INTRODUCTION

Over 500,000 individuals with opioid use disorder (OUD) pass through United States (U.S.) jails each year.1 Recently released people with OUD are at high risk of fatal overdose, and providing treatment in custody is lifesaving, reducing the risk of in-custody and post-release overdose.2,3 Thus, jails represent a crucial point of access to treatment along the cascade of care for OUD. Jail stays are often short-term, making them a high impact moment for treatment intervention. A preponderance of evidence supports treatment of OUD with one of three FDA-approved medications for opioid use disorder (MOUD)—buprenorphine, methadone, or naltrexone. However, the availability of treatment in U.S. jails is unknown. We aimed to assess MOUD availability in U.S. jails.

METHODS

From September 2019 to March 2020, we conducted a cross-sectional survey, completed electronically or paper, of all identifiable jails in the U.S., the largest survey to date of U.S. jails.4 We assessed MOUD availability for non-pregnant individuals, including initiation in custody and continuation of pre-incarceration MOUD, medication type, dosing arrangements, barriers to MOUD, and respondent and jail characteristics. This analysis was part of a parent study of MOUD access in pregnancy in jails.5 We analyzed responses for descriptive statistics and applying Pearson χ2 or Wilcoxon rank sum tests.

RESULTS

Of 2986 surveys sent, 1139 (38%) responses were returned with 836 analyzable responses (28%). Most non-respondents were from rural counties (60%) and did not have an email address (66%). Responding jails represented a wide geographic spread, with a similar distribution in metropolitan and rural settings (Table 1). Thirty-two percent of jails reported MOUD availability in some capacity, with 29% reporting details validating MOUD availability (Table 2). Thirteen percent of all jails both initiated and continued at least one medication, 11% only continued MOUD, and 17% provided more than medication. Of the 238 jails with confirmed MOUD, 47% both initiated and continued. Fifty-nine percent of MOUD jails offered more than 1 medication. Fifty-six jails continued (6.7% of all respondents) and 13 jails initiated and continued (1.6% of all respondents) all three medications. When only 1 medication was available, the most common was naltrexone (21%) and the least was methadone (8%). The most common medication administration arrangement for buprenorphine was by a waivered jail provider (55%) and, for methadone, medications being sent or picked (34%). MOUD-providing jails were disproportionately metropolitan (60%, p<0.01), located in the West (30%) or Midwest (31%) (p=0.01), and utilized non-private health care service delivery (64%, p<0.01). The most frequently reported barriers to providing MOUD in jail included concerns regarding medication diversion (40%), cost of MOUD (36%), and Drug Enforcement Administration (DEA) prescribing regulations (28%); respondents reporting cost as a barrier were more likely to have decision-making roles (p=0.05).

Table 1 Respondent Characteristics
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Table 2 MOUD Availability at U.S. Jails (n=836)
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DISCUSSION

MOUD is not widely available in U.S. jails, either for initiation or continuation. Without treatment access, people with OUD may undergo involuntary withdrawal upon entry to at least 68% of jails in this sample. This signals a failure to treat OUD as a chronic condition and a crucial missed opportunity for intervention to reduce overdose death post-release. Methadone was the least available medication while naltrexone was the most common, which could be attributable to regulatory barriers or dosing logistics. Easing of burdensome DEA regulations could increase availability at jails. Our study is limited by non-responses and the inability to compare our sample to all jails in the U.S. Additionally, more jails in our sample may provide MOUD to non-pregnant individuals in custody but did not respond to the survey due the scope of the parent study regarding MOUD for pregnant people.

Despite the low proportion of study jails providing MOUD, the finding that some jails have availability highlights the feasibility of providing MOUD in jails. Most jails in this study did not adhere to the standard of care by providing MOUD to individuals with OUD. Failure to continue pre-incarceration MOUD has been litigated as violating the Americans with Disabilities Act.6 To reduce adverse health outcomes including overdose and promote recovery, widespread implementation of policies and programs are needed to increase MOUD availability and linkages to community care for people entering and leaving U.S. jails. Jails should be aware of existing legislation, locate community resources to provide MOUD, and increase staff buy-in and reduce stigma through education and trainings.