Skip navigation

Corrections-Based Responses to the Opioid Epidemic, Vera Institute of Justice, 2018

Download original document:
Brief thumbnail
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
March 2018

Corrections-Based Responses
to the Opioid Epidemic:
Lessons from New York State’s Overdose Education
and Naloxone Distribution Program
Vedan Anthony-North, Leah G. Pope, Stephanie Pottinger,
and Isaac Sederbaum

From the Director
The numbers behind America’s current opioid crisis
are grim: 60 percent of all overdose deaths in 2015
involved an opioid, and overdose deaths from opioids
increased nearly threefold between 2002 and 2015. The
epidemic has received attention from the highest levels
of government, with the president declaring it a public
health emergency. As the opioid crisis has swept the
nation, New York State has been especially gripped by its
devastating effects—between 2014 and 2015 the overdose
death rate in the state from synthetic opioids (other than
methadone) grew more than 135 percent, the largest
increase in the nation.
To combat opioid overdose deaths, the federal government
has called for equipping first responders with naloxone,
an overdose antidote that reverses opioid overdoses and
can be administered by bystanders with minimal training.
Naloxone is increasingly being distributed through public
health programs and more and more states and cities
are providing naloxone to police officers so they can
be prepared to react to overdose situations in the field.
All 50 states and the District of Columbia have passed
laws providing some level of protection to people who
prescribe, distribute, or administer naloxone.
One population that is perhaps more vulnerable to
overdose than any other—those who have been recently
released from incarceration—has largely been left out of
these efforts. Yet the majority of people incarcerated in
our nation’s jails and prisons meet the criteria for drug
dependence or abuse, and research shows that newlyreleased people face a dramatically increased risk of death
from overdose due to their lowered tolerance during
their period of abstinence in prison, combined with the
stressors and lack of support that too often accompany
reintegration into the community.
In light of these statistics, New York State instituted
a novel overdose education and naloxone distribution
(OEND) program in its correctional system, training

those who are incarcerated, their family members, and
corrections staff to recognize and respond to the signs
of opioid overdose, and making naloxone kits available
to them. This report assesses the results of these efforts,
and offers insights for other correctional systems
seeking to implement OEND programs.
The results are promising—people who received the
training significantly increased their knowledge about
opioid overdose and their confidence in their ability to
respond. They also responded to messaging about saving
lives and many indicated they would take a kit in order to
help their communities. Not everyone who was trained
took a kit, however—some cited their distrust of the
justice system and concerns about the laws designed to
offer legal protections for people reporting an overdose.
There are thus some areas where training can be
strengthened.
While the opioid crisis must be confronted on many
fronts, harm reduction strategies— public health efforts to
address drug use that promote health and safety without
requiring abstinence—like naloxone distribution offer
one promising avenue toward eliminating unnecessary
deaths, while giving the formerly incarcerated the tools
and agency they need to keep themselves safe during the
critical post-release period. It is our hope that this report
will inspire other corrections systems to integrate OEND
efforts into their opioid crisis responses, so that people
who are incarcerated are given every chance to succeed as
they reenter their communities.

Leah G. Pope
Acting Director
Substance Use and Mental Health Program
Vera Institute of Justice

Contents
3	Introduction
5	

New York State: A case study

	

8	

Methods and limitations

	

10	

Major themes and findings

20	

Implementing corrections-based strategies

		

20	 Program development

		

23	 Programmatic components

28	Conclusion
30 	 Endnotes

Introduction

T

he United States continues to be in the grips of a growing opioid
epidemic. In August 2017, the Centers for Disease Control and
Prevention (CDC) released new data reporting that more than 64,000
Americans died of drug overdose deaths in 2016—a 21 percent increase from
2015.1 The most recent estimates from 2015 show that more than 60 percent of
drug overdose deaths involve an opioid (which includes illicit drugs like heroin
and fentanyl and prescription pain relievers like oxycodone, hydrocodone,
codeine, and morphine)—and that overdose deaths involving opioids increased
nearly threefold between 2002 and 2015.2 Responding to these numbers,
President Trump recently declared the opioid crisis a public health emergency,
and the President’s Commission on Combating Drug Addiction and the Opioid
Crisis released a final report with 56 recommendations, urging Congress to act
quickly to provide appropriate funding for implementation.3
Comprehensive efforts had already been underway across the country
to respond to the dramatic rise in opioid-related overdose deaths. Chief
among these has been the increased availability and use of naloxone, an
overdose antidote that reverses the effects of an opioid overdose and can
be administered by bystanders with minimal training. Naloxone has been
distributed to people who use drugs through public health programs since
1996, and is now increasingly available to first responders and the public. As of
July 2017, all 50 states and the District of Columbia have naloxone access laws
that provide some form of protection from civil and criminal prosecution for
prescribers, dispensers, and laypersons who administer naloxone.4 Naloxone
is also becoming more readily available by prescription at local pharmacies,
and the Federal Drug Administration has publicly supported naloxone as lifesaving and has pushed initiatives to make over-the-counter versions available.5
Furthermore, more and more cities and states are providing first responders,
including police officers, with naloxone to save lives.
Naloxone distribution is one component of a harm reduction approach
to combating drug use---a philosophy and set of practical strategies that
promote public health and safety without requiring abstinence, and includes
such strategies as law enforcement-led diversion and needle exchanges.
As public health officials, harm reduction organizations, policymakers, and

Corrections-Based Responses to the Opioid Epidemic

3

advocates call for an increased supply of accessible and affordable naloxone, a
small but growing group of corrections professionals across the country has
started to implement jail- or prison-based overdose education and naloxone
distribution (OEND) programs to serve people who are returning to the
community following a period of incarceration. People involved in the criminal
justice system have high rates of substance use disorders; new data from the
Bureau of Justice Statistics estimates that 58 percent of people incarcerated
in state prisons and 63 percent of the sentenced population in local jails meet
criteria for drug dependence or abuse.6 People who are incarcerated also face
dramatically increased risk of death from overdose on their release due to their
recent period of abstinence and the stress and inadequate economic and social

Corrections departments are
well positioned to implement interventions
that curb the heightened risk of overdoserelated mortality following incarceration.
support that many experience during their reintegration into the community.7
A widely-cited study in Washington State found that the relative risk of
death from overdose within the first two weeks after release from prison was
129 times that expected in similar demographic groups in the general state
population.8 More recently, the Massachusetts Department of Public
Health released findings from a statewide analysis of opioid-related deaths
from 2013 to 2014 and found that people released from Massachusetts prisons
were 56 times more likely to die of an opioid overdose than the general public.9
Given the acute dangers associated with the early reentry period and
the high rates of substance use disorders among incarcerated people,
corrections departments are particularly well positioned to implement
interventions that curb the heightened risk of overdose-related mortality
following incarceration. This report focuses on the novel efforts of New
York State to implement an OEND program in the New York State
Department of Corrections and Community Supervision—a program that
teaches all soon-to-be-released people in state correctional facilities about
the risks of opioid use, especially after periods of confinement; trains them
in the use of naloxone; and offers it to them free of charge at release. The
report also highlights key considerations for other jurisdictions interested
in implementing OEND in their own correctional systems.

