The primary purpose of the present quantitative research was to assess the impacts of MAT on one-year post release treatment retention among adult inmates with in the correction facilities in the United States. The study would compare and contrast the retention rates between inmates initiated before the release compared to their peers initiated in the post-release. Furthermore, types of medications administered to the inmates would also be evaluated for their possible differences in the retention rates. Evidence from the existing literature, including studies by Brinkley-Rubinstein et al. (2018) and Degenhardt et al. (2014), identifies Medication Assisted Treatment (MAT) as an important approach (when used together with counseling and behavioral therapies) as a holistic approach for treating substance use disorders (SUD).
Even though MAT has been established as a key strategy for SUD, including opioid addiction, there is still little evidence showing the significance of MAT treatment within the correctional settings especially on its ability to influence occurrence of higher probability of post-release treatment retention. Therefore, extensive research is needed in this context in order to establish the applicability of MAT treatment option within the correctional setting. In order to achieve its goal, the present study would use the biopsychosocial approach as the theoretical framework. Specifically, the biopsychosocial approach accounts for the impacts of social, biological and psychological factors on an individual’s health and addiction (Banta-Green et al., 2019). Therefore, its adoption is appropriate for the present study as the key treatment option being assessed, MAT, is also involved in the provision of counseling and medication care tailored based on the biological, social and psychological factors of individuals whose SUD conditions are being treated and managed.
In the United States’ general population, opioid use disorder is among the most common type of SUD, with about 2.7 million in 2017 people experiencing opioid use disorder and that about 68% of overdose related deaths involved opioids (Brinkley-Rubinstein et al., 2018). In the US correctional settings, it has been reported that at least 85% of the inmates are experiencing active SUD or being incarcerated of crimes that involve drugs and drug use (Csete, 2019). Furthermore, Banta-Green et al. (2019) and Degenhardt et al. (2014) reported that inmates with SUD, especially opioid use disorder, are vulnerable to experiencing overdose after being released from the incarceration. Therefore, there is need to address both active and recurrent SUD incidences among inmates. The primary goal of this chapter is to critically appraise evidence from the existing literature about SUD and MAT use in the US correctional settings in order to identify key gaps in literature that should be addressed by the present study. The chapter is organized into different sections such as the literature search strategy, history of MAT, theoretical foundation of the study and the literature review associated with the key variables being assessed in the present study.
Literature search process was conducted on electronic databases to facilitate identification of appropriate studies for critical appraisal of existing literature about SUD, opioid use disorder and MAT treatment within the US correctional settings. Specifically, the literature search process was conducted on SAGE journals, PsycARTICLES, PsycINFO, ProQuest Central, Science Direct, and the Criminal Justice databases. The selection of these databases was primarily influenced by their higher reputations in hosting top-quality and up-to-date studies on SUD incidences, consequences and treatment options, including the use of MAT. Different keywords and search terms were used during the literature search process on the selected databases. The keywords were combined using Boolean operators “AND” and “OR” to widen the scope of literature search process. The adopted keywords include “medication assisted treatment” OR “MAT” OR “suboxone” OR “methadone” OR “buprenorphine” OR “addiction therapies” AND “substance use disorder” OR “heroin addiction” OR “opioid use disorder” AND “correctional settings” OR “jails” OR “prisons” OR “detention center” AND “post release treatment” OR “treatment facilities”. Wide variety of eligibility criteria was applied in order to facilitate identification of most appropriate studies for review.
