A new study reported in Health Affairs revealed that only 4.6% of people referred to opioid treatment programs by U.S. courts received methadone or buprenorphine, compared with almost 41% of patients outside the criminal justice system.

A wide evidence base documents the effectiveness of medication treatment among justice-involved individuals in decreasing risk for overdose, reducing HIV and hepatitis C transmission, and improving criminal justice outcomes.

“Indeed, there is a vast amount of evidence documenting the effectiveness of ongoing medication treatment over non-medication-based treatment on a range of outcomes, including better retention in care, reduced illicit opioid use, reduced overdose, reduced criminal justice involvement and overall better functioning.

For the study, researchers examined 2014 data from drug treatment programs in all 50 states, the District of Columbia, and Puerto Rico. They focused only on adults in rehab for overuse of opioids, including heroin as well as nonprescription methadone.

Out of about 72,000 patients receiving opioid treatment, 24% had been referred to the criminal justice system, the study found. When the courts ordered treatment, patients’ odds of getting medication were more than 90% lower than for people outside the criminal justice system.

The analysis only included clients receiving treatment for the first time, and it’s possible the odds of medication use might be different for people who are repeating rehab patients. The study did not include data on buprenorphine prescribed by primary care providers outside a rehab setting.

The researchers lacked data on patients’ health insurance status, which might have influenced the treatment options available to them. Even so, the findings add to evidence that people in the criminal justice system receive substandard opioid addiction treatment.

While approaches like peer counselling and psychotherapy may help patients recover from addiction, they are often not enough. Despite the advantages of psychotherapy such as strengthening insight, resolve, and coping, they may not be able to prevent drug craving and subsequent drug use.

Patients who receive psychosocial treatment have higher relapse rates and are more likely to leave treatment than patients receiving agonist therapy. Including buprenorphine and methadone in treatment has been shown to increase the odds that patients stick with treatment and to reduce the odds that they will return to opioids in the future or die from an overdose.

The most concerning the finding of the study is that the source of referral for treatment is such an overwhelmingly strong predictor of what treatment is received. The choice of treatment should be up to the patient and their treatment providers, not criminal justice system practitioners or judges who have no medical training to support their influence on treatment, the researchers said.