4

Vera Institute of Justice

New York State: A case study

N

ew York State has been dramatically impacted by the national
epidemic of drug overdose deaths. Between 2009 and 2013, the total
number of drug-related deaths rose by 40 percent across the state
and, from 2010 to 2015, the age-adjusted drug overdose death rate increased
from 7.8 to 13.6 per 100,000 residents.10 Newly-released data shows that the
rate of unintentional drug overdose deaths in 2016 reached 16.7 per 100,000
residents in New York State (excluding New York City) and 19.9 per 100,000
residents in New York City.11 Opioids are involved in the majority of these
deaths, and synthetic opioids other than methadone—such as fentanyl—
count for a rising share of deaths: between 2014 and 2015 the overdose
death rate from synthetic opioids other than methadone grew more than 135
percent in New York, the largest percent increase in the country.12
In response, the state has implemented a multipronged strategy
to equip first responders and others likely to witness overdoses with
the knowledge and tools to recognize and respond to overdoses using
naloxone. As of 2015, there were more than 225 registered overdose
prevention programs across the state, which had trained 75,000 overdose
responders and reversed more than 1,800 overdoses.13 To increase the
distribution of naloxone into high-risk communities, public health and
correctional leadership in New York State recognized the potential of
expanding overdose prevention and naloxone access to individuals
incarcerated in state prisons. In 2015, the New York State Department
of Health (DOH), the New York State Department of Corrections and
Community Supervision (DOCCS), and the Harm Reduction Coalition
(HRC) partnered to develop a novel opioid overdose and prevention
training program in New York State prisons (see “Bringing naloxone to
people incarcerated in New York State prisons” at page 7). The program
targets three key audiences for OEND.
>> People who are incarcerated. The OEND program targets all
soon-to-be-released people who are incarcerated across the state’s
54 correctional facilities, training them to understand the risks
of opioid use and to administer intranasal naloxone. Naloxone is
offered to trained individuals when they are released from prison.

Corrections-Based Responses to the Opioid Epidemic

5

Notably, all soon-to-be-released individuals are offered the training
and kits, not only those people documented to be drug-involved.
>> Corrections staff and parole officers. Recognizing that program
success hinges partly on staff acceptance, and that substance use
disorders do not exclusively impact people who are incarcerated,
the state offers overdose prevention training to corrections staff
and parole officers.14
>> Family members of incarcerated people. In partnership with
Community Health Action of Staten Island (CHASI), a local
community-based organization, Queensboro Correctional Facility
offers OEND training to family members, further elevating the
capacity of the community to respond to overdose. After family
members are trained, they are offered naloxone. 15
The training offered includes modules on a number of topics, including:
>> the risk factors for overdose, including using drugs at dosages your
body may not be accustomed to following periods of sobriety and/
or incarceration;
>> how to recognize when an overdose is occurring (for example,
shallow breathing or skin discoloration);
>> what to do when witnessing an overdose, including calling 911,
administering naloxone, and putting the person who is overdosing
in a safe position;
>> how to assemble and use an intranasal naloxone applicator;16
>> an overview of legal protections for people using naloxone or
summoning help when witnessing an overdose, like New York
State’s 911 Good Samaritan law (see “New York State’s 911 Good
Samaritan law” at page 20); and
>> a 15-minute educational video produced by HRC that reviews
important lessons from the training curriculum and features
DOCCS leadership endorsing naloxone.17

6

Vera Institute of Justice

Bringing naloxone to people incarcerated in New York State prisons
training and then will train their peers as a standard
part of their reentry planning program.

The development of New York State’s corrections-based
OEND program was initiated by the Superintendent of
Queensboro Correctional Facility, Dennis Breslin. Queensboro
Correctional Facility is a minimum-security men’s prison
located in Queens, New York that is primarily focused on
community reentry for men who are within 90 days of release.
Initially conceptualized as an effort to train corrections
officers and other staff in overdose recognition and responses
for use in their own lives, Superintendent Breslin quickly
realized the program would also be relevant to individuals
incarcerated in his facility. The program has two components.
>>

Overdose prevention training: When the pilot
program launched in February 2015, HRC conducted
train-the-trainer trainings with corrections officers
and program staff who were designated trainers.
These trainers were certified by HRC to deliver the
OEND training to their corrections peers as well as to
the people who were incarcerated. As the program
began to roll out across the state and, with an eye
toward future sustainability, it is transitioning to a
peer-to-peer model whereby incarcerated people
themselves will become certified to deliver the

>>

Naloxone distribution: Since naloxone requires a
doctor’s prescription, a “standing order” is necessary
to legally distribute naloxone to incarcerated people
within New York State prisons. A standing order is an
order from a physician that can be carried out by other
health care workers and, in some cases, laypersons,
when predetermined conditions have been met.a By
issuing a standing order in collaboration with DOH,
the medical director of DOCCS was able to designate
individuals—here, the corrections staff—who could
distribute naloxone to incarcerated people who had
received the OEND training.b

Since the program’s inception, more than 6,000 formerly
incarcerated people have received kits. Furthermore, there
have been 14 incidents of naloxone administration by formerly
incarcerated people in the community using kits distributed
to them on release. The popularity of the pilot led the state
to expand the program statewide. As of June 2017, the OEND
training was available at all 54 prisons located throughout
New York State.c

For non-patient specific prescribing and dispensing specifics of the law, see New York State Consolidated Laws, Public Health Law – PBH
§3309 (opioid overdose prevention), https://perma.cc/27D4-NH93.

a

b
The standing order also enables DOCCS nursing staff to administer naloxone by injection to any incarcerated person, staff member, or
visitor suspected of an overdose without first obtaining a physician order. See Howard Zucker, Anthony J. Annucci, Sharon Stancliff, and Holly
Catania, “Overdose Prevention for Prisoners in New York: A Novel Program and Collaboration,” Harm Reduction Journal 12, no. 1 (2015), 51-52,
https://perma.cc/YE4J-K9RS.
c

Data provided by NYS DOCCS, February 2018.

In 2016, the Vera Institute of Justice (Vera) partnered with the New
York State DOH, DOCCS, and HRC to conduct a process evaluation of the
state’s corrections-based OEND program. Vera’s six-month evaluation had
three primary goals:
>> to understand the development and implementation of the OEND
program as it began scaling across the state;
>> to describe early program results, measuring changes in knowledge
and attitudes among corrections staff and incarcerated people; and
>> to provide suggestions for program improvement based on
perceptions of key stakeholders and analysis of data showing
people who do or do not take the kit when they leave custody.

Corrections-Based Responses to the Opioid Epidemic

7

Methods and limitations
Vera’s evaluation design relied on a mixed-methods approach, using both
qualitative and quantitative data to answer the research questions. Data
collection occurred between November 2016 and April 2017 and focused
on two correctional facilities—Queensboro Correctional Facility and
Wallkill Correctional Facility. Research activities included:
>> interviews with DOCCS, DOH, and HRC leadership, as well as
with DOCCS staff who were integral to launching and expanding
the program (n=19);
>> focus groups with incarcerated people who had received the
training (n=5);
>> observations of family trainings (n=1) and trainings of incarcerated
people (n=5);
>> anonymous pre- and post-training tests of incarcerated people
(n=69); and
>> administrative data analysis on naloxone kit uptake among
individuals leaving Queensboro and Wallkill Correctional
Facilities.
For analysis of the qualitative data, the research team used Dedoose, an
application that allows researchers to organize and analyze qualitative data,
to identify major themes. All researchers on the team independently read
through all the qualitative data collected (such as observation, interview,
and focus group notes) and generated a list of main themes. The team
used these themes to define codes related to impressions of the training,
relevance to incarcerated people, and suggestions for improvement. Codes
were refined in regular research team meetings and, after a complete code
list was developed, two researchers independently coded the qualitative
data. This process allowed Vera to understand how frequently themes
arose, the relevance of particular topics, and the diverse perspectives of
leadership, corrections and program staff, and incarcerated people who
received the training.