The first inclusion criterion was based on the study purpose where only those studies that assessed SUD incidences and consequences within the US correctional settings and the use of MAT in SUD treatment were selected for review. The literature search process was further limited only studies originally published in English language, US-based and published in 2010-2022. All of these inclusion criteria were applied to allow for the identification of up-to-date studies on the phenomenon being investigated. The literature search process was further limited to primary peer-reviewed studies, including qualitative, quantitative and mixed-methods research studies. Therefore, grey literature and studies which adopted secondary research methodologies such as systematic reviews, meta-analyses and narrative reviews were excluded. Full-text availability is another key criterion that was applied, with only studies with full-text formats being selected for further assessment and included in the final evidence synthesis. Furthermore, the conducted literature search strategy was readjusted to facilitate identification of key studies about the biopsychosocial approach, which was used in the present study as the theoretical framework. Even though the initial literature search on the electronic databases led to the identification of 905 records, only 41 peer-reviewed studies met all the inclusion criteria and were selected for the critical appraisal in this chapter.
MAT for SUD or opioid addiction disorder generally involves the use of medications together with behavioral therapies and counseling (Mittal et al., 2017). Specifically, this treatment approach works by blocking the brain chemistry, relieving physiological cravings, blocking the euphoric effects of alcohol and opioids as well as normalizing the body functions without causing further negative consequences of the abused substances (Jones et al., 2015). With reference to the explanations by Connery (2015), opioid abuse and addiction first emerged in the United States during and after the Civil War when this type of medication was prescribed to facilitate alleviation of chronic and acute pain, stress among other forms of discomforts. In the late 19th Century, the number of people affected by opioid addiction significantly increased, with the largest portion being middle- and upper-class white women, with the trend generally attributed to the increased prescription of opiates for menopausal and menstrual discomforts (Timko et al., 2016). Consistently, Connery (2015) identified Civil War veterans as another group of people who were adversely affected by the opioid addiction during the 19th Century, with at least 300000 individuals experiencing opioid addiction disorder in the United Stats by 1900. With reference to the explanations by Jones et al. (2015), increased opioid addiction among women and Civil War veterans in the late 19th Century and early 20th Century was generally perceived by the United States general society to be sympathetic, as an unfortunate medical condition, especially because members of this groups experienced major social problems. Healthcare practitioners, including doctors, largely prescribed more opioids to the members of this population, leading to the establishment of sanatoriums for questionable cures for the associated additions (Mittal et al., 2017). The chronic nature of opioid use disorder then became evident mainly because most of the people who underwent the sanatoriums for cures later relapsed to the opioid addiction and use after the discharge.
Crime rates associated with the use and acquisition of illicit opioids significantly increased in the United States in 1920s, a trend which forced the Congress to appropriate funds for developing two novel treatment facilities, which were referred to as the “narcotics farms” in both Lexington, Kentucky and Fort Worth, Texas (Timko et al., 2016). The primary role of these institutions was to detoxify people addicted to opioid use, as well as serving as medical centers for prison inmates with opioid addiction. As stated in the studies by Connery (2015) and Jones et al. (2015), the prescribed stays at these narcotics farms were approximately 6 months, even though some of the patients had longer stays depending on their response rate to the treatment options prescribed to them. For example, Connery (2015) noted that the prisoners could stay for more than 10 years, and that these narcotics farms provided medical, social, psychiatric and psychological health services to the affected individuals. Consistent with the explanations by Uebelacker et al. (2016), efficiency of these firms was generally impacted by low patient-to-staff ratio, with Jones et al. (2015) reporting significant failure of the program. Important changes in the rates of opioid addiction were reported during the World War II following the migration of European immigrants from the major cities to areas with pre-existing problems of addition and abuse; the shift further led to the development of hardened attitudes among the addicted individuals (Uebelacker et al., 2016). Increased additions of heroin in New York in 1952 motivated the development of Riverside Hospital which mainly cared for adolescents with addiction disorders, a program which later failed mainly because of low public awareness and limited resources to support effective treatment and management of individuals experiencing addictions (Timko et al., 2016). Specifically, Timko et al., (2016) reported high relapse rates in the high post-treatment periods, with at least 86% of the patients treated in the facility experiencing relapse. The facility was later closed in 1961 with poor performance being cited as the major factor.
