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Community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated: a review of Wisconsin legislation and regulations

Substance Abuse Treatment, Prevention, and Policy volume 20, Article number: 17 (2025) Cite this article

Abstract

Opioid use disorder (OUD) is highly prevalent among jail and prison populations in the United States, including in Wisconsin. Medications for opioid use disorder (MOUD), including long-acting injectable naltrexone, are crucial in the treatment of OUD. These medications are especially important for individuals transitioning out of jail or prison and back into the community. Unfortunately, few individuals who were formerly incarcerated continue MOUD after reentry due to a variety of barriers. Wisconsin community pharmacists are highly accessible and uniquely positioned to provide care for this population, specifically by administering injectable naltrexone. However, community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated has not been previously explored. As a first step, this legislative and regulatory review aimed to identify Wisconsin statutes and administrative codes that may impact these services for this population. Two legal databases were searched to identify relevant Wisconsin statute and administrative code subsections. Overall, 24 statute subsections (from 7 chapters) and 31 administrative code subsections (from 12 chapters) were identified that (1) highlighted a need or potential role of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated or (2) served as a potential barrier or facilitator to the availability, access, or use of these services. Future work should focus on helping community pharmacists leverage available resources and overcome existing legal barriers to providing or supporting MOUD services. Importantly, work should be done to ensure that individuals who were formerly incarcerated can be linked to these services upon reentry.

Introduction

The opioid crisis is a major public health issue and has led to more than three million United States citizens suffering from opioid use disorder (OUD), a specific substance use disorder (SUD) characterized by a pattern of continued opioid use despite harmful health and social outcomes [1,2,3]. Wisconsin has been hard-hit by this crisis, as there were 1,464 opioid-related deaths in 2022 alone [4]. Opioid use disorder is highly prevalent among individuals impacted by the legal system, including in Wisconsin. Notably, the Wisconsin Department of Corrections (DOC) reported an 89% increase in overdose hospitalizations among individuals who were formerly incarcerated from 2013 to 2019. The Department also reported a 49% increase in overdose deaths among this same population from 2014 to 2020 [5].

Medications for opioid use disorder (MOUD), including long-acting injectable naltrexone, are a crucial component of OUD treatment [6]. As a result, several carceral facilities have started providing MOUD due to the high prevalence of OUD among individuals within the facilities, though there is still progress to be made [7]. Beyond being available within carceral facilities, MOUD is especially important for individuals transitioning out of these facilities and back into the community. Those receiving MOUD are less likely to have a drug overdose and/or face rearrest after release [8]. Unfortunately, few individuals who were formerly incarcerated continue MOUD upon community reentry. Previous research has shown that less than half of these individuals who are released with doses of MOUD continue to use it in the community [9,10,11,12]. As a result, this population has incurred a 40-fold greater likelihood of opioid overdose following reentry compared to the general population, and 40–50% of these individuals are arrested for a new crime within a year of release. (13–14)

Individuals who were formerly incarcerated face several barriers to accessing MOUD within the community. For instance, factors such as unstable housing, lack of insurance, lack of transportation, and drug cost can deter individuals from continuing treatment. Individuals may also be inhibited by a lack of motivation or fear of stigma with using MOUD. These individuals may also lack social support, have networks with limited treatment knowledge, or reside in areas with few or inflexible treatment resources [15,16,17,18,19,20,21,22,23,24,25,26]. Furthermore, carceral facilities do not always facilitate community linkage to MOUD when these individuals reenter the community. For example, in Wisconsin, less than half of jails provided individuals who were formerly incarcerated with resources for accessing MOUD upon reentry [9].

