Two decades into an opioid crisis that has claimed more than 1 million American lives, policymakers are still searching for ways to reduce overdose deaths. They would do well to focus on jails and prisons.
There are 4,000 correctional facilities in the U.S., of which only a few dozen operate on-site opioid treatment programs. On any given day, there are almost 2 million incarcerated, about 15 percent of whom meet screening criteria for opioid use disorder. For many, incarceration is part of an unrelenting cycle of addiction, arrest and recidivism. Allowing this cycle to continue is a dangerous proposition for society and individuals alike.
Jail and prison are treacherous places for people with opioid addiction. Many are forced to undergo substance withdrawal without medical management while incarcerated, which actually increases their risk of a fatal outcome if they return to use after release. One study found that people recently released from incarceration are as much as 100 times as likely to die from an overdose as the general population.
To break the cycle, a national effort is underway to treat opioid addiction behind bars. Correctional facilities are partnering with treatment providers to start treatment programs that offer incarcerated people lifesaving medications.
Research has shown that the FDA-approved medications methadone and buprenorphine decrease opioid-related deaths and all-cause mortality by more than half. They also reduce criminal recidivism, as noted by the high-profile organizations — including the National Sheriffs Association, the American Society of Addiction Medicine and the National Governors Association — that support providing these treatment programs.
The good news is that federal policy is opening up new pathways to treatment by setting legal expectations, providing regulatory flexibility and offering reimbursement for care. There is clear guidance that jails and prisons have legal obligations to make reasonable efforts to ensure that medications are available to people with a diagnosis of opioid use disorder, including ensuring that those who were on medications before being incarcerated can stay on them. However, there is much work yet to be done to ensure that treatment programs become a standard practice in jails and prisons.
In February, the Biden administration released updated regulations clarifying that methadone can be provided by any correctional facility that is registered as a hospital or clinic (a registration that is easy to obtain under federal rules), provided that the patient also is being treated for another condition. The implications of this regulation are wide-ranging and can expand methadone access.
Paying for treatment is another piece of the puzzle. While federal insurance programs, including the expanded Medicaid and private insurance coverage under the Affordable Care Act, already require state programs to cover substance use disorder treatment, these same provisions do not apply in correctional facilities.
The Biden administration is now allowing state Medicaid programs to apply for waivers to reimburse for health care services provided to those incarcerated in the weeks prior to their release. One requirement of these waivers is that state programs must include medications to treat substance use disorder and ensure that people have medication in hand after their release.
California and Washington state already are implementing these waiver programs, and more than a dozen states have applications under consideration. Lessons from these Medicaid waivers can directly inform further efforts in Congress to make such coverage permanent through proposed legislation such as the Medicaid Due Process Act.
Ensuring access to medications during reentry is a final piece of the puzzle. New flexibilities in federal regulations now allow patients to receive take-home doses of methadone from their opioid treatment programs for longer periods of time, sparing them daily trips to get dosed. Another recent regulation creates opportunities for mobile medication units, a potential game-changer for patients — including incarcerated people, those with disabilities and people living in rural areas — who have difficulty accessing brick-and-mortar opioid treatment programs.
Correctional facilities, from the Denver City Jail to the six facilities operated by the Rhode Island Department of Corrections, have already shown that it is both possible and transformative to treat opioid addiction in carceral settings.
Helping people with substance use disorder receive the care they need while incarcerated is the first step on their journey to a healthier life and a successful return to their community. The gold standard of treatment with medications in correctional facilities will save lives and promote recovery in a setting where help has long been delayed — a change that benefits all of us.
Brendan Saloner is a Bloomberg Professor of American Health at the Johns Hopkins Bloomberg School of Public Health.