In late 1960s, there was a significant increase in the rates of heroin use among the middle class, especially the young white Americans, a trend which led to the rise of addiction associated crimes (Bogenschutz et al., 2015). Members of the US military who were involved in the Vietnam also reported significant effects in 1970s (Mittal et al., 2017). As a control mechanism for opioid prescription and use among the general public, the New York Academy of Medicine recommended the development of clinics affiliated with major hospitals to dispense opioids in a controlled manner, especially to the patients experiencing addiction (Stein et al., 2016). The American Medical Association (AMA), in 1956, advocated a research study focused on assessing the feasibility of using opioid treatment program for dispensing opioid (Bogenschutz et al., 2015). In 1963, Advisory Commission on Narcotic and Drug Abuse further recommended research project to assess levels of effectiveness of the outpatient opioid treatment program in the dispensing of opioid to individuals experiencing addiction (Uebelacker et al., 2016). Both the research projects recommended the elimination of short-acting opioids such as morphine as options during the maintenance therapy, with more support for the use of methadone which is generally long-acting and more effective on oral administration (Stein et al., 2016). In the 1980s, at least 500000 Americans were using illicit opioid, especially heroin, with the addiction becoming both medical problem and explosive social issue in the United States; at least 800000 people had chronically or infrequently used heroine by 1990s, but only 10% of the affected individuals were seeking treatment for the disorder (Mittal et al., 2017). Naltrexone was later developed as a treatment option for opioid addiction, with its use being approved by the FDA in 1995, including as a preventive treatment option for relapse to alcohol abuse among individuals who are dependent on alcohol (Bogenschutz et al., 2015). Therefore, it is justifiable to note that methadone, suboxone and naltrexone treatment options had all influenced the rise of MAT, with most of the rehabilitation centers in the United States currently using the MAT together with behavioral therapy in the treatment and management of SUD, including opioid use disorder.
The purpose of this quantitative study is to examine whether starting MAT pre-release improves retention rates post release in selected state adult correction facilities in the United States. The present study adopted the biopsychosocial theoretical approach to explain the impacts of MAT on the pre-release retention rates. The biopsychosocial model of addiction postulates that genetic/biological, sociocultural and psychological factors play a central role in influencing the development of substance abuse behaviors, and that all these factors should be accounted for during the prevention and treatment efforts (Al Ghaferi et al., 2017; Sokol et al., 2021). Specifically, evidence from the previous studies by Dailey et al. (2020) and Hulla et al. (2019) shows that the biopsychosocial approach was developed in response to the criticisms of the originally used biomedical model. Precisely, the traditional biomedical model generally perceived addiction as a chronically relapsing brain disease with biochemical or genetic cause (Cheatle, 2016). Therefore, it can be noted that the traditional biomedical model of addiction perceived addiction as a manifestation of disturbances in measurable neurophysiological or biochemical processes among the affected individuals. On the contrary, the biopsychosocial model acknowledges the significant roles played by social, behavioral and psychological factors in the development of addiction (Asieieva, 2017; Sokol et al., 2021). Nonetheless, Dailey et al. (2020) argued that all of these factors are relatively less significant in the etiology and treatment of addiction. Even though the traditional biomedical model has been widely used by scientists and healthcare practitioners in the treatment and management addiction (Purcell et al., 2019), evidence from the previous studies by Hulla et al. (2019) and Haug et al. (2017) about the addiction behavior fails to support efficiency of the medical disease model of addiction, by favoring the biopsychosocial model which provides more emphasis on the essential roles of biological, sociocultural and psychological factors in the development of addictive behaviors, including in the context of substance abuse. Therefore, it is important to note that the biopsychosocial model does not only emphasize on the role of biological factors but also environmental factors in the development of addictive behaviors.
