key: cord-0686580-c0xudsl3
authors: Aslim, Erkmen G.; Mungan, Murat C.
title: Access to Substance Use Disorder Treatment During COVID-19: Implications from Reduced Local Jail Populations
date: 2020-09-25
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108147
sha: 8d23d3ac736c863c38731e4f63f43cfe09464792
doc_id: 686580
cord_uid: c0xudsl3

Many states have responded to the spread of COVID-19 by implementing policies which have led to a dramatic reduction in jail populations. We consider the benefits associated with providing the population of individuals who would, but for these policies, be incarcerated with substance use disorder (SUD) treatment. We discuss problems that may prevent this population from receiving SUD treatment as well as policies which may mitigate these problems.

Many states have responded to the spread of COVID-19 by implementing policies which have led to a dramatic reduction in jail populations. (PPI, 2020, Marcum, 2020 and Figure 1, below) . A large proportion of individuals who would be incarcerated but for these new policies are likely to have substance use disorders (SUDs) (Belenko and Peugh, 2005; Mumola and Karberg, 2006) .

Failing to provide medical care for these individuals carries exceptionally large social costs (Wakeman, McKinnet, and Rich, 2009 ) partly due to the harms that may come about from criminal propensities of a sub-set of individuals within this group, which could substantially be mitigated through appropriate medical care (Aslim et al., 2019; Vogler, 2020; He and Barkowski, 2020) .

Moreover, because the spread of COVID-19 exacerbates existing barriers and expected costs to receiving conventional SUD treatments, 1 there is an important risk that many of these individuals will not receive the SUD treatments they need. Thus, it is likely that the pandemic not only increased the number of individuals in need of SUD treatment, but also reduced the average propensity of individuals in need to receive such treatment. Of course, the pandemic may have contributed to similar access problems among the general population. However, given the unusual drop in jail populations as well as the exceptional SUD-related risks associated with this group, we limit our focus on the channels through which the pandemic may have exacerbated access to SUD treatment problems within this population. With the limited information that is already available, we consider potential methods to mitigate this problem.

In the United States, 2.3 million people are incarcerated each year, and about one-third of this population is confined in local jails (Sawyer and Wagner, 2020) . About two-thirds of inmates who were sentenced in local jails meet the DSM-IV 2 criteria for drug dependence or abuse (Bronson et al., 2017) . To flatten the curve 3 against the spread of COVID-19, local jails have downsized their population. Figure 1 shows the changes in local jail populations (thick curve). The break in the trend corresponds to March 16, 2020, which is the date that the White House released COVID-19 guidelines for America. This downward trend is partially a result of local jails responding to the pandemic by either lowering the bar for releases or enhancing the requirements for detention (see, e.g., UCLA Law, 2020 providing a detailed breakdown of jail releases by types of release across different states). Given the evidence that most individuals cycling through the criminal justice system have serious substance use and addiction problems, the reduction in jail populations creates an increase in the number of unincarcerated individuals with potential behavioral health problems during the COVID-19 pandemic. There are obvious private costs to individuals who have SUDs and are unable to receive care. Releasing individuals from incarceration without providing them adequate SUD treatment is actually likely to increase such costs born by these individuals, since the average inmate has access to some SUD treatment while incarcerated (Karberg and James, 2005) . 4 Moreover, a failure to provide SUD care for these individuals also carries social costs in the form of future offenses that may be committed by a sub-set of these individuals, which they cannot otherwise commit while incarcerated. Prior work suggests that health coverage is an effective tool in reducing crime through access to SUD treatment (Wen, Hockenberry, and Cummings, 2017) . Consistently with this literature, Aslim et al. (2019) provide both theoretical and empirical support that access to SUD treatment is a potential channel through which Medicaid reduces the likelihood of recidivism. Therefore, limitations in accessing substance use treatment is likely to contribute to higher crime rates.

Given these risks, we identify potential constraints for released inmates to access substance These challenges are likely to cause a large gap between the SUD treatments that are needed and those that are actually received. We discuss two policies that can be implemented to reduce access problems and increase the utilization of SUD treatment. 9 To mitigate the enrollment problem among exiting inmates, jails in expansion states can adopt outreach and assistance strategies to facilitate connections to Medicaid coverage prior to release. 10 While informing exiting inmates about coverage options and SUD treatment services they are entitled to, local jails can advance these policies by coordinating access to SUD care, including medication treatment with methadone and buprenorphine. 11 Non-expansion states, on the other hand, may have to provide temporary solutions to enable exiting inmates to receive care, given the large scale of the problems we have discussed. Vehicles to implement these solutions include vouchers that can be given to exiting inmates which can be used to receive SUD treatment, or simply providing universal telemedicine for SUD treatments to the entire population.

The political feasibility of these options may be debatable. However, we note that states have been invited to apply for (and many have been provided) additional funds to supplement their SUD treatment budgets, which they may use to meet the increased demand for telemedicine that these policies may generate (see, e.g., the emergency grants on SUD treatment during COVID-19 by SAMSHA, 2020b). Thus, it is important for governments to consider the potential benefits associated with various policies when seeking to secure and allocate funds. We note that universal telemedicine for SUD treatments naturally go beyond mitigating problems for former and potential inmates, since it can reduce access problems among the general population as well. 12

Telemedicine has the potential to mitigate barriers to SUD care, and we already see evidence of states expanding coverage for these services during the pandemic, as we discuss next.

Although telemedicine programs were widely available in more than 50 U.S. health systems prior to the pandemic, it was neither widely adopted nor implemented (Hollander and these policies were to be implemented. Although it is difficult to find conclusive evidence to answer this question, available interviews with physicians, especially residents in emergency departments, suggest that the capacity is available and that access is the primary problem (see, e.g., the interview by NIDA, 2020). 10 Using data from the 50-State Medicaid Budget Survey of Kaiser Family Foundation, we calculate that about 22% of the expansion states do not provide enrollment assistance to inmates prior to release. Outreach and assistance data were obtained from the following source: https://bit.ly/3dujqaz.

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