"Yeah, this is not going to work for me"-The impact of federal policy restrictions on methadone continuation upon release from jail or prison

Introduction: Individuals impacted by the criminal-legal system face increased risk of opioid overdose. Medications for opioid use disorder (MOUD) provide a life-saving intervention. Multiple barriers prevent access to MOUD, including federal policies regulating opioid treatment programs (OTPs). This study aims to identify how federal policy affects anticipated barriers to methadone treatment access at a high-risk time for opioid mortality: community re-entry after incarceration.

Methods: The study used standard qualitative methods to conduct 40 in-depth-interviews with incarcerated individuals enrolled in the Rhode Island Department of Corrections MOUD treatment program. Semi-structured interviews took place between June and August 2018 and focused on participants' experiences with MOUD and anticipated treatment barriers upon re-entry. A deductive coding framework incorporating the SAMHSA "8-point" criteria for take-home methadone as the a priori codebook and additional identified barriers informed further inductive analysis.

Results: Four themes emerged: (1) logistical hurdles such as transportation and clinic location impeded clinic access; (2) punitive measures within clinics, like dose reduction for rule infractions, discouraged treatment continuation; (3) the environment of methadone clinics often tempted return to use; (4) while the structured nature of methadone treatment provided accountability, it also posed challenges. Federal policies, particularly around daily dosing and "take-home" regulations, exacerbated barriers for those re-entering the community. State and clinic level policies, however, were also identified as direct or exacerbating barriers to treatment access.

Conclusion: Significant hurdles persist for methadone access among individuals released from incarceration. Though the federal 8-point criteria have now been replaced with more flexible take-home policies, our findings highlight critical treatment barriers for individuals during the high-risk period of community re-entry. State and clinic level policies also exacerbate many of the barrier-driven themes identified in this analysis. Future work can explore how to best implement the identified benefits of a structured program without forcing the punitive measures that discourage treatment retention. Additional policy reform can help mitigate the effects of other social determinants of health (including transportation access). Ultimately, the many barriers to community methadone treatment retention also apply to individuals involved in the criminal legal system; they can be exacerbated at the federal, state, and clinic policy level.