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. Author manuscript; available in PMC: 2026 Jan 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Oct 10;168:209538. doi: 10.1016/j.josat.2024.209538

“Yeah, this is not Going to Work for Me” – The Impact of Federal Policy Restrictions on Methadone Continuation Upon Release from Jail or Prison

Justin Berk 1, Cameron Miller 1, Michael-Evans James 1, Megan Martin 1, Josiah Rich 1, Eliana Kapolwitz 2, Lauren Brinkley-Rubinstein 3
PMCID: PMC11624052  NIHMSID: NIHMS2030693  PMID: 39393533

Abstract

Introduction.

Individuals impacted by the criminal-legal system face increased risk of opioid overdose. Medications for opioid use disorder (MOUD) provide a life-saving intervention. Multiple barriers prevent access to MOUD, including federal policies regulating opioid treatment programs (OTPs). This study aims to identify how federal policy affects anticipated barriers to methadone treatment access at a high-risk time for opioid mortality: community re-entry after incarceration.

Methods.

The study used standard qualitative methods to conduct 40 in-depth-interviews with incarcerated individuals enrolled in the Rhode Island Department of Corrections MOUD treatment program. Semi-structured interviews took place between June and August 2018 and focused on participants’ experiences with MOUD and anticipated treatment barriers upon re-entry. A deductive coding framework incorporating the SAMHSA “8-point” criteria for take-home methadone as the a priori codebook and additional identified barriers informed further inductive analysis.

Results.

Four themes emerged: (1) logistical hurdles such as transportation and clinic location impeded clinic access; (2) punitive measures within clinics, like dose reduction for rule infractions, discouraged treatment continuation; (3) the environment of methadone clinics often tempted return to use; (4) while the structured nature of methadone treatment provided accountability, it also posed challenges. Federal policies, particularly around daily dosing and “take-home” regulations, exacerbated barriers for those reentering the community. State and clinic level policies, however, were also identified as direct or exacerbating barriers to treatment access.

Conclusion.

Significant hurdles persist for methadone access among individuals released from incarceration. Though the federal 8-point criteria have now been replaced with more flexible take-home policies, our findings highlight critical treatment barriers for individuals during the high-risk period of community re-entry. State and clinic level policies also exacerbate many of the barrier-driven themes identified in this analysis. Future work can explore how to best implement the identified benefits of a structured program without forcing the punitive measures that discourage treatment retention. Additional policy reform can help mitigate the effects of other social determinants of health (including transportation access). Ultimately, the many barriers to community methadone treatment retention also apply to individuals involved in the criminal legal system; they can be exacerbated at the federal, state, and clinic policy level.

Keywords: addiction, criminal justice, methadone, qualitative, opioid use disorder

Background

People involved in the criminal legal system are confronted with a significantly elevated risk of opioid overdose when compared to the general population (Binswanger et al., 2013). With the rapid escalation of overdose rates (Jalal et al., 2018), the adoption of medications for opioid use disorder (MOUD) has emerged as the prevailing standard of care for addressing opioid use disorder (OUD) (National Academies of Sciences Engineering and Medicine, 2019). The introduction of MOUD, including methadone within carceral systems, has demonstrated a significant reduction in post-incarceration fatalities due to overdose as well as diminished illicit opioid use, and decreased recidivism (Cates & Brown, 2023). However, obstacles in accessing and sustaining treatment within the jail and prison environment continue to hinder the availability of life-saving medications during the critical phase of community re-entry (Kaplowitz et al., 2023),

Each year, over one-third of the two million individuals with OUD encounter the criminal legal system (Winkelman et al., 2018), The elevated rates of incarceration among those with OUD underscore the importance of integrating MOUD treatment within correctional facilities. Extensive research highlights the pivotal role of methadone treatment in mitigating recidivism and post-release overdoses among incarcerated individuals (Cates & Brown, 2023), A seminal study by Rich et al. (2015), conducted in a carceral facility, revealed that individuals assigned to continue methadone were over twice as likely to engage with a community methadone clinic within one month of release compared to their forced-withdrawal counterparts (Rich et al., 2015). Other MOUD, namely buprenorphine, face fewer regulatory barriers and can be offered through office-based addiction treatment (OBAT). Methadone, however, continues to see unique federal and state barriers to administration for people with OUD (Conway et al., 2023).

