The Importance of Treating Opioid Use Disorder in the Justice System

If we are to effectively turn the tide on the opioid crisis, one of our top priorities must be integrating treatment for opioid addiction into the justice system.

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More than half of those in prison in the U.S. have been diagnosed with a substance use disorder, and 15 percent of those in jails and prisons have an opioid use disorder (OUD), according to a recent report by the National Academies of Science, Engineering, and Medicine (NASEM). But few incarcerated individuals receive medication for OUD, now the widely acknowledged medical standard of care. According to a survey cited in the NASEM report, most prison medical directors are not aware of the benefits of medications in treating OUD.

Lack of access to medications has devastating consequences in any OUD-affected population. For those in jail or prison, who undergo withdrawal and prolonged abstinence without treatment in most cases, the consequences upon release can be dire.  

Since most persons with an OUD go untreated in jail or prison, they are very likely to relapse into opioid use after they return to the community. Their risk for overdose is then extremely high, because they are likely to re-initiate their opioid use at the same dose they were using in the past, not realizing that their body has lost its tolerance to opioids. The prevalence of fentanyl-contaminated heroin further increases the risk of overdose. One widely cited study found that formerly incarcerated individuals ran a 12.7-fold risk of death in the two weeks following release from prison, compared to the general population, mostly due to drug overdose.

A growing number of studies show the benefits of initiating medication treatment (methadone, buprenorphine, or naltrexone) before release from jail or prison. The benefits include reduced drug use and risk of overdose death, as well as reduced risk of infectious disease transmission and improved clinical outcomes when infected with HIV. After release into the community, an individual needs to be supported to remain in treatment, as is true of anyone with a substance use disorder. And of course, to treat OUD, it’s important to detect it in the first place, which means that it’s important to screen individuals as they enter the justice system.

How can opioid addiction screening and medications for OUD be integrated into justice settings? Are there cost-effective technologies and strategies that could help? And how can justice systems interact with healthcare providers in a way that ensures justice-involved individuals stay in treatment for their OUD as well as for other medical co-morbidities when they return to the community?

To find scientific answers to these questions, NIDA is funding a major effort, the Justice Community Opioid Innovation Network (JCOIN), as part of the NIH HEAL (Helping to End Addiction Long-termSM) Initiative, an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid crisis.

JCOIN consists of grants to 12 research institutions to create a national network of researchers that will identify effective and cost-effective approaches to serve the needs of justice-involved individuals who have OUD or who are at risk, as well as find ways to scale up and disseminate these approaches. In 15 U.S. states and Puerto Rico, the grants will be used to study evidence-based medications and behavioral interventions, digital therapeutics, and approaches that provide a comprehensive set of treatment options that are tailored to patients’ individual needs.

Effectively delivering OUD treatment in the justice system will give individuals with OUD a chance of recovery, and will make a huge difference in reducing the toll of the opioid crisis in the U.S. It will also bring about additional health and economic benefits like reducing the spread of HIV and hepatitis C and reducing the costs from re-incarceration and family disruption, which are much higher when OUD is not treated.

For more information on JCOIN and the grants recently awarded, see NIH establishes network to improve opioid addiction treatment in criminal justice settings.

Dr. Nora Volkow, Director

Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.

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Dear Dr. Volkow, I have been inspired by you today after learning about your brilliant work in the Mpls Strib on addiction; of which I understand all too well. Yet, so much more to learn...having been assaulted by a troubled student in my classroom, ending my 30 plus year Teaching career (due to chronic pain, 3 surgeries from injuries, PTSD, and suicidal attempts from depression and opioid addiction) I continue to be compelled/addicted to make changes in the fight for school safety and mental health needs for kids across the country-which brought me to speak to the US Dept of Ed, Civil Liberties and Civil Rights teams in DC, 3X. Please contact me as I would like to support your work. And I discovered a way to heal the brain/gut health that transformed my life and has naturally/nutritionally supported over 18 million children nationally. Bless you for your passion!

 The importance of treating drug abuse as a HEALTH issue

“Prohibition... goes beyond the bounds of reason in that it attempts to control a man's appetite by legislation and makes a crime out of things that are not crimes... A prohibition law strikes a blow at the very principles upon which our government was founded.”

