Reducing Overdose Risks for Individuals Impacted by Incarceration
Individuals who are incarcerated or returning from incarceration have significantly increased rates of substance and opioid use disorders (SUD/OUD), mental illness, and other complex needs compared to the general population. Despite high levels of need for OUD treatment in carceral settings, only an estimated 32 percent of jails offer any form of medication for opioid use disorder (MOUD). Untreated SUD and mental illness — coupled with a lack of insurance and access to community services — increases the risk of recidivism and overdose in the weeks immediately following release. People leaving prison are 129 times more likely to die of an overdose in the two weeks following prison than the general population.
To reduce these risks, states are employing a variety of strategies to strengthen services and supports across the continuum of justice involvement, including pre-release diversion strategies and expanding access to MOUD and other behavioral health services and social supports. Interest in expanding MOUD access in carceral settings and strengthening reentry supports have been bolstered by new federal flexibilities through state Medicaid 1115 demonstrations that allow Medicaid reimbursement for certain services provided to individuals during the 90 days before they are released from incarceration (see text box below). Leveraging flexible opioid settlement funding to align with the expansion of Medicaid-reimbursable reentry services for justice-involved populations — including upfront investments in infrastructure, data, and capacity building — can help lay the groundwork for sustainable financing of these services moving forward.
Opportunities to Leverage Settlement Funding to Expand Access to Services for Justice-Involved Individuals
The unique flexibility of opioid settlement funding provides a vehicle for plugging gaps in state and federal funding to support justice-involved populations, including by financing upfront investments in capacity building, data systems, and other infrastructure needed to effectively expand care in carceral settings and upon release. Expanding access to treatment and related supports for incarcerated populations is highlighted as a core strategy of Exhibit E, which lists allowable opioid remediation uses to be supported by opioid settlement funding.
Initial investments of settlement funds for justice-involved populations have included staffing and planning support for Medicaid 1115 reentry waiver development and implementation; investing in staffing, training, and infrastructure costs related to implementing MOUD services in carceral settings; and strengthening transitions to and capacity for community-based services and navigation support for recently released individuals. Braiding settlement funds with other federal funding sources can help states cover the upfront infrastructure and costs that are needed to align with Medicaid financing and other grant-based programming (e.g., state opioid response investments) to create a sustainable financing approach.
Expanding Reentry Supports through 1115 Waivers
Strengthening reentry planning and ensuring warm handoffs to community services is particularly important for reducing overdose risks for individuals transitioning from incarceration to community settings. Under new Centers for Medicare and Medicaid Services flexibilities, many state Medicaid programs are implementing 1115 demonstration waivers that allow states to provide a set of Medicaid-covered services to individuals during the 90 days before they are released from incarceration. These policies create significant new pathways to expand access to quality evidence-based OUD services for people leaving the justice system. Core pre-release strategies can include delivery of MOUD in carceral settings, a 30-day supply of medication upon release, and case management to support individuals in accessing and navigating community-based services. Under these waivers, states must cover the three services outlined above, with flexibility to offer more. As of July 25, 11 states have approved reentry waivers.
How States are Investing Funding to Expand Supports for Justice-Involved Populations
Below are several examples of state opioid settlement investments to expand access to treatment and reentry services for justice-involved populations. Additional information on each state’s individual opioid settlement spending and processes can be found in NASHP’s State Opioid Settlement Spending Decisions tracker.
Alabama
For the fiscal year ending on September 30, 2024, Alabama’s state legislature made several appropriationsrelated to reentry supports from the Opioid Treatment and Abatement Fund, which houses the state’s share of opioid settlement funding. $1 million was allocated to the Department of Corrections to support implementation or expansion of medication for OUD in state prisons, and $5.49 million was allocated to the Board of Paroles and Pardons. Of the $5.49 million, $1.515 million is to be used for SUD treatment services for women, $2.3 million for recovery and housing services, $175,000 to expand prevention services, and $1.5 million to support implementation of a program that streamlines SUD service navigation.
