Diversion of medications to treat opioid use disorder: Qualitative findings from formerly incarcerated adults in Massachusetts

Abstract

Background:

Carceral officials often cite diversion of medication for opioid use disorder (MOUD) (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons with little understanding of patient perspectives. We aimed to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

Methods:

We conducted thematic analyses of semi-structured interviews held in 2021–22 with 38 adults who received MOUD treatment and were released from eight Massachusetts jails that had implemented a MOUD program on or after September 2019.

Results:

Consistent with prior reports from carceral staff, patients perceived MOUD diversion to happen less frequently than expected, lwhich they attributed to dosing protocols that have effectively reduced it. Patients reported that MOUD availability reduced the contraband buprenorphine market, although other contraband substances have entered jails (fentanyl, oxycodone, K2). Patients perceived Subutex to have greater misuse potential and added diversion risks. Patients valued graduated consequences and other efforts to reduce MOUD diversion and contraband for making jails safer and for enabling patients to receive treatment. Nearly all participants reported having heard about, witnessed, or been involved in actual or attempted diversion, with variation in reports by jail. Patients suggested that dispensing MOUD to all who need it immediately upon intake would be the most effective way to reduce MOUD diversion and contraband.

Conclusion:

Formerly incarcerated patients perceived MOUD diversion within jail medication programs as occurring less often than expected and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings have implications for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

INTRODUCTION

Incarcerated populations have a high prevalence of opioid use disorder, yet few carceral settings offer the community-standard evidence-based treatment – medications for opioid use disorder (MOUD) (Grella et al., 2020; Maruschak et al., 2023; Simon et al., 2021). To address this problem, Massachusetts passed Chapter 208 of the Acts of 2018, known as the CARE Act: An Act for Prevention and Access to Appropriate Care and Treatment of Addiction. The CARE Act mandated a pilot program for five Departments of Correction (hereafter “jails”) to provide all, United States Food and Drug Administration (FDA) approved forms of MOUD, i.e., buprenorphine and methadone, in addition to naltrexone. Within two years, all but one MA jail was providing all types of MOUD. As jails in Massachusetts and elsewhere have piloted the implementation of MOUD treatment programs, concerns have surfaced about the risk of diversion of the orally-administered agonist medications buprenorphine and methadone (Evans et al., 2022; Klemperer et al., 2023; Krawczyk et al., 2022; Pivovarova et al., 2022).

While some jails have provided naltrexone, an injectable antagonist MOUD, to people in carceral settings over the past decade, the introduction of buprenorphine and methadone as treatment in carceral settings in recent years has resulted in heightened concerns about the increased potential for medication diversion (Bandara et al., 2021; Kouyoumidjian et al., 2018). Carceral officials often cite the potential diversion of MOUD as a reason for not offering MOUD treatment (Doernberg et al., 2019; Gryczynski et al., 2021). Few carceral settings provide data on MOUD diversion. As a notable and recent exception, within five newly established opioid treatment providers in Massachusetts prisons, the rate of detected medication diversion over 13 months was low, with 1.78 diversions per 1,000 buprenorphine doses and 0.16 per 1,000 methadone doses (Nankoe et al., 2022). Within jails, staff report that diversion is mitigated when appropriate dosing protocols are in place as part of the MOUD program (Evans et al., 2022).

Studies of community-dwelling individuals, including a few focused on formerly incarcerated populations, reported that diverted buprenorphine use frequently occurs for therapeutic purposes (e.g., to prevent withdrawal, maintain abstinence, self-taper off opioids), and when buprenorphine treatment is inaccessible (Carroll et al., 2019; Cicero et al., 2018; Kavanaugh & McLean, 2019; Smith et al., 2020). Provision of MOUD treatment in carceral settings is expected to reduce non–prescribed buprenorphine use and illicit opioid use (Gryczynski et al., 2021).

