Abstract
Diversion of medications for opioid use disorder (MOUD) is a well-documented concern among correctional staff and leadership and is cited as a barrier to evidence-based treatment. In this Viewpoint, we explore the perceptions of medication diversion among correctional health care professionals (HCPs) as it pertains to access to care, availability of contraband MOUD in the facility, strategies to reduce diversion, and barriers to such strategies. Data come from a survey administered to 180 correctional HCPs employed within a jail or prison facility in the United States. Among respondents, the majority (n = 66, 68% in jails; n = 50, 75% in prisons) reported that contraband MOUD could be found in their correctional facility. Eighty-eight percent of jail and 87% of prison respondents believed that a long-acting injectable buprenorphine formulation could help reduce MOUD diversion within their facilities. A key barrier to reducing MOUD diversion is related to inadequate staffing for medication administration and monitoring. Policy implications and recommendations are discussed.
Introduction
It has been well documented that individuals with opioid use disorder (OUD) are disproportionately represented in U.S. correctional facilities relative to the general adult population (Bronson & Stroop, 2020; Victor et al., 2022; Winkelman et al., 2018). Medications for opioid use disorder (MOUD), including partial- and full-agonist medications buprenorphine, methadone, and opioid receptor antagonist naltrexone, are effective in achieving treatment goals and reducing overdose deaths upon release when provided during incarceration (Maruschak et al., 2023; Moore et al., 2019; Ranapurwala et al., 2022). Despite an increasing legal imperative to provide this treatment, MOUD remains unavailable in many U.S. jails (Balawajder et al., 2024). There are various reasons for the underutilization of MOUD within U.S. carceral facilities, including stigma and a lack of buy-in among leadership, the unavailability of treatment in the community, and a shortage of adequately qualified staff to administer medication and supervise dosing (Balawajder et al., 2024; Bandara et al., 2021). Additionally, buprenorphine and methadone are agonist medications and are therefore subject to misuse, a concern often cited by correctional officials as a reason for not offering MOUD treatment (Evans et al., 2022; Doernberg et al., 2019). Prior studies have demonstrated the risk of buprenorphine diversion, particularly via tablet and film formulations, as a barrier to providing MOUD (Bandara et al., 2021; Doernberg et al., 2019).
Bandara et al. (2021) conducted semi-structured interviews with medical and security leadership across several jails and prisons where initiation and continuation of agonist treatment were ongoing. They found that MOUD diversion was a common issue at their facilities. While participants indicated policies and procedures were developed and in place to minimize diversion opportunities, such efforts were described as time and resource intensive (Bandara et al., 2021). Moreover, participants reported pressure from security leadership and judges to prescribe naltrexone, which requires complete withdrawal from opioids prior to initiation, rather than opioid agonists or partial agonists. Furthermore, buprenorphine doses were also described as being limited under the suspicion that higher doses would lead to increased diversion (Bandara et al., 2021).
To the best of our knowledge, only one study has provided recommendations for preventing MOUD diversion (Evans et al., 2022). Following semi-structured interviews with jail custody and clinical staff who oversee an MOUD program in Massachusetts, six strategies were noted to reduce diversion: (1) determine reasons; (2) use flexible, but routinized dosing protocols; (3) engage in patient communication and education; (4) ensure sufficient staff to monitor medication administration; (5) conduct routine monitoring and surveillance; and (6) respond to diversion incidents effectively, without prematurely discontinuing treatment (Evans et al., 2022).
Few studies have examined medication diversion from the perspective of correctional health care professionals (HCPs) (i.e., health administrative, behavioral health, and clinical staff). To build on the limited evidence base on MOUD diversion in correctional facilities, we believe that correctional HCPs’ perspectives are valuable in deconstructing the barriers that exist in reducing MOUD diversion and improving evidence-based access to treatment in correctional settings. The current study had three main research questions: (1) How is MOUD diversion perceived (e.g., does it frequently occur, does it impact the decision to provide MOUD treatment in the facility) among correctional health care staff? (2) What strategies can be implemented to minimize diversion in correctional facilities? and (3) What barriers may exist that inhibit the implementation or effectiveness of such strategies?
