Estimated reading time: 11 minutes

Introduction: When the Opioid Crisis Meets the Justice System

The opioid epidemic in the United States hits especially hard inside jails and prisons, a critical aspect of the criminal justice system. People with opioid use disorder (OUD) are vastly overrepresented in custody. Many arrive on stable Medication-Assisted Treatment (MAT) in the community only to have that treatment abruptly discontinued once they enter a facility, highlighting the inclusion criteria that could facilitate continuity of care.

This ‘forced withdrawal’ is not a neutral policy choice. It inflicts intense suffering, destabilizes medical and mental health conditions, and sets people up for subsequent aversion to overdose and death in the critical days and weeks after release, especially considering the prevalence of opioid use in this population.

For sheriffs, jail medical directors, prison wardens, and county leaders, the stakes are high. The choice is not between “tough” vs “soft” on crime, it’s between evidence-based medicine, like that found on Google Scholar, and policies that are medically risky, legally vulnerable, and harmful to public safety.

DevotedDOc’s physician-led MAT telehealth model is designed to help facilities move away from forced withdrawal and toward safe, compliant, and scalable treatment options that continue from intake through re-entry.

What MAT Is – and Why It Matters Behind the Fence

MAT as Evidence-Based Medical Care

Medication-Assisted Treatment is not “substituting one drug for another.” It is an evidence-based approach that combines:

• FDA-approved medications
• Counseling and behavioral support in community substance abuse treatment to treat opioid use disorder as a chronic medical condition much like insulin is used to manage diabetes.

to treat opioid use disorder as a chronic medical condition much like insulin is used to manage diabetes.

Common medications used in opioid-focused MAT include:

• Methadone – A full opioid agonist that reduces withdrawal and cravings, dispensed through specialized programs.
• Buprenorphine (Suboxone and similar) – A partial agonist that eases withdrawal with a lower overdose risk and can be prescribed in office or via telehealth by qualified clinicians, as highlighted in several cohort studies.
• Naltrexone (oral or extended-release injection) – An opioid antagonist that blocks opioid effects and is non-addictive.

These medications stabilize brain chemistry, reduce cravings, and allow patients to focus on recovery, mental health, and long-term planning. In the community, MAT is considered the standard of care for moderate to severe OUD.

Why Continuity of MAT in Custody Matters

When someone stabilized on MAT is incarcerated, their treatment needs do not stop at the jail door. Disrupting MAT:

• Reverses medical gains made in the community
• Triggers painful and sometimes medically dangerous withdrawal
• Increases the chance of illicit drug use inside the facility and may also contribute to HIV risk behaviors.
• Heightens overdose risk after release, when tolerance is reduced

Continuing MAT during incarceration is a medical best practice and a critical harm-reduction strategy. From a correctional standpoint, it also supports calmer housing units, better engagement in programming, and safer re-entry.

DevotedDOc’s telehealth MAT model helps jails and prisons maintain continuity of care with licensed physicians and addiction specialists, without requiring full in-house specialty staffing.

What Forced MAT Withdrawal Looks Like in Practice

How MAT Is Stopped in Many Facilities

In many jurisdictions, outdated beliefs and administrative convenience still drive how facilities manage MAT in custody, rather than clinical standards. Common patterns include:

• Immediate cessation (“cold turkey”) – Medication is abruptly stopped on intake, with only symptomatic comfort care, if any.
• Rapid taper – In many jurisdictions, outdated beliefs and administrative convenience still drive how facilities manage MAT in custody, rather than clinical standards

Policies are often blanket in nature: “We do not provide methadone or buprenorphine,” regardless of prior prescriptions, diagnoses, or risk factors.

The drivers of these policies usually include:

• Philosophical objections to MAT (“real recovery must be drug-free”)
• Stigma that sees MAT as “just another addiction”
• Concerns about diversion inside the facility
• Limited staffing and infrastructure to run a MAT program

As a result, facilities abruptly cut people off from evidence-based treatment and force them into withdrawal in a high-stress, high-risk environment.

Health Consequences of Forced Withdrawal

Severe Physical Distress

Forced withdrawal from methadone or buprenorphine can be more intense than opioid withdrawal from short-acting opioids like heroin. Common symptoms include:

• Nausea, vomiting, and diarrhea
• Severe muscle and bone pain
• Tremors, chills, sweating
• Insomnia and extreme restlessness

Increased risk of in-custody medical emergencies requiring urgent medical treatment

• Dehydration and electrolyte imbalance
• Exacerbation of underlying conditions (cardiovascular disease, hypertension, pregnancy-related complications, etc.)
• Increased risk of in-custody medical emergencies

These are not abstract possibilities; they are predictable outcomes when long-term opioid medication is abruptly stopped.

