Clinical Question: Among patients with opioid use disorder in county jails, does initiation or continuation of medication for opioid use disorder (MOUD) during incarceration reduce risk for overdose after release?
Background: Providing MOUD in jails has several real-world limitations, particularly regulatory barriers and gaps in continuity of care. Federal regulations require methadone for opioid use disorder to be dispensed through a certified opioid treatment program (OTP), but most jails are not certified OTPs. Jails must partner with a community OTP or obtain on-site certification. Additionally, maintaining treatment after release can be difficult because of delays in community OTP intake appointments, along with transportation and insurance barriers. These delays may lead to missed doses and increased risk of returning to illicit opioid use (the primary cause of opioid overdose deaths). The U.S. opioid epidemic remains a severe public health crisis, causing more than 80,000 overdose deaths annually.
Study Design: Prospective observational cohort study using linked administrative data
Setting: Seven county jails in Massachusetts characterized by high turnover and short lengths of stay
Synopsis: This prospective cohort study included 6,400 incarcerated individuals with probable opioid use disorder from 2019 to 2020; 2,711 (42%) received MOUD, primarily buprenorphine or methadone, during incarceration, while 3,689 did not. MOUD was associated with substantially higher post-release treatment initiation (60.2% versus 17.6% at 30 days) and engagement (50.4% versus 12.3% at 90 days), as well as reduced risks of fatal overdose (adjusted hazard ratio [aHR], 0.48; 95% confidence interval [CI], 0.36 to 0.64), nonfatal overdose (aHR, 0.76; 95% CI, 0.68 to 0.85), all-cause mortality (aHR, 0.44; 95% CI, 0.35 to 0.56), and reincarceration (aHR, 0.88; 95% CI, 0.81 to 0.94) compared with no MOUD. Hospitalization rates did not differ significantly between groups. Despite improved outcomes, only about half of MOUD recipients remained engaged in treatment at 90 days, indicating ongoing attrition during community reentry. As an observational study, findings are subject to unmeasured confounding and selection bias. These results support existing evidence that MOUD in correctional settings improves treatment continuity and reduces overdose and mortality risk after release.
Bottom Line: Hospitalists should initiate or continue MOUD during hospitalization and ensure coordinated transitions to outpatient care, including linkage to treatment programs and naloxone at discharge, given the association with reduced overdose and mortality after institutional transitions.
Citation: Friedmann PD, et al. Medications for opioid use disorder in county jails – outcomes after release. N Engl J Med. 2025;393(10):994-1003. doi: 10.1056/NEJMsa2415987.
Dr. Fatayerji
Dr. Fatayerji is a hospitalist in the department of internal medicine at UC San Diego Health in San Diego.