Opioid Use Disorder Screening Practices in US Jails

Abstract

Objectives:

To describe the screening processes for opioid use disorder by jails in localities with high concentrations of opioid involved overdose deaths.

Methods:

A secondary data analysis of structured interviews on opioid use disorder practices from 185 jails in the United States was conducted. Descriptive statistics detailed jail screening characteristics, and bivariate statistics examined the association between screening characteristics and annual jail population.

Results:

The majority of jails in high-overdose-burden localities had screening protocols in place for opioid use disorder (95.1%). The protocols varied, with most jails reporting the use of substance use (85.4%) or opioid use (77.0%) specific screeners. Yet few jails used validated screening tools (23.3%) and instead relied on agency or state-specific tools (89.0%). Significant differences by annual jail population were found related to who conducted screenings, such that the use of medical staff for screening (P < 0.01) and clinical assessments (P < 0.05) was more likely among larger jails.

Conclusions:

Screening and assessment of opioid use disorder is essential for individuals in jails, given the disproportionate burden of the disorder. Jails tended to rely on agency-created tools over the use of validated screeners, and more efforts may be needed to close the research-practice divide.

Opioid use disorder (OUD) is a significant public health concern for individuals within the criminal legal system (CLS). Individuals incarcerated in jails are among the most vulnerable populations, owing to jails holding individuals with diverse relationships to the CLS, such as those awaiting trial or serving short sentences. This population is at an elevated risk of adverse health outcomes, including overdose and death, both during and after incarceration.^1-3 A first step in mitigating risk is the identification of vulnerable individuals. Effective screening and assessment of OUD are needed within jail settings to inform intervention strategies and address the significant health risks faced by this population.

Despite the critical importance of addressing substance use disorders (SUD) in jails, screening practices often fail to adhere to established best practices. The Substance Abuse and Mental Health Services Administration (SAMHSA), the National Commission on Correctional Health Care (NCCHC), and the American Society of Addiction Medicine (ASAM) recommend evidence-based protocols,^4-6 including standardized screening tools, to ensure consistency in identifying SUD. However, prior qualitative work by our study team found that 27% of jails in a national survey did not include any substance use screening questions in their intake forms, and those that did screen relied on nonstandardized tools.⁷ This inconsistency weakens the ability to identify individuals with SUD and undermines appropriate care, such as withdrawal management and linkage to treatment services. Smaller jails, in particular, face additional barriers, including limited resources, staffing shortages, and inadequate training, which exacerbate these challenges.⁸ To assess current practices, the current study assessed the most recent data on screening and treatment practices for OUD in jails.

METHODS

This current study is a secondary data analysis of a larger protocol that assessed the availability of each part of the OUD service cascade^9,10 in jails and prisons in localities with high concentrations of opioid involved overdose deaths.⁸ Details of the sampling methods are published elsewhere.⁸ Jail representatives completed the structured assessment on their own or by phone with trained research staff in 2019. The current study reports data for jails only. The New York University Grossman School of Medicine Institutional Review Board deemed this secondary data analysis exempt from oversight.

A total of 185 jails were examined. Bivariate statistics examined the association between opioid use screening characteristics and annual jail population. The Kruskal-Wallis (categorical variables) and Mann-Whitney U test (dichotomous variables) assessed the association between variables and annual jail population. Missing data were minimal, with 0 to 5 cases missing per variable. All statistical analyses were performed using R software.

RESULTS

Descriptions of the jails and screening characteristics are provided in Table 1. The median annual population was 6529, but there was substantial variability (IQR: 8,923.5; range: 545–636,883). Jails primarily provided health care delivery via contracted care (72.4%), and the delivery method was significantly associated with annual jail population (P < 0.05). The majority of jails (95.1%) reported they had a screening protocol for OUD.

TABLE 1.

Opioid Use Disorder Screening Characteristics of Jails (n = 185)

	N (%)	Annual Jail Population Median [IQR]	P
Annual jail population	—	6529 [8923.5]	—
Health care delivery system
Contracted care	134 (72.43)	6000 [6613]	0.0179
Services provided by the county/jail	21 (11.35)	20,088 [29606.75]
Hybrid/other	30 (16.22)	7687 [11108.5]
Has an opioid screening protocol	176 (95.14)	6625 [9852]	0.3395
Opioid use disorder (OUD) screening methods
Urinalysis to detect opioids	89 (51.45)	6634 [7098.5]	0.9961
Self-report of days of opioid use	171 (97.71)	6765 [10199]	0.0684
Instrument or tool specific to screen OUD	134 (77.01)	6705.5 [10455.5]	0.4438
Instrument or tool specific to screen substance use disorder (SUD)	146 (85.38)	6451 [9221.25]	0.3101
Clinical assessment to determine OUD	125 (72.67)	6451 [8798]	0.3231
Other	13 (7.51)	8731.5 [8678.75]	0.3721
Screening tool(s)
Agency or state-created tool	153 (88.95)	6602 [8817]	0.1011
Validated tool*	40 (23.26)	6647 [7552.75]	0.6888
Other instrument	19 (11.05)	6052.5 [7603.5]	0.9080
Staff who conducted the screening
Use of more than 1 staff role to conduct screening	104 (59.09)	6529 [10,897]	0.9533
Physician	52 (30.06)	6346.5 [11607.75]	1.0000
Nurse, physician assistant, or medical assistant	157 (90.23)	7113 [11444]	0.0082
Social worker or counselor	62 (35.84)	6000 [8497]	0.4650
Correctional staff	54 (31.03)	4178 [5669]	0.0008
Other staff	10 (5.85)	21263 [15293.75]	0.0027
Clinical assessment to determine OUD diagnosis	134 (73.63)	6500 [10132.25]	0.7533
Staff who conduct the clinical assessment
Use of more than 1 staff role to conduct a clinical assessment	87 (63.50)	6768 [11793]	0.2605
Physician	77 (57.46)	7470 [12108.75]	0.0434
Nurse practitioner, advanced practice registered nurse, or physician assistant	102 (76.69)	7113 [11793]	0.1939
Social worker or counselor	64 (48.12)	6352 [8639.25]	0.6849
Correctional staff	0 (0)	—	—
Mental health professional	8 (5.84)	6768 [19056.5]	0.1833
Other	3 (2.26)	6491 [4500]	0.6725