Few studies have examined MOUD diversion after implementation of an in-jail MOUD treatment program from the perspective of incarcerated patients. Centering the perspectives and experiences of program recipients can help ensure that patient needs are prioritized (Damschroder et al., 2022). Also, patient feedback on implementation processes can increase the chance of adaptation, successful routinization, and scale-up (Baumann & Cabassa, 2020; Greenhalgh et al., 2004). Moreover, triangulating data from multiple sources, by interpreting findings in light of prior reports from jail officials, may help to describe a more complete picture of MOUD diversion. Thus, we aim to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

METHODS

Parent study

Legislation passed in 2018 in Massachusetts (Chapter 208) mandated five jails to pilot-test programming to offer all FDA-approved forms of MOUD, which eventually expanded to all but one MA jail, to offer buprenorphine and methadone, in addition to injectable extended-release naltrexone which was already offered. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) is conducting a Type 1 hybrid effectiveness-implementation study of the MOUD program (Evans et al., 2021). The Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework, adapted for work with justice-involved populations (Ferguson et al., 2019), guided the implementation study. Multiple stages of qualitative data collection with jail staff have reported on overall implementation barriers and facilitators (Pivovarova et al., 2022), and in relation to re-entry (Matsumoto et al., 2022; Stopka et al., 2022), and on MOUD diversion (Evans et al., 2022). In this paper, we present results from qualitative interviews with formerly incarcerated individuals who received MOUD while incarcerated.

Participants

We conducted interviews with 38 adults who received MOUD while incarcerated in eight jails located in urban, suburban, and rural communities in eastern and western Massachusetts. These eight jails encompassed all jails in Massachusetts that had initiated MOUD programming by the time of recruitment. Recruitment flyers were distributed in jail release packets, community locations where previously incarcerated individuals gather (e.g., community opioid treatment programs, transitional housing), and via direct outreach. Following release from jail, interested individuals contacted research staff who provided study information, verified in-jail receipt of MOUD as recorded in jail electronic health records, and conducted verbal consent for participation.

Data collection

Participants engaged in a semi-structured 30–60 minute telephone interview (see Appendix 1) and completed a brief socio-demographic survey. Participants were paid $40. Data were collected September 2021-October 2022. Interviews were digitally recorded, professionally transcribed, and redacted. Interviewers had prior experience and training on conducting qualitative research interviews and included a range of expertise (social worker, anthropologist, clinical psychologist, epidemiologist; public health doctoral candidate, masters level staff). The Baystate Health Institutional Review Board approved all study procedures.

Data analysis

We developed an initial codebook based on the interview guide and featuring a priori codes and we added additional codes to reflect salient emerging topics. We refined codes using open coding and constant comparative methods, resulting in a codebook with 23 parent codes and 32 child codes. A four-person team coded four initial transcripts concurrently and met to review coding application agreement and refine coding definitions until sufficient agreement was reached. Thereafter, the four staff worked in two dyads, coding transcripts independently and meeting with their partner to resolve discrepancies. We analyzed coded transcripts in Dedoose v9 (Dedoose, 2018).

This manuscript summarizes thematic findings from two codes on medication diversion and contraband. Using deductive and inductive strategies, data were reviewed independently by each analyst [EE, RS, EP] and emergent themes were derived using a data-driven thematic coding scheme consistent with grounded theory (Strauss & Corbin, 1990,1994). Analysts compared summaries of emergent themes and collaborated to interpret data as an analytic whole. Colloquialisms and utterances were removed from quotes to improve readability.

RESULTS

Participants were 41.5 years old on average, 14.3% were female, and White (84.2%), Hispanic/Latino (23.7%), Black (7.9%), and from other racial/ethnic subpopulations (Table 1). About two-thirds had attained a high school diploma or more education and most were currently taking MOUD. Figure 1 presents a visual representation of themes that emerged from the data.

Table 1.

Characteristics of participants (n = 38)

Age, mean (SD)	41.5 (9.3) Missing=1
Female, n (%)	4 (14.3)
Race, n (%)
White	32 (84.2)
Black or African American	3 (7.9)
Native Hawaiian or other Pacific Islander	1 (2.6)
More than one race	2 (5.3)
Hispanic/Latino ethnicity, n (%)	9 (23.7)
Education, n (%)
No high school diploma	8 (21.1)
High school diploma or equivalent	19 (50.0)
Some college, but no degree	9 (23.7)
Associate’s degree	2 (5.3)
Currently taking MOUD, n (%)	36 (94.7)
Buprenorphine (e.g., Suboxone, Subutex)	20 (55.6)
Methadone	11 (30.6)
Extended-release buprenorphine (Sublocade)	4 (11.1)
Extended-release naltrexone (Vivitrol)	1 (2.8)
Not currently taking MOUD, n (%)	2 (5.3)
County of incarceration, n (%)*
A	1 (2.6)
B	6 (13.2)
C	4 (10.5)
D	8 (21.1)
E	3 (7.9)
F	6 (15.8)
G	3 (7.9)
H	7 (18.4)

^*County names have been blinded for confidentiality purposes.

