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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: J Subst Abuse Treat. 2021 Dec 13;137:108690. doi: 10.1016/j.jsat.2021.108690

Treatment Preference for Opioid Use Disorder Among People who are Incarcerated

Eliana Kaplowitz 1,2,3, Ashley Truong 4, Justin Berk 5,6, Rosemarie A Martin 3, Jennifer G Clarke 7, Morgan Wieck 7, Josiah Rich 1,2,3,6, Lauren Brinkley-Rubenstein 1,8
PMCID: PMC9686073  NIHMSID: NIHMS1765714  PMID: 34930575

Abstract

Introduction:

The devastating overdose crisis remains a leading cause of death in the United States, especially among individuals involved in the criminal legal system. Currently, three classes (opioid agonist, partial agonist-antagonist, and antagonist) of FDA-approved medications for opioid use disorder (MOUD) exist, yet few correctional settings offer any medication treatment for people who are incarcerated. Facilities that do often provide only one medication.

Methods:

We conducted 40 semi-structured qualitative interviews with individuals receiving MOUD incarcerated at the Rhode Island Department of Corrections.

Results:

Results from this study indicate that people who are incarcerated have preferences for certain types of MOUD. Individuals’ preferences were influenced by medication side effects, route of administration, delivery in the community, and stigma.

Conclusion:

MOUD programs in the community and in correctional settings should use a patient-centered approach that allows choice of medication by offering all FDA-approved MOUD treatment options.

Keywords: incarceration, opioid use disorder, medication for opioid use disorder, patient preference

1. Background

The devastating overdose crisis remains a leading cause of death in the United States (O’Donnelle et al., 2020). The burden of infectious and chronic diseases is disproportionately higher in incarcerated populations, and people who are incarcerated are less likely to have access to appropriate medical treatment (Nijhawan, 2016). This is true of the overdose epidemic, which has disproportionately affected individuals involved in the criminal legal system. This health inequity is especially relevant to medications for opioid use disorder (MOUD), the most effective, evidence-based treatment for opioid use disorder. Recent data show that roughly 60% of individuals incarcerated in local jails or state-run prisons have a substance use disorder, yet access to MOUD remains extremely limited (Jail and Prison Opioid Project [JPOP] 2020; National Institute on Drug Abuse [NIDA] 2020).

The Food and Drug Administration (FDA) has approved three classes of MOUD that are proven as effective treatments for OUD and dramatically reduce overdose risk (Huhn 2017; Jones et al., 2015). The FDA-approved medication classes include methadone, an opioid agonist; buprenorphine, a partial opioid agonist; and naltrexone, an opioid antagonist (Clarke et al., 2018; FDA Center for Drug Evaluation and Research, 2019). Despite the effectiveness of MOUD, few correctional settings offer any treatment for people who are incarcerated. Those facilities that do, often only provide one medication to an extremely limited portion of the incarcerated population (e.g., individuals who are pregnant). Individuals receiving treatment in the community, even those who get incarcerated in a facility that offers treatment, are often tapered off medication within the first few days to weeks of incarceration, a practice shown to decrease treatment retention on release and increase overdose death (Rich et al., 2015).

In 2016, Rhode Island was the first state to implement a comprehensive state-wide program that provides access to all three MOUD to individuals incarcerated at the Rhode Island Department of Corrections (RIDOC). The program allows individuals with OUD to continue or initiate treatment with all three available MOUD options. The RIDOC’s MOUD program was designed to optimize patient retention and adherence (Clarke et al., 2018). The patient and provider jointly make medication decisions, with the major factors being prior experiences with treatment and patient preferences. Patients and providers can adjust and change treatment plans as needed. Preliminary evaluations of this program, designed specifically to emphasize patient preference, have documented a significant decrease in overdose deaths among those who were treated during a recent incarceration (Green et al., 2018).

Extensive literature on patient participation in medication decision-making emphasizes that incorporating patient treatment preference leads to higher rates of retention and the desired outcomes (Joosten et al., 2009; Swift and Callahan, 2009). While a number of studies explore the role of patient participation and treatment preferences generally, a limited number of studies focus specifically on patient preferences and participation in medication decisions regarding OUD (Fredrichs et al., 2016; Gryczynski et al., 2013; Mooney et al., 2020; Puglisi et al., 2019). This paper explores the attitudes about and preferences for MOUD among individuals incarcerated in the RIDOC and enrolled in the comprehensive MOUD program.

