By Louise Durand, Eamon Keenan, Deirdre O’Reilly, Kathleen Bennett, Andy O’Hara & Gráinne Cousins 

Background- Pharmacotherapy is essential for the delivery of an equivalent standard of care in prison. Prescribing can be challenging due to the complex health needs of prisoners and the risk of misuse of prescription drugs. This study examines prescribing trends for drugs with potential for misuse (opioids, benzodiazepines, Z-drugs, and gabapentinoids) in Irish prisons and whether trends vary by gender and history of opioid use disorder (OUD). Methods- A repeated cross-sectional study between 2012 and 2020 using electronic prescribing records from the Irish Prison Services, covering all prisons in the Republic of Ireland was carried out. Prescribing rates per 1,000 prison population were calculated. Negative binomial (presenting adjusted rate ratios (ARR) per year and 95% confidence intervals) and joinpoint regressions were used to estimate time trends adjusting for gender, and for gender specific analyses of prescribing trends over time by history of OUD. Results - A total of 10,371 individuals were prescribed opioid agonist treatment (OAT), opioids, benzodiazepines, Z-drugs or gabapentinoids during study period. History of OUD was higher in women, with a median rate of 597 per 1,000 female prisoners, compared to 161 per 1,000 male prisoners. Prescribing time trends, adjusted for gender, showed prescribing rates decreased over time for prescription opioids (ARR 0.82, 95% CI 0.80–0.85), benzodiazepines (ARR 0.99, 95% CI 0.98–0.999), Z-drugs (ARR 0.90, 95% CI 0.88–0.92), but increased for gabapentinoids (ARR 1.07, 95% CI 1.05–1.08). However, prescribing rates declined for each drug class between 2019 and 2020. Women were significantly more likely to be prescribed benzodiazepines, Z-drugs and gabapentinoids relative to men. Gender-specific analyses found that men with OUD, relative to men without, were more likely to be prescribed benzodiazepines (ARR 1.49, 95% CI 1.41–1.58), Z-drugs (ARR 10.09, 95% CI 9.0-11.31), gabapentinoids (ARR 2.81, 95% CI 2.66–2.97). For women, history of OUD was associated with reduced gabapentinoid prescribing (ARR 0.33, 95% CI 0.28–0.39). Conclusions - While the observed reductions in prescription opioid, benzodiazepine and Z-drug prescribing is consistent with guidance for safe prescribing in prisons, the increase in gabapentinoid (primarily pregabalin) prescribing and the high level of prescribing to women is concerning. Our findings suggest targeted interventions may be needed to address prescribing in women, and men with a history of OUD.

BMC Psychiatry, 2023. 12p.

By Donata Favretto, Cindi Visentin, Anna Aprile, Claudio Terranova, Alessandro Cinquetti

The most effective therapy for people with opioid use disorder (OUD) involves the use of Food and Drug Administration-approved medications—methadone, buprenorphine, and naltrexone. Despite evidence that this approach, known as medications for opioid use disorder (MOUD), reduces relapse and saves lives, the vast majority of jails and prisons do not offer this treatment. This brief examines what policymakers should consider when exploring how to best manage OUD in incarcerated populations.

It helps to first answer this question: How common is OUD in incarcerated populations? Data from 2007-2009 (the most recent available) showed that more than half of individuals in state prisons or those with jail sentences met the criteria for a non-alcohol and nicotine-related substance use disorder (SUD), meaning a problematic pattern of using a drug that results in impairment in daily life or noticeable distress, compared with only 5 percent of adults in the general population.

The gold standard of care is MOUD. In community-based settings, such as opioid treatment programs and primary care facilities, methadone and buprenorphine have been proved to reduce overdose deaths and illicit opioid use as well as the transmission of infectious diseases such as HIV and hepatitis C. A growing body of literature also exists on the benefits of naltrexone, the third Food and Drug Administration-approved medication.

Philadelphia: Pew Charitable Trusts, 2020. 22p.

