On a humid summer evening in downtown Atlanta, a patient of ours living in an encampment near Peachtree Street is arrested for the minor offense of trespassing and loitering. He is then taken to Fulton County Jail. During booking, the Methadone medication he takes daily for opioid use disorder is stopped.
Within 24 hours, withdrawal begins — muscle pain, nausea, vomiting, chills and insomnia. Days or weeks later, he is released. While the withdrawal may have passed, something else has changed: his body’s tolerance to opioids. When he returns to the encampment and begins using the same amount of opiates he always has, his brain and respiratory system are no longer adapted to handle it. This can quickly turn a previously familiar amount into an overdose.
Homelessness, addiction and the jail cycle
The City of Atlanta’s Point-in-Time Count estimates that nearly 3,000 people are experiencing homelessness across metro Atlanta. People experiencing homelessness are at higher risk of substance use disorders. Long-term living in public areas increases encounters with police for low-level offenses such as trespassing or public sleeping, leading to short stays in jail. The result is a revolving door that many Atlantans experiencing unstable housing and mental health or substance use disorders know well: unstable housing leads to police contact, police contact leads to incarceration and incarceration interrupts progress in treatment or recovery.
What happens inside
Despite clear medical consensus from healthcare providers, medications for opioid use disorder (such as methadone and buprenorphine) are not consistently continued in many county jails. Instead, individuals are often forced into withdrawal. This contradicts modern medical standards. The American Society of Addiction Medicine recognizes methadone and buprenorphine as the gold standard for treating opioid use disorder. National correctional health guidelines similarly recommend continuing treatment during incarceration.
Physicians would never abruptly stop insulin for someone with diabetes or a blood-pressure medication for someone with severe hypertension. Yet medications for addiction, a chronic medical condition, are still treated differently due in part to societal perceptions of addiction as a moral and not a medical issue.
A predictable medical risk
When medications like methadone or buprenorphine are stopped, the body adapts quickly. Within days, opioid tolerance begins to drop. That change can turn a previously tolerated dose into a fatal one. When individuals return to opioid use, they often take the same amount they used before incarceration, but their bodies can no longer tolerate it safely. Research consistently shows that because of this, the weeks immediately following release from incarceration carry an exceptionally high risk of fatal overdose. Intervening at the cusp of withdrawal could prevent overdose from becoming a risk for these patients.
Paying for the consequences
For people experiencing homelessness, release from jail rarely means stability. Instead, it may mean returning to the same encampment, the same uncertainty, and the same barriers to care; but now with an untreated medical condition layered on top. Withdrawal and relapse make it harder to attend case management meetings, navigate shelter intake systems, or follow through on housing applications. Small disruptions like this can undo months of progress toward stability. Each arrest and forced withdrawal pushes people further from the support systems meant to help them.
From an economic perspective, the math is simple: maintaining treatment in jail with a daily dose of methadone or buprenorphine costs far less than repeatedly responding to preventable crises. Ambulance transports, Emergency Room visits, ICU admissions, and repeated incarceration costs add up, and hospitals like Grady Memorial Hospital see these consequences regularly. Taxpayers ultimately pay for every step of the cycle. Continuing treatment is not only medically appropriate, but it is fiscally responsible.
A path forward
Recent federal scrutiny of conditions at Fulton County Jail has prompted broader conversations about health and safety within the facility. As medical students, we have identified a few ways Fulton County can improve this system overall. First, county jails should continue medications for substance use disorders like opioid use for individuals who are already receiving them. Treatment should also be initiated during incarceration when medically appropriate. Second, before release, individuals should be connected directly to community healthcare providers, so treatment continues without interruption. Medicaid coverage should be activated prior to release so people can access care immediately. Finally, local jurisdictions should report overdose data connected to incarceration so communities understand the scope of the problem, and interventions can be introduced.
Atlanta has an opportunity to lead on this issue. As Fulton County considers reforms to improve healthcare within the jail system, we encourage them to consider expanding access to medications and therapy for substance use disorders. This represents one practical step to immediately reduce overdose risk after release. Across the country, counties that have implemented jail-based treatment programs have seen reductions in overdose deaths and improved engagement in care after release.
Interrupting the jail-to-street pipeline
The overdose crisis is often described as something happening on sidewalks, in encampments, or behind closed doors. But part of the crisis is built into our systems. When addiction treatment is stopped during incarceration, we create a predictable pipeline: incarceration, withdrawal, reduced tolerance, release, and increased overdose risk.
If Atlanta is serious about reducing overdose deaths and responding to chronic homelessness with evidence-based care, the jail-to-street pipeline must be interrupted at its most predictable point — inside our jails. Withdrawal and overdose should not be thought of as inherent parts of Atlanta’s punishment bureaucracy; instead, such stories should invite us to think of structural ways we are not meeting our patients’ needs in jail and how we can solve this issue sustainably.
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The authors are medical students at Emory University School of Medicine, Morehouse School of Medicine, and Philadelphia College of Osteopathic Medicine. They are members of Health-Students Taking Action Together (H-STAT), a student advocacy group focused on health equity and affordable housing in Atlanta. They are:
Michael Daugherty, medical student, Emory University School of Medicine
Megan Blasberg, medical student, Philadelphia College of Osteopathic Medicine
Nicholas Wilson, medical student, Morehouse School of Medicine
Isabelle Blanchard, medical student, Emory University School of Medicine
Kimberly Cang, medical student, Philadelphia College of Osteopathic Medicine
Supriya Jain, medical student, Emory University School of Medicine
