Cascade of Care in the Legal System: Best Practices and Goals for Agencies Providing Care to Patients Concurrently Navigating Substance Use Disorders and Criminal Legal Involvement

Abstract

Fewer than 1% of United States’ largest corrections facilities allow access to MOUD. The cascade of care is an organizing framework that quantifies treatment processes within and across systems of care ranging from screening to treatment discharge. This study highlights best practices for the implementation of MOUD across the cascade of care, addressing unique characteristics of legal settings and individuals within them. After reviewing best-practices for MOUD implementation in legal settings and examining jail and community provider’s use of and goals toward improving these practices, this study concludes that despite interest from agencies to improve care considerable variation remains in treatment availability between agencies and within agencies at different stages of incarceration. Seamless systems of care require multiagency collaboration, staff and provider competency, and patient awareness of MOUD. These strategies will decrease punishment-oriented ideologies surrounding MOUD application in justice settings and improve access to resources that remove barriers to care.

Keywords

opioid use disorder (OUD)medications for opioid use disorder (MOUD)cascade of care jails community provider behavioral health treatment

Introduction

Opioid overdoses have accounted for as many American deaths as in the peak of the AIDs epidemic (Brinkley-Rubinstein et al., 2018). Since 2013, national initiatives to reduce prescription opioids have decreased overdose deaths associated with prescription opioid drugs, while synthetic opioid (e.g. fentanyl) related deaths increased 1,040% (Mattson et al., 2021). Opioid use disorder (OUD), defined by the DSM-V a the use of opioids at a level that become problematic in that is causes impairment or distress (American Psychiatric Association, 2013), disproportionately affects minorities and disadvantaged subpopulations (Brinkley-Rubinstein et al., 2018). Among those most greatly impacted by this epidemic are individuals involved in the criminal legal system.

Individuals housed in criminal legal settings, such as jails and prisons, experience behavioral health disorders at higher rates than the general population. Most recent estimates are that 45% of individuals in federal facilities (Mumola & Karberg, 2006), 58% of those in state facilities, and 63% in county jails (Bronson, 2017) met criteria for drug dependence and abuse. These number are starkly different than the 5% of the general population (Bronson, 2017). Providing quality treatment can reduce recidivism and help individuals address behavioral health issues; however, only 11% of people receive any type of behavioral health treatment during incarceration (de Andrade et al., 2018; Evans et al., 2022b; Taxman et al., 2007; The National Center on Addiction and Substance Abuse at Columbia University, 2010). Access to treatment is further restricted in justice settings where less than 1% of United States’ 5,000+ prisons and jails allow access to medications to treat opioid use disorder (MOUD) that have been approved by the FDA and supported by addiction experts as a gold standard for OUD treatment (Vestal, 2018). Among those that do allow access to MOUD, 75% of facilities only provide medication to pregnant people (Toyoshima et al., 2021). The consequences of not providing treatment or allowing continuation of medications are deadly. Relative to the overdose risk for the general population, released individuals are 12.7 times more likely to die in the first two weeks following release from prison due to accidental drug overdose (Binswanger et al., 2007).

The cascade of care is a framework that quantifies the treatment process within and across systems of care ranging from screening to treatment discharge. The cascade of care approach has been used successfully for HIV/AIDs, hepatitis C, tuberculosis, and diabetes to track treatment, identify gaps, and implement improvements in the continuum of care (Ali et al., 2014; Kazemian et al., 2019; O’Donnell & Mathema, 2022; Prabhakar & Kwo, 2019; Subbaraman et al., 2020; Thomas, 2020). This framework has been used to understand and improve care for substance use disorders (SUD) in the community and in criminal legal settings (Dennis et al., 2019; Mintz et al., 2020). A common finding across settings is that many individuals are screened for alcohol or substance use disorders and identified as being in need of treatment, yet few are appropriately referred to services and even fewer engage with treatment, either behavioral health or medicinal (Dennis et al., 2019; Mintz et al., 2020; Williams, et al., 2019).

Recent policy attention within criminal legal settings (i.e. jails, prisons, and community corrections) has been devoted to allowing for and/or expand the use of MOUD (see National Drug Control Strategy, 2022). The unique characteristics of punishment-oriented criminal legal settings requires adapted principles underscoring the cascade of care. This paper serves to: (1) provide a detailed application of each stage of the cascade of care using best and/or evidence-informed practices; (2) review the utilization of, and goals toward, these practices in 49 settings that participated in a study of MOUD implementation strategies; and (3) offer guidance to advance practices based on the practical realities of criminal legal settings. This will build on the work of Scott et al. (2022) and Ludwig et al., (2022) by integrating the cascade of care framework to the discussion of best-practices in implementation of MOUD—a necessary step in order to facilitate agencies in pinpointing problem areas and more efficiently progress patients through the cascade toward recovery.

The (Unique) Context of Care for Criminal Legal Settings and Clients

Individuals involved with the criminal legal system present with a number of behavioral and/or physical health disorders. Individuals tend to have comorbid conditions with elevated rates of substance use disorders, mental health disorders, physical ailments, and social and educational deficits (Bronson, 2017; Cloud et al., 2014). Involvement in the criminal legal system can exaggerate these comorbid conditions due to coerced mobility—the involuntary movement in and out of the justice system—and collateral consequences such as interruption of medications, treatment regimes, instability in housing and employment, and disruption to social supports (Kirk & Wakefield, 2018). The criminal legal system has not historically held the role of being a treatment provider, but it does include a unique concentration of individuals needing services to ameliorate conditions that affect criminal behavior and social functioning.

The legal system predisposes individuals to a constant state of uncertainty due to legal procedures and embedded measures of accountability. Legal procedures (i.e. pretrial detention, court hearings, probation and parole, etc.) restrict individual’s liberties in various ways. Coupled with the uncertainty of the liberties an individual will have is the system’s use of accountability measures to ensure that individuals are not violating rules of abstinence. Drug testing for illicit drug use is commonplace (Khatri & Aronowitz, 2021), with consequences for use including incarceration or additional punishments and restrictions. Individuals on medications prior to incarceration are often unable to continue MOUD and other medications given that they are prohibited while incarcerated—a favored approach that is being altered in Massachusetts, New York, California and select states that are now mandating continuation of medications for individuals that are incarcerated. Even with mandated availability, failure to adhere to treatment protocols and/or maintain abstinence may further jeopardize access to medications, behavioral therapies, or other privileges. Hesitancy from agencies to use medications and/or offer behavioral health treatments can exacerbate stigma which furthers disrupts and discourages individuals from participating in care (Moore et al., 2022). Collectively, the legal system views medications as more of a privilege than medical necessity (Klein, 2018; Mace et al., 2020).

