Saving Lives: Ensuring Access to Medications for Opioid Use Disorder (MOUD) in NC Jails

Section 1: Opioids, Opioid Use Disorder and MOUD

Opioids and the overdose crisis

The U.S. and North Carolina are experiencing an overdose death crisis. In 2021 in the U.S. there were 80,411 overdose deaths and 75.4% of all overdoses nationally involved an opioid.[i] We lost more than 36,000 North Carolinians from opioid overdose deaths from 2000-2022[ii] and opioids were involved in 78.9% of all NC overdose deaths.[iii] At least five people in NC die every day from opioid overdoses.[iv] The risk of overdose death is much higher for people leaving incarceration. People leaving carceral settings in NC have a 50 times greater chance than the general population of dying from an overdose within the first two weeks of release.[v]

In addition to the staggering cost of human life, there are considerable economic costs to our communities from opioid use disorder (OUD): $35 billion in health care costs, $14.8 billion in criminal justice system costs, and $92 billion in lost productivity.[vi] However, each dollar spent on OUD treatment produces a return of $4-7 dollars by reducing drug related crimes and related criminal justice costs.[vii]

The opioid crisis impacts people from all walks of life and all racial and ethnic groups. However, it has disproportionately impacted black, indigenous and people of color (BIPOC) communities. In 2020, data from the CDC showed overdose death increased from the previous year by 44% for Black/African Americans, 40% Hispanic/Latinos, and 39% for Native Americans, while Whites saw a 22% increase in overdose deaths. [viii] Racial and ethnic disparities also exist in the receipt of medications for opioid use disorder (MOUD), with BIPOC populations receiving MOUD less frequently than whites.[ix]

In the criminal legal system, racial disparities also increase the risk for time in jail. BIPOC populations, especially Black/African Americans, with similar charges/histories to whites, are disproportionately overrepresented in jail admissions (instead of probation), have higher bail set, and receive longer sentences.[x] The rise in overdose deaths for black/African Americans and Hispanic/Latino communities started in 2015.[xi]

According to the CDC there have been 3 waves impacting the rise of opioid overdose deaths:[xii]

The first wave began in the 1990s – increased prescribing of opioids led to an increase in overdose death from prescription opioids.
The second wave began in 2010 – when heroin caused a rapid increase in overdose deaths.
The third wave of overdose deaths began in 2013 and continues to the present – caused by synthetic opioids, mainly fentanyl.

Not only people who use opioids and/or have an opioid use disorder are at risk of overdose death. People who use other drugs can unknowingly risk exposure to fentanyl and overdose as the drug supply has been contaminated with fentanyl. [xiii] Another consideration is polysubstance use, which is also common.[xiv]

Opioids are not in and of themselves a problem. Opioids are necessary medical tools for treatment after surgery or injury, cancer, end of life care, etc.[xv] It is important to understand that not everyone who uses opioids will go on to develop opioid use disorder[xvi], even if they have a physical dependence and increased tolerance or experience withdrawal.[xvii] Opioid use disorder is a medical condition diagnosed by medical providers.[xviii]

Opioid Use Disorder

OUD is a serious medical condition, not a moral failing. It is a chronic, but treatable, brain disorder that responds to medications that normalize brain structure and function.[xix] OUD affects people from all walks of life, education/socio-economic levels and racial/ethnic groups.[xx] According to 2022 data released by SAMHSA, among people aged 12 or older in 2022, 2.2 percent (or 6.1 million people) had an opioid use disorder in the past year.[xxi]

OUD can be mild, moderate or severe and is characterized by 2 or more from the following groups of symptoms in a 12-month period: physical dependence (developing tolerance, experiencing withdrawal), loss of control over their use of opioids (taking greater quantities, inability to quit, etc.) and continued use despite negative consequences (such as problems at home or work, loss of job, legal system involvement, impaired relationships, etc.).[xxii] As with other medical conditions, effective medical treatments are available.

