Access to opioid agonist treatment in prisons saves lives, researchers say

Receiving opioid agonist treatment (OAT) in prison and after release into the community substantially cuts the risk of death among people who use drugs, a new study shows.

Researchers led by the National Drug and Alcohol Research Center (NDARC) say their findings, published in The Lancet Public Health, suggest that high coverage of OAT is crucial to reducing drug-related harm.

OAT interventions, such as methadone and buprenorphine, can reduce opioid cravings and prevent withdrawal symptoms in those with opioid dependence.

"This review supports a considerable body of evidence showing that OAT is integral to significantly reducing deaths both in prison and post-release," said Christel Macdonald, an NDARC research fellow and first author of the paper.

"We know that being incarcerated is associated with significant harm, including higher rates of substance use, mortality and self-harm, than the general population. Therefore, it is vital that effective interventions to reduce these harms are implemented in prison settings."

The first-of-its-kind global review of 126 studies—with a combined 586,000 participants—encompassing 18 interventions aimed at reducing drug-related harms in people who have been incarcerated also shows that therapeutic community interventions reduce re-arrest and reincarceration rates.

While previous studies have mostly focused on specific interventions or only assessed their impact on drug use and recidivism, none have examined the benefits of interventions delivered after release from prison.

The researchers found that access to OAT among people who have been incarcerated cuts the risk of death—both in prison and after release—by about 75%, and this effect was particularly strong in the first four weeks after release.

There was also evidence of therapeutic community interventions reducing the risk of re-arrest at 6-12 months by 28%, and reincarceration by 34%.

The authors said the findings had important implications for public health and demonstrate the importance of such interventions in reducing drug-related harm.

"Populations within prison may include people that are difficult to identify and treat within the community, and thus incarceration represents an important opportunity to improve the health of individuals before they return to the community," they wrote.

"Moreover, reducing drug use has important public health implications, including reducing drug-related harm and reoffending."

They also said that coverage of OAT "should be increased in carceral settings, including achieving optimal dosing, and should be continued after release."

However, there was scarce evidence that either OAT or needle and syringe programs were effective in reducing injecting risk behaviors or needle sharing, though the authors said this was due to substantial gaps in the research.

"One of the main points coming out of the review is the need for more research of interventions that are delivered during incarceration and evaluated while people are still incarcerated," said Macdonald.

"It's important to understand what can reduce drug-related harm while people are still in prison and how to continue to reduce these harms and maintain positive outcomes after release into the community."

She added that their findings were limited by the variability of the interventions, which made it difficult to evaluate and compare their effectiveness.

"For example, therapeutic communities or psychosocial interventions are two interventions commonly used in this space that can vary greatly from each other, from things such as program duration to specific features of programs," she said.

"Therefore, it's difficult to tease apart what characteristics of these interventions may be driving positive outcomes like reduced reoffending or drug use."