OUD in jails: buprenorphine decreases recidivism

 A new analysis of 2 rural Massachusetts jails found that people incarcerated with opioid use disorder and treated with buprenorphine were less likely to be arrested again (see opiate buprenorphine in jail dec recidivism DrugAlcDependence2022 in dropbox, or doi.org/10.1016/j.drugalcdep.2021.109254 for the article, or the NIH news release at https://www.nih.gov/news-events/news-releases/offering-buprenorphine-medication-people-opioid-use-disorder-jail-may-reduce-rearrest-reconviction ). and thanks to Coleen Labelle for bringing this to my attention.

 

Details:

--469 adults (197 in Franklin County and 272 in Hampshire County jails) were incarcerated, had opioid use disorder, and left the jail between 1/1/15 and 4/30/19

--Franklin County (FC) jail, but not Hampshire Country (HC)  jail, began offering buprenorphine in these two contiguous, similar counties in western Massachusetts

-- 95% male, 96% white, mean age 35

-- age at first arraignment 18, mean number of arraignments 13, number of incarcerations 4

-- FC jail: 170 ( 86%) were on buprenorphine; 14 (7%) on naltrexone, and 12 not documented

-- data from each jail's electronic booking system

 

--primary outcome: post-release recidivism, defined as time from jail exit to a recidivism event (incarceration, probation violation, arraignment)

 

Results:

--recidivism rate:

    -- FC: 48.2%

    -- HC: 62.5%

        -- difference of 32%, adjusted HR 0.68 (0.53-0.86), p=0.001

        -- recidivism related to property crime was much more significantly reduced as opposed to violent or drugs crimes 

--arraignment rate:

    -- FC: 36.0%

    -- HC: 47.1%

        -- difference of 33%, aOR 0.67 (0.45-0.99), p=0.046

--re-incarceration rate:

    -- FC: 21.3%

    -- HC: 39.0%

        -- difference of 63%, aOR 0.37 (0.24-0.58), p<0.0001

--3% of people died at each site

-- mean days from jail exit to first react recidivism event was 130 days for both groups

 

 

 

-- sensitivity analyses for overall reduction in recidivism rates showed:

    -- males only: 31% decrease, HR 0.69 (0.54-0.87)

    -- those less involved with the criminal justice system: 25% decrease, HR 0.75 (0.57-0.99)

    -- first arraigned as an adult: 36% decrease, HR 0.64 (0.46-0.90)

    -- those on pretrial status at index jail stay (sentenced individuals excluded): 36% decrease, HR 0.64 (0.49-0.84)

    -- those at FC on buprenorphine (not naltrexone): 38% decrease, HR 0.72 (0.57-0.93

Commentary:

-- this is a totally expected finding. similar to starting buprenorphine in the emergency department (see opioid dependence subox in ER jama 2015 in dropbox, or doi:10.1001/jama.2015.3474). or getting people with OUD into medication treatment right away in other clinical settings. overall, meds work. and dramatically so for large numbers of people!!! especially if they are started as soon as possible

-- and, one related issue is the particularly high mortality of incarcerated individuals being released and starting to use opiates again: those who do not use drugs in jail, and especially women, presumably have an upregulation of their opiate receptors from the lack of continued opiate use and are much more susceptible to opioid effects, eg severe respiratory depression and really high opioid-related mortality in those released and who start using their pre-incarceration quantity of opiates (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7349469/ )

-- I would like to add the other big issue post-incarceration in a few of my patients is that they are unable to get a job because of having been incarcerated. some have no money, and their inability to have a job has driven them back into the drug world. One of my patients has been drug-free for 40 years, on buprenorphine for the last ten years or so, and has not been able to find a job despite trying very hard. He has been fortunate enough to have a sister who is able to support him a bit in her apartment. And he volunteers working with kids to help them stay off drugs, but even then, is unable to get a paid position

 

-- Several of the large urban jails (New York City, San Francisco , Albuquerque) and several state systems (Rhode Island, Vermont) do offer medications for opiate use disorder, typically naltrexone but occasionally buprenorphine; there have been several reports of reduced overdoses and risks of infectious disease as a result. A meta-analysis/systematic review of medication assisted treatment in correctional facilities was able to analyze the effects of methadone (too few studies on buprenorphine or naltrexone), found increased subsequent community treatment engagement eightfold, reduced illicit opioid use 78% and injection use 74%, though no evident effect on recidivism (see doi.org/10.1016/j.jsat.2018.12.003 )

-- As a result of the “war on drugs”, half of the prisoners in the US have substance use disorders with a minority in formal treatment programs

    -- as per many commentators, our penal system is one of punishment, not rehabilitation/reintegration into society. It is painful how many people end up being ultimately criminalized for even minor drug problems, since incarceration leads to stigmatization, harder integration back into society (or even into back into their family/support community), further marginalization, and in some cases, into a truly criminal life. And, the "war on drugs" never did work, other than as a means to make the US have the highest incarceration rate in the world... 

 

Limitations:

-- this was a natural experiment in that one jail system decided to give meds and the other did not. so, not a formal randomized controlled trial and there may have been unexpected confounders distorting the results

-- unclear that the opioid screening/participant identification was the same in each system

-- no data on medical, psychological, or other social characteristics of the participants that might have influenced the findings in the different jail systems

-- likely different approaches to treating those with OUD. FC likely had more educational programs related to OUD, access to and utilization of psych resources, perhaps more linkage to outside programs/health care (there would need to be some to continue the buprenorphine), perhaps more services overall outside the jail.  all of these other things may have contributed to differences in recidivism rates

-- this was a sample of rural white males, and may not be generalizable to women or those living in the cities

so, further evidence that the best approach to treating OUD is early identification of those on opiates and providing meds in a truly supportive environment. and the more ancillary services likely the better (counseling, medical care, help with social issues like housing, jobs, food etc). Part of the issue here and in the ED is that these are crisis points in people's lives and are great times to intervene to help with their opiate use disorders. it was notable that the curves in the graph above started to show benefit within 2 months of exit from the jails. and this was without an integrated multifaceted system of care....

--but, the elephant in the room: we desperately need to fundamentally reorganize our criminal justice system, with a goal of actual rehabilitation and not punishment, with reintegration of people into society, decriminalization of drug use, and increased transparency (which translates into the criminal justice system NOT being privatized but run by government agencies and accountable/transparent to the public) ....

see http://gmodestmedblogs.blogspot.com/2018/01/immediate-access-to-opioid-agonist.html for a former blog on the costs (monetary and human) of our current incarceration system

geoff

 

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