We hypothesized that (1) diverted MOUD would be perceived as available in the facility, and that such occurrences present a barrier to evidence-based MOUD treatment provision by the highest proportion of respondents; (2) long-acting injectables (LAIs), surveillance of medication administration, and coordination between custody and medical staff would be cited as by the highest proportion of respondents as strategies to reduce diversion; (3) inadequate staffing levels, training, and coordination among and between custody and medical staff would be perceived by the highest proportion of respondents as barriers to minimizing diversion.
Methods
Surveying Correctional HCPs
To understand the perspectives of correctional HCPs on medication diversion, including availability of contraband MOUD and its potential impact on access to treatment, as well as strategies to minimize diversion and the associated barriers, a Qualtrics survey 1 was distributed to a sample of correctional HCPs (e.g., health services administrators, directors of nursing) registered with the National Commission on Correctional Health Care (NCCHC). NCCHC is a national, non-profit organization that provides accreditation, education, consulting services, and professional certification to correctional facilities and correctional HCPs. For the purposes of this study, only correctional HCPs who were currently employed or had been employed within the 2 years prior in a jail or prison and had routine (defined as at least once per week), direct contact with incarcerated people with OUD were eligible for participation. The survey was distributed five times between February and May of 2024. Survey distribution was stopped once fewer than five participants completed the survey in the span of 2 weeks following the last email invitation. Survey questions solicited participants’ perceptions on issues related to MOUD diversion (i.e., perceptions of its occurrence, strategies for prevention, and barriers to the implementation of various strategies) and did not ask for objective data. Response choices were multiple choice or a 5-point Likert scale. A total of 180 eligible respondents completed the survey. Figure 1 illustrates this study’s sample selection.
Sample selection. MOUD = medications for opioid use disorder.
Results
Statistical analyses were performed using IBS SPSS Statistics (Version 25) and, as this study was exploratory in nature, included only descriptive analyses. Table 1 describes the characteristics of the respondents and the facility in which they work. Nearly two-thirds of those employed by a jail reported working in an urban population-density area. Among those employed in a state or federal prison, 51% were in rural areas. Briefly, prisons tended to have higher average daily populations compared to jails, with more than half of prisons holding an average of 1,000 or more people on any given day. In contrast, only about 26% of respondents reported working in large jails. The highest proportion of jail respondents were health services administrators (43%), and the highest proportion of prison respondents were mental health clinicians (50%).
Respondents and Facility Characteristics (n = 180)
Table 2 presents findings on the availability of MOUD within respondents’ facilities. While nearly all respondents, regardless of facility type, noted MOUD was provided for those with OUD, at least under special circumstances (e.g., pregnant patients), there was variability in the types of medications available. For example, more than half of respondents employed within a jail facility indicated methadone, buprenorphine (including various formulations), and long-acting injectable (LAI) naltrexone were available; comparatively, the only medications offered within prisons at the same threshold were sublingual buprenorphine–naloxone films/tablets and LAI naltrexone. LAI buprenorphine was reported to be available by 36% of jail respondents and 42% of prison respondents.
Availability of Medications for Opioid Use Disorder in Facility (n = 180)
One respondent from each category (jail and prison) did not respond to this question.
Only 97 jail employees and 70 prison employees answered this question.
Only 96 jail employees and 62 prison employees answered this question.
MOUD = medications for opioid use disorder; OUD = opioid use disorder.
Findings regarding respondents’ perceptions of the availability of contraband MOUD in their facility are presented in Table 3. Nearly all respondents across facility types (85%) agreed that incarcerated individuals should be provided access to MOUD. While a majority agreed that contraband, controlled MOUD (i.e., methadone and buprenorphine) could be found in their facility (68% of jail respondents; 75% of prison respondents), 48% of jail and prison respondents agreed that provision of agonist MOUD in the facility had no impact on the availability of contraband MOUD. Among jail respondents, 31% perceived an increase in contraband MOUD, and 21% perceived a decrease in contraband MOUD, which was associated with the medication being available via a prescription in the facility. Among prison respondents, 33% perceived an increase and 18% perceived a decrease in the same question.