2. Methods

We conducted semi-structured, qualitative interviews from July to August 2018 with participants in the RIDOC MOUD program. The study conducted the interviews via the Evaluating the Implementation and Impact of a Novel Medication Assisted Treatment Program in a Unified Jail and Prison System (E-MAT; R21DA044443) study, which is detailed in previously published papers (Brinkley-Rubinstein et al., 2019; Marin et al., 2019).

The RIDOC MOUD program comprises the following major components: 1) screening all incarcerated individuals for OUD upon intake; 2) initiating or continuing buprenorphine, methadone, or naltrexone as clinically appropriate; and 3) linking to community MOUD upon release (via a medical discharge planner). The research team recruited study participants at the RIDOC during program group sessions where the study was described, and participants confidentially signed up for the study and were later contacted for an hour-long interview. The team purposively stratified the sample to proportionally represent patients’ type of MOUD, time of MOUD initiation (i.e., prior to vs. during incarceration), and facility of residence at the RIDOC (e.g., intake, minimum, and medium security facilities).

The interviews covered a wide range of topics relating to individual experiences on MOUD before and during incarceration. Two researchers, trained in qualitative research interviewing and with experience conducting research in criminal justice settings, conducted the interviews. The interviews were digitally recorded and later transcribed. All participants received a $25 money order reimbursement for their time that the study deposited into their commissary account. The Miriam Hospital’s Institutional Review Board, The Office for Human Research Protection (OHRP), and the RIDOC Medical Research Advisory Group approved the study.

Qualitative data analysis employed a general inductive approach and thematic analysis to identify major themes from the raw data (Thomas, 2006). The coding team consisted of five individuals trained in qualitative research analysis who developed an initial codebook that mapped onto the study objectives. Four interviews were then cross-coded by all five team members to further refine and add to the codebook, and ensure coder agreement and uniform use of the codes. After this initial coding exercise, all codes were compiled into a final codebook, and three members of the coding team coded the remaining transcripts. The team performed the final analyses in NVivo 12. This paper specifically analyzed the results from the following codes: MOUD type preference, Community based MOUD experience, MOUD service preferences, MOUD provision preferences, Medication attitudes and MOUD stigma.

3. Results

3.1. Participants

We interviewed 40 participants who ranged from 22 to 66 years of age with a mean age of 37. Of those participants, 50% (n=20) were receiving methadone, 48% (n=19) were receiving sublingual buprenorphine, and one person (3%) was receiving depot naltrexone while incarcerated (this breakdown represents the proportion of patients at the RIDOC receiving each medication). In total, 50% of participants started their current MOUD prescription in the community prior to arrest and 50% initiated their current MOUD prescription while they were incarcerated at the RIDOC. Participants demographic makeup was also proportional to the incarcerated population in Rhode Island; most participants were male (70%; n=28) and white (83%; n=33). Refer to previously published articles for a more thorough breakdown of participant demographics (Brinkley-Rubinstein et al., 2018).

3.2. Participant medication preferences

3.2.1. Acknowledgment of preference

All participants were prescribed and taking methadone, buprenorphine, or depot naltrexone. Participants shared their knowledge and beliefs about the various MOUD, particularly what did and did not work for them. Many participants had previous experiences with MOUD (both illicit and prescribed) in the community. When asked to describe their knowledge of MOUD, most participants stated that they preferred one MOUD option over others, underscoring the importance of having access to the MOUD option that works best for them.

For instance, a 52-year-old female was one of many participants who acknowledged that patient preferences for medications was unique and personal to the individual:

I think it depends on what you – it depends on the person you are, which way it will go. It helps them both ways, but you have to have the right mindset and it has to be the right substance replacement for you.

3.2.2. Medication delivery in the community

The structure of MOUD programs in the community emerged as one of the most predominant factors participants named when justifying their MOUD preference. Due to regulations surrounding certain MOUD in the United States, each medication has a unique program and method of administration in the community.

