buprenorphine

A white and blue sign reading "Inmate Intake" points to the High Point Detention Center, a tall white building with small windows.

Could MAT be the key to reducing recidivism in NC’s jails?

July 28, 2021 by Elizabeth Thompson 1 Comment

Could MAT be the key to reducing recidivism in NC’s jails? - North Carolina Health News

A large number of justice-involved individuals have substance use problems, but most jails across North Carolina still don’t offer the standard of care for Opioid Use Disorder, Medication Assisted Treated (MAT).

By Elizabeth Thompson

Rain or shine, whether it is a holiday, the weekend or a regular workday, patients at Johnston Recovery Services come in every morning for the medication that helps them manage and overcome their opioid addiction.

At the height of the COVID-19 pandemic, some patients were allowed to take home medications such as methadone or buprenorphine to reduce the number of people in the clinic, which offers medication-assisted treatment, otherwise known as MAT, to help treat people with opioid use disorder in and around Clayton, but otherwise they are expected to come in daily.

But sometimes patients disappear for days, going off of their medication because they were in jail, said Mary Anne Hughes, a psychiatric nurse practitioner at Johnston Recovery Services.

“We have a patient that was jailed on Saturday,” Hughes said. “And he was on methadone, you know, standard dosage. But once he’s incarcerated, he can’t get access to that medication.”

According to the Centers for Disease Control and Prevention, MAT is best practice to care for people with opioid use disorder. But despite federal data showing that as much as 85 percent of the prison population either has a substance use disorder or was arrested for crimes related to drug use, MAT is often unavailable for the country’s incarcerated population.

Medication-assisted treatment (MAT) is the use of one of three drugs approved by the U.S. Food and Drug Administration — methadone, buprenorphine (also known as Suboxone, the brand name for the drug) and naltrexone — along with counseling to provide a holistic approach to treating Opioid Use Disorder.

The medication allows patients to begin recovery without going through the symptoms of withdrawal while remaining clear-headed, able to go to work and otherwise rebuild their lives, Hughes said.

At least 13 of the state’s more than 100 jails have started programs to implement MAT in their facilities, according to North Carolina Department of Health and Human Services, but MAT providers urge more widespread use of the treatment in order to combat the opioid epidemic and reduce recidivism.

A small white window with blinds closed is pictured inside an office building. — The front desk of Johnston Recovery is where patients check in. Photo Credit: Elizabeth Thompson

MAT in Jails

The National Sheriffs’ Association has come out in support of implementing MAT programs in jails, saying “jails are on the front lines of this epidemic, and they are also in a unique position to initiate treatment in a controlled, safe environment.”

Buncombe County identified the need for a MAT program, as the county is one of North Carolina’s most disproportionately affected by the opioid epidemic, said Sarah Gayton, division director of community integration and MAT services at the Buncombe County Sheriff’s Office, in an email. Buncombe County started its MAT program in 2019.

Data is limited, but Gayton said Buncombe County has seen a 17 percent reduced recidivism rate for program participants compared to those who remain untreated over the course of a 9 month period in a sample of Buncombe County’s MAT and opioid using population. The program both continues medication for inmates who were already on MAT before incarceration and inducts inmates to begin treatment.

“All facilities (detainment, residential and treatment alike) in NC and the USA would do well to begin the process of evaluation, development, and implementation of MAT programs,” Gayton wrote “ 1) MAT is considered the gold-standard to address opioid addiction, 2) increasing momentum on the national stage frames MAT treatment with the [Americans with Disabilities Act], and 3) untreated addiction and involvement in the criminal justice system have undeniable overlaps.”

Some other jails in North Carolina have implemented MAT programs, but as opioid overdoses soared throughout the COVID-19 pandemic, safety protocols generated by the pandemic also forced many programs that combat opioid use disorder among incarcerated people to delay their plans.

Durham’s jail-based MAT program, which started in 2019, continues to offer MAT to incarcerated people who were already on this medication. But the pandemic delayed the second phase of its MAT program – identifying and treating new patients – which had been set to start in March 2020.

This second phase is key to fighting the opioid use before reentry, said Dr. Eric Morse, an addiction psychiatrist who serves on the board of Morse Clinics — which includes Johnston Recovery.

“It would be great if the folks in the jail would identify new [opioid use] patients,” Morse said, since jails are already identifying patients to put them on a detox protocol.

The new start up date for the second phase of Durham’s MAT program is now October 2021, said David Bowser, spokesperson for the Durham County Sheriff’s Office.

The pandemic also delayed the North Carolina Departments of Public Safety and Health and Human Services plan to pilot a MAT program in three prisons. DPS spokesperson John Bull said the state plans to operate the programs by fall 2021 at the N.C. Correctional Institution for Women (where pregnant women with opioid use disorder are prescribed MAT before they give birth), Wake Correctional Center and Orange Correctional Center.

For up-and-coming programs in jails, staffing and funding are key issues, said Margaret Bordeaux, justice-involved overdose prevention specialist at the NCDHHS.

Resistance to MAT

One study, funded by the National Institutes of Health, found that MAT significantly reduced overdoses by 60 percent for people receiving methadone and 38 percent for people receiving buprenorphine, but there is still resistance to the medication among some members of the medical community, said Dr. Jana Burson, an opioid treatment specialist in western North Carolina.

Some providers may be opposed to MAT because of the stigma tied to the drugs, which were illegal until 2000, Burson said.

“Doctors didn’t get educated about addiction in general, and Opioid Use Disorder, it’s specific,” Burson said. “So it takes a lot of time to turn that ship around. It just takes time and education. And that’s I think the biggest problem.”

Some jails that do not allow MAT prohibit those drugs because they are afraid they could be diverted to other prisoners, Burson said. Morse said this fear is based on negative stigma around people in jail who use drugs.

“If you select the right patients, the folks who legitimately have Opioid Use Disorder, they’re going to function better on the medicine than off the medicine,” Morse said. “ … if they’re not in withdrawal, then they’re not suffering.”

Instead of keeping a person with opioid use disorder on their medication if they are participating in a MAT program or putting that person onto MAT, many jails instead put people on a detox protocol, forcing them into withdrawal.