In general, research focused on improving access to MOUD within the community for individuals who were formerly incarcerated remains limited [27]. One resource that has not been previously explored is community pharmacists. In Wisconsin, community pharmacists can administer injectable naltrexone, an effective and widely accepted MOUD option for individuals impacted by the legal system and the most prevalent option within Wisconsin jails and prisons. (9, 28–29) Importantly, the success of interventions such as mobile treatment show that accessible MOUD locations and flexible treatment options can facilitate MOUD uptake by individuals who were formerly incarcerated within the community [30]. Previous work has shown that community pharmacies offer an accessible and flexible location for patients to seek care. (31–32) This can be especially important for those without stable housing or transportation. Furthermore, community pharmacists have knowledge on the pharmacological aspects of MOUD and can add to the available resources within a community [33].

In Wisconsin, there is a clear need to improve access to MOUD for individuals who were formerly incarcerated and are reentering the community, and community pharmacists are uniquely positioned to help address this need. However, community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated has not been previously explored. Accordingly, the objective of this study is to explore the legal environment in Wisconsin and identify legislation and regulations that potentially impact community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated.

Methods

A legislative and regulatory review was conducted to compile and synthesize the existing statutes and administrative codes in Wisconsin with implications for community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated within the community. Statutes include acts passed by the Wisconsin Legislature. Administrative codes include regulations made by state executive agencies to guide how these agencies enforce statutes [34].

The lead researcher (JC) met with three librarians at the University of Wisconsin-Madison Ebling Library and Law School to discuss optimal search methods for identifying relevant statutes and codes. A scoping review approach was used as a guiding framework for this review [35]. Similar methodology was used in previous research analyzing laws related to pharmacist-provided MOUD services [28]. The librarians assisted the researcher in identifying keywords to use in the initial search. Keywords were categorized using an adapted version of the Patient/Population, Intervention, Comparison, and Outcome (PICO) method and are outlined in Table 1 [36]. An adapted version of PICO was utilized to better fit the study objective, as this study did not seek to compare outcomes between different groups. The lead researcher (JC) then used these keywords to search relevant electronic databases, including Fastcase and Thomas Reuters Westlaw. The search string is further detailed in Supplementary Material Section 1.

Table 1 Keywords used in initial database search
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The initial search was used to identify Wisconsin statute and administrative code chapters that included the keywords in Table 1. Full chapters were compiled, and no duplicates were included between the two databases. In total, 26 statute chapters and 40 administrative code chapters were included for full review. To identify relevant subsections, the researchers determined two a priori categories related to the study objective, including subsections that (1) highlighted a need or potential role of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated or (2) served as a potential barrier or facilitator to the availability, access, or use of these services. The lead researcher (JC) manually reviewed full chapters for specific subsections that fit these categories. Ambiguities and/or questions were addressed in meetings between both researchers. After the manual review, 24 statute subsections (from 7 chapters) and 31 administrative code subsections (from 12 chapters) were included and summarized in table format. Both researchers then met to discuss implications for each subsection. All statutes and administrative codes were current as of July 2024.

Results

Overall, 7 Wisconsin statute chapters included subsections with implications for community pharmacist-administered injectable naltrexone services for individuals who were formerly incarcerated [37,38,39,40,41,42,43]. These 7 chapters are outlined in Table 2. From these 7 chapters, a total of 24 relevant subsections were identified. Additionally, 12 Wisconsin administrative code chapters included subsections with implications for community pharmacist-administered injectable naltrexone services for individuals who were formerly incarcerated [44,45,46,47,48,49,50,51,52,53,54,55]. These 12 chapters are outlined in Table 3. From these 12 chapters, a total of 31 relevant subsections were identified. All subsections and potential implications are summarized below.

Table 2 Statute chapters with implications for community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated [37,38,39,40,41,42,43]
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Table 3 Administrative code chapters with implications for community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated [44,45,46,47,48,49,50,51,52,53,54,55]
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Need and potential roles of community pharmacist-administered injectable naltrexone

From the statute and administrative code subsections that were identified in the review, several emphasized the need for MOUD providers and/or injectors for individuals who were formerly incarcerated, a role that community pharmacists could help fill. There are several state-level programs and facilities, such as treatment alternative programs (TAPs), Comprehensive Community Services (CCS) programs, work programs, and recovery residencies, that can be utilized by individuals impacted by the legal system, including individuals who were formerly incarcerated. These programs and facilities recommend or even require that individuals receive treatment for SUDs, which may include MOUD.

