Transitions Clinic Network Programs
Improving Access to and Engagement into Care upon Release from Incarceration
Overdose, SAMHSA indicates, is the “leading cause of death among formerly incarcerated individuals.”1 A study in Washington State found that people’s mortality rate in the two weeks after release from incarceration was 12.7 times higher than the rate for other people in the state. Their rate of overdose was 129 times higher than other residents’.2
Access to medications for opioid use disorder (MOUD) during incarceration lowers the risk of opioid mortality after release.3 When Rhode Island’s Department of Corrections implemented an MOUD program, overdose deaths after incarceration declined by 60.5 percent.4 MOUD in jail or prison and upon release is a CDC-recommended evidence-based strategy to prevent opioid overdose.
Given the dangers of withdrawal and return to use, it is important that patients continue their MOUD upon release and that a “warm handoff” to treatment is provided.5 Since not all prisons and jails offer MOUD,6 some people with OUD will have experienced withdrawal during incarceration. A handoff that ensures access to MOUD, along with linkage to transitional housing and other supports, is important for these patients as well. They will have a lowered tolerance that puts them at greater risk for overdose. To save lives at a time of heightened risk, the CDC also recommends naloxone distribution programs for people leaving criminal justice settings.7
With social isolation and other hardships during the COVID-19 pandemic leading to more overdose deaths,8 these measures are all the more critical.
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Challenges in rural communities
The jail population in rural areas has increased 27% since 2013, while decreasing 18% in urban areas.9 One reason for the increase—which occurred even though crime rates declined—is that rural counties tend to have limited resources to build alternatives to jail for people who have mental health or substance use disorders. Another is that rural county jails confine a growing number of individuals for other authorities, such as state prison systems.10
People transitioning from incarceration face many challenges—particularly in housing, employment, and health care. In rural counties with struggling economies and limited resources for mental health, substance use, and other needs, these challenges can be even greater.11 Individuals with OUD in rural areas face a shortage of MOUD providers. Distance and transportation are common challenges. So is a lack of anonymity that can make it hard to seek treatment in a small community.12 People with a history of incarceration carry an additional burden of stigma beyond OUD-related bias, which can negatively impact their health care.13
Support through—and for—primary care
People with OUD who were recently released from incarceration need support in accessing treatment. Simultaneously, rural providers who serve them post-release need support in providing care for this population.
Implementing a Transitions Clinic Network (TCN) program in a primary care practice—preferably in a Federally Qualified Health Center (FQHC), which provides funding for behavioral health and navigation assistance—is a way to address the health risks and other challenges of reentry in rural communities. A TCN program provides recently released patients with care for chronic health conditions including OUD. It distributes naloxone and plays an important role in life-saving MOUD treatment. TCN programs can provide the spectrum of needed MOUD treatment—from induction, to maintenance, to referrals to higher levels of care—but specific TCN programs vary in where they land on this spectrum. For instance, some programs focus on prescribing maintenance MOUD after patients have completed the induction phase through an inpatient or outpatient treatment program, while other programs induce patients themselves and provide counseling for MOUD on site. Following this stabilization period after release from incarceration, patients remain in the TCN program or the broader primary care practice and continue to have MOUD prescribed in primary care.
Through culturally informed and trauma-informed care, a TCN program also seeks to reduce the stigma patients face. A community health worker (CHW) embedded in the practice, who has a history of incarceration, connects with individuals before release and coordinates their care. CHWs builds relationships with SUD treatment programs, transitional housing, and other resources to support warm handoffs upon release. They work closely with patients to navigate services in the community, including in the areas of employment, insurance, and parental rights. Adding a CHW to manage this work at the clinic can make the job of the primary care provider much easier.
For a practice interested in becoming a TCN program, comprehensive implementation assistance and ongoing support are available through the network. TCN works with clinics across the U.S. to adapt the TCN framework to the particular needs of the community. Studies have found that this model can reduce emergency department visits, preventable hospitalizations, and reincarceration for parole or probation technical violations.14 They support the autonomy and health literacy of patients and lead to successful receipt of primary care, SUD, and mental health treatment.15
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Part 3: Live Q&A
Live Q&A Recording
Diane Morse, M.D., Associate Professor of Psychiatry and Medicine; Director of Women’s Initiative Supporting Health–Transitions Clinic (WISH-TC); University of Rochester Medical Center; UR Medicine Recovery Center of Excellence
Shira Shavit, M.D., Clinical Professor of Family and Community Medicine at the University of California in San Francisco; Executive Director, Transitions Clinic Network
Anna Steiner, M.P.H., M.S.W., Program Manager, Transitions Clinic Network
Evan Ashkin, M.D., Professor of Family Medicine, University of North Carolina School of Medicine; Founder of Formerly Incarcerated Transition (FIT) Program
 Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Use of medication-assisted treatment for opioid use disorder in criminal justice settings. National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, p. 3.
