We searched PubMed and Scopus for English-language publications published between January 1, 2015 and March 10, 2026. The core PubMed search string included the following terms:

(“substance use disorder” OR addiction OR opioid OR methamphetamine OR stimulant) AND (prison OR prisons OR jail* OR correction* OR incarcerated OR “community reentry” OR parole OR probation) AND (treatment OR “medication for opioid use disorder” OR MOUD OR methadone OR buprenorphine OR naltrexone OR “extended-release naltrexone” OR psychotherapy OR “cognitive behavioral therapy” OR “motivational interviewing” OR telehealth OR “digital health” OR reentry).

Equivalent search syntax was adapted for Scopus using TITLE-ABS-KEY fields. In addition to database searches, targeted searches of U.S. government and quasi-government sources—including the U.S. Department of Justice (DOJ), Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), Centers for Disease Control and Prevention (CDC), and Centers for Medicare & Medicaid Services (CMS)—were conducted using keyword combinations such as “MOUD jail,” “MOUD prison,” “Medicaid 1115 reentry,” and “correctional telehealth SUD.”

Retrieved records were compiled and screened for eligibility. Duplicate records were removed through automated matching of titles, authors, and publication year, followed by manual verification. Eligibility was assessed through title and abstract screening, with full-text review conducted when necessary. Studies focusing on correctional or reentry populations and addressing epidemiology, mechanisms, screening or diagnosis, treatment, implementation strategies, digital health modalities, or policy were prioritized for inclusion.

Inclusion criteria emphasized research on correctional or reentry populations addressing epidemiologic, neurobiologic, genetic, psychotherapeutic, pharmacologic, or policy aspects of SUD care. Reference lists of key articles were screened to capture implementation and translational studies. Given the heterogeneity of evidence, a narrative synthesis approach was employed to integrate quantitative findings, policy frameworks, and implementation outcomes and to identify cross-cutting biological, behavioral, and systemic themes.

SUDs are vastly overrepresented in correctional populations, with lifetime prevalence exceeding 60% versus ~5% in the general U.S. population ([12]). Serious mental illnesses—major depression, schizophrenia, and bipolar disorder—frequently co-occur ([45]). Formerly incarcerated individuals face sharply elevated mortality during the early post-release period, driven primarily by drug overdose, followed by cardiovascular disease, homicide, and suicide ([8]; [108]). In statewide prison-release cohort studies, overdose mortality risk is highest during the first weeks following release from incarceration, particularly within the first 2 - 4 weeks, highlighting the importance of initiating medications for opioid use disorder prior to release and ensuring rapid linkage to community treatment ([8]; [62]).

Addiction in justice-involved populations reflects complex interactions among genetic predisposition, environmental stressors, and psychological vulnerability. Twin and family studies estimate that genetic factors account for approximately 40% - 70% of the vulnerability to SUDs, depending on the substance involved ([59]; [32]). Addictive disorders arise from dysregulated mesolimbic dopamine and glutamatergic signaling that drive pathological reward learning and compulsive drug seeking ([172]; [180]; [75]). Concurrent prefrontal and frontostriatal impairments weaken executive control and inhibitory regulation, further reinforcing maladaptive drug use patterns ([60]; [86]). Interactions between genetic and early-life stress factors further modify these neural systems, increasing susceptibility to addiction ([40]).

Chronic stress, adverse childhood experiences ([47]; [3]), mood and anxiety disorders ([61]), and socioeconomic disadvantage ([67]) compound vulnerability to substance use in incarcerated populations. Early maltreatment alters stress-response systems and brain development, promoting emotional dysregulation and impulsivity ([3]; [47]). Incarcerated individuals report disproportionately high adversity—nearly fourfold that of community samples ([138]). Trauma exposure during adolescence, often through community violence, disrupts regulation and heightens risk for later substance misuse ([113]). These experiences intersect with stigma and structural disadvantage, limiting coping and recovery resources ([67]). Within carceral settings, untreated psychiatric comorbidities exacerbate SUD severity and impede rehabilitation ([61]). Chronic exposure to stressors, trauma, and dysregulated environments produces lasting disruptions across subjective, cognitive, and neurobiological components of the adaptive stress-response system, increasing craving, relapse risk, and maladaptive coping ([151]).

