The NEW ENGLA ND JOURNAL of MEDICINE

Perspective 

Opioid Use Disorder and Incarceration — Hope for Ensuring

the Continuity of Treatment
Ingrid A. Binswanger, M.D.​​

I
Opioid Use Disorder and Incarceration
n my addiction medicine practice, patients with
opioid use disorder (OUD) have asked me to
help them discontinue use of buprenorphine or
methadonebefore upcoming jail stays for pending
or new charges, even when they
are doing well on their current
treatment. Because treating OUD
with medications is prohibited in
most jails in the United States,
my patients anticipate having
painful opioid-withdrawal symp-
toms when their treatment is
stopped in jail. People who use
heroin, illicitly manufactured fen-
tanyl, or opioid analgesics have
similar fears about withdrawal.
Their apprehension is understand-
able. Although many physicians
are still under the impression that
opioid withdrawal is nonlethal,
the media have reported deaths of
young people with opioid with-
drawal during incarceration. Ef-
forts to self-treat withdrawal in
jail can also lead to other medical
risks, such as those posed by us-
ing nonsterile injection equip-
ment.1 Patients who have been
traumatized by “imposed with-
drawal” may be reluctant to re-
sume medication treatment or to
take effective medication doses
for OUD after they are released.1
Although jail stays for pending
and new charges may be brief,
the effects of modifying treat-
ment plans to accommodate out-
dated correctional policies can be
permanent. The risk of overdose
death after release from correc-
tional facilities has been shown
to be more than 10 times the risk
in the general population.2 Treat-
ment with buprenorphine or meth-
adone, however, is associated with
considerably lower overdose rates
for people with OUD.3 Clinicians
cannot predict which patients will
resume opioid use and which
will experience an overdose, nor
is there a clearly identifiable treat-
ment duration after which such
risks are known to be negligible.
To avoid potential harm associat-
ed with abrupt opioid withdrawal
during incarceration, I try to ac-
commodate patients’ requests to
taper or discontinue medications
in preparation for jail stays. Giv-
en the high risk of overdose after
incarceration, however, continuing
patients’ medication treatment
without disruption would be more
medically appropriate.
Although jails were not de-
signed to deliver addiction treat-
ment, they are now part of a
complex system adapting to a
worsening public health crisis.
According to the U.S. Bureau of
Justice Statistics, there were more
than 10 million admissions to
local and county jails in 2016, in
addition to the 606,000 admis-
sions to state and federal prisons.
It is estimated that nearly one fifth

