Overcoming Barriers to MOUD in the Justice System

The opioid crisis continues to devastate communities across the United States, and the justice system often finds itself on the front lines. Individuals with opioid use disorder (OUD) are overrepresented in courts, probation, and jails, yet many continue to face significant obstacles to receiving evidence-based care. Medications for opioid use disorder (MOUD)—including methadone, buprenorphine, and extended-release naltrexone—are gold-standard treatments that reduce overdose deaths, improve treatment retention, and support long-term recovery. Still, use of MOUD in the justice system remains alarmingly limited.

An expanding body of research is shedding light on the complex and persistent barriers that limit access to medications for opioid use disorder (MOUD) within the justice system. Studies conducted in Illinois, Florida, Alabama, and New York reveal the primary challenges preventing court-involved individuals from these medications.

Stigma and Misconceptions: A Persistent Cultural Divide

One of the most entrenched barriers to MOUD in the justice system is stigma—within the courts, probation departments, treatment systems, jails, and communities. Many court professionals, including judges, prosecutors, attorneys, and probation officers, harbor misconceptions about MOUD, viewing it as “trading one addiction for another.” Methadone, in particular, is frequently distrusted, even though it is the most rigorously studied and effective MOUD.

In both Florida and Illinois, researchers found that court and probation staff were significantly more open to referring individuals to treatment with naltrexone or buprenorphine than methadone^{1, 2}. This preference seems to reflect treatment biases rather than clinical guidance. Importantly, attitudes toward MOUD were closely tied to perceptions of treatment providers. Providers who offered wraparound care and counseling were seen as more trustworthy, while clinics that focused solely on medication were sometimes labeled as “pill mills”¹.  Court professionals often lacked accurate information about how these medications work, their safety, and their efficacy.

Cost and Accessibility: Structural Challenges in a Fragmented System

Cost remains a formidable barrier, especially in states that have not expanded Medicaid. In many jurisdictions, individuals are responsible for paying out-of-pocket for MOUD, including transportation to and from appointments. This is especially problematic in rural areas, where treatment providers may be few and far between².

Even when providers exist, limited program capacity, long waitlists, and restrictive intake procedures delay treatment. For methadone, federal law requires individuals to access the medication through a certified opioid treatment program (OTP), which may be inaccessible in certain communities. Buprenorphine prescribers, too, are in short supply, particularly in rural areas³.

Training and Knowledge Gaps: A Missed Opportunity for Engagement

Across court and probation settings, limited training and understanding of MOUD contribute to underutilization of MOUD in the justice system. A statewide survey in Illinois found that most probation department leaders and their staff had received little to no training on how MOUD works, how to refer clients, or what the long-term benefits are². In Florida, similar knowledge gaps were found among court team members, with many unsure about provider trustworthiness and treatment outcomes¹.

This lack of training extends to perceptions of client readiness. Staff may wrongly assume that clients must be fully abstinent or highly motivated before initiating MOUD, despite evidence showing that starting medication early—even during periods of ambivalence—can reduce overdose risk and increase engagement in other services⁴.

Policy and Regulatory Restrictions: Misaligned Mandates

Policies within court systems and probation departments often restrict access to MOUD. Some departments have formal or informal bans on certain medications, or favor abstinence-based treatment approaches that exclude pharmacotherapy. In some jurisdictions, probation conditions prohibit MOUD use outright, even though federal law protects individuals receiving such medications from discrimination^{2, 5}.

Court philosophies can also serve as either a facilitator or barrier. For example, New York’s Opioid Intervention Courts (OICs) have adopted a non-punitive, person-centered approach that embraces MOUD and focuses on stabilization rather than abstinence⁶. These courts emphasize rapid referral to treatment, collaboration with providers, and flexible engagement strategies. But even within this promising model, barriers remain, including community stigma, provider capacity, and confusion stemming from broader criminal justice reforms like bail reform⁶.

Moving Forward: Recommendations to Reform MOUD in the Justice System

The research is clear: overcoming barriers to MOUD in the justice system will require a comprehensive and multi-level response. Key recommendations include:

• Training and Education: Court and probation staff need consistent, evidence-based education on OUD and MOUD. Training should address stigma, explain how each medication works, and provide practical referral tools^{2, 4}.
• Cross-System Collaboration: Courts should build strong relationships with reputable MOUD providers, including co-locating services where possible and embedding peers or case managers into court teams⁶.
• Policy Reform: Departments must eliminate internal rules that restrict access to MOUD and align with federal protections. Judges and administrators should support individualized treatment decisions made by qualified medical providers—not by court personnel⁵.
• Financial Access: Medicaid expansion, increased funding for court-based treatment programs, and removing prior authorization requirements can ease financial burdens and improve continuity of care^{2, 3}.

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Footnotes

1. Ahmed, S., Bhattacharya, A., Silverstein, S. M., & Vest, N. A. (2022). Barriers to Medications for Opioid Use Disorder in the Court System: Provider Availability, Provider “Trustworthiness,” and Cost. 
2. Reichert, J., & Gleicher, L. (2019). Probation Clients’ Barriers to Access and Use of Opioid Use Disorder Medications.
3. Clark, R. E. et al. (2014). The impact of prior authorization on buprenorphine treatment access.
4. Li, X., Callaghan, B. C., White, D. A., & Gold, M. S. (2020). Characteristics Associated with Success for Opioid Use Disorder Treatment in Court-Involved Patients.
5. Legal Action Center (2011). Legality of Denying Access to Medication-Assisted Treatment in the Criminal Justice System.
6. O’Grady, K. E. et al. (2024). Referral to and Engagement in Substance Use Disorder Treatment within Opioid Intervention Courts in New York: A Qualitative Study of Implementation Barriers and Facilitators.