For most people using substances, time in jail means forced detox. This is also true for those trying to improve their lives with opioid addiction programs, such as medication-assisted treatment (MAT).
More and more North Carolinians are entering these MAT programs, where they receive daily doses of drugs, such as methadone or buprenorphine that hold off the symptoms of withdrawal.
But if someone in MAT is arrested and put in a North Carolina jail, they’re usually cut off their medication. Within hours, they end up in withdrawal, a multiday process marked by extreme flu-like symptoms and pain.
Then when that person is released, they need to restart their medication-assisted treatment. And in some cases, they don’t make it back to treatment, but instead, seek out street drugs.
Statistics show people being released from incarceration are more likely to overdose after detoxification because their body’s drug tolerance has decreased.
In Buncombe County, officials found that 50 percent of people who died from an overdose had been in jail at some point. Of those deaths, half died within 24 hours of release.
Statewide, inmates are 40 times more likely than the average person to die of an opioid overdose within two weeks of release. And they are 74 times more likely to die of a heroin overdose, according to a recent study out of the University of North Carolina.
“The reason that any sheriff in this state or any other state needs to understand the importance of entering into this [MAT] program is simply: if nothing changes, nothing changes,” said Orange County Sheriff Charles Blackwood.
And changes are happening in some North Carolina counties, which offer continued MAT for people entering jail who are already in a community-based MAT program.
N.C. Division of Public Health has identified Blackwood’s county, along with Durham, Nash, Buncombe and Rutherford as having active MAT programs in their detention centers. New Hanover and Brunswick counties are in the planning stages of opening MAT programs.
It took a huge paradigm shift and multiple local entities joining together to get MAT programs into these detention centers.
These programs are relatively new and many are still working out the kinks. But the local representatives hope their programs continue to grow, save lives and serve as a model for other interested counties.
Need county and sheriff support
More than 60 percent of jail inmates meet the requirements for drug dependence or abuse, according to the National Sheriffs’ Association.
“Many of these individuals have Opioid Use Disorders and could benefit from access to MAT, a combination of behavioral interventions and medications that have been shown to decrease opioid use, increase treatment retention, reduce overdose, and reduce criminal activity,” the organization wrote in a 2018 guide for providing MAT in jail.
Despite support from the National Sheriffs’ Association, less than 1 percent of U.S. jails and prisons offer medication-assisted treatment.
When the N.C. Sheriffs’ Association started talking about MAT in jails a few years ago, their conversation consisted of reasons why it wouldn’t work, said Sheriff Blackwood. The criticisms were that it was too much money and would require more staff or an upgraded facility.
Blackwood said he had to fight against the old adage: “We can’t do that because that’s never been done.”
In Buncombe County, one challenge to getting a consensus for a jail MAT program was the lack of county and population-specific data.
Sarah Gayton, programs director for Buncombe County Detention Center, said county officials had national and state data, but they needed to know the story behind the people coming in and out of their jail.
She reached out to the health department and register of deeds and asked for the data on people who died from overdoses in Buncombe County. She wanted to know how many had been through the detention center.
They discovered that 50 percent of the people registered as overdose deaths in Buncombe County had been in jail at some point. Of those deaths, half of them had died within 24 hours of release.
“So that told us we had a very small window,” she said. “That information informed a different process. So that was the biggest challenge, having no information to work with and figuring out the process of gathering the data and getting to know our population.”
It took a few years, but the Buncombe County Board of Commissioners finally came to a consensus on the MAT jail program.
“Part of how we built to that was understanding that for some folks on the commission, this is primarily an emotional and spiritual issue,” said Buncombe Commissioner Jasmine Beach-Ferrara. “For some folks, this is primarily about saving money. For some folks, this is primarily about empirical data and evidence.
“Being able to make the case for [MAT] through all of those lenses was the way to build that level of resounding support.”
Challenges and unknowns
Challenges arise when some counties offer MAT and others don’t.
For example, if someone has charges in more than one county and one provides MAT and the other does not, should you start that inmate on treatment?
“Is it ethical to put someone on medication that will lead to their withdrawal if they’re transferred elsewhere?” said Carlyle Johnson, clinical psychologist and Alliance Health’s lead representative on opioid projects, who works with Durham’s detention center on its MAT program.
There’s also the issue of an unknown discharge time. Someone could start on MAT and be released on bail overnight and connection with that person is lost, Johnson said.
Some law enforcement officials are concerned that inmates receiving treatment will give their medication to others or attempt to sell it.
Johnson said he’s heard anecdotally that medication diversion within jail or prison often occurs because inmates are trying to self-medicate their withdrawal symptoms. A way to fix this would be to offer MAT to all inmates who use substances, whether it’s MAT or illicit drugs, he said.
That is the end goal for many of the North Carolina counties providing MAT now.
As awareness builds around opioid addiction, public perception has shifted. Addiction is now seen as a chronic illness, rather than a moral failure.
“I think it also perpetuates the stigma if we treat this differently from other medical conditions,” Johnson said.
“As I look at this as a chronic illness model, I don’t see how we can’t move in the direction of making it a requirement to offer in all of detention settings.”
This is what lawyers have argued in states, such as Washington and Maine. They said that withholding medication to people with substance use disorder is a violation of the Americans with Disabilities Act (ADA).
These lawsuits ended with inmates receiving MAT in jail. Additionally, there have been lawsuits and expensive settlements after in-custody overdose deaths. And jail overdose deaths are on the rise in North Carolina.
Building funding and support
So for Sheriff Blackwood, the cost of a MAT program is worth it considering the lives and money saved.
“The cost of an in-custody death lawsuit far outweighs the money we would spend on implementing half of this program,” he said.
Securing funding for a new jail program has been difficult. Many of the N.C. counties with MAT programs launched with grant funding.
Blackwood urged counties interested in MAT to start by getting all the relevant people in a room and see what can be done just by partnering together.
“You can do so much right now that you don’t even know because you haven’t sat down with the stakeholders and written those things down,” he said.
Once those conversations are started and the framework has been laid out, Blackwood said the county and others will be more likely to fund the program.