MOUD Resources
Opioid Use Disorder (OUD) is a Chronic Brain Disorder
Opioid use disorder (OUD) is a chronic disorder with potentially deadly consequences. Symptoms may include uncontrollable cravings for and compulsive use of opioids, decreased sensitivity to them, and excruciating withdrawal symptoms.
Opioid use disorder is a progressive brain disease, meaning it often becomes more severe over time. People who regularly use opioids, prescription or otherwise, develop a tolerance to them and need to use increasing amounts to feel the de
sired effect. At high doses, opioids depress the respiratory system, which can cause the individual to stop breathing and can result in death. Without effective treatment, opioid use disorder can lead to serious physical and emotional harm, including overdose death.
Opioid use disorder breaks down the body’s dopamine system. Dopamine is a chemical that plays a key role in feeling pleasure, movement, memory, and other body functions, and is necessary for the brain to feel a sense of normalcy and perform cognitive functions required for survival. People who have dopamine level changes due to opioid use disorder have difficulty enjoying life activities and feeling normal, and often experience feelings of depression, anxiety, and irritability.
People with opioid use disorder cannot simply “will” or “reason” their way out of continued opioid use, even when they are aware of the dire consequences. Because the disorder negatively impacts the brain’s reward system, the disease makes it difficult for individuals to stop taking opioids even when they experience negative consequences and have stopped feeling the drug’s pleasurable effects due to increased tolerance. Continued use does not indicate a person lacks willpower, but rather is the predictable outcome of chemical changes in the brain. Opioid use disorder has proven especially resistant to non-medication-based treatment methods, such as abstinence-only and twelve-step programs, which have been popular in treating other addictions such as alcoholism.
The 3 stages of opioid use disorder
People who struggle with opioid use disorder are frequently stuck in a three-stage cycle. The first is the binge/intoxication stage (using opioids). The second is the withdrawal/negative stage (suffering the negative physical results of coming down from a high or intoxication). The third is the preoccupation/anticipation stage (seeking or wanting to seek substances to use). Each stage in this cycle is associated with changes in neurobiological mechanisms.
The first stage, binge/intoxication, involves changes in the mesolimbic dopamine system, the brain’s reward system. This stage initially includes enhanced dopamine activity, which results in feelings of pleasure. With chronic substance use, however, people experience neurobiological changes including downregulation of dopamine receptors, meaning it takes progressively higher doses of a substance to get the same effect. If there is excess dopamine activation on a regular basis, the brain responds by reducing the number of dopamine receptors that can be activated. Once the excess dopamine activation is not there, there is an overall deficit in the ability of dopamine to create pleasure.
The second stage, withdrawal and negative affect, results in a decreased ability to cope with stress and negative affective or emotional states in the absence of opioid use. During this stage, patients also experience decreases in dopamine activity and receptors. These neurobiological changes cause people to feel anxiety, stress, depression, and discomfort when they are not maintaining the same or increasing amounts of opioids.
The third stage, preoccupation and anticipation, involves changes in the prefrontal cortex. This is the area of the brain that helps in decision making, executive function, planning, self-control, and recognizing the importance of one reward (e.g., safety and shelter) over another (e.g., feeling a “high” from substance use).
These neurobiological changes cannot be overcome with “willpower,” making it very difficult, and impossible for many patients to break this cycle without medication. For more information about the three cycles of addiction and the brain changes that result, Society are helpful.
Medications for Opioid Use Disorder (MOUD)
The Food and Drug Administration has approved three medications for treating opioid use disorder, also referred to as “MOUD”: methadone, buprenorphine, and naltrexone. The brand names for these medications include DISKETS, Dolophine, Methadose, Buprenex, Butrans, Sublocade, Suboxone, Subutex, Depade, Revia, and Vivitrol.
These medications are not the same and cannot be used interchangeably for every patient. This is important when addressing barriers to MOUD. For example, some jails and prisons will offer only one form of MOUD—usually naltrexone—which may be ineffective for an individual’s medical needs. Treatment decisions should only be made after an evaluation with an individual and their doctor.
