The risk for drug overdose is 12.7 times greater in individuals who have been incarcerated than in individuals in the general population.1 An article published in the Journal of Law, Medicine, and Ethics described the consequences of limited treatment options for individuals with opioid use disorder in the criminal justice system.2

Curtis Bone, MD, MHS, from the Yale University School of Medicine, and colleagues recalled a patient who refused treatment with methadone for opioid use disorder because he worried about withdrawal: although heroin withdrawal effects are significant, the patient worried more for the prolonged effects of methadone withdrawal, particularly in a prison environment. After this patient encounter, Dr Bone explored the reasons behind prison refusal to accommodate methadone, recognizing also that the criminalization of drugs across the United States has led many with substance use disorders to regard “incarceration…[as] a foregone conclusion.”

Among those treated with methadone or buprenorphine, 70% return to employment or schooling,3 and risk for overdose and viral illnesses are significantly reduced.4 Despite these positive effects, just 55% of federal prison medical directors report offering methadone, and even fewer offer buprenorphine.5

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Among prisons that do supply addiction treatment, the outcomes include reduced rates of mortality, hepatitis C infection, and re-incarceration. Dr Bone also noted that methadone treatment “returns 12-14 dollars for every dollar spent,” a significant financial incentive for its use.6 Even so, prisons largely do not adopt methadone treatment programs, often citing “staff objections.” Many prison staff members report not endorsing methadone because they perceive it as substituting 1 drug for another, or as a facilitator to addiction.5 However, scientific evidence and bioethics alike renounce these perceptions as unproductive and inaccurate.

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Failure to treat addiction is detrimental both to incarcerated individuals themselves and to their communities, Dr Bone noted. The effect of addiction is disproportionately shouldered by low-income communities and communities of color. Children of parents with a substance abuse disorder have higher rates of emotional and behavioral problems than the general population. In addition, communities among which rates of addiction and incarceration are high have increased risk for HIV and hepatitis.

Dr Bone postulates that the heightened risk for these diseases may be a byproduct of the federal prison system’s failure to address substance abuse among the incarcerated. In addition to systematic refusal to accommodate methadone programs, patients themselves often reject the option because they fear the “horrific” experience of methadone withdrawal in prison, as Dr Bone’s once did.

“Continued indifference” to the problem, Dr Bone wrote, allows opioid use disorder to “flourish” in communities with low income and high incarceration rates. Appropriate treatment methods, including the use of methadone and other opioid agonists, must be adopted by the criminal justice system to adequately address the effect of opioid use disorder on incarcerated individuals and their communities.


  1. Bone C, Eysenbach L, Bell K, et al. Our ethical obligation to treat opioid use disorder in prisons: a patient and physician’s perspective [published online July 17, 2018]. J Law Med Ethics. doi: 10.1177/1073110518782933
  2. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison — a high risk of death for former inmates. N Engl J Med. 2007;356:157-165.
  3. Tsui JS, Evans JL, Lum PJ, et al. Association of opioid agonist therapy with lower incidence of hepatitis c virus infection in young adult injection drug users. JAMA Intern Med. 2014;174(12):1974-1981.
  4. Bruce RD. Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings. Int J Drug Policy. 2010;21(2):122-124.
  5. Friedman PD, Hoskinson R, Gordon M, et al. Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers and intentions. Subst Abuse. 2012;33(1):9-18.
  6. Nunn A, Zaller N, Dickman S, Trimbur C, Nijhawan A, Rich JD. Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug Alcohol Depend 2009;105(1-2):83-88.