“People really suffer, it’s not just like having the flu,” Burson said. “If someone’s medically fragile they can actually die of opioid withdrawals if they are ignored and not taken for medical care, like if they had coronary artery disease, or if they’re a brittle diabetic.”

“Things can really go off the rails.”

Not only is withdrawal dangerous in and of itself, it also makes returning citizens more likely to relapse. People leaving a prison or jail were 40 times more likely to die of an opioid overdose two weeks after their release, according to a study conducted by the University of North Carolina at Chapel Hill. That’s because returning citizens who have detoxed are likely to reenter society and relapse, taking the same dosage they took before they were incarcerated which is now way above their body’s tolerance level.

MAT providers sometimes try to work with jails to get patients their medication, but the process means jumping through bureaucratic hoops, Morse said.

Burson recently worked with Ashe County Detention Center to bring a patient to the clinic once a week to get their buprenorphine dosage, so jail personnel could give them their medicine for the rest of the week. Hughes recalls Johnston County Jail bringing in a patient to get their dosage in shackles.

A chance for a better life

When a patient comes back to Johnston Recovery after they’ve been absent, the first question they’re asked is: “Where have you been?”

“We don’t scold them,” Hughes said, “We’re just happy to have them back. Because we know they’re safer with us.”

A window in an office is pictured. There is an orange sign reading — Patients get their dose of methadone or buprenorphine at this window every day. Photo Credit: Elizabeth Thompson

It’s up to Hughes to determine the dosage a patient needs based on their history, their medical condition and the days they’ve been absent. It’s also about knowing the patients, Hughes said. She’s known a lot of her patients for eight years.

MAT therapy at Johnston Recovery is a holistic process, and patients also have access to counseling services in addition to their medication.

“What you learn in here, you take it out there,” said Claire Hayes, a counselor at Johnston Recovery. “…Think about when you have used substances and you are now in recovery, now you’re reflecting on all the things you’ve done. You can feel pretty low about yourself.”

Hayes said she works with patients to accept the things that they have done and to focus on their rise and recovery. But that can be difficult when patients with felonies have a hard time finding a job because of their record. Financial stability is crucial for people trying to get off of opioids to start a new part of their lives.

Flyers of different colors are hung on a brown corkboard. The most prominent flyer advertises a suicide hotline, another says — As patients at Johnston Recovery wait in line, they look at a variety of flyers. Photo Credit: Elizabeth Thompson

MAT therapy is a first step in what Hughes calls a “transformation.”

“I’ll admit somebody today, and I’ll see them four weeks from now,” Hughes said, “And they say, ‘I didn’t realize life could be like that.’”

Making the standard of care the standard

Several lawsuits across the country, including in Maine, Massachusetts, Washington and New York, may force jails to allow MAT medications in their facilities.

“It’s a civil rights issue,” Morse said. “I just believe that people who are on methadone or buprenorphine going into jail should be allowed to stay on their dose. And the opioid treatment programs in the state would be happy to partner with all the jails and prisons and continue them on their medicine.”

Morse has recently received grants to work with Vance County and Wake County jails to provide MAT for people reentering society, and other organizations like North Carolina Formerly Incarcerated Transition Program (NC FIT) work with Orange and Durham County jails to help keep people on their MAT medication.

Addiction is a “brain disease” like any other, Hughes said, and while people do bad things at the height of their addiction, “they change also, which people have to realize.”

“And that’s part of their brain disease, that’s part of the addiction process,” Hughes said.
“A lot of the crimes are related to the addiction. And by the time we see them, they’re not trying to get high anymore.”

“They’re just trying not to be sick.”

semi white crystal methamphetamine on a black background, both shattered pieces and full crystals

Communities struggle with meth outside spotlight of opioid crisis

July 17, 2021 by Carolina Public Press Leave a Comment

Communities struggle with meth outside spotlight of opioid crisis - North Carolina Health News

Increase in methamphetamine use in Western North Carolina affects 'misery index,' even if death rate is lower than opioids.

by Christian Green for Carolina Public Press, July 13, 2021

While the opioid crisis gripped many rural areas of the state, the proliferation of methamphetamine challenged communities in Western North Carolina.

“The biggest thing out here in Graham County is meth,” Graham County Health Director Beth Booth said.

“Unlike opioids, with meth, there’s nowhere to point the blame and no one picking up the staff to fight it,” Booth said.

“There might not be as many deaths directly associated with it, but meth is readily available, it’s really cheap, it ruins lives, and there really is no good treatment.”

Insufficient data

The impact of meth on a specific community is difficult to assess from data, in part because one key data point used to illustrate the severity of a substance is overdose deaths.

While the high rate of opioid deaths indicated the seriousness of the opioid epidemic, the outcomes of meth use were more difficult to decipher because it is less likely to result in a direct overdose death.

In 2018, the state medical examiner told Carolina Public Press 160 people had died during the previous year as a result of methamphetamine-related overdoses. That was less than 10% of the 1,974 opioid-related deaths reported by the state medical examiner in the same year.

But the death rate is only one factor in understanding the effect of meth use on communities.

“I would certainly not want to give the impression that, just because deaths are lower, methamphetamine is somehow less devastating to communities and individuals,” said William T. Stetzer, acting U.S. attorney for the Western District of North Carolina.

“Methamphetamine might not have the same number of overdose deaths, but I think the misery index it brings is still very high as far as communities, tribes and families who are suffering.”

Stetzer, who oversees the prosecution of criminal cases against drug trafficking organizations, described a “significant” increase in the amount of methamphetamine arriving in North Carolina from cartels in Mexico via a supply line that runs through Atlanta to Charlotte, before continuing to Tennessee and then north.

In 2012, U.S. Customs and Border Protection listed that it seized about 18,000 pounds of methamphetamine crossing into the country. By 2018, that number had increased to 85,000 pounds, and in 2020 that number skyrocketed to 177,000 pounds of methamphetamine and crystal meth.

Local producers of meth within communities still exist, Stetzer said, but the influx of high-purity crystal meth had caused prices to decrease by more than half.