Best Practices for OUD Within the Cascade of Care Framework

The cascade of care typically includes six steps: (1) screening, (2) identification of a need, (3) treatment referral, (4) treatment initiation, (5) treatment engagement, and (6) treatment continuation of care (Belenko et al., 2017; Williams et al., 2018). While these features have been discussed as core principles (National Institute on Drug Abuse, 2014), application of the cascade of care regarding MOUD in criminal legal settings and for justice involved populations requires special consideration. Table 1 and the following text provides a comprehensive overview of these considerations.

Table 1.

Best practices by Cascade of Care Stage.

Screened

1. Screen every individual at the point of intake for signs of opioid misuse and withdrawal

2. Implement innovative screening and outreach strategies that reduce stigma and judgement

3. Utilize universal, systematic screening using tools that are validated and standardized

4. Use the screening process to divert non-violent individuals from the criminal/juvenile legal system and offer services as appropriate

In need of treatment

1. Do not detox people on MOUD upon arrest/incarceration

2. Do not require people on MOUD to switch medications upon arrest/incarceration

3. Meet patients where they are and provide treatment without contingencies on abstinence

Referred to treatment

1. Concurrent SUD and mental health disorders should be considered when treatment referrals are being made to ensure treatment plans are comprehensive based on patients’ needs

2. Chronic pain needs should be considered when treatment referrals are being made

3. OUD related emergency room visits and inpatient hospital stays should be followed-up with treatment referrals for all applicable needs

Initiation of treatment

1. All three FDA MOUD should be available to patients

2. Patient preference of medication should be considered. Education and counsel should be available to patients during this decision-making period

3. Facilities should be prepared to initiate MOUD treatment and continue MOUD treatment that was initiated in the community

4. Patients should never be required to switch MOUD type upon entering a facility

5. Interim MOUD or low-threshold programs should be available while care is being established in the facility

6. MOUD treatment should be initiated as soon as possible and no longer than 14 days of diagnosis, without contingencies or prerequisites

7. MOUD dosing should be carefully considered during treatment initiation

8. Telehealth, peer navigators, and staff training and working groups should all be utilized in the implementation of MOUD treatment in correctional facilities

Treatment engagement (in corrections facility)

1. Individualized dosing and continuous monitoring should occur throughout treatment

2. Other necessary biological, psychological and social services should be provided, but not required, alongside MOUD treatment

3. MOUD treatment should not be terminated for ANY reason other than if the treatment is harming the patient

4. Client accountability measures should be used when necessary to assist individuals in continuing care as safely as possible

5. Patients should be informed about the justification for accountability measure to decrease perceptions of shame or punishment. They should also be informed of the risks associated with discontinuing MOUD treatment and reengaging with opioids

Continuing care (transition to community)

1. Coordination between institutional and community service providers should be solidified and warm handoffs should be made between providers

2. Discharge planning should occur immediately upon intake or treatment initiation to ensure seamless transition of care

3. Upon release, individuals/community providers should have free access to medical records

4. Utilize harm reduction approaches such as naloxone distribution

5. Bridge prescriptions should be available upon release

6. Community-based treatment should be immediate and intense for a minimum of 6 months

7. Recovery management check-ups should occur regularly to ensure care is still meeting the patient’s needs

8. Treatment alterations or termination should be decided by the patient in consultation with their medical practitioner

General

1. Juvenile and pregnant populations should have the same guidelines and access to MOUD as adult general populations

2. Correctional staff should receive training and education about MOUD to help avoid stigma and improper medication dispersion or withholding practices

3. Develop robust evaluation approach at outset (outcome metrics, data collection, implementation processes, etc.)

4. Correctional and community treatment providers should have specific training/safeguards to prevention diversion of agonist medications

5. Staff and justice-involved individuals should receive training and resources to prevent overdose

Screening

A validated and standardized screening tool helps determine whether a more in-depth assessment is needed, how severe the need of care is, and who needs immediate care. Screening at intake—the process that occurs upon arriving to a correctional facility—can facilitate the use of early intervention programming and, when appropriate, help divert non-violent individuals to services rather than incapacitation (National Drug Control Strategy, 2022; Substance Abuse and Mental Health Services Administration, 2019). Early intervention is needed to identify those who may be experiencing, or will soon be experiencing, withdrawal (Justice Community Opioid Innovation Network, 2021b; Klein, 2018; National Drug Control Strategy, 2022; Substance Abuse and Mental Health Services Administration, 2019; Williams et al., 2019). Implementing universal, systematic screening for every individual upon arrival to a correctional or treatment facility can reduce the stigma and bias around OUD by normalizing the process and not selecting individuals based on assumptions, stereotypes, or incomplete information.

Various screening tools have been created to assist jails and community-based providers in identifying those who use and misuse opioids and other addictive substances (Curtis, 2019; Screening & Assessment Tools, 2023). Most of the standard substance use disorder screening tools do not identify drug of choice, but the TCU Drug Screen and the more involved Addiction Severity Index are two that do specify individuals primary drug of choice (Knight et al., 2002; McLellan et al., 1992). Understanding drug of choice can be useful for identifying specific risk factors and needs associated with specific drugs, individualizing treatment plans, and anticipating barriers to recovery (Clark et al., 2012).

In Need of Treatment

The second stage is determining “next steps” for those with a positive screening by tending to the needs that are driving criminogenic behavior. Because the referral process is sometimes delayed and often takes a long time, specific guidance for this group of individuals in need of treatment during the gap of time between identifying needs and initiating care is important. Understanding that a need, such as OUD, is a behavioral health concern rather than a criminal offense worthy of punishment is important when deciding on next steps for care. Offering treatment and services without requiring abstinence (unless abstinence is medically necessary for a specific medication, as with naltrexone) may help retain patients in services by decreasing pressure and expectations that may not be obtainable for those in need of treatment (Williams et al., 2019). Removing the focus from abstinence and toward initiation and retention in treatment should be the goal of anyone institution providing treatment for OUD.

Individuals who are on MOUD at the time of arrest should not be detoxed or required to change medications while in holding cells or incarceration (Justice Community Opioid Innovation Network, 2021b; National Drug Control Strategy, 2022). The cessation of MOUD will cause withdrawal and increase the risk of overdose (Rich et al., 2015). Continuation of MOUD treatment has been found to increase treatment engagement and decrease the risk of overdose (Magura et al., 2009; Moore et al., 2019; Rich et al., 2015).

