America is missing out on a crucial opportunity to contain opioid overdose deaths

Treatment of opioid use disorder starting in jails could curb America’s fatal drug overdoses. But the country is missing the opportunity.

A new nationwide study conducted by researchers at two federal health agencies shows that only 43.8% of jails in the U.S. are providing medications to incarcerated people to treat opioid use disorder, a chronic brain condition.

Two-thirds of incarcerated people have a substance use disorder, the majority of which involve opioids. Long-term studies show significant benefits of medications such as naloxone, which can reduce the risk of death from opioid overdose by 50%.

Though the opioid crisis was declared a national health emergency in 2017, the correctional and criminal justice systems haven’t seen much momentum to fight against the epidemic. The process is showing, but slowly.

“There are fairly regular surveys by federal agencies of the jails in the U.S., but we didn’t have the detail we needed about what’s going on in terms of substance use treatment in the jail,” said Lori Ducharme, an author of the study and a health scientist administrator from National Institute on Drug Abuse. “It really does give us a baseline for moving forward.”

“There’s no national jail health survey that’s more comprehensive or better or has a higher response rate than this paper,” said Joshua D. Lee, a clinician–researcher focused on addiction pharmacotherapies in primary care and criminal justice who is a professor at New York University and was not involved in the study.

People who have been in and out of a county jail have a higher risk of overdose. Within the first two weeks of release, the risk of death for a former inmate is 12 times higher than other individuals. The leading cause is a fatal drug overdose. One reason is that the level of tolerance of their body to the substances is lowered after incarceration, when they have no access to drugs. But once they leave the jail and resume using them again, an increased risk of overdose appears.

“They’re trying at the same doses as they were using before, but their body no longer can handle that. And that’s why,” said Charles J. Neighbors, a behavioral scientist with a focus on substance use disorders treatment system, who is also an NYU associate professor and not involved in the study.

Neighbors was surprised that as many as 43.8% of jails provide some sort of medication for opioid use disorder. It is “much higher than I would have anticipated, because it’s traditionally been a system that’s been reluctant to adopt medications for opioid use disorder,” he said.

But the reluctance is still there. Less than half of all American jails provide medications for opioid use disorder, and only 12.8%  provide them to anyone who have requests. The rest of the jails only allow specific groups to receive the medications, such as people who are pregnant, who are already on the medication when booked or who are about to be released.

There are three main options for medications for opioid use disorder: methadone, buprenorphine and naltrexone. They are all evidence-based, long-approved treatments. If jails made all three available to all detainees with this condition, opioid overdose deaths could be reduced as much as 31%, according to a study by scientists at Brown University School of Public Health.

According to the study, among jails with those medications available, buprenorphine is used the most, naltrexone the second and methadone the last. Buprenorphine and methadone are both on the controlled substance list for the risk of being abused or causing addiction.

The restrictions are expansive and rigid on both federal and state levels, especially when it comes to prescription qualifications and storage and administration requirements.

Methadone, due to its potency and risk of overdose, is subject to more intense regulations. It also has the longest track record, having been used to treat opioid use disorder since the 1970s. “It can be a very effective medication, particularly for people who have heavy dependence and have really struggled,” Neighbors said.

Neighbors criticized the current regulations on buprenorphine and methadone for not meeting the needs of those people who need them most. He points out that such restrictions not only heavily limit access to those medications but also create an invisible wall of distrust between doctors and patients.

“It’s important to talk about stigma, which is the way that we think about people who use drugs,” Neighbors said. “And by putting on extra restrictions and restrictions that suggest criminal activity for these medications, it’s stigmatizing the medications, and so it’s keeping doctors away from using it as well.”

Such restrictions and challenges apply to jails, too. Of the jails in the study that are not providing any medications for opioid use disorder, 49.8% indicated a lack of adequately licensed staff as the most common reason. The second and third reasons are that policies prevent jails from providing them, and that the budget doesn’t allow it.

“Jails are not healthcare institutions,” Lee said. They’re often not funded to address chronic medical problems, including substance use and addiction. “And that is amazingly complicated in part because jails are completely local.”

Local features and differences will impact budgets and resources. “A big variable we found was being in the southern region of the United States,” said Bruce G. Taylor, an author of this study and a senior fellow with NORC at the University of Chicago.

Jails in the south are providing much less treatment compared to other regions. “They don’t have an orientation towards treatment,” Taylor said.

Regulations are loosening up a bit on methadone and buprenorphine at the federal level and some progressive states are pushing the criminal justice system to be more involved in the availability of such medications. But it’s not moving fast enough. “These are people that need treatment. Let’s make it as easy as possible for them,” Neighbor said. “We always have to balance things out. And right now we have a lot of people dying.”