Opioid use disorder is associated with high rates of criminal-legal involvement. Medications can help but the role of criminal histories in medication engagement and effects has yet to be fully assessed. This study examined the association between criminal-legal involvement and the effects of buprenorphine and extended-release naltrexone.
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High rates of criminal-legal involvement (also called criminal justice involvement; e.g., arrest, incarceration, law enforcement interactions) are seen among individuals with opioid use disorder. Moreover, individuals with criminal-legal involvement are more likely to experience opioid-related overdose deaths than the general population. Though the complex relationship between criminal-legal involvement and overdose risk is not fully understood, providing medication treatment to inmates with opioid use disorder, during incarceration or upon release, is shown to decrease risk of opioid-related relapse, overdose, and death. With much of this research in the criminal-legal system focused on jails and prisons, little is known about community-based initiation of medication treatment among individuals who have a history of criminal-legal involvement. To date, most studies have examined the role of criminal-legal involvement on the efficacy of buprenorphine, with mixed results. Therefore, it is unclear whether a criminal-legal history marks a different response to community-based initiation of medications other than buprenorphine treatments or patient outcomes like overdose.
Given that medication treatment outcomes are likely influenced by a multitude of individual patient factors, and that criminal-legal involvement is common among individuals with opioid use disorder, it is important to evaluate the potential impact of criminal-legal histories on medication treatment pathways and outcomes. This study examined the impact of lifetime incarceration and recent criminal-legal system involvement on opioid use disorder medication treatment outcomes, among patients receiving extended-release naltrexone versus buprenorphine treatment.
This study was a secondary analysis of data from the X:BOT trial, an open-label 24-week randomized trial comparing the effectiveness of buprenorphine (in a formulation with naloxone, also known by the brand name Suboxone) versus extended-release naltrexone (also known by the brand name Vivitrol) for opioid use disorder, conducted in the United States between 2014 and 2016. All participants in this study were ages 18 or older, had used illicit opioids in the past 30 days, and were enrolled in 1 of 8 specialty addiction treatment sites across the US for a current opioid use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients started medication in medically supervised inpatient settings, followed by 24 weeks of outpatient medication treatment.
The original trial found that buprenorphine was better than extended-release naltrexone at preventing a return to illicit opioid use (i.e. relapse). In this secondary analysis, the researchers investigated whether criminal-legal involvement influenced the effects of medication treatment (buprenorphine vs. extended-release naltrexone) on patient outcomes.
Criminal-legal involvement was assessed at baseline as: (1) recent criminal-legal involvement: any involvement with the criminal-legal system or engagement in illegal activities for profit within the past 30 days; (2) lifetime incarceration: incarceration for 1 or more months at any point during one’s lifetime. Patient outcomes included: (1) successful induction, or sufficiently beginning the medication with an initial dose of buprenorphine (required patients to exhibit significant withdrawal symptoms) or extended-release naltrexone (required 3 days of opioid abstinence, a negative opioid drug test, and a negative naloxone challenge); (2) “relapse” defined as ≥ 4 consecutive weeks of illicit opioid use as determined by a positive or missed drug test, or ≥ 7 consecutive days of self-reported illicit opioid use; (3) overdose as determined by medical records and adverse events reported by study staff. Relapse and overdose data were analyzed (1) for all patients who successfully initiated the medication they were assigned to receive (“per protocol”), and (2) for all patients assigned to a medication regardless of whether or not they successfully initiated it (“intent-to-treat”). This summary focuses on intent-to-treat findings as these reflect randomized groups constituting more scientifically rigorous tests.
Five hundred and seventy patients were randomized to receive one of the medication treatments. Among them, 58% had a history of lifetime incarceration and 60% reported recent criminal-legal involvement, which did not differ between patients assigned to buprenorphine and extended-release naltrexone conditions. Patients with a lifetime history of incarceration were more likely to be older Black men and those with recent criminal-legal involvement were more likely to be younger and White, relative to those without lifetime/recent criminal histories. Patients with a lifetime history of incarceration and recent criminal-legal involvement were more likely to have more severe opioid use disorder diagnoses and/or co-occurring psychiatric disorders than those without criminal-legal involvement.