Treatment of OUD-MOUD

The standard of treatment for OUD is the use of medications for opioid use disorder (MOUD).[xxiii] MOUD is the preferred term, as the older term ”medication assisted treatment (MAT)“ supports the belief that medication is simply an adjunct to other treatments.[xxiv] Medications for opioid use disorder can successfully be the sole treatment and does not require that someone engages in other therapies in order to be effective.[xxv] Engaging in other therapies should not be a requirement in order to receive or continue on MOUD.[xxvi]

There are three FDA approved medications for opioid use disorder: methadone, buprenorphine and naltrexone. Methadone and buprenorphine are agonist medications. Naltrexone (e.g., Vivitrol) is an antagonist medication. These medications work in different ways.

Methadone and buprenorphine, the agonist medications, are much more effective than other forms of treatment as they address withdrawal and cravings by acting on the opioid receptors in the brain.[xxvii] Agonist medications work by binding to the receptors in the brain that opioids would bind to, and they produce a similar response to the intended chemical and receptor.[xxviii] However, they are longer acting and safer than illicit opioids and to a person with OUD, these medications do not provide the euphoria or other effects that opioids produce[xxix], so these agonist medications are not simply trading one drug for another[xxx]. Methadone and buprenorphine relieve withdrawal symptoms and minimize cravings and substantially reduce the risk of opioid overdose and death[xxxi] Research shows that agonist medications at the right dose for an extended period are the most successful to treat OUD.[xxxii]

A 2020 study comparing 6 different treatment pathways found that only agonist medications, methadone and buprenorphine, had a 76% reduction of overdose at 3 months and a 59% decrease at 12 months; similar benefits were not found with other treatments or treatment with antagonist medications.[xxxiii]

A 2024 Connecticut study concluded, “Exposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.”[xxxiv]

People who receive agonist medications are more likely to remain in treatment[xxxv] and reduce illicit drug use.[xxxvi] As one person described it after they took suboxone (an agonist medication):

“I was a different person than I am now. I had lost everything. I was tired, I was sick, it was more than a full-time job – the urge to use was always there. The drive-always doing everything and anything to get it [opioids].” After starting suboxone: “it [opioids] wasn’t the number one focus-it takes it off the table-it [the urge to use] is so far back there, not in my face. I’d rather be on the medication having a normal life, being a productive member of society – a parent, working. … That’s the difference between life and death-I don’t think I would still be here [without the medication]. I’m trying to help other people now.”

Antagonist medications such as naltrexone and Vivitrol work by entirely blocking the opioid receptor which stops the receptor from producing a response to opioids, they require detoxification before use, do not relieve withdrawal symptoms or cravings, and have poor tolerance and treatment adherence/retention.[xxxvii] Withdrawal/detoxification with abstinence puts people at increased risk for return to use and overdose.[xxxviii]

Even though agonist medications are the standard of treatment, only 1 in 5 U.S adults with OUD receive this medication.[xxxix] According to the National Institute of Drug Abuse, failing to use these proven and lifesaving medications perpetuates opioid use disorder, is prolonging the opioid overdose crisis and makes existing health disparities, including racial/ethnic disparities, worse in our communities.[xl] Stigma is the most common barrier to the provision of MOUD, with logistical issues the second most common barrier (time, cost, insurance, regulatory issues).[xli] Stigma is also a barrier to MOUD treatment in the criminal legal system, including jails.[xlii] People in NC jails have experienced this stigma.

At a facility not offering MOUD:

“I was the sickest I had ever been- I couldn’t rest, eat, sleep, do anything. I was puking, feeling like i was going to die…and given motrin- when I asked for it….at med pass. I even mentioned it was against the law or my rights as a human to be denied my prescribed medication. I was told I had no rights…I know that to be false, but I was treated so badly, it was horrible. Degraded, … laughed at, called a junkie, all the things [officers] would say about anyone addicted to drugs … just a junkie, not worth the narcan used…it was terrible. I wanted to die everyday.”