Previous research discussed barriers and facilitators to jail-based re-entry programming for MOUD among jail staff (Matsumoto et al., 2022) and community-based treatment providers after release from jail (Stopka et al., 2022) as well as patient perspectives on the role of patient navigation services upon release from jail (Mitchell et al., 2021) and compared extended-release naltrexone to other forms of MOUD following release from jail (Velasquez et al., 2019). More broadly, recent literature explored why patients discontinue methadone in the community (Thakrar et al., 2023). Common themes include dissatisfaction with daily observed dosing requirements, exposure to actively using peers, economic insecurity (including transportation employment and housing), and stigma. This study focuses on individuals currently incarcerated, in both prison and jail settings, and utilizes a policy-based approach to understand how federal regulations impact treatment access in this population.

Lack of access to treatment among individuals in the criminal legal system exacerbates health disparities (Wildeman & Wang, 2017). Similar to the racially skewed effects of mass incarceration policies fueled by a War on Drugs rhetoric, the devastating consequences of synthetic opioids, such as fentanyl, along with heroin, have had a markedly disproportionate effect on historically Black and Latinx communities (Drake et al., 2020; Furr-Holden et al., 2021).

While an evolving policy landscape has led (and continues to lead) to increased access to MOUD treatment in carceral settings (Berk & Rich, 2021), barriers remain on re-entry, particularly among people taking methadone. In the United States, Opioid Treatment Programs (OTPs) serve as the exclusive avenue through which individuals prescribed methadone can obtain their medication. OTPs are subject to intricate federal regulations, namely 42 CFR Part 8, a section of the Code of Federal Regulations written by the Substance Abuse and Mental Health Services Administration (SAMHSA) specific to the certification of OTPs (Substance Abuse and Mental Health Services Administration (SAMHSA), 2024). Beyond federal constraints, onerous state policies may prohibit access to methadone (McGaffey, 2024) and OTPs must navigate these regulations as well also create their own clinic policies, each of which can place an additional burden on a population with other psychosocial barriers to care (Conway et al., 2023).

Restrictions exist because methadone, a full opioid agonist, has potential for misuse, diversion, and overdose.(Conway et al., 2023; National Academies of Sciences Engineering and Medicine, 2022) Buprenorphine, a partial opioid agonist, and naltrexone, an opioid antagonist, do not have the same overdose or risks associated with misuse. However, while misuse of buprenorphine is rare (and with limited risks of exacerbating overdose), it still exists and should be acknowledged (Doernberg et al., 2019; Evans et al., 2022; Yokell et al., 2011). Because of these differing risk profiles, buprenorphine and naltrexone are subject to more lenient policies that allow for their prescription in office-based settings. Indeed, unlike methadone, a Schedule II drug under the Controlled Substances Act, buprenorphine is a Schedule III medication while naltrexone is not a controlled substance at all given it has no obvious potential for misuse.

The requirement of daily attendance at methadone clinics offers an illustrative example of regulatory constraints impeding medication access. Historically, OTPs had stringent requirements (written in the federal code 42 CFR Part 8) that had to be met before patients could qualify for “take-home” doses. These criteria were widely known as the “8 point criteria” (See Table 1), These regulations also stipulated that during the first 90 days of treatment, patients could only be eligible for a single take-home dose for a day when the clinic is closed.

Table 1.

The 8-point criteria (from Prior SAMHSA Guidelines)

(1) Absence of Recent Abuse of Drugs
(2) Regular Clinic Attendance
(3) Absence of Serious Behavioral Problem
(4) Absence of Recent Criminal Activity
(5) Stable Home Environment and Social Relationships
(6) Length of Time in Comprehensive Maintenance Treatment (including therapy)
(7) Safe Storage of Medication
(8) Whether the Rehabilitative Benefit the Patient Derived from Decreasing the Frequency of Clinic Attendance Outweighs the Potential Risk of Diversion
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Given individuals impacted by the criminal legal system face higher risk of overdose-related death (Gan et al., 2021) and lower rates of MOUD receipt (Krawczyk et al., 2017), these regulatory barriers may disproportionately affect people getting released from jail and prison.