Psychosocial factors such as personality variables, higher-order cognitive processes and learning factors have been established to play a central role in the development of addictive behaviors (Cheatle, 2016; Sokol et al., 2021). With reference to the explanations by Dailey et al. (2020), substance or alcohol abuse is often highly y comorbid with affective disorders among other psychiatric diagnoses. According to Hulla et al. (2019), significant number of people involved in substance abuse often experience different psychosocial problems such as nonconformity, antisocial behavior, impulsivity and low self-esteem. Therefore, research studies on the impacts of psychosocial factors on addiction behavior have established that addiction is generally multifactorial problem, and not a problem that is primarily caused by quantifiable underlying physiological abnormalities, hence supporting the use of biopsychosocial model in the addiction treatment and management. Environmental impacts on the substance use and addiction behavior have also been extensively researched and reported in wide range of existing literature. For example, Al Ghaferi et al. (2017) and Purcell et al. (2019) identified substance availability as a major risk factor for the initiation of substance use and subsequent development of SUDs. For the genetic predispositions to influence development of addictive behaviors, an individual must first interact with the agents of addiction, including alcohol and drugs (Sokol et al., 2021). Therefore, increased availability of drugs and alcohol increases vulnerability of an individual to addiction and SUDs. Extensive research studies have been conducted to assess the impacts of biological factors on the development of addictive behaviors. Specifically, Asieieva (2017) noted that both biological and genetic predispositions often increase vulnerability of an individual to substance abuse problems. Results from the previous study by Hulla et al. (2019) reported that male children of alcohol-dependent parents are 4 times at risk of developing substance abuse behaviors compared to their peers with nondependent parents, with female children being 3 times at greater risk. Correspondingly, Al Ghaferi et al. (2017) reported that 27% of their participants with alcohol dependence had alcohol-dependent fathers compared to 4.9% who had alcohol-dependent mothers. Therefore, it can be noted that male children are likely to develop substance abuse behaviors compared to their female peers if born and raised with alcohol-dependent parents.
Effective addiction treatment and management programs largely incorporate strategies for reducing cravings, coping, managing triggers as well as preventing relapse (Purcell et al., 2019). Even though most of the programs involve medication, pharmacotherapy-based strategies are increasingly being adopted and considered to be most effective in enhancing recovery from the addiction problems (Turakhia, 2020). The biopsychosocial approach is increasingly being adopted in the treatment of addiction as it focuses on addressing the social, biological and psychological aspects of addiction (Cheatle, 2016; Sokol et al., 2021). Specifically, Dailey et al. (2020) and Haug et al. (2017) established that the biopsychosocial approach has the ability of facilitating effective management of challenging emotions, promoting resilience among people experiencing addiction by enabling them to cope with the negative life circumstances, developing lifestyle that is free from substance use as well as enhancing social support for sobriety. Even though the biopsychosocial model has been widely used in understanding and explaining the problem of addiction, comparative assessment of evidence from the previous studies by Al Ghaferi et al. (2017), Asieieva (2017) and Purcell et al. (2019) shows that this model has not generated testable hypotheses as in the case of different theories of behavior such as theory of reasoned action and theory of planned behavior. Therefore, the adoption of biopsychosocial model in the present study was appropriate as it would be used as a guide in developing and testing hypothesis about the impacts of MAT approach in preventing SUD relapse, hence bridging the existing gap in literature about the ability of biopsychosocial model to generate testable findings. According to Haug et al. (2017) and Turakhia (2020), the primary concept of biopsychosocial model is that both mind and body are connected and are actively involved in the development and progression of addictive behaviors with the cultural and social contexts. Therefore, there is need to account for all of these factors in order to promote appropriate conceptualization of the addiction.