Justice-involved individuals often exhibit neurobiological vulnerability shaped by chronic stress and trauma. These adverse experiences induce lasting changes in reward-stress circuitry, predisposing to compulsive drug seeking ([87]). During withdrawal, within-system reward deficits and stress activation (Corticotropin releasing factor, dynorphin, norepinephrine) contribute to pathological negative affect ([85]).

Neuroimmune and gut-brain interactions further influence relapse susceptibility ([99]; [51]). Environmental stressors common in carceral contexts—poor nutrition, infection, circadian disruption—exacerbate neuroinflammation and cognitive impairment. Social learning frameworks complement neurobiological evidence by showing that drug use persists through reinforcement and environmental contingencies ([153]).

Effective correctional interventions should therefore address both neurobiological factors and social dynamics.

Genomic studies (Table 1) have identified numerous variants influencing susceptibility, neurobiological signaling, and treatment response in substance use disorders (SUDs) ([32]; [97]; [52]). In addition to inherited genetic variation, transcriptional regulators such as immediate early genes (e.g., CREB1 and FOSB) play a key role in linking drug exposure to downstream changes in neuronal gene expression and synaptic plasticity ([124]). Consistent with these mechanisms, variants in ADH1B and ALDH2 affect alcohol metabolism ([188]; [39]; [53]), while CHRNA5-CHRNA3-CHRNB4 influence nicotine dependence through nicotinic acetylcholine receptor signaling that mediates synaptic transmission ([166]; [32]). Variants in OPRM1 (rs1799971), OPRD1, and GABRA2 confer risk for opioid and polysubstance dependence ([64]; [82]; [189]; [152]; [120]; [41]; [112]; [103]). Variants in KCNJ6, which influence neuronal excitability and neural oscillations, further demonstrate genetic modulation of reward circuitry ([76]). Dopaminergic genes such as DRD2/ANKK1 and SLC6A3 highlight the role of mesolimbic reward pathways in addiction vulnerability ([176]; [169]; [13]; [77]).

Table 1. Genes and substances in substance use disorders.

AUD = Alcohol Use Disorder; OUD = Opioid Use Disorder; CUD = Cannabis Use Disorder; METH = Methamphetamine; MUD = Methamphetamine Use Disorder; MDMA = 3,4-methylenedioxymethamphetamine.; [54]—Human Genes|Gene Database| Gene Search.

Additional pathways implicated in addiction include serotonergic (HTR2A, HTR1B), glutamatergic (GRIN2B), and stress-response genes (FKBP5, CRHR1), which link mood regulation and stress reactivity to addiction risk ([149]; [22]; [93]; [44]; [80]; [7]). Variants in CNR1 and FAAH modulate endocannabinoid signaling pathways involved in stress response and relapse vulnerability ([98]; [91]). Emerging evidence also implicates BDNF Val66Met, FAAH C385A, and SLC18A1/A2 in methamphetamine use disorder, linking neuroplasticity, cognition, and relapse processes ([84]; [27]; [63]). Muscarinic receptor genes (CHRM1, CHRM4, CHRM5) have also shown therapeutic potential in alcohol use disorder and comorbid depression ([174]; [181]; [101]; [177]).

Pharmacogenomic polymorphisms—particularly in CYP2B6 and CYP2D6—influence metabolism and treatment response to several addiction and psychiatric medications ([141]; [92]; [69]; [56]; [55]). Despite growing pharmacogenomic evidence involving these and other genes, genetic testing has not yet been widely implemented in correctional health systems, leaving precision medicine approaches largely unrealized in these settings.

Substance use disorders (SUDs) are chronic, relapsing brain-based conditions characterized by compulsive substance use despite adverse consequences, arising from alterations in neural circuits governing reward, motivation, and self-control ([170]). The DSM-5 defines SUDs using 11 diagnostic criteria encompassing impaired control, risky use, social impairment, and pharmacologic dependence ([2]), while complementary diagnostic classifications are provided by the International Classification of Diseases, 11th Revision (ICD-11) ([183]).

As summarized in Table 2, accurate identification of SUDs in correctional settings is frequently complicated by high rates of psychiatric comorbidity, trauma exposure, and pervasive stigma ([170]; [83]; [18]; [117]; [118]) as well as the overall high prevalence of SUDs in incarcerated populations relative to the general population ([12]; [4]; [187]). Validated screening instruments—including the Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework—have demonstrated effectiveness in improving early detection and facilitating linkage to treatment services ([12]; [4]; [102]; [187]; [159]). However, many screening tools were originally developed for primary care or community settings and may require adaptation for carceral environments where privacy, staffing resources, and clinical infrastructure are limited ([165]; [73]).