Perceptions on Diversion and Access to Prescribed and Contraband Medications for Opioid Use Disorder (n = 180)
Total may not add up to 100% due to rounding.
Only 97 jail employees and 67 prison employees answered this question.
Only 97 jail employees and 66 prison employees answered this question.
MOUD = medications for opioid use disorder.
Table 4 presents findings on the variety of methods implemented by jails and prisons as part of the facility’s diversion control plan. Interestingly, a greater number of jails were utilizing these methods to curb diversion compared to prisons, and this appears true across each individual method presented.
Strategies to Minimize Diversion (n = 180)
Only 74 of jail employees and 44 of prison employees answered this question.
Only 97 of jailed employees and 67 prison employees answered this question.
MOUD = medications for opioid use disorder.
Respondents’ perceptions on barriers to reducing medication diversion within their facilities are presented (Table 5). Respondents from both jails and prisons cite a lack of adequate medical staff for medication administration and post-dose monitoring (48% of jail respondents; 38% of prison respondents) and a lack of adequate custody staff to transport individuals for medication administration and post-dose monitoring (40% of jail respondents; 29% of prison respondents) as barriers to minimizing MOUD diversion. Among jail respondents, the highest proportion (53%) cited the prohibitive costs of LAI buprenorphine formulations as a barrier. Among prison respondents, 32% cited a lack of coordination between custody and medical staff as a barrier.
Barriers to Reducing Medication Diversion (n = 180)
Only 85 jail employees and 68 prison employees answered this question.
MOUD = medications for opioid use disorder.
Most respondents perceived that an LAI buprenorphine formulation may be beneficial in curbing MOUD diversion within their facilities (88% of jail respondents; 87% of prison respondents). Barriers to offering this particular MOUD are presented in Table 6. Overwhelmingly, for both those employed within a jail (80%) and those employed within a prison (58%), the highest proportion of respondents cited the cost of the medication as a barrier.
Barriers to Offering Long-Acting Injectable Buprenorphine
Only 93 jail employees and 62 prison employees answered this question.
Discussion/Implications
In this cross-sectional survey study, we add to the literature seeking to understand MOUD diversion in correctional facilities and the associated implementation of methods to reduce its occurrence from the perspective of 180 correctional HCPs.
Evans et al. (2022) found that providing access to prescription MOUD disrupted the contraband buprenorphine market. In theory, when buprenorphine is prescribed through health services in the facility, the value of contraband buprenorphine is reduced because all in need of treatment can access it, and the need to self-medicate is reduced or eliminated. In the present study, in support of this theory, 21% of jail respondents and 18% of prison respondents perceived prescription MOUD to reduce contraband MOUD. However, the highest proportion among both facility types perceived there to be no impact. This may be attributed to inadequate screening and treatment protocols that result in individuals in need of MOUD treatment not receiving it or individuals being underdosed and still experiencing symptoms. In this case, there would still be a market for contraband buprenorphine. Continuous quality improvement studies within these facilities, examining relevant processes and outcomes, may provide valuable insights.
Furthermore, many respondents reported that their facility had a diversion control plan with various methods of reducing diversion. However, similar to the findings of Bandara et al. (2021), respondents report that a lack of custody and medical staffing hinder the ability to implement the often time and resource-intensive nature of the strategies. Staffing in correctional facilities is a major and persistent problem. A 2018 report offers recommendations to increase the correctional workforce, including improving the working environment and condition and clarifying the mission of the sector, among others, that may apply to both disciplines (Russo et al., 2018). Research seeking to understand the barriers and facilitators to recruiting and retaining correctional health and security professionals is needed.
