The Impact of Policy Changes on Heroin and Nonmedical Prescription Opioid Use Among an Incarcerated Population in Kentucky, 2008 to 2016

Published date01 June 2020
Date01 June 2020
Subject MatterArticles
/tmp/tmp-17ctkgEYv6fv2p/input 838029CJPXXX10.1177/0887403419838029Criminal Justice Policy ReviewBunting et al.
Criminal Justice Policy Review
2020, Vol. 31(5) 746 –762
The Impact of Policy Changes
© The Author(s) 2019
Article reuse guidelines:
on Heroin and Nonmedical
DOI: 10.1177/0887403419838029
Prescription Opioid Use
Among an Incarcerated
Population in Kentucky,
2008 to 2016
Amanda M. Bunting1 , Grant Victor III1,
Erika Pike1, Michele Staton1, Erin Winston1,
and Kevin Pangburn2
In response to the opioid epidemic, there have been several national- and state-
level policies enacted. Consideration of how criminal justice–involved individuals are
affected by such policies has received limited attention, despite disproportionately
higher use among this population. Bivariate statistics examined yearly trends, and
logistic regressions examined demographic correlates of nonmedical prescription
opioid and heroin use among Kentucky inmates over an 8-year time span of
important national and local policy changes (N = 34,542). Results indicate that
among incarcerated individuals, prior use of heroin increased 204% from 2008 to
2016, with increases possibly linked to key policy changes associated with OxyContin
reformulation and state implementation of a prescription drug monitoring program.
The current incarcerated population had more severe use patterns when considering
general population research. Consideration of criminal justice–involved populations
is crucial to understanding and treating the opioid epidemic.
opioids, trend, criminal justice, heroin, nonmedical prescription opioid
1University of Kentucky, Lexington, KY, USA
2Department of Corrections, Frankfort, KY, USA
Corresponding Author:
Amanda M. Bunting, University of Kentucky, 1505 Patterson Office Tower, Lexington, KY 40506, USA.

Bunting et al.
The use of nonmedical prescription opioids (NMPOs) and heroin has reached preva-
lence rates emblematic of a national crisis, as demonstrated by increases in incidence
rates, emergency room visits, treatment admissions, and overdose fatalities (Cai,
Crane, Poneleit, & Paulozzi, 2010; Martins et al., 2017; Paulozzi, 2012; Slavova et al.,
2017). Drug overdose is now the leading cause of accidental death for individuals
below the age of 50 years (Ahmad, Rossen, Spencer, Warner, & Sutton, 2017). In
2016, opioids were involved in 66.4% of all overdose mortalities for a total of 42,249
lives lost (Centers for Disease Control and Prevention [CDC], 2017). Societal costs of
opioids are estimated between US$55 billion and US$1 trillion, owing to health care
costs, lost earnings from premature deaths, and criminal justice costs (Altarum, 2018;
Birnbaum et al., 2011).
The increase in use and adverse outcomes have been primarily described as a pro-
gression of initiation to abuse—from NMPO to heroin—and this progression has been
explained by a host of factors. The factors of most interest to the current study include
the unintended consequences of federal- and state-level policies (Cicero, Ellis, Surratt,
& Kurtz, 2013; Haegerich, Paulozzi, Manns, & Jones, 2014; Muhuri, Gfroerer, &
Davies, 2013). To that end, the current research seeks to explore trends in NMPO and
heroin use in the context of national- and state-level policies among a population of
justice-involved persons—a vulnerable population that has been underrepresented
from national conversation and data related to the opioid crisis.
The Opioid Landscape in Kentucky
Appalachian states have suffered extensively from negative outcomes related to opioid
misuse. West Virginia, Ohio, and Kentucky ranked among the top 10 states for over-
dose mortalities (Ahmad et al., 2017). For Kentucky, the rate of 33.5 deaths per
100,000 persons is nearly double the national rate (CDC, 2018a). Furthermore, nonfa-
tal opioid overdoses significantly increased in Kentucky from 2016 to 2017 (CDC,
2018b). A national vulnerability assessment found that nearly 25% of the 220 identi-
fied counties to be at risk of rapid dissemination of an HIV outbreak due to injection
drug use (IDU) practices are located in Kentucky (Van Handel et al., 2016). In response
to the opioid crisis, Kentucky has enacted several state-level policies to expand treat-
ment efforts, implement a prescription drug monitoring program (PDMP), and increase
diversion-related criminal penalties (Slavova et al., 2017; Victor, Walker, Cole, &
Logan, 2017). These policies build on national-level changes, such as reformulation of
In 2010, the U.S. Food and Drug Administration (FDA) designated OxyContin as
an “abuse-deterrent” drug owing to the reformulation of the drug which made it more
difficult to crush, snort, or inject. This policy, along with the state-level interventions
that included implementation of a PDMP, was initiated to make NMPO more difficult
to misuse or divert and to increase the regulation of the distribution of NMPO through
a supply-side drug policy approach. Supply-side policy interventions are concerned

