Jail-based opioid addiction treatment saves lives and reduces reincarceration

A new study has found that providing medications for opioid addiction to individuals while they are incarcerated can dramatically improve their health and reduce their chances of returning to jail after release. The research, published in The New England Journal of Medicine and supported by the National Institutes of Health, found that this approach significantly increased engagement in treatment and was linked to a substantial drop in overdose deaths. These findings suggest that correctional facilities could serve as a vital front in the public health response to the nation’s opioid crisis.

The rationale for this investigation is rooted in the severe and overlapping crises of opioid addiction and mass incarceration in the United States. In 2023 alone, more than 81,000 people were known to have died from opioid-related overdoses. People who use opioids are at a heightened risk for incarceration, and the period immediately following release from jail or prison is one of extreme vulnerability. Individuals reentering the community after a period of forced abstinence have a much lower tolerance to opioids, placing them at an exceptionally high risk of a fatal overdose. Estimates suggest that nearly half of all community overdose deaths may involve people who were recently incarcerated.

This situation presents a clear opportunity for intervention within the justice system. Medications for opioid use disorder, which include methadone, buprenorphine, and naltrexone, are well-established, effective treatments that reduce opioid use and prevent overdose deaths in community settings. Despite this evidence, these life-saving medications have been slow to penetrate the American carceral system, particularly local jails, where most incarcerated individuals are held.

A nationwide survey found that only 13 percent of jails offer these medications to all incarcerated people who need them. Recognizing this gap, the state of Massachusetts mandated a pilot program in 2019 requiring seven county jails to provide all federally approved forms of medication for opioid use disorder. This new study was designed to evaluate the real-world effects of that state-mandated program. Researchers wanted to determine if receiving medication inside a jail would be associated with better outcomes after release, including continued treatment, lower rates of overdose, fewer deaths, and less recidivism.

To conduct the study, researchers analyzed data from 6,400 people who had been identified as having a probable opioid use disorder while incarcerated in one of the seven participating Massachusetts jails between September 2019 and December 2020. The participants were divided into two groups for analysis: a group of 2,711 individuals who received medication for opioid use disorder during their incarceration, and a group of 3,689 who did not.

Free daily newsletter

To track what happened to these individuals after they left jail, the research team linked the jail records to a comprehensive state health database managed by the Massachusetts Department of Public Health. This powerful data repository contains information from over 35 state administrative sources, including ambulance encounters, hospital records, prescription monitoring programs, death certificates, and subsequent incarcerations. This allowed the scientists to follow the participants for at least six months after their release.

Because this was an observational study of a real-world program and not a randomized experiment, the two groups of participants had some baseline differences. For instance, individuals who received medication in jail were more likely to have already been receiving it before their arrest. To ensure a fair comparison, the researchers used a statistical method known as propensity-score weighting.

This technique allowed them to adjust for dozens of differences between the groups, including age, race, sex, education level, history of homelessness, prior overdoses, and length of incarceration. This adjustment helps to isolate the effect of receiving the medication in jail from other factors that could influence post-release outcomes.

The findings were consistent across several key areas. First, receiving medication in jail was strongly associated with continuing treatment in the community. Among those who received medication while incarcerated, 60 percent started community-based treatment within 30 days of release. This stands in stark contrast to the group that did not receive medication in jail, where only 18 percent initiated treatment in the same timeframe. The effect persisted over time. Six months after release, 58 percent of the group treated in jail were still retained in some form of treatment, compared to just 23 percent of the other group.

The study also found a powerful association between in-jail treatment and a lower risk of life-threatening events. Individuals who received medication for opioid use disorder while incarcerated had a 52 percent lower risk of a fatal opioid overdose after release compared to those who did not. They also had a 24 percent lower risk of a non-fatal opioid overdose. The benefits extended beyond opioid-specific events. The group that received medication in jail experienced a 56 percent lower risk of death from any cause during the follow-up period.

Finally, the program appeared to have a positive impact on public safety and the cycle of incarceration. Those who received medication while in jail had a 12 percent lower risk of being reincarcerated within the state’s county jail or prison system. This suggests that stabilizing individuals with effective medical treatment can also help reduce criminal justice system involvement.

The researchers did note a concerning disparity in their data. Black non-Hispanic and Hispanic individuals were less likely to receive medication for opioid use disorder in these jails. The study authors suggest this could reflect existing inequities in access to treatment in the community, which are then carried into the carceral setting, but they could not rule out other factors like bias or patient preferences.

The study has some limitations that the authors acknowledge. Because it was not a randomized controlled trial, it demonstrates a strong association between in-jail treatment and positive outcomes but cannot definitively prove causation. The findings are from a single state, Massachusetts, which may not be representative of the entire country. The data system was also unable to capture outcomes for individuals who may have moved out of state after their release. The study period also overlapped with the beginning of the coronavirus pandemic, which could have influenced health outcomes and correctional system practices in unforeseen ways.

Despite these limitations, the evidence provides a case for expanding access to medications for opioid use disorder in jails across the country. The results show that these programs are not only feasible but are associated with profound benefits for individuals and society, including greater engagement in life-saving treatment, fewer overdose deaths, and lower rates of reincarceration.

Future research could explore the reasons for the racial and ethnic disparities in treatment access and identify best practices for ensuring equitable care. The authors conclude that jails, which are often at the epicenter of the opioid crisis, have a significant opportunity to become key sites for public health intervention. By offering all forms of effective medication to incarcerated people with opioid use disorder, they can help break the cycle of addiction and save lives.

The study, “Medications for Opioid Use Disorder in County Jails — Outcomes after Release,” was authored by Peter D. Friedmann, Donna Wilson, Thomas J. Stopka, Dana Bernson, Ekaterina Pivovarova, Warren Ferguson, Randall A. Hoskinson, Jr., Rebecca E. Rottapel, Benjamin Bovell‑Ammon, Ayorkor Gaba, Jake R. Morgan, Thomas Senst, Edmond Hayes, and Elizabeth A. Evans, for the MassJCOIN Research Hub.