Figure 1.

Summary of patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

Diversion frequency

Many participants reported knowing of diversion, which was described to have occurred in all sites, with fewer reporting having participated in instances of it. The reported frequency of diversion varied by site and was difficult to assess comprehensively as participants often relayed secondary reports from other incarcerated individuals. For example, some participants perceived buprenorphine diversion to occur often, as much as “everyday” and “…running all over the jail.” Diversion was described as standard behavior in carceral settings, “There’s always diversion. You’re never going to get rid of it. It’s always going to happen. It doesn’t matter where you are, it’s always going to be a problem” [ID 702].

Others reported never seeing or hearing about diversion, describing it as “not frequent,” not common,” “very rare,” and “impossible.” Participants noted how the same person or people repeatedly engaged in diversion attempts.

I didn’t really hear--no one on our side did that [diverted]. I mean, anybody that wanted it will just take it [via the MOUD program]. I think it was the other people, sentenced side [i.e., not the pre-trial population] I heard of people doing it, but it was only like one person out of all the people there….

[ID 403]

Participants also reported that while diversion attempts did occur, successful diversion was limited.

There’s been a couple [diversion incidents]…but it’s not as frequent…as people think…it’s just very very difficult because…you get your mouth checked…before and after [medication administration]…and usually people would just get caught for doing stuff like that. Very rarely people are successful, but some people have been successful in the past.

[ID 503]

Speaking clearly, they have surveillance there for everyone…nobody is going to be dumb enough--people try to trick them, but they always get caught.

[ID 303]

Protocols to detect and reduce diversion are effective

Protocols designed to detect and reduce diversion were recognized as effective, primarily because staff were able to identify most diversion attempts and limit successful diversion. Most reports of diversion were in reference to buprenorphine, which was typically provided by staff who crushed tablets into a powder and placed it under the patient’s tongue. Buprenophine was diverted with “cheeking,” described as hiding medication in the mouth. To prevent buprenorphine cheeking, one participant said:

They [jail staff] check your mouth…when they put it [in]. You’re gonna put it under your tongue. [They] check your mouth right then, to make sure you put [it] under your tongue. Then your hands have to stay in sight and you can’t move and again you can’t really talk and, and then they check your mouth afterwards.

[ID 305]

Participants described dosing protocols in detail, which were largely consistent with prior staff reports. These safeguards, patients reported, made it “quite a bit of work” to divert buprenorphine during medication administration.

…people do [divert]. I mean, it’s nothing anymore, just like do a thorough mouth check, the flashlight and everything…they make you sit…for…15 minutes…And…drink a cup of water afterwards. And the same thing with the methadone, they shut their mouths…it’s not really easy…people will find ways sometimes, but it’s really…not common.

[ID 106]

Many participants reported it was easier to divert buprenorphine than methadone. One participant explained:

…with methadone, it’s liquid…you have a cup of water and you…dump it in…mix it together…in the methadone bottle itself and then you drink it. And then you rinse it out with water and you drink that. And then they make you eat a cracker. So, it’s kind of harder…[to divert] with methadone.

[ID 402]

Participants shared that COVID-19 regulations made it easier to divert. During the pandemic, most jails dispensed MOUD to individuals in their cell or cell block instead of in a centralized dispensing area. This change minimized staff observation after medication administration. A participant shared:

…from what I heard was the nurse who would come, cause the Suboxone, they have to sit there and watch you…at least for five, ten minutes to…make sure it dissolves, you take it the right way. But because of the whole COVID thing and they had people locked down, they couldn’t do that. So I heard they would just give you Suboxone and just going out to the next cell. That’s it. So people would just hold it till they had the opportunity to sell it to somebody else.

[ID 302]

Diverse reasons for medication diversion

A common reason for medication diversion was to self-treat or help others who were not enrolled in the MOUD program through opioid withdrawal. Some participants explained that untreated people stopped seeking diverted MOUD once they were enrolled in the MOUD program. One participant explained:

…there was people in my unit that were coming in sick, coming in with their prescription that was maybe two weeks behind schedule. They [jail staff] didn’t fill it, but they’ve [newly incarcerated people] been on them for years…there’s a program there for that, but yet, they weren’t helping out those people. So, me as a solid White guy would sometimes deviate my medication however way possible and bring it back to a couple people that needed it…Just the dynamics is just those people in jail when you’re there and what they expect from other guys…if the shoe was on the other foot, I would expect somebody that I know, if I was sick and I didn’t have medication, to do the same for me.