For some participants, methadone’s daily clinical visits resulted in a disinclination toward methadone. A 42-year-old male participant shared:

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 [burden].

While some people’s recovery relied on structure, as described by the participant above, others often used “liquid handcuffs” to describe the limitations of being required to go to a clinic daily. Many others, including a 37-year-old male, preferred buprenorphine because it required fewer clinical visits:

At least with Suboxone [buprenorphine] I am able to have a little more freedom with it. I can take it, I have a script. You know, you take it in, it doesn’t, you know, I don’t got to wake up early in the morning and go to the clinic. I can have it, I can take it and it’s a little more responsibility as opposed to just having to go to the methadone clinic every morning, which can be a hassle.

While these participants disliked going to the clinic daily, others found methadone’s more structured program dosing structure a helpful aspect of their treatment. A 38-year-old male participant expressed excitement around the structure offered by methadone; noting that their previous experience with the more flexible medication structure of buprenorphine had allowed them to previously divert it:

I was on Suboxone [buprenorphine], like I told you before. But the suboxone for me – my mind frame wasn’t strong enough to just take the one every day like I needed. My foundation, my tools, wasn’t all there to stay clean. My mind – it wasn’t all set up. So, I was getting the suboxone, and I was selling it to get fentanyl to get high. Now I’m going to do methadone, when I leave 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.

As detailed in the above quote, he had previously struggled to use buprenorphine as prescribed due to the lack of perceived accountability associated it. However, while incarcerated at RIDOC, they switched medications and began methadone. The participant expressed excitement about the rigidity of methadone’s daily dosing structure, emphasizing how it would prevent them from misusing the MOUD. Few participants in our study were on naltrexone; however, many were particularly interested in naltrexone’s monthly treatment requirement over more frequent clinic trips for methadone or buprenorphine:

I’ve heard it lasts a month or something like that. I’ll be honest, the methadone has zero to me. I’ve lost great jobs because of it. You can’t leave the state. You can’t just go do these things (42-year-old male participant).

3.2.3. Route of administration

In addition to the program structure, the actual of route of medication administration emerged as an important factor in participants’ medication preference. A number of participants disliked the taste of sublingual buprenorphine and had an aversion to medications administered via injection due to their history of intravenous drug use, thus they expressed a preference for methadone:

I don’t like the taste, and I was done with needles, so unfortunately, I got stuck with methadone (33-year-old female).

Similarly, a 33-year-old male disliked the taste of buprenorphine and found the dosing of sublingual buprenorphine imprecise. He, therefore, tried, and preferred, methadone:

I never really liked the Suboxone [buprenorphine], to be honest with you. Just the simple fact that I’ve got to sit it under my tongue, and then at certain times – like if I swallow – I might not get my meds. I might swallow a piece, and then one day I don’t feel as – one day I might feel fine. The next day I might not feel as – you know not as good or something. I might feel like crap. So, with this stuff you just drink it, and it’s done. It’s easy. You can’t mess that up.

In this quote, the participant describes their experience taking buprenorphine in the form of a crushed sublingual tablet (Subutex), a non-traditional method of administration that is used in some correctional settings to avoid diversion. In the quote, the participant describes swallowing a piece of the tablet and then consequently not feeling the effects of the medication. The lack of the drugs effect is because swallowed buprenorphine is not absorbed into the blood stream.

3.2.4. Feeling and symptoms of medications

When explaining medication preferences, participants often emphasized how they felt on the medications. Certain medications occasionally made participants sick, particularly nauseous. For example:

This is how I know I don’t like suboxone [buprenorphine]. I like methadone better because suboxone makes me nauseous. Methadone don’t (35-year-old male).

Some participants describe feeling incredibly tired and “off” while on certain MOUD. For example, one participant tried methadone for the first time while incarcerated and felt “down” and sick while on it:

It had me down, sleepy. For two days I was really down. I got there on a Friday, and on Monday I got out of jail, and I was still feeling it (55-year-old male).