 Binswanger, I.A., Stern, M.F., Deyo, R.A., Heagerty, P.J., Cheadle, A., Elmore, J.G., & Koepsell, T.D. (2007). Release from prison—a high risk of death for former inmates. New England Journal of Medicine, 356(2), 157-165.
 Green, T.C., Clarke, J., Brinkley-Rubinstein, L., Marshall, B.D.L., Alexander-Scott, N., Boss, R., & Rich, J.D. (2018). Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry, 75(4), 405-407; Marsden, J., Stillwell, G., Jones, H., Cooper, A., Eastwood, B., Farrell, M., Lowden, T., Maddalena, N., Metcalfe, C., Shaw, J., & Hickman, M. (2017). Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Addiction, 112(8), 1408-1418.
 Centers for Disease Control and Prevention (CDC). (2018). Evidence-based strategies for preventing opioid overdose: What’s working in the United States. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, p. 22. SAMHSA (2019) features the Kentucky Department of Corrections’ approach to providing MOUD and linking to services upon release, including referrals to Recovery Kentucky for ongoing treatment, p. 42.
 When MOUD is provided during incarceration, patients typically do not have access to any of the three FDA-approved medications (methadone, buprenorphine, and naltrexone). Blanco, C., Ali, M.M., Beswick, A., Drexler, K., Hoffman, C., Jones, C.M., Wiley, T.R.A., & Coukell, A. (2020). The American opioid epidemic in special populations: Five examples. NAM Perspectives. Discussion Paper, National Academy of Medicine, pp. 2-3.
 McFarling, U.L. (2021, February 16). As the pandemic ushered in isolation and financial hardship, overdose deaths reached new heights. Stat.
 Kang-Brown, J., Hinds, O., Schattner-Elmaleh, E., & Wallace-Lee, J. (2019, December). People in jail in 2019. Vera Institute of Justice.
 Kang-Brown, J., & Subramanian, R. (2017). Out of sight: The growth of jails in rural America. Vera Institute of Justice, pp. 16-21. See also Warren, D. (2020, January 21). Geography of incarceration shifts from urban to rural. Nonprofit Quarterly.
 Wodahl, E.J. (2006). The challenges of prisoner reentry from a rural perspective. Western Criminology Review, 7(2), 32-47.
 People who perceive stigma relating to their history of incarceration are more likely to report fair or poor health. Redmond, N., Aminawung, J.A., Morse, D.S., Zaller, N., Shavit, S., & Wang, E.A. (2020). Perceived discrimination based on criminal record in healthcare settings and self-reported health status among formerly incarcerated individuals. Journal of Urban Health, 97(1), 105-111.
 Wang, E.A., Hong, C.S., Shavit, S., Sanders, R., Kessell, E., & Kushel, M.B. (2012). Engaging individuals recently released from prison into primary care: a randomized trial. American Journal of Public Health, 102(9), e22-e29; Wang, E.A., Lin, H.J., Aminawung, J.A., Busch, S.H., Gallagher, C., Maurer, K., Puglisi, L., Shavit, S., & Frisman, L. (2019). Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven. BMJ Open, 9(5), e028097; Shavit, S., Aminawung, J.A., Birnbaum, N., Greenberg, S., Berthold, T., Fishman, A., . . . Wang, E.A. (2017). Transitions clinic network: Challenges and lessons in primary care for people released from prison. Health Affairs, 36(6), 1006-1015.
Thomas, K., Wilson, J.L., Bedell, P., & Morse, D.S. (2019). “They didn't give up on me": A women's transitions clinic from the perspective of re-entering women. Addiction Science & Clinical Practice, 14(1); Morse, D.S., Wilson, J.L., McMahon, J.M., Dozier, A.M., Quiroz, A., & Cerulli, C. (2017). Does a primary health clinic for formerly incarcerated women increase linkage to care? Women's Health Issues, 27(4), 499-508.