“More drugs come in, larger quantities are distributed to local dealers who, in turn, sell even more crystal meth into our communities,” Stetzer said.

Part of polysubstance use

Across the state, 75% of drug-related deaths were caused by multiple drugs taken by a single user, or polysubstance use, according to a recent report by NC Health News.

Polysubstance use compounds the challenge of determining meth’s impact in Western North Carolina.

Though meth is the dominant substance in Graham County, Booth said, it’s not uncommon for people to use multiple substances. Most commonly, they mix meth, a stimulant, with another substance that serves as a depressant, such as opiates.

“Right now, a lot of our participants are mixing meth with heroin or fentanyl,” said Tanasia Boyd, the harm reduction coordinator with Buncombe County Department of Health and Human Services.

In North Carolina, the majority of recent overdose deaths have been among individuals using multiple substances, and nationally the majority of overdose deaths involving stimulants like methamphetamine also involve an opiate.

Over the past two decades, Rebecca Smith, social work division director with the Buncombe County DHHS, has seen different drugs come into and fade out of popularity. Today, though, she said it seems as if illicit substances are more available than ever before. Boyd agreed.

In her experience, Boyd said, not a lot of people of color were using meth. “Now I’m starting to see more and more people,” she said. “It’s everybody. Everybody using everything.”

Treatment challenges

Even for those who are using only meth, receiving care or resources can be more difficult than for those using opiates, Boyd said.

In one situation that Boyd encountered, a woman was using meth and wanted to seek treatment, but she had not yet been using it long enough to qualify for any detox protocols.

“She ended up having to wait a couple of weeks before finally getting in and getting treatment,” she said.

“She’s doing great now, which is good. But if she had had opiates in her system, it would have been automatic. She would have gotten in that day.”

Even when those using meth are able to seek treatment, they face a difficult road because, unlike many other substances including opiates, no approved medication to treat a meth overdose or to alleviate withdrawal symptoms exists currently.

“That’s the biggest difference when treating addiction for meth and for opiates — there are no treatment options for methamphetamine.” said Michael Nader, a professor of physiology and pharmacology at Wake Forest University School of Medicine who specializes in stimulants.

Nader’s colleague Thomas Martin, professor of anesthesiology at Wake Forest who studies pain and opioid abuse, said that when it comes to treating opiate addiction, three approved medications offer options.

Naloxone, also known by its brand name Narcan, is a fast-acting medication that blocks the effects of opioids. It is often used in emergencies to save someone experiencing an opioid overdose.

The other two medications, methadone and buprenorphine, are long-term treatments used to counter addiction to opioids. They are able to prevent or lessen withdrawal symptoms while also decreasing the body’s response to opioids so that an individual is less likely to abuse them in the future.

These drugs are used in combination with other treatments such as therapy and counseling in a process known as “medication-assisted treatment” to aid those who are addicted to opiates.

“It’s honestly generally a lot easier to wean someone off of opioids than it is to get them off meth,” said Booth of Graham County.

“There is no substance-use treatment for meth, so they just have to quit on their own, and that’s really hard. So, it’s kind of counterintuitive, but opioid addiction honestly seems probably like it would be the easier one to tackle.”

Joel Chisholm, an addiction psychiatrist and the behavioral health medical director of the Cherokee Indian Health Authority in Swain County, said he saw a similar dynamic in his clinics.

“We see a lot more people who use opiates engage with treatment because we can provide them medication,” Chisholm said. “The carrots are just a lot bigger for them to engage with treatment versus someone using meth; we still provide them therapy and recovery classes, but it’s a lot tougher.

Ongoing research seeks to create medication that can serve a similar purpose for people who use stimulants, such as cocaine or methamphetamine, Nader said.

Creating treatment drugs in the current climate may be more difficult than in the past, Nader said. Methadone, which was approved for use in treating opioid addiction in the 1960s, would likely not be approved today because it has some potential for abuse, he said.

“The way the FDA has approached potential treatments for stimulant abuse,” Martin said, “… they want something that makes people abstinent but also has pretty much zero abuse liability and of itself. Methadone certainly doesn’t meet that criteria for opioid treatment, so it’s true. There’s a chance it wouldn’t have been approved today.”

Nader said he hopes the U.S. Food and Drug Administration will set out specific guidelines for what it would like to see in a methamphetamine treatment, possibly a drug like methadone, which still has some similar effects, but to a much lesser degree so that it would have less chance to be abused.

In the meantime, while no medication exists for treatment of meth and opioid use continues to receive higher prioritization in many clinics when beds are scarce, it can be difficult for meth users to find help.

“If we have someone coming … off meth (who) wants to get in for treatment and beds are limited, there’s a chance they are actually not going to take them in,” said Samantha Brawley, a peer-support specialist with the Asheville-based Sunrise Community for Recovery and Wellness and a medication-assisted treatment user.

“When that happens, we suggest that they sleep, eat and rest. But sometimes they don’t have a place to sleep, eat or rest, so it becomes a battle. It’s always a battle to try to get somebody in the right place at the right time.”

A wrapped strip of suboxone is on a counter.

Expanding medication-assisted therapy training for health care professionals

June 14, 2021 by Melba Newsome

Expanding medication-assisted therapy training for health care professionals - North Carolina Health News

The opioid overdose crisis has highlighted the need for more medication-assisted therapy.

By Melba Newsome

About a decade ago, Blake Fagan vowed he would never write a prescription for Suboxone, a combination of buprenorphine and naloxone used to curb the opioid craving. The Asheville family physician had seen the ravages of the opioid crisis up close and couldn’t imagine aiding and abetting it which he believed medication-assisted therapy would do.

“I said, you’re just substituting one addiction for another,” said Fagan, chief education officer at UNC Health Sciences at the Mountain Area Health Education Center in Asheville.

These days, Fagan not only prescribes Suboxone (the generic name is buprenorphine), he sees that primary care doctors in residency programs in North Carolina are qualified to prescribe the drug, too. He views this as another spoke in the wheel of addiction treatment.

