Methadone and buprenorphine treatment in United States jails and prisons: lessons from early adopters

Aims To identify implementation barriers and facilitators to the adoption and implementation of programs that provide opioid agonist treatments (OAT) with methadone and buprenorphine to treat opioid use disorder in jails and prisons in the United States. Design Qualitative analysis: semi-structured interviews were conducted and thematic analyses of transcripts and notes were performed using a hybrid inductive/deductive coding approach. Setting Jails and prisons in the United States. Participants From August 2019 to January 2020, we conducted 20 key informant interviews with 35 individuals representing 19 carceral systems that both initiate and maintain OAT. Measurements Interviews covered four domains: (1) program adoption; (2) policy influence on implementation; (3) program structure; and (4) program outcomes. Findings Stigma among staff, particularly medical staff, challenged program adoption, but reduced over time as staff were exposed to the program. Regulations on OAT dispensation, such as licensing requirements and prescribing limits, were key challenges to program implementation and shaped program structure. Dispensing medication required significant staff, time and space. Facilities were further challenged to overcome stigma and concerns about diversion, as OAT medication is often treated as contraband in carceral settings. Some systems deviated from evidence-based treatment by limiting OAT dosage to low levels, requiring counseling for participation and requiring detoxification before medication initiation. Despite these challenges, early adopters felt strongly that other jails and prisons in the United States should provide OAT and that legislation and litigation may soon force OAT expansion in these carceral settings. Conclusions Despite identifying regulatory and logistical challenges, early adopters of opioid agonist treatment (OAT) programs in US jails and prisons demonstrate that OAT programs can successfully be implemented in carceral settings with tailoring to the specific context.