The Rhode Island Department of Corrections (RIDOC) offers a commonly cited model for MOUD program delivery in jail and prison settings. Starting in 2016, the RIDOC MOUD program began offering all three FDA-approved MOUD as community continuations or new initiations in all awaiting trial and sentenced populations (Clarke et al., 2018). This paper sought to build on prior work identifying barriers or facilitators to community treatment retention among RIDOC MOUD program participants to identify how best to deploy methadone during community re-entry (Kaplowitz et al., 2023).

Notably, in 2022, SAMHSA enhanced the flexibility around take-home dosing (after COVID-19 led to emergency relaxation of restrictions without negative outcomes (Amram et al., 2021)) and, subsequently, eliminated the 8-point criteria with hopes of expanding access to treatment (Substance Abuse and Mental Health Services Administration (SAMHSA), 2023). Despite the federal relaxations, however, the implementation has been inconsistent at state and clinic levels (Krawczyk et al., 2023; Pessar et al., 2021). Thus, many barriers to methadone access persist from the pre-Covid era. This paper seeks to explore the interaction between federal policy and treatment delivery. Specifically, this qualitative study involves a deductive approach to investigate how federal policy impacts treatment access and retention.

Methods

Study methods have been described in detail previously (Kaplowitz et al., 2023). Briefly, between June and August 2018, the study conducted 40 semi-structured, qualitative interviews with persons who were incarcerated and enrolled in the RIDOC MOUD program. Participants were recruited during group sessions, where study participants were able to confidentially sign up and later had an hour-long interview that included their perspective on the RIDOC MOUD program and discussed their prior experiences with MOUD in the community. Inclusion criteria included current enrollment in the MOUD program, being 18 years old and older, and being able to read and write in English.

The stratified sample proportionately represented participants’ medication type, facility where they were incarcerated (e.g., pretrial, minimum, and medium security), and whether MOUD induction occurred before incarceration or at RIDOC. All participants were included in the data as some individuals on buprenorphine provided important insights about methadone barriers. Participants’ length of incarceration and previous experience with MOUD also varied significantly.

Participants ranged from 22 to 66 years old, with a mean age of 37.2 years. Half (50%, n = 20) were receiving methadone, 47.5% (n = 19) were receiving buprenorphine, and one person (2.5%) was receiving injectable naltrexone. The majority were male (70%, n = 28) and White (82.5%, n = 33). Additionally, 5% (n = 2) were Black, 12.5% (n = 7) identified as belonging to an “other” racial group, and 10% (n = 4) were Hispanic. Most participants identified as heterosexual (87.5%, n = 35), with 5% (n = 2) identifying as gay and 7.5% (n = 3) identifying as bisexual. Educationally, 40% (n = 16) had finished high school, 20% (n = 8) had not completed high school, and the remaining 40% (n = 16) reported completing education beyond high school. Before incarceration, 95% (n = 38) had used heroin, 75% (n = 30) used prescription opioids non-medically, 53% (n = 21) used cannabis, 30% (n = 12) reported non-medical benzodiazepine use, and 20% (n = 8) reported alcohol use (Brinkley-Rubinstein et al., 2019).

Two team members with bachelor’s degrees, trained in qualitative research methods, conducted the interviews in a private room. Both interviewers were female, had conducted research before in criminal legal system settings, and were well versed in how best to build rapport and to work with people who are incarcerated. The study audio recorded and later transcribed interviews verbatim. Participants were compensated $25, deposited in their commissary. The interviewer used a semi-structured interview protocol, which consisted of open-ended questions that covered a broad range of topics around MOUD, including predetermined questions on previous experience with MOUD and anticipated barriers to treatment continuation. The Miriam Hospital’s Institutional Review Board, the RIDOC Medical Research Advisory Group, and the Federal Office for Human Research Protections approved the study.