Table 2. Challenges and emerging solutions for substance use disorders in U.S. prison populations.

MOUD = Medications for Opioid Use Disorder; NASEM = National Academies of Sciences, Engineering and Medicine; AUDIT = Alcohol Use Disorders Identification Test; DAST = Drug Abuse Screening Test; CBT = Cognitive Behavioral Therapy; DBT = Dialectical Behavior Therapy.

Limited access to evidence-based treatments further exacerbates unmet clinical need and contributes to elevated risks of relapse and overdose, underscoring the importance of expanding access to medications for opioid use disorder (MOUD), including methadone, buprenorphine, and naltrexone ([115]; [62]). Stigma toward MOUD and mental health care further reduces uptake and retention, although staff training in addiction neuroscience and peer educator programs may im-prove engagement ([115]; [38]). Co-occurring mental health disorders are associated with higher relapse and recidivism and add clinical complexity, supporting the need for integrated dual-diagnosis care and trauma-informed approaches such as CBT and DBT ([83]; [18]; [117]; [118]).

Disruption of care at release contributes to elevated overdose risk in the im-mediate post-release period, underscoring the importance of Medicaid suspen-sion (rather than termination), warm handoffs, and pre-release planning ([110]; [8]). Understaffing of behavioral health providers leads to delays and reduced engagement, though telehealth expansion and cross-training of custody staff may help address these gaps ([144]; [35]). Continued limited integration of precision medi-cine contributes to suboptimal treatment matching, with emerging approaches such as pharmacogenomics and digital therapeutics offering potential improve-ments ([10]; [30]; [69]; [144]). Coverage gaps during reentry, including delays in insur-ance activation and access to medications, further increase overdose risk; policy strategies such as Medicaid Section 1115 reentry waivers may help address these barriers ([14]; [70]).

Accurate disclosure during screening is further hindered by underreporting related to fear of disciplinary or judicial consequences, limited confidentiality during intake assessments, and insufficient training of correctional staff in substance use assessment ([4]; [165]). Implementation of universal intake screening using validated instruments, combined with trauma-informed clinical assessment—including suicide risk evaluation—represents best practice for identifying SUDs and guiding individualized treatment planning. Evidence suggests that under-detection of SUDs in correctional environments is driven less by diagnostic uncertainty than by structural barriers, including stigma, fear of punishment, and workforce limitations within correctional health systems. Qualitative research further highlights how individuals who co-use opioids and methamphetamine often experience criminal legal involvement and mandated treatment as stigmatizing or coercive, which may undermine trust in treatment systems and reduce engagement in care ([72]).

1) Cognitive-behavioral therapy (CBT): CBT focuses on restructuring maladaptive thoughts and behaviors that contribute to substance use and relapse. In U.S. prison populations, CBT-based interventions have demonstrated moderate efficacy in reducing criminal thinking and recidivism, with meta-analyses consistently identifying structured, group-based CBT programs as among the most effective correctional rehabilitation approaches ([89]; [128]). Within substance use treatment specifically, CBT-informed therapeutic community and relapse prevention models implemented in U.S. prisons have shown improvements in drug use outcomes and post-release functioning ([178]; [132]).

Trauma-informed interventions such as Seeking Safety reduce PTSD symptoms and improve coping skills among incarcerated women. Group-based CBT and CM interventions enhance engagement and reduce relapse when paired with structured aftercare ([110]; [3]).

Clinical trials demonstrate that CBT reduces craving and psychiatric symptoms in individuals with methamphetamine use disorder ([148]; [74]). Similarly, combined MI-CBT formats significantly increase abstinence rates and reduce adverse outcomes associated with methamphetamine use ([5]; [154]). Digital and telehealth platforms now deliver CBT effectively in resource-limited correctional facilities ([136]; [130]). These findings support CBT as a foundational modality in correctional substance use disorder programming, consistent with risk-need-responsivity principles and the structured delivery formats typical of U.S. prison systems.

Across clinical trials and implementation studies, no single psychotherapy demonstrates superiority; rather, structured, evidence-based modalities delivered consistently and paired with pharmacotherapy produce the most durable outcomes. Evidence further supports integrated treatment models combining psychotherapy and pharmacotherapy.

