Reentry is an incredibly vulnerable time for individuals with a history of addiction. In one study in Washington state, during the first 2 weeks after release from prison, the risk of death from drug overdose was 129 times higher than the general populations.2 Other research clearly demonstrates that medications for opioid use disorder, and particularly opioid agonist medications, reduce this risk.3 Therefore, correctional and community supervision programs must consider the risks associated with COVID-19 as well as the risks associated with addiction when planning for reentry.
The coronavirus presents unique challenges for correctional settings, where physical distancing may not be possible. Many jurisdictions are working to rapidly release incarcerated individuals who are at high risk for severe COVID-19 illness and pose a low risk to public safety. However, many individuals with addiction are being released from correctional settings with insufficient planning for ongoing addiction treatment post-release.
While reentry planning may need to be simplified and expedited as prisons and jails work to more rapidly release individuals into the community, for individuals with addiction, whether active or in remission, overdose prevention, medication continuity, community treatment, and safe housing must be addressed.
Individuals with active, or a history of, opioid addiction should be provided with naloxone upon release.
Consistent with ASAM’s National Practice Guideline for the Treatment of Opioid Use Disorder, all individuals with addiction involving opioids as well as stimulants (because stimulant drugs may be adulterated with fentanyl or other opioids) should be given a naloxone rescue kit prior to release and instructions on how to use them. If distribution of kits prior to/at time of release is not possible, the jail/prison should work with local naloxone distribution programs, local or state health departments, or a local pharmacy to ensure that individuals in need can access naloxone upon release.
Medication Initiation and Continuity
Individuals with addiction who are reentering the community should be provided a clear plan for uninterrupted supply of medications, including medications to treat addiction.
Ideally, coordination with a community buprenorphine prescriber prior to release would allow for a phone-based initial evaluation and establishment of concrete steps for follow-up post- release.
- A clear chain of responsibility for ensuring that the individual maintains access to medications upon re-entry should be created. For example, the probation or parole officer could be assigned the responsibility of ensuring the individual is able to access their community treatment providers to assure uninterrupted treatment.
- Individuals taking methadone for treatment of OUD should be proactively connected to a community opioid treatment program (OTP) with sufficient take-home doses until their scheduled visit with the community OTP. Ideally, this gap would stretch no longer than 48-72 hours post-release, as evidence shows the longer the wait, the less likely someone is to engage in ongoing care. In addition, the transition should be carefully coordinated between the OTP that has been providing care to the patient during incarceration and the OTP that will provide care after community reentry.
- Individuals taking buprenorphine for treatment of OUD should have a prescription waiting for them at a nearby pharmacy for pickup at time of release. This prescription ideally provides 30 days of buprenorphine because individuals may have delays in effectively accessing buprenorphine in the com- munity, particularly during the COVID pandemic. At a minimum, these individuals should be provided enough medication to cover the time until they can reasonably be expected to obtain follow up in the community.
Patients taking non-controlled medications for treatment of OUD, alcohol use disorder or tobacco use disorder, should be given a 30-day supply of medication and proactively connected with ongoing care.
- Consider including refills with a “do not fill before” date if the likelihood of finding an available prescriber within 30 days post-release is small.
- The individual should also be provided guidance related to how to get refills if they are not able to access follow up care in a timely manner. For example:
- Provide instructions regarding who they can reach out to for assistance if they are unable to access care and need more medication (e.g. their probation or parole officer, or the re-entry coordinator).
- Provide guidance on options for low barrier access that might be in the community.
- Individuals receiving buprenorphine should be educated about and alerted to the need for safe, secure storage and the dangers of sharing medication with others. While diversion of buprenorphine may occur, current research suggests that most diverted buprenorphine is used for therapeutic purposes (i.e., to reduce withdrawal symptoms, reduce heroin use, etc.).
