Locked Out of Care
Gabe Kortlever entered federal custody at 23, three months into recovery from opioid use disorder. Inside, there was no medication, no program, no continuity. What existed in the community disappeared at intake, and so did his chance at staying clean.
per 100,000 people US state and federal incarceration rate (BJS, 2022)
Approximately 2 million people are incarcerated in the United States at any given time the highest rate of any country on earth. Behind that number is a population disproportionately living with substance use disorder, with fewer than one in ten receiving any form of evidence-based treatment while inside.
The gap between what treatment science recommends and what facilities deliver is not a resource problem. It is a policy problem and one that comparative research is positioned to solve.
US Incarceration Rate per 100,000, 1900 to 2022
per 100,000 people (BJS, 2022)
Incarceration rate per 100,000 people
Photo used for illustrative purposes only. The individual pictured is not Brenda Smith and has no connection to this case or the research described on this site.
"You're doing it because your freedom is on the line."Iacobelli et al., 2026 · on participation motivation in therapeutic incarceration programs
In the US, access to treatment is not a right. It is a coincidence of geography, facility policy, and budget. Most people in custody with opioid use disorder receive nothing. Participation is not a choice made in the interest of health, but a calculation made under coercion.
Brenda Smith had been in recovery for five years. On buprenorphine, she had not relapsed once. She had regained custody of her four children, found stable housing, and held a job. Then she was sentenced to 40 days in a Maine county jail. Administrators told her the medication was contraband. She had to sue to keep her prescription. She won, but most people never get a lawyer. Smith v. Aroostook County, ACLU of Maine (2019)
What the Evidence Shows
Six findings across US and German systems what works, what fails, and where the gap lives.
Reduction in overdose death among incarcerated individuals who received Medication-Assisted Treatment upon release the strongest signal in the literature.
Strange et al., 2022
Range of MAT access across four New England state prison systems the same country, the same evidence base, wildly different outcomes by jurisdiction.
Ferguson et al., 2019
Incarcerated individuals in the US are estimated to meet diagnostic criteria for substance use disorder a population receiving, at best, fragmented care.
BJS; Kopak, 2024
MAT alone produces no statistically significant reduction in rearrest. Treatment must bridge into reentry housing, legal support, continuity of care to hold.
Strange et al., 2022
Structured reentry support housing, employment linkage, continued treatment access correlates with sustained recovery in both US and German systems.
Ferguson et al., 2019; Schalast et al., 2025
Reduction in recidivism among completers of Germany's Section 64 therapeutic incarceration program treatment as a legal pathway, not a privilege.
Schalast et al., 2025
Policy Barrier
No Federal Mandate
The US has no federal law requiring prisons or jails to provide MAT. Access is entirely facility-dependent creating a nationwide lottery where geography, not medical need, determines whether someone receives evidence-based care.
Regulatory Barrier
DEA Certification Requirements
Prescribers historically required specialized DEA certification to dispense buprenorphine. Administrative burden, prescriber stigma, and institutional liability fears turned a regulatory requirement into a de facto wall against treatment inside correctional settings.
Cultural Barrier
Stigma Within Facilities
Correctional staff and administrators frequently characterize MAT as "substituting one drug for another." This cultural opposition documented across facilities operates as a barrier even where legal and regulatory authority for treatment exists.
Lived Experience
Entrapped by Treatment
Individuals on MAT at arrest may face forced withdrawal in pretrial detention. Those who begin treatment inside may lose access at release if no community provider is arranged a structural gap that turns treatment into a bridge to nowhere.
Rehabilitation as a Legal Mandate
The fundamental difference between the US and German systems is not resources or outcomes. It is legal philosophy. Germany's Basic Law enshrines rehabilitation as a constitutional obligation. The US has no equivalent.
The Key Difference
"Germany treats incarceration as an opportunity for rehabilitation. The US treats it as punishment. That single distinction determines whether treatment is a right or a coincidence."
per 100,000 people
National incarceration rate, nearly 7 times lower than the US (World Prison Brief, 2022)
recidivism reduction
Among Section 64 program completers compared to matched controls (Schalast et al., 2025)
StGB (German Penal Code)
The statute mandating therapeutic incarceration for eligible individuals with substance use disorder
Section 64 StGB
Therapeutic Incarceration by Law
Under Section 64 of the German Criminal Code, courts are required to order therapeutic incarceration alongside standard sentencing for individuals with substance use disorder whose offenses are linked to their addiction. Treatment is not a diversion from the sentence; it is embedded within it.
The legal foundation is the Resozialisierungsgebot: Germany's constitutional rehabilitation mandate, derived from the Basic Law's guarantee of human dignity. Unlike the US, where treatment access depends on facility budgets and administrator attitudes, the German system begins from the premise that a person leaving custody must be able to reintegrate into society. Treatment is not optional under that framework. It is obligatory.
In practice, Section 64 places individuals in specialized forensic psychiatric facilities operating alongside conventional prisons. Participants receive individualized treatment plans, MAT where appropriate, vocational training, and structured reentry support. Completion of the program can reduce the original custodial sentence, creating a legal incentive structure the US system entirely lacks.
"The German goal is to help prisoners understand the environment into which they were born, the consequent anger and resentments that grew out of those formidable years."Rosemary Jenkins, LA Progressive
Where Germany's System Struggles
A meaningful share of Section 64 participants exit before program completion, and some evidence suggests dropouts fare worse than non-participants (Querengässer et al., 2017). Germany's frontier question is retention and scale. The US has not yet reached that question, because access itself remains the unsolved first step.
Five Questions the Research Hasn't Answered
These are not abstract gaps. They are the missing knowledge keeping policy from moving.
