Abstract
Objectives:
Little is known about the correlates of use of medications to treat opioid use disorder (MOUD, i.e., buprenorphine, methadone, naltrexone) offered in jails. We evaluated the implementation and outcomes of a MOUD program offered by two of the first jails nationwide to provide access to such care.
Methods:
We examined use of MOUD among adults with opioid use disorder (n=347) incarcerated by two rural jails in Massachusetts (2018 – 2021). We examined MOUD transitions from intake to during incarceration. Using logistic regression, we examined factors associated with in-jail use of MOUD.
Results:
At jail entry, 48.7% of individuals with opioid use disorder were being treated with MOUD. During incarceration, 65.1% received MOUD, attributable to a 9.2% increase in use of methadone (from 15.9% to 25.1%) and a 10.1% increase in use of buprenorphine (from 28.5% to 38.6%). During incarceration, 32.3% of individuals were continued on the same MOUD from the community, 25.4% were started, 8.9% stopped, and 7.5% switched type. 25.9% entered jail not on any MOUD and were not started on it. Use of MOUD during incarceration was positively associated with having received MOUD in the community (OR 12.2, 95% CI [5.8, 25.5]) and incarceration at Site 1 compared to Site 2 (OR 24.6, 95% CI [ 10.9 – 54.4]).
Conclusions:
Expanded access to MOUD in jails can engage an at-risk population with treatment. Understanding factors related to this population’s use of MOUD may aid efforts to optimize care during incarceration and after community re-entry.
Keywords: medications to treat opioid use disorder (MOUD), opioid use disorder (OUD), correctional setting, public health
Introduction
Incarcerated individuals with opioid use disorder (OUD) have high risks of overdose and other adverse outcomes upon release into the community1,2. The three types of FDA-approved medications to treat OUD (MOUD, i.e., buprenorphine, methadone, and naltrexone) have the potential to decrease overdose events and reduce illicit opioid use and recidivism3–5. However, the delivery of this medication has been very limited in many U.S. jails and prisons6–8. Those correctional facilities that do deliver MOUD have historically offered only naltrexone because of the perception that naltrexone has a lower risk of diversion and misuse compared to other medications; while fewer facilities also offering methadone and buprenorphine9,10.
Most recently, correctional facilities have pivoted to offer all three types of MOUD and to maintain individuals on MOUD for the duration of their sentence9. Prior to these policy changes some jails and prisons inducted individuals on MOUD only during the pre-release period; this approach reduced continuity of care upon incarceration and unintentionally reduced access to MOUD for individuals with uncertain release dates11. Given this rapid change in policy, little is known about jail and prison-based MOUD programs9. For jails in particular, the processes to provide MOUD and factors that shape patient receipt of MOUD are not well-established12. Importantly, jails may provide critical access to MOUD in rural areas and other communities where availability and access are limited13. However, with some exceptions (e.g.,14,15), the ability of rural jails to provide access to MOUD has not been examined.
Extant evidence suggests that who is offered MOUD and which type of MOUD is received involves a complex set of multi-level factors. For example, at a contextual level, some jails have policies to continue MOUD only for individuals who are already taking it as documented at jail intake, i.e., these jails do not initiate MOUD for individuals who are untreated at intake16,17. Additionally, individuals with a short length of jail stay may go untreated with MOUD, for example due to policies that direct treatment only for sentenced individuals, and preclude treatment of pre-trial individuals, or due to logistical challenges that mean individuals enter and exit jail quickly before MOUD can be initiated16,17. MOUD use while incarcerated is also shaped by factors such as anticipation of transfer to a carceral system that does not offer MOUD or expected release into a community that has limited or no access to MOUD16,18,19.
At the individual-level, incarcerated women may be more likely than men to receive MOUD, for example due to policies that prioritize provision of MOUD to pregnant women9; while a significant proportion of incarcerated women have co-occurring mental illnesses and do not receive treatment20. Recent literature suggests Black and Hispanic individuals are less likely to enter carceral facilities with a MOUD prescription and are more likely to be inducted on buprenorphine while incarcerated, compared to White individuals21. Also, individuals may not receive MOUD while incarcerated due to patient preferences, a lack of patient knowledge about MOUD, and MOUD-related social stigma22.
