This manuscript was an outgrowth of an ongoing effort by ASAM to revise current SUD treatment guidelines for CJ settings. The first author (NZ) is a co-Chair of the committee convened by ASAM to revise these guidelines. The other coauthors are affiliated with the NIDA funded Justice Community Opioid Innovation Network (JCOIN), a national network of researchers and CJ and SUD practitioners working on implementation of medications to treat opioid use disorder (MOUD) in CJ settings. The ASAM committee identified a dearth of literature regarding evidence-based SUD treatment outcomes in CJ settings as a primary challenge for revising current guidelines for SUD treatment in CJ settings. We worked independently of the ASAM committee to highlight important areas where further research is needed. For each area discussed below, we conducted targeted literature searches in each area. We completed a review of EBSCOhost (CINAHL, PsychInfor, PsycArticles, Psychology & Behavioral Sciences Collection, SocINDEX, etc.), and Pub Med in our targeted searches to identify examples in the extant literature associated with each area. We then met as a group to review the state of knowledge and to reach consensus regarding the evidence-base, or lack thereof, associated with each area.

SUD treatment duration, intensity and compositionHow to assess needs for SUD treatment and ancillary services?

The prominent tools used to assess service needs among those in correctional settings—Level of Service Inventory-Revised (LSI-R), Correctional Offender Management Profiling for Alternative Sanctions (COMPAS), and Ohio Risk Assessment System (ORAS) which are typically criminal legal system risk and need assessment tools—can be costly (both in terms of fiscal requirements and staff burden) and time consuming. Costly, burdensome assessments may actually pose a barrier to treatment. A study examining service-need determinations based on scores from the LSI-R and COMPAS compared to results of four yes/no questions regarding need for education, vocational assistance, substance use treatment, and housing showed that the single-item indicators identified 70–90% of those flagged as having high need for these services on the LSI-R and COMPAS instruments [19]. The latter study was based on a relatively small sample, but the findings are consistent with other trends in the literature. A study by Smith et al. [75] compared results of a single-item screen for drug use (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) with the results of the 10-item Drug Abuse Screening Test (DAST-10). The single item was 100% sensitive and 74% specific for the detection of a drug use disorder (as determined by the CIDI Substance Abuse Module)—almost identical to that of the DAST-10. Citing the time constraints in primary care settings, Smith et al. [75] advised the expanded use of simpler, more straightforward approaches to screen for potential drug problems. As the implementation of screening for SUDs in CJ settings increases, finding approaches that are simple, expeditious, and cost-effective are important considerations.

What is the effective dose–response?

The literature has long relied on the positive correlation between treatment retention and reductions in substance use, dating to the cohort studies of Drug Abuse Treatment Outcomes (DATOS), which found that those individuals who were in treatment 90-days or more tended to have reduced drug use and re-arrest relative to those with shorter treatment durations [73, 74]. DATOS was conducted in community-based treatment services and does not necessarily translate into services within correctional settings. Nonetheless, DATOS was instrumental to understanding factors that affect retention in treatment for 90 days or more.

We are only aware of one randomized controlled trial assessing prescribed treatment duration. That study, conducted by Rawson et al. [65], was conducted with individuals (N = 85) in a community-based treatment programs, and showed a slight improved effect on drug use outcomes for those randomized to longer treatment; however, few participants in either group successfully completed treatment (defined as having attended 75% of CBT treatment sessions: 12 CBT sessions within a 4-week period or 48 CBT sessions within a 16-week period). The study found that individuals who completed treatment, regardless of study condition, had greater odds of stimulant-free urines [65]. The above study was not based on a CJ sample, however, the results point to a common problem in the SUD and CJ treatment literature: the misattribution of treatment outcomes to programs rather than individual-level factors (e.g., ability/willingness to complete a prescribed treatment regimen as compared to severity of need). Why does the same modality have no effect in prison but large effects in the community? It is difficult to know if this is because of the unique attributes of the prison or community environment or because of individual factors (e.g., motivation to participate in treatment is a more important factor in the community than in jail or prison). Alternatively, it is possible that treatment is ineffective in both settings but that those who opt to enter and remain in aftercare (commonly ~ 10% of those who agreed to attend; [6] are more committed to recovery and the presumed effects of treatment are really the spoils of selection bias. Similarly, we lack research on the length of time individuals should receive medications for opioid use disorder (MOUD) to affect their long-term substance free or reduced substance use outcomes. Just as with clinical therapy, there is a need to have more research on the dose needed to achieve positive outcomes for therapies, whether they are pharmacological or behavioral in nature.

