Structural contradictions in providing opioid use disorder care within the total institution of carceral facilities: Perspectives from patients and community service providers in Maryland.

Though carceral facilities have emerged as a de facto substance use treatment system, access to medications for opioid use disorder (MOUD) in carceral facilities remains restricted. Limited research has focused on the lived experience of individuals who are incarcerated and examined how structural factors shape their experiences receiving carceral-based MOUD. Drawing on Total Institution Theory, this study qualitatively explores MOUD provision in Maryland carceral facilities and how patients experience opioid use disorder (OUD) care while incarcerated. We conducted in-depth interviews with patients with OUD who were recently released from incarceration (n = 16) and staff at (n = 11) a community-based low-barrier buprenorphine program. Hybrid inductive-deductive coding and the constant comparison method were applied. Structural-level contradictions within the total institution of carceral facilities were challenges in the effective provision of MOUD (e.g., misalignment of medical and carceral priorities in OUD management). These contradictions manifested in patients' negative experiences with medical care (e.g., lack of person-centered care) and with drug use- or MOUD-related stigma. Patients' reliance on the carceral drug market to self-treat their OUD and withdrawal symptoms, within the context of a total institution that was failing to meet their unique medical needs and MOUD preferences, emerged as a critical aspect of their experiences. As states consider implementing or expanding carceral-based MOUD programs, carceral medical systems must examine their goals in providing MOUD and evaluate how best to provide person-centered care. The expansion of mandates requiring MOUD provision in carceral facilities, realistic enforcement of mandates, and accompanying funding can enhance quality of care.