To analyze data through a federal policy lens, the study used a deductive analysis utilizing a priori codes based on the “8-point” methadone criteria for take-home dosing (See Table 1). Additionally, an inductive analysis incorporated other identified barriers and facilitators related to community methadone treatment retention to form a finalized codebook. The coding team consisted of five individuals trained in qualitative research analysis (JB, MM, CM, MEJ, AM). Three interviews were cross-coded by all team members to refine the codebook, ensuring coder agreement and uniform use of codes. Following this, three members of the coding team (CM, MEJ, and MM) coded the remaining transcripts. The team completed analysis of qualitative using Dedoose software. Importantly, while the paper focused on the policy impact leading to methadone barriers, important facilitators for treatment retention did emerge from the data that had clear overlap with policy implications.

Results

Analysis of qualitative coding data revealed four main themes related to methadone treatment and regulations facing recently incarcerated individuals. These themes were: (1) logistical limitations on getting to clinic, (2) punitive responses to breaking clinic rules, (3) temptation to return to use, and (4) benefits of structure and accountability. Within each theme, specific codes highlighted barriers or facilitators that stemmed from the 8-point criteria as well as state or clinic-dictated effects on care access that emerged from the data.

Theme 1: Logistical Limitations on Getting to Clinic

Incarcerated individuals planning to continue community methadone treatment commonly cited transportation, clinic location, and time constraints as anticipated barriers to treatment access after release, often related to the requirement of frequent clinic visits. At the time of the interviews (2018), incarceration prohibited take-homes as federal policy did require daily dosing upon release from incarceration, so logistical concerns about treatment access were warranted. Policy requiring daily dosing exacerbated these logistical challenges.

Transportation

Accessing transportation was frequently cited by incarcerated persons as a barrier to obtaining daily methadone dosing following community reentry. Due to clinic mandates for daily in-person dosing, obtaining methadone is contingent on patients’ ability to maintain a reliable means of transportation. One incarcerated 31-year-old female patient described a prior experience accessing methadone treatment in the community setting: “I was on methadone, and then I stopped methadone because I couldn’t get to the clinic. My car broke down. It was just a hassle. So I went on Suboxone, and I couldn’t stay clean.”

Another respondent identified lack of legal access to a drivers’ license made daily clinic visits difficult. When asked about barriers to methadone treatment continuation, one 29-year-old male respondent stated, “Right now I’m here for my third DUI. So transportation would be the issue.”

Another respondent, a 35-year-old male, described their past experiences meeting requirements for mandated daily clinic visits without a license: “[I]f I have to be at work, sometimes I literally run to the clinic at my lunch break and run back. Because I don’t have a license, so I literally have to run, or jump a bus.”

Other patients may rely on family members for transportation to continue required in-person methadone dosing. One 35-year-old male respondent described his concerns relying on his mother during community reentry: “That’s the other reason why I’m like nervous about the whole discharge thing. You know, I’m relying on a 60-year-old woman to help me get everywhere.”

Clinic Location

Closely related to the barrier of obtaining daily transportation to receive methadone were logistic challenges related to methadone clinic locations. When the same respondent was asked about anticipated barriers to methadone continuation in the community, they responded:

“We live in [Town A], you know, where here [in prison] it is awesome that I’m on it and it works and it’s helping me. On the outside, because right now the only place I’m going to be able to get dosed at is in [Town B], it becomes an inconvenience…I think there should be more dosing facilities. I totally think you should be able to get dosed at the hospital. Location is, I think, going to be the big one.”

The same respondent described his anxiety toward return to use as a potential consequence of barriers related to clinic location:

“I am slightly worried about using. It’s not at the forefront of my mind, but you know, methadone is dosed Monday through Saturday in [Town B]; and on Sunday, you have to go to [Town C] to get dosed. That’s the closest one…. I don’t know why it’s like that. So, I’m working towards doing the take-homes as far as that’s concerned because again, I’m relying on a 60-year-old woman to help me get around.”