Even at facilities that offer MOUD, a person with OUD taking MOUD can have vastly different experiences. One person reported at the first jail they were continued on MOUD:

“[I was] treated like an individual taking a medication, I was not treated like a Junkie.” After transfer to a different facility in another county where they were not allowed to continue MOUD: “I was treated like I was on street drugs, like I am an addict…Being treated like a drug addict, when I am in recovery.”

Unfortunately, not enough people in our jails nationwide or in North Carolina have access to these lifesaving medications, especially methadone and buprenorphine.

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[i] Nat’l. Ctr. for Injury Prevention, Drug Overdose Deaths, CDC (Aug. 22, 2023), https://www.cdc.gov/drugoverdose/deaths/index.html.

[ii] Overdose Epidemic: Combating North Carolina’s Opioid Crisis, NCDHHS, https://www.ncdhhs.gov/about/department-initiatives/overdose-epidemic (last visited Feb. 16, 2024).

[iii] Attorney General Josh Stein, Opioid Crisis, NCDOJ, https://ncdoj.gov/responding-to-crime/opioid-epidemic (last visited Feb. 16, 2024).

[iv] Id.

[v] Shabbar I. Ranapurwala, et al., Opioid Overdose Deaths Among Formerly Incarcerated Persons and the General Population: North Carolina, 2000‒2018, 112 Am. J. Pub. Health 300, 301–302 (2022). Other studies outside of NC have also consistently found higher rates of overdose mortality immediately after release from incarceration. See Commonwealth of Mass. Dep’t of Pub. Health, An Assessment of Fatal and Nonfatal Opioid Overdoses in Massachusetts (2011-2015) 49–52 (2017), https://www.mass.gov/doc/legislative-report-chapter-55-opioid-overdose-study-august-2017/download; Md. Dep’t. Health and Mental Hygiene, Risk of Overdose Death Following Release from Prison or Jail (2014), https://health.maryland.gov/vsa/Documents/Overdose/Briefs/corrections%20brief_V3.pdf ; Lia N. Pizzicato et al., Beyond the Walls: Risk Factors for Overdose Mortality Following Release from Philadelphia Prisons, 189 Drug Alcohol Depend. 108, 108–115 (2018); Ingrid A. Binswanger, et al., Release from Prison—A High Risk of Death for Former Inmates, 356 New Eng. J. Med. 157, 159–160 (2007).

[vi] Substance Use Prevention and Treatment Project, The High Price of the Opioid Crisis, 2021, PEW (Aug. 27, 2021), https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2021/the-high-price-of-the-opioid-crisis-2021.

[vii] Id.

[viii] Mbabazi Kariisa et al., Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics –25 States and the District of Columbia, 2019-2020, 71 Morbidity Mortality Wkly. Rep. 940, 941–42 (2022).

[ix] Timothy Dean, New Study Finds Substantial Racial Inequities in Treatment for Opioid Use Disorder, Dartmouth Sch. Med. (May 12, 2023), https://geiselmed.dartmouth.edu/news/2023/new-study-finds-substantial-racial-inequities-in-treatment-for-opioid-use-disorder/. See also Tami L. Mark et al., Improving Research on Racial Disparities in Access to Medications to Treat Opioid Use Disorders, 17 J. Addiction Med. 249 (2023).

[x] Public Safety Performance Project, Racial Disparities Persist in Many U.S. Jails, PEW (May 16, 2023), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2023/05/racial-disparities-persist-in-many-us-jails.

[xi] Joseph R. Friedman & Helena Hansen, Evaluation of Increases in Drug Overdose Mortality Rates in the US by Race and Ethnicity Before and During the COVID-19 Pandemic, 79 JAMA Psychiatry 379, 379–81 (2022).

[xii] Nat’l. Ctr. for Injury Prevention, Understanding the Opioid Overdose Epidemic, CDC, https://www.cdc.gov/opioids/basics/epidemic.html (last visited Feb. 8, 2024).

[xiii] Jeffrey Brent & Stephanie T. Weiss, The Opioid Crisis—Not Just Opioids Anymore, 5 JAMA Network Open 1 (2022), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792965.