Referred to Treatment

Referrals from the criminal justice system to a behavioral health system is usually the point in the cascade that has a cascading effect—if referral rates are low, then treatment initiation rates are also low, as shown by Dennis et al., (2019) and Wasserman et al., (2021). Referrals can be passive (which tells the person that they need care) or active (which identifies the provider and also sets up an appointment). Most referrals are passive which partially explains the low initiation rate, whereas active referrals (also called warm-handoffs) pave the way along the treatment cascade. Concurrent SUDs, mental health disorders, and chronic pain related needs should also be addressed during the referral process (Substance Abuse and Mental Health Services Administration, 2019; Williams et al., 2019). Although screening positive is the typical means to acquiring a referral to treatment, it is not the sole path. In the event of a substance-related emergency involving an individual in custody, referrals should be made to the appropriate treatment and services regardless of the individuals outcome at the time of screening (Williams et al., 2018). This should be the case following emergency room visits or inpatient stays.

Treatment Initiation

The fourth stage of care is initiating treatment. This refers to a variety of services including behavioral therapy and pharmacological therapies such as all three FDA approved medications for OUD—methadone, buprenorphine, and naltrexone—or some combination of services. Treatment could also be for other social services such as assistance obtaining employment, housing, food security, and so on.

Justice organizations benefit from offering all three FDA medications at all stages of the criminal legal experience (i.e. booking, during incarceration, and at release). This ensures that individuals are not forced to switch medications at different phases in the legal system. Individuals in need of care should receive education on the various medications and patient preferences should be considered when treatment plans and medication type are being selected (i.e. shared decision making; Klein, 2018; Mace et al., 2020; National Drug Control Strategy, 2022; National Governors Association, 2021; Rodriguez et al., 2021; Williams et al., 2018, 2019). Treatment should be initiated as soon as possible (and no longer than 14 days after a positive diagnosis) without any contingencies. To ensure timely access to services, systems should monitor the length of time to acquire treatment.

Justice agencies should provide interim MOUD or low-threshold programs while plans are being made for the individuals to access their medication (Mace et al., 2020; National Drug Control Strategy, 2022; Williams et al., 2019). Interim MOUD is the use of a bridge prescription that provides 3–5 days’ worth of medication in the time between referral and being connected with services. Low threshold treatment is providing MOUD treatment quickly with as few barriers as possible (i.e. same day treatment, harm reduction approaches, flexible, and highly accessible; Jakubowski & Fox, 2020). Before initiating MOUD, tolerance level should be taken into consideration to ensure safe use of a medications, identify proper dosage, and reduce the risk of precipitated withdrawal when using naltrexone. Non-tolerant, low-tolerant, and high-tolerant individuals will have varying dosing needs to effectively reduce opioid cravings, manage withdrawal symptoms, prevent relapse, and minimize MOUD side effects (Justice Community Opioid Innovation Network, 2021a).

Technological advances can ease the burden of service delivery within correctional facilities. Telehealth provides flexible access to providers, even in jurisdictions that are low resourced on treatment providers (Justice Community Opioid Innovation Network, 2021b; National Drug Control Strategy, 2022). Telehealth not only decreases the resources required to transport and provide care to individuals, it increases the number of individuals who can access MOUD. Peer navigators or peer coaches can also provide support for individuals with OUD in navigating access to MOUD in jail and in the community, and addresses some stigma issues (Justice Community Opioid Innovation Network, 2021b; National Drug Control Strategy, 2022).

Treatment Engagement

The goal of treatment engagement is to provide continuous access to treatment beyond the initial appointment/meeting. Continuous monitoring of individual’s responses to medications and periodic dose alterations are important for maintaining treatment engagement and efficacy (Justice Community Opioid Innovation Network, 2021a; Klein, 2018; National Drug Control Strategy, 2022). MOUD should not be contingent on the individual’s willingness or ability to participate in other aspect of their care plan such as counseling, behavioral therapies, or medical assessments, although it is beneficial for MOUD to be provided with biological, psychological, and social services, (Klein, 2018; Mace et al., 2020; Missouri Department of Mental Health, Division of Behavioral Health & Opioid, 2018; National Drug Control Strategy, 2022, National Governors Association, 2021, Substance Abuse and Mental Health Services Administration, 2019; Rodriguez et al., 2021; Williams et al., 2019). MOUD services should not be terminated or delayed for any reason other than if the medications are worsening the patient’s conditions (Mace et al., 2020; Missouri Department of Mental Health, Division of Behavioral Health & Opioid, 2018; Williams et al., 2019).

Continuing Care

The final stage of the cascade of care is continuation of care for both medications and behavioral therapy. MOUD providers for justice involved populations should recognize that it is likely that there will be at least one transition between correctional-based services and community providers during client’s road to recovery. Communication and coordination between jails, prisons, courts, and community corrections should be solidified and protocols should be put in place to assist in a smooth transition of care (Klein, 2018; National Drug Control Strategy, 2022; National Governors Association, 2021).

Discharge planning should begin at intake, or as soon as MOUD treatment is initiated, to ensure individuals will have seamless care even if they are released unexpectedly. Discharge planning should cover Medicaid (insurance), housing, transportation, identification, and other needs (Justice Community Opioid Innovation Network, 2021a; Klein, 2018; Mace et al., 2020; National Drug Control Strategy, 2022; National Governors Association, 2021; Rodriguez et al., 2021; Substance Abuse and Mental Health Services Administration, 2019). During the transition, individuals on MOUD should receive bridge prescriptions to ensure continuation of MOUD access during the reentry transition (Mace et al., 2020; National Drug Control Strategy, 2022; Substance Abuse and Mental Health Services Administration, 2019). Medical records from the correctional facility should be transferred to community providers and any other party involved in individual’s medical care for free upon release (Justice Community Opioid Innovation Network, 2021b; Mace et al., 2020).

At the time of release, warm handoffs should be made to community providers and community-based services should commence immediately and intensely (National Drug Control Strategy, 2022; Williams et al., 2019). Warm handoffs are the practice of personally and directly connecting individuals navigating the reentry process with service providers and treatment in the community. Upon release, community-based behavioral treatment is recommended for a minimum of six months with recovery management check-ups occurring regularly (Missouri Department of Mental Health, Division of Behavioral Health & Opioid, 2018; Williams et al., 2018, 2019). The Substance Abuse and Mental Health Services Administration (SAMHSA) suggests these post-release community-based services be “intensive in nature” with a minimum of 8 hours a week dedicated to treatment and social-service needs (Substance Abuse and Mental Health Services Administration, 2019, p. 27).

A maximum time limit should never be set for MOUD treatment and changes in dosage or decisions to discontinue use of MOUD should be made by patients in consultation with their medical practitioner (National Drug Control Strategy, 2022). Studies have found increased duration of treatment engagement is a key factor in reducing the risk of overdose upon relapse with each additional 60 days of treatment decreasing overdose risk by 10% (Burns et al., 2022). If the time comes that an individual and their medical provider feel discontinuation of medication is a promising route forward, doses should be tapered down and not cut off cold turkey.

