...not being able to work and bring an income to your family is a tremendous blow to some of these patients… [ID28, Clinical supervisor, OTP].

Transportation is another important SDOH consideration that impacts MOUD treatment continuity, especially if the patient is released and needs to visit an opioid treatment program daily for methadone treatment. Transportation was particularly salient for jails in exurban settings:

It’s not, like, a city setup …There’s not public access to transportation, most of our folks that are gonna be coming to this clinic are gonna need to be able to, um, provide their own transportation or access PT-1 services [subsidized transportation] through [PUBLIC INSURANCE], so that’s also a factor that we try to, um, help folks prepare for when they are referring to us, [ID15, Clinical supervisor, OTP].

Despite these SDOH-related hurdles, however, it is important to note that some patients do reenter life on the outside successfully, particularly when staff recognize the importance of the first MOUD visit within the larger context of reentry into the patients’ day-to-day lives post-release:

That’s why we push that first visit philosophy to just get ‘em in here and realize that, you know, we want to help you, we want to be a part of the solution…Which is what we see on a day-to-day/week-to-week basis, is people getting their lives back. You know…they’re going from being in jail or losing their kids, losing their jobs, being homeless to: well now I’m in a shelter, oh well now I’m in an apartment, well now my wife is talking to me again, and now I can see my kids [ID7, Senior medical staff, Outpatient clinic].

DISCUSSION

Treatment continuity after jail release, without interruption, is a fundamental function of successful OUD treatment and overdose prevention. Our findings focused on the inner, bridging, and outer contextual dimensions of MOUD continuity, highlighting the importance of jail staff buy-in and training, care coordination and communication among key constituencies, interagency collaboration, and consideration of SDOH that facilitate and impede successful treatment continuity.

Informed by the EPIS implementation science framework, inner context findings from our analysis highlighted perceived culture clashes and stigma relative to MOUD treatment. Participants disclosed that some clinical and patient navigator staff within jails found it hard initially to get beyond viewing MOUD as a crutch, and less effective than the 12-step and abstinence-based programs they had experienced. This finding was consistent with previous research, which highlights stigmatizing views associated with MOUD in self-help groups, as well as greater emphasis on interventions that target behavioral changes, rather than medications in correctional settings.^45–48 Community-based providers in our study emphasized the value of treatment education as part of MOUD implementation to inform patients, as well as staff within jails, to begin to break down judgments and stigma. A scoping review of MOUD in correctional settings similarly noted the importance of training interventions to increase staff knowledge.¹⁴ Our inner context findings also align with results from our previous research with jail staff within the same seven jails in Massachusetts, which highlighted MOUD-focused staff training as an essential facilitator of implementation.⁴⁹ Of note, the results of this study were shared with respondents from each participating community organization for the purpose of enhancing the credibility of results; participant feedback emphasized that in many cases, jails have been making significant efforts for many years to provide MOUD treatment and support successful re-entry for individuals who have OUD;⁵⁰ they acknowledged that there is more work to be done.

We found that salient bridging factors included pre-release planning, patient releases at pre-planned times, bridge prescriptions to cover gaps between jail release and intake at community MOUD treatment sites, and easy sharing of treatment information across agencies. Given the exceedingly high opioid-related overdose risk post-release from jails,^7,51–53 and exacerbated overdose rates during the COVID-19 pandemic,⁵⁴ coordinated efforts between jails and community-based MOUD treatment providers are more important than ever.^55,56 Joudrey and colleagues, in their multi-level post-release opioid-related overdose risk model, highlight the need for “improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, reduce interruptions in care continuity and reduce stigma.”³³ Despite advocacy for pre-release or discharge planning for serious medical conditions as a constitutional right⁵⁷ and essential to continuity of care, great variability exists in the quality and rigor of discharge planning.^58–60 MOUD bridge prescriptions and clinics have shown great promise in hospital settings and emergency departments,^61,62 but experiences with bridge prescription programs that cover gaps between release from jails and MOUD treatment programs in local communities are limited. The COVID-19 pandemic has changed MOUD treatment guidelines and protocols,^63–66 that could create opportunities to facilitate more effective access to MOUD treatment,⁶⁶ including enhanced bridging services during transitions from jail to community-based MOUD treatment.

Outer context domains centered on issues with SDOH, health insurance (e.g., re-initiating Medicaid post-release),³⁶ and care navigation to enhance partnerships between community providers and patient navigators. Respondents reported substantial barriers to services intended to meet basic SDOH needs post-release, including shelter, food security, employment, transportation, and insurance coverage to access care, echoing previous studies that highlighted that when needs are unmet, they undermine opportunities to access substance use treatment.^67–69 Participants emphasized the importance of patient navigators to help overcome these competing priorities, so individuals could ultimately focus on the critical need to continue with MOUD treatment. Previous studies have not found consistent evidence that allied health care professional support for persons transitioning from jail to community-based treatment programs had significant positive impacts on health outcomes, including opioid use. Results from a prospective study of people recently released from prison, which incorporated community health workers with lived experience, demonstrated reductions in the need for acute medical care, as well as fewer jail days and violations of probation and parole.^70,71 However, an RCT of patient navigator assistance for patients released on methadone did not yield improved outcomes with medication continuation post-release nor with reduced illicit opioid use.⁷² Research is currently underway on how to design and implement effective recovery management check-ups and navigator programs in this population.⁷³

We also found that unplanned release from jails led to major disruptions in discharge planning. Many of the tenets of care coordination prior to hospital discharge mirror care coordination from jail: medication management; shared health information technology; and linkage to a community-based treatment provider. Unplanned release from court or poorly communicated early release from jail led to disruption of care and poor coordination.⁷⁴ Better communication and stop-gap measures are needed to limit unplanned releases, and to provide important continuity of care services, on-the-spot, when they cannot be avoided.

These findings should be considered in light of several limitations. Results represent a single period of data collection, with a focus on MOUD treatment implementation relatively early in program rollout. As MOUD programs mature in jails, other issues relevant to sustainability may, for example, become more salient.⁷⁵ Second, results are specific to Massachusetts community-based MOUD treatment providers, within the context of a legal mandate to treat OUD in carceral settings. Additional studies are needed elsewhere to assess local experiences and outcomes. Our team is also exploring community re-entry perspectives among jail staff,⁴⁹ which has the potential to fill additional gaps in knowledge. While few jurisdictions in the United States mandate the delivery of all FDA-approved MOUD in carceral settings, legal precedents and actions taken by the U.S. Attorney’s office on violations of the American with Disabilities Act have provided considerable policy momentum. Finally, we conducted data collection during the COVID-19 pandemic, a time when community-based MOUD treatment providers and jail staff needed to modify some components of their treatment models. Further research is needed to learn about potential long-term effects of COVID-19 on community-based MOUD treatment models post-release from corrections settings.

CONCLUSION

Qualitative interviews with community-based MOUD treatment program leaders and staff identified barriers and facilitators to continuity of MOUD treatment for patients post-release from jails. The findings point to key elements of successful collaboration between community-based and jail-based MOUD programs, as well as inner, outer, and bridging facilitators and barriers to MOUD treatment continuity after release. The hope is that these findings will advance the implementation of MOUD in jails and in transition to the community, an essential strategy to address the alarming and increasing rate of fatal opioid overdose in this high-risk population.⁷⁵