Many NC jails violate legal requirements by skipping meds for opioid use disorder

For almost six years, R struggled with addiction. He said he tried to quit using opioids and ​​benzodiazepines more than 50 times — mostly “cold turkey” — but it never worked.

In 2020, he got arrested. When he got out of jail on bond a few days later, R said he knew he needed to do something different so his life wouldn’t be cycling in and out of jail. 

That change came on March 14, 2020, when he started taking Suboxone. The medication containing buprenorphine and naloxone is one of the most effective known treatments for opioid use disorder.

“I gave it a shot, and it worked,” R said. “Ever since I started taking Suboxone, I haven’t craved. I haven’t slipped up. I haven’t gone back or thought I want to do drugs again. I think I’m past that.”

R said taking Suboxone helped him “get a grip” on his life. He went back to school. He got a job.

R typifies how 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.

But in August 2023, R needed to return to jail to serve a total of 30 days for the 2020 offense. While there, he was forced to go off his medication after taking it for more than three and a half years. That’s because jail staff said they would not administer his prescription in the facility.

As a result, R went into withdrawal while serving his first seven days in jail. R said he sweated profusely. He felt nauseous and in constant pain. He was restless and anxious.

“It just got worse every day,” R said. “After like four or five days I actually called the nurse and I was like, ‘Hey, I can’t do this.’ I need something.’ They offered me a Tylenol, and I had to pay like $20 to see the nurse to get the Tylenol.”

His experience of being forced off his medications for opioid use disorder shouldn’t have happened. Jails have a legal responsibility to provide those medications because people with opioid use disorder are protected under the Americans with Disabilities Act. Guidance from the U.S. Department of Justice issued in April 2022 states that it is a violation of the ADA if correctional facilities do not continue an individual on the medications to treat their addiction that they were receiving in the community before incarceration.

The DOJ has the authority to investigate potential ADA violations if an individual files a complaint, and it can also initiate its own compliance review if it receives information about a potential violation. Based on the findings, the DOJ does have enforcement authority. 

NC Health News is withholding R’s full name and the name of the central North Carolina jail that denied him his medication because he still has days left to serve on his sentence and does not want to risk retaliation.

R said he even went to the jail with an informational pamphlet on the legal requirements, but jail staff, including a nurse, dismissed it and told him he would just have to deal with the withdrawal. 

It was not the response he expected. He thought he would be able to continue taking his medications while serving his time — just as people are continued on insulin and heart medication while in custody. 

Many North Carolina jails have yet to meet these legal requirements. Only about one-third of 92 jails provide medications for opioid use disorder in their facilities, according to a report released last month by Disability Rights North Carolina.

Detoxification and withdrawal, like R experienced, are the most common outcomes for people with opioid use disorder when they enter jails. Slowly, though, more detention centers in the state are starting to provide medications for opioid use disorder — not just because it’s best practice, but because it’s now a legal imperative. 

Didn’t have to be withdrawal

If R had been at one of the 34 local jails across the state that Disability Rights NC found were continuing people on medications while in custody, his experience serving his sentence could have gone much differently. 

After that experience of withdrawal, R still had more days to serve to complete his 30-day sentence. But he knew he could not endure going through withdrawal again — or the disruption to his treatment.

For years, he had been doing well on the medication and built routines. R said going home after that seven-day stint felt like “starting over.” He said he had to build back up to his proper dosage at the clinic where he was getting substance use treatment. 

R worked with his probation officer. He has served the rest of his sentence in 24-hour stints in jail so he does not have to go off his medications again. He said he’s glad about that, but this means completing his sentence is slow going. 

“It’s holding me back,” R said. “I’ve been trying to get another job, and I can’t because I have to be free once a week to go. And it’s really hard to work that out with employers.”

R expects to complete his sentence this summer. He said he would have preferred to serve longer stints of time if he could have continued his meds. 

“I got unlucky because of where I live,” R said. “If I lived like a county over, I could have been fine. You would think everybody follows the same rule.”

Building momentum

For many years, medical providers and others have been advocating that medications for opioid use disorder be accessible to incarcerated people, in particular because people with addiction are overrepresented in the state and nation’s criminal justice system. It’s estimated that 15 percent of the 1.8 million people incarcerated in the U.S. have an opioid use disorder. 

Studies show that providing these medications in correctional settings decreases opioid use, criminal activity after release and the spread of infectious disease. Studies have also found that overdose death rates after incarceration are lower when people receive medications for their addiction in custody. That’s a good thing because a study 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 jail or prison.

Recognizing these benefits, the National Commission on Correctional Health Care and the National Sheriffs’ Association recommend that jails provide access to and continuity of medications for opioid use disorder — to save lives and fight the opioid epidemic.

