The U.S. saw its highest number of overdose deaths—more than 93,000—in 2020. One significant risk factor for overdose is recent incarceration, yet few people have access to effective treatment while incarcerated. In this Q&A, adapted from the August 13 episode of Public Health On Call, Joshua Sharfstein, MD, speaks with Brendan Saloner, PhD, a Bloomberg Associate Professor of American Health in the Department of Health Policy and Management, about preventing overdose deaths by expanding access to medications for treating opioid use disorder in jails and prisons. Saloner highlights a new report that outlines a path forward.
Among the different strategies to save lives from the overdose epidemic is a renewed focus on people who are incarcerated. Why has that become such a focus?
BS: The short answer is that people who are incarcerated are at very high risk of overdose. Many people who have an opioid use disorder—and that population is certainly overrepresented in jails and prisons—often undergo forced withdrawal when they are incarcerated. That forced withdrawal dramatically increases the risk that they will fatally overdose if they go back to using drugs after they are released from jail or prison. So, it's an incredibly important moment to potentially change the trajectory of someone's life when they're incarcerated.
I don’t think the most therapeutic place to treat people with opiate addiction is in jail or prison, and we would like to see more people being treated outside of that context. But there is so much opportunity to save people's lives when they're incarcerated by giving them access to evidence-based treatment.
Can you tell me more about that treatment?
BS: Sure. Treatment with medication is the gold standard treatment for opioid use disorders. Three medications are currently approved by the FDA: methadone, buprenorphine, and naltrexone. Each of those medications has been shown to substantially reduce risk of overdose.
The key thing is that there's no wrong moment to start people on medication treatment. The treatment can start basically from the moment they're incarcerated and hopefully follow them into the community after release.
How effective is the medication treatment?
BS: Methadone and buprenorphine medication treatment reduces the risk of overdose by more than 50% compared to treatment without medication. Medication is a huge lifesaving intervention for many people.
How common is it to get these lifesaving treatments?
BS: We don't have any hard data on this question. I would say that it is certainly not the standard of care right now for incarcerated people to get access to [these] medications. There are a few facilities that are in the vanguard—jails like Rikers Island in New York or the Rhode Island Department of Corrections—that have been providing medication as the standard of care. What we can say from those places is that it takes a lot of logistical change—it takes a lot of implementation work—but it can be done. It’s something that we'd like to see happen universally, but there are some real steps that have to be undertaken to make it widely accessible for people who are incarcerated.
Can you walk me through some of those steps?
BS: Our team put out a report [in July] based on a convening we did with experts from across the spectrum to identify key challenges that need to be overcome. Basically, we broke it down into five key challenges, one of those being controlled substance regulations. Methadone is a highly controlled medication that can only be dispensed through specialty clinics. So, if you want to provide methadone as a medication for incarcerated people, you need to have one of those kinds of programs either set up, or a close partnership with one of those programs in jail and prison. Many facilities have worked through the logistical challenges, but there's so much regulation and red tape that has to be overcome to actually get the medicine to the patients.
Would policy change just make it easier for jails and prisons to provide access to this treatment?
BS: Absolutely, and some things can be done in the very near term to pave the path for greater access to these medications in jails and prisons. We see a lot of opportunity to change the laws, to make it easier to get that medicine to the patients.
What other things can be done differently?
BS: Another one is culture. There is a lot of work to be done in changing the attitudes around addiction for incarcerated people and toward people who have an opiate addiction. We need to reframe the issue so that it's understood to be a medical condition that can be treated, rather than a failing of a person's character. We also need to destigmatize the medications, which are often incorrectly seen as either being a crutch or substituting one addiction for another, which is absolutely not how they work. Again, many jails and prisons have done that work of trying to change the culture, and it's made a big difference.
What is the trajectory for getting more jails and prisons on board? What has to happen?
BS: One thing that's happening in a very real way is litigation. Lawsuits are showing that [not providing treatment for addiction] is a violation of the Americans with Disabilities Act and may also be a violation of the Eighth Amendment of the U.S. Constitution, which prohibits cruel and unusual punishment of people who are incarcerated. People have been bringing those lawsuits—and winning those lawsuits—and that's made a big difference.
It's also important to try to get more voluntary change, and we're seeing voluntary change encouraged through resources from states, from localities, trying to get government bought in and saying, “Let's pay a little extra money to get this going because it's an investment that will ultimately pay for itself.”
Do there need to be more sources of funding for this kind of work? Are the resources adequate?
BS: It’s something that has to get budgeted for, and unfortunately, correctional medicine is always a little under-budgeted. Money has to be set aside for these programs, but they might not be as expensive as many people fear—[especially] when you think about potential cost savings. You see lower recidivism and better outcomes after release. It's a big chance to ultimately save some money by spending a little bit up front.
Maybe with the settlements from opioid litigation and some of other federal funding, if states and localities can put some money to this, they'll find that not only are the jails experiencing fewer problems, but fewer people suddenly show back up after release because they're able to transition to treatment and recovery.
Joshua Sharfstein, MD, is the vice dean for Public Health Practice and Community Engagement and a professor in Health Policy and Management. He is also the director of the Bloomberg American Health Initiative and a host of the Public Health On Call podcast.