By Rachel Crumpler
Elijah Bazemore believes there needs to be a paradigm shift in the way detention facilities — jails and prisons — are managed.
“What we’re doing is putting a person back into the community the same way they came in — broken and torn up,” said Bazemore, who recently retired as a major from the Durham County Sheriff’s Office after more than 30 years.
“We should be in a position to try to help that person be a better person when they are released out of the facility. That’s going to reduce recidivism,” he said. “We should be working to eliminate our jobs by helping people.”
Establishing programs that provide medications for opioid use disorder in jails is part of that paradigm shift, he said.
Momentum is building for this type of treatment in jails due to recent guidance from the U.S. Department of Justice that states it is a violation of the Americans with Disabilities Act if correctional facilities do not continue an individual on the medications they were receiving to treat their addiction in the community prior to incarceration.
There are three medications approved by the U.S. Food and Drug Administration to treat opioid use disorder — methadone, buprenorphine and naltrexone — that are often paired with counseling. Treatment that includes these medications is considered best practice for people with opioid use disorder. They suppress withdrawal symptoms, reduce drug cravings and decrease the risk of overdose death.
Approximately three-fourths of jails in North Carolina are not yet providing this gold standard treatment and now need to consider how to put the logistics in place to provide the treatment to incarcerated folks. Failure to do so could open a jail to liability and lawsuits for violating the Americans with Disabilities Act.
“We’re in the midst of this culture standard of care shift, real-time, and we’re all working to evolve with that,” Sarah Gayton, Buncombe County Detention Facility’s community integration and addiction treatment services director, said in an August webinar series called “MAT in Jails: Legal, Medical, Community, and Security Considerations.” MAT or medication-assisted treatment refers to the three medications used for opioid use disorder.
In part, implementation of addiction treatment in jails has been slow due to persisting stigma. Gayton said in an interview with NC Health News that there’s still a “huge lack of understanding” about addiction and treatment both inside and outside of jail, so education is “incredibly important” in explaining opioid use disorder and the need for these medications.
To get the buy-in needed to launch a program, Bazemore, who is now a consultant with Vital Strategies specializing in jail-based opioid use disorder treatment, suggests assembling a group of all relevant parties, including detention staff, medical staff, county commissioners, community treatment centers and peer support specialists.
“You cannot move the needle if you don’t have all those people together,” said Bazemore, who helped launch the program providing medications for opioid use disorder at the Durham County Detention Facility in 2019.
These discussions can help identify motivations as well as points of resistance that need to be overcome in order to form an implementation plan that works best for each county jail.
“Every person brings something different regarding their motivation and their vantage point to the situation,” Gayton said. “For some, the focus is lives lost. For some, it’s the child welfare — the kids that are impacted within that system. For some, it’s straight economic costs. For others, it’s crime rates.”
Gayton said one of the best ways to alleviate stigma is hearing from real people who have benefited from addiction treatment.
“If you just get to know individuals who have walked through this process, they will be your biggest salesmen for the why and they will bring an absolute unshakable conviction of the need to move forward when you get to see their successes when they have treatment support,” Gayton said during the webinar.
MOre stories about medication-assisted treatment
A success story
That’s where Samantha Brawley came in, sharing her own story in her previous role as a peer support specialist in the Buncombe jail’s addiction program with both detention staff and people going through the program. Her personal experience illustrates just how effective these medications can be.
Brawley said she had tried everything for her opioid use disorder: faith-based programs, Narcotics Anonymous and Alcoholics Anonymous meetings, in-patient treatment centers.
None of it worked.
She described herself as a “chronic relapser” whose cravings always led her back to drug use. She thought she would never get well, that is until she started taking medication for her opioid use disorder six years ago. The medication, along with a lot of hard work, has kept her from returning to drug use.
“Without it, I’d be on edge and have a lot of cravings,” she said. “I’m not myself. I’m agitated and aggravated. It’s a brain disease. The medication is healing my brain and that’s the goal — to make people well. We should just normalize it.”
But Brawley didn’t start the medication for opioid use disorder until well after serving several stints in jail. It wasn’t offered or available to her then. She’s glad that’s starting to change.
“I just kind of think back to how much it’s always been needed,” Brawley said. “Thank goodness, we’re kind of finally at this point.”
Options for starting to provide MAT
There are two options to provide medication to treat opioid use disorder to individuals in jail. The easiest option is for a jail to partner with an Opioid Treatment Program (OTP), which is a certified and accredited outpatient entity that provides these medications, which are classified as controlled substances. Due to federal regulations, methadone for the treatment of opioid use disorder can only be obtained through a licensed OTP.
North Carolina has at least 85 Opioid Treatment Programs spread across the state, though one is not located in every county.
Partnerships can operate differently based on what jail administrators and Opioid Treatment Program staff decide is the most workable and efficient process.
For example, staff from one of the certified facilities can bring medication to the jail and administer it to a patient themselves or leave doses to be given by jail workers.
Another more laborious process would involve jail staff transporting an incarcerated individual to an Opioid Treatment Program to receive the medication. Until a few months ago, that’s what staff at Forsyth County Detention Center were doing to maintain individuals on medication for opioid use disorder, said Crystal VanBencoten, a registered nurse and director of jail operations with NaphCare, the health care provider at the facility.