^*Addiction Severity Index (ASI), CAGE (Cut-down, Annoyed, Guilty, Eye-opener), DAST (Drug Abuse Screening Test), Drug Use Screening Inventory (DUSI), Global Appraisal of Individual Needs (GAIN), TCUDS (Texas Christian University Drug Screen), Rapid Opioid Dependence Screen (RODS), NIDA ASSIST, Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool, AC-OK Screener; P values of < 0.05 bolded.

The screening protocols varied and 94.3% of jails reported use of more than 1 method; 51.5% using urine analysis, 97.7% used self-report, 77.0% used a tool/instrument to assess OUD, 85.4% used a tool/instrument for SUD, 72.7% used a clinical assessment, and 7.5% used “other” unspecified screening or assessment tool. Some jails used more than 1 tool (23.3%), with the majority of tools reported to be created by the state or agency (89.0%). About 1 in 5 jails (23.3%) reported the use of validated tools. Fifty-nine percent of jails used more than 1 staff member for OUD screening. Specific roles utilized to conduct screening included nurses, physician assistants, or medical assistants (90.2%), social workers or counselors (35.8%), physicians (30.1%), and correctional staff (31.0%). Least likely to conduct screenings, 5.9% of jails reported use of “other staff.” Screening by medical staff (P < 0.01), correctional staff (P < 0.001), and other staff (P < 0.01) was associated with the annual jail population. Jails in which new admissions were screened by medical staff had a higher median annual jail population (7113 vs. 3410), as did those screened by other staff (21,263 vs. 6500). In contrast, jails relying on correctional staff for screening protocol had a lower median annual jail population (4178 vs. 7894). Best practice indicates individuals who screen positive should be further assessed,⁴ and 73.6% of jails reported conducting clinical assessments. Clinical assessments were likely to be conducted by more than one staff role (63.5%), including the use of nurses (76.7%), physicians (57.5%), and/or social workers/counselors (48.1%). Only clinical assessment by a physician was significantly associated with annual jail population (P < 0.05), with the use of physicians associated with a higher median annual jail population (7470 vs. 5817.5).

DISCUSSION

The current study indicated that the majority of jails in high-overdose-burden localities are screening their populations for SUD and OUD. However, in line with our previous research, jails tend to rely on agency-created tools, and only 1 in 5 jails used validated screeners for OUD. In addition, the role of the person conducting screening and assessments was significantly related to the annual jail population. Smaller jails were more likely to use correctional staff for screenings and also more likely to use contracted care to provide health services. These jails may be located in more rural locations and are less likely to have physicians, nurses, or medical assistants as part of their regular on-site staff and thus more likely to use correctional staff to conduct screenings. The use of correctional staff may impact the validity of self-reported screening data due to fear of confidentiality and concerns regarding how the data could be used in pending criminal charges. Screenings by medical staff and clarity on the intended use of screeners could assist in lessening these concerns. These challenges to screening further amplify the need for the use of validated screeners to provide unbiased results to indicate possible OUD.

The consequences of inadequate screening and assessment for SUD in jails are significant. Individuals who are not properly screened may miss critical opportunities for treatment, including being prescribed and receiving medications for OUD.¹¹ Jails also tend to use screening to determine who receives naloxone at release,¹² which indicates that inappropriate screening for OUD could have critical postrelease implications. Nearly 1 in 5 jails reported using more than 1 tool for screening, which may be duplicative or unnecessary, particularly in the context of restrained resources. Previous research indicates that screening does not need to be lengthy to be valid and reliable for assessing treatment needs.¹³ While the current study is limited by reliance on self-report and a focus on jails in high-overdose counties, findings indicate a need to better understand the implementation barriers that jails face in using validated screeners for assessment of OUD, which may include barriers related to staffing, resources, and knowledge/training. In addition, given the high rates of use of agency-created tools for screening, research that examines these tools and the screening procedures of jails more in-depth is warranted. Effective screening could improve postrelease care by appropriately identifying individuals in need of treatment and support services.