Study: Most people referred for opioid treatment by criminal justice system don't receive optimal care

Gap in quality of care represents a missed opportunity for treatment during deepening crisis, Johns Hopkins researchers say

A new study by researchers at the Johns Hopkins Bloomberg School of Public Health found that fewer than 5 percent of people referred for opioid treatment from the criminal justice system were directed to medication-assisted programs, which are widely considered the most effective way to manage opioid abuse and reduce instances of overdose.

"If we want to address overdose risk among the most vulnerable people while also cutting down the constant cycle of people in and out jail, we need to get more-effective treatment to people in the criminal justice system."
Brendan Saloner
Assistant professor, Bloomberg School

In contrast, 40 percent of clients referred for treatment by other sources, such as health care providers, employers, or self-referral, attended medication-assisted programs—usually consisting of treatment with methadone or buprenorphine, both of which are opioids that help control symptoms of withdrawal and cravings that can cause relapse.

The referral gap suggests a missed opportunity to link one of the most at-risk groups of people to effective treatment at a time when the nation faces a deepening opioid crisis. The study will appear in the December issue of Health Affairs.

"This new research demonstrates that a large majority of persons referred for opioid treatment from the criminal justice system are not receiving optimal care for their disorder," says Noa Krawczyk, a doctoral student in the Bloomberg School's Department of Mental Health and the study's lead author. "This underutilization of medications is due to many factors, including the cultural stigma that these medications are 'replacing one drug for another' and that recovery can only be attained through abstinence. This thinking runs contrary to the scientific evidence."

Justice-involved individuals are especially vulnerable. While there is no current data on opioid addiction among the incarcerated, an estimated two-thirds of people in U.S. correctional settings have a diagnosable substance-use disorder, the researchers note. An earlier study, from 2004, suggested that between 9 and 13 percent of incarcerated individuals were using opioids regularly before their incarceration. Research suggests that incarcerated individuals are more than 100 times more likely to die of an overdose in the two weeks post-release than members of the general population.

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For the study, researchers analyzed 72,084 first-time treatment admissions using the 2014 Treatment Episodes Data Set compiled and managed by the Substance Abuse and Mental Health Services Administration. The data included treatment admissions in 41 states and the District of Columbia and Puerto Rico. The sample included people ages 18 and older who entered specialty treatment programs primarily for problems related to the use of opioids, including heroin, nonprescription methadone or other opiates, or synthetics such as prescription painkillers.

Of the clients receiving treatment for opioid use in the sample, 24.3 percent—or 17,536 clients—were referred to treatment through the criminal justice system. Of these, only 805 clients, or 4.6 percent, were referred for medication treatment.

A second analysis included in the study found low rates of medication treatment regardless of specific referral source—clients referred from a DUI or DWI program were the most likely to be referred to medication treatment (9.9 percent), while clients referred from a diversionary program or a court were least likely to be referred to medication treatment (1.9 and 3.4 percent, respectively).

These findings suggest that while criminal justice referral to medication treatment is low overall, certain criminal justice bodies—such as courts and diversionary programs—may be high-priority targets for policy interventions to ensure that referred clients are receiving the highest quality of care.

"If we want to address overdose risk among the most vulnerable people while also cutting down the constant cycle of people in and out jail, we need to get more effective treatment to people in the criminal justice system," says Brendan Saloner, assistant professor in the Bloomberg School's Department of Health Policy and Management and a senior author. "The justice system has an opportunity to be a vital partner to stem the tide of the opioid crisis."

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