OAT Coverage Rates Inside Prisons
No comprehensive national dataset tracks the percentage of incarcerated individuals with OUD who receive opioid agonist therapy. Without this denominator, advocates cannot quantify the treatment gap or measure progress if policy changes.
Long-Term Post-Release Outcomes
Most studies follow individuals for 6–12 months post-release. We do not know whether MAT initiated in prison produces durable recovery at 2, 5, or 10 years the timescale that matters for both individuals and cost-benefit policy arguments.
Lived Experience Inside German Forensic Facilities
Section 64 outcomes are measured through recidivism and reoffense data. The subjective experience of participants what works, what coerces, what fails them is largely absent from the published literature, limiting what the US can meaningfully adapt.
Recovery-Centered Outcome Measures
Both systems measure success through rearrest and recidivism the criminal-legal lens. Recovery science uses different metrics: housing stability, employment, social connection, quality of life. No study yet bridges these frameworks for incarcerated populations across systems.
The Dropout Paradox in Germany
A meaningful share of Section 64 participants exit before completion, and dropouts may fare worse than non-participants. Understanding why individuals leave and what support could retain them is the frontier question for Germany's system and a critical design caution for any US equivalent.
The Research Case
Each of the five knowledge gaps is answerable with the right comparative methodology, cross-national access, and sustained investment. This research will quantify OAT coverage baselines, track outcomes past the standard 12-month window, recover lived experience from German Section 64 facilities, bridge recovery-science and criminal-legal metrics, and explain the dropout pattern that limits what the US can safely adapt, producing the first policy-ready evidence base with direct implications for federal reform.
average annual cost to incarcerate one person in the US
reduction in overdose deaths when MAT continues through the release threshold
recidivism reduction under Germany's Section 64 the outcome the US has not yet achieved
people currently inside this policy failure, without access to evidence-based care
Methodology
This study uses a mixed-methods comparative design to examine MAT access, implementation, and outcomes across US and German correctional systems. By combining quantitative outcome analysis with qualitative inquiry into lived experience, the research produces both statistical evidence and policy-transferable insight.
01: Research Design
Mixed-Methods Comparative Study
A parallel convergent design integrates quantitative outcome data with qualitative interviews. Findings from each strand inform the other, producing triangulated conclusions that neither approach could achieve alone. The unit of comparison is the policy-to-outcome chain in each system.
02: Site Selection
Cross-National Facility Sample
US sites selected to represent variation in MAT policy: one facility with a mandate, one with voluntary access, one with no program. German sites draw from Section 64 forensic psychiatric facilities in at least two federal states to capture regional variation.
- US: 3 facilities across 2 states
- Germany: 2 Section 64 facilities
- Selection criteria: facility size, SUD population, policy type
03: Data Collection
Multi-Source Evidence Base
Three parallel data streams are collected simultaneously to ensure cross-validation and reduce single-source bias.
- Interviews: semi-structured with formerly incarcerated individuals, correctional health staff, and policy architects (n=60 target); transcripts coded in Taguette (open-source qualitative coding)
- Administrative records: treatment access rates, dosage continuity, overdose incidents, reincarceration at 12 and 24 months
- Policy documents: facility protocols, legal mandates, program evaluations
04: Analysis
Comparative Policy & Outcome Analysis
Quantitative data analyzed using propensity-score matched regression to control for individual risk factors across systems. Qualitative transcripts undergo thematic analysis using a recovery-science framework. A structured cross-case synthesis identifies transferable vs. system-specific findings.
- Regression modeling for outcome comparisons
- Thematic analysis (Taguette) for interview transcript coding
- Cross-case matrix for policy transferability
24-Month Timeline
Research Goals: Answering the Five Gaps
Quantify the Coverage Gap
Quantify the Coverage Gap
Answers Gap 1. This study produces the first systematic OAT access estimate across a representative US facility sample, the denominator advocates have lacked to measure policy progress.
24-Month Longitudinal Outcomes
24-Month Longitudinal Outcomes
Answers Gap 2. Tracking participants through 24 months post-release (double the typical study window) generates the durable outcome data cost-benefit policy arguments require.
Center Participant Voices
Center Participant Voices
Answers Gap 3. Semi-structured interviews with Section 64 participants and alumni recover what published literature omits: the subjective experience of treatment, what works, and what fails.
A Unified Outcome Framework
A Unified Outcome Framework
Answers Gap 4. Integrating recovery-science metrics (housing, employment, quality of life) alongside criminal-legal measures, this study proposes a cross-system standard for what successful treatment looks like.
Explain Section 64 Dropout
Explain Section 64 Dropout
Answers Gap 5. Interviews and administrative records will illuminate why participants exit before completion and what supports could retain them, a critical design lesson for any US reform model.
Social Impact Goals
Addiction as a Disease
Addiction as a Disease
Advance a paradigm shift toward treating addiction as a medical condition rather than a moral failure. People with substance use disorder deserve patient-centered care, not punishment, regardless of where they are held.
Reduce Social Stigma
Reduce Social Stigma
Challenge the cultural narratives that dehumanize people in the carceral system. Evidence-based research is one of the most powerful tools for shifting public and institutional attitudes toward compassion and inclusion.
Decrease Recidivism
Decrease Recidivism
When people leave incarceration healthier, supported, and connected to care, they are less likely to return. Improved treatment access directly translates to fewer reincarceration cycles and better quality of life for individuals, families, and communities.
Fund This Research
This research is currently seeking funding partners to support a 24-month comparative study. If you believe the treatment gap in US prisons is worth closing and that evidence is the fastest path there we want to hear from you.
One-time donations of any amount directly support research access and dissemination.
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