8

Vera Institute of Justice

For the administrative data, the research team provided DOCCS
with data on all individuals from Queensboro and Wallkill Correctional
Facilities who had taken a kit on release, including their names. DOCCS
research staff then added to this file information on individuals who were
released but did not take a kit. Next, demographic and other key variables
such as length of stay, criminal offense, and release type were appended
for both groups. Finally, DOCCS stripped identifying information from
the data before returning a de-identified (anonymous) file to Vera. Vera
researchers analyzed the de-identified administrative data to examine
potential differences between those who took kits and those who did not.
Data collection was limited in a few ways. First, due to the short
evaluation period, Vera researchers were only able to collect data from
two DOCCS facilities, which were selected in collaboration with project
partners. The limited geographic scope of the research may limit the
applicability of findings across other prisons in the state. Second, analysis
of administrative data on the number of individuals taking naloxone
kits on release from custody was complicated by inconsistencies in the
way facilities throughout the state tracked kit uptake (for example, only
tracking the aggregate number of kits given out each month). This made
it difficult to draw broader conclusions about whether any factors linked
to individuals may be associated with kit uptake, such as the charges
for which a person was sentenced. Finally, although Vera had originally
intended to have DOCCS administer a brief, confidential paper-and-pencil
survey to people leaving custody to better understand why people do or
do not take naloxone when they are released, this data collection activity
was stopped after it was reported by DOCCS that the surveys were
discouraging people from taking the kits. The evaluation results do not
include any analysis of the surveys that were collected prior to cessation of
this activity.
Despite these limitations, the regularity with which core themes appeared
and their overlap with some of the existing—albeit limited—literature on
corrections-based OEND programs suggest that there are lessons from New
York that can guide the expansion of these programs nationally.18

9

Major themes and findings
Vera’s evaluation uncovered five major themes.
>> People in all positions found the program to be relevant and
empowering.
>> The training increased peoples’ knowledge about overdose and
confidence in administering naloxone.
>> Charge type (top charge in an individual’s conviction) and release
type (whether the person was released on parole, conditional
release, or reached the maximum expiration date of their sentences)
were significant predictors of whether someone took a naloxone kit
at release.
>> Incarcerated people who said they would take the kit when
released felt the potential to save a life and contribute to the public
good trumped their fears of consequences for having the kit (for
example, being in a situation while using the kit that might lead to
a parole violation).
>> Trainees who said they would not take the kit cited their distrust
of the justice system and concerns about the laws designed to offer
legal protections for people reporting an overdose.
These themes and findings are discussed in detail below.

Program relevance
The overwhelming theme that emerged in interviews, focus groups,
and observations was that New York State’s corrections-based OEND
program is both relevant and empowering to people who work within
DOCCS, as well as those who are incarcerated in the state’s prison system.
Conversations with leadership at DOCCS, DOH, and HRC emphasized
the importance of this intervention as a public health response to a
worsening opioid crisis, frequently referring to their own communities
and the experiences people in custody have when they are released. Some
DOCCS staff did cite concerns that distributing naloxone might encourage
drug use on release. The available literature on prison-based take-home

10

Vera Institute of Justice

naloxone programs indicates that these perceptions are not unique to New
York State.19 However, there is no data to suggest that the potential lack of
negative consequences from drug use that naloxone affords encourages the
misuse of opioids.
Even with this concern, most staff interviewed were supportive of
the program. As one interviewee stated, “drug problems are an issue for
everyone, not just people that are in prison,” while also highlighting that
training people and equipping them to save a life with naloxone is one
way to empower incarcerated individuals as they transition back to their
communities. As one corrections officer said, “The value of [the program]
is to put the power back into someone who does not have power—to save
someone’s life who does not have power…. We are empowering people who
otherwise wouldn’t be allowed to be empowered to do anything.”
People who were incarcerated expressed almost uniformly favorable
views of the OEND program, a finding that echoes a recent summary of
the available literature on this topic that those who participate in jail- and
prison-based training programs have overall positive impressions of takehome naloxone programs.20 Training participants emphasized the relevance
of the training to their lives as people who come from neighborhoods
and communities where drug use and overdose is common. Indeed, more
than one-third of the 69 people who filled out the pre-test administered
by Vera reported having witnessed an overdose in the past, and 9 percent
of those individuals reported having used naloxone before. People also
talked about having family members or friends who had overdosed, with
one person saying, “It’s a terrible thing to lose someone to overdose. I
saw my best friend die.” Such experiences provided the backdrop against
which many focus group participants reflected on how meaningful it was
to receive training that would equip them to save a life in the future. One
person commented, “I know there’s active use in my family since I’ve been
incarcerated, so I try to get in as much as I can from the training today. I
know I’m gonna be around that, around the holidays. I don’t use myself. But
if they’re using, I want to be able to save their life if I can.”

Corrections-Based Responses to the Opioid Epidemic

11

Increased knowledge and confidence about responding
to drug overdoses
Vera administered tests before and after naloxone training to 69 training
participants to better understand whether the OEND program increased
participant knowledge and confidence about responding to drug overdoses.
Questions were designed to assess changes in knowledge around key topic
areas covered in the training, such as how naloxone works and the steps
one should take in the event of witnessing an overdose. Vera researchers
found that the training program increased participants’ understanding
of overdose, naloxone, and legal protections available in New York State.
Although only 13 percent of respondents answered more than half of
questions correctly prior to receiving training, 73 percent were able to do
so after the training. After receiving training, 94 percent of all respondents
correctly identified the function of naloxone as stopping an opioid
overdose (compared to 50 percent prior to the training), and 93 percent

Vera researchers found that the
training program increased participants’
understanding of overdose, naloxone,
and legal protections available
in New York State.
correctly identified that people leaving prison are at increased risk of
overdose (compared to 51 percent before the training).
Furthermore, as shown in Figure 1, while before the training the
majority of respondents reported a lack of confidence in their ability to
assist in the case of an overdose, after receiving the training 89 percent
responded that they either agreed or strongly agreed with the statement “I
know how to help someone during an opioid overdose.”

12

Vera Institute of Justice

Figure 1

Increase in opioid overdose knowledge after training:
“I know how to help someone who is overdosing from an opioid.”

• Pre-training

• Post-training

60%

53%

50%
36%

40%

31%
30%
20%

26%

14%

15%

14%
8%

10%

3%
0%

0%
Completely agree

Agree

Unsure

Disagree

Completely disagree

Kit uptake at release
Vera’s administrative data analysis revealed that more than two-thirds (68 percent)
of incarcerated people who were trained in overdose prevention at Queensboro
and Wallkill took a naloxone kit on release. Notably, Queensboro and Wallkill had
different distribution strategies for naloxone kits, with Queensboro having people
affirmatively opt in to take a kit at release and Wallkill placing the naloxone kit
in the materials given to all releases and having people opt out of taking the kit
if desired. This resulted in 59 percent of people taking kits at Queensboro and 88
percent of people taking kits at Wallkill.21
Vera also used the administrative data for people released from
Queensboro between December 2016 and March 2017 to examine differences
between people who took the kit and those who did not.22 Table 1 describes
demographic characteristics and other key factors for “kit takers” and “kit
leavers.” The race-ethnic distribution within each group was similar, with
more than half identifying as black, more than one-third as Hispanic, and
less than 10 percent as white. Similarly among both kit takers and kit leavers,
about 13 percent were under 25 years of age while almost one quarter were
over 50. Just over one-third of kit takers, but fully one-half of kit leavers, had a
length of stay of less than one year. The proportion of those convicted of drug
selling was twice as high for kit leavers versus kit takers.

Corrections-Based Responses to the Opioid Epidemic

13

Table 1

Characteristics of naloxone “kit takers” and “kit leavers” released between
December 2016 and March 2017 from Queensboro Correctional Facility1
Kit takers
%

n

Kit leavers
%

n

Significant
differences2
p value

Race-ethnicity3

.72

White

5.9

14

8.6

14

Black

55.3

131

51.9

84

Hispanic

35.9

85

37.0

60

2.9

7

2.5

4

100.0

237

100.0

162

Other

Age (years)

.77

18-24

13.5

32

12.8

21

25-34

28.7

68

30.5

50

35-49

36.7

87

32.3

53

21.1

50

24.4

40

100.0

237

100.0

164

50+

Offense category

.02 **

Violent

38.4

91

31.7

52

Other coercive

15.6

37

9.2

15

Drug sales

11.4

27

21.3

35

24.5

58

26.8

44

Youthful offense

0.8

2

0.0

0

Juvenile offense

0.8

2

0.0

0

Drug possession

8.4

20

11.0

18

100.0

237

100.0

164

Property and other

Length of stay

.03 **

< 1 yr

37.1

88

50.6

83

1 - 2 yrs

37.6

89

30.5

50

3 + yrs

25.3

60

18.9

31

100.0

237

100.0

164

Release type

.01 **

Parole

31.7

75

45.7

75

Conditional release

62.9

149

48.2

79

Maximum expiration

3.8

9

6.1

10

1.7

4

0.0

0

100.0

237

100.0

164

Other

1 Twenty-five people who took kits were excluded from this analysis because their ID numbers could not be linked to
demographic and administrative data.
2 Tests were conducted to determine whether there were statistically significant differences between takers and leavers.
*** p<0.01, ** p<0.05, * p<0.10.
3 Two people who did not take kits had missing values for race and were excluded from the race panel above.