Current Study

This study examines 49 institutions serving criminal legally involved populations to gain insight in how OUD care is provided to this population. We explore the various practices jails (n = 29) and affiliated community-based treatment providers (CBTP) (n = 20) have available for serving individuals with OUD and successfully progressing them along the cascade of care. Then, we take a closer look at the goals these jails and CBTP’s have identified as they work to expand their OUD care.

Data

The data for this study comes from a larger study that includes jails and CBTPs across 14 states focused on testing two implementation strategies to improve MOUD access and care. A baseline survey obtained information on the jail and CBTP practices concerning the cascade of care components, prior to any intervention, and the goals set by study sites which provided the data for the current study. This data is purely descriptive of the current processes and procedures occurring in agencies and can provide insight to what might be considered “typical” work concerning the cascade of care.

Measures

The baseline survey is an adaptation of the Chestnut Survey of Jails (Scott et al., 2019) which was administered to 29 jails and used to examine a national picture of practices. The survey was augmented to include a working relationship scale from the National Criminal Justice Treatment Practices Survey (Taxman et al., 2007), organizational readiness scale (Gustafson et al., 2003), staff attitudes (Knudsen et al., 2005), Program sustainability assessment (Luke et al., 2014), and NIATX Fidelity (Gustafson et al., 2011). Each scale includes items used to operationalize site’s adherence to best practices along the cascade of care. These items are used to gain a snapshot of how the study sites are currently operating, identify shortfalls and gaps in care, and compare their practices to other comparable sites.

As part of the study, jails and CBTPs identified areas for improvement and set specific goals based on each site’s individual needs. These baseline goals can be used as an indication of which stages of the cascade sites perceive their biggest needs and priorities are for improving their access to MOUD treatment.

Sample

Table 2 displays descriptive statistics about the sites included in the study. The sample included 29 jails which reported on various aspects of their procedures and practices across all stages of the cascade of care. Sites are located evenly across the four regions of the country with seven jails located in the Northeast, South, and Midwest, and eight jails located in the West. The average jail population size is 461 individuals with a range of 13 to 2,300. All 29 jails served males and females and about 17% serve young adults (16 years and older). The majority of jails are operated at the county level (72%) and half are operated by the sheriff’s office (51%).¹ Nearly half of the jails receive healthcare services through contracted providers from other institutions (44%), 24% have healthcare providers employed by their facility (direct), and 31% have a combination of direct and contracted providers.

Table 2.

Characteristics of 29 Study Sites.

Variable	Jail (N = 29)
Variable	Mean (Range)/% (n)
Region
Northeast	24.14% (7)
South	24.14% (7)
Midwest	24.14% (7)
West	27.59% (8)
Average jail population size	461 (13–2300)
Jail population composition
Male and female	100% (29)
Young adults (16+)	17.24% (5)
Service location
County	72.41% (21)
City/Town	6.90% (2)
State	3.45% (1)
Jail operated by
Private contractor	6.90% (2)
Department of corrections	6.90% (2)
State unified system^a	3.45% (1)
Sheriff’s office	51.72% (15)
Other elected official	13.79% (4)
Regional public entity^b	6.90% (2)
Healthcare service model^c
Direct service model	24.14% (7)
Contracted model	44.83% (13)
Hybrid model	31.03% (9)
Accompanying community partner	48.28% (14)

Note.

^aA state unified system is one where all pretrial and sentenced individuals are under the same jurisdiction.

^bA regional public entity jail is where one or more jurisdictions enter a formal agreement to operate a single jail for their joined region.

^cDirect healthcare service model indicates the jail employs healthcare workers, contracted models have healthcare providers contracted from other institutions, and a hybrid model utilizes both employed and contracted providers.

A subsample of 20 accompanying CBTP also provided some insight into their practices for the two stages of the cascade that are relevant to them in regards to MOUD in justice settings—screening and continuation of care. Nearly half (48%) of the jail sites entered the study with at least one accompanying community treatment provider who play an integral role in the continuation of care component of the cascade of care. The screening and continuing care practices of CBTP are discussed under those respective heading of the results section; however, the CBTP did not report on other stages of the cascade for the sake of this study since we are specifically focus ed on MOUD care in justice settings that included the continuum of care that extended to CBTPs.

MOUD Access in Justice Settings

The baseline survey captures the processes used to facilitate the cascade of care. Table 3 provides the results for the baseline survey on the use of best practices in jails and CBTPS and Table 4 has the key goals articulated by the sites to advance use of MOUD. These goals were set by each site with the guidance of a coach and then coded into like categories by the research team.

Table 3.

Frequency of Best Practices by Cascade of Care Stage for 49 sites.