Fagan’s thinking changed after a patient was brought into the emergency room after an overdose and later died. Years earlier, he had delivered the young woman’s two children.

“It just broke my heart,” he says. “I realized that this medicine could have saved her life. That’s what’s been driving me.”

Preliminary 2020 data shows the coronavirus pandemic exacerbated North Carolina’s opioid crisis, increasing overdose-related ER visits by 23 percent. But Suboxone, a drug that can help, is still too hard to get.

Overdose crisis forces a change in prescribing

Fortunately, the one upside to the epidemic of overdose deaths is a slew of new initiatives and additional funding to improve the way physicians, physician assistants, nurse practitioners and other health care providers prevent, identify, treat and support the recovery of their patients who have, or are at risk of developing, an opioid use dependency.

Much of the focus has been on educational outreach to health care providers about safer opioid-prescribing practices. But many addiction medicine specialists believe the greatest opportunity to curb opioid overdoses lies in expanding access to medication assisted treatment.

Most training efforts have focused on practicing primary care providers, but these efforts have fallen short in North Carolina and elsewhere. North Carolina is one of 11 states where buprenorphine prescribers per opioid death rates are well below the national average. Nationally, fewer than 4 percent of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and roughly half of all counties lack a buprenorphine-waivered physician.

According to a report created by the U.S. Department of Health and Human Services Office of Inspector General in 2018, 64 North Carolina counties (colored in red) reflect a high, or highest, need for treatment services for opioid misuse and abuse. Map courtesy: US DHHS

Prioritizing medication assisted therapy

When Mandy Cohen first came in as secretary of the North Carolina Department of Health and Human Services, Fagan says she made the opioid crisis a big priority.

“Dr Cohen said ‘I want our state to be progressive. What are some of the progressive things around opiates we need to do?’” he recalls.

To prescribe Suboxone, doctors must complete an eight-hour training program and get a waiver from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine for addiction but not for pain. Physician assistants and nurse practitioners require 24 hours to get the waiver that enables them to provide opioid treatment with buprenorphine in an office-based setting.

One of the things Fagan and others suggested was the need to train more providers in the state to write prescriptions for buprenorphine. A few days later, Fagan got a call from DHHS asking how MAHEC could help more doctors get waivered to prescribe the drug.

“We said, we need to train the residents that are actually in training, the majority who will practice across the state,” he said.

Learn more about practitioner buprenorphine training requirements.

Physician Buprenorphine Waiver Training 8-hour training
Nurses Buprenorphine Waiver Training (NPs, CNSs, CRNAs, CNMs) – 24-hour training
Physician Assistant Buprenorphine Waiver Training – 24-hour training

Training residents

North Carolina first released its Opioid Action Plan in June 2017 and has updated it twice since — in June 2019 and May 2021. The Opioid Action Plan addresses the provider shortage through coordinated residency training in family medicine, internal medicine, ob gyn, psychiatry, emergency medicine and pediatrics, the six first line residencies.

So far, over 1,000 residents in over 50 residencies in the state have been trained. Since there are new residents each year, Fagan and MAHEC devised a training plan for the faculty at each of these programs so that this education is ensconced into their training.

According to DHHS, since the Opioid Action Plan was launched, dispensing opioids as a pain reliever has decreased by 34 percent while at the same time prescriptions for drugs used to treat opioid use disorders increased by 33 percent. In addition, opioid use disorder treatment specifically for uninsured and Medicaid beneficiaries has gone up by 48 percent.

Looking for a health care provider who prescribes Suboxone/ buprenorphine? Click here.

Training medical school students

The Governor’s Institute, a Raleigh nonprofit focused on improving how the health care professions prevent, identify and treat substance use disorders, was awarded the three-year SAMHSA grant to expand medication-assisted therapy by training medical school students, physician assistants and nurse practitioners.

According to executive director and program director Sara McEwen, the schools of medicine at UNC Chapel Hill, East Carolina University, Wake Forest University and Campbell University have all integrated eight hours of opioid use disorder training into their standard medical school curriculum. Collectively, they churn out approximately 545 physicians each year who have the option to apply for their waiver once they receive their prescribing authorization number from the federal Drug Enforcement Administration.

Participants in seven of the state’s nurse practitioner programs and one of the physician assistant programs have integrated a mandatory 24-hour training course into their curricula. In North Carolina, waivered Advanced Practice Providers, or APPs, cannot prescribe buprenorphine unless their physician supervisors are also waivered. The Governor’s Institute is offering professional mentoring to encourage physicians who are on the fence to take the training.

The Institute’s SAMHSA training grant runs out in September but, given the program’s success, fingers are crossed that the funding will be renewed.

“We are hoping to get a no-cost extension so that we can further build out the clinical exposure/faculty development components which were affected by COVID,” says McEwen. “We have also applied for funding to work with several of the APP schools next year.”

According to a report created by the U.S. Department of Health and Human Services Office of Inspector General in 2018, the U.S. counties colored in green reflect a high need for treatment services for opioid misuse and abuse. Those include 20 North Carolina counties listed as being at “highest need” and 44 listed as “high need.”

shows a large envelope with drawings on it, inside the flap are taped four strips of Suboxone wrapped in plastic wrap.

Overdoses are on the rise. Is it time to provide medication assisted treatment in NC prisons?

August 25, 2020 by Hannah Critchfield

Overdoses are on the rise. Is it time to provide medication assisted treatment in NC prisons? - North Carolina Health News

COVID-19 stalled the expansion of medication assisted treatment into NC’s prisons, but the demand for it is just as high -- if not increasing.

By Hannah Critchfield

The agency that runs North Carolina’s prisons has a Flickr account. It’s littered with pictures of contraband confiscated from people incarcerated across its 55 facilities: pounds of tobacco, cell phones, marijuana in a shoe.

There are also photos of hundreds of Suboxone strips.

Suboxone strips aren’t like other illicit drugs — they’re a treatment for people struggling with opioid use disorder.

“Last year in the prison system, the number one snuck-in illicit substance was Suboxone,” said Lauren Brinkley-Rubinstein, professor and public health researcher at the University of North Carolina School of Medicine.