14

Vera Institute of Justice

Figure 2

Association between offense type and kit taking

Those convicted of other offenses are more likely than those convicted of drug sales to take naloxone kits.

Less likely More likely than those convicted of drugs sales
Other coercive offenses
OR 3.66***

Reference = Drug sales

Property and other
offenses
OR 1.96*

0

0.5

1

Violent felony
OR 1.95*
Drug possession
OR 1.26

1.5

2

2.5

3

3.5

4

Odds Ratios (OR)
Adjusted for age, race-ethnicity, length of stay, and release type
***p<.01 **p<.05 *p<0.1

Further analysis was conducted using logistic regression to determine if length
of stay, offense type, or release type were associated with the likelihood of taking
a kit upon release when controlling for race-ethnicity and age.23 Vera researchers
calculated odds ratios (OR) to assess the strength of association between kit taking and
variables such as length of stay, offense type, and release type.24 Length of stay was not
statistically significantly associated with kit taking. However, two other significant
predictors emerged.
Figure 2 displays the associations between offense type and kit taking. Using drug
sale offenses as a reference group, Vera researchers assessed whether people convicted
of other offense types were more or less likely to take a naloxone kit upon release.
Figure 2 shows that those convicted of other coercive offenses were statistically
significantly more likely to take kits than those convicted of drug sales—in other
words, the odds are more than three-and-one-half times greater (OR 3.66, p<.001).
Although not statistically significant, there was a similar trend among those convicted
of property and other offenses (OR 1.96, p<0.1) and violent felony convictions (OR
1.95, p<0.1). The relative reluctance of those convicted of drug sales to take kits may be
partially explained by the fear of future law enforcement contact and mistrust of the
legal protections. (See “Reasons for refusing the naloxone kit at release” on page 18.)

Corrections-Based Responses to the Opioid Epidemic

15

Figure 3

Association between release type and kit taking

Those released on conditional release were more likely than those released on parole to take naloxone kits.

Less likely

More likely than those released on parole

0

0.5

Reference =
Released on parole

Maximum
expiration
OR 0.81

Conditional release
OR 2.00**

1

1.5

2

Odds Ratios (OR)
Adjusted for age, race-ethnicity, length of stay, and offense type
***p<.01 **p<.05 *p<0.1

Figure 3 shows the associations between release type and kit taking. Using
parole as a reference group, Vera researchers assessed whether people with
other types of releases were more or less likely to take a naloxone kit. The
results indicate that people released to the community through conditional
release were statistically significantly more likely than those released on parole
to take kits (OR 2.00, p<.05). The result was not statistically significant for
those released through maximum expiration of their sentences.
In New York State, the difference between “parole” and “conditional
release” types is determined by whether the parole board is involved in
the decision to release an individual.25 In both cases, the individual is
released to community supervision. However, while a release type of parole
means that there was a parole board interview or hearing resulting in an
individual’s release, a release type of conditional release is based primarily
on the individual’s conditional release date calculation (typically two-thirds
of the maximum expiration sentence for those who received indeterminate
sentences). Although the results of the kit uptake analysis are preliminary,
they suggest that some groups may be more likely to take kits than others.
This points to the need for further research to help inform program design
and improve uptake among target groups.

16

Vera Institute of Justice

2.5

Reasons for accepting the naloxone kit at release
Even with fears about potential legal consequences of using naloxone, the
relatively high kit uptake rates suggest that many people are still willing to
use naloxone on someone who is overdosing. Focus groups with OEND
trainees and interviews with staff revealed that this willingness to accept a kit
at release centered on the theme of “saving a life.” Some participants spoke of
the potential, in the case of an overdose, to save the lives of family members
who use opioids, while others referenced their own past history of either
using or selling drugs. Even respondents who had used drugs in the past and
did not plan to use after release voiced their intention to be prepared and the
responsibility they felt to help members of their communities. One person
reflected on this, saying, “I would feel less than a man knowing that I had an
opportunity to be able to do something constructive and not take the chance.
Nah, I can’t see [myself] doing that. Plus, me, I’m just different now.”
Vera also observed trainers talking about how saving a life was an
opportunity for people to do good in their communities, especially as a

People released to the community
through conditional release were
statistically significantly more likely than
those released on parole to take kits
tactic to refocus the training if participants were fixated on their fears
and the intricate details of the 911 Good Samaritan law (see “New York
State’s 911 Good Samaritan law” at page 20). Similarly, in focus groups
and observations, Vera researchers heard people who were incarcerated
use language around “saving a life” to talk to their peers about the
benefits of taking the naloxone kit. One person said, “If you’re in a
situation to save a life, to hell with it. Even if you will get in trouble, I’m
not gonna walk by somebody dying and not do something if I can.” The
emphasis on this from program participants suggests messages conveyed
in training about saving lives and providing a public good are heard
and internalized; people who are incarcerated and receive the OEND
training overwhelmingly see naloxone as something that can benefit
their communities at large, allow them to be valuable members of their
communities, and be worth using even if it saves just one life.
Corrections-Based Responses to the Opioid Epidemic

17

Reasons for refusing the naloxone kit at release
Focus groups with people who are incarcerated and observations of
trainings also offered insights into why some people were reluctant to take
the naloxone kit at release. Although a small number of people expressed
they did not anticipate taking the kit because they did not use drugs or spend
time with people who use drugs, most people talked about their fears of
further involvement with the legal system. Two categories emerged.
>> Law enforcement, parole, and probation. People who were
incarcerated talked frequently about their previous contact with
police, parole, and probation officers—three categories of people
who have the ability to arrest and detain individuals. While not
every encounter with these justice system actors is negative,
many people voiced a deep mistrust of these agencies and
recalled personal experiences where they felt they were treated
unfairly. These past experiences contributed to skepticism about
the advisability of carrying the kit in the community, despite
reassurances from trainers that police and parole officers know
about naloxone and frequently carry the kit themselves, and that
all parole officers are receiving the same OEND training through
the Department of Corrections and Community Supervision
(DOCCS). For example, one trainee talked about how he suspected
that merely being in possession of the kit would give police officers
more reason to search them for drugs, saying “… now you’re
profiled; carrying that big, bulky, ugly bag in your pocket.” Others
feared the possibility of receiving a parole violation—even though
having or using the kit is not a parole violation in and of itself. As
one training participant reflected, “They takin’ you to the station for
more questioning. I’m [going to] leave the kit right here; I’m done. I
seen data and people get violated for less.”
>> Good Samaritan laws. In addition to distrust of individual system
actors, people who were incarcerated also described mistrust of
the legal protections—known as Good Samaritan laws—that are
designed to minimize fear of arrest and encourage people to call
911 when someone is having a drug or alcohol overdose. (See “New
York State’s 911 Good Samaritan law” on page 20.) The feeling
among many focus group respondents was that individuals on

18

Vera Institute of Justice

parole are “not regular citizens” and are therefore not afforded the same
protections as other people under the law. One person remarked:
The Good Samaritan law, they say they won’t violate
you, but who’s to know that particular parole officer is
in the loop? Now you gotta fight to get out of it even
though there is the Good Samaritan law. How are they
gonna apply it? If it’s being used the same way courts use
regular criminal activity, then I don’t trust it. It might as
well not exist. They can interpret it the way they want….
If you’re the felon you don’t ever get the benefit of the
doubt. You can’t sit there and tell the cop at the scene
that you’re claiming Good Samaritan. You have to wait
and tell your PO, meanwhile you’re sitting on Rikers
Island waiting, and you might’ve had a job. It can get a
little hairy in that situation.
Interviews with staff and leadership further revealed that trainers
struggled to determine what to convey about the 911 Good Samaritan law
and interactions with parole. Some trainers distributed detailed handouts
that describe what the 911 Good Samaritan law covers in New York, while
others talked about the law and its interactions with parole in more general
terms, telling trainees that they would not receive a parole violation for drug
possession, but could expect to be violated for things like being in possession
of a gun or being out past curfew. The ambiguity of what the law does and
doesn’t cover, and how it protects or doesn’t protect people with criminal
records who are on parole, led some trainers to caveat the information they
conveyed to trainees. For example, in one of the trainings Vera observed, a
trainer said, “In all honesty, they say it [the 911 Good Samaritan law] will help
you. You can believe it or not, it’s up to you.”