Best Practice	Jail (N = 29)		Community Provider (N = 20)
Best Practice	Yes	No	Yes	No
Screened
Organization has screening protocol to ID people who have OUD	89.7%	10.3%	95%	5%
Organization has protocol to ID those who are withdrawing from opioids	86.2%	10.3%	85%	15%
In need of treatment
Is buprenorphine used for people already on MOUD at booking?	48.3%	51.7%	—	—
Is methadone used for people already on MOUD at booking?	34.5%	65.5%	—	—
Is naltrexone used for people already on MOUD at booking?	31.0%	69.0%	—	—
Jail uses medications to address withdrawal from opioids	82.8%	10.3%	—	—
Benzodiazepine	31.0%	37.9%	—	—
Buprenorphine	44.8%	24.1%	—	—
Lofexidine	.0%	51.7%	—	—
Methadone	17.2%	44.8%	—	—
Referred to treatment
Jail has non-MOUD substance use treatment and recovery support options	75.9%	20.7%	—	—
Alongside MOUD, the jail provides the following non-MOUD services…
Outpatient Substance use treatment by licensed provider	44.8%	27.6%	—	—
Intensive outpatient substance use treatment by licensed Provider	10.3%	55.2%	—	—
Therapeutic community or residential substance Abuse Treatment within correctional setting by licensed provider	17.2%	51.7%	—	—
Other recovery-based unit within correctional setting	44.8%	27.6%	—	—
Transfer to residential or inpatient substance use treatment programs in the community by licensed provider	48.3%	20.7%	—	—
On-Site short-term or long-term residential substance use treatment by licensed provider	24.1%	41.4%	—	—
Co-occurring substance use and mental health services by licensed provider	58.6%	13.8%	—	—
Self-help meetings	48.3%	20.7%	—	—
Other recovery support	51.7%	20.7%	—	—
Is buprenorphine use for managing acute or chronic pain?	6.9%	93.1%	—	—
Is methadone use for managing acute or chronic pain?	6.9%	93.1%	—	—
Is naltrexone use for managing acute or chronic pain?	3.4%	96.6%	—	—
Initiation of treatment
Jail uses medications to treat OUD	82.8%	10.3%	—	—
Buprenorphine	51.7%	27.6%	—	—
Methadone	31.0%	37.9%	—	—
Injectable or oral naltrexone	51.7%	13.8%	—	—
Jail has procedures in place to prevent diversion of methadone (out of the 20 that provide methadone at booking, stay, or transition to community)	41.4%	27.6%	—	—
Jail has procedures in place to prevent diversion of buprenorphine (out of the 16 that provide methadone at booking, stay, or transition to community)	48.3%	3.4%	—	—
Treatment engagement (in corrections facility)
Jail provides staff training on how to use naloxone	93.1%	3.4%	—	—
Jail has naloxone available for staff to reverse overdoses	93.1%	3.4%	—	—
Jail provides incarcerated individuals training on how to use naloxone	51.7%	44.8%	—	—
Continuing care (transition to community)
Jail has formal agreements in place to coordinate care with community treatment programs	65.5%	13.8%	—	—
Organization schedules appointment with MOUD providers the month prior to release	—	—	85%	15%
Organization exchanges key information with community MOUD provider the month prior to release	—	—	80%	20%
Organization assists with paperwork to get MOUD quickly in the community the month prior to release	—	—	80%	20%
Organization inducts detainees on MOUD the month prior to release	—	—	50%	45%
Organization connect detainees with peer mentor/navigator/coach the month prior to release	—	—	75%	20%
Organization provides transportation to community MOUD provider the day of release	—	—	60%	40%
Organization connect detainees with peer mentor/navigator/coach the day of release	—	—	80%	20%
Staff have electronic access to help submit the medicaid application	34.5%	58.6%	55%	70%
Staff help complete paperwork/application to reinstate or apply for medicaid prior to release	44.8%	48.3%	75%	25%
In my county, other agencies or the individual manage the medicaid enrollment process	69.0%	24.1%	—	—
Organization provides naloxone kits at release to detainees	48.3%	48.3%	70%	25%
Is buprenorphine used for continuity of care?	55.2%	44.8%	—	—
Is methadone used for continuity of care?	41.4%	58.6%	—	—
Is naltrexone used for continuity of care?	48.3%	51.7%	—	—
General
Jail is tracking people on MOUD who enter community treatment post-release	51.7%	31.0%	—	—
Jail is tracking people on MOUD who are retained in community treatment	37.9%	41.4%	—	—
Jail is tracking people on MOUD who are rearrested	41.4%	37.9%	—	—
Jail is tracking people on MOUD who overdose	24.1%	55.2%	—	—
Jail is tracking substance use treatment for people on MOUD	41.4%	37.9%	—	—
Jail is tracking medication for people on MOUD	41.4%	37.9%	—	—

Note. Missing data is not reported in this table. Questions that do not have 100% of jails and/or CBTP reporting can be assumed to be missing on unreported cases.

Table 4.

Site Goals for 29 Jails by Cascade of Care Stage.

Screened

Improve/implement screening procedures to be able to identify individuals with OUD

Increase the number of screenings with incarcerated individuals to identify OUD at entry. (n = 5)

In need of treatment

Implement MOUD within the jail

Setup an opioid treatment program (OTP) within the jail

Increasing the number of individuals connected to MOUD through use of flyer/hotline number

Referred to treatment

Initiation of treatment

Increase the # of individuals receiving MOUD medication. (n = 4)

Add buprenorphine induction to existing MOUD and scale it to all appropriate residents. (n = 5)

Increase MOUD treatment with buprenorphine for those in need

Transition from suboxone to sublocade to improve efficiencies including staff time/diversion. (n = 2)

Co-staff all incoming bookings with community service providers and jail medical to increase number of people on MOUD. (n = 2)

Hire a medical doctor (MD) to begin doing MOUD initiation/inductions

Increase nursing staff to expand capacity for MOUD care

Make peer support more consistently available to those with OUD.

Treatment engagement (in corrections facility)

Increase interdisciplinary jail staff communication and coordination of care for MOUD patients

Increase the number of individuals continuing with suboxone while incarcerated

Increasing the number of inmates staying on buprenorphine when transferred to other DOC facilities rather than taper off

Continuing care (transition to community)

Improve the warm handoff to local community treatment providers upon release. (n = 3)

Increase the number of community partners the jail has connections to

Increase connection to community resources upon discharge (n = 8)

Increase the rate in which individuals are connected with community MOUD clinic (n = 3)

Create a bridge script protocol for release to the community. (n = 2)

Implement care navigators to improve linkage to MOUD in the community

Increase the distribution of naloxone kits at release for individuals who request or have been diagnosed with OUD.

Increase community providers presence in jail to improve coordination of care upon release

Increase jail staffs’ knowledge and awareness of MOUD services and providers in the community

General

Create formal protocol for pregnant women (n = 2)

Track those suspended from jail program for violations and to create consistent policy

Track recidivism back to jail of previous jail MOUD patients

Screening

Among the sites in the sample, 90% of jails and 95% of CBTP reported having screening protocols in place to identify people with OUD while slightly less (86% of jails and 85% of CBTP respectively) had screening protocols to identify individuals experiencing withdrawal. Five sites identified goals related to screening—four of which indicated they already had screening protocols in place for OUD. The site that did not currently have OUD screening in place aimed to improve their current screening procedures to specifically identify OUD. All five of these sites’ goals were to increase the number or percent of individuals who were screened at booking. One site specified they wanted to increase from 0% to 20% screening rate, one site aimed for screening 75% of new intakes, one wanted to double their current number of screens, and two sites did not specify a specific target goal.

In Need of Treatment

There are three timepoints in which jails may or may not offer different types of MOUD medication—during booking, during the incarceration stay, and at the point of release. We tracked MOUD availability at all three timepoints. Three (10%) of the 29 sites indicated they offered all three MOUDs—buprenorphine, methadone, and naltrexone—to those who were booked into jail with an MOUD prescription from a community-based provider. Nearly 38% (n = 11) of jails did not have any MOUD options available for individuals already on medication at the time of booking. Roughly 21% of the jails only offered one MOUD medication: buprenorphine only (n = 3), methadone only (n = 2), or naltrexone only (n = 1). Of the nine sites that had two medications available, four offered buprenorphine and naltrexone, four offered buprenorphine and methadone, and one offered methadone and naltrexone. In total, 48% of jails had buprenorphine available, 34% had methadone, and 31% had naltrexone available for individuals who were booked into jail with a community-based MOUD prescription. The vast majority (82%) of jails in the study use at least one medication to address withdrawal from opioids such as Benzodiazepine (31%), Buprenorphine (44%), and Methadone (17%).

