Medications for opioid use disorder (MOUD) are the leading evidence-based treatment for opioid use disorder (OUD). Abundant research shows that MOUD reduces the risk of recurrence of opioid use, involvement with the justice system, and death, both in the community and in jails.[1]

FDA-Approved MOUD

The following medications are safe and effective treatments for OUD.

Buprenorphine: brand names include Sublocade, Suboxone, and others; available as sublingual or buccal film or tablet, or as an injection

Methadone: available as tablets and liquid

Naltrexone: brand name Vivitrol; available as injection or tablet

Source: U.S. Food & Drug Administration. (2019). “Information about Medication-Assisted Treatment (MAT).“

While many jails nationwide have started to offer MOUD, there are others that are not ready or able to take that step. One concern is the possibility of medication diversion.[2] Diversion is defined as the illegal movement or abuse of drugs from legal and medically necessary uses toward uses that are illegal and typically not medically authorized or necessary.[3]

However, recent research indicates that concerns about MOUD diversion in jail may be assuaged with some proven strategies. Liz Evans, PhD, a public health professor at the University of Massachusetts Amherst, and Peter Friedmann, MD, a physician and scientist at Baystate Health and the University of Massachusetts Chan Medical School, held interviews and focus groups at seven Massachusetts jails to understand staff perceptions of diversion and how staff work to reduce and prevent it.[4]  This research was conducted during a time period (2019-2020) when Massachusetts was doing a statewide pilot project to implement MOUD programming for people with OUD living in jails. The following provides a brief summary of the findings of that research, real-world experience from the MOUD program team at one of the jails studied—Hampden County Correctional Center—and best and promising practices from the field.

Perception vs. Reality of Diversion

Leading up to implementation of the MOUD program in Massachusetts jails, leaders expressed worry about diversion of medications and cited it as a barrier to gaining staff buy-in for MOUD programming. “We had heard reports from leaders in jails that one of their concerns about implementing MOUD was this fear that diversion would happen, and they were worried about the safety of people that they were responsible for,” says Dr. Evans. However, Dr. Evans and her team found that upon implementation of an MOUD program, diversion actually happened less frequently than staff had expected. (Most often the primary medication in these MOUD programs was buprenorphine.)

Jail staff reported that there were as few as 6 documented diversion events per 4,000 doses or “under 10” cases of diversion among 70 participants.[5] In fact, Dr. Evans and colleagues were told by jail staff that not only was diversion of MOUD less common than expected, but also that formal MOUD programs disrupted the illicit buprenorphine trade within their jails, as treatment was now available to anyone who needed it.

Understanding Why People Divert

To stop diversion, it’s important to understand why people in jail may divert medications in the first place. Some of the most common reasons for diversion include the following:

  • Coercion or “strong-arming.” This is a very common reason for diversion, both in the study in Massachusetts and in other literature.[6] This happens when someone who is receiving MOUD is threatened or coerced into bringing it back into the housing area for another resident. This issue is often alleviated by a comprehensive jail-based MOUD program. While some coercion may be based on individuals wanting the medication for recreational use, much of it is from people who are experiencing cravings and withdrawal from opioids. Making MOUD programming available to these individuals greatly reduces their perceived need to divert someone else’s medication.
  • Hoarding or saving. Some MOUD program participants divert medication in order to save up enough to take a large dose to “get high” or experience euphoria. But more often jail staff report that MOUD program participants may save their own medication to split (take some during their assigned dosing time and some later). This is usually related to dosing practices that lead participants to experience withdrawal later in the day. This can be alleviated through dosing adjustments managed by medical staff.

Research and experience show that it is important to involve patients in understanding and coming up with solutions to prevent diversion. While Dr. Evans and her team found that clear policies around the response and consequences for diversion are important, it is essential that clinical staff drive treatment and medication decisions in response to diversion activities. “Rarely do we take people off of treatment for diversion,” says Keisha Williams, RN, health authority and director of nursing at Hampden County Correctional Center. “Nobody wants that to happen.”

“We use a stepped approach to address diversion,” adds Tom Lincoln, MD, medical director of the opioid treatment program (OTP) at Hampden County Correctional Center. “There are two pathways: the security pathway, which focuses on the security response like loss of privileges and lock-up periods and other consequences; and the medical pathway, through which we offer one-on-one counseling and work with the participant to figure out why they diverted and what we can do about, such as changing medication (from buprenorphine to methadone or naltrexone for instance), delivery (from sublingual crushed tablet to injection for instance) or dosage.”

Strategies to Reduce and Prevent Diversion

Many of the standard strategies for planning and implementing an MOUD program in a jail can help prevent and reduce diversion activities. The following provides guidance on how to leverage these strategies to offset the risk of diversion:

Multidisciplinary training and education. Multidisciplinary teams with clear communication and ongoing training can ensure that everyone working in a jail is on the same page in the implementation of an MOUD program, which can increase the success of the program and reduce issues such as diversion. “From the beginning, we had participation from all different areas of the jail in planning and implementation,” says Williams. “We involve everyone from maintenance, to security, to counselors and providers to make sure everyone understands and is committed to the success of the OTP.”

