Criminal justice populations were significantly less likely to receive medication-assisted treatment (MAT) for opioid use disorder (OUD) -- such as methadone and buprenorphine -- even with the increased access brought about by Medicaid expansion in certain states, a recent study found.
When compared to individuals referred to treatment by all other sources, those referred to treatment by the criminal justice system were far less likely to receive MAT in the years before (2008-2013) and after (2015-2017) enactment of the Affordable Care Act (pre-ACA, adjusted risk ratio 0.15, 95% CI 0.15-0.16; post-ACA, ARR 0.28, 95% CI 0.28-0.28), Utsha Khatri, MD, of the University of Pennsylvania's Perelman School of Medicine, and colleagues reported in Health Affairs.
Those risk ratios also differed significantly between the two periods. (P<0.001).
In Medicaid expansion states, criminal justice populations saw higher rates of receiving medications for OUD than did those in states without this expansion (ARR 2.07, 95% CI 2.00-2.13) over the course of the entire study period, 2008-2017. The trend was similar when researchers looked at those who received MAT through other referrals in Medicaid expansion states (ARR 1.60, 95% CI 1.59-1.61).
Khatri and her team used 10 years of data from the Treatment Episode Data Set-Admissions (TEDS-A), a national database of substance treatment facility admissions organized by the Substance Abuse and Mental Health Services Administration. The sample -- which lists the primary, secondary, and tertiary substances that led to an individual's admission to treatment -- was limited to those over the age of 18 whose primary reason for seeking treatment was opioid-related.
Those who were referred to evidence-based treatments through the criminal justice system tended to be younger than those from other referral sources (ages 18-24, 23.4% vs 17.9% respectively) and somewhat more likely to be white (64.6% vs 60.7%).
"It's important to note that this disparity existed before the implementation of the Affordable Care Act, but then also continues beyond that," Khatri told MedPage Today. Medicaid expansion as a policy, she said, was clearly effective in addressing some of that disparity, with those states seeing a 165% increase in individuals referred to evidence-based treatment for OUD from criminal justice agencies. "But even though things got better after Medicaid expansion, the disparity between the people who have criminal justice involvement and people who don't persisted."
Khatri also emphasized that one of the study's major drawbacks is that it can only capture the number of individuals who do get referred to evidence-based treatment. When looking at the general population outside of those involved in the criminal justice system, Black and brown patients were significantly less likely to receive medications like buprenorphine than their white counterparts.
"So when you're adding on the stigma of also having criminal justice involvement on top of the stigma of being a person of color who has an addiction, the disparity is even more pronounced," Khatri said. "We can assume, just knowing what we know about substance use disorder treatment in this country, that all systems are likely under-referring people of color into treatment."
For individuals in the criminal justice system, gaining access to medications for OUD can be life-saving at many different points in the justice process. One study found that formerly incarcerated people were 40 times more likely to die from opioid overdose in the first two weeks after their release from prison; when examining just heroin overdoses, the likelihood of overdose death for the same population increased to 74 times the normal overdose rate within the same two weeks.
"Overdose rates are so high because people have spent a period of time confined and not using, they lose their tolerance," said Christine Grella, PhD, of the University of California Los Angeles's Integrated Substance Abuse Programs. "So they may leave and then resume use at similar levels and their bodies are no longer habituated to that level."
Khatri noted that addicts released from prison, beyond having the increased risk of relapse and overdose, may not put health insurance high on their long list of immediate needs and priorities.
"People are looking for housing, they're trying to reconnect with families, they're trying to find a job," Khatri said. "I think the less burden we put on the individual and the more we can formalize into policy things that we know help folks getting treatment, like having active Medicaid, the more people will be able to prioritize their recovery and their substance use treatment during that vulnerable period."
The COVID-19 pandemic has prompted efforts to reduce the volume of people in our country's prisons and jails. But Noa Krawczyk, PhD, a population health professor at New York University, said the haste and disorganization of the release process may add more complications to getting formerly incarcerated individuals referred to evidence-based treatment programs.
"There is some concern about people who are being released who might have been receiving treatment while incarcerated or would benefit from treatment when they come out of incarceration, and yet the linkage to services isn't there," Krawczyk told MedPage Today.
The stigma surrounding the use of medications used to treat opioid use disorder seems to be the most everlasting and ubiquitous barrier to treatment, in states both with and without Medicaid expansion.
"There are still a lot of misconceptions that are driving people to receive treatment, but treatment that's not as effective as it could be if it involves medication," Krawczyk said, noting that many still believe methadone and buprenorphine merely replace one addiction for another. "There's a lot of work to do in correctional settings and in the community of people who are criminal-justice-involved to get people up to speed, to make sure that everybody has at least equal access and the knowledge of the effectiveness of these treatments."
Disclosures
Khatri's work is funded by the Department of Veterans Affairs. One co-author reported grants from the National Institute on Drug Abuse.
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