People are 40 times more likely than the average N.C. resident to die of an opioid overdose within two weeks of their release from a North Carolina prison or jail, according to a study conducted by researchers from state agencies and experts from UNC Chapel Hill.

Medication-assisted treatment (MAT) is a therapy that’s considered best practice for treating opioid use disorder and helps prevent overdose and reduce the risk of relapse. Currently, state prisons do not offer MAT to inmates.

The N.C. Department of Public Safety and Department of Health and Human Services had a plan to pilot MAT programs in three prisons — but this initiative has been stalled due to COVID-19.

As opioid-related overdose deaths are on the rise in North Carolina and nationwide, contraband numbers from the state prison system suggest the demand for medication therapy for opioid use disorder remains high during the pandemic.

What is MAT?

Medication-assisted treatment (MAT) uses medications, often those that act on opioid receptors in the brain, to suppress withdrawal symptoms and reduce drug cravings. It’s a therapy for opioid use disorder that avoids the painful experience of withdrawal.

The Centers for Disease Control and Prevention consider it a best practice for preventing opioid overdose deaths, according to their 2018 report “Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States.”

“It highlights what science has demonstrated as the most effective ways to prevent opioid overdose that have been implemented in the United States,” said Jennifer Carroll, professor of medical anthropology at Elon University and the primary author of the study. “MAT in jails and prisons is one of them.”

MAT involves the use of one of three U.S. Food and Drug Administration-approved drugs — buprenorphine, methadone and naltrexone — which can be used safely throughout a person’s lifetime to mitigate overdose risk. (Suboxone, a common type of contraband in prison systems, is a brand name for a formulation of buprenorphine.)

“I think it’s really important to make sure that everyone has access to the medication that’s right for them,” said Elyse Powell, state opioid coordinator for the NC Department of Health and Human Services. “So in an ideal world, each person has an option, but obviously for some medicines there’s a large amount of regulation.

“Buprenorphine and naltrexone are a little easier to do than say methadone, which has to go through specific federal vendors.”

Studies show people are more likely to die of overdose after release if they’ve undergone detoxification, or the process of completely removing all addictive drugs from the body, while incarcerated.

“Relapse is normal,” said Carroll. “That’s why these medications, especially methadone and buprenorphine, are so effective at preventing fatal overdose. If you relapse while you have a good opioid tolerance, the heroin that you buy off the street is less likely to kill you than if you have no tolerance because you’ve been abstinent.

“It’s also why being incarcerated in a place where medication is not provided increases overdose risk. Cause they’re just as likely to relapse as anyone else, but you’ve taken away their tolerance.”

Shows a book clearly labeled — A Bible dictionary confiscated at Caswell Correctional Center with Suboxone strips sequestered in the binding. Photo credit: NC Dept of Public Safety

Treating opioid use disorder in prison

Though a widely accepted treatment outside of correctional settings, MAT use in jails and prisons is sparse.

“The vast majority of jails and prisons don’t provide medication for opioid use disorder at all to non-pregnant people,” said Joseph Longley, equal justice fellow for the American Civil Liberties Union National Prison Project, who focuses on expanding access to medication for opioid use disorder in correctional settings.

He noted that about half of all facilities nationwide, including the North Carolina Correctional Institute for Women in Raleigh, provide MAT for pregnant people, but cut them off after giving birth.

“It’s extremely rare right now,” said Longley. “But it’s a growing number.”

An estimated 120 jails across the country and 10 state prison systems now offer some form of medication treatment for opioid addiction, according to a Pew Research analysis conducted earlier this year. That’s triple the number offered in 2018.

“It’s pretty regional in my experience,” said Brinkley-Rubinstein. “In the Northeast and the West Coast, there’s more progress around MAT. If you look at the southeast, there’s in general less availability of MAT in correctional settings.”

Three states — Rhode Island, Vermont, and as of a few weeks ago, New Hampshire — provide MAT programs in all of their correctional facilities.

Rhode Island is a unified prison-jail system, with pre-trial detainees housed alongside convicted prisoners. The state has had a MAT program since 2016.

The program’s implementation has led to a 60 percent decrease in overdose deaths among people who were recently incarcerated, according to a review done by Brinkley-Rubenstein and researchers from Rhode Island

hands in blue latex gloves hold up the bible so you can see down the hollow binding where the contraband was tucked. — Corrections officers at the Swannanoa Correctional Center for Women found packets of Suboxone tucked into the binding of this Bible that was mailed to an inmate. Photo credit: NC Dept of Public Safety

Reservations around MAT

Health experts said many prison officials are hesitant to adopt MAT programs because they fear the medication will end up in the hands of a person to whom it was not prescribed — something that’s known as “diversion.” Many will cite high contraband numbers from people attempting to smuggle these medications into facilities.

“Oftentimes when it’s diverted, it’s diverted because that other person needs it too,” said Powell of DHHS. “And so I think that’s just more evidence that these programs are actually needed.

Of course I’ve heard many concerns as I’ve talked to different partners. And I think that’s part of the power of lifting up programs who have already been done, including programs in North Carolina.”

Brinkley-Rubinstein, who has researched MATs in Rhode Island and North Carolina jails, said recreational use of these medications is relatively nonexistent.

“It’s very hard to overdose on Suboxone, so its use is therapeutic,” she said. “These myths around like using it recreationally are just that — they’re myths. Diversion instead happens simply because MAT isn’t provided.

“If they allowed Suboxone in the door to treat people’s opioid use disorder, there wouldn’t be illicit use,” she continued. “In Rhode Island, we did qualitative research where we asked people who were incarcerated and staff at their facilities what the general benefits of their MAT expansion were. And across the board people said, ‘When we allow methadone, Suboxone and naltrexone to be provided here, there was way less illicit drug use.'”

Carroll, who has looked at use of MAT-involved drugs in the United States and abroad, echoed this.

“In the United States, we haven’t seen that pattern [of recreational use],” she said. “Study after study after study, including studies that I have done, tell us that the vast majority of diverted Suboxone is diverted for therapeutic purposes.”