A handful of participants shared that certain medications were more effective than others in preventing them from craving certain illicit substances. For example, one 26-year-old male craved heroin less when taking methadone than when they were on buprenorphine:

I tried Suboxone [buprenorphine] like multiple times throughout my addiction, but it was really just – it didn’t seem to work with the cravings as well as methadone.

A 55-year-old male, however, had the opposite experience and felt that buprenorphine helped to reduce cravings

Suboxone [buprenorphine]... I have taken it. I like it. It doesn’t make me crave. My girl doesn’t like it because she says I fall asleep and stuff like that.

A 22-year-old male experienced intense cravings while on both methadone and buprenorphine; however, depot naltrexone was the first drug to alleviate his cravings:

I’ve been taking the pill [naltrexone] for a month that when I start to like get a craving in my mind, like even when I’m in my cell, and I think about using, I can kind of like just put it out of my head easier than if I was like actually able because before I started taking vivitrol [naltrexone], I would get a craving; and it would like eat away at me, like, all day long, and I would just keep thinking about using. So, I was like losing sleep at night. I was always like really anxious and stressed out [before taking naltrexone] – [the doctor] said that it helped the cravings, and it did help with cravings.

Some participants also expressed that certain medications, especially at the beginning of their treatment, led to a slight high, euphoric, and disorienting feeling. Some participants expressed desire to experience this feeling, while others preferred buprenorphine because once stabilized on treatment the intoxicated feeling subsides:

Of the two, I prefer that. Suboxone [buprenorphine]. It doesn’t get you high after you get used to it. I just think it’s all in all better (41-year-old male).

Similarly, the 22-year-old male participant explained that he did not want to feel any medication side effect that resembled that of his illicit heroin use, thus when he was informed that depot naltrexone would not “make him feel high,” he opted to try it:

Well, I mean the whole issue with me was when I first got involved in the [MOUD] program, I actually was told– they initially wanted to give me straight-up methadone or suboxone, and I was kind of like, well, the way I look at my addiction I’m not trying to get high, I don’t want to take something that’s going to make me high because then I’m going to remember what it’s like to be high, and I don’t like that feeling. I feel really guilty now inside when I feel like any type of like chemical high in my body. So, it’s like I feel really guilty about it, and I don’t want to do it anymore; and when I told the doctor that, he said, well, I mean there is vivitrol [naltrexone], and I was like, what’s vivitrol [naltrexone]? I’ve never heard of that.

A 55-year-old female shared how methadone affected both her cravings for polysubstance use and led her to feel intoxicated:

Well, I’ve been on methadone, too, but see for me, methadone just kept me high. Like when the dose was – like when I would get leveled off, I would just raise it. And for me, it made me crave other drugs. I did a lot, like when I was on methadone, I found myself doing a lot of cocaine. I don’t know why, but it just seemed to me like it made me crave a different high. So I don’t know, it just wasn’t something that worked for me.

Because of buprenorphine’s composition as a partial agonist, withdrawal can be induced when individuals are taking full agonist opioids:

The only problem with the suboxone [buprenorphine] was, you know, it works great to keep you from using. But if you are going to slip up and like I did for I think it was five days in a row I used. I couldn’t get back taking the medication because it would just make me sick because of the opiate property. It would just make me like extremely sick. So that’s the only bad thing is if you do slip up, you might have trouble getting back on your program whereas Methadone you can just, you know, go the next day and be fine (36-year-old male)

3.2.5. Medication stigma

For some participants, stigma, both held by others and self, affected their medication choice. One participant shared how MOUD influenced their status in 12-step programs such as NA:

I never wanted to be on methadone. I don’t really like the way it makes you look, I don’t like the stigma of it, people that – you know backgrounds that are [set in stone]. At the NA meetings you weren’t considered clean if you were on suboxone [buprenorphine] or methadone in Fall River, like they don’t recognize your clean time. They gave more of a hard time to people on methadone than they did with suboxone [buprenorphine] (41-year-old female).

In another interview, a participant addressed the stigma surrounding particular medications. She emphasized how they believed that peoples medication preferences do not actually suggest any differences:

[Users of different MOUDs are] no different from me, you know what I’m saying, so I don’t think any differently of them. I mean we all have a problem; just you choose to do methadone and I choose to do suboxone [buprenorphine],” (47-year-old female).

