Starting medication for opioid use disorder prior to prison release substantially reduces overdose deaths

Individuals with opioid use disorder being released from prison are at particularly high risk for fatal overdose, yet virtually no U.S. correctional facilities initiate or continue medications for addiction treatment that would protect people against overdose following release from prison. This study explored whether a novel program in the state of Rhode Island that continued inmates’ opioid use disorder medications led to decreased drug overdoses.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Opioid overdose among individuals recently released from prison is a massive problem. In 2016, the state of Rhode Island introduced a new model of care for inmates with opioid use disorder that includes providing medications for addiction treatment (e.g., methadone, buprenorphine, or naltrexone) both during incarceration, and immediately following release, to reduce individuals’ risk of overdose following release from prison. This paper reports preliminary data speaking to the potential benefits of this program.

HOW WAS THIS STUDY CONDUCTED?

STUDY SETTING: In 2016, the state of Rhode Island introduced a new model of care for inmates with opioid use disorder that includes screening and structured treatment with medication known to support opioid use disorder recovery, and/or reduce overdose risk immediately after prison release. In this model, individuals arriving into Rhode Island correctional facilities currently receiving medication for opioid use disorder are maintained on their medication regimen, which is contrary to the typical practice in US prisons of taking inmates off addiction treatment medications. Additionally, a system of 12 community-located centers of excellence for opioid use disorder outpatient care has been established to promote transitions and referrals of inmates released from Rhode Island correctional facilities. Ultimately the goal of this program is to prevent inmates relapsing to opioid use after release from prison, and critically, to reduce the high incidence of post-incarceration overdose deaths caused by individuals being released from prison with reduced physiological tolerance to opiates, and no medication to protect them.
STUDY DESIGN: The authors conducted what’s known as a retrospective cohort analysis that linked data from the Rhode Island Office of State Medical Examiners for all unintentional deaths from overdose occurring from January 1 to June 30, 2016, and from January 1 to June 30, 2017, to data on prisoner releases from Rhode Island correctional facilities. Their analysis—designed to be preliminary in nature—compared overall overdose fatalities in the state of Rhode Island in the first half of 2017 (January 1 to June 30, 2017) to the same period a year before implementation of the new program (January 1 to June 30, 2016). The authors gave special consideration to the number of these deaths involving individuals who had recently been released from prison, and had died within 12 months of prison release.

WHAT DID THIS STUDY FIND?

Overall overdose deaths decreased from 2016 to 2017: Statewide in Rhode Island, there were 179 overdose deaths from January 1, 2016, to June 30, 2016, compared with 157 overdose deaths during the same period in 2017, a reduction of 12.3%. Notably, most of these overdose deaths were fentanyl-related.

Prescription of opioid addiction treatment medications increased from 2016 to 2017: In line with the intervention’s goal, the monthly receipt of medications such as Suboxone and methadone increased for individuals recently released from prison. The provision of naloxone—a medication that reverses the effects of opiate overdose—declined however, perhaps because prescribers were less concerned about relapse and overdose because individuals were receiving appropriate medications.

Overdose deaths among individuals recently released from prison decreased from 2016 to 2017: Even though the total number of incarceration admissions and releases were similar in 2016 and 2017, in the 2016 period 26 of 179 individuals (14.5%) who died of an overdose were recently incarcerated compared with 9 of 157 individuals (5.7%) in the 2017 period. This represents a 60.5% reduction in mortality.

Further, the number of people dying within the first 30 days of release from prison decreased from 10 individuals over the first 6 months of 2016, to 1 during the same period in 2017 following implementation of the new program.

Taken together, these results indicate that for every 11 inmates treated under the new system, 1 death from overdose was prevented.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Results from this study indicate the state of Rhode Island experienced a large and clinically meaningful reduction in post-incarceration deaths from overdose among prisoners being released from jail following implementation of this new model of care for inmates with opioid use disorder. This reduction in deaths resulted in a meaningful decline in overdose deaths state-wide.

Notably, reductions in deaths were observed in the year this program was implemented, in spite of the fact less prisoners were released with naloxone that year (presumably because prison staff were less concerned about overdose risk in inmates being released from prison because they were maintained on relapse and overdose buffering medications such as buprenorphine).

The authors highlight that these results are consistent with other studies of the provision of medication for opioid use disorder during and immediately following incarceration, such as a UK study that found individuals being released from prison with opioid use disorder medications were 75% less likely than those without medications to die from overdose.

Possible alternative explanations for the observed reductions in overdose deaths such as the provision of naloxone were not supported, since naloxone provision actually declined from 2016 to 2017.

LIMITATIONS

The authors note that the study was limited by the small sample size (in comparison to epidemiological studies like this that often sample thousands of individuals).
They also recognize that complete medication data may not have been available for the deceased, and possible misclassification of program exposure (e.g., some individuals with opioid use disorder may have not disclosed they had opioid use disorder).
It should also be noted that although it is likely that the observed reductions in overdose deaths were related to the intervention, it is possible that additional environmental or population-level factors not measured or controlled for in this observational study could have been responsible for the differences in overdose deaths.

BOTTOM LINE

For individuals & families seeking recovery: Medications such as methadone, buprenorphine, or naltrexone reduce relapse risk and dramatically reduce the risk for opioid relapse and overdose. The first 6 months after prison release is a particularly vulnerable time for individuals with opioid use disorder as in most instances inmates have not had access to opioids or supportive medications, and as such, will typically have reduced opioid tolerance. Reduced tolerance means that doses once considered low risk to the individual, may produce an overdose. Medications such as methadone and buprenorphine can help reduce relapse risk because they provide partial stimulation of the brain’s opioid receptors, thus reducing opioid craving. Further, medications such as buprenorphine and naltrexone can directly reduce overdose risks because they partially block opioid receptors in the brain.
For scientists: This retrospective cohort analysis adds to the growing body of evidence supporting the use of pharmacotherapy for opioid use disorder in incarcerated individuals and those recently released from prison. While more work is needed on the effects of opioid use disorder medication in criminal justice settings, given the accumulating evidence suggesting the potential of medication to reduce fatal overdose post-release from prison, it may be helpful to work with policy makers to integrate medications into prison-based drug treatment. In addition, future research might help determine what is needed to maintain the benefit of medication on overdose death post-release.
For policy makers: It is well appreciated that medications such as methadone, buprenorphine, or naltrexone reduce relapse risk and dramatically reduce the risk for opioid relapse and overdose. This paper, and others like it, show that maintaining individuals with opioid use disorder on these potentially life-saving medications while they are incarcerated, and ensuring they have access to these medications after release from prison is critical for buffering this particularly vulnerable population from overdose risk.
For treatment professionals and treatment systems: The first 6 months after prison release are a particularly vulnerable time for individuals with opioid use disorder. Providers working with this population should ensure that individuals suffering from opioid use disorder have access to medications such as methadone, buprenorphine, or naltrexone.