National Sheriffs’ Association

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

July 28, 2021 by Elizabeth Thompson

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.”

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.

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