[ID 505]

Another common cause of diversion was “strong-arming”, i.e. bullying, coercion, intimidation, or pressure from other incarcerated individuals. One participant shared how newly incarcerated MOUD patients without resources are vulnerable to coerced diversion. One participant explained:

You’re waiting for that guy to come in on the unit that’s on it. Put them on a chokehold, so you can get it. And then, a guy will see a guy that comes in and he’s on it, some green horn…[he] doesn’t make commissary, has no sneakers on his feet. Put a pair of sneakers on them, give him some food for the night, and then now he owes you.

[ID 505]

Other reasons for diversion included making money and a preference to receive medication in two doses throughout the day (split-dosing) rather than only once in the early morning. Fear of being taken off medications after being caught diverting was a key deterrent to diversion.

No, it [diversion] doesn’t happen often, no, because the people that come in there that want to be on it are on it, and if you’re on the dose you’re supposed to be on then you don’t need more, you don’t need it. So, there’s nobody that’s going to buy it, so people aren’t going to take the chance to divert and then get taken off of it.

[ID 602]

It’s [diversion] very rare because they take a lot of actions in order for people to not do that, it’s really hard to. But maybe one or two times it happened that I’ve heard of. But some people did try, but they got caught. They got in trouble and went to the hole [solitary confinement] and they took you off the medication. So, it really didn’t happen that very often because people were scared to get taken off of it.

[ID 404]

Subutex was perceived to have added risks for diversion and addictive properties

Subutex, a sublingual tablet which lacks the abuse deterrent ingredient naloxone, was noted as a type of medication that individuals might be especially motivated to divert. It was desirable for use in unmonitored ways for euphoric effects.

And like [the jail]…they gave me Subutex…there’s no [naloxone] blocker in Subutex, you can get higher if you took more versus Suboxone, [which] has a limit on it [because of the naloxone ingredient].

[ID 603]

Another person described a diversion incident in which a person tried to save up Subutex.

“[they tried]…to cheat, their Subutex, to sell it or to save it up to a higher amount, so they can take it all at once…[and] still…continuing with the addiction process…still wanting more to get high.

[ID 101]

Some participants felt that when the MOUD program offered Subutex as a medication option, it created a context in the jail in which some untreated people would be more likely to seek out diverted Subutex and become addicted to it.

…people…are getting a habit when they go to jail, people that…didn’t have any problem before going to jail, then they go to jail and they start doing Subutex, you know cause people, to buy it illegally now, obviously…those are only people that really couldn’t get on it, it’s the ones that started doing it once they got to jail…not because of heroin use, [but] just because of being incarcerated….

[ID 305]

Consequences of MOUD diversion

Most participants reported that disciplinary actions for medication diversion involved a graduated set of consequences that started with warnings and increased surveillance during dosing, usually resulted in a slow reduction in dosage amount (taper) and sometimes an immediate “dose cut,” and may have entailed placement in an isolated unit (“segregation” or “the hole”). A participant stated:

I’ve seen situations…where people would misuse the medicine…whether it’s Suboxone or…methadone, and that can result in getting a warning or…potentially getting the medication…taken away from you. But, they [jail staff] will give you the option, whether or not…you wanted to stop or they will taper you off, they will give you that option.

[ID 503]

With multiple diversion attempts, some participants explained that there is an option to either be removed from the MOUD program or switch to a different type of medication that is harder to divert, such as methadone or injectable buprenorphine (Sublocade). A participant shared:

They give you one chance, and you go to the hole and come back, but you’ll still be on your medication. But they would drop it in half, like if you were on 16 and you got caught, they drop it to eight milligrams. And then if you got caught again, they would shut you off and give you the Sublocade shot. Unless the person didn’t want it, and then they would just wean them down, and just cut them off.

[ID 601]

Protocols for buprenorphine administration were also described as more stringent for individuals who had previously been caught diverting. For example, one participant shared that when a person is known to divert, then the person is watched very closely by multiple correctional officers during the dosing process.

