Disparities in Medication Use for Criminal Justice System-Referred Opioid Use Disorder Treatment

Abstract

Importance: Individuals with opioid use disorder (OUD) and criminal justice system involvement experience high rates of overdose death. Historical data point to limited use of medications for opioid use disorder (MOUD) in criminal justice system-referred treatment for OUD as playing a role. However, how MOUD use among those referred to treatment by the criminal justice system has changed relative to other referral sources over time is still unclear, as well as how it varies across states.

Objective: To examine disparities in the use of MOUD between individuals referred to treatment by the criminal justice system compared to other referral sources over time.

Design, setting, and participants: This cross-sectional study included admissions to specialty substance use treatment facilities for OUD in the national Treatment Episodes Dataset-Admissions from 2014 to 2021. Logistic regression models were used to examine trends in the probability of MOUD use among individuals with and without criminal justice referrals for OUD treatment, as well as any differential trends by state. The data were analyzed from September 2023 to August 2024.

Main outcome and measure: The main outcome was the probability that treatment for individuals with OUD included MOUD.

Results: A total of 3 235 445 admissions were analyzed in the study data. Among individuals referred to OUD treatment by the criminal justice system, the probability that treatment included MOUD increased by 3.42 percentage points (pp) (95% CI, 3.37 pp to 3.47 pp) annually from 2014 to 2021. This was faster than the increase in the probability of MOUD use for noncriminal justice-referred admissions (2.49 pp [95% CI, 2.46 pp to 2.51 pp) and reduced, but did not eliminate, disparities in MOUD use between individuals with and without criminal justice system-referred treatment. In 2021, only 33.6% of individuals in criminal justice system-referred treatment received MOUD, 15.6 pp lower than for individuals referred to treatment by other sources. Trends in the probability of MOUD use varied substantially for individuals in criminal justice system-referred treatment across states, but very few experienced enough growth to eliminate this disparity.

Conclusions and relevance: The results of this cross-sectional study suggest that targeted efforts to address persistent disparities in MOUD use among those with OUD and criminal justice system involvement are needed to address the poor health outcomes experienced by this population.

Figure 1.. Trends in Medication for Opioid Use Disorder (MOUD) Use for Individuals Referred by Criminal Justice System and Other Sources

The data are from the Treatment Episodes Dataset–Admissions, 2014 to 2021. The point estimates denote the probability that a treatment admission included MOUD in each year, separately for clients referred to treatment by the criminal justice system (depicted as orange circles) and other sources (depicted as dark blue squares), adjusted for patient characteristics. The figure overlays trend lines for each type of treatment referral, and the slope (95% CI) values are provided below each line. The disparities in the probability of MOUD use for individuals referred to treatment by the criminal justice system compared to other sources (holding individual-level characteristics fixed) are reported for 2014 and 2021. Percentage points are abbreviated as pp. See eAppendix 1 in Supplement 1 for more detail.

Figure 2.. Trends in Medication for Opioid Use Disorder (MOUD) Use for Individuals Referred by the Criminal Justice System by State

The data are from the Treatment Episodes Dataset–Admissions, 2014 to 2021. The figure shows the annual rate of growth in MOUD use for clients referred to OUD treatment by the criminal justice system in different states. Growth rates and 95% CIs, which are represented by the error bars, were estimated using logistic regression of the probability of MOUD use on an indicator, including whether treatment was referred by the criminal justice system, year, an interaction between whether treatment was referred by the criminal justice system and year, and client characteristics, stratified by state. The figure also shows a benchmark for each state, defined as the rate of growth needed for 50% of individuals referred to treatment by the criminal justice system in each state to receive MOUD in 2021. Percentage points are abbreviated as pp. See eAppendix 1 in Supplement 1 for more detail and eTable 5 in Supplement 1 for numerical results.