Criminal-legal involvement was associated with reduced benefits from buprenorphine on successful induction
Consistent with the original trial and among the entire patient sample, induction was more successful with buprenorphine (94%) than with extended-release naltrexone (73%). Among patients with recent criminal-legal involvement, buprenorphine was still better than extended-release naltrexone on successful induction though to a lesser degree than for those without such involvement (75% vs. 96% increased odds of successful induction with buprenorphine relative to extended-release naltrexone, for those with and without recent criminal-legal involvement, respectively). Lifetime incarceration did not influence induction rates by medication type.
Criminal-legal involvement and incarceration did not influence the effect of medication on relapse
Overall, patients were more likely to relapse when assigned to extended-release naltrexone than buprenorphine. Descriptively, the advantage of buprenorphine was not as large for those with criminal-legal history though this did not reach statistical significance. Rates of relapse – 4 consecutive weeks or 7 consecutive days of non-medical opioid use — were 50-60% during the 24-week trial across the four sub-groups (see figure below). This effect was similar for those with and without criminal-legal involvement.
Criminal-legal involvement did influence the effect of medication on overdose
Recent criminal-legal involvement, however, did influence the effect of medication type on overdose. Patients without criminal-legal involvement had an increased risk of overdose when assigned to extended-release naltrexone (9%) compared to buprenorphine (1%), whereas patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment (extended-release naltrexone: 5%; buprenorphine: 4%). Lifetime incarceration, specifically, however, did not moderate the effect of medication on overdose rate during the trial.
In this study, recent criminal-legal involvement was associated with a reduction in the relative effectiveness of buprenorphine (vs. extended-release naltrexone) for successful induction and overdose prevention. Consistent with prior research, lifetime incarceration did not influence treatment outcomes, suggesting that the impact of criminal-legal involvement on medication treatment outcomes may apply only when such involvement is current or more recent.
Compared to extended-release naltrexone, buprenorphine induction rates were 27% points higher in patients without criminal-legal involvement, and only 19% points higher in patients with criminal-legal involvement. Buprenorphine is thought to be an easier medication to start than extended-release naltrexone because of the need for longer periods of abstinence prior to starting extended-release naltrexone. The reduced difference among those with legal involvement, however, was due not only to their lower rates of buprenorphine induction, but also to their marginally higher rates of extended-release naltrexone induction.
Reduced likelihood of successful buprenorphine induction for those with criminal-legal involvement may be partially due to personal preference or to the stigma associated with opioid agonist treatments like buprenorphine, within and outside of the criminal-legal system (e.g., “just swapping one drug for another”). Stigmatizing beliefs and attitudes among criminal-legal professionals have the potential to influence the medical decisions of individuals seeking treatment, which might encourage the avoidance of agonist treatments. Less stigma is associated with the opioid receptor-blocking extended-release naltrexone, which may have contributed to somewhat higher rates of extended-release naltrexone induction among criminal-legal involved patients. These patients may have also been more motivated to initiate treatment in an effort to avoid the legal consequences of illicit opioid use or to better comply with criminal-legal requirements (e.g., providing negative drug tests during parole). Though we might expect those with legal histories on average to have more severe opioid use disorder histories as well – which might then explain reduced benefits (e.g., those who are more chronic and severe have a harder time with all treatments, which might mute benefits) – analyses controlled for opioid use disorder severity, making this an unlikely explanation for the observed reductions in buprenorphine’s benefit for those with criminal-legal history, but did not control for chronicity. Additional research will help determine why and how criminal-legal involvement affects one’s ability and/or decision to initiate different types of medication treatment.
Buprenorphine’s advantage on overdose prevention (relative to extended-release naltrexone) was also reduced among those with recent criminal-legal involvement. This could be explained by lower buprenorphine induction rates among those with criminal-legal involvement – overdose benefits were lower because they had a harder time starting the medication. However, this effect of criminal justice involvement was apparent (though not significant) when examining only those who successfully started their assigned medication, which means induction success didn’t fully explain this finding. There may be additional individual patient characteristics (e.g., gender, motivation for treatment) and treatment factors (medication regimen, adherence, route/frequency of administration) that influence overdose risk and demand further investigation.
