Best Practice of the Month
Supporting Patients With OUD Who Anticipate Incarceration: Planning and Advocacy

Individuals with opioid use disorder (OUD) face a heightened risk of legal involvement, with 24% to36% passing through jails and prisons annually. [i]  Post-release, this population is at a significantly increased risk of fatal opioid-related overdoses due in part to poor access to medications for opioid use (MOUD) while incarcerated.[ii],[iii] Federal courts have found that not allowing individuals to continue MOUD while incarcerated is a violation of the Americans with Disabilities Act (ADA)[iv],[v] and the Department of Justice Civil Rights Division released guidance explaining how the ADA offers protections for individuals who are taking prescribed MOUD during incarceration. However, many jails and prisons are still not offering MOUD to incarcerated individuals, with recent estimates suggesting that less than 5% of all incarcerated people with OUD receive buprenorphine.[vi] This advisory aims to guide rural health clinics in supporting patients who anticipate upcoming jail time.

  1. Screening for legal involvement:
    • Standardize questions about outstanding charges, probation or parole, and drug court involvement during intake appointments
    • Approach these sensitive questions with empathy, seeking permission and explaining their purpose to support and advocate for the patient
  2. Planning for jail time:
    • If a patient anticipates a jail sentence coming up, gather the following information to assist with treatment planning:
      • Identify the county of charges and inquire about MOUD availability in that county’s jail. If the patient takes other daily medications (psychiatric or hepatitis C medication, for example), also ask about whether those medications are on formulary. Patient information should not be given unless a signed release of information is on file.
      • Determine if a patient coming to the jail can bring their own medications. Particularly in more rural jails with limited medical staffing, patients may be allowed and encouraged to bring their own medications. The clinical team can plan medication refills around anticipated date of presentation to the court and jail.
      • Discuss the possibility of signing a release of information of medical problem and medication lists to be sent to the jail.
      • Offer the option for a release of information for communication with a friend or family member during incarceration.
      • Explore alternative medications, such as long-acting injectable buprenorphine, if sublingual options are restricted in the jail.
  3. Planning for re-engagement at release:
    • Discuss re-engagement plans, including having a friend, family member or jail re-entry staff support the scheduling of appointments prior to release and emphasizing the patient’s welcome return.
    • Develop a plan to ensure that the patient will not have a disruption in medication access. This could include a one- or two-week bridge prescription to last from the time of release to the time of the appointment.
    • Ensure the patient and their support network have access to naloxone.
  4. Other considerations:

[i] Boutwell AE, Nijhawan A, Zaller N, Rich JD. Arrested on heroin: a national opportunity. J Opioid Manag. 2007;3(6):328-332. doi:10.5055/jom.2007.0021

[ii] Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005

[iii] Merrall EL, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after release from prison. Addiction. 2010;105(9):1545-1554. doi:10.1111/j.1360-0443.2010.02990.x

[iv] Pesce v. Coppinger, Civ. A. No. 18-cv-11972-DJC (D. Mass. Nov. 26, 2018)

[v] Smith v. Aroostook Cnty., 922 F.3d 41 (1st Cir. 2019)

[vi] Thakrar AP, Alexander GC, Saloner B. Trends in Buprenorphine Use in US Jails and Prisons From 2016 to 2021. JAMA Netw Open. 2021;4(12):e2138807. doi:10.1001/jamanetworkopen.2021.38807