- The individual should be provided guidance related to how to get refills if they are not able to access follow up care in a timely manner. For example:
- Provide instructions regarding who they can reach out to for assistance if they are unable to access care and need more medication (e.g. their probation or parole officer, the re-entry coordinator, a state warm line, local low barrier addiction treatment clinicians, programs, or community health centers).
Reentry planning from prison typically takes months of coordination. However, the urgencies of the COVID-19 crisis will necessitate more rapid planning for individuals with addiction. Many federal and state policies can create barriers to this process, particularly around obtaining insurance coverage. Correctional and community supervision programs should work with their state and community leaders to try to reduce these barriers. These steps might include, for example, working with their state Medicaid Director to explore opportunities for supporting more rapid access to Medicaid, such as instituting a rapid application and initiation process for emergency access to Medicaid and working to automatically activate this upon re-entry. Another example could include working with the state addiction agency to identify state-funded treatment programs that can prioritize intake for people leaving incarceration, support Medicaid enrollment, and ensure free care while waiting for Medicaid activation.
Community Treatment Connection
There should be a proactive plan for connection to community treatment.
- Even prior to the COVID-19 crisis, some communities did not have sufficient treatment capacity. During the COVID-19 crisis, access to addiction treatment has been reduced further in many com- munities because of reductions in accepting new patients, limitations on how many individuals can be physically present in the facility, and/or because many individuals do not have the resources to participate in virtual treatment. Treatment capacity in the community may be insufficient. Consideration should be given to how patients leaving incarceration can access treatment. For example:
- Are local OTPs or buprenorphine clinicians or programs taking new patients?
- OTPs presently have no caps on the number of patients they can treat with buprenorphine. Current federal guidance provides flexibility for addiction treatment providers during this public health emergency (see ASAM’s Telehealth Guidance and Guidance for OTPs). These waivers on regulations allow OTPs to initiate and maintain patients on buprenorphine through telehealth, including telephone-based visits.
- Is there a local federally qualified health center (FQHC) that can provide buprenorphine treatment? ( https://findahealthcenter.hrsa.gov/)
Buprenorphine can be initiated and maintained through telehealth, including telephone-based visits.
- Are there providers, within or outside of the community that can provide the necessary services through telehealth for the patient?
- Consideration should also be given to the individual’s access to healthcare coverage.
- Can the patient afford their medications and clinical care? If not, are there community pro- grams available to subsidize the individual’s medication or treatment costs, e.g. FQHCs, 340b, pharmaceutical discounts, state or county programs?
- Is the patient eligible for Medicaid or other health care coverage? What needs to be done to re-enroll the individual or reactivate their coverage?
- Consideration should be given to how the individual will participate in telehealth-based appointments.
- Does the individual have reliable access to a phone?
- Could a phone be provided to them for this purpose? For example, through referral to the federal lifeline program that helps provide phones and limited minutes. https://www.fcc.gov/sites/ default/files/lifeline_support_for_affordable_communicatio ns.pdf
- Consider assigning a staff person to assist individuals with installing any required apps on their phones that will be needed to access the telehealth services they will be expected to use.
- Consider establishing telehealth services for addiction treatment or contracting with addiction treatment programs or clinicians who can provide telehealth services. These services can be used to provide reliable access to care (including treatment with opioid use disorder medications) to individuals with addiction immediately post-release.
Safe Housing in the Community: Individuals should have a pro-active plan for shelter/ housing post-release
The COVID-19 pandemic is likely to make it more challenging for individuals re-entering the community to find housing. Jails and prisons are high-risk environments for virus transmission. Relatives or friends, particularly those that are at risk for severe COVID-19 illness, may be unwilling to provide temporary housing. In addition, many residential addiction treatment programs and recovery residences are limiting acceptance of new patients/residents. Similarly, homeless shelters are also limiting access to be able to enforce and maintain physical distancing recommendations. Jails and prisons should coordinate with local and state partners to identify options for emergency or transitional housing.