Taken together, the evidence suggests there are contextual-level and individual-level factors that can impact receipt of MOUD, including whether individuals start, stop, or maintain MOUD while incarcerated or receive a type of MOUD during incarceration that is different from what was being taken while residing in the community. Importantly, transitions in the provision of MOUD from intake to during incarceration have mostly been described in qualitative research conducted with carceral staff16,17. A critical gap in knowledge is that there is little quantitative evidence on the prevalence of MOUD receipt among individuals living in jail, the extent to which these individuals transition to different types of MOUD while incarcerated, and the factors that are associated with receipt of MOUD.
Two jails in Massachusetts, located in the mostly rural western region of the state, were among the first in the nation to provide incarcerated populations with access to MOUD23. Starting in 2018 and funded by a 3-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), these two jails expanded MOUD capacity by offering agonist medication (buprenorphine, methadone), in addition to the antagonist medication naltrexone, to individuals during incarceration14,23. An added component of the MOUD program was re-entry programming that was designed to connect individuals to continued MOUD and other care after release14,23. The University of Massachusetts Amherst (UMass) conducted an independent evaluation of the MOUD program. The project provides an opportunity to document the provision of MOUD in these jails, discuss the pattern of MOUD utilization by type of medication, and identify factors that are associated with use of MOUD during incarceration. Findings have the potential to inform understanding of whether rural jails can expand MOUD access and use for justice-involved individuals.
Methods
Study sites
The two participating jails were located in rural and semi-rural communities in western Massachusetts (one county defined as nonmetro and one county defined as metro with population hub and outer lying nonmetro communities, per the U.S. Department of Agriculture (2020)). For both sites, the daily jail census in 2018 averaged about 250 individuals, with about 40% self-reporting problems with opioids23. Most individuals, 77.9%, were pre-trial and 22.1% were sentenced24.
The jail in one county (Site 1) initiated its MOUD program in 2015; by 2018 about one-third of incarcerated individuals eligible for MOUD received naltrexone and two-thirds received buprenorphine, either as a continuation of medication being received at jail intake or via buprenorphine initiation. In contrast, during this same time-period, the other county’s jail (Site 2) provided only extended-release naltrexone and typically only to sentenced individuals and in preparation for community re-entry.
Under the SAMHSA grant awarded to expand MOUD capacity, Site 1 increased efforts to offer buprenorphine to pre-trial individuals in addition to sentenced individuals. Site 2 began to offer buprenorphine, starting with individuals who already had a prescription for it at intake and later expanding to offer buprenorphine induction. Also, Site 1 arranged to offer methadone on-site and Site 2 transported patients to community-based methadone clinics for dosing each day. Both jails enhanced re-entry programming to support continued use of MOUD and other services after jail release.
Clinical jail staff used several processes to screen and assess for opioid use as part of normal jail intake procedures. For both sites, clinical staff at the jails collected a urine sample from all individuals at jail entry to test for opioids and other substance use. If an individual entered jail on a MOUD (per urine test results and/or self-report), jail staff verified MOUD prescription information by checking the statewide Prescription Drug Monitoring Program database or by checking with the prescribing clinic. Individuals with a verified MOUD prescription were assumed to have an OUD diagnosis, which was entered into each jail’s electronic medical record. A difference by site was that Site 1 conducted OUD screening/assessment on all individuals who entered the jail (regardless of urine test results and/or MOUD prescription information) whereas Site 2 conducted OUD screening/assessment when indicated by the urine test results, or when requested by incarcerated individuals, or when staff perceived there to be a need for screening/assessment.
Participants
Data were collected from all individuals with OUD who were incarcerated at the participating sites between April 2019 and July 2021 (n=347). For research purposes, trained clinical staff at the participating jails assessed all adults with OUD at intake using SAMHSA’s Government Performance Results and Modernization Act (GPRA) form25.