2) Motivational interviewing (MI): MI is a collaborative, person-centered approach designed to enhance intrinsic motivation and resolve ambivalence toward change ([17]). MI has been shown to increase treatment engagement and adherence ([100]), particularly when combined with other behavioral interventions such as contingency management ([145]). In correctional settings, MI is especially effective for individuals entering treatment involuntarily and helps promote sustained participation in treatment programs ([106]). Consistent with the Substance Abuse and Mental Health Services Administration’s ([153]) Treatment Improvement Protocol (TIP) 35, MI emphasizes expressing empathy, eliciting clients’ own reasons for change, and strengthening commitment by helping individuals align behavior change with their personal values and goals for a healthy life. U.S.-based studies demonstrate that brief motivational interviewing delivered prior to jail release is feasible and associated with increased treatment entry, greater abstinence, and reductions in heavy substance use among incarcerated adults, with participants reporting high acceptability.

Additionally, research in U.S. community corrections and juvenile detention settings ([157]; [126]; [155]) shows that MI-consistent clinician behaviors predict treatment initiation and improved drug use outcomes, and that brief MI interventions during incarceration can reduce post-release alcohol and marijuana use among justice-involved adolescents.

3) Contingency Management (CM): Although CM demonstrates strong efficacy for stimulant use disorders in community treatment settings, evidence in U.S. correctional populations is more limited; available PubMed-indexed studies suggest that CM can improve substance use and supervision outcomes when implemented with adequate incentive magnitude and structured monitoring, whereas reduced or delayed reinforcement within justice settings may attenuate effectiveness ([48]; [133]).

Meta-analytic evidence supports CM effectiveness across diverse settings, including criminal justice-involved populations (e.g., [134]; [129]), and subsequent implementation research has documented its adaptability to structured environments.

4) The Matrix Model: an integrative treatment approach combining cognitive behavioral therapy, motivational interviewing, relapse prevention, psychoeducation, and structured monitoring—has demonstrated superior abstinence and retention outcomes among stimulant users in U.S. outpatient trials ([135]; [150]). Although large randomized controlled trials in U.S. prison populations are limited, correctional therapeutic community programs have incorporated Matrix-informed components, including manualized group sessions and relapse prevention strategies. Evaluations of prison-based programs for methamphetamine-using inmates report improvements in treatment engagement and post-release substance use outcomes, supporting the feasibility of structured, CBT-driven stimulant treatment models in custodial settings ([16]). Collectively, these findings suggest that the Matrix Model’s structured and accountability-focused framework is well aligned with correctional treatment environments and applicable to stimulant use disorders in U.S. prisons.

Twelve-Step Facilitation (TSF) therapy promotes participation in mutual-help fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), emphasizing acceptance, accountability, and peer support ([81]; [136]; [71]). Faith-based organizations—including Teen Challenge, Celebrate Recovery, and The Lovelady Center—that include overtly religious activities play a significant role in reentry and rehabilitation for justice-involved individuals. While these programs support sustained recovery engagement and reduce stigma, some faith-based interventions historically have not endorsed medication-assisted treatment, underscoring the need for integration with evidence-based pharmacologic care ([110]; [36]; [34]). Chaplaincy-led recovery groups have demonstrated acceptability and effectiveness in maintaining engagement during incarceration and after release ([147]).

Medications for opioid use disorder (MOUD)—including methadone, buprenorphine, and extended-release naltrexone—have been shown to significantly reduce post-release overdose mortality and improve treatment continuity among incarcerated populations ([62]; [42]). National guidelines emphasize offering the full MOUD formulary with continuity across custody transitions ([115]; [161]).

The fentanyl crisis has accelerated MOUD adoption. Methadone, buprenorphine, and extended-release naltrexone reduce relapse, all-cause mortality, and reincarceration ([171]; [173]). Individuals receiving MOUD during incarceration are significantly more likely to continue treatment after release and experience lower risks of fatal overdose ([50]; [23]; [42]; [49]). Long-acting buprenorphine formulations further improve retention and social outcomes ([90]; [105]; [131]).