A few participants reported immediate and severe consequences for diversion, such as removal from the MOUD program without any tapering of medication dosage and being moved to an isolation unit. A participant explained, “They got lugged, which means they got brought down to the segregation…And they got kicked off of the Suboxone program. From what I know of…they only [got] kicked off. That’s it. It was pretty brutal from what I know.” [ID 801]

The MOUD program disrupted the contraband buprenorphine market in jails

Many participants reported that the MOUD program reduced the flow of contraband buprenorphine into the jail. Participants explained that individuals who wanted to be treated with buprenorphine while incarcerated could now receive medications “legitimately” under the MOUD program and thus jail residents did not seek contraband buprenorphine. These changes were attributed to “simple supply and demand” principles. Specifically, the MOUD program made prescribed buprenorphine available inside jails. With a greater supply of prescribed buprenorphine, there was a simultaneous decrease in the value of contraband buprenorphine which, in turn, decreased incentives to bring in contraband buprenorphine. Participants noted:

It stopped a lot of the actual [contraband] Suboxone coming in…the guys that were getting that [contraband]…ended up on the [MOUD] program…I know for certain that there’s a few people who…went from…sneaking it in, to longer doing it because they could receive it on their own…right in custody….

[ID 304]

As the MOUD program rolled out, individuals with contraband buprenorphine who tried to sell it inside the jail either could not find buyers or could not command the same price as before.

It did make a big impact of people that try to make money off of individuals [who are] calling their people outside. ‘Oh, I need money, I need money, I need money’…for canteen…[to spend on contraband] drugs. So, the people that have the [contraband] drugs…it [the MOUD program] made an impact on them, because they wasn’t making no money…[and they] get mad saying like ‘damn, these people fucked up my situation. I came in here planning to make some money [selling contraband] and I can’t.’

[ID 705]

Most participants shared how the value of contraband buprenorphine decreased significantly after MOUD program implementation, with variation in prices depending on medication amount and form, the location and type of facility/detention (e.g., pre-trial vs. sentenced), and the time-period being referenced. For example, one participant explained that eight milligrams of contraband buprenorphine was worth $100 before MOUD program implementation, which decreased to $40 after implementation began. Another participant said that one strip of Suboxone [sublingual film] used to go for $100 and now was only worth $10. A third participant reported that a strip of Suboxone used to be worth $200–$400 and was now worth $100.

Participants also reported that once jail residents were able to receive prescribed buprenorphine, they did not need or want to obtain contraband buprenorphine.

I didn’t use any other contraband substances while I was there…I just get my [medication]…it made me feel okay. I was able to do what I needed to do.

[ID 505]

…I was in there in COVID, so there really wasn’t nothing [no contraband drugs], because there was no visits or nothing…and I was on the Suboxone [program], so it didn’t matter, you know what I mean? I wasn’t part of that group [the group that wanted contraband drugs].

[ID 401]

Moreover, participants shared that being involved in the contraband buprenorphine market was just not worth the associated effort and personal risks.

…before the MAT program within the institutions, there was a lot more [contraband buprenorphine]. Now it’s limited. They’re saying, ‘oh it’s not even worth it trying to bring Suboxone into the jail, because they get them prescribed’

[ID 705]

Participants compared the current situation to prior historical eras, remarking how times had changed, as evidenced by today’s level of contraband drugs inside jails being remarkably less than what had been experienced before. One participant said, “…there used to be a lot more contraband in jails…in the 90s and earlier, but nowadays it’s not that much, just some, but you know, some places more than others, but nothing compared to what it was.…” [ID 704]

Persistence of contraband substances: Reasons, types, routes

Some participants shared that the MOUD program did not impact contraband substances. Individuals warned that jails would always have a problem with contraband drugs, including those not being treated with MOUD, people in active addiction, and people seeking ways to relieve boredom and stress. Participants reported that after implementation of the MOUD program, there were changes in the types of contraband drugs being brought into the jail, moving from buprenorphine to K2, oxycodone, and fentanyl.

Participants shared several different routes for contraband drugs to enter jails. One method was when newly incarcerated individuals hid contraband drugs on or inside their body, a practice that participants reported meant contraband was more likely to reach the unsentenced or pre-trial population (i.e., a population awaiting trial or other court processes) than the sentenced population (i.e., a population that has been convicted and is serving time related to their sentence). In some jails, individuals who are sentenced are detained in a different area than those who are awaiting trial. Another way that contraband buprenorphine was reported to be entering jail was through mail that had been sprayed with the substance. Staff instituted protocols to check mail more carefully or to photocopy it, which meant that mail was not delivered to jail residents in a timely manner. Two participants from one jail recounted news of correctional officers bringing contraband drugs into the jail and a third participant from a different jail mentioned that “some crooked cops” trade in contraband drugs in the jail.

