Opioid crisis: Criminal justice referrals miss treatment opportunities, study suggests

December 4, 2017, Johns Hopkins University Bloomberg School of Public Health

A new study by researchers at the Johns Hopkins Bloomberg School of Public Health found that under 5 percent of those referred for opioid treatment from the criminal justice system were directed to medication-assisted programs to treat their disorder. Medication treatment, usually consisting of methadone or buprenorphine, both of which are opioids, helps control symptoms of withdrawal and cravings that can cause relapse. It is considered the most effective way to manage opioid misuse and reduce opioid-related harms such as overdose.

In contrast, the researchers found that 40 percent of clients referred for by other sources, such as health-care providers, employers, or self-referral, attended medication-assisted programs. The referral gap suggests a missed opportunity to link one of the most at-risk groups of people into effective treatment at a time when the nation faces a deepening crisis.

The study appears in the December issue of Health Affairs.

"This new research demonstrates that a large majority of persons referred for from the 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 nine and 13 percent of incarcerated individuals were using opioids regularly before their incarceration. Research suggests that incarcerated individuals have a greater than a hundred-fold higher risk of fatal overdose in the two weeks post-release than members of the general population.

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 age 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 pain killers.

Of the 72,084 clients receiving treatment for opioid use in the sample, 24.3 percent - or 17,536 clients - were referred to treatment through the criminal system, i.e., police officials, judges, prosecutors, probation officers, and other persons affiliated with a federal, state, or county judicial system. Of these, only 805 clients, or 4.6 percent, were referred for .

To determine how different criminal justice bodies were referring individuals to medication-assisted treatment, the researchers conducted a second analysis of 13,459 people referred to opioid treatment, both medication-assisted and others, from the criminal justice system. They found that 38.7 percent were referred to some form of opioid treatment by probation or parole programs; 30.1 percent by state, federal, or other courts; 10.9 percent by diversionary programs; 2.6 percent by prisons; 2.1 percent through a DUI or DWI program; and 15.5 percent by other legal system referral sources.

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 assure referred clients are receiving the highest quality of care. This is especially critical as specialty courts and diversionary programs are often designed to provide a mechanism through which people can be diverted to needed treatment as an alternative to incarceration. Promoting evidence-based care as part of this alternative is fundamental to assuring these programs achieve successful outcomes and reduce recidivism.

The most common type of medication-based treatment for opioid disorder, which is known as "opioid agonist therapy" takes two forms. Methadone treatment is administered through regulated outpatient opioid treatment programs while buprenorphine can also be prescribed by physicians who obtain a waiver from the Drug Enforcement Agency.

"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, PhD, 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."

In addition to cultural stigmas, there are regulatory hurdles to using medication treatment in settings where justice-involved individuals receive care, such as the need to obtain licensure from the Drug Enforcement Agency or fears about diversion, the authors note. 

"One solution is for policymakers to require criminal justice entities to support medications both within criminal justice settings, such as jails and prisons, and to encourage their use when justice-involved persons are referred for opioid use disorder treatment," says Krawczyk. "Efforts can be made to reduce stigma and educate criminal justice staff about the benefits of these medications in improving health and criminal justice outcomes.

"One in Twenty Justice-Referred Adults in Specialty Treatment for Opioid Use Receive Methadone or Buprenorphine" was written by Noa Krawczyk, Brendan Saloner, Kenneth Feder and Caroline Picher.

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