CATR: Why is it important for clinicians to understand how addiction is treated in the correctional system? 

Dr. Waddell: Clinicians who treat patients with active substance use or mental health disorders should understand these patients’ elevated risk of incarceration and associated disruptions in treatment. For example, up to a third of persons who use heroin cycle through prisons and jails every year (Rich JD et al, N Engl J Med 2011;364(22):2081–2083). A recent Pew study found that nearly 10% of adults with co-occurring substance use and mental health disorders are arrested annually, which is 12 times more than adults without these challenges and six times more than those with a mental illness alone (www.tinyurl.com/yu9yem26)[PDF]. Providers who treat substance use disorders (SUDs) are likely to have patients heading into or out of jails and prisons. Supporting patients during periods of transition is crucial. When possible, patients should be able to enter jail or prison with their prescriptions. Adequate release planning to connect patients to treatment after release is an important piece of helping them reintegrate into the community.

CATR: How big of a problem is addiction in correctional facilities?

Dr. Waddell: It’s a massive problem, and opioid overdoses are a leading cause of mortality after release. In mid-2022, there were more than 630,000 people held in jails and over 1.2 million people incarcerated in US prisons, and additional research suggests that more than half of people in prison have an SUD (www.tinyurl.com/ncf2ad8h; www.tinyurl.com/5dr2ptvz). How many have an opioid use disorder (OUD) specifically? That’s difficult to answer because we don’t have great data. Based on findings from the Bureau of Justice Assistance’s National Inmate Survey (2007, 2008–2009), 15% of males and 22% of females in state prisons regularly used “heroin/opiates” prior to incarceration. Among sentenced jail inmates, 17% of males and 25% of females used heroin or opiates (Bronson J et al. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007–2009. Bureau of Justice Statistics Special Report. NCJ 250546; 2017). Other research suggests that up to 20% of adults in custody in the US have an OUD (Joudrey PJ et al, Addict Sci Clin Pract 2019;14:17).

CATR: How often is treatment available for inmates?

Dr. Waddell: Treatment options don’t meet the need, though it’s difficult to know the full scope. A 2019 survey found only 64% of new jail admissions were screened for OUD (Maruschak LM et al. Opioid Use Disorder Screening and Treatment in Local Jails, 2019. Bureau of Justice Statistics. NCJ 305179; 2023). We do know that within facilities that have the capability, about 15% of folks screened are positive for OUD. So even though we don’t have exact numbers, we know there are hundreds of thousands of adults in custody with OUD.

CATR: What can providers do for OUD patients prior to incarceration?

Dr. Waddell: Clinicians usually don’t know when someone is going to be detained. In those cases, good OUD treatment before going to jail is critical.

CATR: Why is that?

Dr. Waddell: People coming into jail with a community prescription for buprenorphine, for example, will be more likely to get it continued compared to someone without a prescription. Encourage patients to advocate for themselves if they know they are facing incarceration by requesting that their prescription be sent to jail health services, or by requesting a paper copy of their prescription in advance. Sometimes the most effective means for care coordination is a phone call between providers. Of course, this is not the norm, but it is a practice to strive for. Having dedicated staff to coordinate care is essential.

CATR: How about correctional facilities that aren’t set up to provide medications for opioid use disorder (MOUD)?

Dr. Waddell: Unfortunately, not all facilities prescribe MOUD. Anecdotally, I’ve heard about patients reluctant to start MOUD if they are likely to be incarcerated—because why start taking a medication if they’re just going to be taken off it? They don’t want to go through buprenorphine withdrawal, especially in a jail where they won’t be given medication for withdrawal management. But, if they’re not on MOUD, they’ll just withdraw from whatever opioid they are using and are far less likely to get treatment in jail.

CATR: What about long-acting formulations?

Dr. Waddell: Long-acting injectable buprenorphine or naltrexone can work well. The long half-life ensures a gradual tapering of serum levels, and withdrawal symptoms are much less severe if the medication is discontinued. The injectables can be challenging to start for outpatients but are a good option for those worried about withdrawal (Lee JD et al, Lancet 2018;391(10118):309–318). Injectables are also expensive, but they should be considered when possible for people heading into the carceral system.

CATR: And what about within facilities? When someone with OUD comes in, what are the options?

Dr. Waddell: First, it’s important to distinguish between jails and prisons. Jails are local facilities, usually managed by a city or county, meant for holding people awaiting trial or serving sentences of under a year. People sometimes remain in jail for a long time, but that is not by design. Prisons are state or federal facilities that hold people serving longer sentences. Jails are usually more limited in the services they provide. In 2019, the Bureau of Justice Assistance found that only about half of jails offer withdrawal treatment. That might be buprenorphine, but not necessarily. When buprenorphine is offered as part of withdrawal treatment, it may be given for five days then tapered. Only 24% of jails continued MOUD, and 19% provided MOUD prior to release. And keep in mind that release from jail can happen without much notice, so getting a medication properly started can be hit or miss. Location matters too; urban jails are more likely to give MOUD than rural jails (Maruschak et al, 2023).