Despite demonstrated efficacy, access to medications for opioid use disorder (MOUD) remains uneven due to stigma, diversion concerns, regulatory constraints, and logistical barriers that perpetuate health inequities ([6]). Limited availability of certified OTPs, which are federally regulated facilities authorized to dispense medications such as methadone for opioid use disorder, further restricts treatment access in many correctional and community settings. In addition, genetic variation influences susceptibility and treatment response, with polymorphisms in CYP2D6 affecting opioid metabolism and variants in OPRM1 altering receptor sensitivity and treatment outcomes.

Alcohol Use Disorder (AUD) is a chronic, relapsing brain disease characterized by impaired control over alcohol use despite adverse health, social, and legal consequences. Alcohol is implicated in more than half of incarcerations, and 47% of jail inmates meet criteria for alcohol dependence or abuse ([79]). FDA-approved medications include disulfiram, acamprosate, oral naltrexone, and extended-release injectable naltrexone. A recent systematic review and meta-analysis supports oral naltrexone (50 mg/day) and acamprosate as first-line pharmacotherapies when combined with behavioral treatment ([107]). Initiating pharmacotherapy during incarceration and ensuring continuity of care post-release reduces relapse and alcohol-related harms.

Cannabis Use Disorder (CUD) involves a problematic pattern of cannabis use leading to clinically significant impairment or distress. Although no FDA-approved pharmacotherapies currently exist, behavioral interventions—including cognitive behavioral therapy, motivational enhancement therapy, and contingency management—have demonstrated effectiveness ([15]). CUD is prevalent among justice-involved individuals yet remains under-addressed in correctional systems. Structured behavioral treatment during incarceration may reduce post-release relapse and substance-related recidivism.

Nicotine is a highly addictive compound that binds to α4β2 nicotinic acetylcholine receptors in the brain, stimulating dopamine release and reinforcing dependence. Tobacco use prevalence in incarcerated populations is substantially higher than in the general population ([31]). Combining behavioral therapy with pharmacotherapy significantly increases cessation rates ([19]). Varenicline, a selective partial agonist at the α4β2 receptor, is recommended over bupropion due to superior quit outcomes ([139]). Comprehensive tobacco treatment programs within correctional facilities are desirable to reduce relapse and long-term health disparities.

Methamphetamine overdose deaths continue to rise, and currently no medications are FDA-approved for methamphetamine use disorder. Pharmacologic agents such as modafinil, varenicline, and atomoxetine have shown modest cognitive benefits but limited impact on sustained abstinence ([114]; [185]). The ADAPT-2 trial demonstrated that extended-release naltrexone plus bupropion significantly improved abstinence compared with placebo ([167]).

The co-use of opioids and methamphetamine—commonly referred to as “goofballing”—is increasingly documented in polysubstance-use research and is associated with elevated overdose risk and adverse outcomes, as stimulants and opioids have opposing pharmacologic effects that may mask intoxication or delay recognition of respiratory depression ([163]; [96]). CDC surveillance data further demonstrate rising stimulant involvement in opioid overdose deaths ([164]). Qualitative research among individuals who co-use opioids and methamphetamine also highlights how treatment systems often struggle to address polysubstance use and may be experienced as fragmented or poorly aligned with patient needs, underscoring the importance of integrated treatment approaches across community and correctional settings ([72]).

Genetic studies indicate that stimulant and opioid use phenotypes share polygenic liability, suggesting overlapping biological risk pathways that may inform future precision interventions. Large genomic studies demonstrate that methamphetamine and broader stimulant use traits are highly polygenic and genetically correlated with other substance use disorders ([88]). Candidate genetic variants—including those affecting dopamine transporter and reward-related signaling pathways—have been explored as potential risk factors influencing susceptibility and treatment response ([84]).

In justice-involved populations, the high prevalence of methamphetamine use, co-occurring psychiatric disorders, and stimulant-related impulsivity underscores the need for integrated behavioral interventions—including contingency management—initiated during incarceration and sustained through community reentry to reduce relapse and overdose risk.

Operationalizing MOUD and evidence-based stimulant-treatment approaches in correctional settings commonly involves several practical challenges. These include diversion risk (mitigation: observed dosing, formulary controls, medication counts, and structured diversion-response workflows); induction logistics during withdrawal, particularly in jails with rapid turnover (mitigation: standardized withdrawal protocols, rapid clinical assessment pathways, and low-threshold buprenorphine initiation with clear continuation planning); staffing and licensing constraints (mitigation: telehealth prescribing, telepsychiatry, cross-training nursing staff, and formal partnerships with community opioid treatment programs for methadone continuity); and handoff failures at release (mitigation: “warm handoffs,” prerelease appointment scheduling, navigator models, and bridging medication strategies where permitted) ([8]; [111]; [140]; [115]; [175]).