Interestingly, criminal involvement did not influence the relationship between medication treatment and relapse. Though one would expect findings for relapse to parallel findings for overdose, disparate findings here may be due to the way relapse was defined, as 4 consecutive weeks of illicit opioid use determined by drug testing or 7 consecutive days of illicit opioid use determined by self-report. These ways of defining relapse reflect a relatively higher bar for the duration of opioid use, which is more in line with how relapse is defined in the real world.
Recent criminal-legal involvement was associated with reductions in the advantage of buprenorphine compared to extended-release naltrexone on successful treatment induction (i.e. medication initiation) and overdose prevention. Relative to those without recent criminal-legal involvement, individuals with recent criminal involvement may be less likely to successfully initiate buprenorphine and more likely to initiate extended-release naltrexone, perhaps due to personal preference or to the stigma of agonist treatments like buprenorphine in criminal-legal settings. In addition, patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment, whereas patients without criminal involvement had an increased risk of overdose when assigned to extended-release naltrexone, as opposed to buprenorphine. Findings emphasize the importance of individual patient factors in treatment planning and underscore the variability in medication treatment outcomes that can occur as a result of individual patient history and characteristics.
Balter, D. R., Puglisi, L. B., Dziura, J., Fiellin, D. A., & Howell, B. A. (2024). Buprenorphine-naloxone vs. extended-release naltrexone for opioid use disorder in individuals with and without criminal-legal involvement: A secondary analysis of the X:BOT randomized controlled trial. Journal of Substance Use and Addiction Treatment, 164. doi: 10.1016/j.josat.2024.209438.
l
High rates of criminal-legal involvement (also called criminal justice involvement; e.g., arrest, incarceration, law enforcement interactions) are seen among individuals with opioid use disorder. Moreover, individuals with criminal-legal involvement are more likely to experience opioid-related overdose deaths than the general population. Though the complex relationship between criminal-legal involvement and overdose risk is not fully understood, providing medication treatment to inmates with opioid use disorder, during incarceration or upon release, is shown to decrease risk of opioid-related relapse, overdose, and death. With much of this research in the criminal-legal system focused on jails and prisons, little is known about community-based initiation of medication treatment among individuals who have a history of criminal-legal involvement. To date, most studies have examined the role of criminal-legal involvement on the efficacy of buprenorphine, with mixed results. Therefore, it is unclear whether a criminal-legal history marks a different response to community-based initiation of medications other than buprenorphine treatments or patient outcomes like overdose.
Given that medication treatment outcomes are likely influenced by a multitude of individual patient factors, and that criminal-legal involvement is common among individuals with opioid use disorder, it is important to evaluate the potential impact of criminal-legal histories on medication treatment pathways and outcomes. This study examined the impact of lifetime incarceration and recent criminal-legal system involvement on opioid use disorder medication treatment outcomes, among patients receiving extended-release naltrexone versus buprenorphine treatment.
This study was a secondary analysis of data from the X:BOT trial, an open-label 24-week randomized trial comparing the effectiveness of buprenorphine (in a formulation with naloxone, also known by the brand name Suboxone) versus extended-release naltrexone (also known by the brand name Vivitrol) for opioid use disorder, conducted in the United States between 2014 and 2016. All participants in this study were ages 18 or older, had used illicit opioids in the past 30 days, and were enrolled in 1 of 8 specialty addiction treatment sites across the US for a current opioid use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients started medication in medically supervised inpatient settings, followed by 24 weeks of outpatient medication treatment.
The original trial found that buprenorphine was better than extended-release naltrexone at preventing a return to illicit opioid use (i.e. relapse). In this secondary analysis, the researchers investigated whether criminal-legal involvement influenced the effects of medication treatment (buprenorphine vs. extended-release naltrexone) on patient outcomes.
