For those with addiction, going into and coming out of prison can be a minefield.

At the Ninilchik Community Clinic on Alaska’s rural Kenai peninsula this summer, Dr. Sarah Spencer stood next to a patient lying on an exam table, and swiped her belly with alcohol. The patient was there for a monthly buprenorphine shot to treat her opioid use disorder – a shot she thought might be her last for a while since there was a warrant out for her arrest. The Alaska Department of Corrections does not provide comprehensive access to this life saving medication.

“I’m gonna give you a little pinch,” Spencer said, sliding the needle into a fold of skin on the patient’s belly for the subcutaneous injection.

Alaska’s not an outlier. Despite the fact that those recently released from incarceration are some of the most vulnerable to dying from drug overdose, addiction experts say that many jails and prisons around the country don’t provide medication treatment.

Organizations like the Ninilchik Community Clinic say they do what they can to treat people going into or coming out of jail or prison, but can’t help those inside. And according to addiction medicine specialists, any interruptions in treatment could make it harder for people to stay in recovery – and survive their opioid addiction.

“I really wanted to do good” 

Spencer’s patient at the clinic that day in August was a woman who asked that NPR use only her first initial, H., because she criticized the Alaska Department of Corrections and she was afraid of retaliation from staff in jail. She said she was expecting to be incarcerated for about 6 months.

H. said there are sometimes contraband drugs in jail, and she wanted to get these shots so she had the best chance of staying sober while incarcerated.

“I wanted to cover my bases, because I really, really wanted to do good,” H. said. “I didn’t want to go backwards.”

Many studies have shown that medication for opioid use disorder makes recovery more likely and reduces the risk of overdose death.

If people aren’t able to get medication while incarcerated, they may relapse in prison on black market drugs, or, if they don’t use opioids inside, they will detox and their tolerance will go down. That makes them more susceptible to overdose when they leave.

“There is no population that’s at higher risk than people who have been recently incarcerated and a big part of that is because… it only takes two weeks for people to lose their tolerance to opioids,” Spencer said.

Research backs up the idea that people sent to jails and prisons are incredibly vulnerable to drug death. Federal data released by the Biden administration showed up to 1 in 4 overdose deaths nationally in 2021 involved people “recently released from jail or prison.” And one National Institute of Health study found that in the weeks after being released from prison, people were up to 40 times more likely to die from overdoses compared with the general population.

H. said the treatment for her opioid use disorder was interrupted when she was incarcerated earlier in 2025. She said the Alaska Department of Corrections denied her medication and she started using illicit opioids again when she got out.

“It happens super fast,” H. said. “I didn’t have a phone or anything, but you run into people. You see people. It just – there’s 1,000 different ways.”

Limitations on treatment

Interviews with healthcare providers like Dr. Spencer and formerly incarcerated people like H. indicate that many who want medication while incarcerated don’t get it.

Alaska’s Department of Corrections, or DOC, declined repeated requests for an interview for this story, but they responded to questions over email.

They confirmed that they only give 30 days of medication treatment to people who were already getting it before incarceration. No one gets treatment for more than a month, unless they’re pregnant. When people are released, DOC said they give some a list of providers they can go to for treatment.

But Spencer said best practice is to make it much easier for any inmate to start and stay on medication and to provide them with a transition plan – like DOC setting up an appointment for them with a healthcare provider in the community – to help them stay safe after release.

“If a patient isn’t continued on their medication or isn’t offered medication, you’re really missing that opportunity to stabilize this life threatening disease while they’re in DOC custody,” she said.

DOC said their aim is to expand access to medication for opioid use disorder, and they hope to pilot a more comprehensive program by February of 2026.

Spencer said in the absence of comprehensive treatment, her team tries their best to provide care for people before and after incarceration, at least on the Kenai peninsula.

Her colleague Annette Hubbard is a case manager who routinely checks the court docket for active warrants – and helps those who she knows have opioid use disorder get treatment before they go in.

“I do that voluntarily, because I know that the people that I work with and for are always at risk,” Hubbard said.

A contrasting approach in Rhode Island 

Spencer said she wishes Alaska’s system were more like Rhode Island’s. In 2016, the state started offering treatment for substance use disorders to anyone eligible in DOC care. Within a year, there had been a 61% reduction in overdose death rates among people recently incarcerated, and a 12% reduction in overdose deaths statewide.

Dr. Jennifer Clarke developed the program as medical director at the Rhode Island Department of Corrections.

Before she could freely dispense medication for substance use disorders, she said, “it was like practicing medicine with one hand tied behind my back.”

According to Clarke, the results of the new program were palpable: when people weren’t going through withdrawal and having cravings, they could focus better on recovery.

“I heard multiple times, people would tell me, ‘This was the first time I could really participate in the treatment classes, in the behavioral therapy,'” Clarke said.

But she said it wasn’t always easy. The program required two million dollars in funding to start, the backing of the then-governor, and it had to overcome many logistical hurdles. And she said, there was stigma.

“I was called frequently a drug pusher,” she said. “So with the medical staff, I would just talk data. I’m like, ‘We’re scientists… We’re going to follow the science.'”

Across the country, inconsistent access to care

Other states have been slow to develop similar life-saving medication programs. In a recent study published in JAMA Network Open, representative of over 3,000 U.S. jails, fewer than half offered some access to medication for opioid use disorder.

Redonna Chandler, a psychologist formerly at the National Institute on Drug Abuse, said medication can be hard to access for anyone with opioid use disorder, and often jails and prisons don’t have providers with the expertise necessary to give the medications.

“I think it’s still a patchwork of programs,” Chandler said.

And because medications like buprenorphine are opioids themselves and help alleviate symptoms of withdrawal, there are black markets for them inside jails and prisons.

“You’ll hear a lot of concerns about ‘diversion’ and about pills being diverted, but there are ways to deal with and get around that, either through other formulations or through the ways in which you would administer the medication,” Chandler said. That could mean shifting from pills to injectable formulations, which are much harder to divert.

In the meantime, some patients like H. in Ninilchik may only be able to get treatment outside incarceration.

“It would just be so huge to be able to get it in jail too, and then gain that strength to be able to help yourself when you did hit the streets again,” H. said.

It’s unclear when she will start her new jail sentence, but she said she hoped when she got out, she’d go right back to treatment. If she does, it may save her life.