Corrections-Based Responses to the Opioid Epidemic

19

New York State’s 911 Good Samaritan law
Signed into law by Governor Andrew Cuomo in 2011,
New York’s 911 Good Samaritan law offers New Yorkers
criminal immunity from charge or prosecution for certain
offenses if they witness or are a victim of a life threatening
medical emergency and seek medical attention.a In limited
circumstances, the law also protects against arrest for very
small or residual amounts of controlled substances.b New
York’s law is broader than most other Good Samaritan laws
because, in addition to applying to people who witness or
are a victim of a drug or alcohol overdose, the law protects
people who seek medical services for life threatening
emergencies that are not drug- or alcohol-related.
Immunity is only applied to certain criminal offenses directly
resulting from the individual seeking medical care. The
offenses covered under the law include:

a

>>

possessing controlled substances
(anything under eight ounces);

>>

possessing alcohol, where underage drinking
is involved;

>>

possessing marijuana (any quantity);

>>

possessing drug paraphernalia; and

>>

sharing drugs.

The law does not protect individuals from the following:
>>

felony possession of a controlled substance (eight
ounces or more);

>>

sale or intent to sell controlled substances;

>>

open warrants for one’s arrest; and

>>

violation of probation or parole.

The law also provides for an “affirmative defense”—or
a defense which, if proven by the defendant, defeats or
mitigates negative legal consequences—for criminal sale
of controlled substance offenses. The affirmative defense
protection does not apply to defendants who have prior Class
A 1st or 2nd degree felonies or any Class B felony convictions.

For the provisions of the law, see New York S04454 (2011), https://perma.cc/G4FY-ZLRZ.

New York State Department of Health, New York State’s 911 Good Samaritan law Protects YOU (Albany, NY: New York State Department of
Health, 2016), https://perma.cc/VV9L-LP6B.
b

Implementing
corrections-based strategies

N

ew York State’s prison-based OEND program offers a number of lessons
for other jurisdictions that are looking to implement similar correctionsbased strategies to reduce opioid-related mortality for people leaving
custody and promote multipronged approaches to the opioid epidemic. Key
considerations center on program development and programmatic components.

Program development
To develop a successful OEND program, a number of factors are important to
address from the outset to avoid pushback from correctional leadership and
staff, as well as the community at large. In interviews with leadership, DOCCS
largely attributed programmatic success to three key factors: (1) having a

20

Vera Institute of Justice

strong champion for the program; (2) focusing on staff buy-in at inception;
and (3) forming key partnerships with community-based organizations.

Identifying a champion
The New York State program required strong leadership from the beginning
to ensure successful implementation and expansion. Administrators across
DOCCS recognized the importance of this leadership, identifying the
superintendent of Queensboro Correctional Facility as “a major driving force”
in both getting the pilot off the ground and expanding the program statewide.
Jurisdictions looking to pilot similar programs should identify a champion who:
>> understands the value of the program and can convincingly
communicate its importance to stakeholders;
>> tackles obstacles with tenacity and creatively solves problems; and
>> has the respect of line staff, mid-level management, and agency
administrators.

Generating staff buy-in
Leadership in New York State emphasized the importance of having staff at
all levels on board with the program, which was achieved by initially training
staff on overdose prevention and distributing naloxone to them for personal
use.26 This approach to generating buy-in accomplished three goals.
>> It brought agency leadership on board by centrally focusing
the program on staff wellness. In conducting overdose education
training and distributing naloxone among corrections officers
and other staff who work in facilities, DOCCS demonstrated its
commitment to ensuring staff have the tools they need to lead
healthy lives and promote wellbeing in their communities. This
focus on staff wellness was appealing to agency leadership as well
as to facility leadership, like prison superintendents, who live and
work in communities throughout the state that are deeply impacted
by the opioid crisis. Offering these managers tools to address
the needs of their staffs and their communities was essential to
generating excitement for the program, especially as the pilot
expanded statewide.

Corrections-Based Responses to the Opioid Epidemic

21

>> It introduced important harm reduction concepts to staff. Justice
systems—and particularly correctional facilities—have historically
responded to substance use disorders by relying on abstinencebased treatment options that require the cessation of all drugs in
order to achieve recovery. In contrast, harm reduction hinges on
the understanding that drug use is complex and encompasses a
continuum of behaviors, that there are some ways of using drugs
that are safer than others, and that negative consequences—like
overdose death—can be reduced.27 While many people interviewed
continued to emphasize the importance of abstinence, staff
also discussed their shifting attitudes regarding drug use. One
corrections officer emphasized the need to equip incarcerated people
with practical information, commenting, “There’s no point of telling
them no, they can’t do it, it’s illegal. So let’s look at it with another
aspect . . . let’s give you information and education on doing it safely
. . . it’s hard to get them off [drugs] but maybe we can inform them to
where they make proper decisions about what they do.” A different
officer reflected on the need to separate substance use from a person’s
worth. “You don’t need to be a good or bad person to overdose,”
he reflected. Exposure to harm reduction principles through staff
training allowed staff to see drug use not as a moral issue, but as one
that requires a holistic approach to treatment and recovery.
>> It limited “us” versus “them” dynamics between corrections
officers and incarcerated people within the facilities.
In addition to engendering support for the program among
correctional leadership, staff training also offered additional
opportunities to build support with officers. In correctional
settings, where resources are frequently devoted to programming
for people who are incarcerated and where staff often work long
hours, it is not uncommon for staff to feel as if their needs are
not the priority of department leadership. In providing the same
training to corrections officers and people who are incarcerated,
DOCCS signaled to staff that their needs were equally as important
as the needs of the incarcerated population. Furthermore, staff
frequently addressed skepticism from incarcerated people toward
naloxone in training settings, citing their own training and
emphasizing the legitimacy of the training they were receiving.

22

Vera Institute of Justice

Partnering with community-based organizations
Community partnerships with the Harm Reduction Coalition (HRC) and
Community Health Action of Staten Island (CHASI) were essential for
launching and sustaining the New York State program. HRC provided
train-the-trainer trainings to DOCCS trainers and created supplemental
training resources, like the production of a video that is shown during
trainings; and they continue to be instrumental partners as the program
expands statewide. CHASI, on the other hand, conducts training for
the family members of incarcerated people at Queensboro Correctional
Facility. For jurisdictions looking to pilot similar programs, building strong
partnerships with community-based harm reduction and public health
organizations, as well as primary care providers, is an important first step
in constructing the training curriculum, solving challenges unique to each
agency and community, and developing sustainability mechanisms.

Programmatic components
Beyond the design of the program, jurisdictions implementing correctionsbased programs should consider a number of logistical factors that can
contribute significantly to programmatic successes and failures. Focus
groups with incarcerated people in New York State cited a number of
elements of the OEND training that either served to facilitate the training
lessons or created barriers to learning.

