 So I'm a nurse, I'm a addiction nurse, and I go into the prison system and I meet with people returning into society. So I meet with them and I do their assessments and try to help bridge their care for them when they're upon release, and I mean the fear is real. They're so afraid. I've had them actually cry during the assessments because you know they have a different persona while they're in there, but inside they're full of fear and anxiety and what's going to happen when I get out. It's almost like impending doom when they walk out that door. So I met with this young man, he was about 24, 25 years old. It was his first time being incarcerated. So his day of release he came to us over at Boston Medical Center. He met with the doctor, he met with the nurse, he was started on a very low dose of medication for treatment. He's still with us today, he's engaged with care, and he meets with psychiatry, he has a social worker and he has his daughter in his life and he's grateful. I believe that a lot of the people that are incarcerated are there for behaviors that occur due to impairments. Everybody I talk to over there is typically it's because they're impaired at the time of their crime. I feel like if they had been able to get to treatment sooner this may have stopped this incarceration and this behavior that led to their incarceration. Racial justice exposure is extremely common for patients with opioid use disorder. Half of the people in the federal prison system are currently serving time for a drug offense. In the 1980s, shortly after taking office, President Reagan expanded drug laws such as mandatory minimum sentences and a 100 to 1 sentencing disparity between crack and powder cocaine. Opioids catalyzed blatant racial disparities in the U.S. incarceration system as well as a mass incarceration for drug offenses with an impact that has lasted for decades. Heroin possession and use is illegal in the United States. Additionally, opioid use disorder results in a compulsion to use opioids despite its negative consequences and this often leads to what is commonly referred to as acquisitive crimes like stealing or selling drugs. In fact, a study conducted in Baltimore, Maryland, found that over a six-year period people who injected drugs had a 60% risk of becoming incarcerated as compared to people who do not inject drugs. Each year, one in three people with opioid use disorder will be arrested. And unfortunately, for many, multiple incarcerations are common. In the New York City Jail System, about 40% of people with opioid use disorder reported 11 or more incarcerations. Incarceration can cause health-related harm to people with opioid use disorder. Most of these harms are related to lack of access to evidence-based treatment while incarcerated. Specifically, these harms include 1. Untreated or under-treated opioid withdrawal. 2. Disruption of the opioid agonist treatment, methadone or buprenorphine and 3. An increased risk of fatal overdose. The process of being arrested, arraigned and transferred to correctional custody can take up to 72 hours, depending on a variety of factors including the time of arrest. Because opioid withdrawal is not considered life-threatening, it is not uncommon for patients to go untreated during this time. This can be extremely uncomfortable, and it can lead to death from dehydration or suicide. It can also lead to drug use in order to stop withdrawal symptoms, increasing the risk of overdose. Despite the large number of individuals with opioid use disorder currently incarcerated in the United States, and the fact that both methadone and buprenorphine are proven to reduce the risk of death by greater than 50% in people with opioid use disorder, it is puzzling that the majority of jails and prisons do not offer these life-saving treatments. This means that if a person on methadone or buprenorphine becomes incarcerated, his or her medication is abruptly stopped and discontinued. In addition to being extremely uncomfortable, forcing people to withdraw from these medications makes them less likely to want to use the medications in the future. It also means that people who use opioids and who may benefit from starting these life-saving medications do not have the opportunity to do so while incarcerated. The third harm of incarceration is extremely important. Incarcerating people with opioid use disorder is associated with an increased risk of death. This risk is most pronounced during the post-release period. This is primarily driven by forced withdrawal, persistent cravings, and reduced tolerance to opioids. Similar to opioid agonist treatment, meaning methadone or buprenorphine is associated with a 75% reduction in death post-release. How do we reduce these harms? Primarily by ensuring timely access to opioid agonist treatment, either from medically supervised withdrawal, or preferably as part of a long-term maintenance strategy if the person is interested. To reduce suffering and ensure treatment continuation, correctional settings should continue opioid agonist treatment for people already on these medications and initiate and maintain people on opioid agonist treatment inside correctional settings. Healthcare teams should prioritize linking individuals to post-release care and offer addiction treatment services inside correctional facilities.