Written consent for use of data for research purposes was obtained. Individuals were told that study participation would not affect their medical treatment, legal status, or other rights and benefits. Omitted from the study were incarcerated individuals who did not complete the assessment, for example because of brief jail stays (e.g., incarcerated for <48 hours), and those who refused research participation. The study was approved by the UMass Institutional Review Board (IRB) and data were protected by a federal Certificate of Confidentiality.
Measures
The dependent variable was use of MOUD while living in jail, defined as having been prescribed buprenorphine, methadone, or naltrexone while incarcerated and coded as a categorical variable. Clinical jail staff recorded this data using the jail’s electronic medical records.
A key independent variable was use of MOUD at intake into jail (i.e., what the individual was prescribed in the community at time of intake), as self-reported by participants and verified by clinical staff via urine test and checking of statewide prescription monitoring program records. Site was recorded at jail intake. Patient socio-demographics and other characteristics and experiences were self-reported by participants at intake.
Data Analysis
We examined the characteristics at jail intake of individuals with OUD who were and were not already on MOUD at intake into jail. Chi-square tests for categorical variables and two-tailed paired t-tests for continuous variables were used (significance level of α = 0.05). We used a Sankey plot, which is useful to examine the immediate transition of participants between two related events26, to show transitions in type of MOUD received as measured first at intake and then again during incarceration. We used logistic regression to examine factors associated with use of MOUD while incarcerated (yes vs. no). All analyses were completed in Stata SE version 16.
Results
Participant characteristics by MOUD type at jail intake
We examined the characteristics of participants by the type of MOUD individuals were receiving as assessed at intake into jail (Table 1). About half, 51.3%, were not being treated with MOUD at jail entry. Of the remainder, most were being treated with buprenorphine (28.5%), followed by methadone (15.9%), and few, 4.3%, were on naltrexone.
Table 1.
Characteristics of participants by type of MOUD being received at jail intake
| Buprenorphine | Methadone | Naltrexone | None | Total | |
|---|---|---|---|---|---|
| (n=99; 28.5%) | (n=55; 15.9%) | (n=15; 4.3%) | (n=178; 51.3%) | (n=347) | |
| Site 1 | 50 (50.5) | 37 (67.3) | 10 (66.7) | 95 (53.4) | 192 (55.3) |
| Site 2 | 49 (49.5) | 18 (32.7) | 5 (33.3) | 83 (46.6) | 155 (44.7) |
| Gender, % a ns | |||||
| Male | 88 (88.9) | 43 (78.2) | 13 (86.7) | 147 (82.6) | 291 (83.9) |
| Female | 11 (11.1) | 12 (21.8) | 2 (13.3) | 31 (17.4) | 56 (16.1) |
| Race/Ethnicity, % ns | |||||
| White | 72 (72.7) | 47 (85.5) | 10 (66.7) | 110 (61.8) | 239 (68.9) |
| Hispanic | 15 (15.1) | 5 (9.0) | 3 (20.0) | 30 (16.9) | 53 (15.3) |
| African American | 7 (7.1) | 0 (0.0) | 2 (13.3) | 18 (10.1) | 27 (7.8) |
| Other, Unknown | 5 (5.1) | 3 (5.5) | 0 (0.0) | 20 (11.2) | 28 (8.0) |
| Age, % ns | |||||
| 18 – 24 | 4 (4.0) | 3 (5.5) | 1 (6.7) | 16 (9.0) | 24 (6.9) |
| 25 – 34 | 53 (53.5) | 29 (52.7) | 3 (20.0) | 93 (52.2) | 178 (51.3) |
| 35 – 44 | 29 (29.3) | 16 (29.1) | 8 (53.3) | 51 (28.7) | 104 (29.9) |
