Structural and organizational factors shaping access to medication treatment for opioid use disorder in community supervision

Background: Four million individuals in the U.S. criminal-legal system are supervised in the community under probation or parole. Sentences to community supervision often mandate participation in substance use treatment. Yet evidence-based treatment with medication (i.e., methadone, buprenorphine, or naltrexone) is rarely offered to people under community supervision with opioid use disorder (OUD). This qualitative study explores the structural and organizational factors shaping OUD medication treatment use in community supervision. Methods: We conducted in-depth interviews with 31 community supervision professionals. Thematic analysis characterized interview participants’ perceptions of the key factors shaping use of OUD medications in community supervision. Findings: Findings indicate that authorities making decisions about OUD treatment include community supervision agencies, treatment providers, judges and courts, and jails and prisons. Agencies with more rehabilitative cultural orientations are more forgiving of relapse and supportive of OUD medications. Punishment/enforcement orientations align with an emphasis on surveillance and drug testing, which can inhibit medication treatment and interrupt continuity of care. Community supervision agencies generally reported deference to the recommendations of substance use treatment providers regarding the details of treatment, including the use of medication. Given that most treatment providers do not offer OUD medication, community supervision agencies must develop a sophisticated understanding of the various services offered by local treatment providers to tailor referrals accordingly, a responsibility for which they may be inadequately trained. Conclusions: Efforts to improve engagement with medication treatment in U.S. community supervision settings could have a significant impact on reincarceration, morbidity, and mortality among individuals with OUD under supervision.