Jails and prisons were never meant to be treatment centers for people with substance use disorders. But because more than half of individuals in prisons or jails meet the criteria for the disorder, correctional settings have become an important treatment location.
While many jails and prisons lack the resources and capacity to provide life-saving treatment, policymakers are uniquely positioned to help align systems and facilitate collaboration and innovation to reduce some of these barriers.
Death due to drug overdose is a challenge communities have faced for years, but as recent data has shown, COVID-19 has exacerbated the problem. Between April 2020 and April 2021, about 100,000 people died by overdose, a nearly 29% increase from the previous year and the nation’s highest-ever rate of death due to overdose.
Opioids Driving Overdoes Deaths
Opioids, especially synthetic opioids such as fentanyl, have been the main driver of drug overdose deaths. Synthetic opioid deaths increased by 38.4% in 2020, accounting for nearly 70% of all overdose deaths.
People involved with the criminal justice system are at especially high risk for overdose because they have disproportionately higher rates of opioid use disorder.
A 2018 study found the majority of people with an opioid use disorder will be incarcerated at least once in their lifetime, often in a county jail. Within three months of release from custody, 77% of people with the disorder will use opioids again. People released from incarceration are between 10 and 40 times more likely to die of an opioid overdose than the general population, especially within a few weeks after reentry, due to lowered tolerance and challenges related to treatment access.
Synthetic opioids accounted for nearly 70% of all overdose deaths in 2020.
Treatment providers consider counseling and therapy along with medication assisted treatment, also referred to as medications for opioid use disorder, to be the gold standard in opioid use disorder treatment.
Medications for opioid use disorder is a particularly effective treatment during incarceration and has been associated with substantial reductions in overdose deaths after release. But due to tight budgets, lack of infrastructure and fear of theft or reselling of methadone or buprenorphine, most jails and prisons do not provide the medications and lack staff to offer counseling.
Disruption to continuity of care during incarceration can also create treatment challenges. With more than 8.7 million admissions to jails annually and high levels of need, the constant churning of jail populations can make it difficult to initiate medication in these settings or meet minimally accepted standards of care.
Continuing Treatment After Release
Connecting individuals to treatment and retaining them in programs upon release can be affected by a lack of supportive housing, employment and health insurance. For example, the inmate exclusion policy historically limits the role Medicaid can play in covering services for people who are incarcerated. This policy can create challenges related to long-term recovery, as application to and enrollment in Medicaid could be delayed until release, ultimately hindering a person’s access to services and increasing the risk of overdose.
States have tried to mitigate these disruptions through prerelease enrollment programs and leveraging different data systems to suspend Medicaid benefits rather than terminate them, making them available immediately upon release.
In recent years, states have also mitigated some of these challenges through legislation to improve treatment in or following incarceration.
- Colorado required county jails that receive Jail Based Behavioral Health Services funding to have a medication-assisted treatment policy in place on or before Jan. 1, 2020. The bill required the Department of Corrections to allow medication assisted treatment or medications for opioid use disorder maintenance for individuals moving from a local jail to their facility.
- Massachusetts enacted legislation establishing a treatment pilot program in partnership with seven sheriffs’ offices and the state Department of Correction. Participants are assigned a recovery coach or navigator and enrolled in Medicaid with suspended access while incarcerated to ensure continued treatment coverage for reentry. A legislatively required evaluation showed participants who completed the program had a one-year post release recidivism rate of 10.87% versus the comparison group (24.75%). As of April 2018, fewer than 2% of participants had succumbed to a fatal overdose after release.
- Oklahoma appropriated $500,000 in 2019 for a pilot program using medications to treat substance use disorder. The program allows individuals in jail to access federally approved, evidence-based medication assisted treatment for opioid and alcohol dependence. Funding can also be used for individual and group counseling services, cognitive behavioral therapies, and necessary medical and behavioral health staff needed to run the program.
- Utah enacted legislation requiring the Department of Corrections and county jails to report treatment policies for incarcerated people with substance or alcohol use disorder. The law requires medications to be dispensed during incarceration and the Utah Substance Use and Mental Health Advisory Council to convene a work group to study alcohol and substance use withdrawal in county jails.
When enacting these policies, data is an essential tool for policymakers, corrections officials and public health officials to evaluate which programs and policies are effective in improving health outcomes and reducing recidivism.
Outside of state legislative action, many counties, including some in Florida, Kentucky, New Mexico, Texas and Virginia, improved access to medication assisted treatment or medications for opioid use disorder and subsequently reduced recidivism rates through local correctional initiatives and partnerships with health departments.
Tammy Jo Hill is a policy specialist and Charlie Severance-Medaris is a senior policy specialist in NCSL’s Health Program.
NCSL gratefully acknowledges The Pew Charitable Trusts for its support in producing this article.