By Rachel Crumpler
The N.C. Department of Adult Correction says it is putting resources into expanding access to medications for opioid use disorder to those who are incarcerated and those who are headed back into the community.
Roughly 70 percent of the more than 31,000 people in North Carolina’s prison population is in need of treatment for some kind of substance use, according to Gary Junker, deputy secretary of Comprehensive Health Services at the N.C. Department of Adult Correction. About 1,700 people have an opioid use disorder.
“That’s relatively small but impactful and meaningful,” Junker said.
But the resources to provide treatment haven’t kept pace with growing demand, he said. In fact, there’s a widening gap, as NC Health News has reported.
Junker told members of the North Carolina Joint Reentry Council on July 24 that prisons are like “health care stations,” where people receive care for a period of time. And because 95 percent of the people incarcerated in the state will eventually return home, how the prison system performs that care will eventually impact the health of the community.
That means any treatment received in prison — or lack thereof — makes a difference.
This can be especially true for people with substance use disorders because research has found that people who are newly out of prison are at higher risk of death from overdose. After leaving the controlled prison environment, people may relapse and find their tolerance is much lower, while the street drugs available have become more potent.
Researchers have found that providing medications for opioid use disorder can help curb overdoses post-release, and giving them to people leaving prison is now considered best practice. Many studies also show that providing these medications in correctional settings decreases opioid use, results in less criminal activity after release and dampens the spread of infectious disease.
In recent years, the Department of Adult Correction has explored this philosophy, offering treatment to a small fraction of people in a pilot program. Before that, the state prison system only provided these medications to pregnant women who were incarcerated.
Junker, who’s worked in corrections for 35 years, acknowledged it’s a “huge cultural shift.”
New guidance from the U.S. Department of Justice issued in April 2022 on the Americans with Disabilities Act has put pressure on correctional facilities to provide medications for opioid use disorder. It’s now a legal imperative that correctional facilities keep an individual on medications to treat their addiction if they were receiving them in the community before incarceration. If prisons don’t provide this treatment, they will be deemed in violation of the ADA.
Reaching people before release
Amid limited resources, Chief Medical Officer Arthur Campbell told the Joint Reentry Council that the Department of Adult Correction is focused on providing substance use treatment where the “most dire need is.” He said the prison system is targeting the critical point of exit from prison to a person’s home community — a particularly deadly time for people with substance use disorders.
A 2018 study done in North Carolina found that formerly incarcerated people are 40 times more likely than the average person to die of an opioid overdose within two weeks of release from prison.
To help reduce risk during this vulnerable period, the Department of Adult Correction is working to provide incarcerated people with medications for their opioid use disorder before their release. Treatment for opioid use disorder that includes one of three U.S. Food and Drug Administration-approved medications (buprenorphine, methadone and naltrexone) — paired with counseling — is considered best practice. The medications suppress withdrawal symptoms, reduce drug cravings and decrease the risk of overdose death; the counseling helps people readjust and rebuild their lives so they can stay substance-free.
The Department of Adult Correction started providing medication-assisted treatment to people with opioid use disorder who are incarcerated at the North Carolina Correctional Institution for Women and Orange Correctional Center in 2022 as part of a pilot project. To launch the program, the department partnered with the Mountain Area Health Education Center and the North Carolina Formerly Incarcerated Transition Program.
Evan Ashkin, who leads NC FIT and works with the Department of Adult Correction on the pilot program, said starting people on medication before they are released is crucial to protecting people from overdose post-release.
“I’ve had patients in previous years who were not started prior to release and even in the couple of days between release and when they got in the clinic, they had used and overdosed,” Ashkin previously told NC Health News.
The Department of Adult Correction starts program participants on Suboxone leading up to their release. The medication containing buprenorphine and naloxone is one of the most effective known treatments for opioid use disorder.
Program participants are also given Sublocade, a long-acting injectable buprenorphine, seven to 10 days before their release, Ashkin said. This medication — costing about $1,000 per injection — was chosen because it lasts for a month, giving people time to connect with a treatment provider in the community who can prescribe more medications for opioid use disorder.
“We have a window of one or two weeks post-release to get them into care, so there is no gap — no return to use,” Ashkin said, explaining the value of the injection.
From the pilot’s launch through May, 287 people have enrolled in the program, and 229 of them have received treatment medications before release, according to data Junker shared at the Joint Reentry Council meeting.
The program also links participants to treatment for their opioid use disorder in the community through NC FIT or other providers. A FIT Recovery program community health worker meets with pilot participants before their release to discuss substance use treatment and assess their needs. The community health worker continues to follow up with the person post-release — even helping them get to appointments when needed.
Nearly half of participants have linked to NC FIT post-release, and the FIT Recovery Network now covers nearly 60 counties. Ashkin said that he plans to grow the network to all 100 counties so it can help people anywhere in North Carolina, even as participants in non-FIT eligible counties have been connected to other community providers.
Ashkin said the initial results from the pilot are promising. He said a high rate of people have attended their first clinic appointments and continued taking medications for opioid use disorder after release.
“If you start people on medication prior to release, there’s a decrease in death rates that’s significant and persistent,” Ashkin said.
The Department of Adult Correction pays for visits and medications for the first six months, Ashkin said. After that, people are responsible for covering the costs of the medications. But, Ashkin said, most people returning to the community from prison are eligible for Medicaid coverage under expansion, and that coverage can prevent out-of-pocket expenses and avoid situations where people suddenly have no resources for medication.
Campbell said the Department of Adult Correction plans to expand the program to other prisons and has selected four more facilities, though he did not tell the Joint Reentry Council which ones they are or share a timeline on when medications will be provided. He did share that the prison system has hired several physicians with specialized training in addiction medicine to help oversee the wider distribution of medications for opioid use disorder.
Although Campbell said the prison system eventually plans to provide medications for opioid use disorder at all of its prisons, he said cost remains a factor hindering growth. Right now, Campell said, the prison-based medications for opioid use disorder have been funded by the Department of Adult Correction’s budget, with no outside funding or grants.
Aiding the community transition
The Department of Adult Correction’s Division of Community Supervision started connecting people on probation, parole or post-release supervision to medication-assisted treatment in January 2023. The initiative is funded by $8 million in nonrecurring funds from the federal Substance Abuse Prevention and Treatment Block Grant from the 2021-22 state budget. The funding, which is set to expire in September 2025, allows treatment for opioid use disorder to be provided at no cost for these individuals.
The community supervision medication-assisted treatment initiative is operating in 14 counties across the state — those identified to have the highest need for expanded access to the treatment.
In June, 71 people were actively being served in the program, Karen Buck told the Reentry Council. She is an evidence-based practice manager at the Department of Adult Correction.
Buck said some people on probation or parole are only learning about medication for opioid use disorder when they end up in violation for using a substance.
After starting on the medications, she said, many tell probation/parole officers that access to the care saved their lives.
Buck said positive stories from participants have trickled in. She shared that one person in Wayne County who was referred for medication-assisted treatment services in January has been able to maintain sobriety, gain full-time employment, complete probation and is working toward regaining custody of their children as a result.
“You could be on the medications all your life, just like for diabetes,” Buck said. “If it helps you function, and it deals with the cravings and the pain and different things, and it’s a controlled substance that’s federally approved, then hey, that’s great! It works.”
Anne Blythe contributed reporting.
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