Paused by pandemic

In April 2019, NCDPS announced plans to begin a pilot MAT program in three state prisons. Still, medication has yet to be prescribed at N.C. Correctional Institution for Women, Wake Correctional Center, and Orange Correctional Center.

“The pilot development has been suspended due to COVID-19,” said John Bull, spokesperson at NCDPS.

Though no timeline is set, he added, “We intend to launch the three facility MAT pilots in the future.”

Meanwhile, attempts to obtain the medication by other means continue. In February 2020, prison staff confiscated 44 Suboxone strips, pills or pieces, according to NCDPS numbers obtained by public information request. That number increased every month until June, when 296 Suboxone substances were confiscated.

Bull credited this increase to better use of the agency’s “relatively new” electronic contraband tracking system rather than to a leap in the amount of suboxone smuggled into prisons.

“In short, we think this computerized system is being used more now than earlier in the year, he said. “In the past, contraband interdictions were kept on paper at the facility level.

“Suboxone is a much-desired drug in the offender population. We have seen no trends or patterns that show Suboxone is in greater demand at different times of the year, or that attempts to get Suboxone into the prisons have increased or decreased in recent years.”

When asked if NCDPS had any plans to integrate the two recording systems so data could present a more accurate picture of the 2020 contraband numbers, Bull said: “The prisons have been busy prioritizing the health and safety of the staff and offender populations during the first pandemic in a century.”

Jail delays

Currently, at least three North Carolina jails, which are run at the county level, have MAT programs.

shows a stack of blue and white suboxone packages stretched out on a table — Staff at Eastern Correctional Institution in Maury, NC found 60 prepackaged Suboxone strips in the prison yard in July, 2020. The items were wrapped in electrical tape and camouflaged with grass. Photo credit: NC Dept of Public Safety

Buncombe and Orange County detention centers each offer both naltrexone and Suboxone. Durham County Detention Center offers all three types of MAT drugs.

But Brinkley-Rubinstein, who researches the Durham jail program, said COVID-19 has also disrupted progress.

“The Durham folks started their program about a year ago, and they started just with ‘continuing,’ which means just [giving MAT to] people who already had a community prescription when they came in,” she said.

She said that the program was planning to expand to “Phase II,” also called “initiation,” where detainees who are diagnosed with opioid use disorder upon arrival to the jail are able to begin medication-assisted therapy for the first time.

“But because of COVID, that has kind of been put on hold,” said Brinkley-Rubinstein. “We still have plans to do it, but there’s just a lack of resources to get it up off the ground for now.”

MAT programs inside prisons and jails require staffing resources, and time, particularly during the pandemic.

“We can no longer have people stand in a medication line, for example,” said Brinkley-Rubinstein. “They instead need to have their meds delivered to their cell, which just takes a lot more staff time.”

Facilities offering methadone, like Durham, additionally require a specialized provider to administer the medication. The more detainees involved in the program, said Brinkley-Rubinstein, the more often that provider needs to come into the correctional setting.

“You want less traffic inside because that can be an exposure risk to COVID,” she said. “There are just all these really difficult decisions that are having to happen around how best to keep people safe.”

Increasing risks

The cost of putting these programs on pause is high, according to Longley. North Carolina has seen a 15 percent increase in opioid overdoses since the pandemic began.

“Some of those are happening behind bars,” said Longley.

He added that there’s been another unintended consequence from the lack of carceral MAT programs during the pandemic.

“People going through opiate withdrawal, either in a jail or prison, experience hot and cold flashes, get really sick, cough and have fevers — and that sounds a lot like COVID-19,” said Longley. “We’re seeing an issue with jails and prisons where they misidentify: Somebody they think is just going through opiate withdrawal symptoms actually has COVID-19.

“Jails and prisons are a hotbed for transmission of COVID-19, and the lack of medical care for people who have opioid use disorder is exacerbating that.”

Carroll said that the relatively lower risk of overdose death while a person is incarcerated is only half the story.

“There’s this narrative of, ‘Why do we need maintenance treatments in prisons, where there’s no drug market? Why do we need medication that reduces cravings for drugs when those drugs don’t exist in our prison system?’” Carroll said.

She pointed out that the vast majority of inmates eventually return to the community, and denying those medications for people in jails and prisons creates overdose risk.

“Without that understanding, the story can turn deadly very quickly,” she said. “It’s so much cheaper for the state to treat than to resuscitate.”

shows an inmate in a orange jail jumpsuit and handcuffs behind a bottle labeled methadone, an opioid use disorder drug that can help reduce cravings.

For some opioid users in NC, jail doesn’t mean detox

February 25, 2020 by Taylor Knopf

For some opioid users in NC, jail doesn’t mean detox - North Carolina Health News

To prevent overdose deaths, some counties are allowing inmates to continue medication-assisted treatment.

Taylor Knopf

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.

NC counties with MAT programs in jails for opioid use disorders as of Dec. 31, 2019 — Source: NC DHHS

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.

Shows a white man with a big smile — Orange County Sheriff Charles Blackwood. Photo courtesy: NC Sheriffs’ Association

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.

Medication-assisted treatment is FDA approved and considered to be the “gold standard” for opioid addiction treatment because it has been so effective.

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.

Shows a woman hugging a little boy she's had in foster care. She is signing his adoption papers.

Foster care case numbers continue to climb in NC, as opioid crisis affects families

September 24, 2019 by Sarah Ovaska

Foster care case numbers continue to climb in NC, as opioid crisis affects families - North Carolina Health News

Record numbers of children, almost all of whom have trauma of their own, are entering the foster care system as a result of abuse and neglect.

By Sarah Ovaska-Few

North Carolina could use more people like Lisa Link, as the state grapples with record numbers of children entering and staying in the already stretched foster care system.

Link, an auto broker and owner of a small used-car lot in Charlotte, opted five years ago to become a foster parent after years of helping with family members’ children. She was single, in her early 40s, and wanted to help children coming out of difficult situations in need of a stable and loving home even if temporarily. More than 20 children have been under her care since, some for short stays of a few days or weeks and others for a year or more.