However, when the detention center had three people at once who needed to continue on the medication, it became too taxing to coordinate daily transport to the local methadone clinic. To make the process more efficient, the jail partnered with the local treatment program to have the medication delivered.
This marked the first time methadone would be brought inside the facility, and Detention Services Bureau Commander Major Robert Whitaker was initially apprehensive. He feared there could be issues if the medication was diverted to someone besides the patient. Forsyth County, like many other jails providing medications for opioid use disorder, opted for liquid methadone, instead of the pill form that could be easily hoarded, to lessen diversion risks.
“Keeping them in a program that they were already successful in is important to continue,” VanBencoten said. “That’s the way we’ve looked at it.”
The second option for providing these medications in jails is for a detention center to become a licensed Opioid Treatment Program. However, it is an expensive and time-consuming process to become licensed, said Jana Burson, an addiction medicine doctor at an outpatient opioid addiction treatment facility in North Wilkesboro, during the August webinar. It is likely only practical for large facilities, she added.
Durham County Detention Facility is in the process of becoming an OTP.
Taking a phased approach
Continuing people on addiction medication they were receiving prior to incarceration is needed for a jail to be compliant with the latest U.S. Department of Justice guidance. A jail doesn’t have to provide access to the medications for their entire population.
For now, Forsyth County only has plans to continue people on medication who were receiving it prior to incarceration, Whitaker said. He said the jail does not have the capacity to initiate everyone who could potentially benefit from addiction treatment due to resource restrictions and staffing vacancies.
Other detention centers are planning to serve more people by also offering to start incarcerated individuals with opioid use disorder on treatment.
Bazemore, who helped launch Durham’s addiction treatment program in 2019, is taking the lessons he learned to help other counties start their own programs now as a consultant. He’s available to provide assistance for free and is already working with two counties and in conversations with a couple more.
He advises a phased approach for program implementation, starting with continuing people who were already receiving medication for opioid use disorder prior to incarceration for six months to a year to work out logistics and troubleshoot problems. Once all the kinks are ironed out, he recommends expanding the program for voluntary initiation of new people on medication.
“It’s going to reduce recidivism, and it’s going to keep them from overdosing once they have been released from the facility,” Bazemore said.
The phased approach is exactly what Guilford County Sheriff’s Office plans to do, mirroring its work after the success of Durham’s program, said First Lieutenant Brandon Burley working at High Point Detention Center. After experiencing implementation delays, Guilford plans to start continuing people on MAT at its facilities in October. Later in 2023, the detention center plans to open up the program to more people.
To start providing this addiction treatment, Burley said the jail’s medical provider is working to hire additional medical staff to handle the screening process, medication administration and record keeping.
“The more detention facilities that we can get up and going, the better our state is going to be,” Bazemore said, adding that counties can make their program as small as it needs to be in the beginning for a test run.
Though there are logistical challenges, Burley said he doesn’t think it is a significant burden on any facility to continue individuals on medications for opioid use disorder.
“I think your main constraints that everybody kind of pushes away from it is just, does your medical provider have the staff to get this done in a timely fashion so that it doesn’t disrupt normal operations?” Burley said. “The same thing with custody. It’s all based around, do we have the people that can get it done?”
Additionally, Bazemore noted that one of the biggest lifts for a jail isn’t even in the building, but rather about lining up the community resources so that treatment can continue once a person is released. He emphasized that an addiction program cannot be created in a silo.
“You’ve got to have that continuity of care — that’s critical,” he said, recognizing that there will be issues with this in some areas with fewer community recovery resources.
Funding also must be considered. For fiscal year 2020, Buncombe County’s MAT program costs $285,000 with three full-time employees. After expanding, the program cost $375,00 in fiscal year 2021 to operate with four full-time employees and increased recipients.
A model program
Fortunately, jails just starting to think about providing medications for opioid use disorder have some established examples to look to within North Carolina.
For example, Buncombe County Detention Facility has one of the most comprehensive programs in the state that is both continuing and initiating new individuals on medication. In fact, when North Carolina Attorney General Josh Stein toured the facility in July, he referred to its program as the “gold standard.”
About 120 people a month passing through Buncombe County’s 604-bed detention facility say they’ve used opioids. On average, the jail provides medication for opioid use disorder to 15 to 30 incarcerated individuals each day, offering all three FDA-approved medications.
The county’s data indicates the program is working. Since the program’s launch, Buncombe County has seen a 22 percent reduction in overdose deaths of people previously incarcerated at the detention center.
“That right there to me is telling and is more powerful than anything,” Captain and Buncombe County Detention Facility Administrator Jeffrey Littrell, who admitted he initially had doubts about the program, said during the webinar last month. “That’s the message that really needs to be getting sent to staff and the community.”
There is no one-size-fits-all approach for every jail facility to implement but Gayton emphasized that addiction treatment works.
“Whatever your disposition or your interest point is when it comes to the impacts of untreated addiction, MAT is never a wrong answer,” she said. “It always brings a meaningful, successful result when it’s offered.”
Clarification: The word “all” was removed from the sentence “Continuing people on addiction medication they were receiving prior to incarceration is needed for a jail to be compliant with the latest U.S. Department of Justice guidance” to reflect that there could be instances when a jail needs to start someone on medication to be compliant with the Americans with Disabilities Act.