A large-scale study backed by the National Institutes of Health found that access to medication for opioid use disorder (MOUD) while in jail is strongly associated with better post-release outcomes across the board—not just lower risk of overdose, but lower risk of death from any cause, as well as lower risk of reincarceration.
Researchers analyzed data from seven county jails in Massachusetts, which under a state-mandated pilot program began providing all three Food and Drug Administration-approved MOUD—methadone, buprenorphine and naltrexone—in 2019. Outcomes for 2,711 people who received MOUD in jails in late 2019 were compared to 3,689 people who did not receive MOUD. The study was published September 10 in the New England Journal of Medicine and funded through the Justice Community Opioid Innovation Network, a National Institute on Drug Abuse initiative launched in 2019.
In the six-month period following release, receiving MOUD in jail was associated with a 52-percent reduction in fatal opioid overdose risk; a 24-percent reduction in nonfatal opioid overdose risk; a 56-percent reduction in risk of death from any cause; and a 12-percent reduction in risk of reincarceration.
Of the MOUD group, 82.7 percent accessed treatment upon release, compared to 52.1 percent of the non-MOUD group. And after six months, 57.5 of the MOUD group remained in treatment, compared to 22.8 of the non-MOUD group.
Notably, 67.9 percent of the MOUD group received buprenorphine while 25.7 percent received methadone. Only 6.5 percent received naltrexone, which of the three is has by far the most uptake among corrections departments.
Most of the jails had already been offering naltrexone.
Methadone and buprenorphine, which are full and partial opioid agonists, respectively, are both strongly associated with reductions in overdose risk. Naltrexone is an opioid antagonist—like naloxone, or the lesser-known nalmefene—and carries a warning about raising “risk of opioid overdose” as a side effect.
Better known by the brand name Vivitrol, naltrexone is formulated as a once-a-month injection. It blocks the effects of opioids like fentanyl or heroin, but it doesn’t ease cravings or treat withdrawal, and over the course of the month it wears off. As as a result, people end up using greater quantities of opioids than they would have otherwise.
The authors noted that while all seven jails offered all three MOUD as of the study start date, most of them had already been offering naltrexone.
“[I]nstitutional and other barriers slowed the uptake of the agonist medications, buprenorphine and methadone, which have stronger evidence for reducing mortality,” the authors wrote. “These findings provide the impetus for the majority of jails in the United States and internationally that do not provide agonist [MOUD] to implement these effective medications.”
County jails are uniquely positioned to exacerbate the racial inequities of MOUD access, but also to improve them.
Jails and prisons have made some limited concessions in providing buprenorphine, and to a lesser degree methadone, to people who were receiving them prior to arrest; mostly because they’re compelled to do so by law. This is why nearly three out of four people in the MOUD group had been receiving methadone or buprenorphine in the community prior to their incarceration—which, in turn, likely contributed to the high rate of continuity of care after release.
There’s significantly more resistance when it comes to initiating treatment for people who would be first-time patients, especially with methadone. This would be why the buprenorphine-heavy MOUD group was 75-percent white. But the data are also a stark illustration of how county jails are uniquely positioned not just to exacerbate the racial inequities of MOUD access, but also to improve them.
“Some jails did go beyond the [pilot program] mandate to offer MOUD induction to all persons with OUD soon after intake,” the authors wrote, “including those who were using street opioids and had short stays (e.g., nonsentenced, pretrial detention); jails with a greater Black non-Hispanic and Hispanic population might have been less proactive in offering early induction to persons who were not receiving MOUD at jail entry.”
Jails and prisons are the most obvious settings to effectively offer MOUD; previous research has suggested that almost half the community overdose deaths in the US represent people who were formerly incarcerated. But as the authors note, access to MOUD in correctional settings, “especially the agonist medications,” has progressed very slowly.
Corrections departments love naltrexone because it is a punitive, abstinence-rooted MOUD. They also love it because they’re understaffed.
As of 2023, less than half US county jails were estimated to offer some form of MOUD to some small subset of detainees, and less than 13 percent of jails were estimated to offer MOUD to anyone who requested it.
“[A]fter extended-release naltrexone (XR-NTX) received FDA approval for OUD, criminal justice officials have been more receptive to it than agonist treatments, in part, because XR-NTX has no abuse potential,” the authors wrote in the study supplementary materials. “Reluctance to deliver the agonist treatments in jails is understandable given concerns about misuse and diversion, the need for secure storage and dispensing, and the burden of daily dosing on clinical and correctional staff time.”
This accounts for a lot of what the authors describe as “continued skepticism in some quarters about the benefits of … the agonist MOUDS in particular” that prompted their research.
Corrections departments love naltrexone because it is a punitive, abstinence-rooted medication that essentially presents recovery as a matter of willpower. They also love it because they’re understaffed. A medication that only has to be dispensed once a month, and is of no interest in the contraband drug market, is a lot more appealing than ones that have to be dispensed every morning amid a ton of additional surveillance and security protocols. They offer it because it’s the easiest to offer. Not because it’s effective.
Photograph (cropped) via Stanislaus County Community Corrections Partnership