She cherishes being a dependable, caring presence for children who are often coming from chaotic or unpredictable households. She makes sure they get the childhood joys of playing at local parks or experiencing what might be new things such as eating out at a restaurant, a day at the nearby Carowinds amusement park, or going to museums.

“I’m going to take this a level up, where I can help children that needed help,” said Link, about her decision to become a foster parent. “That’s when I felt like this was my place and my calling.”

And something else happened she hadn’t expected or intended – she met her 6-year-old forever son, Latrell Ma’az Link, who has lived with Link since he was 3. Latrell ended up in the foster care system and Link’s home because of neglect. His adoption to Link was formalized last month.

“I’ve had him three years and wiped his little nose,” Link said. “I couldn’t see him going anywhere else.”

The foster care system in North Carolina continues to experience record levels of need, the increases believed to be yet another aspect of the devastation from the opioid abuse epidemic.

As of mid-summer, there were 11,700 children and teens younger than 20 in the foster care system. According to the N.C Department of Health and Human Services, that’s a 20 percent jump from just five years ago. Some of those children are in family foster homes such as Link’s. Other children stay with non-parental relatives as part of the state’s focus on kinship care to lessen the trauma experienced by children entering the system.

Those numbers also include more than 800 older teenagers. Those young people can opt to continue receiving support services such as health care through the age of 21 if they are working or in school, one of a series of reforms passed in 2017 by the state legislature.

Prescription drugs, heroin abuse behind surge

Opioid misuse and addictions are the likely culprits behind the recent growth, say those that work in and around the foster care systems. The effects of pervasive poverty, untreated mental illness and domestic violence also continue to be significant factors driving increases in foster care.

Parental substance abuse was the primary reason for the removal of a child for nearly 40 percent of the cases during the 2017-18 fiscal year, up from 30 percent five years ago and from 25 percent a decade ago, according to data provided by DHHS.

The state and most counties don’t track what specific substances – drugs or alcohol – were at the root of a family’s troubles, however. The actual number of affected children may be higher, as each county categorizes information differently. Some counties, for instance, report no substance abuse-related removals of children from homes, an unlikely scenario given the pervasiveness of addiction and the current opioid crisis.

At the state level, the focus on children removed from homes because of substance abuse is the same as any other scenario – a desire to get them in a stable and safe situation. Ideally, these children would be reunified with their parents, said Erin Baluyot, the interim program manager for DHHS’ State Foster Care and Adoption Services. If reunification is not a safe option and parental rights are terminated, the goal is to find a child an adoptive home as soon as possible.

“We do business as usual; our goal is to achieve permanency for children no matter the reason for them coming into foster care,” Baluyot said.

Sadly, children can spend years in the foster care system before being reunified with family members, or being adopted, according to DHHS.

More kids, more time

Statistics kept by the DHHS show the median time a child spends in the system was 525 days in the 2018 fiscal year that ended in June. That’s up by nearly 20 percent from four years prior, when the median stay was 441 days. The state is intent on reducing the amount of time children dwell in foster care, whether they end up going back to family or being adopted. This is one of the measurable goals in the department’s ongoing early childhood action plan.

Several high-profile deaths of children in recent years, including the 2016 drowning death of 3-year-old Rylan Ott, led to the state legislature passing changes in 2017 restructuring how child abuse investigations are handled across the state. The law was named for 3-year-old Rylan Ott, who wandered away from his Carthage home and drowned in a nearby pond. He had been returned to his mother’s home shortly before his death by the Moore County Department of Social Services, despite the mother’s erratic behavior and over a court-appointed guardian’s objections.

100 counties, one system

Though the state oversees North Carolina’s child welfare system, each of the state’s 100 counties is responsible for handling abuse and neglect claims in their respective areas, as well as the placements and well-being of children in foster care. That’s led to great disparities in how children fare in the foster care system, as the non-profit journalism outlet Carolina Public Press has highlighted in reports about Cherokee County. There, multiple children were improperly removed from their homes by county-level workers who also falsified records related to the children’s care. In addition, some children in the Western North Carolina county were put up for adoption without a judge’s knowledge or permission – major violations of the laws dictating how children are treated in the child welfare system.

Baluyot acknowledged those failings but also pointed out that there’s more to the system than tragic headlines.

“We always hear about the negative and bad things that happen, but a lot of good things happen too,” she said, pointing out that 1,300 to 1,400 children are adopted out of foster care each year. “It’s certainly a good thing. That’s 1,400 children we don’t have lingering in foster care.”

How to address the current influx of children in the foster care system is not a settled question.

A bill introduced last month in the state legislature is seeking to change how the state does business as usual. House Bill 918 would speed up the time to terminate parental rights to as little as nine months for children born with illicit drugs in their systems. The bill would also give a foster family nearly equal standing as biological family when deciding permanent placement for a child and also broadening the reasons why a child can be taken from a home.

The bill drew heated debate when it was heard in committee and has not progressed since late August.

Rising need across country

This trend of rising numbers of children in the child welfare system isn’t isolated to North Carolina. The U.S. has seen foster care cases steadily rise since 2012, following decades in which the numbers dropped, according to research published in July in JAMA – Pediatrics.

Parental drug abuse was a root cause of a child’s entry into foster care in 36 percent of cases in 2017. Young children – those under 5 – were most likely to be affected by removals because of substance abuse, according to the research. Young age is a particular concern given that those years are also when children form bonds with caretakers.

“[W]hen children enter foster care because of parental drug use, episode duration is longer and less likely to result in reunification with the parent,” wrote journal authors Angelica Meinhofer, a Cornell University researcher, and Yohanis Anglero-Diaz, a psychiatrist with Boston Children’s Hospital and Harvard Medical School.

Those trends are reflected in North Carolina, where more children 0 to 8 years old entered the foster care system last year than in previous years, according to DHHS data.

That creates a unique challenge for social workers, foster parents, teachers and other caregivers, given that those are critical ages in a child’s development.