[xiv] Nat’l. Ctr. for Injury Prevention, Other Drugs, CDC (Aug. 22, 2023), https://www.cdc.gov/drugoverdose/deaths/other-drugs.html; see also Daniel Ciccarone, The Rise of Illicit Fentanyls, Stimulants and the Fourth Wave of the Opioid Overdose Crisis, 34 Current Op. Psychiatry 344, 348 (2021).

[xv] Nat’l. Ctr. for Injury Prevention, Prescription Opioids, CDC, https://www.cdc.gov/opioids/basics/prescribed.html (last visited Feb. 20, 2024); see also Am. Psychiatric Ass’n., What is an Opioid? (2022), https://www.psychiatry.org/patients-families/opioid-use-disorder.

[xvi] Cleveland Clinic, Opioid Use Disorder (Oct. 4, 2022), https://my.clevelandclinic.org/health/diseases/24257-opioid-use-disorder-oud.

[xvii] Jeremy Ledger, Opioid Use Disorder, Yale Med. (2020), https://www.yalemedicine.org/conditions/opioid-use-disorder; see also https://www.cdc.gov/opioids/healthcare-professionals/prescribing/opioid-use-disorder.html

[xviii] American Psychiatric Association, The Diagnostic and Statistical Manual of Mental Illness, DSM 5-TR (5th ed., 2022); see also Nat’l. Ctr. for Injury Prevention, Opioid Use Disorder: Preventing and Treating, CDC, https://www.cdc.gov/opioids/healthcare-professionals/prescribing/opioid-use-disorder.html (last visited Feb. 20, 2024).

[xix] NASEM, Medications for Opioid Use Disorder Save Lives 3–4 (2019).

[xx] Cong. Budget. Off., The Opioid Crisis and Recent Federal Policy Responses 2 (2022), https://www.cbo.gov/publication/58532 http://www.cbo.gov/publication/58221 (“Although people from all income levels, regions of the country, and backgrounds use and misuse opioids, the opioid crisis has affected demographic groups in different ways.”); see also Nat’l. Ctr. for Injury Prevention, Opioid Overdose Prevention Saves Lives, CDC, https://www.cdc.gov/drugoverdose/featured-topics/abuse-prevention-awareness.html (last visited Feb. 8, 2024) (“OUD is a medical condition that can affect anyone – regardless of race, gender, income level, or social class.”).

[xxi] SAMHSA, Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health 36 (2022), https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report.

[xxii] Jeremy Ledger, Opioid Use Disorder, Yale Med. (2020), https://www.yalemedicine.org/conditions/opioid-use-disorder.

[xxiii] Shelley R. Weizman et al., To Save Lives, Prioritize Treatment for Opioid Use Disorder in Correctional Facilities, Health Affairs (Jun. 22, 2022), https://www.healthaffairs.org/content/forefront/save-lives-prioritize-treatment-opioid-use-disorder-correctional-facilities.

[xxiv] Opioid Sols. Ctr., Medication-Assisted Treatment (“MAT”) for Opioid Use Disorder, Nat’l. Ass’n. of Cntys. (NACo), https://www.naco.org/sites/default/files/documents/OSC_Strategy_MOUD_References.pdf (last visited Feb. 8, 2024).

[xxv] Id. See also NASEM, Medications for Opioid Use Disorder Save Lives (2019) (chronicling how medications for OUD are the most comprehensive and sustainable treatment strategy).

[xxvi] SAMHSA, Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings 25–29 (2019), https://store.samhsa.gov/product/Use-of-Medication-Assisted-Treatment-for-Opioid-Use-Disorder-in-Criminal-Justice-Settings/PEP19-MATUSECJS. SAMHSA, Advisory: Low Barrier Models of Care for Substance Use Disorders 5 (2023), https://www.med.unc.edu/fammed/justicetateam/wp-content/uploads/sites/1256/2023/12/SAMHSA-Low-barrier-models-SUD_dec-2023.pdf.

[xxvii] NIDA, How do Medications to Treat Opioid Use Disorder Work?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work.