One site’s goal was to increase the number of individuals connected to medications through the use of flyers and a hotline number utilized within the jail to increase awareness of MOUD as a treatment option. Another site aimed to set up an Opioid Treatment Program within the jail in order to add Methadone to their available medications. With the addition of the OTP the jail will be able to provide all three medications without needing to transport patients to a community-based treatment center. A third site did not provide access to any medications for OUD at baseline and aimed to implement MOUD treatment within their facility.

Referred to Treatment

Over 75% of the 29 jails report having non-MOUD behavioral health services available for those in need and 7 (24%) did not. Non-MOUD behavioral health services include things like outpatient treatment, therapeutic treatment, inpatient treatment, self-help meetings, and other forms of non-medicinal treatment and services (see Table 3 under “Referred to Treatment” for list of non-MOUD services we tracked). Three of the seven sites without non-MOUD services were among the 11 sites that do not provide any MOUD options at booking, whereas four of the seven provide MOUD as their sole treatment option. About 50% of jail sites offer three or more behavioral health treatment options alongside MOUD. Many sites have licensed providers for outpatient services (44%), inpatient community services (48%), specialized recovery-based units (44%), and/or self-help meetings (48%). The majority of jail sites (58.6%) reported they were able to provide substance use and mental health services simultaneously to those in need. Fewer jails reported being able to provide intensive outpatient services (10%), on-site therapeutic treatment (17%), or on-site residential substance use treatment (24%). The vast majority of jails in this study reported that they do not use MOUD for individuals with chronic pain. Two of the 29 jails use buprenorphine for managing pain, two use methadone, and one site uses naltrexone.

Initiation of Treatment

During the incarceration experience, over 82% of jails reported using medications to treat OUD within their facilities including Buprenorphine (51%), Methadone (31%), and Naltrexone (51%). Six (20%) sites did not provide any medications to those with OUD, 10 (34%) sites provided one medication, 10 (34%) sites provided two, and three (10%) sites provided all three medications. Sites that provide medications for OUD are not always the same jails that use medication to treat withdrawal. Our sample includes 22 jails that use medications to treat withdrawal and OUD, one jail that only uses medication for withdrawal, two jails that only use medication for OUD, and one jail that does not use medication for either withdrawal nor OUD. The other three sites declined to report their use of medications.

Many of the jail sites report having protocols in place to manage diversion risk for methadone (45%) and buprenorphine (55%); however, two of the nine jails that reported treating patients with methadone and two of the 15 jails that reported treating patients with buprenorphine do not have diversion prevention procedures in place for these medications.

Treatment initiation was one of the most common stages of the cascade of care where sites wanted to make improvements. Seventeen (17) sites set goals in this stage all focused on increasing the number of patients receiving MOUD. One of these techniques’ sites set goals toward was to transition to Sublocade to improve staff efficiency to be able to serve more people in less time and to decrease risk of diversion (n = 2). Two sites aimed to co-staff between community service providers and jail medical to increase the number of staff able to assist in the MOUD distribution. Another treatment initiation related goal reported by five sites was to add buprenorphine to the MOUDs they provide to patients. Three sites aimed to increase MOUD treatment capacity through hiring and more efficiently using specialized staff including medical doctors, nurses, and peer support staff.

Treatment Engagement

Jails set goals to increase monthly coordination meetings for continuous monitoring, increase the percent of patients that remain on MOUD during their stay in the jail, and increasing the percent of patients that remain on MOUD when they are transferred to new jails.

The jails reported on their practice surrounding naloxone—a medication intended to prevent/reverse overdose. Over 93% of the 29 jails provide training to staff on how to use naloxone to reverse overdose that occur in the jail and over 93% of jails provide naloxone for their staff to use (26 jails provide training and medication, one jails provides staff training only, and one jail provides the medication without training). Slightly over half of the jails reported providing incarcerated individuals training on how to use naloxone.

Continuing Care

Best practices for continuation of care upon release from correctional facilities focuses largely on planning for release, coordination with community providers, and access to resources and medication in the community. Over 65% of jails reported they had formal agreements in place with CBTP to coordinate post-release MOUD care. Among the 20 CBTP included in the study, many begin working up to a full month prior to scheduled releases to coordinate care as seamlessly as possible upon release. This includes tasks such as scheduling appointments (85%), exchanging key patient information (80%), assisting with paperwork for prescriptions (80%), initiating individuals with OUD on MOUD (50%), and connecting patient with peer navigators (75%). In the day prior to release, 60% of CBTPs reported they provide transportation for patients to community MOUD providers and 80% connect (or reconnect) patient with peer navigators.

About 34% of jails and 55% of CBTPs reported they had electronic access to submit Medicaid applications and 45% of jails and 75% of CBTPs reported their staff completed the Medicaid applications for individuals prior to release.

Jails and CBTP reported on their utilization of harm reduction techniques used during the reentry process—specifically naloxone distribution. Despite high rates of naloxone training and availability for use within jails (as reported under “Treatment Engagement”), fewer jails provide access to naloxone to individuals at release. Of the 29 jails, 48% provide naloxone kits to individuals at release, whereas 70% of the 20 CBTP do so. Of the 14 jails that provided naloxone kits, nine provide kits only to individuals with OUD and four provide kits to individuals that complete a SUD course and request a kit. Of the 14 jails that had at least one CBTP provider involved in the study, nine of them provided naloxone through the jail and the CBTP, four only had naloxone available through the CBTP, and two did not have naloxone available through either agency.

The third timepoint where medications may be offered is during the reentry process. Use of MOUD for continuity of care is important to assist in seamless transitions of care as individuals are released from correctional facilities to the community. Offering all three FDA approved medication to ensure individuals do not have to switch medications upon release would be best practice. Only five (17%) of the jails reported using all three medications for continuity of care, whereas nine (31%) jails reported using two medications, nine (31%) jails reported using one medication, and six (20%) jails reported not using any medications for continuity of care. Buprenorphine was the medication most often reported as being used for continuity of care with 55% of jails utilizing it at release, followed by naltrexone (48%) and methadone (41%).

This final stage of the cascade of care for justice-involved individuals—continuing care post release—is where the majority of sites focused at least one of their goals. Twenty-one (21) sites had goals to improve their continuing care practices to better align with best practices and to improve their implementation of care. Eleven (11) sites set goals to increase the frequency (n = 8) and/or rate (n = 3) at which their patients with OUD connect with services post-release. Some sites focused on increasing referrals to CBTP, some focused on increasing initial contacts with CBTPs, and some sought to increase the number of patients that return for follow-up appointments with CBTP. One site focused its goal specifically toward improving care among tribal communities after noticing disparities in the continuity of care among that population. Three sites indicated they wanted to improve their warm-handoff procedures, two sites aimed to implement protocol for bridge prescriptions, one site sought to increase the number of naloxone kits they distribute to individuals at release, one site wanted to initiate connections with CBTP in their community using care navigators, one site wanted to increase CBTP presence in their corresponding jails, and one site wanted to increase jail staffs’ knowledge and awareness of community based services.