If medications are part of the treatment plan, what level of counseling support is needed to achieve optimal outcomes?

The requirement (for methadone) or recommendation (for naltrexone and buprenorphine) of counseling seems to be an intuitive complement to MOUD alone. It is worth noting that there is significant variation in counseling services for SUD and the legal requirements do not specify the nature, type, or length of services. As with the prior section describing treatment dose–response relationships, it is unclear the extent to which the nature and duration of counseling would provide additional benefit, especially among incarcerated populations. It is therefore unsurprising that the evidence that counseling improves outcomes over and beyond MOUD is mixed, with the strongest support derived from post-hoc analyses. In an experimental comparison (of a non-CJ sample), Ling and colleagues [39] found no additional improvements for those randomized to receive buprenorphine with counseling compared to those assigned to buprenorphine alone. In a randomized comparison of methadone only versus methadone combined with counseling in a jail sample, Schwartz and colleagues [70] found no differences between groups in drug-test results collected over a 12-month period following release, an effect that has since been widely replicated without specifying the type of counseling services that are included [46]. This is an important consideration—much like the example of assessments described below, further research is needed to accurately assess the additive value of counseling for MOUD patients, especially for incarcerated populations, and whether requiring it improves outcomes or merely serves as another barrier to treatment access.

Consideration of co-occurring SUD and mental health disordersWhat do we know about co-occurring disorders and trauma in correctional settings?

The majority of people who are incarcerated have had lifetime exposures to trauma, including the experience of being incarcerated itself [55], with trauma exposure particularly prevalent in women [44]. In addition, co-occurring disorders, CODs (e.g., mental health and substance use) are common in incarcerated populations. For example, overall half of the people in prison or jails have mental health disorders (MHD, [32]), and 17% of those admitted to jail are estimated to have co-occurring disorders (CODs), with women disproportionately affected [4, 67] Given incarcerated populations’ need for myriad overlapping treatments, understanding how evidence-based practice for treating underlying trauma, MHD, and SUD used in community settings could translate to feasible and effective treatments in carceral settings remains a research gap. However, very few corrections-based SUD treatment programs sufficiently incorporate trauma and/or co-occurring MHD in treatment programming [2, 12].

What does trauma-informed care look like in carceral settings?

In particular, while there is increasing understanding of the importance of integrating trauma-informed care (TIC) into carceral treatment and settings [33], we know little of what is effective and feasible in these settings [50]. There is less research emphasis on trauma and CODs (e.g. substance use and mental health disorders) treatment for men in jails/prisons, while there is evidence of the association of trauma exposure and incarceration among men [31, 51]. Intersectional trauma and daily stress exposure for racial/ethnic minority populations add burden to these populations and very little is known about how best to tailor interventions in CJ settings that address the nexus of intersectionality and CODs [41], although there is a prescribed evidence-based principle of providing SUD treatment in CJ settings [53]. While there is some research of COD treatment in criminal justice settings, much of what has been reported has a wide range of outcomes and was largely underpowered [59].

Lack of agreement over what the goals of SUD treatment in CJ settings should be

It may be common sense that any clinical intervention or policy initiative should have clearly stated goals, but goals of SUD treatment vary across—and even within—criminal justice agencies. In this section, we pose several unanswered questions that merit further debate and study.

Is reduced drug use and/or abstinence within the justice setting an appropriate outcome?

In 2002, addiction researcher Thomas McLellan [47] published an influential editorial titled, “Have we evaluated addiction treatment correctly? Implications from a chronic care perspective.” In his article, McLellan pointed out that lower levels of drug use during a treatment episode should be viewed as evidence that the treatment was effective—even if the post-treatment follow-ups showed no improvement. Similar to hypertension patients who show improvements while taking their medication and poorer outcomes after they stop, the fact that symptoms improved during the active phase of treatment suggests that the treatment: (1) had an effect, and (2) should be extended indefinitely for those managing chronic disorders. Additionally, NIDA Director Nora Volkow [84] recently wrote in Health Affairs Forefront that “the magnitude of the drug overdose crisis demands out-of-the-box thinking and willingness to jettison old, unhelpful, and unsupported assumptions about what treatment and recovery need to look like. Among them is the traditional view that abstinence is the sole aim and only valid outcome of addiction treatment.” suggesting that we should look at reduced drug use, use of alcohol, or other indicators of changes in use patterns.