Psychological Trauma and Long-Term Impact

The psychological toll of forced withdrawal among drug users is profound:

• Extreme anxiety and agitation
• Depressive symptoms, including hopelessness
• Sleep disruption and emotional instability
• Loss of trust in the medical system

Many individuals who endure forced withdrawal in jail later become wary of returning to MAT even though it could be life-saving because they associate the medication with a traumatic experience in custody.

That aversion can follow them for years and becomes one more barrier to sustained recovery.

Overdose Risk After Release

Perhaps the most serious consequence is the dramatic spike in overdose risk immediately after release, particularly for individuals with a history of injection heroin use, highlighting how this situation contributes to a public health crisis. During incarceration:

• The person’s opioid tolerance drops sharply.

If they return to opioid use in the community and take the same dose they used before incarceration, their body may no longer tolerate it, leading to:

• Fatal overdose, often within the first days or weeks after release.

Studies have found the risk of overdose death shortly after release to be many times higher than in the general population. Forced withdrawal, by lowering tolerance without providing a treatment bridge, directly fuels this risk.

Continuous MAT supported by transitional planning and community linkage reduces this post-release danger. This is where telehealth partners like DevotedDOc can provide structured continuity and rapid follow-up in the community.

Ethics and Law: Why Forced Withdrawal Is Increasingly Indefensible

Patients’ Rights in Custody

In Estelle v. Gamble (1976), the U.S. Supreme Court held that “deliberate indifference to serious medical needs of prisoners” violates the Eighth Amendment’s ban on cruel and unusual punishment.

Opioid use disorder is widely recognized as a serious medical condition. When facilities knowingly withhold a medically accepted, life-saving treatment like MAT, they are increasingly vulnerable to claims of deliberate indifference.

Medical Ethics

Core medical ethics principles require clinicians to:

• Do no harm
• Provide care in the patient’s best interest
• Use evidence-based treatment

Denying MAT while acknowledging that OUD is a chronic brain disease conflicts directly with these principles. Systems treat addiction, including injection drug use, differently from other chronic conditions; no one would accept abruptly discontinuing insulin for diabetes or antihypertensives for severe hypertension simply because a patient entered custody.

Providers working with or within correctional systems often experience “dual loyalty” torn between institutional priorities and patient care. Partnering with external telehealth practices like DevotedDOc can help align treatment plans with both ethical standards and operational realities.

ADA and Civil Rights

The Americans with Disabilities Act (ADA) recognizes opioid use disorder as a disability when it substantially limits major life activities. Under the ADA:

• Jails and prisons (as state and local government entities) must provide reasonable accommodations and cannot discriminate based on disability.

Blanket policies that deny access to MAT for individuals with OUD regardless of medical need have been successfully challenged as discriminatory. Federal courts and the Department of Justice have increasingly supported the position that:

• Denying prescribed MAT can violate both the ADA and the Eighth Amendment.

Facilities that proactively modernize their MAT policies not only improve health outcomes but also reduce legal exposure and potential litigation costs.

What the Research Shows: Continuing MAT vs. Forced Withdrawal

Across multiple studies, the pattern is consistent: continuing MAT during incarceration produces far better outcomes than forced withdrawal, particularly in reducing opiate use, as demonstrated in a randomized trial.

Typical findings include:

Outcome	MAT Continued in Custody	MAT Forced Withdrawal
Recidivism and re-arrest in the context of a randomized clinical trial	Much higher	Much lower
Relapse to illicit opioid use	Significantly lower	Significantly higher
Overdose risk after release	Reduced	Dramatically increased

One often-cited line of research shows that individuals who remain on methadone or buprenorphine treatment while incarcerated are far more likely to reconnect with community programs after release and far less likely to die of overdose, according to the Bureau of Justice Statistics.

From a systems perspective, MAT continuation is not just clinically superior it is also a public safety strategy that reduces recidivism and supports safer communities.

Barriers to MAT in Correctional Systems

If the evidence is so strong, why does forced withdrawal still happen?