[xxviii] Boukje A.G. Dijkstra et al., Does Naltrexone Affect Craving in Abstinent Opioid-Dependent Patients?, 12 Addiction Biology 176, 176–82 (2007); Nat’l. Inst. on Drug Abuse (NIDA), How do Medications to Treat Opioid Use Disorder Work?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work.

[xxix] NIDA, How do Medications to Treat Opioid Use Disorder Work?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work.

[xxx] NIDA, What are Misconceptions About Maintenance Treatment?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/what-are-misconceptions-about-maintenance-treatment.

[xxxi] Shoshana V. Aronowitz et al., Lowering the Barrier to Medication Treatment for People with Opioid Use Disorder, Leonard Davis Inst. of Health Econ. (Jan. 18, 2022), https://ldi.upenn.edu/our-work/research-updates/lowering-the-barriers-to-medication-treatment-for-people-with-opioid-use-disorder/; see also Bertha K. Madras, Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers Within the Treatment System, NAM Persp. Online (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8916813/.

[xxxii] NASEM, Medications for Opioid Use Disorder Save Lives 11–14 (2019).

[xxxiii] Sarah E. Wakeman, Marc R. Larochelle, & Omid Ameli, Comparative Effectiveness of Different Treatment Pathways for Opioid use Disorder, 3 JAMA Network Open 1, 8 (2020) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032 .

[xxxiv] Robert Heimer et al., Receipt of Opioid Use Disorder Treatments Prior to Fatal Overdoses and Comparison to No Treatment in Connecticut, 2016-17, 254 Drug Alcohol Depend. 1, 5 (2024) (“It is also clear that risk of death associated with exposure to non-MOUD forms of treatment was no less than that for no treatment; indeed, non-MOUD treatment might have produced worse outcomes than no treatment.”).

[xxxv] NASEM, Medications for Opioid Use Disorder Save Lives 38 (2019).

[xxxvi] Id.

[xxxvii] NIDA, How do Medications to Treat Opioid Use Disorder Work?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work . See also Shoshana V. Aronowitz et al., Lowering the Barrier to Medication Treatment for People with Opioid Use Disorder, Leonard Davis Inst. of Health Econ. (Jan. 18, 2022), https://ldi.upenn.edu/our-work/research-updates/lowering-the-barriers-to-medication-treatment-for-people-with-opioid-use-disorder/.

[xxxviii] NIDA, How do Medications to Treat Opioid Use Disorder Work?, NIH (2021), https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work . See also Sarah E. Wakeman, Marc R. Larochelle, & Omid Ameli, Comparative Effectiveness of Different Treatment Pathways for Opioid use Disorder, 3 JAMA Network Open 1, 8 (2020) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032.

[xxxix] NIDA, Only 1 in 5 U.S. Adults with Opioid Use Disorder Received Medications to Treat it in 2021, NIH (Aug. 7, 2023), https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021. (citing Christopher M. Jones, Beth Han & Grant T. Baldwin, Use of Medication for Opioid Use Disorder Among Adults With Past-Year Opioid Use Disorder in the US, 2021, 6 JAMA Network Open (2023), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2807964?resultClick=1).

[xl] Id.

[xli] Shoshana V. Aronowitz et al., Lowering the Barrier to Medication Treatment for People with Opioid Use Disorder, Leonard Davis Inst. of Health Econ. (Jan. 18, 2022), https://ldi.upenn.edu/our-work/research-updates/lowering-the-barriers-to-medication-treatment-for-people-with-opioid-use-disorder/; see also Whitney Bremer et al., Barriers to Opioid Use Disorder Treatment: A Comparison of Self-Reported Information from Social Media with Barriers Found in Literature, 11 Frontiers of Pub. Health 1, 2 (2023).

[xlii] Kelly E. Moore, Negative Attitudes About Medications for Opioid Use Disorder Among Criminal Legal Staff, 3 Drug Alcohol Depend. Rep. Online (2022), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9948914/#:~:text=Background,on%20what%20drives%20these%20attitudes.

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