Is recidivism an appropriate outcome?

Advocates of expanding SUD treatment in CJ settings often argue that doing so also reduces recidivism risk [9]. Randomized trials using an intent-to-treat approach and systematic reviews of more rigorous studies, however, suggest that the effects of CJ-based SUD care on criminal recidivism are minimal and short-lived [15, 60, 71]. Interestingly and perhaps counter-intuitively, problem-solving courts show reductions in recidivism but no changes in drug use patterns [49]. However, if CJ-based SUD treatment can produce meaningful reductions in illicit substance use, is it reasonable to require that it also reduce subsequent criminality? A national, multisite RCT of a drug testing and sanctions approach for probationers found no differences in recidivism [37]. The program was deemed ineffective because of the measured outcome (e.g., recidivism), even though the intervention reduced positive drug tests by half relative to probation as usual (see [30]). A recent National Academies of Science report questions the utility of recidivism as the main fixture of justice-related research and argues for other measures of success such as engaged in treatment, housing stability, employment, reduced use, particularly those that support an individual’s pathway to desistance from criminal behavior [69]. This report helps to further interest in varied outcomes that address improved functionality and stability in the community as being valuable and critical.

Relatedly, a recent meta-analysis by Goodley et al. [27], regarding predictors of recidivism following release from custody, found that while there is significant heterogeneity with respect to predictors of recidivism across the extant literature, the authors identified 17 factors with sufficient evidence from the published studies reviewed that were associated with either an increase or decrease in recidivism. Importantly, many of these factors were not necessarily directly related to SUD and were generally categorized by the authors into factors related to: History of Criminal Behavior, Antisocial Personality Pattern, Antisocial Cognitions and Antisocial Companions, all of which have been previously described by Andrews and colleagues [1, 27]. Two additional factors related to increased risk for recidivism identified by Goodley et al. included history of mental illness and race, with the latter posited to reflect the larger context of racial inequality in CJ involvement in the US [27]. It is also important to acknowledge that SUD treatment alone may be unlikely to significantly impact many of the factors identified above by Goodley et al., which is why we believe that recidivism may not be the most appropriate outcome to assess for CJ-involved individuals with an SUD.

Consideration of mandating SUD treatment

Central to the issue of providing SUD care for those in correctional environments is the role of coercion. In recent decades, many practitioners have justified their support of coerced treatment on the accepted notion that “coerced patients do as well or better than voluntary patients” [48]. As described below, this is an oversimplification that obscures a host of related concerns, including assessment, treatment effectiveness, and the ethics of overriding personal choice.

Issues related to voluntary vs. mandatory treatment participation

One of the greatest challenges to the coerced-treatment literature is the synonymous use of terms that are only loosely associated. Our review of the formative literature in this area found that terms such as “coerced,” “compulsory,” “mandated,” “involuntary,” “legal pressure,” and “criminal justice referral” were often used synonymously in the literature, and sometimes the terms are even used interchangeably within the same article [17, 89]. There is some evidence suggesting that mandated SUD treatment may support treatment completion among specific populations, e.g. adults aged 55 and older [63]. In truth, an incarcerated adult with SUD may simultaneously desire SUD treatment and be mandated to participate in it. As a result, many people who are justice-involved and required to receive SUD treatment acknowledge the need for help. In a sample of people on parole receiving psychiatric care, the majority of those who reported no control over admission to the clinic recognized their need for psychiatric treatment [18]. The blurring of these concepts has led to a mixed set of findings regarding the effectiveness of coerced treatment [40]. Another factor (especially from the early literature is that the majority of these studies focused on treatment retention, rather than outcomes [88]. Although it may not be surprising that legal pressure to enter and remain in treatment results in lower dropout rates, its value in reducing the severity of substance use behavior remains unclear.

Conspicuously absent from the typical debate over coercion is the treatment to which people are coerced to receive. Most SUD treatments offered in prison, and other carceral settings, show no effect unless capitalizing on the selection effects of the subgroup who opt to continue treatment in the community. If we were to assume an effect size of 0.15 of these programs (see [58]), the expected outcomes—with or without coercion—are modest and raise the question whether the coercion or the treatment programs can be justified. Importantly, there is a need to more clearly define what is meant by coercion, particularly within the context of court ordered treatment (e.g. through problem solving courts such as Drug Courts). Coercion can range from legal pressure to engage in treatment to mandates to participate in treatment to placement in a facility, many studies do not differentiate among the various types of coercion but rather indicate that coercion is involvement in treatment without the consent of the patient [89]. In the criminal legal system, this is perplexing because many programs are offered as an alternative to the justice system/incarceration but the individual must still concur to participate in this program. Further work is needed to disentangle two factors that are often conflated: perceived treatment need and level of choice [18].