Additionally, there are several collaborative roles that community pharmacists could take. The identified subsections highlight various departments, groups, and agencies, such as the Milwaukee County Mental Health Board or Council of Offender Reentry, that support individuals who were impacted by the legal system, formerly incarcerated, and/or dealing with SUDs. Through fostering collaborative relationships, community pharmacists could potentially work with these groups to increase access to MOUD resources, specifically by administering injectable naltrexone to individuals needing this treatment option. Community pharmacists could also increase collaborations with MOUD providers and take on the role of administering injectable naltrexone for their patients, including those who were involved with the legal system or formerly incarcerated. All subsections related to the need or potential roles of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated are included in Table 4.

Table 4 Subsections highlighting the need and potential roles of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated
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Potential barriers or facilitators to community pharmacist-administered injectable naltrexone

In addition to the statute and administrative code subsections discussed above, several subsections also highlighted potential barriers or facilitators to the availability, access, or use of community pharmacist-administered injectable naltrexone by individuals who were formerly incarcerated. In general, the language used in many subsections either excludes or does not implicitly recognize pharmacists as a resource for MOUD. These subsections also highlight requirements for pharmacists to administer injectable naltrexone, including completing a training course and reviewing a comprehensive patient profile prior to dispensing or administering any medication. These requirements may inhibit community pharmacists from providing naltrexone injection services, including for individuals who were formerly incarcerated.

On the other hand, certain subsections may facilitate these services. Importantly, subsections of Chap. 450: Pharmacy examining board and Pharmacy Examining Board Chap. 7 provide the legal authority for community pharmacists to administer naltrexone injections for any patient with a valid prescription. Additionally, pharmacists can enter a collaborative practice agreement (CPA) with a physician, allowing the physician to delegate patient care services – including management of individuals with SUDs – to the pharmacist. Pharmacists are also recognized as providers under Medicaid, allowing them to be reimbursed for services within their scope of practice, including administering injectable naltrexone. Finally, numerous subsections highlight sources of state-level funding for SUD treatment that could potentially be pursued by community pharmacists to support injectable naltrexone services and help treat individuals who were formerly incarcerated. All subsections related to potential barriers and facilitators are listed in Table 5.

Table 5 Subsections highlighting potential barriers and facilitators to community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated
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Discussion

As shown, the legislative and regulatory review identified several Wisconsin statute and administrative code chapters and subsections with potential implications for community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated. The subsections both highlighted the need and potential roles for community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated and included potential barriers and facilitators to these services. Notably, the requirements of several state-level programs and residences often used by individuals who were formerly incarcerated emphasize a need for available treatment resources for those with SUDs, including MOUD providers and injectors. By administering injectable naltrexone, community pharmacists can add to the available resources and support this need. Additionally, community pharmacists may collaborate with several departments and agencies outlined in the legislation that support individuals who were formerly incarcerated and/or deal with SUDs. Some of these groups even have goals specifically related to supporting reentry. For example, the Council of Offender Reentry (as outlined in Wisconsin Statute Chap. 301: Corrections) serves several purposes, including coordinating reentry initiatives, identifying methods to improve coordination of transition services, and promoting collaboration between the department and community organizations [42]. Overall, fostering relationships between pharmacists and these groups can help improve awareness of community pharmacy services, facilitate pharmacist involvement, and increase referrals to community pharmacist-administered injectable naltrexone for those needing treatment.