Training delivery
Observations of trainings for incarcerated people and family members, as
well as focus groups with people who were incarcerated, indicated that
the method of training delivery was an important factor in its success.
Jurisdictions seeking to implement similar programs should:
>> Emphasize discussion. Observations of trainings revealed
that some instructors delivered the training in a rigid format,
sometimes reading off a script or addressing bullet points, which
limited opportunities for discussion. In contrast, other trainers
were more comfortable with a flexible approach to communicating
training materials, frequently asking trainees to discuss their
personal experiences with the subject matter and allowing
enough time for questions and dialogue. Focus groups suggested

Corrections-Based Responses to the Opioid Epidemic

23

discussion-based formats may be more successful; and multiple
people talked about how having an “open conversation” would be
more productive.
>> Find credible messengers. Another important consideration for
jurisdictions is the credibility of the individual delivering the training.
With the exception of one observation of a peer-led training at
Wallkill, all trainings Vera observed were led by program and security
staff. Focus group respondents cited tensions between security staff
and incarcerated people as being counterproductive to the training’s
effectiveness, saying that their distrust of security staff made them
have a difficult time believing staff were invested in their success.
Furthermore, incarcerated people questioned the credibility of
DOCCS-sponsored information, believing that the information may
be out of date and that security staff were communicating information
that was beyond their areas of expertise. Both staff and incarcerated
people suggested that the most effective trainers would be those with
some experience of addiction, overdose, or naloxone. One focus group
participant, when discussing the prospect of having someone who
is incarcerated conduct the training instead of DOCCS staff, said, “I
think they can reach and communicate better. They feel our pain. And
they can get the message across.” Finding credible messengers has
the added benefit of mitigating any fears of taking the naloxone kit;
by ensuring the training is delivered by someone incarcerated who
people trust and respect, jurisdictions can address fears proactively. If
a jurisdiction includes information regarding Good Samaritan laws
in the training, instructors should be well-trained on the law, should
have access to supplemental materials (such as handouts and FAQs)
that can be shared with trainees, and should be prepared to facilitate
discussions about what the law does and doesn’t protect.

Timing and location of the training
To ensure information presented is retained, feedback gathered in focus
groups indicates that training should be conducted at a time when people
are not otherwise unsettled. For example, given the short lengths of stay
for many of the people who are incarcerated at Queensboro Correctional
Facility, the OEND training is provided at intake orientation. While this
method ensures that all people in the facility receive the training before they

24

Vera Institute of Justice

are released, it is also a time that can be hectic and stressful. Indeed, Vera
heard from some people that they did not remember the OEND training
conducted during intake orientation at all until they were reminded by their
peers. If—due to administrative and logistical reasons—it is not possible
to avoid conducting trainings during an otherwise chaotic time period,
jurisdictions should consider strategies to mitigate those factors, such as
supplemental trainings or reminder notifications prior to release.

Reinforcing lessons
Finding ways to reinforce training materials is an important consideration
for jurisdictions implementing corrections-based OEND trainings, and
methods should be employed with fidelity. Interviews and focus groups
in New York State revealed people appreciate opportunities to reinforce
the information provided during trainings. The New York State program
accomplished this in two ways.
>> Hands-on training. Having the ability to practice assembling the
naloxone kits as part of the training, rather than only observing a
demonstration of it, was widely cited—by staff, leadership, and people
who are incarcerated—as the most important training component.
Some people talked about how having the opportunity to put the kit
together helped give them “confidence” they could do it on their own,
without having to read the instructions, when an emergency was
occurring. Other people talked about how many “people learn better
hands on.” In addition to being able to practice assembling the kits,
people also recommended incorporating other props, like rescue dolls,
to better demonstrate key concepts such as rubbing the sternum with
the knuckles to stimulate an overdosing person, the recovery position,
rescue breathing, and chest compressions.28
>> “Staying Alive on the Outside (New York State)” (https://vimeo.
com/164337787) training video. The inclusion of a brief video in
trainings allowed DOCCS to include perspectives on naloxone and
overdose prevention from people who would not be able to present
at every training, like a person who used naloxone to save someone’s
life while they were on parole. Focus group participants said they
responded well to hearing from people they could relate to:
The video was good. It was people from our
neighborhoods, you could just see. Not some

Corrections-Based Responses to the Opioid Epidemic

25

doctors sitting there. A lot of time that creates a
wall; using words we don’t know. It had people
just like us—ex-prisoners, ex-cons, people in the
community that might never been arrested but
in the cycle of drug addiction.
If a video is used in conjunction with the training curriculum,
jurisdictions should ensure that trainers are equipped with the
appropriate technology, and trainers should do their best to create
an environment conducive to watching the video (by, for example,
making sure the volume is at an audible level, pulling the television
close enough to be seen, and darkening the room if needed).

Family involvement
As with many aspects of reentry, family involvement is an important
component of success when people are released from custody.29 Studies
indicate family engagement is critical for ensuring people have access to
housing, social, and financial support—important ingredients for success for
everyone, including those who are reentering the community after a period of
incarceration and people who have a substance use disorder.30 Offering family
members training provided a number of benefits in New York, including:
>> Incentivizing training. At Queensboro Correctional Facility,
the opportunity for a visit with family is the primary way in
which this training is marketed, and it appears to be a successful
technique. Queensboro Correctional Facility reported that as of
February 2017, approximately 169 visitors had been trained on
overdose prevention.
>> Encouraging larger conversations about drug use. Vera staff
observed family members encouraging people who are incarcerated
to take the naloxone kit when they are offered it at release.
>> Increasing the number of kits in the community. The family
trainings had high rates of kit uptake. Of the 169 visitors that
Queensboro Correctional Facility reported had received training on
overdose prevention, approximately 152 kits had been taken. During
Vera’s observations of the family trainings, some family members
took more than one kit in order to have additional kits in their home

26

Vera Institute of Justice

When implementing family trainings, jurisdictions should consider
the proximity of correctional facilities to the communities where the
incarcerated population is returning. Investing resources into developing
a family training when the incarcerated population cannot easily have
visitors due to distance or travel costs is not likely to be worthwhile,
though those facilities may consider offering trainings when families are
more likely to visit (for example, on holidays). For jurisdictions that are
proximate to reentry communities, family trainings should be offered
at times that are convenient for family members in order to optimize
participation. Additionally, jurisdictions should consider sustainability
mechanisms, including budgeting staff time to scheduling trainings and
forming partnerships with community-based organizations.

Distribution methods
Unlike community-based initiatives, where naloxone kits are typically
distributed directly following the training, corrections-based settings
require a delay between the initial training and the actual distribution
of naloxone, since naloxone is distributed at the time of release from
custody and trainings are conducted while people are still incarcerated.
Distribution mechanisms influence the rate of kit uptake, and jurisdictions
should consider the goals of their program when determining which
mechanism makes the most sense for them. Depending on the facility,
DOCCS uses both an opt-in system, where people leaving custody are
offered the kit at the time of release and individuals may choose to either
take or leave the kit; and an opt-out system, where kits are included in a
person’s belongings and an individual has to ask to have it removed. Both
systems have their advantages and their disadvantages: the opt-in system
allows people who feel like the kit will be most relevant to them to take it,
while people who don’t think the kit will be useful can leave it behind, thus
conserving available kits; the opt-out system allows wider distribution,
even if some people taking the kit are unlikely to ever encounter a situation
where it would need to be used. If a jurisdiction has a limited supply of
kits, the opt-in system may be helpful in reserving kits for those who are
most likely to use them. If naloxone kit availability is not a concern, the
opt-out system is likely the most effective option for wide distribution.31

Corrections-Based Responses to the Opioid Epidemic

27

Helpful resources for jurisdictions implementing corrections-based naloxone distribution programs
The following resources provide useful information
and programmatic tools for jurisdictions seeking to
implement naloxone distribution programs through their
correctional systems:
>>

“Staying Alive on the Outside (New York State).”
(https://vimeo.com/164337787) This video can be used
as part of a corrections-based naloxone distribution
training program. It explains the risk of post-release
overdose and teaches viewers to recognize and
prevent opioid overdoses.

