The overdose crisis is claiming lives across the United States, but it reaches new depths of despair in the criminal justice system. Overdose is the leading cause of death among people returning to their communities after being in jail or prison. Providing addiction treatment in these settings could change that.
Roughly 60% of people who are incarcerated have a substance use disorder, in many cases an opioid use disorder. When people with addiction leave prison or jail and return to their communities, they are at very high risk of returning to drug use and overdosing. Their tolerance to drugs has diminished during incarceration, and fentanyl is pervasive in the street drug supply. Even one relapse could be fatal.
It remains a common belief that simply stopping someone from taking drugs while in jail or prison is an effective approach to treatment. But that belief is inaccurate and dangerous. As scientists, we look to research to guide us. And when research shows strategies with clear benefits, they should be deployed.
The Food and Drug Administration has approved three medications for opioid use disorder: methadone, buprenorphine, and naltrexone. All three are effective, safe, and lifesaving. But they are woefully underused, particularly in criminal justice settings.
A 2020 study in Rhode Island estimated that overdose deaths could be reduced by 30% in the state if jails and prisons made all three medications available to those who needed them. Studies also show that people who receive these medications while in jail or prison are less likely to return to substance use and more likely to continue with treatment in the community afterward.
Less than half of jails nationwide, and fewer than 10% of state prisons, offer all three medications. While 96% of jails did provide the overdose reversal drug naloxone to staff, only 1 in 3 provided naloxone and training on how to use it to decarcerated citizens during the critical period when they were returning to their communities.
Neglecting to provide access to these lifesaving treatments and harm-reduction measures creates deadly gaps for people when they leave jail or prison. The repercussions reverberate throughout communities and generations. They deepen racial inequities and overrepresentation of communities of color within the criminal justice system. They cause devastation for children and families.
Providing medications for opioid use disorder in jails and prisons benefits public health and public safety. It’s cost–effective. It can help break the cycle of recidivism. It can reduce the burden on the wider health care system, including emergency departments.
Programs across the country are underway to offer naloxone and medications for opioid use disorder in jails and prisons, paired with instruction, training, and social support. Federal agencies have launched programs to help people manage withdrawal in jails and provide financial health care support for people who are about to reenter the community. A recently published revised methadone rule now allows any jail or prison registered as a hospital or clinic to dispense medications for opioid use disorder in certain circumstances.
Law enforcement leaders are starting to see how addiction treatment increases safety for everyone. Chris Donelan, the sheriff of Franklin County, Mass., has partnered with researchers to study what happens when jails offer all three FDA-approved opioid use disorder medications. His jail became one of the few in the nation to be licensed as an opioid treatment program.
“When someone is booked into our facility, often we are the first treatment provider the person has seen in years,” Donelan told his University of Massachusetts research partners. “These treatments save lives and help people enter into recovery. Treatment makes the work of our facility much easier. We have less fights, less contraband, and a much safer facility.”
Since 2019, the National Institutes of Health has funded partnerships across the country to figure out how to link people with addiction to care during and after their time in the corrections system. These researchers are poised to share new evidence as it emerges that will help other communities make data-driven changes so they can implement what is most efficient in justice settings.
There is still a long way to go. A dangerous supply of street drugs, fragmented treatment systems, lack of funding, lack of training, pervasive stigma, and complex logistics all work against people with substance use disorders as they work to rebuild their lives after incarceration. Support in recovery and continuity of care are essential during this vulnerable time.
Fundamentally, an individual’s best or only option to receive addiction treatment should not have to be during incarceration. In an ideal world, treatment and prevention systems in the U.S. would proactively address social drivers of health and mental health needs to stop the cycle between addiction and incarceration. Moving away from criminalization of substance use disorders toward a public-health approach would remove a key structural practice that perpetuates inequalities. It would improve lives for people and their families.
Nora D. Volkow, M.D., is a psychiatrist, scientist, and director of the National Institute on Drug Abuse, which is part of the National Institutes of Health. Tisha Wiley, Ph.D., is a social psychologist, associate director for justice systems at NIDA, and leads the NIH Justice Community Opioid Innovation Network initiative, which studies approaches to increase high-quality care for people in justice settings with opioid misuse or opioid use disorder.