Drug overdose deaths in the United States continue to hit staggering highs. Over 90,000 estimated overdose deaths were recorded in 2020. Synthetic opioids like fentanyl and carfentanil are fueling the opioid epidemic. The United States has less than 5% of the world’s population but imprisons more people than any other nation every year, and retains nearly 25% of the earth’s total incarcerated population, and holds the highest prisoner rate of any nation on the planet. Currently, 2.3 million Americans are behind bars, equaling more than 1 in 100 adults are incarcerated in state and federal prisons and local jails and 1 in 5 or 20% of the prison population are nonviolent drug offenders. According to the National Center on Addiction and Substance Abuse, 65% of the U.S. prison population meets the medical criteria for drug or alcohol use disorders, but less than 11% receive treatment for those illnesses.

Over 600,000 men and women are released from prison each year and reports show that the current strategies used by the justice system to achieve rehabilitation and increased public safety have been ineffective, with more than 80% of those leaving state prisons being rearrested again.

The close correlation between drugs and jail is a hot topic among legislators, taxpayers, and the general population. and most Americans agree something must change because the status quo in the criminal justice system is not working. All criminal justice agencies need to embrace Medically Assisted Treatment (MAT) as an essential tool in fighting the opioid epidemic and crime. Substance use treatment in the justice system offers a chance of recovery and will make a huge difference in reducing the toll of the opioid crisis.

“Addiction” or Substance Use Disorder (SUD) is a complex brain disorder combined with mental illness, is characterized by compulsive drug-seeking and prolonged drug use despite destructive consequences which cause long-lasting changes in the brain function. If you take away anything, understand this…people with SUD have a chronic relapsing brain disorder. SUD is not a moral failing, it is a treatable medical condition that can be successfully managed by combining medication with behavioral therapy, known as Medication Assisted Treatment or MAT. Research shows that MAT is at least twice as effective as abstinence-based treatment that does not include medications.

In 2018, the Surgeon General reported evidence-based treatments— both medications and behavioral therapies—can save lives and restore people’s health, wellbeing, and functioning, as well as reduce the spread of infectious diseases and lessen other consequences. Incarcerated people have the right to medical care for SUD and jails and prisons as government institutions, are obligated to provide that treatment. Jails and prisons must address the systematic barriers that prevent them from fulfilling that responsibility. The community needs to demand it.

The prison system is antiquated and does not have a good track record of dealing with public health issues. That needs to change, and fast because failing to do so will allow the opioid epidemic to continue. Jails have become a revolving door for individuals struggling with mental health and substance use disorders. Jails not only oversee individuals struggling with substance use disorders and withdrawal but represent perhaps the most unique place to initiate treatment from entry to release in a controlled, safe environment, arm inmates with recovery tools and resources to get individuals off drugs and on the path to long-term recovery. Incarceration-focused approaches to drug use are not rooted in evidence and have led to mass incarceration. The criminalization of people who use substances or suffer from addiction just serves to perpetuate the stigma of addiction and prevent those with this disease from seeking treatment. Another unintended consequence is the way officials/authorities perceive and deal with the users of illicit drugs. A system appears to have been created in which those who fall into the web of addiction find themselves excluded and marginalized from the social mainstream, tainted with a moral stigma, and often unable to find treatment even when they may be motivated to want it.

MAT in the prison system is proven to be effective and creates a culture to ensure those with a criminal history are better equipped for productive, law-abiding futures, secure meaningful employment, acquire true closure after punishment is fulfilled, and avoid criminal behavior in the future. Evidence-based MAT in prison programs has been shown to reduce recidivism by 13%, reduce incident reports for prisoner misconduct by 4%, and increase post-release employment by 13%. Substance abuse treatment in one California prison resulted in a 48% reduction in reincarceration. Collectively, these outcomes represent enormous safety and economic benefits to the public but the stigma against both medication treatments for OUD and harm-reduction approaches like naloxone programs has created additional barriers to these strategies’ acceptance and use. It is ethically incumbent upon everyone in the criminal justice system to recognize SUD, addiction not as a moral failing but as a treatable disease.

But jails can only help individuals begin that journey—communities must shepherd those in need through that journey. Society, stakeholders, all levels of government, and prison administrators need to open their hearts and minds to the fact there are proven scientific, evidence-based treatment options and allow prisons to become an essential touchpoint to help people successfully navigate the road to recovery. People need to get involved. Community activism is crucial to changing the prison system to make real drug rehabilitation and Medically Assisted Treatment easily accessible in prison. Raising awareness, dispelling myths, and facilitating a culture change about MAT in justice-involved populations is a key strategy.

