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Addressing Barriers to MOUDs Faced by People in Incarceration

Haylea Hannah, MSPH, PhD, discusses her research on the barriers to medications for opioid use disorder that people who are incarcerated can face and what pharmacists can do to address the barriers.

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Drug Topics®: What are the key takeaways from your study on the barriers to medication for opioid use disorder (MOUD) treatment during incarceration?

Haylea Hannah: I think there are 4 key takeaways from this study. One is that people who use drugs in our study were largely supportive of medications for opioid use disorder treatment or MOUDs. I also want to note, though, that we did see themes that reflected that things like stigma, racism, and discrimination may impact how people feel about treatment, and also their likelihood to start MOUDs. For example, a common concern was that using MOUDS would trade one addiction for another. This is largely a stigma that's resulted from treatment systems historically favoring abstinence as the sole goal of treatment versus being more open to medication-based treatments as well.

Secondly, there's just generally more medical and substance use disorder support needed during incarceration. Treatment for opioid withdrawal, which when not treated is painful and life threatening, can be very rare in incarcerated settings. People also really supported the idea of accessing treatment during incarceration for MOUDs and said basically ‘it's easier to stay clean than it is to get clean.’

Thirdly, trust is really important with this community, Black, African American, Native American, Hispanic, Latinx, and multiracial people who use drugs in our study supported themes of self-blame and being dropped from services after one mistake more often than White respondents. These types of experiences can reduce trust in our treatment systems, which ultimately can make people hesitant to access them. To that end, it's really important to acknowledge the collective and continuous trauma that people who use drugs face, and that these traumas are more concentrated among communities of color as a result of things like structural racism and white supremacy that play out at different levels of our system.

And then lastly, a very commonly supported theme in our study was that people wanted to be treated like humans. A common ask from participants was just to experience empathy, authenticity, and nonjudgmental understanding from our systems when they do reach out and seek help.

Drug Topics®: How can pharmacists help address these barriers?

Hannah: I think one of the quickest ways they can address these barriers at multiple levels is just being a partner, and spreading evidence- based practices throughout our systems, including not only to their patients, but also to the partners that they work with. One example of how this might play out is that methadone can be dispensed outside of an opioid treatment program for up to 3 days to continue treatment. Accessing methadone is often challenging for jails and prisons because of the strict regulatory requirements that it has to be delivered in an opioid treatment program. This would permit methadone to be provided, for example, when a community opioid treatment program is closed on a weekend, or an individual within a really brief sentence in a jail who just needs to be continued on their treatment. Pharmacists would be permitted to actually dispense in that scenario under that kind of 72-hour rule.

Another discussion point around advocacy for pharmacists is that the Department of Justice in April of 2022 released guidance that protects a person with an opioid use disorder’s right to MOUD treatment, noting that not providing it in different settings, including incarceration, is a violation of the Americans with Disabilities Act. The first point is just to be a partner in spreading these evidence-based practices. The second piece is to dispense MOUDs. If you receive a prescription, make sure you're filling and dispensing it. Prescribe them if you can, which really depends on the state. So, check in with your local state laws.

Thirdly, consider partnering with people from other sectors like the criminal legal system to improve medication access. Depending on your role, you could be a key partner in those types of relationships. I think we've learned a lot in Marin County about the power of bringing multiple stakeholders together to tackle a complex problem. We launched a community collaborative in 2014 that was really led by the community to address the prescription opioid crisis at the time. They've now shifted to focusing on the overdose crisis. As part of that community collaborative, they work with law enforcement, criminal legal system, health care, pharmacists. I think sometimes just having the right people in the room to talk through these really complex problems can be a really fruitful place to move forward and move the needle on these health outcomes.

Lastly, just support and attend trainings related to harm reduction and trauma-informed care. As I mentioned, a lot of people in our study noted that they felt that they had faced stigma and judgment from our different treatment systems. The more people are trained and can understand that trauma-informed approach and the value in harm reduction practices and frameworks, the more that will arm them with the authenticity, empathy and understanding that people were really asking for.

So just to summarize, the 4 things I think pharmacists can do to help address these barriers include being a partner in spreading evidence-based practices throughout our system, dispensing MOUDs because they save lives, consider partnering with people from other sectors like the criminal legal system, and support and attend trainings related to harm reduction and trauma-informed care.

Drug Topics®: What’s next for your research in this area?

Hannah: We're working on producing resources that can be shared more broadly with stakeholders and community members, including sharing these results back to the community of people who use drugs, ideally through a forum where we can discuss and get their thoughts on all of this feedback. I'm also working on finalizing 2 additional analyses related to evaluating jail based MOUD treatment in California, that were part of my PhD dissertation projects funded by the National Institutes of justice. The first is a multi-county study that evaluated how offering opioid agonist therapies like methadone and buprenorphine, in county jails influence county-level emergency department visits, deaths, arrests, and convictions. We're also currently working on publishing this work in a peer-reviewed journal so that we can continue sharing it with other folks and kind of permeating what we learned from the great folks that participated in this study.

Drug Topics®: Any final thoughts?

Hannah: I'd love the opportunity to share a quote from one of our participants. They were talking about the importance of meeting people where they are physically. “So, a lot of people don't go to the doctor. They just don't make it past their 10. They're stuck in a rut. There should be a global bus that reaches out to them, because they don't like to reach out to you guys. We have a hard time with that. But I think there should be more outreach.” I would say that the importance of meeting people where they are physically also translates to meeting them where they are in their substance use disorder, emotionally and mentally, no matter what the starting point might be. Participants throughout our study really talked about how important open, understanding, and nonjudgmental relationships have been for them, and that a lot of them ended up entering treatment as a result of those kinds of kind, nonjudgmental relationships. I would say that a great piece to end on is meet people where they are physically and also emotionally and mentally in their current substance use disorder.


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