This chapter has discussed the importance of ensuring care for people in custody, but what does that care look like? The details of treatment that can be provided in custody are beyond the scope of this criminal justice-focused text, but treatment can and does include the psychological (counseling) and psychiatric (medication) treatments that were mentioned in Chapter 2 of this text. You have also heard a little about treatment that may occur in jails and prisons from the AVID videos embedded throughout this chapter. If you are interested in learning more about what it is like to be a mental health provider in a controlled environment, you may also hear from several of those professionals via the videos linked in Chapter 10 of this text. Additionally, feel free to take a look at this interview with a supervising psychiatrist who works in the California prison system [Website]. The interview touches on approaches to treatment within prison, as well as the challenges and satisfactions of treatment in this environment from the perspective of a mental health provider.

One specific and important type of treatment in custody that will be briefly addressed here is treatment for substance use disorders. Substance use treatment can include any number of approaches that help a person manage and recover from a substance use disorder, a diagnosis discussed more in Chapter 2. Evidence-based therapies, such as cognitive behavioral therapy, can be part of treatment, as can medication-based treatments (U.S. Department of Veterans Affairs, 2024).

Availability of Substance Use Treatment in Custody

In custody, substance use disorders can be detected at the assessment stage, and treatment should be planned, identified, and coordinated—though that does not always occur. There is an enormous unmet need for substance use treatment in custody. Substance use disorders are common in U.S. jails and prisons. Although this text uses the term mental disorders broadly to include substance use disorders, many statistics do not take that approach. SAMHSA estimates that close to 60% of people in jails and prisons have substance use disorders, while rates are closer to 10% outside of custody (SAMHSA, 2022a). However, adequate screening and assessment are frequently lacking. Even when problems are identified, many people do not have access to treatment in custody, and symptoms of these disorders (like other mental disorders) are frequently worsened by incarceration (figure 7.26) (SAMHSA, 2022a).

For example, in Oregon, it is estimated that two-thirds of all state prisoners (about 8,000 total) have substance use disorders needing treatment. Yet, only 4 of Oregon’s 12 prisons have intensive substance use treatment programs, so access remains very limited. For example, the Oregon State Correctional Institution outside of Salem houses 800 people, but the intensive substance use treatment program there takes only 24 participants who are close to their release date—rendering this type of treatment unavailable to most (Frost, 2023).

Recognizing the huge need, Oregon is engaged in efforts to expand substance use treatment in innovative ways. The Oregon DOC has recently created a new program that is located at the high-security Oregon State Penitentiary. This program uses prison-trained certified recovery mentors (peer mentors) alongside certified drug and alcohol counselors to provide treatment to incarcerated people. Reportedly, the program is in high demand, and it is very meaningful to its participants, many of whom are in the facility for lengthy terms. If you are interested, watch the video in figure 7.27 to hear from some of the Oregon participants in this initiative.

https://www.youtube.com/watch?v=hRrIoDmttqA

Medication Treatment for Substance Use Disorders

An important form of treatment for substance use disorders is medication, which can be used alone or in combination with counseling and behavioral therapies to provide a “whole-patient” approach to treatment. This type of treatment is often referred to as medication-assisted treatment (MAT). Medications are uniquely effective for difficult-to-treat alcohol and opioid use disorders, and sometimes these approaches are referred to in more specific terms as either medication for opioid use disorder (MOUD) or medication for alcohol use disorder (MAUD). Both MOUD and MAUD are discussed in more detail in Chapter 8 as critical post-incarceration interventions for people in the community (figure 7.28).

The FDA has approved several different medications that can be safely used to treat substance use disorders. These medications relieve withdrawal symptoms and cravings that a person with a substance use disorder would otherwise experience, without the negative or euphoric effects of the substance. The medications are also safe to use for extended periods. Medication treatment for substance use has been shown to have significant benefits: it reduces drug use, prevents overdose events, and promotes recovery among substance users. It is also effective in reducing criminal activity and arrests, including probation revocations that result in incarceration (SAMHSA, n.d.).

Medication-Assisted Treatment (MAT) in Custody

Despite its effectiveness, the use of medications for substances has been limited in many criminal justice settings, including prisons. The reasons for this are numerous. Misunderstandings associated with the use of these medications are one barrier. Some people believe—incorrectly—that medication treatment involves “substituting one drug for another.” The idea that medication functions like a drug of abuse leads to resistance to its use in the criminal justice field, even though medication treatment is a tested and proven approach with strong positive outcomes.

Misuse of medication, sometimes called diversion of medication, is another concern that limits prison (and other criminal justice program) use of these treatments. While misuse is a valid concern, criminal justice programs and facilities can limit this risk, even in the prison setting. Strategies might include the use of dedicated staff for oversight, ensuring safe storage of medications, and conducting drug testing.

The costs of medication treatment are an additional concern for many correctional programs. Although long-term benefits abound, the immediate costs of medication, staffing, and training may be prohibitive. Often, the required medications are not on correctional facilities’ formularies, or lists of allowed and funded medications. In a related concern, formerly incarcerated people without insurance coverage may not be able to continue medication treatment when they are released, limiting the value of the investment during incarceration. Additionally, setting aside affordability, many communities do not even have sufficient medication treatment providers or ones who can effectively serve the justice-involved population.

Because medication treatment can be so helpful to a person in recovery from a substance use disorder, its use has been expanded across many custodial environments in recent years, despite identified barriers (Homans, et al., 2023). With these efforts, medication treatment for substance use, particularly in custodial settings, is evolving rapidly. Ask a criminal justice or mental health professional in your community: what are the current approaches to medications for substance use, or MAT, in correctional settings? What terminology is used to describe the approach? What have we learned, and what changes are on the horizon?

Licenses and Attributions for Substance Use Treatment in Custody

Open Content, Original

“Substance Use Treatment in Custody” by Anne Nichol is licensed under CC BY 4.0

Open Content, Shared Previously

“Medication Treatment for Substance Use Disorders” is adapted from:

• “Medication-Assisted Treatment (MAT) in the Criminal Justice System: Brief Guidance to the States” by SAMHSA, which is in the Public Domain.
• “Medications for Substance Use Disorders” by SAMHSA, which is in the Public Domain.

Modifications by Anne Nichol, licensed CC BY 4.0, include rewording, condensing and expanding upon the texts.

“Medication-Assisted Treatment (MAT) in Custody” is adapted from:

• “Medication-Assisted Treatment (MAT) in the Criminal Justice System: Brief Guidance to the States” by SAMHSA, which is in the Public Domain.
• “Medications for Substance Use Disorders” by SAMHSA, which is in the Public Domain.

Modifications by Anne Nichol, licensed CC BY 4.0, include rewording, condensing and expanding upon the texts.

Figure 7.26. Metro Programs by CoreCivic is licensed under CC BY-ND 2.0.

Figure 7.28. IMG_1607 Dispensing area for medication assisted treatment by NYS OASAS is licensed under CC BY-NC-ND 2.0.

All Rights Reserved Content

Figure 7.27. Oregon State Penitentiary Diversion Program by Oregon DOC is licensed under the Standard YouTube License.