Evan Ashkin, a family physician and director of the North Carolina Formerly Incarcerated Transition Program, has long been concerned about people who are returning to the community from prison — especially people with substance use disorders.
Nearly 80 percent of people entering North Carolina state prisons need treatment for substance use disorder, according to the N.C. Department of Adult Correction. And that’s a higher proportion than in the population as a whole.
Each year, more than 18,000 people leave custody and return to the community. And those first weeks after someone leaves prison are among the most dangerous in their lives.
Research shows it’s a period when the risk of overdose death spikes. A North Carolina study found that formerly incarcerated people are 40 times more likely to die of an opioid overdose within the first two weeks after leaving prison than is the average person. That’s because if they relapse after leaving the controlled prison environment, people may find their tolerance is much lower — even as the street drugs have grown more potent.
“Folks post-release remain probably the most vulnerable to overdose death of any population,” Ashkin said. “This is a serious, serious issue.”
To help reduce that risk, the Department of Adult Correction launched a program in 2021 at two prisons to provide people who were nearing release with medications for opioid use disorder — an initiative Ashkin helped develop.
The U.S. Food and Drug Administration has approved three medications (buprenorphine, methadone and naltrexone) to treat opioid use disorder, and use of at least one is considered best practice. The medications suppress withdrawal symptoms, reduce drug cravings and decrease the risk of overdose death.
Research shows that providing these medications in correctional settings decreases opioid use, reduces the spread of infectious disease, results in less criminal activity after release and curbs overdoses post-release.
This year, the Department of Adult Correction expanded the number of facilities where they provide these medications before release to 24 — about half of the state’s prisons. In the past 12 months, more than a thousand incarcerated people received them before release, according to Arthur Campbell, chief medical officer at the Department of Adult Correction. He presented the data at a State Reentry Council Collaborative meeting on Nov. 26.
“I think it’s making a tremendous difference,” Ashkin said. “There is an opportunity which did not exist previously for people who want to get into treatment to have a real chance of being successful, because they already have this medication on board [prior to release].
“I am certain that we have avoided many overdose deaths, and that numerous people have been successful where they would not have been.”
Reaching people before release
Ashkin said starting people on one of these medications before they leave prison is crucial. He’s seen firsthand what can happen without it: patients who returned home, returned to using before they could get to a clinic and fatally overdosed — within days.
Campbell said that the Department of Adult Correction recognizes this is a vulnerable time and is focusing its limited resources on providing this treatment to people nearing release, when overdose risk looms largest.
Of the more than 18,000 people leaving state prisons each year, Ashkin said that an estimated 3,000 to 4,000 people could be eligible for these medications before their release if the program was operational at all facilities. That demand far exceeds current capacity and resources.
“Inarguably, the most critical need is where we need to focus, and that’s going to be on individuals that are reentering from custody, where there’s up to 40 to 50 times increased risk of overdose deaths in those first weeks after their reentry,” Campbell said. “That continues to be our priority effort at this point.”
Campbell noted that while some could benefit from opioid use disorder medications earlier during their time in prison, overdose deaths inside state prisons are low — and opioids are not the primary cause. He said the last opiate-related in-custody death occurred in February 2024. This year, he said, of the six deaths from illicit drug overdoses confirmed by the N.C. Office of the Chief Medical Examiner, five were linked to synthetic cannabinoids and one to methamphetamine.
In addition to providing medications for opioid use disorder before release, the Department of Adult Correction provides this treatment to:
- Pregnant prisoners
- People entering a state prison from the community or county jails who are already taking one of these medications and have a sentence of 90 days or fewer
A June 2025 report by the federal Substance Abuse and Mental Health Services Administration endorsed expanding access to opioid use disorder medications in correctional settings, citing the effectiveness of treatment in reducing overdose deaths and recidivism. The report says providing these medications in state prisons aligns with the Trump administration’s Make America Healthy Again agenda and emphasizes the need to treat opioid use disorder as “the chronic medical condition it is.”
“The evidence is clear: MOUD reduces mortality by more than 50 percent and breaks the devastating cycle of addiction, incarceration, and overdose that impacts millions of American families,” the report states.
Other groups, including the National Commission on Correctional Health Care and National Sheriffs’ Association, also support broader access to this treatment in prisons and jails, though availability is limited in many states.