Concern regarding inaccessible methadone dosing locations and daily travel was a commonly expressed sentiment among incarcerated persons. Another patient, a 42-year-old male, described the challenges of navigating to distant clinic locations every day while maintaining stable employment:

“I don’t like methadone because I don’t like showing up every day. I just don’t. That can be fucking - listen, if you’re living in a gutter, it can be life-changing and to your benefit. But if you come out of the gutter and you start to succeed, like some people do, then it’s also a fucking albatross. I lived in [Town D] and had to drive to [Town E] every day before I could turn around and work in [Town F] or [Town G] or any of these other places. In my day, it added an hour. Nobody likes it to add an hour to the morning.”

Respondents also highlighted the clinic environment often being a barrier to treatment. Methadone locations are often dictated by local (and often discriminatory (Peterkin et al., 2022)) zoning laws. This can result in a clinic being built in in locations that are not only inconvenient but also potentially stigmatizing. The connection between a clinic’s physical surroundings can reinforce negative perceptions and compound the logistical challenges of distance. One respondent noted:

Respondent: Yes. Or even if they cleaned up the clinic itself and, you know, and didn’t have it looking so dumpy. And the fact that it’s right next door to a junkyard does not help at all, you know, so.

Interviewer: So the whole environment.

Respondent: Yes, it just looks bad and it just, yes.

Interviewer: Yes. Do you think that prevents some people from taking MAT?

Respondent: I would guarantee it.

Clinic Hours

In addition to clinic location and transportation, many patients also experienced challenges related to methadone clinic hours and timing. If a patient is unable to attend in-person dosing due to time constraints, then they are often unable to receive their methadone for the day. One 35-year-old male patient described their experience navigating the time-related challenges of mandated in-person dosing: “[O]ne time I missed because I was literally four minutes late and then the next day I couldn’t get there because of work, so then that was two days. And being on a low dose doesn’t carry you as long.”

Consequences of missed methadone doses include unpleasant withdrawal symptoms and urges to return to opioid use. Another patient, a 35-year-old male, discussed their attempt to continue methadone treatment under the time constraints of in-person dosing guidelines: “I did it for two days and then one morning, I didn’t wake up and I went and the place was closed so I couldn’t get it. So I ended up using. So I was like, ‘Yeah, this is not going to work for me.’”

Patients delineated the tension between maintaining stable employment with managing the time constraints of required in-person methadone dosing. One 28-year-old male patient outlines the difficulties of coordinating their workday start time with obtaining their methadone dose each morning:

“I’m going to have to make sure it [work] starts after – say they want me to come in for breakfast shift if I’m a cook; they want me to do breakfast at 6:00 in the morning. How in hell am I going to do that? I’m going to have to not do it [methadone] or I’ll be able to come in at 8:00, because I can’t come in at 6:00. Then what if it doesn’t fly with my bus schedule? If I can’t get there ‘til 9:00, after the time the bus connects to this, once it gets to that place – I don’t know.”

Of note, hours of methadone clinics are not dependent on federal policy though the time restrictions clearly become exacerbated given the daily dosing requirement. One 33-year-old female participant described their most recent experience taking methadone: “The last time I did it, and I actually just hopped off the program, and I got high again; because I was sick of going to [unintelligible] every day. That’s really, really aggravating. Then if you miss a day, or you don’t wake up early enough, or I can’t go anywhere, that’s just frustrating to me.”

Theme 2: Punitive Response to “Breaking the Rules”

Punitive responses to breaking clinic rules were frequently described as barriers to community treatment. Screening positive for other substances, failing to complete urine drug tests, missing supervised methadone doses, or appearing “high” were all specified as causes of dose reductions or clinic program termination among respondents. “Rules” regarding recent drug use and missing supervised doses are directly from the federal policy of the 8-point criteria, though the guidelines do not explicitly require dose reductions or program termination.

