Jail-based treatment for opioid use disorder in the era of bail reform: a qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative

Abstract

Background Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge. Methods In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services. Results Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January–September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails’ limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic. Conclusions Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.

Treating Opioid Use Disorder in Patients Who Are Incarcerated

“…In addition, 70% of people who use heroin will have encounters with the legal system. 3 Loss of tolerance to opioids during incarceration is associated with increased risk of overdose and death after release. 4 Jails do not routinely continue MOUD or provide linkage to outpatient treatment facilities that can provide MOUD.…”

“…Inadequately managed OUD leads to worse outcomes, such as risk of overdose with loss of opioid tolerance, and patients leaving the hospital by patient-directed discharge before their medical condition is stabilized. In addition, 70% of people who use heroin will have encounters with the legal system . Loss of tolerance to opioids during incarceration is associated with increased risk of overdose and death after release .…”

Correlates and Patterns in Use of Medications to Treat Opioid Use Disorder in Jail

“…16,17 In addition, individuals with a short length of jail stay may go untreated with MOUD, for example, due to policies that direct treatment only for sentenced individuals, and preclude treatment of pretrial individuals, or due to logistical challenges that mean individuals enter and exit jail quickly before MOUD can be initiated. 16,17 MOUD use while incarcerated is also shaped by factors such as anticipation of transfer to a carceral system that does not offer MOUD or expected release into a community that has limited or no access to MOUD. 16,18,19 At the individual level, incarcerated women may be more likely than men to receive MOUD, for example, due to policies that prioritize provision of MOUD to pregnant women, 9 while a significant proportion of incarcerated women have co-occurring mental illnesses and do not receive treatment.…”

“…16,17 MOUD use while incarcerated is also shaped by factors such as anticipation of transfer to a carceral system that does not offer MOUD or expected release into a community that has limited or no access to MOUD. 16,18,19 At the individual level, incarcerated women may be more likely than men to receive MOUD, for example, due to policies that prioritize provision of MOUD to pregnant women, 9 while a significant proportion of incarcerated women have co-occurring mental illnesses and do not receive treatment. 20 Recent literature suggests that Black and Hispanic individuals are less likely to enter carceral facilities with a MOUD prescription and are more likely to be inducted on buprenorphine while incarcerated, compared with White individuals.…”

“…Importantly, transitions in the provision of MOUD from intake to during incarceration have mostly been described in qualitative research conducted with carceral staff. 16,17 A critical gap in knowledge is that there is little quantitative evidence on the prevalence of MOUD receipt among individuals living in jail, the extent to which these individuals transition to different types of MOUD while incarcerated, and the factors that are associated with receipt of MOUD.…”