Should we provide SUD treatment to CJ participants who don’t want it?

As mentioned in the previous sections, many of the SUD programming referrals in the CJS are based on the presumed validity of screening and needs assessments and (for those referred to treatment against their wishes) the benefits of coercion. These presumptions are unlikely to be challenged when a facility struggles to find enough participants to fill its designated SUD treatment beds (or when cost of screening/assessment is a prohibitive barrier). Consider, in contrast, a facility with limited SUD treatment slots. Can we justify filling beds with those deemed to have a substance use problem (regardless of their desire to participate) even if it means excluding others who specifically requested it? Evidence would suggest not. Parhar and colleagues [58] reviewed 129 correctional treatment studies and found that mandated treatment was largely ineffective, whereas voluntary treatment showed significant, positive effects. Might we be better off simply offering treatment and other services to those who request it? As suggested above, this remains an unsettled question.

What we do know about the effectiveness of SUD treatment for coerced participants poses an important ethical question: Does the existing evidence for psychosocial treatment justify overriding individual choice in whether to participate? After conducting a systematic review of compulsory treatment evaluations in several countries, Werb and colleagues [86] found that 90% were associated with either null or deleterious effects on drug use and recidivism outcomes. Citing concerns over the documentation of human rights abuses in these settings, the authors concluded: “In light of the lack of evidence suggesting that compulsory drug treatment is effective, policymakers should seek to implement evidence-based, voluntary treatment modalities in order to reduce the harms of drug use” (p. 8). None of these individual studies—or even reviews—can be considered dispositive, but at the very least it is clear that existing evidence provides an insufficient basis for the use of coerced SUD treatment. As SUD treatment itself becomes more effective, it will be interesting to re-examine the potential role of coercion. An alternative method for overcoming patient resistance is to offer incentives for desired drug-use outcomes. This approach—known as “contingency management” (CM)—involves providing small, incremental payments for negative drug-test results and no requirements to attend counseling sessions. Although the CJS has been slow to adopt CM, a recent analysis by the Washington State Institute for Public Policy [85] revealed that CM produced the highest cost–benefit ratio of all of the dozens of interventions reviewed.

Limitations of political and policymaking leadership: implications for SUD treatment

While this paper speaks to additional research and knowledge gaps relative to SUD treatment in correctional systems, another shortcoming of the current legal-health systems rests in the lack of integration of what is evidence-based into formal policies and practices implemented through executive/legislative policy or action. Policymaking and policy implementation often are slow and incremental, with significant gaps between initial formulation and actual implementation. Advancement of MOUDs in correctional settings is one example, though the gap between what national leaders in the field recommend and policies actually put into place is significant, though improving somewhat in the past 1–2 years. For example, a recent study surveyed state prisons in states with disproportionate opioid overdose mortality and found that while all prison systems within the states surveyed reported offering at least one medication to treat OUD, only 7% of the 538 individual prisons within the states offered all three medication types (methadone, buprenorphine and naltrexone); 61% of the 538 prisons did not offer any type of MOUD [72]. A recent study on medications used in a nationally representative same of 832 problem solving courts reported that while 86% of the courts would authorize the use of medications, only 14% of those with an opioid use disorder were on MOUD [20]. Other models employing evidence-based cognitive-behavioral treatment (CBT are in place, including in the Federal Bureau of Prisons’ non-residential treatment program (a 12-week course for those serving short sentences and/or who are transitioning back to the community as part of their SUD treatment, Federal Bureau of Prisons, n.d.). Georgia’s Department of Corrections also offers a CBT model for some individuals with SUD, incorporating moral reconation therapy, Motivation for Change, and other approaches (Georgia Department of Corrections, n.d.).

Why are uptake and acceptance of current best practices for SUD treatment in correctional facilities lagging by legislative and executive leaders?