| 45 – 54 | 11 (11.2) | 6 (10.9) | 3 (20.0) | 13 (7.3) | 33 (9.5) |
| 55–64 | 2 (2.0) | 1 (1.8) | 0 (0.0) | 4 (2.2) | 17 (2.1) |
| 65+ | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 1 (0.3) |
| Age, Mean (SD) ns | 34.7 (7.5) | 35.2 (7.6) | 37.8 (8.2) | 34.1 (8.5) | 34.6 (0.4) |
| Employment, % ns | |||||
| Full time | 13 (13.1) | 4 (7.3) | 1 (6.7) | 16 (9.0) | 34 (9.8) |
| Part time | 8 (8.1) | 4 (7.3) | 0 (0.0) | 9 (5.1) | 21 (6.1) |
| Unemployed | 20 (20.2) | 5 (9.1) | 0 (0.0) | 25 (14.1) | 50 (14.4) |
| Not in labor force | 58 (58.6) | 42 (76.3) | 14 (93.3) | 127 (71.8) | 242 (69.7) |
| Enrolled in school or job training, % ns | 6 (6.1) | 4 (7.3) | 0 (0.0) | 21 (11.8) | 31 (8.9) |
| Educational status, % ns | |||||
| Less than high school | 22 (2.2) | 13 (23.6) | 3 (20.0) | 47 (26.4) | 85 (24.5) |
| High school/GED | 48 (48.5) | 27 (49.1) | 7 (46.7) | 84 (47.2) | 166 (47.8) |
| At least some college | 29 (29.3) | 15 (27.3) | 5 (33.3) | 47 (26.4) | 96 (27.7) |
| Where living most of the time in past 30 days, % ns | |||||
| Homeless/houseless | 58 (58.6) | 39 (70.9) | 10 (66.7) | 128 (71.9) | 235 (67.7) |
| Own/rent apartment, room, or house | 41 (41.4) | 16 (29.1) | 5 (33.3) | 49 (27.5) | 111 (32.0) |
| Refused/missing | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 1 (0.3) |
| Status in 30 days prior to jail entry | |||||
| Used opioids *** | 47 (47.5) | 41 (74.5) | 10 (66.7) | 128 (71.9) | 226 (65.1) |
| Used drugsb ns | 84 (84.8) | 51 (92.7) | 11 (73.3) | 153 (86.0) | 299 (86.1) |
| Used alcohol ns | 51 (51.5) | 39 (70.9) | 7 (46.7) | 93 (52.2) | 190 (54.8) |
| Attended self-help groups ns | 52 (53.1) | 28 (50.9) | 4 (26.7) | 77 (43.3) | 161 (46.5) |
| Experienced mental health symptoms ** | 94 (95.0) | 44 (80.0) | 11 (73.3) | 160 (89.9) | 309 (89.0) |
| On probation or parole ns | 40 (40.8) | 24 (44.4) | 6 (40.0) | 59 (33.2) | 129 (37.2) |
| Arrested * | 17 (17.2) | 7 (12.7) | 3 (20.0) | 53 (29.8) | 267 (76.9) |
| Incarcerated * | 35 (35.3) | 20 (36.4) | 8 (53.3) | 45 (25.3) | 240 (69.2) |
One individual who identified as transgender was omitted from analysis.
includes crack/cocaine, cannabis, hallucinogens, inhalants, methamphetamines, and non-prescription benzodiazepines, barbiturates, GHB, Ketamine, other tranquilizers, or other illegal drugs.
p ≤ 0.05
p ≤ 0.01
p ≤ 0.001;
ns = not significant
More of the individuals being treated with buprenorphine at jail intake self-reported having abstained from opioid use in the prior month than those not on any type of MOUD (52.5% vs. 28.1%). Compared to those not on any MOUD at jail entry, fewer individuals being treated with buprenorphine or methadone had been arrested in the prior month (12.7% - 17.2% vs. 29.8%) and more had been incarcerated (35.3% - 36.4% vs. 25.3%). There were no differences in gender, race/ethnicity, and age.
MOUD transitions from intake to during incarceration
We examined transitions in type of MOUD received as measured at intake and again during incarceration (Figure 1). Overall, the proportion of individuals being treated with MOUD increased by 16.4% from intake (48.7%) to during incarceration (65.1%), attributable to a 9.2% increase in the use of methadone (from 15.9% to 25.1%) and a 10.1% increase in the use of buprenorphine (from 28.5% to 38.6%). The proportion on naltrexone decreased by 2.9% (from 4.3% to 1.4%).
Figure 1. Use of MOUD at jail intake and during incarceration (Sankey Plot).