Evidence further suggests that engagement in behavioral health services improves retention on MOUD among justice-involved individuals, highlighting the importance of coordinated treatment and continuity-of-care during reentry ([186]). These operational strategies align with emerging statewide models demonstrating feasibility and improved post-release treatment engagement ([29]; [35]; [62]; [156]).

While access to evidence-based SUD treatment remains inconsistent across U.S. correctional systems, several states have implemented comprehensive models integrating medications for opioid use disorder (MOUD), behavioral health services, and structured reentry supports. Evidence supporting integrated treatment models is strong. Meta-analytic evidence indicates that combining pharmacotherapy with structured behavioral therapies such as cognitive-behavioral therapy improves substance use outcomes compared with pharmacotherapy or usual care alone, supporting integrated treatment approaches used in several state correctional health programs ([137]; [119]).

Several states have implemented system-level correctional treatment models that illustrate different approaches to integrated care (Table 5). In California, the Integrated Substance Use Disorder Treatment (ISUDT) program implemented by California Correctional Health Care Services integrates screening, MOUD (methadone, buprenorphine, and naltrexone), cognitive-behavioral interventions, and prerelease care coordination with community providers to support continuity of treatment following release ([1]; [21]; [20]). The Rhode Island Department of Corrections operates one of the first statewide correctional programs providing universal access to all FDA-approved MOUD medications during incarceration, coupled with counseling services and Medicaid-supported linkage to community treatment providers after release ([29]; [11]; [62]). In New York, the New York State Department of Corrections and Community Supervision implements the Comprehensive Alcohol and Substance Abuse Treatment (CASAT) model, combining therapeutic community programming with MOUD access and phased community reintegration designed to support treatment engagement during reentry ([95]; [43]; [122]; [123]; [121]; [190]). Similarly, the Minnesota Department of Corrections provides prison-based chemical dependency treatment programs using cognitive-behavioral interventions and structured rehabilitation services, including transitional work-release and community supervision components that support continuity of care after incarceration ([37]; [109]; [127]).

Table 5. Comparative overview of SUD treatment programs in selected state correctional systems.

ASAT = Alcohol and Substance Abuse Treatment; CASAT = Comprehensive Alcohol and Substance Abuse Treatment; California (CCHCS) = California Correctional Health Care Services; CD = Chemical Dependency; SUD = Substance Use Disorder; MOUD = Medication for Opioid Use Disorder; MAT = Medication Assisted Treatments; New York (DOCVCS) = New York State Department of Corrections and Community Supervision; Rhode Island DOC = Rhode Island Department of Corrections; Minnesota DOC = Minnesota Department of Corrections; T4C = Thinking for a Change; CBT = Cognitive Behavioral Therapy; XR = Extended Release.

Table 5 compares these approaches, illustrating how policy mandates, program design, and Medicaid alignment are being leveraged to improve treatment continuity during incarceration and community reentry. Despite these advances, evidence-based treatment remains unevenly implemented across U.S. correctional systems, with access often constrained by structural inequities—including disparities by conviction type, race, and ethnicity—that contribute to differences in treatment availability and outcomes ([26]).

Emerging innovations increasingly emphasize continuity of care, technology-enabled treatment delivery, and alignment between correctional and community health systems. Pharmacogenomic profiling—already used in psychiatry and pain management—offers a potential pathway to guide treatment options, including individualized medication selection that may enhance safety, adherence, and outcomes ([141]; [30]; [56]).

Telepsychiatry, secure tablet-based programming, and digital recovery platforms can help address workforce shortages while expanding access to behavioral health services during incarceration and community reentry ([33]; [156]; [144]; [58]). Digital tools supporting real-time monitoring of cravings, triggers, and mood have also shown feasibility and acceptability among justice-involved populations ([143]).

Another major innovation involves activating Medicaid coverage prior to release and incorporating care navigators to coordinate appointments, benefits, and MOUD continuity. Section 1115 Medicaid Reentry Demonstrations allow coverage up to 90 days pre-release and significantly improve engagement during the high-risk transition period ([14]; [28]; [94]). State initiatives such as California’s CalAIM Justice-Involved Demonstration exemplify how aligning correctional and community systems can promote uninterrupted medical and behavioral health care ([1]; [21]).