Urine drug screen testing

Patients identified concerns of how concurrent use of drugs hindered their ability for treatment. One 30-year-old female patient describes the regulations of clinics in her region: “The clinics are very strict and you have to, like you can’t be on benzos when you’re on methadone.” The same respondent recounted her past experiences being removed from methadone treatment due to concurrent cocaine use:

“And the methadone actually makes me crave cocaine actually and I kind of want to maybe get off of it…I think I want to do Suboxone because I don’t know. I’ve been having – like that’s kind of why I like when I was on methadone I keep having the urge for cocaine and I think that it might be triggering that…I’ve always had that problem and that’s why I keep getting kicked off.”

Patients who do not complete urine drug screens reported treatment termination at methadone clinics. After a 31-year-old female patient described an instance of return to use, she added “I did stop methadone before that a few times, because I got kicked out of a clinic for not [peeing]. I’d just use. So methadone is my only hope of staying clean.” This patient described a recurring trend of methadone treatment discontinuation – return to opioid use.

Appearing intoxicated

In addition to rules surrounding urine drug screens, patients reported being denied regular methadone dosing for appearing to be under the influence. A 30-year-old female patient recounts her experience going to receive a supervised dose of methadone and being denied treatment when she reportedly was tired because the provider thought she appeared high:

“I’ve been denied my Methadone for looking, for being tired and looking like [high], you know…And they did that to me twice…They didn’t even taper me. They went half. Like I think I missed two days and I went from 120 to 60. And then they were like when I went there they said well you look messed up…And they gave me – didn’t dose me that day. So then I missed another day.”

Theme 3: Temptation to return to use, related to clinic visits

Temptation to return to use following re-entry was a common concern among incarcerated individuals planning release from jail or prison. Oftentimes, this fear was exacerbated by the environment at methadone clinics, where patients can run into social groups from past periods of opioid use, individuals who are actively using drugs, and people who are attempting to sell drugs to patients waiting for methadone dosing. This setting can be triggering for patients looking to avoid returning to use and amplify the temptation to return to opioid use. Clinic and government policy mandates that require daily in-person dosing functionally prolong the amount of time that patients spend in this environment.

Some participants reported experiencing anxiety about returning to use following community reentry. One interviewee, a 33-year-old female described their concerns about the post-release period: “I’m worried about – because I’m starting the methadone tomorrow, I’m worried about getting to the clinic. I’m also worried about pressure. I’m worried about not being able to handle myself and wanting to use, especially if it’s in my face [at the clinic.]”

Other patients found spending time in methadone clinics for in-person dosing placed them in an environment less conducive to recovery. When asked about their plans to continue MOUD after re-entry, one 42-year-old male patient replied:

“I don’t like having to go to clinics every day, because it screws up your confidentiality, you run into people. When you’re an active addict, you know a lot of people that are active, and a lot of the people are still active, smoking crack. It’s harder on methadone clinics, to be around that many addicts, for me, to stay clean.”

Another patient echoed this sentiment, stating: “[A]t the clinic everybody’s like you know everybody and they’re all like gathering. I don’t know. You just meet a lot of wrong people that you shouldn’t be near… Like it’s just you meet a lot of connections that they all get high.”

Multiple incarcerated patients described methadone clinics as a place where the selling of drugs regularly occurred. One patient stated: “[Going to the methadone clinic everyday] does not work. That’s when I was not working, too. But even if I had to work, to go through that. And from what I hear from being in those lines in the mornings, you can find anything you want just standing in line. It’s kind of ridiculous.”

With the preexisting challenges of continuing methadone treatment following community re-entry, criminal legal system-involved individuals face the anxieties provoked by the methadone clinic environment. Mandating daily attendance in a setting where recently incarcerated patients are engaging with people and situations that present opportunities to return to use can make the reentry and recovery process significantly more challenging for individuals exposed to the criminal legal system, during an already high-risk period for overdose.

Theme 4: Benefits of structure and accountability

Of note, some incarcerated individuals stated that the structure and regularity of methadone dosing was helpful, specifically in reducing the urge to divert medication or return to use. Different from the other policy-relevant themes presented herein, this theme is a facilitator of retention and access rather than a barrier.