The subsections in this review may also serve as barriers or facilitators to community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated. Those that do not included pharmacists in the language describing SUD treatment resources, as well as those outlining training and medication review requirements, may hinder awareness and/or availability of community pharmacist-administered injectable naltrexone. However, subsections outlining pharmacist scope of practice authority, reimbursement, and funding opportunities may facilitate the ability of community pharmacists to offer these services. Opportunities like CPAs can both support pharmacists’ abilities to provide patient care services (such as administering injectable naltrexone) and help pharmacists foster relationships with MOUD prescribers. It should also be noted that some subsections have mixed implications for community pharmacist-provided injectable naltrexone for individuals who were formerly incarcerated. For example, Wisconsin law allows providers to deliver care via telehealth. This can facilitate the use of community pharmacist-administered naltrexone injections, especially if individuals who were formerly incarcerated are able to obtain a prescription via telehealth. However, individuals who were formerly incarcerated may not have access to the resources required to attend a virtual healthcare visit (phone, computer, internet, etc.), which has been a concern in previous research [56]. Additionally, community pharmacists are required to complete 30 hours of continuing education every two years to maintain their licensure. Continuing education programs provide an opportunity to educate community pharmacists on injectable naltrexone services and/or caring for patients impacted by the legal system. However, only programs approved by the Accreditation Council for Pharmacy Education (ACPE) can count toward this requirement [55]. As a result, the ACPE should ensure that such training programs exist and are available to community pharmacists.

Outside of implications for community pharmacists, a few subsections may impact access to treatment for individual patients. As an example, Medicaid and small employer health plans provide coverage for treatments related to substance use. Additionally, several residential facilities (including community-based residential facilities) and state-level programs provide transportation services to support individuals seeking treatment for SUDs. These subsections can further improve the accessibility of community pharmacist-provided injectable naltrexone for individuals who were formerly incarcerated and may face financial barriers or lack reliable transportation. (15–16, 19)

While this review focused on injectable naltrexone, it may have implications for other forms of MOUD. Naltrexone is one of three main MOUD options, in addition to methadone and buprenorphine [6]. In Wisconsin, community pharmacists are authorized to dispense buprenorphine products for the treatment of OUD [54]. Additionally, current research has explored community pharmacist involvement in providing buprenorphine and supporting certified opioid treatment programs (OTPs) that provide methadone. (57–58) Many of the potential collaborations, barriers, and facilitators identified in this review could likely impact the ability of community pharmacists to support the use of other forms of MOUD for individuals who were formerly incarcerated. Additional work could be done to explore this further.

Additionally, although this review focused on Wisconsin legislation and regulations, the findings may also have implications for other states. For example, several other states have laws that provide pharmacists the legal authority to administer long-acting injectable medications, including injectable naltrexone [59]. Pharmacists in those states could explore the opportunity to support treatment for individuals who were formerly incarcerated, including via relationships with state-level departments, programs, or agencies that support this population. Work could also be done to explore legislative or regulatory barriers and facilitators in these states, such as training requirements, reimbursement for naltrexone injections, or potential funding sources. With that being said, there are certain areas where this review may be less applicable. As shown, in Wisconsin, many programs and groups that interact with individuals who were formerly incarcerated support the use of MOUD in treating OUD. However, in other states, similar programs and groups may not encourage MOUD for individuals who were formerly incarcerated or even promote abstinence-only approaches [60].

Lastly, it is clear that there are several programs and groups in Wisconsin that could collaborate with community pharmacists to increase the availability, access, and use of injectable naltrexone by individuals who were formerly incarcerated. However, as previously discussed, carceral facilities often fail to link individuals to MOUD resources within the community during reentry [9]. Ultimately, even if community pharmacists are collaborating with state or community-level groups that support individuals who were formerly incarcerated and need MOUD, it is likely that individuals still will not be referred to these services. Work needs to be done to not only ensure that there are enough MOUD resources within the community – a gap that community pharmacists can help fill – but that individuals reentering the community from carceral facilities are being linked to these resources. Ultimately, additional work should explore strategies for improving care linkage and coordination.