Respondents from both jails and prisons noted that the LAI buprenorphine formulation is a means to control medication diversion. Prior research suggests that the implementation of an LAI buprenorphine formulation may reduce medication diversion concerns and overcome issues cited as barriers in this sample. For example, in a study reviewing the implementation of LAI buprenorphine within Rhode Island’s integrated jail and prison system, Martin et al. (2022) concluded that this is an acceptable course of treatment and found that there were no identified attempts at diverting the medication. Furthermore, this sample indicated issues related to having inadequate medical and security staff to administer medications and transport clients for treatment; however, the inclusion of an LAI, a once-monthly injection, has been shown to reduce medical and security staff time by nearly 30%, and reduce indirect health care and correctional costs by nearly 20%, potentially offsetting any increase in direct costs (Wright et al., 2020) related to the cost of the medication. Even so, broad implementation of LAI buprenorphine may be limited in facilities with more restricted budgets. For example, for those who are uninsured, buprenorphine/naloxone strips and tablets range from $90 to 600 per month compared to the LAI formulations ranging from $2,117 to 2,354 per month/injection (Indivior, 2025; Ophelia Health, 2024; SingleCare, 2025). Correctional facilities may be eligible to receive funding from state opioid settlement funds to offset the cost of medication and implementation (Plaintiffs’ Executive Committee, n.d.). Regardless, providing LAIs may conceivably facilitate greater access to buprenorphine in corrections by mitigating diversion concerns. Such adoption could be accelerated by economic analyses showing cost offsets from reduced staffing requirements and by evidence that LAI buprenorphine improves post-release follow-up while minimizing risk for overdose. CHERISH has developed a budget impact tool that could assist in such analyses (see Ryan et al., 2023).
This study is not without limitations. Respondents are from a sample of individuals registered with the NCCHC and may not be generalizable across the United States. Moreover, we assessed perceptions that may be influenced by pre-existing beliefs. However, perceptions, whether grounded in empirical evidence or mistaken beliefs, impact behavior including decisions regarding how to optimally manage OUD. Furthermore, the source of contraband MOUD is not always apparent. While it is often presumed that MOUD is diverted during medication administration, there are other potential sources and points in time when contraband MOUD may become available in a correctional facility, for example, staff or newly incarcerated individuals bringing in diverted MOUD from the community. We did not investigate these other situations in detail, we focused on solutions and barriers pertaining to individuals diverting medication prescribed to them. We did not collect objective data on diversion incidents where this information may be available; instead, we present HCPs’ perceptions of the problem and potential solutions. While important, perceptions are subject to various biases.
Correctional facilities are often the largest providers of mental health and substance use treatment in communities across the country. The present study focused on understanding MOUD diversion and how facilities can reduce its occurrence while providing evidence-based treatment to those in need. Underlying this problem is the systemic issue of jails and prisons playing a role in the health care system that they were not designed to play. Correctional facilities are not treatment facilities. Continuing to treat them as such may reduce the urgency of finding upstream efforts to prevent and treat OUD before individuals become involved with the carceral legal system. Individuals should alternatively be diverted to community-based treatment in lieu of incarceration. Previous research has demonstrated that incarceration has a negative impact on health outcomes over time (Massoglia & Pridemore, 2015). This would require a substantial reorganization of mental health and substance use treatment in this country and a dedicated funding stream to ensure adequate community-based treatment is accessible. To address MOUD diversion in the present, we found that addressing underlying inadequate staffing levels, lack of coordination between custody and medical staff, and broader adoption of LAI buprenorphine were perceived to reduce diversion.
Footnotes
Acknowledgment
The authors thank William Mullen, PA-C, MPH, for his guidance and supervision.
Author Disclosure Statement
L.L.-N. is an employee of the University of Southern Indiana and received funding from NCCHC Resources, Inc. for her collaboration. S.G. and C.F. are employees of Indivior, LLC, which funded the study. C.W. is an employee of NCCHC Resources, Inc., which received funding from Indivior for this study. P.V. is an employee of the University of Rutgers School of Public Health and received funding from NCCHC Resources, Inc. for her collaboration. N.J. is an employee of the Denver Sheriff Department and received funding from NCCHC Resources, Inc. for her collaboration. K.F. is an employee of the University of Rochester Medical Center.
Funding Information
This study was funded by Indivior, LLC.