Criminal-legal involvement was assessed at baseline as: (1) recent criminal-legal involvement: any involvement with the criminal-legal system or engagement in illegal activities for profit within the past 30 days; (2) lifetime incarceration: incarceration for 1 or more months at any point during one’s lifetime. Patient outcomes included: (1) successful induction, or sufficiently beginning the medication with an initial dose of buprenorphine (required patients to exhibit significant withdrawal symptoms) or extended-release naltrexone (required 3 days of opioid abstinence, a negative opioid drug test, and a negative naloxone challenge); (2) “relapse” defined as ≥ 4 consecutive weeks of illicit opioid use as determined by a positive or missed drug test, or ≥ 7 consecutive days of self-reported illicit opioid use; (3) overdose as determined by medical records and adverse events reported by study staff. Relapse and overdose data were analyzed (1) for all patients who successfully initiated the medication they were assigned to receive (“per protocol”), and (2) for all patients assigned to a medication regardless of whether or not they successfully initiated it (“intent-to-treat”). This summary focuses on intent-to-treat findings as these reflect randomized groups constituting more scientifically rigorous tests.
Five hundred and seventy patients were randomized to receive one of the medication treatments. Among them, 58% had a history of lifetime incarceration and 60% reported recent criminal-legal involvement, which did not differ between patients assigned to buprenorphine and extended-release naltrexone conditions. Patients with a lifetime history of incarceration were more likely to be older Black men and those with recent criminal-legal involvement were more likely to be younger and White, relative to those without lifetime/recent criminal histories. Patients with a lifetime history of incarceration and recent criminal-legal involvement were more likely to have more severe opioid use disorder diagnoses and/or co-occurring psychiatric disorders than those without criminal-legal involvement.
Criminal-legal involvement was associated with reduced benefits from buprenorphine on successful induction
Consistent with the original trial and among the entire patient sample, induction was more successful with buprenorphine (94%) than with extended-release naltrexone (73%). Among patients with recent criminal-legal involvement, buprenorphine was still better than extended-release naltrexone on successful induction though to a lesser degree than for those without such involvement (75% vs. 96% increased odds of successful induction with buprenorphine relative to extended-release naltrexone, for those with and without recent criminal-legal involvement, respectively). Lifetime incarceration did not influence induction rates by medication type.
Criminal-legal involvement and incarceration did not influence the effect of medication on relapse
Overall, patients were more likely to relapse when assigned to extended-release naltrexone than buprenorphine. Descriptively, the advantage of buprenorphine was not as large for those with criminal-legal history though this did not reach statistical significance. Rates of relapse – 4 consecutive weeks or 7 consecutive days of non-medical opioid use — were 50-60% during the 24-week trial across the four sub-groups (see figure below). This effect was similar for those with and without criminal-legal involvement.
Criminal-legal involvement did influence the effect of medication on overdose
Recent criminal-legal involvement, however, did influence the effect of medication type on overdose. Patients without criminal-legal involvement had an increased risk of overdose when assigned to extended-release naltrexone (9%) compared to buprenorphine (1%), whereas patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment (extended-release naltrexone: 5%; buprenorphine: 4%). Lifetime incarceration, specifically, however, did not moderate the effect of medication on overdose rate during the trial.
In this study, recent criminal-legal involvement was associated with a reduction in the relative effectiveness of buprenorphine (vs. extended-release naltrexone) for successful induction and overdose prevention. Consistent with prior research, lifetime incarceration did not influence treatment outcomes, suggesting that the impact of criminal-legal involvement on medication treatment outcomes may apply only when such involvement is current or more recent.
Compared to extended-release naltrexone, buprenorphine induction rates were 27% points higher in patients without criminal-legal involvement, and only 19% points higher in patients with criminal-legal involvement. Buprenorphine is thought to be an easier medication to start than extended-release naltrexone because of the need for longer periods of abstinence prior to starting extended-release naltrexone. The reduced difference among those with legal involvement, however, was due not only to their lower rates of buprenorphine induction, but also to their marginally higher rates of extended-release naltrexone induction.