Benefits of preventing MOUD diversion and contraband in jail

Participants perceived the MOUD program as life-saving, primarily by treating opioid use disorder but also by making jails safer. In particular, the decrease in contraband buprenorphine meant less risk-taking related to drug smuggling, fewer opportunities to be exposed to substances that could trigger a return to opioid use, and less conflict among jail residents.

I’m glad that they did put…the MAT program in the jail to save people’s lives from trying to bring drugs in here, you know taking risks on something bursting like the balloon bursting inside of them and it happened in [jail name], a…friend…passed away trying to, smuggle drugs…and I’m glad that they parked this MAT program into the institutions and try to stop all that bull crap, because there’s people that do want to change their lives, but if they see the drugs there they’re going to try to get it.

[ID 705]

…getting involved in buying Suboxone off inmates and using them to get high…causes problems for yourself [and]…can cause a lot of negative behaviors between inmates. Fighting, arguing, just a lot of negativity that you probably don’t want to deal with.

[ID 501]

Participants shared how they valued the opportunity to receive needed MOUD treatment while incarcerated. Many simply wanted to take their medication as prescribed and not get involved in medication diversion or contraband.

…I personally wouldn’t divert my meds because I want them…there’s a reason…why I was on the MAT program, because I feel like I needed it, and diverting my meds wouldn’t have…been beneficial to my goal…of being on the meds. So, diverting them just didn’t make sense.

[ID 102]

The MOUD program was perceived to help patients avoid use of diverted or contraband substances during incarceration, which participants said enabled patients to use their time in jail for good, to become a “normal” or “better” person.

I think it worked well, because…I kept my sobriety…you still have access to drugs in jail. Suboxone is good, because it still keeps you straight in line. It’s good, because I’m able to wake up in the morning, and actually take my doses, wake up energetic and be able to go to work and do what a normal human being does.

[ID 307]

Participants were convinced that being treated with MOUD while incarcerated would lead to better post-release outcomes. Treated patients were thought to be more likely to continue treatment and avoid a return to opioid use after release.

I know they [jail staff] worry about people diverting it, but I see with my own eyes more people that I know in person, I can say for a fact, that are on Suboxone while they’re in there, they’re more likely to stay sober when they get out, and I see that personally.

[ID 202]

The inmates, some took it seriously [and]…were glad to be on it, especially for the ones that are getting out, they were glad to have something to be on as opposed to getting out and not being on anything and possible relapse.

[ID 501]

Suggested improvements to reduce MOUD diversion and contraband in jail

When asked directly for suggestions on how to improve protocols to prevent MOUD diversion and contraband in jail, participants indicated that protocols are generally working well and are thought to be necessary and fair. For example, one participant said, “I don’t see them doing anything better than the way they’re doing it now. It’s working fine…They’re taking the necessary steps [to prevent diversion]….” [ID 506] Reviewing treatment contracts prior to induction into a MOUD program was identified as a useful practice for aiding communication with patients about the reasons for strict protocols during dosing and the consequences for being involved in medication diversion or contraband activities.

Others, however, reported mistreatment from a minority of staff during the provision of medications. Some staff were reportedly rude or disrespectful, communicated stigmatizing views of MOUD, shortchanged the full 15 minutes that is recommended for full absorption of buprenorphine, or used an intimidating level of surveillance in the dosing space (e.g., prolonged eye contact).

The most common recommendation to reduce diversion and contraband was to dispense MOUD as soon as possible after jail entry to all who need it. These comments stemmed from policies and practices at some of the jails that delayed induction or limited MOUD program access to patients who came in with a community prescription. In some jails, waitlists for assessment or issues determining dosage levels in the community prevented MOUD dosing immediately upon jail entry. Other jails followed “the letter of the law” and limited access to those entering with an active prescription or those 30-days pre-release. These policies and practices left untreated many individuals with opioid use disorder who were potential customers for smuggled or diverted contraband to relieve withdrawal symptoms or for euphoric effects.