Limitations

While this review was intended to be exploratory in nature, it presents a few limitations that should be acknowledged. First, it is possible that certain statutes and/or administrative codes were overlooked based on the search strategy or databases used. Additionally, for the purposes of this project, federal legislation and policies or guidelines from professional organizations were not included. This may have provided additional implications for the availability, access, and use of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated in Wisconsin. The review was also focused on Wisconsin legislation and regulations, limiting the overall generalizability for other states or countries, especially those with different legislative landscapes. Also, while community pharmacists can administer injectable naltrexone, individuals still need an active prescription to receive the injection. Unless under a CPA, Wisconsin pharmacists cannot add new prescriptions. This review may not include certain statutes or administrative codes that impact the availability of MOUD prescribers or ability of individuals who were formerly incarcerated to obtain a naltrexone prescription prior to receiving an injection. Finally, while the review highlighted potential collaborations and funding opportunities for community pharmacy-administered injectable naltrexone for individuals who were formerly incarcerated, it does not explore whether or not community pharmacists are prioritizing or pursuing these opportunities. Overall, these limitations provide directions for future work.

Conclusions

The legislative and regulatory review further emphasized the importance of increasing the number of available injectable naltrexone providers and injectors within Wisconsin, especially for individuals impacted by the legal system and those who were formerly incarcerated. Not only do community pharmacists have the authority to administer naltrexone injections, but there are several potential collaborations and funding opportunities that may help facilitate these services. It is important that future work focuses on helping community pharmacists leverage these resources, as well as overcome barriers identified in the legislation and regulations. Importantly, work should be done to ensure that individuals who were formerly incarcerated are connected to MOUD services, including pharmacist-administered injectable naltrexone. This work can help ensure that individuals who were formerly incarcerated are able to continue crucial medications and succeed after community reentry.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

OUD:

Opioid use disorder

SUD:

Substance use disorder

DOC:

Department of Corrections

MOUD:

Medications for opioid use disorder

PICO:

Patient/Population, Intervention, Comparison, and Outcome

DCF:

Department of Children and Families

DHS:

Department of Health Services

SAR:

Special action release

DIS:

Division of Intensive Sanctions

CCS:

Comprehensive Community Services

TAP:

Treatment alternative program

CBRF:

Community-based residential facility

AODA:

Alcohol or other drug abuse

OTP:

Opioid treatment program

CPA:

Collaborative practice agreement

ACPE:

Accreditation Council for Pharmacy Education

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Acknowledgements

The authors would like to thank James H. Ford II, Olayinka O. Shiyanbola, and Paije Wilson for their contributions in conceptualizing this manuscript.

Funding

This work was funded by grants TL1TR002375 and UL1TR002373 awarded to the University of Wisconsin-Madison Institute for Clinical and Translational Research (ICTR) through the National Center for Advancing Translational Sciences (NCATS) and grant T32-HP22238 awarded to the New York University Grossman School of Medicine through the Health Resources and Services Administration (HRSA).

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  1. Grossman School of Medicine, New York University, 180 Madison Ave, New York, NY, 10016, USA

    Jason S. Chladek

  2. Division of Social and Administrative Sciences, University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA

    Jason S. Chladek & Michelle A. Chui

  3. Sonderegger Research Center, University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA

    Michelle A. Chui

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JC was responsible for conceptualization, methodology, analysis, writing the original draft, and reviewing and editing. MC was responsible for supervision, conceptualization, and reviewing and editing. Both authors read and approved the final manuscript.

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Correspondence to Jason S. Chladek.

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Chladek, J.S., Chui, M.A. Community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated: a review of Wisconsin legislation and regulations. Subst Abuse Treat Prev Policy 20, 17 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13011-025-00647-9

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Keywords

Substance Abuse Treatment, Prevention, and Policy

ISSN: 1747-597X