Criminal Justice Policy Review 31(5)
with the reduction of availability of substances to deter use and abuse. However, a
recent study by Alpert, Powell, and Pacula (2018) demonstrated that the disruption to
NMPO supply caused by the OxyContin reformulation caused large and significant
increases in heroin overdose deaths.
Other supply-side policy interventions include PDMPs. PDMPs collect data on pre-
scribed controlled substances so that physicians (Beletsky, 2018) and, in some cases,
other health and criminal justice officials may review a patient’s prescribing history to
identify potential diversion or misuse of NMPO. Research has indicated that required
PDMPs, as opposed to merely enacted programs, may reduce misuse of NMPO
(Buchmueller & Carey, 2017). Kentucky House Bill 1 (H.B. 1 2012, amendment H.B.
217) bolstered the state’s PDMP, which mandated close regulation of pain manage-
ment clinics and the implementation of new practice standards for those prescribing
and distributing prescription opioids (PDMP Center of Excellence, 2016). However,
recent research demonstrates that while H.B. 1 may have reduced the misuse of
NMPO, it is also possibly associated with increasing rates of heroin use (Slavova
et al., 2017; Victor et al., 2017).
Kentucky Senate Bill 192 (KY S.B. 192) was passed in 2015, which designates
sources of funding for substance use treatment and authorizes expanded access to
naloxone. The impact of S.B. 192 on opioid trends in Kentucky is not yet clear.
Kentucky appears to mirror national-level trends that suggest many individuals who
initiate use of heroin, do so at points indicative of policy reform aimed at reducing the
NMPO epidemic (Compton, Jones, & Baldwin, 2016; Muhuri et al., 2013; Slavova
et al., 2017; Victor et al., 2017). However, increased access to treatment, including the
provision for prerelease use of injectable naltrexone as designated in S.B. 192, could
possibly decrease heroin use compared with previous policies which were focused on
restricting access to NMPO through supply-side interventions.
Opioid Use Among Incarcerated Populations
Despite substance use rates that are disproportionately higher than general populations
(Belenko, Hiller, & Hamilton, 2013), incarcerated populations have received limited
attention in the literature regarding how recent drug policy efforts may have affected
their drug use patterns. Upon reentry, criminal justice–involved individuals are
approximately 129 times more likely to die of a drug overdose compared with the
general public (Binswanger et al., 2007; Dumont, Brockmann, Dickman, Alexander,
& Rich, 2012). The heightened risk of mortality reflects the volatility of circumstances
in the days following release, the period of abstinence from substances while incarcer-
ated, and the initiation of high-risk behaviors, such as using opioids with reduced
In a national sample, more than half of individuals who reported opioid use had
past-year criminal justice contact (Winkelman, Chang, & Binswanger, 2018), indicat-
ing that the inclusion of justice-involved persons in responses to the opioid crisis is
essential. Among a sample of African American justice-involved individuals, NMPO
use was estimated at 23.3% in 2014, a rate that significantly increased from 17.6% in

Bunting et al.
2010 (Knighton, Stevens-Watkins, Staton, & Pangburn, 2018). The same study found
that older age was a significant protective factor of NMPO use, whereas greater years
of education and recurrent mental health symptoms increased the odds of NMPO use
(Knighton et al., 2018). Despite this work, it remains unclear how justice-involved
individuals have been comparatively affected by the opioid crisis based on gender,
race, age, and geography.
Current Research
A recent study by the CDC suggested that research aimed at examining NMPO and
heroin use trends among institutionalized populations is needed to accurately under-
stand drug use in ways that are representative of the U.S. general population (Jones,
Logan, Gladden, & Bohm, 2015). The current research responds to this call by exam-
ining NMPO and heroin use trends that coincide with recent national (2010, OxyContin
reformulation) and state (2012, PDMP; 2015, expanded treatment) policy initiatives to
curb the use and...

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