Optimizing Opioid Use Disorder Treatment in Prisons: Strategies for Diagnosis and Shared Decision-Making

About This Grant

PROJECT SUMMARY/ABSTRACT People released from prison have 40 times greater risk of dying of opioid overdose in the first 2 weeks after release than the general population. Initiating medication for opioid use disorder (MOUD) during incarceration reduces that risk substantially, but most people in prison with opioid use disorder (OUD) do not receive MOUD. The objective of this work is to test practical, scalable strategies to identify OUD in prisons and successfully engage people with OUD in MOUD treatment. This study will take place in the Washington state prison system, a largely rural system in a western state. This project will test two distinct strategies: 1) A practical approach for screening for and diagnosing OUD: Diagnosing OUD is a prerequisite to offering treatment, but identification of OUD in prisons is more challenging than in jails and non-carceral medical settings. There is immense need for a brief (1-2 item) OUD screening tool as well as an OUD-specific diagnostic tool that have been validated in prisons. This project will validate (a) a two-item OUD screening tool, intended for population-based screening, and (b) an 11-item diagnostic DSM-5 criteria OUD symptom checklist. Both have been adapted for prison in the research team’s formative work in Washington prisons and extensive prior work developing and validating tools for non-carceral primary care settings. The tools will be validated in a sample of 524 recently incarcerated people against a reference standard of a clinical interview. 2) Shared decision-making for OUD treatment options: After people are diagnosed with OUD, they need to make decisions about treatment. Treatment that aligns with an individual’s values and preferences may improve engagement and treatment outcomes. Shared decision-making (SDM) has been shown to increase treatment engagement for OUD and other behavioral health conditions. SDM involves informing patients that they have a choice, reviewing treatment options, and discussing their prefer- ences to collaboratively select a treatment. SDM can be delivered in a single session by a nurse, which aligns with protocolized, nurse-led prison health care models. Incarcerated people have limited autonomy but retain autonomy over most health care decisions, including whether to start MOUD and which medication to start. Prison, however, presents unique opportunities and challenges for SDM. This project will conduct a hybrid type 1 implementation-effectiveness encouragement trial of SDM for OUD treatment in a prison, randomizing people who are approaching release to be offered brief, nurse-led SDM or to receive usual care. The primary trial out- come is receipt of MOUD at release. Secondary outcomes include post-release mortality, post-release receipt of MOUD, and disciplinary violations in prison; SDM cost and implementation outcomes—acceptability and feasi- bility—will also be assessed to facilitate scale-up of SDM, if effective. Public Health Impact. At least 180,000 people in prison have OUD and are at high risk of post-release death. The proposed research tests practical tools to enable carceral systems to provide high-quality OUD care to this high-risk population.