>>

New York State’s opioid overdose prevention
program. (https://perma.cc/9FQP-F6X9) This website
from the New York State Department of Health
provides resources for the public and providers on
naloxone distribution and opioid overdose prevention.

>>

Harm Reduction Coalition’s overdose prevention
website. (https://perma.cc/5WS3-GDJK) This
clearinghouse provides information about preventing

drug overdose, including tools and best practices
related to naloxone and opioid overdose.
>>

New York State’s 911 Good Samaritan law fact
sheet. (https://perma.cc/VV9L-LP6B) This singlepage handout from the New York State Department
of Health explains in lay terms the legal protections
provided to individuals who call 911 if they are either
experiencing an overdose or witnessing someone
overdosing and require emergency medical care.

>>

State-by-state guide on naloxone access laws and
Good Samaritan laws. (http://www.pdaps.org/)
The Prescription Drug Abuse Policy System is funded
by the National Institute on Drug Abuse to track key
state laws related to prescription drug abuse. Users
can navigate the interactive website to see whether
their jurisdiction has naloxone access laws and Good
Samaritan laws.

Conclusion

E

xpanding access to naloxone is widely recognized as a critical
strategy for tackling the opioid epidemic. The President’s Commission
on Combating Drug Addiction and the Opioid Crisis recently
recommended that naloxone be made as widely accessible as possible, urging
the president to issue a federal mandate that all law enforcement officers carry
it and to empower the Health and Human Services Secretary to negotiate
reduced pricing for governmental units.32 While these recommendations
should undoubtedly be implemented, ensuring that naloxone is available
where there is the greatest chance for an overdose also requires more focused
attention on distribution to populations that have increased risk of overdose
mortality. To achieve this will require closer attention to incarcerated
populations and a broader commitment to ensuring that people who are
incarcerated have naloxone on hand when they return to the community. The
evidence is too extensive—and the consequences too great—to ignore the
needs of incarcerated individuals during such a critical period of transition.

28

Vera Institute of Justice

The New York State OEND program is a milestone collaboration
between a state’s correctional system, its public health department, and
community-based harm reduction programs. It is the first state correctional
system in the country to implement such a comprehensive approach
throughout its facilities, and it joins only a handful of jail-based programs
to make naloxone accessible to individuals as they return to the community
following a period of incarceration. Importantly, this process evaluation
has demonstrated that a corrections-based OEND program is acceptable
to a wide range of stakeholders and feasible within the correctional
environment. Vera’s evaluation found that people in all positions found the
program to be relevant and empowering, and that incarcerated people who
received training increased their knowledge and confidence about overdose
and administering naloxone. Furthermore, the palpable ideal of saving a life
led almost all incarcerated people Vera staff spoke with to anticipate taking
a naloxone kit on their release.
Increasing the number of corrections-based OEND programs is a
critical strategy for combating the opioid epidemic and can save the lives
of formerly incarcerated people as well as members of their families and
communities. But there is work to be done. Capitalizing on the increased
need to develop viable strategies that will stem the rising opioid-related
death toll, criminal justice stakeholders should push for developing
OEND programs in their correctional facilities that can impact public
health and safety. At the same time, concrete guidance is needed for
those jurisdictions that can develop the support for such programs—
guidance on topics ranging from how to partner with public health
departments and community-based harm reduction organizations, to how
to develop standing orders for naloxone distribution, to how to best share
information about Good Samaritan laws so that formerly incarcerated
people have a realistic sense of the legal protections afforded to them. The
experience of New York State demonstrates that, with additional guidance,
many other states can develop OEND programs within their correctional
systems and contribute to a comprehensive response to the opioid
epidemic in this country.

Corrections-Based Responses to the Opioid Epidemic

29

Endnotes
1	Centers for Disease Control and Prevention, Provisional
Counts of Drug Overdose Deaths, as of 8/6/2017,
https://perma.cc/JX4K-BT53.
2	Rose H. Rudd, Puja Seth, Felicita David, and Lawrence
Scholl, “Increases in Drug and Opioid-Involved
Overdose Deaths—United States, 2010-2015,” Morbidity
and Mortality Weekly Report 65, no. 50-51 (2016),
1445-52,https://perma.cc/GMP6-CLDS.
3	The White House, “President Donald J. Trump is Taking
Action on Drug Addiction and the Opioid Crisis,” press
release (Washington, DC: The White House, October 26,
2017), https://perma.cc/MW53-FLSM; and The President’s
Commission on Combating Drug Addiction and the Opioid
Crisis (President’s Opioid Commission), The President’s
Commission on Combating Drug Addiction and the Opioid
Crisis: Final Report Draft (Washington, DC: President’s
Opioid Commission, 2017), https://perma.cc/68JV-H6D6.
4	The Network for Public Health Law, Legal Interventions to
Reduce Overdose Mortality: Naloxone Access and Overdose
Good Samaritan laws (Edina, MN: Network for Public
Health Law, 2017), https://perma.cc/4MWL-4SXN
5	Karen Mahoney, “FDA Supports Greater Access to Naloxone
to Help Reduce Opioid Overdose Deaths,” FDA Voice,
August 10, 2016, https://perma.cc/5YAT-X7FS.
6	Jennifer Bronson, Jessica Stroop, Stephanie Zimmer, and
Marcus Berzofsky, Drug Use, Dependence, and Abuse
Among State Prisoners and Jail Inmates, 2007-2009
(Washington, DC: Bureau of Justice Statistics, 2017),
https://perma.cc/4CQ7-JEVW.
7	Sarah E. Wakeman, Sarah E. Bowman, Michelle McKenzie,
et al., “Preventing Death Among the Recently Incarcerated:
An Argument for Naloxone Prescription Before Release,”
Journal of Addictive Diseases 28, no. 2 (2009), 124-29.
8	Ingrid A. Binswanger, Marc F. Stern, Richard A. Deyo, et
al., “Release from Prison—A High Risk of Death for Former
Inmates,” New England Journal of Medicine 356 no. 2
(2007), 157-65,https://perma.cc/7QPN-7TGQ.
9	Massachusetts Department of Public Health, Data Brief:
An Assessment of Opioid-Related Deaths in Massachusetts
2013-2014 (Springfield, MA: Massachusetts Department of
Public Health, 2016), 6, https://perma.cc/2MMM-B25A.

30

Vera Institute of Justice

10	For the increase in the number of drug-related deaths,
see New York State Department of Health AIDS Institute,
Opioid Poisoning, Overdose and Prevention:
2015 Report to the Governor and NYS Legislature
(New York: New York State Department of Health, 2015), 1,
https://perma.cc/785F-J4GQ. For the increase in the
age-adjusted drug overdose death rate, see Centers for
Disease Control, National Vital Statistics System,
Mortality. CDC WONDER. (Atlanta, GA: US Department
of Health and Human Services, CDC; 2016),
https://perma.cc/4D4U-WJKA.
11	For the drug overdose death rate in New York State, see New
York State Department of Health, New York State – County
Opioid Quarterly Report (Albany, NY: New York State
Department of Health, 2017), 8, https://perma.cc/S5XW-LPQC.
For the rate in New York City, see New York City Department
of Health and Mental Hygiene, “Unintentional Drug Poisoning
(Overdose) Deaths in New York City, 2000 to 2016,” Epi Data
Brief, June 2017, no. 89 (2017), https://perma.cc/6F4A-J3GZ.
12	Rudd et al., 2016. Also see New York State Department
of Health AIDS Institute, Opioid Poisoning, Overdose
and Prevention: 2015 Report to the Governor and NYS
Legislature (New York: New York State Department of
Health, 2015).
13	Howard Zucker, Anthony J. Annucci, Sharon Stancliff,
and Holly Catania, “Overdose Prevention for Prisoners in
New York: A Novel Program and Collaboration,”
Harm Reduction Journal 12, no. 1 (2015), 51-52,
https://perma.cc/5MJX-Z5NE.
14	For the training of corrections officers, the focus was on
potential naloxone kit use in their personal lives, not on
training them to use naloxone within the prison environment
if witnessing an overdose by an incarcerated person.
15	As of the time of this writing, family training is only offered
at Queensboro Correctional Facility. The partnership with
CHASI provides for CHASI staff to run the trainings and
administer naloxone directly to family members. This is
critical since the standing order passed by DOCCS only
covers incarcerated people—not their family members.
See “Bringing naloxone to people incarcerated in New York
State prisons” on page 7 for additional information on the
standing order.
16	Naloxone can be administered either through the nose,
using a nasal spray (intranasal naloxone), or by injecting
the naloxone into a muscle, using a syringe. In New York

successful kit taking, while controlling for the influence
of additional factors (such as age) that may also affect
kit taking.