The North Carolina Sheriffs’ Association has not issued a statement on the subject, but Executive Vice President and General Counsel Eddie Caldwell said the group does not issue positions on various issues.

“Each sheriff works with their local community health folks, as well as whoever provides medical care in their jail, to determine what medical care is appropriate in what circumstances for what type of inmate,” Caldwell said. “That is done on an individual county-by-county basis, and the association has no role in that. We don’t advise sheriffs, one way or the other, on that.” 

Even with mounting evidence about the effectiveness of the medications, implementation in jails has moved slowly and at the discretion of each county sheriff. 

But in the past two years, there’s been more movement. 

In 2022, NC Health News reported that 19 of the state’s county jails had some kind of program providing one or more medications for opioid use disorder. Now, that number has grown, according to Disability Rights’ assessment, with about 37 percent of jails in the state providing the medication. 

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The prevalence of these medications in North Carolina jails is slightly higher than the national average. Nationally, only about 30 percent of U.S. jails provide buprenorphine and about 20 percent of jails provide methadone, two of the three FDA-approved medications, according to a March report from the O’Neill Institute for National and Global Health Law at Georgetown University.

Of the programs that exist in North Carolina jails, some only provide one type of FDA-approved medication.

Robyn Jordan, medical director of the UNC Chapel Hill Addiction Medicine Program, welcomes the growing momentum and interest in providing this treatment. 

“We’re in the middle of a culture shift right now,” said Jordan, who also leads the NC STAR Network, an initiative working to expand access to addiction treatment across the state. In the past year, the STAR Network has offered support and expertise to some county jails working through the logistics of starting programs to provide medications. 

“I think a lot of the jails are trying to figure out how to do this, how to do it safely, how to do this responsibly — where in the past there was no interest in providing this level of care at all.”

Another seven county jails are developing plans to start providing the medications, according to Disability Rights’ survey. Two of the counties have plans to operate Vivitrol-only programs, an injectable form of naltrexone, which has been found to be the least effective of the three FDA-approved medications, but which has been heavily marketed.

Shifting standard of care

Elijah Bazemore has been part of that shift. While working at the Durham County Sheriff’s Office, he helped launch the county detention facility’s program for providing medications for opioid use disorder in 2019. 

But it wasn’t something he understood — or was on board with — from the get-go.

In 2018, then a major at the sheriff’s office, Bazemore recalled being deposed for a county lawsuit and said he was asked what he knew about substance use disorder and medications to treat it. His answer: “Absolutely nothing.”

Until that moment, he didn’t realize the prevalence among the incarcerated population; his focus was purely on managing the detention facility from a security perspective.

In the months after, Bazemore and other jail staff and county stakeholders embarked on a process to learn about substance use and available treatments. It’s a process he said all jail staff need to undertake, just like understanding mental health needs, as the incarcerated population they are charged with caring for increasingly have these issues. 

After hearing the research and learning how the medications work, he was convinced it was something the jail needed to do. 

“You are improving the quality of life of an individual while they are detained at your facility,” Bazemore said about jails providing the meds. 

Now Bazemore is one of the most vocal people in the state promoting the benefits of opioid use disorder medications in jails. Working as a consultant specializing in jail-based opioid use disorder treatment with Vital Strategies, his job involves providing free support to detention facilities in North Carolina that want to implement a similar program.

Bazemore understands better than most what it takes to implement a program and the unique considerations jail staff need to make from his 33 years working in corrections. He said jails have come around to providing the treatment for different reasons.

For some, the evidence of the effectiveness of the treatment has been enough to convince them of the need to provide the treatment to people in custody. 

For other jails, the legal liability and threat of a lawsuit for not providing the medications as required by the ADA has moved the needle on starting a program. In some cases, county attorneys have gotten involved, telling sheriffs they need to comply with the legal requirements.

Starting a program

Motivated by both reasons, the Guilford County Sheriff’s Office started providing medications for opioid use disorder in 2022.They also saw the need within the detention center.

Captain Chamelle Johnson, one of the leaders in the sheriff’s office who helped implement the program, said it’s a daily occurrence to have people with opioid use disorder entering the Greensboro jail  — often about five or six people per 12-hour shift. 

“With that high of a number, we definitely needed to get the individuals some help,” Johnson said. 

But she was initially reluctant to start the program, knowing it would be another responsibility amid ongoing staff shortages. She figured the additional load might be too much for the facility.

