If we focus on one special population with opioid use disorder, it should be people in the prison system
This post is part of a series of takeaways from working in the behavioral health space over the past year
Besides innovation in behavioral health technology, the rest of the insights from this series will be piecemeal and slow to manifest into meaningful change given their complexity. To move quickly in our current legislative and regulatory environment, healthcare leaders should focus on solving a specific problem for a specific population that is going to be politically palatable for both parties. Reforming addiction treatment in the criminal justice system is a good place to focus our collective energy over the next 2 years.
Political liberals should worry about the terrible inequities suffered by people in prison with opioid use disorder (OUD). In a study of inmates in Washington, the risk of death of former inmates was 3.5 times higher than the state’s general population, and 12.7 times higher in the first 2 weeks after release. After going to prison, the risk of overdose was actually higher than before incarceration.
Political conservatives should be concerned about the massive and avoidable tax-burden being incurred from incarcerating people. The average annual cost of incarceration in 2017 was $34,704. Given that 21–43% of people with OUD have involvement with the criminal justice system in the prior year, there may be a large cost savings opportunity by investing in treatment rather than incarceration.
In particular, it would cost a state about $3,000 for comprehensive Medicaid insurance which would reimburse addiction treatment. Even if we include the federal spending portion of Medicaid, as well as other federal benefits like housing and nutrition, the total tax-payer liability would be significantly less than the national average living wage salary of about $23,000.
In other words, investing in treatment rather than incarceration could save taxpayers anywhere from $11,000 to $30,000 per person per year. There are promising programs that safely get people into treatment rather than prison.
In the Law Enforcement Assisted Diversion (LEAD) program, my colleagues in the Baltimore Police Department directed individuals in possession of drugs to addiction treatment facilities for evaluation instead of incarcerating them. Similar programs exist in other parts of the country under different names, such as the Angel program in Gloucester, MA.
Other programs demonstrate safe approaches to transitioning people with OUD out of prison. A study out of Rhode Island showed that providing medication-assisted treatment (MAT) in prison can reduce the risk of overdose deaths by 60.5%.
These innovative prevention and treatment models in the criminal justice system could be accelerated by the flexibilities in the Medicaid statue through the 1115 demonstration authority. Sub-regulatory guidance from the Centers for Medicare and Medicaid Services (CMS) to states on how to take advantage of the 1115 authority for criminal justice would be a helpful catalyst. A more permanent way to scale successful interventions to improve treatment for people with OUD involved with the criminal justice system would be through federal legislation. Such legislation would make both democrats and republicans look better for the 2020 election cycle.
