For people with opioid use disorder (OUD), getting into or staying in an opioid agonist treatment (OAT) program while in jail or prison has never been easy. But incarcerated populations now face a new challenge: the COVID-19 pandemic threatens access to treatment programs and their life-saving medications.
Sachini Bandara, PhD, and her colleagues at Johns Hopkins, launched an online survey in May to explore the effects of COVID-19 on OAT programs in jails and prisons. Because the facilities’ ability to sustain OAT programs is uncertain while they grapple with COVID-19, the survey focused on possible challenges the programs were facing, and any changes that might have resulted. The survey went out to wardens, sheriffs, and other leaders at 19 jail and prison systems, and the article was published online August 27 in the Journal of Addiction Medicine.
Background
When seeking treatment for OUD, inmates of jails and prisons have traditionally faced huge obstacles—many of them insurmountable. Inmates not already in OAT treatment when sentenced have virtually no chance of accessing a program while incarcerated, and even inmates already in programs at time of sentencing face barriers to staying in treatment. But the problems incarcerated populations now face because of COVID-19 may be the greatest challenges yet.
When COVID-19 broke out, jails and prisons were hotbeds of infection just waiting to happen. Given high rates of incarceration, medical services not up to a viral challenge, and high-risk conditions—how do you maintain physical distance in an incarcerated population?—it was no surprise when COVID-19 cases spiked early on.
By April 2020—before many people even realized the gravity of the COVID situation—reports indicated that jails and prisons already housed several thousand cases of COVID-19. Yet that compelling figure was “likely an underestimate,” the authors noted.
Now, as facilities continue to grapple with the effects of COVID-19, their ability to sustain OAT programs appears uncertain. Jails and prisons are, in the words of the Johns Hopkins authors, “at the epicenter of the [COVID-19] pandemic in the United States.”
The Study
The survey was sent to jail and prison systems whose programs were initiating maintenance treatment with methadone or buprenorphine, or both, before COVID-19 struck. Excluded from the survey were systems described as “solely providing OAT for individuals already using OAT at arrest or for withdrawal management.” The goal of the study: describe the effect of the COVID-19 pandemic on OAT programs in jails and prisons.
Changes and Challenges
Eleven survey items zeroed in on program changes that may have occurred because of the pandemic, and four items concerned possible challenges the programs faced—challenges for those enrolled, and for those managing the programs. Recipients responded to the first set of survey questions—those covering changes to the programs—by agreeing or disagreeing with the statements presented. To assess challenges, recipients chose 1 of 4 items on a Likert scale, ranging from 1 = strongly agree to 5 = strongly disagree. Data were collected May 5 to 20.
Results
Of the 19 programs contacted, 16 (84%) responded: 12 jails and 4 prisons. More than half of responders reported they had downsized their OAT programs, and more than 80% indicated they had released some OAT participants early because of COVID-19 risks.
Key responses are summarized below.
Changes Resulting From COVID-19
| Action | Number (of 16) |
|---|---|
| Continued to make follow-up community appointments for participants on their release | 13 |
| Released some OAT participants early (under early release policy) because of COVID-19 infection risk | 13 |
| Downsized their OAT programs | 10 |
| Faced challenges in implementing physical distancing and/or getting personal protective equipment | 8 |
| Changed how they dispensed medication | 7 |
None of the facilities reported discontinuing their OAT program, or increasing its scale.
Challenges the Programs Face
The numbers below show how many of the 16 systems contacted considered the situation listed to be a problem for their program:
| Maintaining enough clinical staff | 8 |
| Finding enough space to maintain physical distancing, while dispensing medication | 8 |
| Providing staff with enough personal protective equipment | 5 |
| Obtaining enough medications for the OUD program | 1 |
Key Problems
| The need to downsize OAT programs Difficulties maintaining clinical staff Difficulties keeping physical distancing while dispensing |
(For details on the survey form and the changes and challenges the facilities reported, go to http://links.lww.com/JAM/.)
Discussion
The surveys revealed that jails and prisons with existing OAT programs have curtailed their operations in the context of the COVID-19 pandemic—a matter of concern, because OAT is known to reduce mortality and improve treatment outcomes.
Especially worrisome: downsizing in jails and prisons.
Downsizing during the pandemic, the authors indicated, “further restricts already limited access to these first-line, opioid use disorder treatments” for populations whose risk of overdose continues to be highly elevated.
Also being downsized, adding to the concern: community OAT programs. Patients are delaying treatment for several reasons—fear of infection; dealing with challenges presented by social distancing requirements; and financial pressures that lead to staff furloughs. Jails and prisons that turn to community programs for medication may find OAT access further reduced, and post-release overdose risk further elevated.
