With the risk of fatal overdose at least ten times higher in released prisoners than in the general population, there’s a clear need for treating opioid use disorder (OUD) during incarceration. Most of the more than 2 million Americans with OUD have contact at some point with the criminal justice system, so incarceration provides a good opportunity to start treatment.
Yet few prisons and jails offer to start OUD treatment during incarceration—and few will even continue treatment that has already begun.
In this cost-conscious era, the possible costs of treating OUD during incarceration has become an issue. Medicaid pays many OUD-related costs, especially in states with expanded Medicaid coverage, suggesting that costs might rise after prisoners are released. Of special concern are costs for continuing treatment for addiction, billed to Medicaid, and costs for health care unrelated to addiction, such as newly diagnosed hepatitis C.
So, what is the overall impact on community health care spending when prisoners are treated with OUD medications, then released?
A team of investigators looked into this topic and found no relevant published studies. So they planned a study involving Medicaid enrollees who received OUD medications during RIDIC (see box below), and accessed claims data for costs of inpatient and outpatient health care services, before and after OUD treatment. They performed a retrospective analysis, and what they learned was reassuring.
The study, “Changes In Health Services Use After Receipt Of Medications For Opioid Use Disorder In A Statewide Correctional System,” appears in the August issue of the health policy journal Health Affairs.
A Rarity: A Program Offers OUD Treatment During Incarceration
In 2016 the General Assembly of the State of Rhode Island earmarked $2 million to establish the country’s first comprehensive OUD treatment program.
Known as RIDOC, for The Rhode Island Department of Corrections, the program is a unified prison-jail system that incarcerates people awaiting arraignment, trial, conviction, or sentencing. Under RIDOC all newly incarcerated individuals are screened for OUD. Those with a positive test result and an indication for treatment can choose any of the three FDA-approved medications. Those already taking an OUD medication can continue their regimen.
Before release time, plans are put in place so that treatment will continue uninterrupted. Arrangements include access to medication, contact numbers, and linkage to a treatment provider. Help in Medicaid enrollment is provided for those who need it.
Study subjects met these requirements:
- Took OUD medications while incarcerated by RIDOC during the study period, November 2016 through December 2018
- Were incarcerated by RIDOC at least once after January 2014, and before receiving OUD medications
- Were enrolled in Rhode Island Medicaid at some time during the study period
- Spent at least 90 days in the community either before or after taking OUD medications within the program
- People who spent fewer than 90 days in the community before or after exposure to the OUD program medications
Data Gathering and Analysis
Investigators’ analyses included tapping into linked data from several sources:
Data on those who received OUD medications while incarcerated (eg, demographics, key dates, type of medication, incarceration data)
From the Rhode Island Executive Office for Health and Human Services:
Data on Medicaid enrollment and paid Medicaid claims, including amount paid
From the Rhode Island Department of Health:
Information on overdose deaths among study participants
Study outcomes included measures of health care use and related costs while participants were not incarcerated.
Data gathered from the study group included acute use, such as emergency department visits, along with inpatient medical admissions and addiction treatment. The Costs category included payments of all claims during the study period.
(The authors describe in detail the categorizations, data analyses, and secondary analyses they used; see the publication for details.)
The 807 subjects received the following initial medications:
—injectable naltrexone, 17
Incarcerations were relatively brief. Only 130 episodes (2.8 percent) during the study period lasted longer than 1 year. The average number of incarcerations was 5.9, for a total stay of 313 days.
About 70 percent of the participants had an inpatient stay after release from RIDOC. Participants averaged about 12 inpatient days per year—4 for inpatient medical care, 8 for inpatient addiction treatment.
Eleven fatal overdoses were reported.
Medicaid paid $43,787,541 for health care services: $23,891,525 before participants took part in the program and $19,896,016 after.
Participants used $15,948 per year of Medicaid services while in the community during the study period. The difference in individual per year costs before the program ($15,780) and after the program ($17,316) was not statistically significant.
Virtually unchanged were yearly costs associated with inpatient admissions (medical or addiction treatment) before the program ($6,796) and after ($7,076).
Yearly costs associated with emergency department visits dropped from $1,898 to $1,356.
Yearly costs for nonacute outpatient services rose from $3,265 to $3,878.
Costs for pharmacy claims rose from $1,560 to $2,508.
The bottom line:
- Claims for nonacute outpatient services increased
- Pharmacy claims increased
- Emergency department visits decreased
- Inpatient admissions did not change
No change occurred in the use of health care services or total health care costs paid by Medicaid. This was true, the authors explained, despite a “modest, non-statistically significant increase in costs.” The cost increase involved a shift from emergency department services to outpatient and pharmacy services.
The authors suggest that their findings are relevant for jurisdictions that plan to make OUD medications more available in correctional institutions.
In offering their conclusions, the authors note that, on average, participants were incarcerated almost six different times during the four-year study period, and that “given their frequent interaction with the criminal justice system, offering evidence-based treatment of OUD in correctional settings serves as an important opportunity to initiate addiction treatment.”
Howell BA, Martin RA, Lebeau R, et al. Changes In Health Services Use After Receipt Of Medications For Opioid Use Disorder In A Statewide Correctional System. Health Aff (Millwood). 2021;40(8):1304-1311. doi:10.1377/hlthaff.2020.02156