Other General Best Practices

Just over half (51%) the jails reported they track individuals on MOUD who enter community treatment after being released. Well under half of the jails reported following up with MOUD patient progress or outcomes beyond their initial treatment engagement. About 38% of jails reported tracking retention in community treatment for those released on MOUD, 41% reported tracking rearrests, substance use treatment, and medication usage for people released on MOUD, and 24% reported tracking overdoses of people on MOUD. Nearly half of the jails (45%) reported that they do not track any of these data points or outcomes. Two sites indicated goals around data collection—one site focused on tracking recidivism among MOUD patients and one focused on tracking MOUD program suspensions among patients. Two sites set a goal to create formal protocol for pregnant women.

Discussion

The current study collected data on select best practices and gained insight on where study sites stood in terms of providing care to justice-involved individuals with OUD, recognizing that these study sites volunteered to participate in a specific study about MOUD utilization for individuals in the criminal legal system. By examining baseline best practices and goals set to improve service provisions, this study reveals some of the challenges of implementing MOUD in criminal legal settings.

This study found that there is variation in the use of MOUD medication and behavioral health treatments among jails and CBTP. In our study, 20% of sites did not provide MOUD at any point of contact with patients, 24% of sites did not have therapeutic (non-MOUD) treatment options for OUD (i.e. outpatient treatment, therapeutic treatment, recovery-based unites, inpatient treatment, residential treatment, mental health services, self-help meetings), and 44% of sites did not track the progress of individuals on MOUD. Yet, 20% of facilities offer all three medications during at least one stage of the incarceration process (i.e. booking, incarcerations, and/or release), nearly 75% of facilities offer two or more non-MOUD services, over 50% track two or more outcomes (i.e. entering community treatment, retention in community treatment, substance use treatment, medication treatment, rearrest, or overdose), and over 65% coordinate care with CBTP very effectively. These differences in care may not appear to be large but it does suggest that institutions that come into contact with high rates of individuals suffering from OUD have varying service delivery systems and difficulties. Variability in available care is not random, as studies have shown the inequality in treatment in certain populations and geographical areas (Bommersbach et al., 2023; Hollander et al., 2021). Considering the fact that individuals involved in the justice system are often coming from oppressed populations (Kaeble & Bonczar, 2016; Kaeble et al., 2016; Minton & Zeng, 2021), adding in more layers of disadvantage through a lack of uniform care will further exacerbate these inequalities.

Second, the number and type of MOUD medications a facility or jurisdiction have available to patients varies widely depending on the stage of incarceration. Eleven (11 or 38%) of the 29 jails reported using different medications at booking than those available during incarceration and/or at release. This creates a problem in the cascade of care because it means that individuals must switch medications in the middle of treatment which can result in reduced care, treatment interruptions, and medical complications. Such practices hinder the success of individuals with OUD on their road to recovery.

Third, while jails and CBTPs are willing to implement MOUD, they seek assistance to increase utilization and capacity for individuals in need. Given that fewer than 1% of prisons and jails provide access to MOUD (Vestal, 2018) does not mean there is a lack of interest, but rather a lack of resources, knowledge, and implementation assistance. Ferguson et al., (2019) found barriers to implementing MOUD included lack of funding and clinical space, stigma about OUD and MOUD, inappropriate discontinuation of medication for various reasons, and poor coordination of care upon release. Scott et al. (2022) found further evidence of these barrier in addition to the need for diversion prevention training and automatic enrollment in Medicaid upon release. Proper utilization and evaluation of the cascade of care model can help sites identify which barriers present the most pressing concern so that they may address their clients needs in a more individualized manner.

Finally, just because an agency has a system or protocol in place does not necessarily mean that system or protocol is being utilized to its fullest potential (or at all). A recent study of problem-solving courts found that 86% of the courts acknowledge that MOUDs are allowed but only around 14% of those in need receive the medications, and the majority of courts do not monitor the use of medications for needy clients (Farago et al., 2023). The goals the work teams in this study selected indicate that they realize the MOUD is underutilized, and there is a need to review practices, procedures, and resources, that are in place. For example, one site set goals to increase screening rates because they realize that despite having a screening tool, their current booking procedures do not include actually screening individuals. This similar phenomenon was seen in the continuing care stage of the cascade where goals were set to increase coordination of care meetings post-release or increase rates of MOUD initiation even though a formal agreement with CBTP exists. This highlights the importance and complexity involved in the implementation of new practices and protocol in legal settings that provide services to individuals in need.

Correction staff often express a substantial amount of concern about diversion of MOUD and safety risks associated with distributing medications such as buprenorphine in a jail or prison setting. Evans et al., 2022a explored these concerns and found that not only did diversion of medication occur infrequently, but the implementation of MOUD use within facilities disrupted the illicit opioid market and decreased safety concerns of coercion. Proactive diversion prevention strategies such as differentiating between reasons for diversion, flexible dosing protocols, written policies to fairly apply consequences for diversion, and communication, education, and monitoring can assist jails and prisons in safely offering MOUD (Evans et al., 2022a).

Not surprisingly, the sites lacked data collection and outcome tracking practices. Just over 50% of sites collected data on MOUD patients who entered treatment following release; however, this was the most common data point collected. Other important data points including retention in community treatment, recidivism, overdose, and treatment engagement were collected by fewer than 45% of sites. Without data points for each stage of the cascade and other relevant outcomes, improving systems of care can be like taking a shot in the dark. Data will allow users to tailor their services, funding requests, and policy priorities to the needs of their population, recognize gaps and disparities in care, and improve implementation of current practices, and motivate new policies and programs.

Facilitating MOUD Utilization

The practices discussed throughout this paper regarding the cascade of care are designed to promote efforts to increase use, continuation, and/or reestablishment of MOUD treatment, increase contact with patients, decrease the risk of overdose, and provide for greater safety in procedures (Klein, 2018; National Drug Control Strategy, 2022). To facilitate implementation of MOUD in legal settings, consideration should be given to building systems of care, providing education and training, integrating harm reduction, and improving data collection related to MOUD.

