Jail-based methadone maintenance treatment (MMT) sounds great in theory, but it’s rarely implemented. Yet opioid use disorders are common, with about 23% of state prisoners and 18% of federal prisoners reporting a history of opioid use. Tragically, once prisoners are released, loss of tolerance and the increased availability of potent synthetic opioids puts them at a high risk of death by overdose.
With the U.S. spending more than $80 billion each year housing inmates, and yearly societal costs of crime on track to reach a whopping $1.7 trillion, a group of investigators at the University of New Mexico decided to take a good look at the possibilities jail-based maintenance MMT might offer. They published their results online May 28 in the Journal of Substance Abuse Treatment, with the print version following in the journal’s August issue.
Below are details of their study.
▬ Perform a cost-effectiveness analysis of jail-based MMT, using data from an MMT continuation program in a large urban jail in New Mexico. The authors’ aim was “to evaluate the economic impact of jail-based MMT continuation, using crime as the main economic outcome variable.”
The team collected three years of recidivism data covering the periods before and after incarceration, for a total of six years. Then they assembled quasi-control groups, consisting of general populations along with populations who used substances.
The Metropolitan Detention Center (MDC), in Bernalillo, New Mexico, site of the study, processes about 25,000 inmates each year, operating under an annual budget of about $64 million. The MDC program was established as a public health clinic in November 2005, and has operated continuously since then. Eligibility for the program is limited to people who had been “enrolled and active in a community-based MMT facility,” and is verified with the clinic at the time of incarceration.
“It is important to note that this is a jail rather than prison program,” the authors emphasize. Typically, jail inmates are awaiting trial or have been convicted of minor crimes and face brief incarceration, whereas prison inmates are looking at longer-term imprisonment.
The team gathered data for 228 inmates who participated in the MMT program. All inmates in the study were released between July 1, 2011 and June 28, 2012. Also, comparison data were collected from three inmate groups:
- 358 who had opioid use disorders, but had no MMT
- 369 who had been detoxified from alcohol
- 545 from the general population, with no known substance use disorders
Thus, the analysis sample totaled 1,500 inmates. These inmates had spent 6 weeks on average in the MMT program.
Costs and Cost Effectiveness
To calculate the costs of implementing jail-based MMT, the team used a modified version of popular tool called the Drug Abuse Treatment Cost Analysis Program (DATCAP). They compared changes in recidivism associated with treatment with the costs of providing jail-based MMT, then determined the cost savings for each day of reduced incarceration.
The investigators’ findings answered key questions.
|Q||Did jail-based MMT reduce the number of days spent in jail due to recidivism?|
|A||Yes. MMT enrollees spent significantly fewer days in jail due to recidivism—29.33—than inmates who had OUDs and hadn’t received MMT.|
|Q||What was the cost of a day in jail?|
|Q||How much did MMT cost?|
|A||The average MMT cost was $115 per week and $689 per episode (in 2011 dollars).|
|Q||How much did it cost to reduce recidivism?|
|A||$23.49 per day.|
We asked the study’s lead author, Brady Horn, PhD, associate professor in the Department of Economics and at the Center on Alcoholism, Substance Abuse & Addictions at the University of New Mexico, how much it cost to bring costs down. He explained in an email reply that a better way to look it was to determine the cost of reducing a day of recidivism, using jail-based MMT. He added that recidivism “can be reduced at a cost of $23.49 per day, which is much lower than the actual cost of incarceration, $116.49.”
|Jail-based maintenance MMT at this large urban jail reduced recidivism at a cost of only $23.49 per day—significantly less than $116.49, the daily cost of incarceration|
How Much Is Society Willing to Pay for MMT in Jails?
Obviously, a key factor in willingness to pay is the break-even point. The study found that if the average cost of one day’s incarceration is $116.49, and society is willing to pay that amount to reduce incarceration by one day, the probability that MMT is cost effective is 93.3%. But if society is willing to pay only $40 for one day’s reduction in incarceration, the probability of cost effectiveness is about 75%.
We asked Dr. Horn to clarify the meaning of the cost-effectiveness probability of 93.3%. He explained that the 93.3% was a statistical calculation, and that “because we only have data drawn from a sample of the population, we can only be 93.3% sure that the observed recidivism results were a result of the MMT program and did not occur by chance.”
It’s clear that the randomized placebo-controlled design that traditional clinical studies use would not be appropriate in the present studies, for it would be unethical to create a control group by withholding methadone treatment for newly incarcerated patients who are in an ongoing MMT program. The best available control group would be inmates whose characteristics are as similar as possible to those of the treated group.
Studies looking into the possible effects of continued MMT on cost-effectiveness, recidivism, or both, have sought statistical significance in a variety of ways. The results have been equivocal.
- A study published in Addiction in 2008 found that jail-based continued MMT neither increases recidivism risk nor reduces recidivism. The authors of the study directly below (Westerberg et al) commented on several weaknesses in this study. For one, they noted that the comparison group may have included a sample of inmates who had no history of substance use. If so, that would lower the chances of identifying the impact of MMT on the dosed and non-dosed groups.
- A 2016 study in the Journal of Substance Abuse Treatment assessed recidivism for one year after release, and did find a decrease in recidivism. Two of the study’s authors are also among the authors on Dr. Horn’s study, both studies involve inmates in a New Mexico jail, and characteristics of the three comparison groups are similar. This study found that the treatment group “displayed a significantly longer time to be rearrested than inmates undergoing opioid or alcohol detoxification, but not inmates without substance use disorders.”
- A review in the Journal of Substance Abuse Treatment (online 2018, print 2019) showed strong support for using MAT in increasing community-based treatment engagement after incarceration, and equivocal support “for reducing recidivism post-release, as re-engagement in community-based MAT after incarceration often is not considered in the prediction of recidivism.”
The authors of this study stress the need for future work and stronger comparison groups. They also recommend that future studies
- Incorporate other societal benefits that could be associated with jail-based MMT “to evaluate criminal justice programs such as this jail-based intervention from a societal perspective”
- “Extend this analysis to evaluate the impact of jail-based MMT initiation”
- Use stronger comparison groups, ones that incorporate alternative perspectives; and consider different criminal justice systems
Dr. Horn is planning a new study to help clarify the impact of jail-based MMT on productivity gains and other factors, such as use of health care facilities.
Given the encouraging results of this study, the authors suggest that jail administrators and policymakers consider “incorporating MMT in other jail systems and settings.”
Horn BP, Li X, McCrady B, Guerin P, French MT. Cost-effectiveness analysis of a large jail-based methadone maintenance treatment continuation program in New Mexico. J Subst Abuse Treat. 2020;Aug;115:108042. doi:10.1016/j.jsat.2020.108042
McMillan GP, Lapham S, Lackey M. The effect of a jail methadone maintenance therapy (MMT) program on inmate recidivism. Addiction. 2008;103(12):2017-2023. doi:10.1111/j.1360-0443.2008.02361.x
Westerberg VS, McCrady BS, Owens M, Guerin P. Community-Based Methadone Maintenance in a Large Detention Center is Associated with Decreases in Inmate Recidivism. J Subst Abuse Treat. 2016;70:1-6. doi:10.1016/j.jsat.2016.07.007
Moore KE, Roberts W, Reid HH, Smith KMZ, Oberleitner LMS, McKee SA. Effectiveness of medication assisted treatment for opioid use in prison and jail settings: A meta-analysis and systematic review. J Subst Abuse Treat. 2019;99:32-43. doi:10.1016/j.jsat.2018.12.003