Organizations as diverse as the National Institute on Drug Abuse, American Society of Addiction Medicine, American Medical Association, National Governors Association, and National Commission on Correctional Health Care (NCCHC) have endorsed MOUD treatment as a best practice. The Legislative Analysis and Public Policy Association even developed model legislation for states and localities to use as a foundation for introduction of legislation to provide MOUD in correctional settings [38] through a panel co-chaired by Regina Labelle, formerly acting Director of the White House Office of National Drug Control Policy (ONDCP). Yet, until very recently, MOUD treatment in prisons and jails has been relatively rare, and few such programs have included coverage of two or more approved MOUDs consistent with established best practices [52]. The lack of widespread coverage of MOUDs and inconsistent administration of them, despite the relatively high proportion of incarcerated individuals with OUD/SUD, occur for several reasons. This is the case, even though the U.S. Department of Justice and recent court rulings have established that a correctional facility’s failure to provide such care may violate the “cruel and unusual punishment” language in the Eighth Amendment to the U.S. Constitution [61, 76, 82], not to mention whether such care is administered in accordance with established standards and best practices. For one, the standards established for correctional health care by the NCCHC, while advancing best practices, are entirely voluntary [68], so conditions, standards, and metrics surrounding healthcare for incarcerated individuals at the state and local level are inconsistent and scattered.

Some programs that do offer MOUD suffer operationally due to lack of trained providers, misunderstanding or lack of information within correctional institutions, and other factors [66, 77]. Even fewer provide counseling or complementary mental health services, and very few programs provide any kind of significant treatment for other SUD. Funding is another concern. While the average annual state budget for an incarcerated individual was $5720 in 2015, the figure was wildly divergent across states, from nearly $20,000 in California to about $2200 in Louisiana [62]. This discrepancy translates to significant variations in staff and expertise dedicated to health care, notably mental health/SUD treatment, for incarcerated individuals, quality of care, and health status of individuals once they are released from correctional facilities [8]. In addition, while incarcerated individuals and pretrial detainees are the only Americans with Constitutionally guaranteed rights to “adequate medical care” [14], what constitutes adequate care is less clear, including in terms of funding. Incarcerated individuals generally are limited as to sources of funding, Medicaid in particular, that may be provided for their medical care under the 1965 Medicaid Inmate Exclusion Policy [13]. Six states have applied to the federal government for waivers that would allow them to cover some Medicaid-eligible services outside of the exclusion policy for individuals nearing release; these applications are under review by the Center for Medicare and Medicaid Services [28].

Another step toward expanding best practice-based OUD treatment in correctional facilities is being pursued on the legal front. The U.S. Department of Justice has challenged existing MOUD policy in correctional facilities, citing potential violations of the Americans with Disabilities Act (ADA) [80]. Because the ADA protects individuals with disabilities, and individuals in treatment/recovery for OUD who are not engaged in illegal drug use are deemed to have a disability [81], denial or non-provision of MOUD treatment for those with SUD/OUD diagnosis, the Department argues, violates the law. The Department has issued guidance on protections for individuals with OUD under the ADA and taken action in several cases through its Civil Rights Division against healthcare institutions, professional boards, state courts, and private employers that have denied treatment and services to justice-involved individuals [83].

Why are uptake and acceptance of current best practices for SUD treatment in correctional facilities lagging by legislative and executive leaders?

Organizations as diverse as the National Institute on Drug Abuse, American Society of Addiction Medicine, American Medical Association, National Governors Association, and National Commission on Correctional Health Care have endorsed MOUD treatment as a best practice. The highly regarded Legislative Analysis and Public Policy Association even developed model legislation for states and localities to use as a foundation for introduction of legislation to provide MOUD in correctional settings [38] through a panel co-chaired by Regina Labelle, formerly acting Director of the White House Office of National Drug Control Policy (ONDCP) in the Biden Administration. Yet, until very recently, MOUD treatment in prisons and jails has been relatively rare, and few such programs have included coverage of two or more approved MOUDs consistent with established best practices [52]. Some programs that offer MOUD suffer operationally due to lack of trained providers, misunderstanding or lack of information within correctional institutions, and other factors [77]. Even fewer provide counseling or complementary mental health services. Very few programs provide any kind of significant treatment for other SUD.

Progress around MOUD is promising for future treatment options

While the pace of adoption has long been lagging, coordinated efforts advancing evidence-based practices, at least around MOUD treatment in correctional facilities, are producing results. Since the beginning of 2020, legislation in at least a dozen states has established or expanded access to MOUD, and most states now have at least one correctional facility that provides some form of MOUD [87]. Additionally, at least 28 states have, through executive action or agency rulemaking, advanced SUD treatment for incarcerated individuals, mostly in state prisons [57]. Under Labelle’s leadership as Acting Director of the ONCDP, the first State