PROJECT SUMMARY: Substance use disorder (SUD) treatment availability and use remain low despite an ongoing drug overdose epidemic in the United States. In 2019, 19.3 million non-institutionalized adults met the criteria for SUD, but only 2.6 million received specialty treatment services. People referred to SUD treatment through the criminal legal system are less likely to receive evidence-based services (e.g., medication for opioid use disorder) than those who self-refer to specialty treatment. Because racial/ethnic minoritized groups are more likely to be criminalized than their white counterparts, as are men versus women, criminal-legal-system-based referrals may contribute to racialized and gendered inequities in SUD treatment use and outcomes. Substantial knowledge gaps remain about how the criminal legal system, specifically county-level incarceration, affects community-level SUD treatment need, availability, use, and related outcomes. These gaps are exacerbated by the siloing of healthcare delivery system and criminal legal system data. To fill these gaps, we will link comprehensive multi-level data from counties in all 50 states from 2004-2023. We will quantify how county jail and prison incarceration rates are associated with: (Aim 1) community SUD treatment need (drug-related mortality rate, drug-related emergency department visit rate, SUD prevalence); (Aim 2) SUD treatment availability (number and types of available treatment services); and (Aim 3) SUD treatment use (self-reported, admission rates) and treatment outcomes (completion, retention) across communities and individuals. We hypothesize that greater county incarceration is associated with greater SUD treatment need (and vice versa), lower treatment availability, smaller increases in treatment use, and worse treatment outcomes. We anticipate that these relationships will have important spatial dependencies and be modified by race/ethnicity and gender. Our hypothesized pathways are grounded in the Socio-Cultural Framework for the Study of Health Service Disparities; our research process is informed by Public Health Critical Race Praxis and the CDC Policy Analytical Framework adapted for systems thinking. Our team, led by an Early-Stage Investigator, has expertise in substance use epidemiology and treatment, criminology, criminal legal systems, health policy and health systems, structural discrimination, minoritized populations, biostatistics, and spatial methods. We will apply this expertise to study the criminal legal system, focusing on modifiable reform targets that can perpetuate and worsen inequities in SUD treatment over time. Our study addresses NIDA’s Notice of Special Interest (NOT-DA- 19-037) calling for multi-level health services research on SUD treatment for vulnerable populations. By leveraging multi-level data sources and engaging with stakeholders, this innovative R01 examines how multiple systems converge to affect community health. We will incorporate experts and people with lived experience in the research process. Our multi-pronged dissemination plan will ensure that findings reach target audiences and inform antiracist health policies and programs that improve community-based SUD treatment-related outcomes.

PROJECT NARRATIVE People with substance use disorders (SUD) in the criminal legal system often cannot access SUD treatment– and those who do are less likely to receive evidence-based services–which can reinforce pathways that worsen community health. We will study the dynamics between the criminal legal system and community SUD treatment system to generate unprecedented cross-sector evidence of the spillover effects of county incarceration on community SUD treatment need, availability, use, and outcomes, and racial/ethnic and gender disparities therein. With input from experts and people with lived experience, we will disseminate findings to inform antiracist health policies that can transform the criminal legal and SUD treatment systems to reduce SUD-related morbidity and mortality.