Institutional and Operational Challenges

Common barriers include:

• Complex internal policies and security protocols
• Concerns about diversion of medications
• Limited clinic space and storage infrastructure
• Staffing shortages among qualified prescribers and nurses
• Budget constraints and uncertainty about reimbursement

These are real challenges but they are solvable, especially with external support in correctional institutions. Telehealth partners like DevotedDOc can:

• Provide MAT-credentialed physicians and advanced practice clinicians
• Support protocols for safe medication management and documentation
• Coordinate with local pharmacies or 340B partners
• Help design workflows that align custody and clinical needs

Stigma and Misconceptions

Perhaps the most powerful barrier is attitudinal:

• Belief that MAT is “not real recovery” and misconceptions about methadone initiation.
• Fear that MAT will “re-addict” people after withdrawal
• Misunderstanding of OUD as a moral failing instead of a chronic disease

These views influence policy and daily decisions. Addressing them requires ongoing training and culture change for custody staff, clinicians, and leadership.

DevotedDOc can support facilities with education around MAT, current guidelines, and real-world outcomes, helping teams move from skepticism to informed buy-in.

Models of Best Practice – and How Telehealth Fits In

Several systems have already demonstrated that robust, facility-wide MAT is possible:

• Rhode Island Department of Corrections offers all three FDA-approved medications in its facilities and has seen a dramatic drop in post-release overdose deaths.
• Rikers Island (NYC) has operated a large methadone maintenance treatment programs for decades, showing long-term feasibility in a complex urban jail system.

Key features of best-practice models include:

• Screening for OUD at intake
• Continued MAT for those already on it in the community
• Initiation of MAT for newly identified patients
• Integration of counseling and behavioral support
• Strong transitional/re-entry planning and linkage to community providers

Where DevotedDOc Can Help

DevotedDOc’s physician-led MAT telehealth model is designed to plug into these best practices and make them scalable for jails, prisons, and community partners across the U.S.:

• Continuity of Care – Maintain or initiate buprenorphine and other MAT options via secure telehealth, even in rural or under-resourced facilities, enhancing treatment engagement for individuals in these systems.
• Standardized Protocols – Help develop evidence-based policies that align with current medical standards, the ADA, and Eighth Amendment obligations.
• Re-Entry and Warm Handoff – Schedule telehealth follow-ups, coordinate prescriptions, and link individuals with community MAT services before release.
• Education and Training – Support custody and clinical staff with ongoing training on addiction medicine, MAT safety, and workflow integration.

Instead of forced withdrawal, facilities can adopt a patient-centered model that improves health outcomes, reduces risk, and supports legal compliance.

Recommendations for a Patient-Centered, DevotedDOc-Aligned Approach

For sheriffs, wardens, medical directors, and county leaders considering their next steps, a modern MAT strategy should include:

1. Methadone (through appropriate partnerships), buprenorphine, and naltrexone, so treatment can be tailored to each patient, addressing any significant differences in patient needs.
   • Replace them with clinically guided decisions based on individual assessment and evidence-based guidelines.
2. Offer All FDA-Approved MAT Options Where Feasible
   • Methadone (through appropriate partnerships), buprenorphine, and naltrexone, so treatment can be tailored to each patient.
3. Leverage Telehealth to Fill Gaps
   • Use partners like DevotedDOc to provide physicians, nurse practitioners, and addiction specialists virtually, reducing the burden on in-house staff.
4. Build Strong Transitional Care
   • Forced withdrawal of MAT in prisons and jails is not just uncomfortable; it is dangerous, ethically troubling, and increasingly legally risky for the prison population at the time of incarceration. It leads to severe withdrawal, long-term trauma, disrupted care, and a sharply elevated risk of overdose after release.
5. Invest in Training and Culture Change
   • Provide education for custody and clinical staff to reduce stigma, improve understanding of OUD, and align the team around shared goals.

Conclusion

Forced withdrawal of MAT in prisons and jails is not just uncomfortable, it is dangerous, ethically troubling, and increasingly legally risky for the prison population. It leads to severe withdrawal, long-term trauma, disrupted care, and a sharply elevated risk of overdose after release.

The evidence is clear: continuing MAT during incarceration, supported by robust transitional care and addiction treatment, saves lives, reduces recidivism, and strengthens public safety.

At DevotedDOc, we believe that people do not lose their right to evidence-based medical care when they cross a gate line. Our physician-led telehealth MAT services are designed to help jails, prisons, and community partners:

• Replace forced withdrawal with safe, scalable treatment
• Align with ADA and Eighth Amendment expectations
• Improve outcomes for individuals, families, and communities

If you are a sheriff, jail administrator, prison leader, or healthcare partner looking to modernize your MAT policies, DevotedDOc can help. Reach out today to explore how our telehealth MAT program can support your facility with clinical expertise, operational guidance, and a patient-centered, legally informed approach to addiction care.

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