Extensive research has been conducted to assess and determine efficiency of different medications that can be used for the treatment of opioid addiction within different population, including the prison population. A key goal in the treatment of opioid dependence with medications often involves substituting the short-acting, high-potency opioid with non-illicit replacement (Banta-Green, et al., 2019; Fox et al., 2015). With reference to the explanations by Brinkley-Rubinstein et al. (2018), some of the MAT options for opioid addiction treatment often involves blocking the user from feeling the potential effects of additional opioids. On the other hand, Degenhardt et al. (2014) established that some of the MAT options of opioid addiction treatment are involved in the limiting of the physical and physiological symptoms of withdrawal. However, efficiency of both MAT treatment options is often enhanced by incorporating behavioral therapy, which can either be in the form of group therapy or counseling. Consistent with the explanations by Csete (2019) and Langabeer et al. (2020), there are multiple forms of medications that are often used during the execution of MAT program, including buprenorphine and methadone (commonly used option) and heroin (which is uncommon). However, it is important to note that all of these medications often have different mode of actions. For example, naltrexone is an antagonist medication which act by blocking the activation of opioid-specific receptors (Langabeer et al., 2020) while heroin are agonists which are involved in either partial of full activation of the receptors in the user’s brain in similar magnitude as opioid (Banta-Green, et al., 2019). Nonetheless, agonist medications are not often recommended for extensive use as they have potential for abuse by acting as active opioid receptors (Degenhardt et al., 2014; Fox et al., 2015). Therefore, the dosing of MAT agonist should be properly monitored and only administered by medically competent professionals.
Based on the potential side effects associated with the use of agonist medications in the treatment of opioid addiction, research has been intensified to establish possible alternatives to such medications, including substituting them with antagonists, the receptor-blocking agents. An RCT conducted by Pan et al. (2015) established that naltrexone has promising efficiency in the treatment of opioid addiction disorder, especially when provided in an extended-release preparation. Along with the drug courts, MAT is currently being used in different settings of criminal justice, with the long-lasting and injectable medications supplementing the commonly used drugs. Heroine among other opioid use is associated with high rates of dependence Brinkley-Rubinstein et al. (2018), mortality and healthcare costs (Banta-Green, et al., 2019) and an important healthcare problem in the United States (Csete, 2019). The adoption of buprenorphine and methadone in the treatment of opioid addiction disorder has been further motivated by the increasing pressure of the present opioid crisis, in the US prison and general populations, despite the fact that such treatment option often represent a small fraction of all cases which require addiction treatment. With reference to the evidence provided in the studies by Degenhardt et al. (2014), Ferguson et al. (2019) and Langabeer et al. (2020), it can be noted that long-lasting buprenorphine and methadone formulations are increasingly being adopted in the treatment and management of opioid addictions in the community and prison population settings. Furthermore, a longitudinal study by Moore et al. (2019) reported positive effects for the extended-release injectable buprenorphine and methadone, with the authors developing a general conclusion that despite the availability of limited randomized evaluations that compare injectable buprenorphine and methadone to the current standard care or placebo, evidence about the clinical efficiency of these medications exists. Nonetheless, the challenges associated with adherence to these treatment options as well as erraticism in the detoxification status among members of the population treated using such options warrant the need for further investigation.
Existing literature has established that the extended-release injectable naltrexone has wide range of features which makes its more appealing compared to the other long-acting antagonists, especially within the justice-involved populations. For example, Ferguson et al. (2019) established that the injectable naltrexone is always administered by medically competent practitioners on a monthly basis hence limiting the possibility of diverting such medications for resale. Therefore, this strategy for administering naltrexone makes it more effective compared to the methadone which often require daily dosing leading to their possible misuse. Even though the approach for administering naltrexone helps in limiting misuse, it is not often possible to cease treatment process immediately once it has been initiated compared to when the daily-dosed MAT medications such as buprenorphine and methadone are involved (Fox et al., 2015). Preliminary evidence from the studies by Brinkley-Rubinstein et al. (2018) and (Csete, 2019) shows that injectable naltrexone is an effective MAT option for reducing substance abuse, including opioid addictions, within the criminal justice settings. The other key advantages of naltrexone compared to buprenorphine and methadone as MAT options for substance addiction include cost effectiveness (Moore et al., 2019) and self-reported recidivism (Ferguson et al., 2019). Specifically, Ferguson et al. (2019) established that 43% of the volunteers with criminal history in the naltrexone group reported relapse compared to 65% in the control group (p<0.001). However, a 24-months longitudinal study conducted by Pan et al. (2015) reported no significant differences in the relapse and incarceration rates among the participants in the naltrexone and control groups. Comparative assessment of evidence from these two studies therefore shows that effectiveness of naltrexone as a MAT option for substance abuse treatment has short-term viability, hence the need to adopt more effective alternatives.
