Opioid-related treatment, interventions, and outcomes among incarcerated persons: A systematic review

Background Worldwide opioid-related overdose has become a major public health crisis. People with opioid use disorder (OUD) are overrepresented in the criminal justice system and at higher risk for opioid-related mortality. However, correctional facilities frequently adopt an abstinence-only approach, seldom offering the gold standard opioid agonist treatment (OAT) to incarcerated persons with OUD. In an attempt to inform adequate management of OUD among incarcerated persons, we conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration. Methods and findings We systematically reviewed 8 electronic databases for original, peer-reviewed literature published between January 2008 and October 2019. Our review included studies conducted among adult participants with OUD who were incarcerated or recently released into the community (<= 90 days post-incarceration). The search identified 2,356 articles, 46 of which met the inclusion criteria based on assessments by 2 independent reviewers. Thirty studies were conducted in North America, 9 in Europe, and 7 in Asia/Oceania. The systematic review included 22 randomized control trials (RCTs), 3 non-randomized clinical trials, and 21 observational studies. Eight observational studies utilized administrative data and included large sample sizes (median of 10,419 [range 2273-131,472] participants), and 13 observational studies utilized primary data, with a median of 140 (range 27-960) participants. RCTs and non-randomized clinical trials included a median of 198 (range 15-1,557) and 44 (range 27-382) participants, respectively. Twelve studies included only men, 1 study included only women, and in the remaining 33 studies, the percentage of women was below 30%. The majority of study participants were middle-aged adults (36-55 years). Participants treated at a correctional facility with methadone maintenance treatment (MMT) or buprenorphine (BPN)/naloxone (NLX) had lower rates of illicit opioid use, had higher adherence to OUD treatment, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received MMT or BPN/NLX while incarcerated had fewer nonfatal overdoses and lower mortality. The main limitation of our systematic review is the high heterogeneity of studies (different designs, settings, populations, treatments, and outcomes), precluding a meta-analysis. Other study limitations include the insufficient data about incarcerated women with OUD, and the lack of information about incarcerated populations with OUD who are not included in published research. Conclusions In this carefully conducted systematic review, we found that correctional facilities should scale up OAT among incarcerated persons with OUD. The strategy is likely to decrease opioid-related overdose and mortality, reduce opioid use and other risky behaviors during and after incarceration, and improve retention in addiction treatment after prison release. Immediate OAT after prison release and additional preventive strategies such as the distribution of NLX kits to at-risk individuals upon release greatly decrease the occurrence of opioid-related overdose and mortality. In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up OAT and opioid-related overdose prevention strategies (e.g., NLX) within a continuum of treatment before, during, and after incarceration. Author summaryWhy was this study done? Opioid use disorder has been rising at an alarming rate, and opioid-related overdose is now a major public health crisis. Persons with opioid use disorder are overrepresented in the criminal justice system and face higher risks for opioid-related mortality. However, opioid use treatment is severely limited in correctional facilities. To address the opioid-related overdose crisis, it is pivotal to improve access to opioid use treatment inside correctional facilities and to assure proper linkage into addiction care post-incarceration. What did the researchers do and find? We conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration. Our search identified 2,356 scientific articles, of which 46 studies were eligible for inclusion in our review. Participants treated at a correctional institution with the gold standard treatment for opioid use disorders, opioid agonist treatment, had higher adherence to addiction treatment, had lower rates of relapse into illicit opioid use, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received opioid agonist treatment while incarcerated and were adequately linked into care post-release experienced a significant decrease in nonfatal overdose rates and mortality. What do these findings mean? In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up opioid-related treatment and prevention strategies within a continuum of treatment before, during, and after incarceration.