Evaluating the impact of Medication for Opioid Use Disorder Treatment Policies in California Jails

Approximately 130 Americans die each day from an opioid overdose. Those exposed to the criminal legal system (CLS) through arrests and/or incarcerations have high rates of opioid use disorders (OUD) and associated adverse outcomes. Access to medications for OUD treatment (MOUD) during incarceration and post-release increases community engagement in treatment and reduces opioid use and involvement with the CLS. However, there is limited evidence for the impact of jail-based OUD treatment policies on population health and crime outcomes. This dissertation describes results from a mixed methods research project evaluating how the integration of medications for OUD treatment into county jails impacts: 1) treatment uptake and access among those with an OUD (Aim 1); and 2) county-level population outcomes to inform policy and program development at the local, state, and national levels (Aim 2). For Aim 1 of the project, we conducted qualitative interviews with 20 individuals in Marin County, California who currently or formerly used opioids and were incarcerated within the past 5 years. We identified several key barriers to accessing MOUD in the CLS, including fear/mistrust of prison and jail staff, logistics, cost, and stigma/discrimination. Respondents desired more logistic support for treatment appointments, warm connections from service providers post-incarceration, and for providers to meet them where they live in the community. For Aim 2 of the project, we evaluated the impact of jail-based opioid agonist treatment (OAT) policies on population-level outcomes using a quasi-experimental design. We conducted a controlled interrupted time series analysis comparing county-level arrests, convictions, emergency department visits, hospitalizations, and deaths before and after policy implementation. We found that counties with jail-based OAT saw significant reductions in their overall and non-drug arrests rates, methadone-involved deaths, heroin-involved deaths, and heroin overdose deaths. However, we also observed increases in drug-related arrests, non-drug convictions, and property convictions. Counties that had OAT maintenance policies for at least 12 months saw decreases in their opioid overdose ED visits, while counties with OAT maintenance and induction policies for 12+ months saw increases in overdose visits. This dissertation provides important insight into the impact that jail-based OAT policies have at the population-level and couples it with feedback from the community of people who use drugs and were formerly incarcerated in one California county.