Post-release opioid-associated overdose mortality is among the leading causes of high mortality rates among people released from jail or prisons. Extensive research has been conducted to establish the opioid and substance abuse and addiction rates in the post-release period. For example, an RCT conducted by Joudrey et al. (2019) established that the inmates who were administered with methadone during incarceration had lower chances of using opioid or developing addiction in the post-release period compared to those in the control. Similar findings were reported in the observational study by Martin et al. (2019) which established that participants administered with 35 mg of methadone before release had reduced chances to self-reporting using heroin after 7-10 months of being released from prison. Contrary to the findings reported in the studies by Banta-Green et al. (2020) and Lee et al. (2015), a longitudinal study by Gisev et al. (2015) reported no significant differences in the rates of opioid use among inmates treated with either buprenorphine-naloxone sublingual tablet or methadone during incarceration after 3 months of being released. Corresponding findings were reported an RCT follow-up study by Schwartz et al. (2021) which established no significant difference among participants inducted to buprenorphinenaloxone and those offered counseling only during incarceration in 12-month post-release period. Comparative assessment of evidence reported in these studies shows that there is no significant difference in the level of efficacy between methadone and buprenorphine in preventing post-release opioid use. Apart from the fact that both methadone and buprenorphine are antagonist medications, there is need to further assess and report primary factors that influence no significant levels in their efficacy.
Heroin users are often at high risk of experiencing frequent incarceration and re-incarceration; hence reducing re-incarceration incidences among members of this group is important for addressing both the health risks linked with the imprisonment and costs for the correctional administration. A longitudinal study by Lee et al. (2015) found that being in opioid substitution treatment during release from prison did not have significant impacts on the ability of an individual to be re-incarcerated. On the other hand, Martin et al. (2019) reported that participants who remained in the opioid substitution treatment program after release experienced reduced risks of re-incarceration by 23%. Therefore, comparative assessment of results from these studies suggests that opioid substitution treatment exposure is not the only factor influencing vulnerability of released inmates to re-incarceration but whether the individual remain in this treatment program after release. Such arguments are further supported with evidence from the research study by Banta-Green et al. (2020) which showed that the opioid substitution treatment benefits are often maintained only during the period when the individuals are still being administered the treatment program. Moreover, Joudrey et al. (2019) established that incidences of criminal offending and incarceration were reduced in the community samples only when the participants were still undergoing the opioid substitution treatment. Even though the reduction in re-incarceration risks is modest, modelling studies such as Gisev et al. (2015) and Schwartz et al. (2021) have established that even small decrease in the re-incarceration risks among people with high vulnerability has significant benefits in relation to decreasing the prison population size as well as the correctional administration costs. Therefore, there is need to develop most effective strategies for ensuring significant reduction in the incarceration and re-incarceration rates among the drug and substance addicts.