A Sankey Plot is used to show the immediate transition of participants between two related events26. This Sankey Plot illustrates the flow of participants between MOUD use at intake and MOUD use in jail. The nodes on the left-hand side of the diagram (type of MOUD i.e., none, methadone) are the source nodes which are connected by arcs to the target nodes on the righthand side of the diagram. The width of the arc indicates the volume of participants in each flow and arcs are defined by color, for example, participants on methadone at intake are defined by the green arcs.
Over half of participants, 58.2%, did not have a change in MOUD status from intake to incarceration. That is, 32.3% continued to receive the same type of MOUD during incarceration as was being received at intake and 25.9% continued to not be treated with any type of MOUD. The remainder did experience a change in MOUD status from intake to incarceration. Specifically, 25.4% were initiated on MOUD while in jail (i.e., entered jail on no MOUD and were inducted onto MOUD while incarcerated), 8.9% entered jail on a MOUD but transitioned to no MOUD while incarcerated, and 7.5% switched from one type of MOUD to another type.
Of the individuals who were treated with buprenorphine or methadone while incarcerated, about half (50.0%−50.6%) had received that same type of MOUD in the community as measured at intake; about one-third or more (32.2%−42.5%) had not received any MOUD in the community immediately prior to incarceration.
Of those who did not receive any MOUD while incarcerated, most had not received any MOUD in the community as measured at intake (74.4%); 18.2% had received buprenorphine prior to incarceration, 4.1% had received methadone, and 3.3% had received naltrexone.
Factors associated with use of MOUD during incarceration
We used logistic regression to examine factors associated with use of any MOUD while incarcerated (Table 2). Receipt of any type of MOUD while in jail (yes vs.no) was positively associated with having received MOUD in the community as assessed at intake (OR 12.00, 95% CI [5.73, 25.14]) and incarceration at Site 1 compared to Site 2 (OR 24.55, 95% CI [10.98 – 54.93]). Age, race/ethnicity, mental health symptoms, use of drugs, and educational attainment were not associated with use of MOUD while in jail.
Table 2.
Factors associated with use of MOUD while in-jail (n=347)
| Odds Ratio | 95% Confidence Interval | |
|---|---|---|
| MOUD at jail intake (ref: No)*** | 12.00 | (5.73 – 25.14) |
| Jail site is Site 1 (ref: Site 2)*** | 24.55 | (10.98 – 54.93) |
| Male (ref: Female) | 0.45 | (0.13 – 1.51) |
| Age (continuous) | 0.99 | (0.95 – 1.03) |
| Race/ethnicity (ref: White) | ||
| Hispanic | 1.77 | (0.70 – 4.48) |
| African American | 0.42 | (0.15 – 1.19) |
| Other, Unknown | 2.28 | (0.69 – 7.50) |
| Education (ref: Less than high school) | ||
| High school degree or GED | 1.50 | (0.68 – 3.33) |
| At least some college | 1.67 | (0.69 – 4.04) |
| Used opioids in last 30 days (ref: No) | 1.65 | (0.75– 3.62) |
| Used non-opioids in last 30 daysa (ref: No) | 1.50 | (0.53 – 4.24) |
| Experienced mental health symptoms at baseline (ref: No) | 0.54 | (0.19 – 1.54) |
includes crack/cocaine, cannabis, hallucinogens, inhalants, methamphetamines, and non-prescription benzodiazepines, barbiturates, GHB, Ketamine, other tranquilizers, or other illegal drugs.
Note: One individual who identified as transgender was coded as sex at birth to include this case in analysis.
p ≤ 0.05
p ≤ 0.01
p ≤ 0.001
Discussion
In our study of incarcerated individuals with OUD, about half were being treated with MOUD at jail entry. After jail entry, however, about 65% of individuals were receiving some type of MOUD, with marked increases during incarceration in use of methadone and buprenorphine. Furthermore, about one-quarter of individuals were initiated on MOUD while in jail (i.e., entered jail on no MOUD and were started on MOUD while incarcerated). Taken together, findings suggest that jails in rural communities can continue and initiate these life-saving medications, and thereby play a critical role in expanding access to and use of MOUD. Use of MOUD during incarceration has been associated with continuity of MOUD 12-months post-release21,27, suggesting that program benefits may continue after community re-entry. Although it will be necessary to research whether MOUD continuity post-release differs in communities with more barriers to MOUD access and utilization, such as rural communities. More broadly, that half of individuals were not on MOUD at jail intake points to potential gaps in care within the community prior to incarceration, which may persist upon release16,18. Future research should examine use of MOUD after release and how it is related to MOUD received before and during incarceration.
