From contraband to collaboration: a qualitative study of how medications for opioid use disorder can reshape correctional culture and safety

Medications for Opioid Use Disorder (MOUD) are a life-saving intervention for individuals at high risk of overdose, particularly in correctional settings. While the health benefits of MOUD in jails and prisons are well established, less is known about its broader impact on institutional culture, operations, and safety. In this qualitative study, we aimed to explore how MOUD implementation (including extended-release injectable buprenorphine) shapes facility culture, operations, and safety, and how medication diversion is perceived, experienced, and managed, from the perspectives of incarcerated people and staff. We conducted semi-structured interviews with incarcerated individuals ( N = 19) and correctional/medical facility staff ( N = 10) at the Rhode Island Department of Corrections, a unified state system housing both pretrial and sentenced individuals operating one of the longest-running MOUD programs in the United States (since 2016). Interviews explored the cultural and operational context of MOUD implementation. Data were audio-recorded, transcribed, and analyzed using applied thematic analysis. Three major themes emerged: (1) Shifts in Facility Climate : MOUD was perceived to reduce contraband use, violence, and disciplinary infractions. Interviewees described improvements in social functioning, including greater participation in court proceedings and programming. (2) Diversion as a Manageable Security Concern : While diversion occurred—often to get high or manage withdrawal—it was perceived as limited in scope, and most patients were perceived to use MOUD as prescribed. Diversion was not unique to MOUD and was also associated with other medications. Extended-release injectable buprenorphine was widely regarded as an effective strategy to reduce diversion and operational burden. (3) Cultural Change and Ongoing Tensions : Despite long-standing program implementation, stigma toward MOUD persisted among some custody staff and peers. Education and leadership support were identified as critical to overcoming skepticism and fostering buy-in. Implementation highlighted opportunities for improved collaboration between medical and security staff, though some tensions remained. MOUD implementation in correctional settings can support a safer, more stable facility environment. Diversion concerns, while present, appear manageable and comparable to other medications. Programs that invest in education, leadership engagement, and medical-security partnerships may be better positioned to overcome resistance and maximize the clinical and institutional benefits of MOUD.