Multiple interviewees described their preference for methadone over buprenorphine due to the accountability required for in-person dosing. These individuals noticed that retaining a monthly supply of buprenorphine was challenging when presented with potential opportunities to sell their MOUD instead of taking it. One 31-year-old female patient compared their experiences of their temptation with buprenorphine compared to methadone:

“I’ve been on Suboxone [buprenorphine] too, but I can’t be on Suboxone, because I end up selling my pills. I’ll sell the pills and then go get dope. To me – I like methadone more, because I have to go every day, and it blocks me more from the urges. If I did use, it blocks me. I was on Suboxone – I’d be like, oh, I’m not taking it today.”

Both buprenorphine and methadone are recognized as effective evidence-based treatments for opioid use disorder, each with its unique advantages. Some patients express a preference for the structured regimen that methadone provides. A different interviewee, a 33-year-old male, described similar past experiences and appreciated the structure of methadone delivery:

“Because methadone you have to be at the place because they’ll close at a certain time. So if you don’t get it you just – you’re either that or you’re screwed. So I said, “All right, so if I start going maybe I’ll just go every day and start taking that.” And therefore I can stop doing this sort of stuff. For a while though I was going to the clinic, and then I was still getting high afterwards, but I stopped.”

The structure of the methadone dosing regime was helpful to this patient in maintaining adherence to their treatment plan.

Another incarcerated patient, a 28-year-old male, described similar challenges as other interviewees while attempting to stay on buprenorphine in the past. They had never pursued methadone in the community setting, but had decided to switch prior to community reentry to reduce the urge to sell:

“I have never been on methadone in the community. But now I’m going to try it. I’ve got to go every day to get it. I can’t take it home. I can’t do nothing with it. So therefore I have to take it every morning. I don’t have the opportunity to say, oh, well, I’m not going to take it today; take my suboxone, I’m going to go get high instead and just take a strip tomorrow. I have to take it every day, so it’s more – keeps me more grounded, I hope, this time, for me to be on methadone; because I’m not going to have that choice to either sell it and get high or not do it, you know? So hopefully it will keep me more grounded.”

Another individual stated, “now I’m definitely going to go with methadone; because I don’t trust myself with the suboxone at this point.”

Discussion

This study identified four main themes relevant to the optimization of methadone treatment continuation for individuals transitioning from incarceration to community settings. These themes—logistical limitations of getting to the clinic, punitive responses to breaking clinic rules, the temptation to return to use, and the benefits of structure and accountability—illuminate the complexities of methadone treatment in community settings and underscore the impacts of federal policy (namely, the SAMHSA 8-point criteria for unsupervised dosing) on treatment access.

While federal policies significantly influence treatment access, it is evident that other factors play a pivotal role. For example: logistical concerns of transportation, distance to a clinic, and even housing are common barriers to access across treatment types, highlighted in our study and in others (Kaplowitz et al., 2023). The direct a priori coding of the 8-point criteria, however, did demonstrate how federal restrictions (e.g., daily dosing requirements) exacerbated these access issues, particularly for individuals at time of community re-entry from jail or prison.

State and local clinic policies also shape the methadone treatment landscape. Although the stringent SAMHSA-dictated “rules” at clinics often originate from federal guidelines, it’s the clinics themselves that enact consequences like the dose reductions or termination of treatment mentioned in interviews.

Indeed, state governments, State Opioid Treatment Authorities (SOTAs), and clinic medical directors have the power to keep these restrictions and “rules” in place. Many have done so (Nesoff et al., 2022). Federal policy relaxation alone is necessary but insufficient to address all treatment barriers. The “liquid handcuffs” of methadone clinics (Frank et al., 2021) and the punitive aspects highlighted by participants can still be stringently maintained through state policy and clinic policies. This qualitative analysis demonstrates that many anticipated challenges to access and treatment retention map to federal and state policy restrictions, demonstrating structural barriers that cannot be addressed solely at the individual level.