Reduced likelihood of successful buprenorphine induction for those with criminal-legal involvement may be partially due to personal preference or to the stigma associated with opioid agonist treatments like buprenorphine, within and outside of the criminal-legal system (e.g., “just swapping one drug for another”). Stigmatizing beliefs and attitudes among criminal-legal professionals have the potential to influence the medical decisions of individuals seeking treatment, which might encourage the avoidance of agonist treatments. Less stigma is associated with the opioid receptor-blocking extended-release naltrexone, which may have contributed to somewhat higher rates of extended-release naltrexone induction among criminal-legal involved patients. These patients may have also been more motivated to initiate treatment in an effort to avoid the legal consequences of illicit opioid use or to better comply with criminal-legal requirements (e.g., providing negative drug tests during parole). Though we might expect those with legal histories on average to have more severe opioid use disorder histories as well – which might then explain reduced benefits (e.g., those who are more chronic and severe have a harder time with all treatments, which might mute benefits) – analyses controlled for opioid use disorder severity, making this an unlikely explanation for the observed reductions in buprenorphine’s benefit for those with criminal-legal history, but did not control for chronicity. Additional research will help determine why and how criminal-legal involvement affects one’s ability and/or decision to initiate different types of medication treatment.
Buprenorphine’s advantage on overdose prevention (relative to extended-release naltrexone) was also reduced among those with recent criminal-legal involvement. This could be explained by lower buprenorphine induction rates among those with criminal-legal involvement – overdose benefits were lower because they had a harder time starting the medication. However, this effect of criminal justice involvement was apparent (though not significant) when examining only those who successfully started their assigned medication, which means induction success didn’t fully explain this finding. There may be additional individual patient characteristics (e.g., gender, motivation for treatment) and treatment factors (medication regimen, adherence, route/frequency of administration) that influence overdose risk and demand further investigation.
Interestingly, criminal involvement did not influence the relationship between medication treatment and relapse. Though one would expect findings for relapse to parallel findings for overdose, disparate findings here may be due to the way relapse was defined, as 4 consecutive weeks of illicit opioid use determined by drug testing or 7 consecutive days of illicit opioid use determined by self-report. These ways of defining relapse reflect a relatively higher bar for the duration of opioid use, which is more in line with how relapse is defined in the real world.
Recent criminal-legal involvement was associated with reductions in the advantage of buprenorphine compared to extended-release naltrexone on successful treatment induction (i.e. medication initiation) and overdose prevention. Relative to those without recent criminal-legal involvement, individuals with recent criminal involvement may be less likely to successfully initiate buprenorphine and more likely to initiate extended-release naltrexone, perhaps due to personal preference or to the stigma of agonist treatments like buprenorphine in criminal-legal settings. In addition, patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment, whereas patients without criminal involvement had an increased risk of overdose when assigned to extended-release naltrexone, as opposed to buprenorphine. Findings emphasize the importance of individual patient factors in treatment planning and underscore the variability in medication treatment outcomes that can occur as a result of individual patient history and characteristics.
Balter, D. R., Puglisi, L. B., Dziura, J., Fiellin, D. A., & Howell, B. A. (2024). Buprenorphine-naloxone vs. extended-release naltrexone for opioid use disorder in individuals with and without criminal-legal involvement: A secondary analysis of the X:BOT randomized controlled trial. Journal of Substance Use and Addiction Treatment, 164. doi: 10.1016/j.josat.2024.209438.
l
High rates of criminal-legal involvement (also called criminal justice involvement; e.g., arrest, incarceration, law enforcement interactions) are seen among individuals with opioid use disorder. Moreover, individuals with criminal-legal involvement are more likely to experience opioid-related overdose deaths than the general population. Though the complex relationship between criminal-legal involvement and overdose risk is not fully understood, providing medication treatment to inmates with opioid use disorder, during incarceration or upon release, is shown to decrease risk of opioid-related relapse, overdose, and death. With much of this research in the criminal-legal system focused on jails and prisons, little is known about community-based initiation of medication treatment among individuals who have a history of criminal-legal involvement. To date, most studies have examined the role of criminal-legal involvement on the efficacy of buprenorphine, with mixed results. Therefore, it is unclear whether a criminal-legal history marks a different response to community-based initiation of medications other than buprenorphine treatments or patient outcomes like overdose.
Given that medication treatment outcomes are likely influenced by a multitude of individual patient factors, and that criminal-legal involvement is common among individuals with opioid use disorder, it is important to evaluate the potential impact of criminal-legal histories on medication treatment pathways and outcomes. This study examined the impact of lifetime incarceration and recent criminal-legal system involvement on opioid use disorder medication treatment outcomes, among patients receiving extended-release naltrexone versus buprenorphine treatment.