Building a System of Care

Given that medications are often perceived to be a substitute for illicit drugs instead of a legitimate treatment, implementation of MOUD requires attention to both procedures and the attitudes and opinion of actors working in this setting (Grella et al., 2020; Rodriguez et al., 2021). Building a system of care that facilitates the collaboration of multiagency teams is believed to improve attitudes and opinions surrounding the use of MOUD within the criminal legal system (Breno et al., 2023). Jail staff who are not in collaboration with community providers maintain more negative perceptions of MOUD than jail staff who are linked with community provider agencies (Breno et al., 2023). Multiagency teams that are able to share data, resources, and knowledge will be better suited to progress patients through the cascade of care and toward recovery.

Part of building a system of care includes hiring specialized staff specially trained to handle populations with behavioral health concerns such as substance use and mental health specialists. Rather than relying on correctional officers or community corrections officers to administer behavioral health services or respond to behavioral health crises—which is outside of their job description and their expertise—hiring specialized staff allow jails to operate more efficiently in terms of progressing individuals through the cascade of care and maintaining safe and secure environments.

Education of Staff and Individuals

A key component of effective MOUD implementation is to educate correctional staff, service providers, and individuals receiving care about the efficacy of MOUD to help avoid stigma of both OUD and use of medication as treatment (National Governors Association, 2021). This includes educating and providing resources about safety measures, as well as the risks associated with terminating MOUD treatment—especially if relapse occurs. Working groups and trainings with correctional officers, treatment providers and other staff are critical to develop and redefine the protocol and policies relating to MOUD (Justice Community Opioid Innovation Network, 2021b; National Drug Control Strategy, 2022). Working groups and trainings should include topics such as diversion control, addressing stigma around MOUD among correctional personnel, and tools to prevent opioid overdose such as naloxone kits and education on how to use them (Klein, 2018; National Governors Association, 2021). Lastly, agencies should utilize checklists to help guide them through implementing MOUD according to evidence-informed best-practices (Ludwig et al., 2022).

Harm Reduction Policies and Practices

It is best practice to embrace harm reduction approaches that look beyond abstinence as a singular goal of treatment and recovery. A few of these approaches include safe drug use education, needle exchanges, naloxone distribution, and supervised injection facilities (for a more comprehensive list of harm reduction approaches see Taylor et al., 2021; Williams et al., 2019). However, it can be difficult to implement practices that facilitate drug use in criminal legal settings since it would be condoning a behavior that is strictly prohibited. In the community, these harm reduction approaches should be used in treatment settings as a way to decrease the risk associated with drug use, decrease the stigma associated with treatment, and increase timely contact with those who need services (Taylor et al., 2021).

In addition to implementing new harm reduction practices, current policies should be reviewed to ensure they do not inadvertently create barriers to treatment and recovery. Policies should not use MOUD as a disciplinary tool or used as a reward in return for desired behaviors (Klein, 2018). Policies should not contribute to the stigma and shame associated with OUD or the treatment of OUD with medication by singling out this behavioral health struggle as a behavioral choice rather than a health condition (Cernasev et al., 2021). Policies should not label individuals as “failing” in their treatment or recovery just as an individuals would not be deemed a failure in recovering from HIV (Cernasev et al., 2021).

Data Collection on OUD and MOUD

One major downfall of OUD treatment and associated outcomes in the correctional setting is the lack of data collection, organization, and utilization that occurs at each stage of care. Agencies should collect data at every stage of the cascade of care within facilities and after release. Robust evaluation and tracking protocols to collect data, track outcomes, and assist in implementation processes to track the stages of care should be at the forefront of priorities when working to improve treatment for OUD (National Governors Association, 2021). In addition, systems should be put in place to ensure data sharing is possible across all agencies involved in the care of patients.

Limitations

This study provides insight to the current practices and goals of jails and CBTPs across the nation; however, limitations of the data must be taken into account when considering how to utilize the study takeaways. While fairly well distributed across the United States, this sample of jails and CBTPs is self-selected and not representative of all agencies in the country. These sites are a convenience sample of agencies that selected into a research study aimed at improving systems of care for people with OUD in justice facilities. Each of these characteristics, among others, introduce biases that certainly influence the numbers reported.

Recognizing that these sites are a convenience sample of select jails and community providers enrolled in a study focused on MOUD, it is likely that this sample is systematically different than the nationwide average jail and CBTP. Compared to a study assessing the availability of best practices among a sample of jails within counties with the highest concentration of opioid overdose mortalities (Scott et al., 2022), our sample has similar rates of sites with screening protocols, therapeutic treatment services, medically managed withdrawal, and coordination of care post-release. In contrast, our sample had higher rates of MOUD availability to ALL patients with OUD, lower rates of MOUD availability to pregnant patients, and higher availability of reentry services.

Conclusion

This paper has outlined adaptations to the cascade of care principles for justice settings and justice involved individuals regarding MOUD. These adaptations are needed to address the socio-legal culture of justice settings. The legal environment is built on the premise that an individual is irresponsible (due to their criminal behavior) and require monitoring, strict rules, and constant reprimands—treatment is usually a secondary goal. Unraveling this is part of transforming the legal environment to be a human service environment where the priority of the medical and social care of an individual. Individuals who work with those in the legal environment are socialized to be suspicious of the individual and their motivations and drug seeking behavior are considered moral failings instead of a chronic disease. The war on drugs contributed to this perspective that individuals are manipulative and deceptive. Movement to a chronic disease framework in this setting challenges these mindsets.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Drug Abuse.

ORCID iD

Kendra J. Clark

Note

Author Biographies

Kendra Clark (ORCID: 0000-0001-5450-072X) is a Research Associate at the Center for Advancing Correctional Excellence (ACE!). She earned her doctorate in Sociology from the University of Colorado Boulder where she was funded by the National Science Foundation GRFP. Her research focuses on incarceration, opioid use disorder, re-entry, and quantitative methodologies.

Jessica Vechinski (ORCID: 0000-0003-4860-8317) is a Project Coordinator at the Center for Health Enhancement Systems Studies located in the Industrial and Systems Engineering Department at the University of Wisconsin-Madison. She earned her master’s in Social Work from the University of Wisconsin-Milwaukee. Her research focuses on opioid use disorder, re-entry, organizational change, systems change, implementation science and aging.

Todd Molfenter (ORCID: 0000-0003-3033-416X) is a Senior Scientist and Co-Director at the Center for Health Enhancement Systems Studies located in the Industrial and Systems Engineering Department at the University of Wisconsin–Madison. His research activities have focused on addressing organizational change, systems change, implementation science, and technology adoption in health services research.

Faye Taxman (ORCID: 0000-0001-9530-731X) is a University Professor at the Schar School of Policy and Government at George Mason University and Co-Director of the Center for Advancing Correctional Excellence (ACE!). She’s a health service criminologist and the PI for NIDA’s Justice Community Opioid Innovation Network (JCOIN) Coordination and Translation Center.

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