4. Discussion

This study demonstrates that many people who are incarcerated have a preference for MOUD options. This preference is critically important because these medications only work if people take them, and thus individual’s preference may influence whether they will continue taking the medication after release. Participants held these preferences based on which medication “worked” best for each individual, as well as individual side effects. For some, cravings were unbearable on buprenorphine and nonexistent while on methadone. For others, the opposite was true. Participants were also significantly influenced by what medication met their needs in the community, anticipating treatment postrelease. While some participants found community methadone programs to be unnecessarily burdensome, others appreciated the regimented structure that held them accountable. A number of participants acknowledged in their interviews that while a particular medication worked well for them no singular treatment met everyone’s needs, emphasizing the importance of providing access to all FDA approved MOUD options. The most appropriate medication differs depending on the individual and may even change over time. Therefore, all FDA-approved options should be available (National Academies of Sciences, Engineering, and Medicine, 2019).

Because of the high rates of overdose deaths among individuals who are recently released from incarceration, access to MOUD treatment that are in alignment with their desired outcomes and community needs is imperative.

This study builds on existing literature on patient preferences surrounding MOUD (Friedrich et al., 2016; Luty 2004; Randall-Kosich et al., 2020; Uebelacker et al., 2016). In early 2020, Cioe et al. conducted a systematic review of literature on patient preferences for MOUD. Our results complement Cioe et al.’s findings that demonstrated how each MOUD had various stigmas and beliefs associated with it, which influence patients’ and providers’ MOUD decisions. Of the articles reviewed, the majority focused on methadone. Some of the most widely held beliefs about methadone among patients were that it is bad for their health and that methadone maintenance was inconvenient (Cioe et al. 2020). Additional studies found that patient preference for MOUD is influenced by factors that include perceived medication benefits, medication delivery strategy, a desire to “remain drug free,” social stigma, fear of withdrawal or dependence from the medication, side effects, and convenience (Cioe et al., 2020; Mooney et al, 2020; Muthulingam et al. 2019; Teruya et al., 2014). Despite our cohort’s unique position of receiving medication while incarcerated, these same beliefs also emerged in our study results. For example, while many participants viewed methadone maintenance in the community as inconvenient, others found the strict structure essential to their recovery.

Prior research shows that incorporating patient preferences into decisions about MOUD is linked to beneficial outcomes, including lower rates of overdose and increased patient adherence and retention (Fellin et al., 2018; Fredrichs et al., 2016; Larochelle et al., 2018,). Additionally, individuals with substance use disorder who are involved in their medical treatment decisions have increased motivation and decreased psychiatric symptoms (Friedmann et al. 2004; Friedrichs et al., 2016; Joosten et al., 2009; Sobel 1992). In fact, in a study that presented people who used opioids the option of methadone or buprenorphine, many participants shared that they would not pursue treatment if methadone was the only available option (Pinto et al., 2010).

Joosten et al.’s study explored the effects of implementing a shared-decision model (SDM) framework, a process where patients share treatment preferences and work together to reach a treatment plan, on treatment retention and engagement. They found a small, but significant, positive effect on the severity of problem areas related to addiction among the patients who engage in SMD (2009). This finding emphasizes how important choice and options are when offering MOUD (Pinto et al., 2010). To maximize patient retention and allow patients to engage in their medication decision process, experts argue that facilities should offer all three forms of MOUD (Comer et al., 2015; Medications for Opioid Use Disorder Save Lives, 2019). Program retention is especially important among individuals leaving an incarcerated setting and reentering the community due to the heightened overdose risk (Binswinger et al., 2013; Green 2018; Merrall et al., 2010).