National bodies and consensus guidelines increasingly endorse integrated models in which MAT is combined with cognitive-behavioral therapy, motivational interviewing, or contingency management ([115]). Statewide implementation of MOUD has been associated with marked reductions in post-release overdose mortality ([62]), while telepsychiatry, secure tablet programming, and peer recovery services expand engagement in rural and resource-limited facilities ([38], [144]).

CBT programs that address criminogenic thinking further reduce recidivism when paired with aftercare and community linkage ([110]). Federal initiatives such as the NIH HEAL and Justice Community Opioid Innovation Network (JCOIN) are actively testing digitally delivered CBT, MI, and peer navigation models that begin during incarceration and extend into community-based care, reflecting growing recognition of the need for longitudinal treatment continuity.

Several state correctional systems illustrate converging best practices. California’s Correctional Health Care Services model, aligned with the CalAIM initiative, provides comprehensive MOUD integrated with CBT, MI, CM, and trauma-informed group interventions, alongside prerelease benefits activation and strong community linkage ([1]). Rhode Island’s statewide MOUD program—maintaining treatment from intake through release—demonstrated substantial reductions in post-release overdose deaths ([62], [29]). Comparable models in New York ([43]; [95]; [121]), and Minnesota ([127]; [37]; [109]) similarly emphasize universal medication access, telehealth infrastructure, and coordinated reentry supports.

Translation of clinical advances into population-level impact depends on policies that bridge custody and community while addressing persistent inequities. Access to MOUD and behavioral health services remains highly variable across states, driven by stigma, insurance disruption, workforce shortages, and fragmented data systems ([38]). Recent DOJ and HHS guidance recognizes MOUD as a clinical standard of care and a protected accommodation under the Americans with Disabilities Act, reinforcing legal and ethical obligations to provide evidence-based treatment in correctional settings ([179]).

Medicaid Section 1115 Reentry Demonstrations represent a transformative policy lever, allowing states to provide medical and behavioral health services up to 90 days prior to release. Early evaluations indicate that prerelease enrollment, care navigation, and immediate post-release follow-up substantially improve treatment engagement and reduce overdose mortality during the high-risk reentry period ([14]; [28]; [94]). Sustained success will require continued cross-agency collaboration, standardized outcome metrics, and alignment with National Institute of Corrections behavioral health and reentry frameworks ([116]).

Evidence-based overdose preventions at release from prison or jail can be deployed at or immediately prior to release include:

1) naloxone distribution with brief training for the individual and, when feasible, family/support persons (as per [24]; [160]);

2) MOUD continuity measures such as prerelease initiation and/or bridging strategies (e.g., scheduled first-dose appointment within 24 - 72 hours; Extended Release (XR) formulations where appropriate) to mitigate the high-risk transition period ([62]; [49]; [42]);

3) scheduled rapid follow-up (e.g., appointment made before release, transportation plan, and documented warm handoff) supported by care navigation models ([14]; [28]); and

4) benefits activation (Medicaid reentry demonstration processes and prerelease enrollment) to reduce coverage gaps ([25]; [94]).

This (recommended) multi-focal approach should also provide economic benefit to the post-incarcerated individuals as well as to the communities in which they reside, as a result of improvements in quality of life and reductions in SUD relapse, criminal activities, and recidivism.

Digital therapeutics, telepsychiatry, and data-driven analytics offer scalable solutions to longstanding access challenges in correctional health. Mobile applications, ecological momentary assessment tools, and app-based CBT platforms show promise for real-time monitoring of cravings, triggers, and mood, supporting relapse prevention during both incarceration and reentry ([104]; [9]; [143]).

Pharmacogenomic-guided prescribing ([10]; [55]) and biomarker-based risk stratification could further personalize treatment, particularly for individuals with co-occurring psychiatric or medical conditions. Novel pharmacotherapies, including combined extended-release naltrexone and bupropion for methamphetamine use disorder, represent important early advances in a domain that has been long neglected in correctional research ([167]). Rising opioid-methamphetamine co-use ([68]) underscores the urgency of prioritizing polysubstance-use research and pragmatic implementation trials within justice settings.