CATR: How do prisons differ?

Dr. Waddell: In a prison situation, stays are most often for a year or more in a single facility. There is more time for treatment, and more services are available. For example, some offer longer-term addiction treatment, individual counseling may be available, and there is more time for prerelease planning. In Oregon, long-acting injectable buprenorphine is offered to all adults who have a release date within 13 months. In a best-case scenario, adults in custody will work with a release counselor or peer navigator who can connect them to community care.

CATR: How can providers find out if facilities provide MOUD?

Dr. Waddell: That is an important question without an easy answer. It’s kind of incredible, but there is no online database where you can find out what facilities offer what treatment. Sometimes state prison systems share a formulary across facilities, but not always, and local jails tend to have their own procedures. On top of that, it’s a moving target depending on fluctuating funding, staffing, and local regulations. The most effective way to find out what is available is just to call the facilities around you.

CATR: We’ve talked about how to best care for our OUD patients before they are incarcerated. What happens when they are released?

Dr. Waddell: People leaving correctional facilities are incredibly vulnerable. They often have very few supports, no job, and hardly any money. After release, they have much higher levels of morbidity and mortality from chronic health conditions, mental health issues, and addiction, especially from OUD. Nationally, overdose is a leading cause of death among adults released from incarceration (Binswanger IA et al, Ann Intern Med 2013;159(9):592–600). Mortality risk is especially elevated in the two weeks after release, when individuals reenter living situations with exposure or access to substances for which they have little tolerance (O’Connor AW et al, Drug Alcohol Depend 2022;241:109655).

CATR: What can we do about this?

Dr. Waddell: One relatively easy lift is patient education about the higher risk of overdose upon release, particularly among those who have not been using while incarcerated. If they exit the carceral system and start using, they’re at a higher risk for overdose.

CATR: You’re referring to loss of tolerance?

Dr. Waddell: Yes, and the danger of the drug supply itself. Fentanyl is much more common in the opioid supply than just a few years ago. It’s in methamphetamines and counterfeit pressed pills. Someone coming out of prison after a few years will be encountering a new, riskier, and more unpredictable drug supply.

CATR: What else?

Dr. Waddell: Many people coming out of facilities will be traumatized and fearful, not wanting to talk with anyone in a position of authority. But establishing trust is essential. Treatment may be seen as punishment, especially if they have experienced mandatory SUD treatment. Be open and honest. Learn about trauma-informed care, and make your office a safe space, not an interrogation room (Editor’s note: For more on trauma-informed care, see CATR Nov/Dec 2022). Familiarize yourself with local and state regulations about what information is reportable or not. Ideally, parole and probation supervisors will have knowledge of MOUD and counties will have clear policies that support MOUD treatment. Care coordinators and counselors who are able to connect directly with community connections (with the patient’s permission) can be helpful. Most importantly, let patients know that their well-being is your top priority as a health care provider, and that you won’t abandon them or “turn them in” if they return to use.

CATR: And what can we do in terms of the care itself?

Dr. Waddell: Ensure that if MOUD is not started before release, it’s started as soon as possible. Every day after release without treatment increases the probability of a bad outcome. Providers should be flexible, especially right after release as people are getting their lives back together. Consider telehealth, especially in rural settings. Some prisons have care coordinators that set up community follow-up; collaborate closely with them. Provide or refer for medical treatment and screen for transmissible infections like HIV and viral hepatitis. Remember, not everyone is going to be ready for SUD treatment, but clinicians still need to engage with these patients.

CATR: This is where harm reduction interventions can be useful.

Dr. Waddell: Exactly. Harm reduction is a priority for these patients (www.tinyurl.com/48rhnh6u; www.tinyurl.com/yvcp68xe). Basic harm reduction approaches, including education about safer use and distribution of naloxone and sterile syringes, are so important. Start with conversations about safer use. Be sure your patients have naloxone available and know how to use it. Remind them not to use alone when possible.

CATR: Is there anything else that we can do to help these patients?

Dr. Waddell: As providers, the instinct is to start medication right away. But we should remember that medication, while important, may not be patients’ top priority. Prison sentences, especially long ones, will have completely upended their lives. They will be interested in housing, employment, and reconnecting with loved ones. Talk to patients about how OUD treatment might help to achieve these goals. Practices can provide referrals to social services like financial assistance, food stamps, and housing. Involve peer supports when possible. If you can help your patient with what matters to them, they will be more likely to engage and more likely to succeed. (Editor’s note: See table for additional resources.)

CATR: Thank you for your time, Dr. Waddell.