Take-Home Naloxone, Release From Jail, and Opioid Overdose—A Piece of the Puzzle | Law and Medicine | JAMA Network Open – Tri-Cities Community Action Team (TC CAT)

December 10, 2024

JAMA Netw Open. 2024;7(12):e2448667. doi:10.1001/jamanetworkopen.2024.48667

Incarceration is a toxic exposure, and individuals released from carceral facilities have a high risk of death, of which opioid overdose is the leading cause, regardless of the type of carceral exposure, whether it be prison or jail. In a 2024 study of mortality risk following incarceration during the fentanyl era, individuals leaving jail experienced an overdose death rate 15 times greater than the general population.¹ This high risk of overdose death, in combination with the vast number of people who move through jails in our country, means that a large percentage of overdose deaths occur in people released from jail. In that study by Hill et al,¹ almost one-fifth of all overdose deaths were among individuals recently released from jail. Given the concentration of overdose risk in this population, if we are to address the ongoing overdose crisis, we must address overdose risk following jail release.

Provision of take-home naloxone, especially to populations at high risk of opioid overdose, is an evidence-based intervention to reduce opioid overdose mortality. Naloxone provision, either widely in the community or targeted to people released from jail, has the potential to decrease overdose mortality in the postrelease period. To date, there has been limited research to quantify the potential impact of such strategies. This study by Tatara and colleagues² works to fill that gap, modeling the impact of a range of naloxone distribution scenarios on opioid overdose fatalities among all people who use opioids and among individuals leaving jail specifically. As modeled, targeted naloxone distribution to people released from jail, in combination with widespread distribution in the community, averted approximately one-quarter of opioid overdose deaths among the jail-released population. Although both strategies by themselves averted overdose deaths, targeted naloxone to all individuals released from jail averted more overdose deaths in the jail-released population compared with broad community distribution. As modeled, this intervention, even absent broad community distribution, could avert more than 20% of overdose deaths among individuals released from jail. Not only could these programs dramatically reduce overdose deaths, but they are also cost-effective, with median (IQR) costs estimated at $11 200 ($7400-$17 300) per death averted, well below typical willingness-to-pay thresholds.

These findings are striking and should bolster efforts to increase targeted naloxone provision to this population, but they should be interpreted with caution. At first blush, implementing a targeted take-home naloxone program in jails should be straightforward; yet, in practice, many implementation barriers arise.³^–6 Jails, which primarily incarcerate people prior to sentencing or serving short sentences, are characterized by churn; a mean of 60% of jail populations turnover within a week, and release, especially for individuals held prior to sentencing, is an unpredictable event.⁷ This churn makes implementing any health care service a challenge, let alone a program that requires correctly identifying and targeting people with histories of opioid use on release. Furthermore, the logic of naloxone, and harm reduction more generally, which emphasizes the autonomy of people who use drugs, contrasts with the punitive, abstinence-focused logic of jails and other carceral institutions. As such, getting buy-in from the carceral staff to implement these programs can be difficult, as knowledge and attitudes about people who use drugs, harm reduction, and naloxone can range from apathy to opposition.³ Finally, barriers often cited by people who use drugs include concern for legal consequences of possessing naloxone, administrating naloxone, or calling emergency services in case of an overdose, all of which may be more pronounced for people leaving jail.⁵

It is unlikely that estimates of overdose deaths averted, as modeled in this study by Tatara et al,² can readily be achieved without significant effort to understand and overcome these barriers. Reassuringly, several jurisdictions, including in the Cook County, Illinois, jail, have successfully implemented jail-based naloxone programs, both highlighting their feasibility and providing replicable models that can be adopted by other jurisdictions.³^–5 A commonly cited facilitator of these efforts is support from jail leadership.⁴^,5 In the highly structured, hierarchical environment of jails, program offerings are often driven by top-down decisions from the sheriff. Garnering buy-in from frontline jail staff can also be achieved via targeted educational efforts aimed at providing jail staff with up-to-date and accurate information on the risk of overdose following release, opioid use disorder (OUD), and the use of naloxone.³ Innovative naloxone distribution approaches have also been tried in jails, including the use of naloxone vending machines and interventions targeting people visiting individuals who are incarcerated.⁵^,6 The high number of opioid overdoses in people who have been released from jail, along with the results of this modeling study by Tatara et al,² highlight the urgency of broader dissemination of these programs; they also provide a menu of options for jurisdictions to choose from that fit their context. There are more than 3000 jails in the United States, from a few large urban jails, like Cook County, which holds approximately 5500 individuals per day, to many smaller jails, holding fewer than 50 individuals.² These heterogeneous jail environments necessitate diverse and adaptable take-home naloxone programs that can be tailored to meet the unique needs of different jails’ capacities, constraints, and demographics.