How the program works
The Department of Adult Correction began offering “reentry MOUD” to a small fraction of its population in 2021 as part of a pilot program started with grant funding at Orange Correctional Center in Hillsborough and the North Carolina Correctional Institution for Women in Raleigh. To launch the program, the department partnered with the Mountain Area Health Education Center and the North Carolina Formerly Incarcerated Transition Program.
When the grant funding ran out in June 2024, Campbell said, the Department of Adult Correction picked up the tab of the program and its expansion — a challenge amid budget pressures and staffing shortages.
“Because we realize how important this program is, we continue to push forward,” Campbell said.
Over the past year, Campbell said, 1,100 people have been released to 88 North Carolina counties and 11 other states after receiving medications for opioid use disorder just before leaving custody. About 60 percent of the participants were women — a trend Campbell said he is watching, noting that the reentry MOUD is now available at all four women’s facilities but not all the men’s prisons.
About 45 to 60 days before release, MOUD program staff start accepting referrals from correctional medical or mental health practitioners, case managers and even self-referrals. The department’s program providers screen each referral for eligibility, and those determined appropriate for the treatment will receive several days of oral buprenorphine, followed by a long-acting buprenorphine injection (Brixadi) three to five days before their release.
Each injection lasts for about a month, giving people time to connect with a treatment provider in the community who can continue prescribing one of these medications and help people set off on a new path.
“They’ve got three to four weeks where they don’t have to worry about picking up a prescription from a pharmacy,” Ashkin said. “Oftentimes, people are unhoused. Things are chaotic. People lose their medications all the time. This way it’s in their system. It’s protecting them from cravings to use opioids and withdrawal.”
A connection to a community provider is just as important for the program’s success, Campbell said. The Department of Adult Correction partners with Ashkin’s program, NC FIT, to help make sure participants are connected to treatment after release.
Ashkin said the FIT Recovery network now covers about 70 counties and works with two virtual providers who can prescribe medications for opioid use disorder, which allows for continuity of care regardless of where someone is returning across the state. The Department of Adult Correction pays for visits and medications for the first six months, Ashkin said. After that, people are responsible for covering the costs of the medications.
When the program was smaller, FIT Recovery community health workers — all formerly incarcerated — met with participants virtually before their release to discuss substance use treatment and assess their needs. But as the program has expanded, prisons have struggled to facilitate those meetings due to staffing shortages.
“Unfortunately, the prisons are not adequately staffed and don’t have the people power to be able to arrange for those in-reaches prior to release,” Ashkin said.
Where pre-release meetings aren’t possible, Ashkin said participants receive information on how to contact NC FIT and its partner organizations — where they can connect to a provider in the community who will continue their treatment. Follow-up rates are lower without the pre-release engagement, Ashkin said, but outcomes are strong for those who manage to connect.
“I have a number of clients I see who came to us from FIT Recovery, and they are extremely happy to have been started on the medication prior to release,” Ashkin said. “Many of them attribute their post-release success to having been started on this program.”
“We have very positive outcomes,” he said. “We’re working on how we can collect better data over time to see how many people are actually staying in treatment.”
Further expansion on hold
Campbell said the department wants to continue expanding access to medications for opioid use disorder in its facilities, but progress hinges on funding and staffing.
“It is our intent to expand reentry MOUD to every one of our institutions,” he said.
But no dedicated funding has been allocated to the department for implementation of the program, Campbell said, and all costs are at the expense of other medical programs. The department requested $10.5 million in recurring funding from the General Assembly to cover costs for correctional health care staff, medications and additional community health workers for NC FIT.
With the ongoing budget impasse in the state legislature, it’s not clear how much money the department will receive — or how quickly expansion can continue.
The Department of Adult Correction’s next goals for expanding access to medications for opioid use disorder:
- Expand reentry MOUD program to all its facilities
- Continue MOUD treatment for those who arrive at the department’s two residential Alcoholism and Chemical Dependency Programs facilities who are already taking these medications while on probation, parole or post-release supervision (Dart Center and Black Mountain)
- Increase the criteria for continuing someone who arrives in the department’s custody on active MOUD treatment beyond the 90-day sentences
Also aimed at lowering overdoses upon release, the Department of Adult Correction gives each person Narcan, a fast-acting opioid overdose reversal medication, as they exit prison. Since July 2024, Campbell said that 13,800 doses of Narcan have been distributed. He said the department plans to continue this effort as long as funding allows.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.