Analysis conducted by Lee et al. (2015) demonstrated that the use of cocaine before baseline incarceration was linked with significant increase in the risks of re-incarceration. Furthermore, an RCT conducted by Gordon et al. (2015) reported that methadone had no significant impacts on post-release recidivism rates. Similarly, Banta-Green et al. (2020) reported no significant difference in the re-incarceration rates among the methadone inducted inmates, but those who continued with the methadone treatment during incarceration and post-release spent longer period of time under the community supervision compared to their peers who terminated the methadone treatment immediately after release. On the other hand, observational study by Wegman et al. (2017) reported that participants treated using methadone before their release had lower rates of reincarceration 7-10 months post release. Therefore, it is justifiable to note that the risks for re-incarceration among inmates with SUD can be reduced by inducting them with methadone both prior to and after the release; the treatment process should not be immediately terminated for better outcomes. Even though the studies by Gisev et al. (2015) and Schwartz et al. (2021) reported significant reduction in the re-incarceration risks as long as the participants retained methadone treatment after release, the median retention time is generally low, less than 63 days. Therefore, it can be noted that the MAT options used in such cases ceased to be effective only after 2 months. As outlined in the studies by Joudrey et al. (2019) and Martin et al. (2019), the post-release period is generally stressful characterized by increased challenges in accessing appropriate housing and legal outcomes. Therefore, detailed pre- and post-release support is required in order to address treatment needs in addition to the challenges experienced by the released inmates which may limit their ability to continue with the assign MAT program.
With the addiction treatment context, undue influence and coercion present a complex paradigm, with some of the existing studies reporting that MAT options have significant impacts on the recipient (Kavanaugh & McLean, 2020; Noska et al., 2015; Smith et al., 2020). Nonetheless, Chang et al. (2015) argued that even those participants who begun their drug treatment process on a voluntary basis are able to reported that they were coerced into taking part in the study, hence limiting the efficiency of the reported findings in such studies. Active justice-involved population should be considered distinctly with reference to the pressures they experience when enrolling to the assigned MAT program (Farahmand et al., 2017; Noska et al., 2015). From an empirical perspective, both informal and legal coercion can have significant impacts on the drug treatment efficiency, with the reported results is some context being negative. For example, the study by Chang et al. (2015) reported that the inmates who were mandated to take part in a MAT program involving suboxone and Subutex became demonstrably less motivated despite the fact that these court-ordered participants were still forced to remain in the assigned treatment program. In studies by Moore et al. (2019) and Smith et al. (2020), inmates who were undergoing mandatory MAT program reported high performance levels compared to the volunteers in the treatment process. However, it is important to note that people who are coerced into MAT treatment through the legally permissible means are likely to perceive their participation to be voluntary (Farahmand et al., 2017; Kavanaugh & McLean, 2020). Therefore, such evidence is not a justification that undue influence and coercion are preclude and inherent treatment, but that they should be properly accounted for as possibly meaningful part of the context.
Comparative assessment of evidence from a wide range of literature has led to the identification of key factors that influence agency use of MAT, which include security concerns (Kavanaugh & McLean, 2020), ability of the agency to favor drug-free over MAT (Noska et al., 2015), administration of MAT through community treatment programs (Wiss, 2019) as well the concerns about the liability issues (Smith et al., 2020). As reported in the study by Chang et al. (2015), the national surveys of state and federal correctional systems have established that at least 50% of pregnant inmates using methadone in their MAT program often experience chronic pain and short-term detoxification. Existing literature has also established that the MAT programs have wide range of health concerns on the inmates, contrary to their primary role of addressing the SUD effects. For example, an RCT conducted by Langabeer et al. (2020) established that the use of methadone was associated with high rates of health risk behaviors such as overdose, hospitalization, mortality outcomes and sexual risks compared to when methadone was combined with cognitive behavioral therapy. Additionally, levels of evidence reported among observational studies involving the use of methadone are significantly different. For example, Moore et al. (2019) reported no significant difference in daily injection use 7 months post-release among the inmates who were and were not inducted to methadone during their jail terms. On the other hand, reported that participants who were inducted to methadone treatment option had reduced chances of sharing syringes as well as having reduced risks to sexually transmitted infections, including HIV/AIDS, compared to their peers who were not inducted to methadone during incarceration. The association between individual autonomy and compulsory long-lasting MAT options such as suboxone, Subutex and naltrexone are complicated, with the issues of agency, autonomy and sobriety nature being implicated (Farahmand et al., 2017; Muthulingam et al., 2019). Potential side effects and pharmacological nature of the MAT program provide distinctly different landscapes. For example, Langabeer et al. (2020) noted that extended-release methadone and buprenorphine, after being initiated, prevents possible withdrawal from the treatment program within the first month, while injection process leads to possible exertion of its effects. Therefore, this needs unambiguous information by using an informed consent procedure.