Taking trauma into consideration

Entry into foster care, in addition to the circumstances that bring a child to the attention of child welfare workers, are considered traumatic events that carry long-term psychological and health effects. Public health researchers found in landmark research conducted two decades ago that adverse childhood experiences (ACES), events such as living in a household with domestic violence or substance abuse, can lead to a lifetime of both mental health and even physical health challenges.

Public health experts have in turn emphasized having more trauma-informed care in many settings, in hopes of lessening the impact of childhood trauma.

In the past, the number of foster care cases has decreased when the economy is doing well. That reduction is a sign that parents are able to find work and have fewer financial stressors to trigger abusive or neglectful behavior, said Ken Maxwell, head of Seven Homes, a privately run High Point nonprofit foster care placement and adoption agency that he co-founded in the mid-1990s.

Shows an African American woman and a little African American boy smiling, they're both dressed up. The little boy is in the foster care of the woman. — LIsa Link and son Latrell Link, 6, who she adopted after he spend three years in foster care in her home.

That’s not what’s happening now, Maxwell said. North Carolina’s foster care system has continuing to swell to record numbers despite the overall strength of the economy and historically low unemployment rates.

“We’re not seeing the numbers decline, we’re seeing the numbers increase,” he said. “The numbers are staying high because of substance abuse or opioid abuse.”

He also said that many of the birth families haven’t had interaction with the foster care system before, a departure from what he’s seen in other illicit drug crises. To him, it’s an indication of how quickly opioid addiction can overtake a person’s ability to maintain the regular rhythms and responsibilities of their lives.

“This sneaks up on families and they don’t realize it until they’re at risk of losing their kids,” Maxwell said. He has seen higher reunification rates, though, with children eventually being able to go back to their parents or with other family members.

Many of the children coming to Seven Homes needing temporary placements are young infants, and Maxwell has had difficulty finding enough foster families with the ability to take in newborns in need of around-the-clock care.

Though the rising numbers are not what anyone wants to see, Baluyot maintains the state currently has enough foster homes, though there’s always a need to recruit more.

Children with complex needs due to disabilities, mental health or behavioral issues as a result of sustained trauma or sibling groups may, however, end up facing longer waits for suitable homes, she said.

“We do have a lot of foster homes, it’s not like we’re in a crisis where we desperately need more,” she said.

How children fare at epicenter of opioid crisis

One county keeping track of the precise reasons why children enter foster care is New Hanover, home to Wilmington and among the most affected in the state and country by opioid misuse.

In 2013-14, 10 percent of the 189 children who entered the foster care system did so because of their caretakers’ heroin or opioid addictions. Substance use was a factor in 36 percent of cases overall, according to statistics provided by the New Hanover Department of Social Services.

Just four years later, nearly half of the 205 children entering the system came from homes where substance use was a factor, with opioids or heroin involved in 23 percent of the cases, according to 2017-18 data collected by New Hanover DSS.

Child welfare reforms

A 2017 state law enacted major changes in how the state’s child welfare and foster care agencies work. Here are some of the major pieces of Rylan’s Law, with changes currently being phased in at the state and local levels:

Requires social services observation before a child removed from custody is reunified with parents or other caretakers.
Funds to help foster care youth obtain driver’s licenses and insurance.
Shortens the amount of time to 65 days (from 180 days) for a parent to appeal court-ordered termination of parental rights.
Third-party assessment of North Carolina’s child welfare system and creation of working group looking at how to improve state oversight.
Requirement that counties agree to performance requirements set by the state, with a data dashboard later available to the public.
Allows counties to join regional departments of social services, to share resources and improve performances.
Creates goals to cut down on time children are in the foster care system and move to reunify families or start the adoption process.

Rylan’s Law followed a number of other laws that made it easier for foster youth to participate in school sports, to obtain driver’s licenses and insurance, and participate in other after school activities such as clubs and the prom.

Source: UNC School of Government, N.C. DHHS

The county also experienced an unexpected surge of need in 2016, when 280 children entered the foster care system. Their current living situations were deemed unsafe or babies born exposed to substances were unable to safely leave the hospitals with their mothers, said Mary Beth Rubright, the assistant director of social work for New Hanover Department of Social Services.

Children aren’t automatically or permanently taken away if there’s someone using drugs in the home, Rubright said. Instead, child protective services workers evaluate whether the home is safe and whether a family member can step in and provide stability if the current situation isn’t tenable.

Social workers are also steering parents toward resources for treating addiction, if applicable, and the courts often include it as a condition of being reunified with children.

“If they’re in recovery and in a program, it makes our job a whole lot easier,” she said.

Hospitals take a bigger role

There have been more babies born in the Wilmington area with opiates or other substances in their system than in the past, with social services getting involved with families in the first days, or even hours, of a child’s life, Rubright said.

In 2016, New Hanover DSS workers were notified of 54 babies born drug-positive, a term that includes both drugs being abused and those prescribed as a part of opiate recovery treatments. That went up by a startling 89 percent within two years, with 102 babies born drug-positive in 2018, Rubright said.

A big part of the increase is due to the county child welfare workers reaching out to local hospitals and making sure hospital staff were properly flagging them about children born drug-positive, a requirement under federal regulations. Reasons for notification include exposure to illicit drugs as well as to drugs such as buprenorphine or methadone that may be prescribed as part of an addiction treatment plan.

Hospital staff wasn’t consistently contacting DSS in those situations in the past, Rubright said.

To help those families, the county launched an intensive support program for mothers who give birth to children with drugs in their system. The goal: having the baby back in their mother’s care within 60 to 90 days, provided the household is assessed as safe by social workers.

The social worker running this program only has three cases at a time, down from the former average caseload of 15. This allows for more visits with the family to offer parenting support, to check in on the mother’s progress with substance abuse recovery programs and to help locate housing or other assistance, if needed.

It’s an expensive program for DSS to administer, at a cost of about $100,000 to pay for the single social worker assigned to the program and the related therapies and programs for affected parents. But the goal is to try and ensure the household is safe for a baby while setting up both mother and baby for longer-term success.

“It’s critical that you give [mothers] opportunities to bond with her children,” Rubright said. “The truth is that in the end, it’s a lot less expensive to pour those resources in on the front end.”

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