That quote has been attributed to Abe Lincoln but it’s never been verified. Regardless, it hit the nail on the head.
STRAIGHT UP TRUTH. We have over A MILLION Americans in cages for non violent drug charges.
At a cost of $25,000- or more, annually!

That’s $25,000,000,000.00+ a year WASTED and over a million Americans lives ruined because our nation treats drug abuse as a crime instead of a health issue.
How much rehab and social / health services could be funded with an extra $25 BILLION a year?

If Someone robs or assaults a person, a crime with an actual VICTIM, sure, let’s get that criminal help with his drug problem while he’s doing time. Great idea. Why are we only thinking about it NOW?
Shouldn’t we thought of this a couple DECADES ago?

Be that as it may, If we want to end this horror show of death and destruction we need to treat drug abuse as a health issue and not turn something that isn’t a crime into a crime, which is EXACTLY what prohibition does.
And Look at where it has gotten us.
Is the “drug war” working?
If you call creating an EPIDEMIC “working” then yea, great success.

 Finding the Underlying Issues

I completely agree that there needs to be something done to help those incarcerated with substance abuse, but I don't necessarily feel medication is the best route. Maybe in an effort to help those on high dosages safely detox but that's about it.

You see as an individual comes off drugs their body and mind start to work better and they are no longer dependent on ANY substance. Putting these individuals on maintenance drugs just prolongs the addiction. For many of these individuals they started using drugs because they were running into problems in life and used illegal substance to escape from these problems. Eventually the drugs become the biggest problem and many individuals ended up incarcerated in an effort to feed their addiction.

With affordable healthcare and job opportunities scarce for ex-cons, I believe starting individuals on these medications before or upon release is setting them up for relapse on to more readily accessible and cheaper street drugs. When their medication runs out, the cost to refill some of these medications is astronomical, and this leads the way for individuals to seek other means.

The best way to truly help these individuals to have workable programs that can help these individuals handle the problems they run into. Solving the problems they have that started them using drugs in the first place would give these individuals a better chance at staying off drugs for good. Handling underlying issues can be more effective than administering drugs.

 The view that medication for

The view that medication for OUD constitutes a new addiction substituted for an old one is not borne out by the science. Without medication, most people with OUD will relapse, each time putting themselves at greatly increased risk of overdose death. As summarized in the recent NASEM report, Medications for Opioid Disorder Save Lives, the evidence is clear that medications reduce opioid use and facilitate recovery, and not providing medications amounts to medical malpractice. Whether or not someone can eventually stop using any medication is still an unanswered question, and likely differs for different people.

 Zero Responsibility

To call opioid abuse a brain disease takes responsibility away from the person CHOOSING to use the drug. I do not doubt that these medications can assist in withdrawal from opioids. I've seen it first-hand. Getting an addict through the initial withdrawal is extremely important but continuing him on medications just prolongs the bodies addiction to a substance.
I've been on these drugs and they actually give you a feeling similar to that of the street drug, so why is it ok for people to be on them. You'll hear different viewpoints from different people but from my personal experience, people who choose to be on medications for a long period of time; 1. Like the fact that they can still get high. 2. Enjoy that they’re not responsible for their actions and are allowed to blame a "brain disease" for their poor decision making, 3. Truly do not want to stop using drugs. Not to say they don't like the idea of being clean, but they lack the willpower to actually do it.
Just take some time to look at the side effects, withdrawal symptoms, and overdose statistics of methadone. If this is what we’re using to "help" individuals with a drug problem, then are we really saving their lives or just prolonging their addiction.
I am genuinely concerned but not rigid in my viewpoint. Is there any research you know of that explores if opioid addiction is different than alcohol addiction? Because alcoholics practice abstinence.

 While the initial decision to

While the initial decision to use a drug is a choice, addiction erodes the ability to make good judgments and stick with resolutions. Without the help of medication, the compromised self-inhibition of the person with addiction will typically lead them to relapse, catching them in an ongoing, self-reinforcing cycle, and putting them each time at increased risk of overdose. Opioid agonists (buprenorphine and methadone), when taken over a span of time, enable the brain to gradually restore balance while the individual returns to normal life and functioning. Taken by a person with opioid addiction and at the correct dose (which will be different for every individual), these medications relieve cravings and withdrawal symptoms but do not cause a high. For more information on why this the case, see Medications to Treat Opioid Use Disorder. Medications don’t absolve the individual of responsibility for their recovery, but they help make recovery more likely.