Imprisonment is meant to punish crimes, deter future unlawful behavior, and encourage people to change behaviors. To accomplish this, jails and prisons need to provide evidence-based effective drug rehabilitation services. If quitting drugs was easy there would be no need for need treatment but it isn’t. MAT treatment has the specific purpose of helping people find and maintain time clean and sober. That’s not to say it’s impossible to quit drugs in jail without treatment but there are far better alternatives. Punishment alone is a futile and ineffective response to drug abuse, failing as a public safety intervention for offenders whose criminal behavior is directly related to drug use. Jails are good at denying access to drugs or alcohol but abstinence alone can’t address the underlying issues of SUD nor does it address the sustained cravings for illicit substances. The SUD brain is wired to associate addictive substances with pleasure or comfort. Prison cannot change that and without treatment, once released, many will likely return to substance abuse. The increase in the number of drug-abusing offenders highlights the urgency to institute treatments for populations involved in the criminal justice system. It also provides a unique opportunity to intervene for individuals who would otherwise not seek treatment.

A type of MAT, opioid agonist treatment involves taking Schedule 1 opioid medications such as methadone, buprenorphine, or Suboxone. These medications act slowly to prevent withdrawal and reduce cravings for opioids. Medications are prescribed in a structured, supervised clinical setting to ensure safety. Decades of evidence supports opioid agonist therapy as a highly effective treatment that improves clinical outcomes and reduces illicit opioid use, overdose death, and cost yet Most correctional settings do not provide opioid therapy to inmates suffering from SUD or offer drug treatment education or resources to those who want to change and worst of all, most correctional facilities discontinue opioid agonist therapy upon entry into the criminal justice system. Several studies of opioid agonist therapy within correctional facilities or initiated prerelease found it to be safe and very beneficial yet very few prisons provide MAT because criminal justice officials do not understand the science of opioid use disorder and its effective treatment. Reasons for not offering opioid agonist therapy include concerns about diversion and the philosophical objection to the notion of agonist therapy—viewing it as a substitution drug and not as legitimate as abstinence-based recovery. Prisons do not prioritize medical and behavioral care, leaving inmates without resources or treatment nor do prisons provide harm reduction and treatment resources like naloxone upon release.

Frequently arresting, jailing and re-jailing people who pose little public safety risk has immediate moral and fiscal costs. These costs are compounded as underlying medical, financial, educational, and mental health needs are exacerbated by arrest and detention. Putting more drug-law violators behind bars for longer periods has generated enormous costs for taxpayers, but it has not yielded a convincing public safety return on those investments. Instead, more imprisonment for drug offenders has meant limited funds are siphoned away from programs, practices, and policies that have been proved to reduce drug use and crime. There is widespread evidence that restorative justice works and if courts sent even a small percentage of those convicted of drug offenses to a community-based treatment program instead of jail, the criminal justice system would save billions of dollars. Re-allocating those savings to other public safety and social issues would be a wise use of public funds.

According to a study cited by the Treatment First Washington coalition, every dollar spent on MAT or SUD treatment saves $4 in health care costs and $7 in criminal justice costs. savings would extend far beyond the cost of housing inmates. Those who receive treatment for SUD are far less likely to commit crimes, face re-arrest and trial costs, and are more likely to become productive citizens. Every taxpayer dollar spent on rehabilitation programs for prisoners saves five dollars on law enforcement and corrections expenditures in the future.

Prisons need to focus more on mental health treatment, vocational training programs, support groups, and continuing education. They should also consider removing non-violent drug users from the general prison population as a prevention strategy. This group often goes into prison as a functioning member of society, and comes out as a hardened criminal, because right now our prisons change people’s lives — but not in a good way. Drug users take up an unnecessary amount of space in prisons for no reason and should go to rehabilitation facilities. Plus, inmates will be re-entering society at some point in their lives, it is a moral obligation for incarceration to return them back to the community better than they left, not worse.

The global “war on drugs” has been fought for 50 years, without any significant decreases in drug supply or drug use. Beyond this failure, the UN Office on Drugs and Crime (UNODC) has identified many serious negative “unintended consequences” of the drug war –including the stigma, discrimination, and mass incarceration.

At the heart of the issue is a question that we, as a nation, are still struggling with: What is the purpose of the criminal justice system? Punishment? Deterrence? Rehabilitation? Redemption? The 2017 Vera survey showed 91% agreed that the U.S. criminal justice system needs reform, and more than two-thirds said they approve of reducing the prison population and spending the savings on drug treatment and mental health programs.

You can help by supporting medically assisted treatment in jails/prisons and harm reduction measures like naloxone training/distribution. You can endorse ballot measures that fund treatment programs or vote for candidates that support prison reform and most powerful, share your ideas and knowledge with friends, family, and others to raise awareness and build capacity for change.

References
Polls Show People Favor Rehabilitation over Incarceration
Pew – November 22, 2016

Opioid Use Disorder Treatment in Jails and Prisons
Pew – April 23, 2020

Expanding Access to Medications for Opioid Use Disorder in Corrections and Community Settings
National Governors Association – February 2021

How America’s prisons are fueling the opioid epidemic
Vox – March 2018

Setting Precedent, A Federal Court Rules Jail Must Give Inmate Addiction Treatment
NPR – May 2019

Meeting the Needs of Individuals with Substance Use Disorders: Strategies for Jails
National Association of Counties – 2018