A smaller but still sizable portion of participants (7.5%) switched from one type of MOUD to another type while incarcerated. Changes in type of MOUD received may reflect patient preferences, an understudied factor28 which could enhance treatment retention and engagement29–31. In community settings, patient preference is also related to geographic access to MOUD; the rurality of these jails may impact medication access in the community and preference while incarcerated. However, medication changes can also incur additional clinical considerations32 and may be related to more behavioral incidents while incarcerated33. Additionally, facility-specific differences in MOUD programming (i.e., restrictive regulations) may impact ability and effectiveness of MOUD changes while incarcerated16. Data were not collected on reasons for medication changes and associated outcomes, underscoring areas for future research.
A significant proportion of individuals entered jail on a MOUD but transitioned to no MOUD while incarcerated (8.9%) or entered jail not on any MOUD and continued to not receive MOUD during incarceration (25.9%). Results may reflect, in part, policies and practices that prioritize provision of MOUD to those who are already prescribed it upon intake. Continuity of healthcare from intake and during incarceration is essential for the health of justice-involved individuals34,35. Results may represent missed opportunities to initiate and engage individuals with needed evidence-based healthcare.
Regression analysis showed that use of MOUD during incarceration was positively associated with already being on MOUD at intake. Results are consistent with recent evidence on the Rhode Island Department of Corrections MOUD program indicating that most MOUD participants, 61%, were continued on MOUD from the community21. We also found differences by site, with receipt of MOUD during incarceration associated with the site that had offered buprenorphine for more years and had lower barriers to use of medications, for example by offering inductions at entry and not only pre-release, providing methadone on-site, and engaging with pre-trial individuals in addition to sentenced individuals. Future research should examine the extent to which specific aspects of MOUD programming and operation are associated with MOUD use and other related patient outcomes.
Limitations and strengths
This study has several limitations. Data were provided by jails located in two rural counties in western Massachusetts that incarcerated a predominately white male population, limiting the generalizability of findings. Both jails are sites in the Massachusetts Justice Community Opioid Innovation Network, which offers future opportunities to replicate findings among a larger and more diverse sample36. We did not have measurement of sentenced versus pre-trial status, timing of MOUD induction, or other factors, precluding examination of their potential effects on MOUD use. OUD screening and assessment processes were mostly comparable by site, with some variation that may have impacted who was identified as having OUD. As detailed elsewhere15, COVID-19 occurred during the implementation of the MOUD program in these jails and staff adapted programming to ensure access to MOUD. More research is needed to examine the impact of COVID-19 on use of MOUD in carceral settings and related outcomes. A key strength, we provide novel insights into the use of MOUD by adults with OUD who were incarcerated in two of the jails that were among the first in the US to offer this type of healthcare.
Conclusions
Individuals with OUD who are incarcerated have complex health needs. Access to MOUD while incarcerated can engage this at-risk population with necessary treatment. Jails in rural settings can effectively maintain and induct individuals on MOUD and provide individuals with options for MOUD type. Use of MOUD prior to incarceration and site-specific characteristics contribute to use of MOUD while incarcerated. Findings advance understanding of who accesses MOUD programming in jail and the extent to which individuals are initiated onto to MOUD, discontinued off of it during incarceration, or switch among MOUD medication types during the transition into jail, highlighting opportunities for future research and service delivery improvements.
Acknowledgements:
The authors would like to thank Calla Harrington for contributions to data analysis.
Source of Funding:
This work was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) (1H79TI081387-01).
Footnotes
Conflicts of Interest: The authors report no conflicts of interest.
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