…if they let everybody who wanted to be on it on it, then there would never be a problem with people cheeking it and selling it…if somebody came in the door, they didn’t have an active script, but they were a heroin user and the CO [correctional officer] let them get on it, then there wouldn’t be a problem with people cheeking their meds, because…the only reason people cheek their meds is to sell it to people who want it. But there wouldn’t be people wanting it if everybody was allowed to get it.

[ID 601]

One of the individuals that I know personally that tried to get on was told that he didn’t qualify…which I think is a whole bunch of bull crap, because…drug test after drug test…[was] positive with either fentanyl or Subutex. So, it’s gonna be a revolving door…they talk about stopping recidivism, but if you’re denying this individual the opportunity that he feels he needs and that we all know that this works, it works, and that it will help him, and you deny him that, you just…you’re feeding into the recidivism….

[ID 101]

Results describe MOUD diversion within jail-based MOUD programs from the perspective of patients and identify patient perceptions of several factors that contribute to and reduce diversion.

DISCUSSION

In-depth interviews with formerly incarcerated individuals treated with MOUD in jail indicated that MOUD diversion occurs less often than commonly thought and is preventable with appropriate dosing protocols, consistent with prior reports from jail staff (Evans et al., 2022). Former patients also corroborated that the systems put in place to supervise MOUD treatment in jail effectively reduce medication diversion. They also corroborated the prior literature regarding the reasons for diversion (e.g., help others, coercion, make money, cope with stress of incarceration) (Cicero et al., 2020; Evans et al., 2022; Havnes et al., 2013; Monico et al., 2021), and that the MOUD program has produced other benefits that patient value, namely access to MOUD during incarceration and making jails safer.

A new finding is that patients recommend that to limit medication diversion, MOUD should be provided to all individuals with opioid use disorder who want it and immediately upon intake. Barriers to MOUD access and unmet need for treatment are known contributors to buprenorphine diversion (Carroll et al., 2020; Cicero et al., 2020; Rubel et al., 2023). Currently, the law in Massachusetts stipulates that MOUD be continued for individuals who are already being treated with it at jail intake and that new MOUD inductions occur at least 30 days prior to release. However, jail induction policies and practices vary. Universal access to MOUD at jail intake for all who need it would require re-organization of aspects of the MOUD program in some facilities, such as identification at intake of all people with opioid use disorder who are not yet receiving MOUD, inclusive of pre-trial and sentenced individuals, and provision of MOUD to all individuals who choose to be treated, with assessment and new inductions occurring within 24-hours of intake. These programmatic changes would help facilities to implement more of the best practice guidelines for treatment of opioid use disorder in jails (Scott et al., 2022). In the meantime, other research has documented that when MOUD programs in carceral settings enact consequences that are inconsistent with clinical guidelines, often resulting in forcible withdrawal or inadequate treatment, it can lead to aversive experiences among justice-involved patients, who consequently hold negative attitudes about MOUD and are reluctant to seek community treatment with MOUD after release (Grella et al., 2020; Rich et al., 2015).

Results suggest several other areas where efforts to address diversion could increase the potential for sustaining MOUD treatment in carceral settings. First, the potential for medication diversion should be recognized as an ongoing issue that jail staff are responsible for monitoring and working to prevent. Practice guidelines for prescriptions of psychotropic medications in carceral settings (e.g., Friedman et al., 2019; Tamburello et al., 2018) may aid in the development of similar guidelines for MOUD. Also, participants’ stories of diversion indicated it was more likely to occur when usual dosing protocols were disrupted, for example during COVID-19 when dosing was done in cells instead of in clinical spaces or when there was inadequate observation during dosing, as mouth checks were not recommended due to potential COVID-19 transmission risks. Findings are consistent with staff reports (Donelan et al., 2021; Harrington et al., 2022) and point to the need for consistency in the application of dosing protocols, as aided by sufficient staff-to-client ratios, staff training, and infrastructural resources. Results also suggest that Subutex, which has previously been implicated in diversion in prison settings (Tompkins et al., 2009), may be more vulnerable to diversion in jail and appears to be a form of buprenorphine that jails should use with great caution or re-consider altogether.