Also mentioned: Capacity for re-entry services, community OAT programs, harm reduction services, and connections to housing—“already limited before COVID-19”—are “likely further threatened by the pandemic.”
On the less-pessimistic side, the authors mentioned that some regulatory restrictions have been loosened during the pandemic, and those changes could be further implemented under specific guidance.
Additional Comments
We contacted Noa Krawczyk, PhD, assistant professor at NYU Grossman School of Medicine, for her thoughts about the article, and for suggestions on possible solutions for some problems facing OUD programs in jails and prisons. Dr. Krawczyk, who was not involved in the Bandra study, is a corresponding author at NYU’s Center for Opioid Epidemiology and Policy, and lead author on a recently published paper, “Lessons From COVID 19: Are We Finally Ready to Make Opioid Treatment Accessible?”
Dr. Krawczyk commented, “Many of us who work on the intersection of opioid use and criminal justice have been concerned about what will happen to jail and prison-based opioid treatment programs in the midst of the chaos detention centers are experiencing to contain the spread of COVID-19. Dr. Bandara’s study is the first to give us a lens into how these treatment programs have been affected and are adapting to the current situation.
Dr. Krawczyk noted that the study shows that the programs “are suffering and reducing their services to some extent” because of the pandemic, but there has been recent progress in implementing the programs inside prisons and jails. Efforts are being made “to link folks who are being released to ongoing treatment in the community”—and that “should still be a priority for these facilities.” She considers this “a critical and life-saving effort that should not be forgotten or diminished in the midst of the COVID-19 pandemic.”
As an example, she mentions new regulations allowing for telephone-initiated buprenorphine therapy. “Detention facilities can partner with community-based programs to help connect released inmates to these programs, so they can begin—or continue—therapy via telephone immediately upon release.”
Another option: Jails and prisons can provide naloxone to all inmates who leave their facility on short notice—an excellent idea, we believe; especially so, given the huge risk inmates face of overdose death as soon as they leave a facility, and for several weeks after.
Health departments can play a key role, Dr. Krawczyk explained, citing as an example a New York City jail re-entry program that “has partnered with a virtual buprenorphine clinic in the City, and directly refers people released from Rikers Island Jail to begin treatment ‘there,’ by phone.” The New York City Department of Health is also helping deliver methadone to people’s homes and to homeless shelters—“another example of making efforts to assure the most vulnerable stay engaged in treatment upon release.”
In her recently published paper, Dr. Krawczyk mentioned the “alternative reality” brought about by COVID-19. Longer take-home periods for methadone are now considered standard, and buprenorphine initiation is accomplished “over a simple phone call.” And she pointed out that efforts to prevent spread of COVID-19 in detention centers have resulted in the recent “unprecedented dismissal of thousands of low-level drug charges.” Previously, those charges would have led to “the incarceration of many drug users,” virtually cutting them off from effective treatment.
How the Criminal Justice System Could Help Slow the Pandemic
Something often overlooked: incarceration of drug users also increases spread of the virus in the criminal justice system, and ultimately, in the general population. Reducing admissions to jails and prisons, and increasing releases, would help ease the problems facing OAT programs in those facilities, and would lessen COVID-19 spread. A recent publication from the Prison Policy Initiative shows some specific ways that could be done.
Conclusions
COVID-19 has resulted in downsizing of OAT treatment programs in jails and prisons. “By threatening access to life-saving medications,” the Bandara study points out, “the COVID-19 pandemic poses an additional threat to an already vulnerable and highly marginalized population.” The study’s authors call for efforts to bolster OAT programs “and further evaluate the pandemic’s impact on overdose and treatment outcomes.”
Reference
Bandara S, Kennedy-Hendricks A, Merritt S, Barry CL, Saloner B. Early effects of COVID-19 on programs providing medications for opioid use disorder in jails and prisons [published online ahead of print, 2020 Aug 27]. J Addict Med. 2020;10.1097/ADM.0000000000000718. doi:10.1097/ADM.0000000000000718
For Further Reading
Krawczyk N, Fingerhood MI, Agus D. Lessons from COVID 19: Are we finally ready to make opioid treatment accessible? J Subst Abuse Treat. 2020;117:108074. doi:10.1016/j.jsat.2020.108074
Wagner P, Widra E. Five Ways the Criminal Justice System Could Slow the Pandemic. March 27, 2020. The Prison Policy Initiative. Accessed September 16, 2020. https://www.prisonpolicy.org/blog/2020/03/27/slowpandemic/
Link to the Virtual Buprenorphine Clinic in New York City: https://www.nychealthandhospitals.org/virtual-buprenorphine-clinic/