This study was a secondary analysis of data from the X:BOT trial, an open-label 24-week randomized trial comparing the effectiveness of buprenorphine (in a formulation with naloxone, also known by the brand name Suboxone) versus extended-release naltrexone (also known by the brand name Vivitrol) for opioid use disorder, conducted in the United States between 2014 and 2016. All participants in this study were ages 18 or older, had used illicit opioids in the past 30 days, and were enrolled in 1 of 8 specialty addiction treatment sites across the US for a current opioid use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients started medication in medically supervised inpatient settings, followed by 24 weeks of outpatient medication treatment.
The original trial found that buprenorphine was better than extended-release naltrexone at preventing a return to illicit opioid use (i.e. relapse). In this secondary analysis, the researchers investigated whether criminal-legal involvement influenced the effects of medication treatment (buprenorphine vs. extended-release naltrexone) on patient outcomes.
Criminal-legal involvement was assessed at baseline as: (1) recent criminal-legal involvement: any involvement with the criminal-legal system or engagement in illegal activities for profit within the past 30 days; (2) lifetime incarceration: incarceration for 1 or more months at any point during one’s lifetime. Patient outcomes included: (1) successful induction, or sufficiently beginning the medication with an initial dose of buprenorphine (required patients to exhibit significant withdrawal symptoms) or extended-release naltrexone (required 3 days of opioid abstinence, a negative opioid drug test, and a negative naloxone challenge); (2) “relapse” defined as ≥ 4 consecutive weeks of illicit opioid use as determined by a positive or missed drug test, or ≥ 7 consecutive days of self-reported illicit opioid use; (3) overdose as determined by medical records and adverse events reported by study staff. Relapse and overdose data were analyzed (1) for all patients who successfully initiated the medication they were assigned to receive (“per protocol”), and (2) for all patients assigned to a medication regardless of whether or not they successfully initiated it (“intent-to-treat”). This summary focuses on intent-to-treat findings as these reflect randomized groups constituting more scientifically rigorous tests.
Five hundred and seventy patients were randomized to receive one of the medication treatments. Among them, 58% had a history of lifetime incarceration and 60% reported recent criminal-legal involvement, which did not differ between patients assigned to buprenorphine and extended-release naltrexone conditions. Patients with a lifetime history of incarceration were more likely to be older Black men and those with recent criminal-legal involvement were more likely to be younger and White, relative to those without lifetime/recent criminal histories. Patients with a lifetime history of incarceration and recent criminal-legal involvement were more likely to have more severe opioid use disorder diagnoses and/or co-occurring psychiatric disorders than those without criminal-legal involvement.
Criminal-legal involvement was associated with reduced benefits from buprenorphine on successful induction
Consistent with the original trial and among the entire patient sample, induction was more successful with buprenorphine (94%) than with extended-release naltrexone (73%). Among patients with recent criminal-legal involvement, buprenorphine was still better than extended-release naltrexone on successful induction though to a lesser degree than for those without such involvement (75% vs. 96% increased odds of successful induction with buprenorphine relative to extended-release naltrexone, for those with and without recent criminal-legal involvement, respectively). Lifetime incarceration did not influence induction rates by medication type.
Criminal-legal involvement and incarceration did not influence the effect of medication on relapse
Overall, patients were more likely to relapse when assigned to extended-release naltrexone than buprenorphine. Descriptively, the advantage of buprenorphine was not as large for those with criminal-legal history though this did not reach statistical significance. Rates of relapse – 4 consecutive weeks or 7 consecutive days of non-medical opioid use — were 50-60% during the 24-week trial across the four sub-groups (see figure below). This effect was similar for those with and without criminal-legal involvement.
Criminal-legal involvement did influence the effect of medication on overdose
Recent criminal-legal involvement, however, did influence the effect of medication type on overdose. Patients without criminal-legal involvement had an increased risk of overdose when assigned to extended-release naltrexone (9%) compared to buprenorphine (1%), whereas patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment (extended-release naltrexone: 5%; buprenorphine: 4%). Lifetime incarceration, specifically, however, did not moderate the effect of medication on overdose rate during the trial.
