Medications to Treat Opioid Use Disorder Research Report
How is opioid use disorder treated in the criminal justice system?

Opioid use disorders are highly prevalent among criminal justice populations. According to data from the U.S. Department of Justice, approximately half of state and federal prisoners meet criteria for substance use disorder.78 Even so, there has been reticence in criminal justice settings to using methadone, buprenorphine, and naltrexone to treat opioid use disorder. In national surveys, utilization of these medications is very low in criminal justice settings, including drug courts,79 jails,80 and prisons.81 Thus, opioid use disorder goes largely untreated during periods of incarceration, and opioid use often resumes after release. 

A former inmate’s risk of death within the first 2 weeks of release is more than 12 times that of other individuals, with the leading cause of death being a fatal overdose.82 Overdoses are more common when a person relapses to drug use after a period of abstinence due to loss of tolerance to the drug. One study found a reduction in post-incarceration deaths from overdose among individuals who had received medication for opioid use disorder in correctional facilities.83 Untreated opioid use disorders also contribute to a return to criminal activity, reincarceration, and risky behavior contributing to the spread of HIV and hepatitis B and C infections (see "What is the impact of medication for opioid use disorder treatment on HIV/HCV outcomes?").84

The World Health Organization’s Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence recommends that incarcerated individuals should receive adequate healthcare and that opioid withdrawal, agonist maintenance and naltrexone treatment should all be available in prison settings, and prisoners should not be forced to accept any particular treatment."85

Many states currently do not offer appropriate access to or utilize medications to treat opioid use disorder among arrestees or inmates even though research has shown many benefits of incorporating medication-assisted treatment into criminal justice treatment programs. Inmates who receive buprenorphine treatment prior to release are more likely to engage in treatment after their release than inmates who only participate in counseling.87 Participants who engage in methadone treatment and counseling in prison are more likely to enter community-based methadone treatment centers after their release (68.6 percent) than those receiving only counseling (7.8 percent) or those in counseling and referred to a treatment center (50 percent).19

In one study, inmates who began buprenorphine treatment while incarcerated engaged in post-release treatment sooner, averaging 3.9 days after release, compared to 9.2 days for participants referred to treatment post-release.84 They were also likely to stay in treatment longer if they were initiated in treatment prior to release (20.3 weeks on average) than if they began treatment after their release (13.2 weeks).84

Inmates who participate in methadone treatment and counseling while in prison are less likely to test positive for illicit opioids at one month following their release (27.6 percent) compared to those who only receive counseling (62.9 percent) and those who receive counseling and a referral to a treatment center (41 percent).19

A randomized controlled trial was published in 2016, comparing prison-initiated extended-release naltrexone (XR-NTX) treatment to standard counseling protocols for prevention of opioid relapse. During the treatment phase, relapse was significantly lower in the group receiving XR-NTX (43 percent vs. 64 percent). The XR-NTX group also experienced no overdose events, while there were seven overdose events in the control group.88

A survey of community correction agents’ views on using medications to treat opioid use disorder showed that more favorable attitudes toward medication use are associated with greater knowledge about the evidence base for these medications and greater understanding of opioid use disorder as a medical disorder.89 Organizational linkage between correctional stakeholders and community treatment providers, along with training sessions, can be an effective way to change perceptions and increase knowledge about the efficacy of these medications, and can increase the intent within correctional facilities to refer individuals with opioid use disorder to treatment that incorporates medications.86

A mechanism to reduce recidivism and divert nonviolent offenders from traditional jail and prison settings is the drug treatment court model, which provides treatment services in combination with judicial supervision.90 Still, resistance to medications persists even in this area of the criminal justice system; a survey published in 2013 reported that 50 percent of drug courts did not allow agonist treatment for opioid use disorder under any circumstances.79 In 2015, the Office of National Drug Control Policy announced that state drug courts receiving federal grants must not: 1) deny any appropriate and eligible client for the treatment drug court access to the program because of their use of FDA-approved medications that is in accordance with an appropriately authorized prescription; or 2) mandate that a drug court client no longer use medications as part of the conditions of the drug court if such a mandate is inconsistent with a medical practitioner’s recommendation or prescription.91