By Avik Chatterjee; Michelle Weitz; Alexandra Savinkina, et al

Key Points - Question: Is provision of medications for opioid use disorder (MOUD) during incarceration associated with fewer overdose deaths? Findings: This economic evaluation of a model of the natural history of OUD in Massachusetts found that a strategy offering buprenorphine, methadone, and naltrexone during incarceration was associated with 192 fewer overdose deaths (a 1.8% reduction) and was less costly than a naltrexone-only strategy averting 95 overdose deaths (a 0.9% reduction). The 3-MOUD strategy was also cost-effective at $7252 per quality-adjusted life-year gained. Meaning These findings suggest that offering 3 MOUDs during incarceration is a life-saving, cost-effective intervention

JAMA Network Open. 2023;6(4):e237036. doi:10.1001/jamanetworkopen.2023.7036

By Jason Rydberg, Rebecca Stone, Christine C. Kwiatkowski

Many areas of the United States are experiencing an epidemic of drug overdose deaths, often involving opioids. In 2017, there were 70,237 drug overdose deaths in the United States, a rate 9.6% higher than 2016. 47,600 of these deaths involved an opioid (National Institute on Drug Abuse [NIDA], 2019). The opioid overdose epidemic has been described as a series of “waves.” The first wave began with increased prescribing of opioid analgesics in the 1990s driving an increase in prescription opioid overdose deaths. The second wave, starting around 2010, was characterized by a rapid increase in overdose deaths involving heroin. Beginning in 2013 and continuing today, many areas of the country are experiencing the “third wave” of the epidemic, characterized by a significant increase in overdose deaths involving synthetic opioids like fentanyl (Centers for Disease Control [CDC], 2018). Some experts have indicated that a coming “fourth wave” may be characterized by overdose deaths related to polysubstance use including opioids, cocaine, and psychostimulants (e.g. methamphetamine). Beyond these general trends, research shows that the nature of the overdose epidemic is region-specific. It could be said that there is not one overdose epidemic, but many epidemics that vary substantially by a region’s economic and demographic characteristics. This “geography of the U.S. opioid overdose crisis” was recently mapped by Shannon Monnat and colleagues (2019), who found that overall drug mortality rates are higher in counties characterized by more economic disadvantage, more blue-collar and service employment, and higher opioid-prescribing rates. Specifically, Michigan shows a pattern of increasing heroin-involved deaths in the west and south-west areas of the state, a mixture of emerging heroin, prescription opioids, and “synthetic+” (synthetic opioids alone or in combination with other opioids) in the rural north, and a “syndemic” (all types of opioids and combinations) in the southeast. In the Upper Peninsula, we see high and emerging heroin counties along the Wisconsin border, and synthetic+ counties along the peninsula’s eastern tip. These patterns map to economic and demographic patterns across Michigan. “Urban professional” areas are related to rapidly rising probability of “syndemic” classification (e.g. the greater Detroit area). Blue-collar worker presence is associated with the emerging heroin and syndemic classes, and service economy areas (e.g. the north half of the state) are associated with rising probability of membership in all five opioid classes (high prescription opioid, emerging heroin, high heroin, synthetic+, and syndemic). The prescription opioid class counties are more likely to be rural, economically disadvantaged, and have high scores on blue-collar and service economy indices. These results make it clear that there is no single solution to the overdose crisis. To understand and, importantly, to effectively respond to the crisis and reduce opioid-related mortality, we must have an in-depth understanding of the crisis in Michigan, both from the perspective of public health and of law enforcement. This research draws on data from a number of different sources to triangulate a comprehensive picture of illegal drug activity in the State of Michigan. These sources are leveraged to combine information gathered from law enforcement sources, prescription monitoring, mortality and vital statistics, and community demographics.

East Lansing, MI: Michigan State University, Michigan Justice Statistics Center, School of Criminal Justice 2019. 55p

By National Council for Behavioral Health and Vital Strategies

This toolkit provides correctional administrators and health care providers recommendations and tools for implementing medication-assisted treatment (MAT) in correctional settings. It provides examples from the field that can be widely applied and adapted for programs that serve justice-involved individuals. It was developed by the National Council for Behavioral Health, Vital Strategies, and faculty from Johns Hopkins University, with support from CDC and Bloomberg Philanthropies.

2020. 312p.