Delaware
Delaware’s Prescription Opioid Settlement Distribution Commission, tasked with outlining funding recommendations for the state’s allocation of settlement funding, recommended several grantees to receive funding for projects that support justice-involved populations. In the first round of grant recommendations, the commission proposed $100,000 to the Hope Commission for Women’s Reentry Services, which provides community-based services and support to adult females and their families post-release from a neighboring prison. In the second round of grant recommendations, the commission proposed $400,000 to the Delaware Center for Justice to expand its transitional reentry services program and an additional $400,000 to provide financial support directly to individuals in their recovery.
Michigan
The Michigan Department of Health and Human Services (MDHHS), which administers funding from the state share of settlement funds, is currently funding a $1.5 million three-year contract to provide technical assistance for county jails interested in implementing or expanding MOUD. Up to 24 county jails can receive grant funding of up to $25,000 to help cover costs associated with expanding MOUD supports in their facilities, as well as ongoing coaching and technical assistance through a learning collaborative model. These counties are prioritized by need using Michigan’s substance use vulnerability index. Additionally, in fiscal year 2024, MDHHS allocated $2.5 million to implement MOUD in Michigan Department of Corrections facilities and $500,000 to cover the development and drafting of a Medicaid 1115 waiver, which would allow the state to use Medicaid dollars to improve care transitions for individuals who are incarcerated or returning from incarceration.
Nevada
The Fund for a Resilient Nevada (FRN) holds the state’s share of opioid settlement funding, and the Nevada Department of Health and Human Services (DHHS) makes allocations from the fund in alignment with goals and recommendations outlined in the Opioid Needs Assessment and Statewide Plan. One of the goals is to “provide opioid prevention and treatment consistently across the criminal justice and public safety systems.” Under this goal, DHHS funds several projects from the FRN. Projects include funding to support development of a 90-day pre-release waiver for individuals in jails and prisons, which allows Medicaid to cover certain health care services prior to reentry. Additionally, settlement funding supported a survey to determine the baseline capacity of jails to implement deflection initiatives, OUD screening and treatment, and community discharge support services. Following this survey, two counties were selected to pilot a model for implementing medication for OUD and other treatment supports in jails.
Virginia
The Virginia Opioid Abatement Authority (OAA) has spending authority over 55 percent of opioid settlement funding coming to Virginia. Featured in the OAA’s 2023 Annual Report, $1.25 million in settlement funding was allocated to the Virginia Department of Corrections to contract for social workers specializing in OUD to pilot an evaluation of long-acting injectable opioid agonists and to develop substance use education and prevention content for inmates. Some city and county grant recipients in fiscal year 2025 also received funding to support justice-involved populations. Russel County received $1.9 million for a 90-day community residential program for recently released inmates from the state prison system, and a number of cities and counties received funding for implementation or expansion of medication for OUD within local and regional jails.
For More Information: NASHP’s Work to Support States’ Reentry Continuum
Through the State Reentry Learning and Action Network, NASHP, in partnership with The Health and Reentry Project (HARP), hosts bimonthly meetings to provide facilitated peer learning with a focus on policies and strategies to meet the health and social needs of individuals leaving incarceration. The network advances learning health and reentry services, including but not limited to OUD care. This forum allows state officials from across health and human services, behavioral health, corrections, and public safety to exchange information, best practices, and resources to align reentry policies and programs on topics such as:
- Strategies for collaboration among key cross-sector partners and programs
- Opportunities for implementing Medicaid coverage of pre-release services
- Data exchange and systems strategies to advance policies and implement programs
- Key considerations for working with counties and jails
If you or other state official colleagues are interested in joining the network, please submit this interest form.
Acknowledgments
NASHP would like to thank The Health and Reentry Project for its support in developing this piece and the Foundation for Opioid Response Efforts for its continued support in NASHP’s ongoing work to assist state leaders in opioid settlement spending and planning.