State, intranasal naloxone is distributed to people leaving
DOCCS custody.
17	The video, “Staying Alive on the Outside (New York State),”
covers the same topics as the training curriculum.
It features the Acting Commissioner of DOCCS, a regional
director of community supervision, peer educators, and a
person who used naloxone to save someone’s life
while they were on parole. It can be viewed at
https://vimeo.com/164337787.
18	For a comprehensive review of take-home naloxone
programs in correctional settings, see Meredith Horton,
Rebecca McDonald, Traci C. Green, et al., “A Mapping
Review of Take-home Naloxone for People Released from
Correctional Settings,” International Journal of Drug Policy
46, no. 1 (2017), 7-16.
19	See Arun Sondhi, George Ryan, and Ed Day, “Stakeholder
Perceptions and Operational Barriers in the Training
and Distribution of Take-home Naloxone within Prisons in
England,” Harm Reduction Journal 13, no. 1 (2016), 5-12;
and Alexander R. Bazazi, Nickolas D. Zaller, Jeannia Jiani
Fu, and Josiah D. Rich, “Preventing Opiate Overdose
Deaths: Examining Objections to Take-home Naloxone,”
Journal of Health Care for the Poor and Underserved 21,
no. 4 (2010), 1108-13.
20	Horton et al. (2017).
21	Vera worked with leadership at Queensboro and Wallkill
DOCCS facilities to gather administrative data related to
kit uptake and people released. The administrative data
available for each facility was different due to differences
in data collection. At Queensboro, data were analyzed for
the period December 2016 to March 2017 and revealed that
59 percent of 401 people released took a kit. At Wallkill,
data was analyzed for the period February 29, 2016 to
March 30, 2017 and showed that 88 percent of 177 people
released during this period took a kit. (Wallkill data did not
include people released in January 2017; no kit distribution
occurred during this month due to a recall on naloxone).
22	Due to the opt-out system of kit distribution at Wallkill
Correctional Facility, which resulted in much higher
kit acceptance rates than the opt-in approach, Vera
researchers only analyzed the demographics of kit takers
and non-kit takers at Queensboro Correctional Facility.
23	Logistic regression is a statistical method that tests whether
the factor of interest (such as release type) predicts

24	Odds ratios are used to assess the relative strength of
associations. An odds ratio greater than one indicates
higher odds of kit taking.
25	New York State Department of Corrections and Community
Supervision (DOCCS), “New York State Parole Handbook,”
https://perma.cc/8HCR-N3WW.
26	The importance of staff engagement and support also
emerged as a critical factor for program success in a
recent study of a take-home naloxone program in 10 prisons
in the United Kingdom. See Sondhi, Ryan, and Day (2016).
27	Jim Parsons and Scarlet Neath, Minimizing Harm: Public
Health and Justice System Responses to Drug Use and the
Opioid Crisis (New York: Vera Institute of Justice, 2017), 5,
https://perma.cc/8AGG-NJQQ.
28	New York State’s training program does not currently use
props other than the naloxone kit. When asked about how
they would improve the training, a number of people who
are incarcerated suggested incorporating other props.
29	Rebecca L. Naser and Nancy G. La Vigne, “Family
Support in the Prisoner Reentry Process: Expectations
and Realities,” Journal of Offender Rehabilitation 43, no. 1
(2006), 93-106.
30	See Marta Nelson, Perry Deess, and Charlotte Allen, The
First Month Out: Post-Incarceration Experiences in New York
City (New York: Vera Institute of Justice, 1999),
https://perma.cc/8CGP-KJG9; and Alicia S. Ventura and
Sarah M. Bagley, “To Improve Substance Use Disorder
Prevention, Treatment and Recovery: Engage the Family,”
Journal of Addiction Medicine 11, no. 5 (2017), 339-41.
31	There is emerging literature on opt-in versus opt-out
strategies for providing naloxone kits, with recent research
about pharmacy-distributed naloxone finding that an optout strategy can improve naloxone provision and reduce
stigma. See Traci C. Green, Patricia Case, Haley Fiske, et
al., “Perpetuating Stigma or Reducing Risk? Perspectives
from Naloxone Consumers and Pharmacists on PharmacyBased Naloxone in 2 States,” Journal of the American
Pharmacists Association 57, no. 2 (2017), S19-S27.
32	The President’s Commission on Combating Drug Addiction
and the Opioid Crisis, Final Report Draft (2017).

Corrections-Based Responses to the Opioid Epidemic

31

32

Vera Institute of Justice

Acknowledgments
The authors are grateful to the many people who shared their experiences with us about the
development of the overdose education and naloxone distribution program in New York State,
particularly the staff and incarcerated men at Queensboro Correctional Facility and Wallkill
Correctional Facility. We especially thank Valerie White, New York State Department of
Health; Carl Koenigsmann, David Aziz, Sarah Peterson, Dennis Breslin, Delta Barometre, and
Catherine Jacobsen, New York State Department of Corrections and Community Supervision;
and Sharon Stancliff, Harm Reduction Coalition. The authors would also like to thank Marilyn
Sinkewicz, for her expert assistance in reviewing the administrative data; Jim Parsons and
Ram Subramanian, for their valuable review and comments; Cindy Reed for excellent editing;
and Gloria Mendoza and Carl Ferrero, for designing the report.

About Citations
As researchers and readers alike rely more and more on public knowledge made available
through the Internet, “link rot” has become a widely-acknowledged problem with creating
useful and sustainable citations. To address this issue, the Vera Institute of Justice is
experimenting with the use of Perma.cc (https://perma.cc/), a service that helps scholars,
journals, and courts create permanent links to the online sources cited in their work.

Credits
© Vera Institute of Justice 2018. All rights reserved. An electronic version of this report is posted on Vera’s
website at www.vera.org/corrections-responses-to-opioid-epidemic.
The Vera Institute of Justice is a justice reform change agent. Vera produces ideas, analysis, and research
that inspire change in the systems people rely upon for safety and justice, and works in close partnership with
government and civic leaders to implement it. Vera is currently pursuing core priorities of ending the misuse
of jails, transforming conditions of confinement, and ensuring that justice systems more effectively serve
America’s increasingly diverse communities. For more information, visit www.vera.org.
For more information about this report, contact Leah Pope, acting director, Substance Use and Mental Health
Program, lpope@vera.org.

Suggested Citation
Vedan Anthony-North, Leah G. Pope, Stephanie Pottinger, and Isaac Sederbaum. Corrections-Based
Responses to the Opioid Epidemic: Lessons from New York State’s Overdose Education and Naloxone
Distribution Program. New York: Vera Institute of Justice, 2018.

Corrections-Based Responses to the Opioid Epidemic

33

Vera Institute of Justice
233 Broadway, 12th Fl
New York, NY 10279
T	212 334 1300
F	212 941 9407

Washington DC Office
1111 14th St., NW, Ste 920
Washington, DC 20005
T	202 465 8900
F	202 408 1972

New Orleans Office
1307 Oretha Castle
Haley Blvd., Suite 203
New Orleans, LA 70113
T	504 655 6277

Los Angeles Office
707 Wilshire Blvd., Ste 3850
Los Angeles, CA 90017
T	213 223 2442
F	213 955 9250

 

 

Prison Phone Justice Campaign
PLN Subscribe Now Ad 450x450
Federal Prison Handbook