Several pharmacogenomic applications have demonstrated clinical utility and are supported by published prescribing guidance. These include genotype-informed considerations for methadone and other opioid therapies involving CYP2B6 and CYP2D6 metabolic pathways, consistent with recommendations from the Clinical Pharmacogenetics Implementation Consortium (CPIC) ([30]; [141]). As summarized in Table 3, pharmacogenomic tools represent one of several emerging strategies aimed at improving treatment personalization in correctional settings. By contrast, broader precision-medicine approaches—such as polygenic risk scoring for relapse prediction, microbiome-informed treatment strategies, or gene-based prediction of stimulant-treatment response—remain largely investigational. Consequently, these approaches should currently be regarded as emerging research avenues rather than established standards of care in correctional health systems.

Pre-release Medicaid activation represents a lifesaving reform, and the Federal initiatives such as Medicaid Section 1115 Reentry Demonstrations and state models like CalAIM exemplify the evolving alignment between correctional and public health systems—an essential step toward reducing overdose deaths, improving reentry outcomes, and advancing equity in correctional health care. Emerging evidence also highlights the promise of digital health tools—such as mobile ecological momentary assessments and app-based cognitive-behavioral platforms—as feasible and acceptable methods for real-time monitoring of cravings, triggers, and mood, thereby enhancing engagement and relapse prevention among justice-involved individuals ([104]; [9]; [143]).

The evidence synthesized in this review underscores the need for coordinated national strategies that integrate pharmacologic, behavioral, digital, and reentry supports within correctional health systems. Policy initiatives such as Medicaid Section 1115 Reentry Demonstrations represent an important step toward institutionalizing continuity of care across custody and community settings. Consistent evidence indicates that medications for opioid use disorder, when initiated during incarceration and sustained through reentry, significantly improve treatment retention and reduce overdose mortality and reincarceration, reinforcing the need for sustained policy investment and infrastructure to expand evidence-based treatment in correctional systems. Research on restrictive housing underscores the importance of trauma-informed, mental health-protective policies ([65]). Addressing high rates of substance use disorder among probationers and parolees will require coordinated diversion programs, community-linked treatment, and emerging pharmacogenomic-guided interventions ([10]; [56]; [65]; [46]; [69]).

The evidence underscores the urgency of a coordinated national framework that unites pharmacologic, behavioral, digital, and reentry supports under an equity-driven strategy. Rising opioid-methamphetamine co-use (“goofballing”) and the absence of approved pharmacotherapies highlight the need to prioritize polysubstance research and pragmatic implementation pilots.

Addressing the growing burden of methamphetamine use disorder, polysubstance use, and trauma-related comorbidity will require coordinated diversion programs, community-linked treatment models, and emerging precision-medicine-guided interventions. Embedding these innovations within reentry frameworks such as CalAIM advances the mission of the National Institute of Corrections to promote equity, improve population health, and strengthen public safety.

This narrative review is novel and has several important strengths. First, it integrates evidence across neurobiology, genetics, psychotherapeutics, pharmacology, digital health, and policy, offering a comprehensive and multidisciplinary synthesis that reflects the real-world complexity of SUDs in correctional settings. By spanning the full continuum from incarceration through reentry, the review highlights how biologic vulnerability, trauma exposure, and structural determinants interact to shape outcomes, moving beyond siloed clinical or policy perspectives. The inclusion of emerging domains—such as pharmacogenomics, digital therapeutics, and Medicaid reentry demonstrations—positions this work at the forefront of translational and implementation-oriented correctional health research. Importantly, the review centers equity, emphasizing populations disproportionately affected by incarceration, stigma, and fragmented care systems, and aligns clinical evidence with evolving legal and policy frameworks.

Several limitations warrant consideration. As a narrative review, the study does not employ formal systematic review or meta-analytic methods, which limits the ability to quantify effect sizes or assess publication bias. The correctional health literature remains heterogeneous, with wide variability in facility type, population demographics, treatment availability, and outcome definitions, constraining direct comparisons across studies. Prospective randomized controlled trials in jail and prison settings are relatively scarce due to ethical, logistical, and regulatory barriers, resulting in reliance on retrospective observational studies and quasi-experimental designs for many interventions. Finally, while emerging precision-medicine and digital approaches show promise, empirical data on long-term effectiveness, cost-effectiveness, and scalability in correctional environments remain limited, underscoring the need for pragmatic, equity-focused implementation research.