The national guidelines recommend the use of buprenorphine/naloxone as first line treatment option for opioid use disorder based on its safety and effectiveness (Noska et al., 2015). Nonetheless, Chang et al. (2015) and Moore et al. (2019) argued that treatment access and quality of buprenorphine/naloxone-based program are highly suboptimal within the US correctional settings because of different factors such as the challenges associated with short or uncertain stay periods, including inmates remanded but with unestablished release dates. Furthermore, Ranapurwala et al. (2018) cited the possibility of institutional barriers associated with the prescription of policies and ensuring healthcare accessibility, in addition to limited process and relationships for supporting continuity of care during the release period. Consistently, the studies by Farahmand et al. (2017) and Ranapurwala et al. (2018) cited the possibility of logistical challenges limiting effective access to buprenorphine/naloxone initiation during the admission period when most of the symptoms for opioid withdrawal may be most prominent. An observational study by Shulman et al. (2019) reported that most of the participants had the desire of becoming opioid-free but were generally not prepared to experience the adverse community re-entry challenges. On the other hand, at least 40% of the participants in the study by Smith et al. (2020) relapsed and initiated the use of MAT or continued with their opioid use behaviors. Therefore, it is justifiable not note that pharmaceutical program can help some of the participants to achieve sustained abstinence in the post-release but it is unlikely that the use of medications alone would help in the realization of similar outcomes.
Additionally, findings from these studies highlight the need for advancements within the opioid addiction treatment options, including longitudinal aftercare and MAT program for most of the released inmates during the community entry. Background data provided in the studies by Muthulingam et al. (2019) and Ranapurwala et al. (2018) shows that there are significant high rates of opioid overdose deaths in the post-release period and that pre-release use of MAT improves possible utilization of addiction treatment during the community re-entry. The decision to release inmates with long histories of opioid use disorder without providing them with MAT in pre-release should be questioned (Kavanaugh & McLean, 2020; Noska et al., 2015; Smith et al., 2020). Generally, the reviewed studies in this context show that while some of the inmates may be reluctant to start and continue with the MAT program, some may find buprenorphine maintenance treatment to be acceptable and participating in such treatment program may help in averting overdose-related deaths and relapse, but only with better awareness programs and linkage to treatment.
The chapter has critically appraised key evidence from the existing literature among MAT-based medications in the context of their efficacy and potential challenges during their administration and use. Key themes reported in this chapter include history or MAT, theoretical foundation regarding MAT use in the correctional settings, application of MAT in the treatment and management inmates with opioid addiction, opioid addiction in post-release period as well as the challenges associated with the use of MAT within the correctional setting. Despite the extensive research and availability of evidence regarding the use of MAT in the correctional setting, critical appraisal of the existing literature has led to the identification of key gaps in knowledge which the present study would be attempting to address. For example, the reviewed studies have demonstrated different efficiency levels of pharmaceutical treatment options for SUD within the correctional setting but failed to provide comprehensive analysis of the most effective medication among the most common ones such as suboxone, Subutex, methadone, and buprenorphine. Furthermore, there is still limited quantitative analysis about the effectiveness of MAT within the correctional setting, with respect to the post-release SUD treatment engagement, criminal behavior or recidivism, risks of relapsed opioid use as well as possible development of negative health behaviors. Even though the reviewed studies in this chapter demonstrate strong evidence base for MATs, it is important to note that such programs are rarely used within the correctional setting among inmates with opioid use disorder or individuals who had been treated with MAT programs before their incarceration. Therefore, the present study would focus on addressing these gaps in literature by exploring whether initiating MAT in the pre-release period has the ability of improving rates of retention in the post-release period. The next chapter provides detailed description and justification of the research methods and methodologies that were used for data collection and analysis.
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