Novel themes were also identified that were related to the disruption of MOUD as contraband, potential introduction of new methods and types of contraband, and recommended prevention approaches to limit contraband. Prior studies have focused on a wide range of contraband items related to substance use in carceral settings, including tobacco products (Thibodeau, 2012), needles and syringes (Treolar, 2016), and controlled substances (Friedmann, 2009). Few have focused on MOUD as contraband. One prior study mentioned that opioid agonist treatment is often considered contraband (Bandara et al, 2021), but substantive findings were not presented on the topic. Participants in the current study noted disruption in the MOUD contraband market and changes in the underground economy of contraband buprenorphine, likely related to the principles of supply and demand, and similar to those reported elsewhere (Treolar, 2016). By making MOUD treatment part of health care within jails, carceral facilities reportedly have diminished the illegal trade of contraband MOUD. Participants in the current study indicated that prevention of contraband MOUD helped to make jails a safer place to live, enabling patients to better focus on treatment and recovery. However, participants also reported alterations in the types of contraband drugs and the modified approaches employed to try to get licit and illicit substances into jails, including through mailed letters and corrections staff, similar to prior reports elsewhere (Cote, 2023; US Attorney’s Office, 2023). Smuggling of contraband substances into carceral settings is not new (Norman, 2022), and has been an ongoing challenge globally (OHagan, 2017), and our findings affirm that vigilance to detect and prevent contraband is needed in local jails.

Another area for better reduction of MOUD diversion centers on patients’ desire for a therapeutic treatment environment in carceral settings. Many patients want to take their MOUD while incarcerated and not be involved in medication diversion or contraband activities. Participants did not talk about MOUD as “replacing one drug for another.” Instead, MOUD was described as enabling patients to use their incarcerated time to become “normal, better people.” Also, participants shared fears of being taken off MOUD suddenly for real or suspected diversion attempts. Recommendations to improve care within the MOUD program included the use of treatment contracts, graduated consequences for actual and attempted diversion rather than immediate dose cuts and, as recommended elsewhere (Whaley et al., 2023), healthcare that is humanizing and provided in a context of dignity and respect for patients.

Limitations and strengths

Several limitations merit consideration. First, data were reported by formerly incarcerated individuals treated with MOUD in several Massachusetts jails that were among the first to implement a legislatively-mandated MOUD program, and were still fine-tuning program implementation. Also, most participants were still receiving MOUD after release. Thus, findings are reflective of people still engaged with treatment and may not represent the experiences of individuals treated with MOUD while incarcerated who have ceased treatment following release. Second, we verified at recruitment whether prospective participants were treated with MOUD at a participating jail, however during discussion it was not always clear which jail or time-period was being referenced. Also, few participants reported having been directly involved in medication diversion or contraband activities within jail, with some claiming to “not know anything” about these topics, and many referencing incidents of actual or attempted diversion involving other people that had been observed or heard about, with variation in reports by jail. Reliability and accuracy of self-reports of stigmatized or undesirable activities, such as substance use and carceral involvement, can be improved with methods such as assurances to respondents that the information provided will be kept confidential and used for research purposes only (Prendergast et al., 2013) as was done in this study. While misrepresentation of information was a possibility, participants did not have an incentive to provide inaccurate information and, in many domains, participant reports were similar to staff reports (Evans et al., 2022). Finally, we did not directly ask how experiences may be different by race and ethnicity or other aspects of identity. Future research is needed to better understand racial and ethnic dynamics related to MOUD receipt and diversion. Also, we did not collect data from individuals who are currently incarcerated, an activity that is underway now.

As strengths, the study was designed to provide depth of information, as is typical of qualitative research (Creswell & Creswell, 2018). Also, the timing of data collection allowed identification of emergent lessons learned on how to adapt MOUD programming from the patient perspective and in the broader context of MOUD program diffusion in carceral settings. This study is among the first of only a few studies of medication diversion and contraband inside jails as perceived by formerly incarcerated patients and as jails are implementing MOUD treatment services.

Conclusion

Concerns about medication diversion and security risks have slowed uptake of MOUD into carceral settings. In this study, formerly incarcerated patients treated in jail MOUD programs reported that, counter to that supposition and consistent with prior reports from carceral staff, MOUD diversion within jail MOUD programs occurred less often than assumed and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings can be used for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

Highlights.

• Jails often cite medication diversion as a reason for not offering medication for opioid use disorder (MOUD).

• Patients reported that diversion of prescribed MOUD happened less frequently than expected.

• Jail protocols to reduce diversion are largely effective.

• Patients felt that MOUD availability in jails reduced MOUD contraband in the jail.

• Participants recommended that offering MOUD to all who need it would reduce MOUD diversion.