While significant work is needed to thoroughly understand why people respond differently to different medications, pharmacogenomics has clearly established that medication effects are impacted by genetics, which cause variations in drug receptors, drug uptake, and drug breakdown (CDC, 2021). Hence, some individual variations might make some feel better on methadone and others feel better on buprenorphine. Thus, we hypothesize that at least some of the preference for different treatments may be biological. Additionally, we found it notable that study participants did not explicitly refer to their incarceration status, previous forced-withdrawal experiences, or anticipated probation or parole post–release requirements when explaining their medication preferences. This may indicate that individuals’ medication preferences are more heavily influenced by biological factors, and the other factors previously identified, such as side effects and treatment protocol specific to each medication type. Participants may not have referred to previous experiences of forced withdrawal as they knew that the established MOUD program would not allow for forced-withdrawal if they were to be reincarcerated. Given that the correctional setting is not an explicit factor in medication preferences, incarceration may presents an adequate environment for individuals to connect to their preferred and most-effective medication.

Our study’s findings should be interpreted in light of several limitations. Our sample was mostly white, and while it represents the demographic make-up of Rhode Island, it was not representative of the national incarcerated population. This is especially important to note given the racialized dissemination of MOUD treatment clinics in the community (Goedel et. al., 2020). Specifically given that methadone clinics in the community are disproportionally located in Black and low-income communities, whereas rates of buprenorphine providers are more prevalent in white, higher income communities ((Nguemeni Tiako, 2021). Therefore, given the demographic make-up the current study, it is not within our scope to analyze how the impact of MOUD availability in the community influences preferences. Our sample only included participants with OUD who, at the time of the interview, were enrolled in the MOUD program. It did not include individuals who were not eligible, refused, or were uninterested in MOUD during incarceration. Thus, answers and preferences may have differed from those who were not enrolled based on their willingness to take MOUD. An additional limitation of this evaluation is that the study participants were predominantly enrolled on either methadone or sublingual suboxone. Only one person reported current enrollment on naltrexone. Additionally, it is important to note that while the study team employed an iterative, community-informed approach in the design of the interview, we do not know if study’s core team members had lived-experience of incarceration or OUD, which may have inadvertently resulted in biased questions. With these limitations present, the study intended to provide a snapshot of those incarcerated and enrolled in a correctional MOUD program in Rhode Island.

5. Conclusion

Results from this study indicate that people who are incarcerated have preferences for certain types of MOUD. These preferences are informed by their experiences with the medications and the structure of receiving medications in the community upon release. MOUD programs in the community and in correctional settings should work to honor individuals’ ability to choose which medication will work best for them by offering all three classes of currently FDA-approved MOUD options. Given the preferences for different medications among different patients, patient preference should be included in future clinical trials and researchers should undertake efforts to find a biological explanation for this difference.

Table 1.

Result by codes and number of respondence based on medication type.

Result Theme Code Definition of Code Total XR-NTR BUP MMT
Study participants 40 1 19 20
3.2.1. Acknowledgment of Preference MOUD Type Preference Use this code to capture any descriptions on a participant’s preferred type of MOUD. 40 1 19 20
3.2.2. Medication Delivery in the Community Community Based MOUD experience Use this code to capture a participant’s experience accessing MOUD in the community. 39 1 18 20
MOUD Service Preferences Use this code to capture a participant’s preferences or other preferences of an MOUD program. 39 1 19 19
MOUD Provision Preferences Use this code to capture any other preferences on MOUD service provision. 26 1 10 15
3.2.3. Route of Administration

AND

3.2.4 Feelings and Symptoms on Medication 		Methadone Attitude Use this code to capture any information relevant to a participant’s attitudes on methadone. 36 1 18 17
Suboxone Attitudes Use this code to capture any information relevant to a participant’s attitudes on suboxone. 31 1 15 15
Naltrexone Attitudes Use this code to capture any information relevant to a participant’s attitudes on naltrexone. 18 1 6 11
3.2.5 MOUD Stigma MOUD Stigma Use this code to capture if a participant discusses stigma toward taking MOUD. 40 1 19 20
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Highlights.

  • Individuals who are incarcerated have strong preferences for certain types of MOUD

  • Side effects effected individuals’ preferences

  • MOUD programs should offer all three classes of currently FDA-approved MOUD options

  • Patient preference should be included in future clinical trials

Funding Source

Funding for this project includes the National Institute of Drug Abuse (R21DA043487; 1U01DA050442), The National Institute of General Medical Research (P20GM125507), and the John and Laura Arnold Foundation. The funders had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Declarations of interest: none

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