What is the recommended management approach for an incarcerated individual with a history of opioid addiction who is currently on Suboxone (buprenorphine/naloxone)?

Management of Incarcerated Individuals on Suboxone

Continue Suboxone (buprenorphine/naloxone) throughout incarceration without interruption, as forced withdrawal significantly reduces post-release treatment engagement and increases overdose risk. 1

Evidence for Continuation During Incarceration

The strongest evidence comes from a randomized controlled trial demonstrating that prisoners who continued methadone during incarceration were more than twice as likely to re-engage with community treatment within one month of release compared to those subjected to forced withdrawal (96% vs 78%; adjusted HR 2.04,95% CI 1.48-2.80). 1 While this study examined methadone, the principle applies equally to buprenorphine as both are opioid replacement therapies with similar treatment retention benefits. 2

Forced discontinuation of medication-assisted treatment upon incarceration is the standard practice in most U.S. correctional facilities, but this approach is medically inappropriate and increases harm. 2, 1

Why Continuation is Critical

Relapse Prevention

• Approximately three-quarters of opioid-dependent individuals relapse to heroin use within 3 months of release when not maintained on medication-assisted treatment. 3
• Inmates with untreated opioid use disorder face increased risk of overdose death, HIV, hepatitis C transmission, and reincarceration upon release. 2
• Only 11.2% of inmates who meet criteria for substance use disorder receive any professional treatment during incarceration, despite 64.5% meeting diagnostic criteria. 4

Treatment Engagement

• Continuation of buprenorphine during incarceration facilitates seamless transition to community-based treatment upon release. 1
• Disruption of established medication-assisted treatment destabilizes recovery and undermines harm reduction efforts. 4

Practical Implementation

Dosing During Incarceration

• Continue the patient's established community dose of Suboxone (typically 16 mg daily, therapeutic range 8-16 mg). 5, 6
• Make dose adjustments only as clinically indicated based on withdrawal symptoms or cravings. 4

Monitoring Requirements

• Continue regular urine drug testing to monitor treatment adherence. 5
• Maintain hepatitis C and HIV screening protocols. 5, 6
• Coordinate with behavioral health providers, as medication-assisted treatment should not be provided as monotherapy. 5, 6

Addressing Barriers to Continuation

Institutional Resistance

• Many correctional facilities maintain policies of forced withdrawal based on outdated addiction paradigms that view incarceration as an opportunity for "detoxification." 3
• Substance use disorder must be recognized as a chronic medical condition requiring continuous treatment, not as a behavioral problem requiring punishment or forced abstinence. 4

Patient Concerns

• Former inmates report fear of medication dependency and reliance on willpower over medications, often stemming from painful withdrawal experiences during prior incarcerations. 3
• Education about the chronic disease model of addiction and the effectiveness of medication-assisted treatment is essential. 4

Post-Release Planning

Transition to Community Care

• Arrange appointments with community methadone or buprenorphine providers before release. 2
• Provide naloxone kits and overdose prevention education, as the post-release period carries extremely high overdose risk. 6, 7
• Ensure financial assistance or insurance coverage for continued treatment, as cost barriers significantly impede treatment engagement. 1

Treatment Outcomes

• Individuals with incarceration history achieve similar treatment outcomes with office-based buprenorphine/naloxone as those without incarceration history (consecutive weeks of opioid-negative urines: 6.2 vs 5.9, p=0.43; retention: 38% vs 46%, p=0.28). 8
• This evidence should reassure providers that prior incarceration does not predict poor treatment response. 8

Critical Pitfalls to Avoid

• Never force withdrawal from Suboxone upon incarceration, as this practice increases mortality, infectious disease transmission, and recidivism. 2, 1
• Never discontinue medication-assisted treatment without ensuring immediate connection to alternative treatment, as gaps in treatment dramatically increase relapse and overdose risk. 1, 3
• Never provide medication-assisted treatment without concurrent behavioral therapy, as combined treatment is significantly more effective than either approach alone. 5, 6