n engl j med  nejm.org 1

The New England Journal of Medicine
Downloaded from nejm.org at Washington University in St. Louis Becker Library on February 27, 2019. For personal use only. No other uses without permission.
Copyright © 2019 Massachusetts Medical Society. All rights reserved.
 PERS PE C T IV E
of people serving a jail sentence
between 2007 and 2009 — the
most recent years for which data
are available — used heroin or
other opioids. Over the past dec-
ade, the evolving opioid epidem-
ic has most likely contributed to
an increasing proportion of peo-
ple in correctional facilities who
have OUD.
Some dedicated public health
advocates, correctional health care
administrators and providers, and
criminal justice health researchers
have long tried to address barriers
to providing effective medications
for OUD in jails. Model programs
have been developed to allow peo-
ple in correctional facilities to
continue receiving these medica-
tions. One example is a treatment
program implemented by the
Rhode Island Department of Cor-
rections unified jail and prison
system that was associated with
fewer postrelease overdose fatali-
ties.4 Because of concerns about
the fetal effects of maternal opi-
oid withdrawals, some jails have
also permitted pregnant women
to take medications for OUD. In
October 2018, the National Sher-
iffs’ Association and the Nation-
al Commission on Correctional
Health Care took an important
step forward when they released
guidelines to aid the implemen-
tation of medication treatment in
jails. The Office of National Drug
Control Policy has also issued
statements calling for the avail-
ability of medications for people
with OUD in the criminal justice
system. Nonetheless, the scale and
reach of jail-based programs that
provide medications for OUD are
still limited.
Implementation of medication
treatment for OUD in jails has
been slow for a broad range of rea-
sons. Many of the roughly 3000
2 n engl j med  nejm.org
The New England Journal of Medicine
Downloaded from nejm.org at Washington University in St. Louis Becker Library on February 27, 2019. For personal use only. No other uses without permission.
Copyright © 2019 Massachusetts Medical Society. All rights reserved.
Opioid Use Disorder and Incarceration
jail facilities in the United States
are small and geographically iso-
lated and don’t have on-site health
care providers. Corrections staff
and available clinicians may have
limited education and expertise
in OUD treatment. According to
a qualitative evaluation conducted
for the Washington State Depart-
ment of Social and Health Services
(faculty​.­washington​.­edu/​­mfstern/​
­WAJailOpiateResponse​.­pdf), they
may also have concerns about the
costs of treatment and whether
they can effectively link people
with ongoing treatment after re-
lease. These and other barriers
have led to persistent gaps in ac-
cess to treatment in U.S. jail fa-
cilities. Similar barriers may also
prevent jails from providing nal-
oxone to reverse potential opioid
overdoses after release. Restric-
tive treatment practices and poli-
cies prevent the delivery of coor-
dinated care to people who use
opioids or have a history of OUD.
A recent court decision, how-
ever, may help accelerate the adop-
tion of medications for OUD in
jails. In November 2018, the Bos-
ton Globe reported on the case of a
32-year-old Massachusetts man
who had experienced numerous
personal, social, and medical set-
backs related to his opioid use.5
He had lost his driver’s license
and job and been charged with
operating a vehicle under the in-
fluence of drugs. According to the
formal legal complaint, he had
also survived multiple overdoses.
After trying several other types
of treatment, he responded well
to methadone. But methadone
treatment generally requires fre-
quent clinic attendance. Accord-
ing to the complaint, in mid-July
2018, the man tried to drive him-
self to the clinic because his
mother, who usually drove him,
couldn’t take him. He was stopped
for driving 6 miles per hour over
the speed limit and faced a man-
datory minimum of 60 days in
jail for driving with a suspended
license. The Essex County House
of Correction in Middleton, like
most jails in Massachusetts and
elsewhere, did not offer metha-
done treatment for nonpregnant
adults. He therefore faced incar-
ceration without access to crucial
treatment.
The basis of the lawsuit brought
on his behalf by the American
Civil Liberties Union of Massa-
chusetts was that discontinuing
treatment during a planned jail
stay violates both the prohibition
against cruel and unusual pun-
ishment in the Eighth Amend-
ment to the U.S. Constitution
and the Americans with Disabili-
ties Act. This case is atypical in
that most people who are put in
jail don’t have the opportunity to
prepare for incarceration, and
most are not already receiving
treatment for OUD. Yet the case
illustrates the complex web of le-
gal, policy, and structural barri-
ers to obtaining effective treat-
ment for OUD in correctional
facilities. In November 2018, U.S.
District Judge Denise Casper
ruled in the man’s favor.
In addition to improving ac-
cess to methadone for people who
are already receiving treatment
for OUD and facing jail time in
Massachusetts, this case could
serve as a catalyst for broad, sys-
tematic policy efforts to improve
the continuity and quality of care
for OUD. Many of the barriers to
continuity of care faced by people
in jails are also faced by people
who have never been in the crim-
inal justice system. Losing health
insurance, moving to a new geo-
graphic area, and being hospital-
 PE R S PE C T IV E
ized can all cause disruptions in
care for OUD. Along with ensur-
ing that people released from jail
can easily reengage in community-
based care, community-based cli-
nicians can seek to minimize all
forms of treatment interruption.
Guaranteeing that people with
OUD have access to medica-
tions, including methadone and
buprenorphine, during incarcer-
ation — regardless of whether
they are already receiving treat-
ment — would represent an im-
portant step for promoting con-
tinuity of treatment. I hope such
reforms will ultimately mean that
The New England Journal of Medicine
Downloaded from nejm.org at Washington University in St. Louis Becker Library on February 27, 2019. For personal use only. No other uses without permission.
Copyright © 2019 Massachusetts Medical Society. All rights reserved.
Opioid Use Disorder and Incarceration
clinicians don’t need to compro-
mise on effective medical care to
prepare patients for incarceration.
Disclosure forms provided by the author
are available at NEJM.org.
From the Institute for Health Research, Kai-
ser Permanente Colorado; the Colorado
Permanente Medical Group; and the Divi-
sion of General Internal Medicine, Univer-
sity of Colorado School of Medicine — all in
Aurora.
This article was published on February 27,
2019, at NEJM.org.
1. Mitchell SG, Kelly SM, Brown BS, et al.
Incarceration and opioid withdrawal: the
experiences of methadone patients and out-
of-treatment heroin users. J Psychoactive
Drugs 2009;​41:​145-52.
2. Binswanger IA, Stern MF, Deyo RA, et
n engl j med  nejm.org
al. Release from prison — a high risk of
death for former inmates. N Engl J Med
2007;​356:​157-65.
3. Sordo L, Barrio G, Bravo MJ, et al. Mor-
tality risk during and after opioid substitu-
tion treatment: systematic review and meta-
analysis of cohort studies. BMJ 2017;​ 357:​
j1550.
4. Green TC, Clarke J, Brinkley-Rubinstein
L, et al. Postincarceration fatal overdoses
after implementing medications for addic-
tion treatment in a statewide correctional
system. JAMA Psychiatry 2018;​75:​405-7.
5. Freyer FJ. Court orders Essex County to
provide methadone to inmate. Boston
Globe. November 27, 2018 (https://www​
.bostonglobe​.com/​metro/​2018/​11/​27/​court​
-­orders​-­essex​-­county​-­provide​-­methadone​
-­inmate/​iz5GxxfwgKPmi5CNWtNrnK/​story​
.html).
DOI: 10.1056/NEJMp1900069
Copyright © 2019 Massachusetts Medical Society.
Opioid Use Disorder and Incarceration
3