While this study by Tatara et al² demonstrates the capacity for jail-based naloxone programs to avert deaths, it also reveals the shortcomings of take-home naloxone as an intervention in isolation: even in the model estimates with high-level naloxone distribution and high probability of bystander presence, it was insufficient to prevent 3 of 4 overdose deaths. As naloxone prevents death in the occurrence of overdose but does not modify overdose risk per se, there is urgent need for additional, more proximal interventions to reduce overdose risk in the post–jail release population.

Risk of overdose death in the postrelease period is mediated by complex, intertwined determinants of health, including health care access barriers, poverty, and social isolation. Provision of medications for OUD (MOUD) and direct linkage to continued treatment on release, while increasing, is still uncommon in most jails in the United States: only 63% of jails screen for OUD and 19% of jails link individuals with MOUD.⁸ The federal government is currently supporting efforts to expand jail-based MOUD programs, whether via innovations that enable Medicaid funding or via threats of litigation from the Department of Justice. More challenging, but ultimately more crucial, are supporting efforts to address the health-related social needs and combat social isolation in individuals who have been exposed to the jail system, such as unconditional cash transfers, safe consumption sites, and peer-based programs. These have the potential to not only reduce opioid overdose deaths but also drive larger changes to improve the health and well-being of this population.

Thus, this study by Tatara et al² highlights the significant capacity of take-home naloxone programs to reduce opioid overdose deaths among individuals recently released from jail in a cost-effective manner. Yet, even with the life-saving capacity of widespread naloxone provision, far too many overdose deaths occur. Robust and sustained reduction of opioid overdose deaths following release from jail requires a holistic approach that addresses both proximal and distal causes of increased overdose risk. While a crucial piece of the puzzle, naloxone alone is not a panacea.

References

Hill K, Bodurtha PJ, Winkelman TNA, Howell BA. Postrelease risk of overdose and all-cause death among persons released from jail or prison: Minnesota, March 2020-December 2021. Am J Public Health. 2024;114(9):913-922. doi:10.2105/AJPH.2024.307723 PubMed Google Scholar Crossref

Tatara E, Ozik J, Pollack HA, et al. Agent-based model of combined community- and jail-based take-home naloxone distribution. JAMA Netw Open. 2024;7(12):e2448732. doi:10.1001/jamanetworkopen.2024.48732
Article Google Scholar

Showalter D, Wenger LD, Lambdin BH, Wheeler E, Binswanger I, Kral AH. Bridging institutional logics: Implementing naloxone distribution for people exiting jail in three California counties. Soc Sci Med. 2021;285:114293. doi:10.1016/j.socscimed.2021.114293 PubMed Google Scholar Crossref

Oser CB, McGladrey M, Booty M, et al. Rapid jail-based implementation of overdose education and naloxone distribution in response to the COVID-19 pandemic. Health Justice. 2024;12(1):27. doi:10.1186/s40352-024-00283-8 PubMed Google Scholar Crossref

Horton M, McDonald R, Green TC, et al. A mapping review of take-home naloxone for people released from correctional settings. Int J Drug Policy. 2017;46:7-16. doi:10.1016/j.drugpo.2017.05.015 PubMed Google Scholar Crossref

Victor G, Hedden-Clayton B, Lenz D, Attaway PR, Ray B. Naloxone vending machines in county jail. J Subst Use Addict Treat. 2024;167:209521. doi:10.1016/j.josat.2024.209521 PubMed Google Scholar Crossref

Adler JL, Chen W. Jail conditions and mortality: death rates associated with turnover, jail size, and population characteristics. Health Aff (Millwood). 2023;42(6):849-857. doi:10.1377/hlthaff.2022.01229 PubMed Google Scholar Crossref

Maruschak LM, Minton TD, Zeng Z. Opioid use disorder screening and treatment in local jails, 2019. Accessed October 30, 2024. https://bjs.ojp.gov/document/oudstlj19.pdf