Background & aims
The COVID-19 pandemic created intersecting health risks for incarcerated people with a history of substance use disorder (SUD). To reduce exposure to COVID-19 in prison, several US ...states enacted decarceration legislation. New Jersey enacted the Public Health Emergency Credit Act (PHECA), granting early release to thousands of incarcerated persons meeting eligibility criteria. This study undertook to explore how large scale decarceration during the pandemic impacted the reentry process for released individuals with SUDs.
Methods
Twenty seven participants involved in PHECA releases – 21 persons released from NJ carceral facilities with past/present SUDs (14 with opioid use disorder, 7 with other SUDs) and 6 reentry service providers acting as key informants – completed phone interviews on PHECA experiences from February–June 2021. Cross-case thematic analysis of transcripts identified common themes and divergent perspectives.
Results
Respondents described challenges consistent with long-documented reentry difficulties including housing and food insecurity, difficulty accessing community services, insufficient employment opportunities, and limited access to transportation. Challenges that were pertinent to mass release during a pandemic included limited access to communication technology and community providers and community providers exceeding enrollment capacity. Despite reentry difficulties, respondents identified many areas where prisons and reentry service providers adapted to meet novel challenges presented by mass decarceration during the COVID-19 pandemic. Facilitators made available by prison and reentry provider staff included providing released persons with cell phones, transportation assistance at transit hubs, prescription support for medications for opioid use disorder, and pre-release assistance with ID and benefits through NJ’s Joint Comprehensive Assessment Plan.
Conclusions
Formerly incarcerated people with SUDs experienced reentry challenges during PHECA releases similar to those that occur during ordinary circumstances. Despite barriers faced during typical releases and novel challenges unique to mass release during a pandemic, providers made adaptations to support released persons' successful reentry. Recommendations are made based on areas of need identified in interviews, including reentry service provision facilitating housing and food security, employment, medical services, technology fluency, and transportation. In anticipation of future large scale releases, providers will benefit from planning ahead and adapting to address temporary increases in resource demands.
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Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation ...challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge.
In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services.
Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January-September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails' limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic.
Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.
Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., ...HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises.
This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19.
From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing.
One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio aOR = 2.14, 95% confidence interval 95% CI 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing.
Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.
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Expanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated ...with buprenorphine dispensing.
To examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents.
This cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder.
State implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined.
The main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023.
The mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 95% CI, 2.36-14.64 months in year 1 to 14.43 95% CI, 2.61-26.26 months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 95% CI, 3.17-10.86 months in the first year to 11.43 95% CI, 0.61-22.25 months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents.
In this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.
Saloner and Sharfstein talk about budget to expand access to effective treatment for substance use disorders. The total includes $920 million for states to support effective treatment, $50 million ...for the National Health Service Corps for investment in the treatment practitioner workforce, and $30 million for research and evaluation.
We examine the effect of Medicaid expansion under the Affordable Care Act (ACA) on substance use disorder (SUD) treatment utilization and financing. We combine data on admissions to specialty ...facilities and Medicaid‐reimbursed prescriptions for medications commonly used to treat SUDs in nonspecialty outpatient settings with an event‐study design. Several findings emerge from our study. First, among patients receiving specialty care, Medicaid coverage and payments increased. Second, the share of patients who were uninsured and who had treatment paid for by state and local government payments declined. Third, private insurance coverage and payments increased. Fourth, expansion also increased prescriptions for SUD medications reimbursed by Medicaid. Fifth, we find suggestive evidence that admissions to specialty treatment may have increased one or more years post‐expansion. However, this finding is sensitive to specification and we observe differential pretrends between the treatment and comparison groups. Thus, our finding for admissions should be interpreted with caution.
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The Affordable Care Act's Medicaid expansion provided insurance coverage to many low-income adults with substance use disorders, but it is unclear whether this led to more people receiving treatment. ...We used the Treatment Episode Data Set and a difference-in-differences approach to compare annual rates of specialty treatment admissions in expansion versus nonexpansion states in the period 2010-17. We found that admissions to treatment steadily increased in the four years after Medicaid expansion, with 36 percent more people entering treatment by the fourth expansion year in expansion states compared to nonexpansion states. Changes were largest for people entering intensive outpatient programs and those seeking medication treatment for opioid use disorder. The share of admissions paid for by Medicaid increased 23 percentage points in expansion states compared to nonexpansion states, largely displacing treatment paid for by state and local governments. The gradual increase in specialty substance use disorder treatment admissions after Medicaid expansion may reflect improving capacity and access to care.
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