Incarcerated people face a dramatically elevated risk of relapse, overdose, and death, especially in the weeks immediately following release, because their opioid tolerances drop while in jail and prison. MOUD treatment is thus necessary to address the serious risk of harm that patients with opioid use disorder face, both inside jails and prisons and after their release.
The American Medical Association is clear that MOUD is the “standard of care for patients in jail and prison settings” and supports the removal of “administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication assisted treatment (MAT) for opioid use disorder.”
How Medications for Opioid Use Disorder Work
Methadone and buprenorphine are “agonists,” which mean they activate opioid receptors in the brain to relieve withdrawal symptoms and control opioid cravings. Methadone is a “full agonist,” meaning that it fully activates opioid receptors (resulting in a stronger therapeutic effect). Buprenorphine is a “partial agonist,” meaning that it partially activates opioid receptors (resulting in a lesser but still effective therapeutic effect).
Because methadone and buprenorphine bind to the opioid receptors they stimulate, they block the receptors from being activated by more powerful opiate agonists. This means that patients cannot get “high” from illicit drugs like heroin and fentanyl while on proper doses of these medications. This in turn trains a brain negatively impacted by opioid addiction to gradually decrease its response and interest in opioids.
Naltrexone is an “antagonist,” meaning it blocks opioid receptors without activating them. This prevents the euphoric effect of opioids, thereby reducing desire for them over time. Unlike buprenorphine and methadone, naltrexone does not relieve withdrawal symptoms. In fact, it can trigger acute and severe withdrawal and an elevated risk of relapse.
Treatment with MOUD is necessarily individualized. A patient may do well on any form of MOUD or find that only one provides effective treatment without causing significant adverse side effects. An MOUD that effectively treats one person may be completely ineffective for another.
There is no maximum recommended duration for MOUD treatment. As the Substance Abuse and Mental Health Services Administration (“SAMHSA”) has recognized, treatment for opioid use disorder— like treatment for other chronic diseases such as insulin for diabetes — is often lengthy and can last for years or even a lifetime. Opioid use disorder is a relapsing disease, which means relapses are common during recovery. Relapses should not be a reason to discontinue access to MOUD.
The longer a patient stays in treatment, the less likely they are to relapse. Studies show that naltrexone treatment produces substantially poorer treatment retention than methadone and buprenorphine. Methadone and buprenorphine, in contrast, produce longer-term treatment retention, which is the key for recovery.
MOUD do not substitute one drug for another. As SAMHSA makes clear, MOUD are “evidence-based treatment options” that “relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body.” For more information about MOUD treatment, this fact sheet by the Pew Charitable Trusts is helpful.
The American Medical Association, the American Society of Addiction Medicine, the U.S. Department of Health and Human Services, the FDA, the National Institute on Drug Abuse, the White House Office of National Drug Control Policy, SAMHSA, and the World Health Organization uniformly endorse the critical role of MOUD, specifically methadone and buprenorphine, in addressing opioid addiction.
Providing Medications for Opioid Use Disorder in Jails and Prisons Saves Lives and Protects Communities
Incarcerated people face a dramatically elevated risk of relapse, overdose, and death, especially in the weeks immediately following release because their opioid tolerances decreased while in jail and prison. One study found that incarcerated people are up to 129 times more likely to die from an overdose in the first two weeks after release compared to the general population.
Numerous studies show that providing MOUD in correctional facilities reduces opioid use, overdose deaths, criminal activity, recidivism, and infectious disease transmissions, and increases the likelihood of continued addiction treatment. Because providing MOUD reduces drug use and criminal activity, studies show it saves taxpayers from paying jail costs.