Federal relaxation change, while critical, must be complemented by further actions on the policy level to ensure comprehensive and compassionate treatment approaches across all facilities. In Europe and Canada, pharmacy-dispensed methadone has provided one effective alternative to methadone access. In a single DEA-approved research study in the United States, this pathway was found to be acceptable and feasible (Wu et al., 2022). Pharmacy-dispensed methadone has potential mitigate the geographic methadone access disparity in the United States (Joudrey et al., 2020) and offers an innovative solution to overcome treatment barriers. Current federal legislation known as the Modernizing Opioid Treatment Access Act (MOTAA) seeks to enable addiction medicine physicians to offer office-based methadone prescribing to local pharmacies to reduce barriers of methadone access.

It is noteworthy that several of the 8-point criteria (e.g., absence of “behavioral problems,” acceptable length of time in comprehensive maintenance treatment, safe storage of medication) were not prominently mentioned by participants during qualitative interviews. This absence highlights that while these issues are relevant, they were not identified as the primary barriers by our study participants, which is a significant finding.

Other notable themes included concerns around temptations triggered by methadone clinics but also supports provided by clinic structure. These structural facilitators of treatment should remain in consideration and inform treatment policy. Some patients may benefit from structure. Stakeholders are charged with ways to support these individuals without harming others’ quest for recovery. They can ask, “how can we provide structure and accountability without exposure to triggers? How can care be provided to ensure medication safety without creating a punitive system, particularly one that disproportionately affects those with limited access to basic recovery capital including transportation?”

Several recommendations emerge. Given increased access to take-home methadone during the Covid-19 pandemic did not show increase in methadone-related overdose (Amram et al., 2021), further expansion of take-home methadone access can likely mitigate post-release addiction disparities among formerly incarcerated individuals. Similarly, clinics can reduce punitive policies for missed doses; decreasing or withholding doses can worsen a patient’s struggles rather than aid their recovery. Other structures can also provide supports for patients including regular check-ins with community health workers, frequent video tele-health visits, and improved Medicaid-covered transportation.

Importantly, the themes identified in this study mirror those reported in the broader community (Cernasev et al., 2021) and are particularly salient for individuals reentering communities following incarceration who face compounded needs such as securing housing, employment, and social support, all while managing their recovery under heightened stress. For example, the requirement for daily clinic visits can be especially burdensome when transportation is unavailable in this context. The shared barriers between CLS-impacted individuals and the broader community underline the necessity of comprehensive community-based reforms. The similarities in findings suggest that addressing community-wide barriers to methadone treatment could have substantial benefits for formerly incarcerated individuals by addressing systemic barriers that exacerbate health disparities.

The cumulative impact of these issues highlights the pressing need for a comprehensive reassessment of regulatory frameworks to better serve the unique needs of individuals exposed to the criminal legal system, relying on methadone as part of their recovery journey. Despite an unprecedented overdose crisis, between 75 – 90% of individuals with OUD do not receive pharmacological treatment (Jones et al., 2023; Krawczyk et al., 2022). Focused research is necessary to determine which level of policy – be it federal, state, or clinic – poses the most significant obstacles to accessing treatment and the gap in treatment calls for a critical rethinking of all MOUD delivery strategies. Moreover, there is a need to better understand treatment preferences of patients with OUD and to address stigma related to MOUD in many community treatment or community legal system contexts.

Our study has limitations, including its focus on a specific population and geographic location. Interviews were conducted before the SAMHSA increased flexibilities replaced the standard 8-point criteria. Future research can explore the long-term effects of recent policy changes and examine the experiences of different demographic groups within the criminal legal system.

Ultimately, to enhance methadone treatment access and continuity, policymakers should consider the implications of both federal and more local regulations on treatment accessibility. Clinics can adopt more flexible policies that help overcome the barriers identified in this research.

Highlights:

  • Barriers to methadone access upon prison release mirror those in the community.

  • Structured programs can facilitate treatment retention for some, though punitive measures and daily clinic visits hindered treatment access for others.

  • Policy at all levels can exacerbate barriers to treatment access, particularly among individuals impacted by the criminal legal system.

Footnotes

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