Training is equally important, notes the team from Hampden County, both for buy-in for the program in general and to increase understanding and reduce concerns about diversion. Best practice is to involve all staff in training around MOUD, including an overview of the facility’s MOUD program, basic information about what MOUD is and its benefits, potential side effects of medications, and things to watch for related to medication diversion, according to SAMHSA recommendations.[7] Jails also benefit from educating residents and program participants along with staff.

Community involvement. “One unique thing about jails is the unknown duration of [the detention of people held in them],” says Cassandra Sarno, MBA, health services program supervisor at Hampden County Correctional Center. “We don’t always know how long they will be in the jail with us.” About 60 percent of Hampden County’s MOUD program population is pretrial individuals. This highlights the importance of having partnerships and collaboration with community justice and treatment stakeholders, especially in regard to continuation of MOUD outside of the jail for participants. “When people can get the treatment they need in the community, if they do end up back in jail, we can continue treatment and reduce the risks that come with discontinuation in the transition into or out of incarceration.”

Policies and procedures. Jails should have specific written policies and procedures for preventing and addressing diversion situations. “What we found was that when jails were prepared for and had strategies around diversion, staff perceived they were able to greatly reduce the incidence of these events,” says Dr. Evans. Some ideas that were reported to work include:

  • Drug screening. Random urine testing of both participants and non-participants is useful to trace any possible diversion activity.
  • Monitoring of canteen funds. One of the biggest indicators of possible diversion in the Massachusetts jails studied by Dr. Evans and colleagues was a noticeable change in canteen funds. If a participant in the MOUD program suddenly has more money than usual in their canteen fund, it may be worthwhile to figure out if it got there via sale of diverted medications.
  • Documented response protocols for diversion. Response to diversion is often best seen through a lens of prevention, rather than punishment. For instance, did this person divert because they aren’t getting a therapeutic dose? Are they being threatened? Jails should have protocols for each of the most common situations.
  • Comprehensive and routine but flexible dosing protocols. Participants in the Massachusetts study shared well-documented and routinized dosing protocols that also allowed for flexibility in dose and delivery method to address participants’ needs and risk of diversion. Dosage decisions are best managed and made by clinical staff, not administrative or correctional officer staff.
  • Monitor dispensing of medications. Some medications are harder to divert than others. Sublingual tablets and buccal films can be monitored within the program area to ensure they are dissolved before participants return to the housing area. In some cases, participants may be switched to liquid or injectable doses of medications to reduce risk of diversion, notes Dr. Lincoln.
  • Stay vigilant and adjust as needed. The Hampden County treatment team noted that as their MOUD program has advanced, some participants have become more creative in attempting to divert. “You have to stay alert to the risk of diversion and new ways people try to get medication out of the dosing area,” noted Dr. Lincoln.
  • Adequately staff the MOUD program. Evans and her team found that sufficient staff-to-patient ratios—around 2 corrections officers and 1 nurse per 15 to 20 patients—help prevent diversion. Regularly assigning the same corrections officers to this team helps them master mouth checks and recognize nuances in patient behavior and needs.
  • Safeguard participants. Some methods for keeping MOUD participants safer from coercion include offering MOUD to all incarcerated individuals with OUD and discretely scheduling dosing times (versus publicly calling patients for treatment over the public announcement system, for instance).

Conclusion

With appropriate planning and protocols in place, diversion of MOUD is an infrequent and preventable issue in jails. The following are some resources for more information and to help plan and implement a jail-based MOUD program.

References

[1] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Medication-Assisted Treatment for Opioid Use Disorder; and M. Mancher, A. I. Leshner, editors, “The Effectiveness of Medication-Based Treatment for Opioid Use Disorder” in Medications for Opioid Use Disorder Save Lives (Washington, DC: National Academies Press [US], 2019), https://www.ncbi.nlm.nih.gov/books/NBK541393/; Joshua D. Lee, Peter D. Friedmann, Timothy W. Kinlock, Edward V. Nunes, Tamara Y. Boney, Randall A. Hoskinson, Donna Wilson, et al., “Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders,” New England Journal of Medicine 374, no. 13 (March 31, 2016): 1232–42, https://doi.org/10.1056/NEJMoa1505409.

[2] SAMHSA, Medication-Assisted Treatment (MAT) in the Criminal Justice System: Brief Guidance to the States, (author; 2019), https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matbriefcjs_0.pdf.

[3] U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, and Center for Program Integrity, Drug Diversion in the Medicaid Program: State Strategies for Reducing Prescription Drug Diversion in Medicaid (2012), https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaidintegrityprogram/downloads/drugdiversion.pdf.

[4] Elizabeth A. Evans, Ekaterina Pivovarova, Thomas J. Stopka, Claudia Santelices, Warren J. Ferguson, and Peter D. Friedmann, “Uncommon and Preventable: Perceptions of Diversion of Medication for Opioid Use Disorder in Jail,”

Journal of Substance Abuse Treatment, 138 (July 2022): 108746, https://doi.org/10.1016/j.jsat.2022.108746.

[5] Evans et. al., “Uncommon and Preventable.”

[6] SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation, Medication-Assisted Treatment Inside Correctional Facilities: Addressing Medication Diversion (Washington, DC: Bureau of Justice Assistance, 2019).

[7] SAMHSA, Medication-assisted Treatment Inside Correctional Facilities (author, 2019), https://store.samhsa.gov/sites/default/files/d7/priv/pep19-mat-corrections.pdf.


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