In Rhode Island’s unified jail and prison system, all people with opioid use disorder are provided access to MOUD. One study showed that (1) 95% of the individuals in the Rhode Island MOUD program continued drug treatment after release, (2) post-release deaths for participants declined by 60%, and (3) all opioid-related deaths in the state fell by over 12% in just the first year of operation. Another large study of a different MOUD program documented an 85% decrease in overdose deaths and a 75% reduction in all-cause mortality in the first four weeks after release for people who were maintained on MOUD while incarcerated.
Ensuring MOUD access in jails and prisons not only saves lives following release but also during incarceration. One study showed that the risk of unnatural death, including from overdose, suicide, and other preventable causes was about 87% lower for incarcerated people on MOUD compared to those whose opioid use disorder needs were ignored. The same study found that incarcerated people receiving methadone or buprenorphine were 94% less likely to die during their first four weeks of incarceration than those not receiving this treatment.
Providing MOUD in jails and prisons also reduces criminal recidivism rates. One recent study compared two Massachusetts jails: one that provided buprenorphine and another that did not. The study concluded that “among incarcerated adults with opioid use disorder, risk of recidivism after jail exit is lower among those who were offered buprenorphine during incarceration.” Accordingly, the National Sheriffs’ Association called for robust MOUD access in the criminal justice system, particularly in jails and prisons, saying this medical treatment “reduces relapses and recidivism.”
Stigma Against People with Opioid Use Disorder Prevents Access to Treatment and Recovery
Despite the broad consensus among medical experts and law enforcement organizations that MOUD are an essential medical treatment that saves lives, improves drug treatment results, and lowers criminal recidivism rates, entrenched stigma towards opioid use disorder generally and MOUD specifically continues to obstruct access to these life-saving medications.
Stigma against MOUD is grounded in deeply rooted misconceptions that opioid use disorder is a choice and a moral failing, rather than a medical condition that alters the brain’s dopamine levels. Research confirms that this stigma against people with opioid use disorder is a formidable barrier to patients accessing necessary MOUD treatment. Many people inaccurately regard MOUD as substituting one drug for another, conflating the professional administration of an essential medicine with the use of illicit drugs. This stigma limits access to this life-saving medication.
Legal Protections Related to Opioid Use Disorder
There are multiple legal protections for people who have substance use disorders. For instance, the Americans with Disabilities Act and Rehabilitation Act prohibits discrimination against people with substance use disorders on account of their disability.
When a lawsuit is brought on behalf of an incarcerated person, it is vital that the person first completes the grievance procedure at their correctional facility, including putting in sick calls and filing grievances. If you have a loved one who is incarcerated and is considering legal action, please advise them to create copies of their grievances and responses and to send you copies of them to preserve their legal rights.
If you wish to discuss your legal options because you or a loved one has been denied access to MOUD or suffered discrimination based on opioid use disorder, please contact us using the form on this page. The MOUD attorneys at Kaplan & Grady are ready to protect your civil rights.
Prison Litigation Reform Act:
Exhaustion of Administrative Remedies Requirement
It is important to note that before any legal action can be taken on behalf of incarcerated people, they must first abide by the Prison Litigation Reform Act (PLRA). The PLRA has requirements regarding the exhaustion of administrative remedies, limits on the types of injuries that are actionable, and limits on attorneys’ fees. The PLRA prevents any lawsuit brought by a prisoner who has not yet fulfilled “such administrative remedies as are available[.]” The Supreme Court has held that if a detention facility’s grievance process is available, the prisoner must complete the process before legal action can be taken. If a prisoner fails to follow the rules governing the grievance process (including deadlines), he has procedurally defaulted, barring any federal claims in federal court forever. It is imperative that incarcerated people complete all levels of their institution’s grievance process when an issue arises, for example, if they are denied medication, before legal action can be engaged.
If you have a loved one who is incarcerated, it is vital that they complete the grievance system at their institution, including by requesting sick calls and filing required medical grievances. Please advise them to create copies of their grievances and responses, and to send you copies of each so they can preserve their legal rights.
Contact us if you or a loved one has been denied access to treatment for OUD. Kaplan & Grady is ready to protect your civil rights.