The Guilford County Sheriff’s Office turned to Bazemore for guidance and support as the county worked to get the program off the ground. They had to work through a slew of logistics, such as how the jail would screen people about whether they needed the medications, whether people on the medications would be grouped together in the same unit, assigning appropriate staffing for dosing and lining up connections to care in the community post-release.

Bazemore explained there’s not one model of how to operate a treatment program that works for every jail; it has to be tailored to facility layout and resources. He added that facilities of all sizes are finding ways to make it work.

The Greensboro jail started by only continuing people on the medications who were already taking them in the community. The sheriff’s office later expanded the program to include identifying and starting people in custody who could benefit from the medication. That’s the two-phased approach Bazemore advises. 

Disability Rights found that 11 jails have progressed to also initiating people on medications. 

Johnson said the program at the Greensboro jail currently doses about 30 to 35 people a day on the medications. She said that’s a manageable load for the facility, which averages a population of 650 to 670 people per day, though the load can fluctuate based on who’s incarcerated.

She said staff shortages aren’t reason enough not to have the program, as they have to find a way to operate it regardless of staffing because the opioid problem is too important.

Now, after almost two years of providing the medications, Johnson has fully bought into the program. She’s heard directly from incarcerated people who like the opportunity to participate and improve themselves. She’s also witnessed a positive impact on staff.

“These individuals usually come into facilities kind of belligerent and stay that way for a while,” Johnson said. “The medication begins to balance them out quicker, which takes some of the burden off of the officers because they’re not having to deal with belligerent and sickly inmates as much.” 

Many sheriffs’ officess cite the fear of the medications being abused somehow as one of their biggest concerns. It was one of Johnson’s. 

But she said that turned out to be an outsized fear, and since October 2022, Johnson said that they’ve only identified two instances of diversion.

“The things we thought were going to be so hard, they really were not,” Johnson said. 

Combating stigma

Willingness to implement these treatment programs in jails remains a mixed bag across the state, Bazemore said. He hopes that jails will have more interest in starting up a program after seeing the success of those operating in about a third of the state’s jails. 

He added that no jail has turned back after starting up.

While there are financial and staffing challenges to getting a program up and running, Bazemore said stigma also remains a significant barrier, slowing uptake. 

Johnson, who has worked in corrections for more than 20 years, admitted that her views on the medications were initially mired in stigma. 

“Initially, I looked at the medication as drugs, not realizing that it’s medication to help these individuals get better — just like if you have an individual who comes in here with high blood pressure, diabetes, things like that,” Johnson said.

It’s a misconception to consider medications for opioid use disorder trading one “drug” for another, Bazemore said. He said he runs into this thinking frequently when he’s making presentations.

That misconception is rooted in considering addiction a moral failing, UNC addiction medicine specialist Robyn Jordan said.

“As long as we look at addiction as a moral failing, then we’re going to have challenges with stigma,” Jordan said. “It requires us to have a shift in thinking and looking at substance use disorders as any chronic disease. If we look at it in the chronic disease model, we would never stop the medication in the first place and we would support them taking their medication.”

Education efforts have led some people to change their views. Bazemore said some folks he tried to make inroads with when he first started as a consultant in 2022 are now circling back. That’s a sign of progress, he said.

“It’s a slow pace, but I think it’s picking up,” Bazemore said. 

Over time, Guilford County’s Captain Johnson said the treatment program and its effect on people in custody has made more staff supportive.

Others remain unmoved. It might take legal action — or new leadership — before some counties get on board with providing medications for opioid use disorder to people in county jails.

Evan Ashkin is a family physician at UNC providing medications for opioid use disorder; he has helped local jails and the state Department of Adult Correction start treatment programs. He recognizes it’s not a simple process to start a program, but it’s still something that has to get done.

“It’s not a matter of if a jail is going to do it,” Ashkin said. “It’s only when, because people have a right to this health care. And so, even understanding all the challenges a jail may have, it is no longer acceptable to sit on the sidelines or resist doing this. Our jails need to work with their communities, work with organizations, which can provide assistance and get this going.”

Disability Rights’ recommendations for expanding access to medications for opioid use disorder in jails across the state:

• Expand public education efforts to reduce the stigma around opioid use disorder and its medications.
• Provide ongoing education to law enforcement, jail staff and detention facility medical providers that focuses on opioid use disorder as a disability and the effectiveness of medications.
• Remove barriers to receiving medication, such as being contingent on drug screens and discontinuing access as a form of punishment.
• The state should require medications to be available at all N.C. jails and prisons, and if someone is held at a facility that doesn’t offer the medications, they can be transferred somewhere that does.
• Improve resources and connections to care so that people returning home from jail or prison can continue to receive medications for opioid use disorder in the community.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.