In this study, recent criminal-legal involvement was associated with a reduction in the relative effectiveness of buprenorphine (vs. extended-release naltrexone) for successful induction and overdose prevention. Consistent with prior research, lifetime incarceration did not influence treatment outcomes, suggesting that the impact of criminal-legal involvement on medication treatment outcomes may apply only when such involvement is current or more recent.
Compared to extended-release naltrexone, buprenorphine induction rates were 27% points higher in patients without criminal-legal involvement, and only 19% points higher in patients with criminal-legal involvement. Buprenorphine is thought to be an easier medication to start than extended-release naltrexone because of the need for longer periods of abstinence prior to starting extended-release naltrexone. The reduced difference among those with legal involvement, however, was due not only to their lower rates of buprenorphine induction, but also to their marginally higher rates of extended-release naltrexone induction.
Reduced likelihood of successful buprenorphine induction for those with criminal-legal involvement may be partially due to personal preference or to the stigma associated with opioid agonist treatments like buprenorphine, within and outside of the criminal-legal system (e.g., “just swapping one drug for another”). Stigmatizing beliefs and attitudes among criminal-legal professionals have the potential to influence the medical decisions of individuals seeking treatment, which might encourage the avoidance of agonist treatments. Less stigma is associated with the opioid receptor-blocking extended-release naltrexone, which may have contributed to somewhat higher rates of extended-release naltrexone induction among criminal-legal involved patients. These patients may have also been more motivated to initiate treatment in an effort to avoid the legal consequences of illicit opioid use or to better comply with criminal-legal requirements (e.g., providing negative drug tests during parole). Though we might expect those with legal histories on average to have more severe opioid use disorder histories as well – which might then explain reduced benefits (e.g., those who are more chronic and severe have a harder time with all treatments, which might mute benefits) – analyses controlled for opioid use disorder severity, making this an unlikely explanation for the observed reductions in buprenorphine’s benefit for those with criminal-legal history, but did not control for chronicity. Additional research will help determine why and how criminal-legal involvement affects one’s ability and/or decision to initiate different types of medication treatment.
Buprenorphine’s advantage on overdose prevention (relative to extended-release naltrexone) was also reduced among those with recent criminal-legal involvement. This could be explained by lower buprenorphine induction rates among those with criminal-legal involvement – overdose benefits were lower because they had a harder time starting the medication. However, this effect of criminal justice involvement was apparent (though not significant) when examining only those who successfully started their assigned medication, which means induction success didn’t fully explain this finding. There may be additional individual patient characteristics (e.g., gender, motivation for treatment) and treatment factors (medication regimen, adherence, route/frequency of administration) that influence overdose risk and demand further investigation.
Interestingly, criminal involvement did not influence the relationship between medication treatment and relapse. Though one would expect findings for relapse to parallel findings for overdose, disparate findings here may be due to the way relapse was defined, as 4 consecutive weeks of illicit opioid use determined by drug testing or 7 consecutive days of illicit opioid use determined by self-report. These ways of defining relapse reflect a relatively higher bar for the duration of opioid use, which is more in line with how relapse is defined in the real world.
Recent criminal-legal involvement was associated with reductions in the advantage of buprenorphine compared to extended-release naltrexone on successful treatment induction (i.e. medication initiation) and overdose prevention. Relative to those without recent criminal-legal involvement, individuals with recent criminal involvement may be less likely to successfully initiate buprenorphine and more likely to initiate extended-release naltrexone, perhaps due to personal preference or to the stigma of agonist treatments like buprenorphine in criminal-legal settings. In addition, patients with recent criminal-legal involvement had similar rates of overdose regardless of medication assignment, whereas patients without criminal involvement had an increased risk of overdose when assigned to extended-release naltrexone, as opposed to buprenorphine. Findings emphasize the importance of individual patient factors in treatment planning and underscore the variability in medication treatment outcomes that can occur as a result of individual patient history and characteristics.
Balter, D. R., Puglisi, L. B., Dziura, J., Fiellin, D. A., & Howell, B. A. (2024). Buprenorphine-naloxone vs. extended-release naltrexone for opioid use disorder in individuals with and without criminal-legal involvement: A secondary analysis of the X:BOT randomized controlled trial. Journal of Substance Use and Addiction Treatment, 164. doi: 10.1016/j.josat.2024.209438.
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