Dear NC Sheriff,

Disability Rights North Carolina (DRNC) recently reached out to all 100 counties in NC to examine the availability of medications for opioid use disorder (MOUD) in NC jails. The US DOJ as well as courts across the country have determined that denial of MOUD violates the Americans with Disabilities Act as well as 8th and 14th Amendment constitutional protections afforded to people in your custody and care. We would like to take this letter as an opportunity to provide you with information on the benefits of providing MOUD in the jail, some basic facts about opioid use disorder (OUD) and effective treatment. We will then review the law and support for this treatment in NC and nationwide. We also provide you with resources on how to successfully implement an MOUD program as these programs are essential to stop the opioid epidemic ravaging our people and communities.

Use of MOUD has substantial benefits both while in jail and post release in the community. The National Sheriff’s Association and the National Commission on Correctional Health Care have found many benefits to providing MOUD in jails, including “stemming the cycle of arrest, incarceration, and release associated with substance use disorders (SUDs),” “contributing to the maintenance of a safe and secure facility for inmates and staff,” and “reducing costs,” among other benefits. [1] Use of these medications for expectant mothers with OUD improves maternal/fetal health outcomes.[2]  The benefits of MOUD continue post release such as by reducing the very real risk of death by overdose; in the first two weeks following release from NC jails people have a 50 times greater chance than others of dying of an opioid overdose.[3] MOUD reduces illicit drug use and recidivism[4], as well as communicable disease.[5] With these medications, people are able function without the disruptions caused by constant craving and can re-establish their lives, mend relationships with the family, friends and community, and gain/maintain employment.[6]  Simply put, medications for OUD saves lives.[7]

Opioid use disorder (OUD) is a serious medical condition. It is a chronic, but treatable, brain disease that responds to medications that normalize brain structure and function.[8] Just as you are required to provide treatments to a person with diabetes, you must also provide all three medically recognized treatments for OUD .[9] MOUD is now the accepted standard of care in community medicine as it has been shown that abstinence-based treatment has a very low success rate.[10] Medications used in treatment for OUD include buprenorphine, methadone, and Naltrexone. They are FDA approved and are evidence-based, safe, and effective.[11] Research shows that agonist medications such as buprenorphine and methadone are significantly more protective against overdose and other poor outcomes and improve the likelihood that the person will continue with treatment.[12] For many, buprenorphine and methadone help normalize brain functions, decreases symptoms of cravings and withdrawal and are highly successful in treating OUD.[13]  There is less evidence to support the use of Naltrexone/Vivitrol, an antagonist medication, which has poor retention in treatment – increasing the risk for overdose.[14] As with any medication, the decision about which medication to use must be made by the patient and the medical provider after an individualized assessment.[15] Medication for OUD is an effective medical treatment; it is not simply trading one drug for another. By law, jails and detention facilities are required to provide adequate medical treatment.

Adequate medical treatment in jail is recognized as a constitutional right under the 8th and/or 14th amendments. Jails cannot show “deliberate indifference” to a serious medical need. Estelle v. Gamble, 429 U.S. 97, 103 (1976). Courts have found that failing to provide MOUD is a violation of the Americans with Disabilities Act (ADA), as well as the 8th and 14th Amendments of the Constitution.[16] Opioid Use Disorder is a disability that is protected under the ADA. The US DOJ has released guidance that it is a violation of ADA to discriminate against those with an opioid use disorder in jail by refusing to provide MOUD.[17]  The DOJ has acted to enforce the ADA for systems failing to provide MOUD.[18]  Providing access to MOUD is required in order to provide adequate medical care. Offering Naltrexone alone, only offering MOUD at discharge, or distributing the overdose antagonist Naloxone/Narcan does not constitute the adequate provision of MOUD. Limiting the medications to special populations, such as inmates who are pregnant, is also not an adequate MOUD program. Best practice would also require initiation of MOUD. Failing to provide MOUD is a violation of the law and can leave you, your facility, and your county subject to not only costly and time-consuming lawsuits but also significant financial liabilities. We need to work together to stop the opioid crisis in our communities.

People with an OUD are overrepresented in the jail population[19]and are at a 50 times greater risk of dying of an overdose within the first two weeks of release.[20] You can make a profound impact on the opioid crisis in your community by providing MOUD treatment which will help those in custody to stabilize and increases the likelihood they remain in treatment once released. Across North Carolina and nationwide, community partners are coming together to stem the opioid crisis and it has been widely recognized that providing MOUD in jails is a crucial step. The NC Department of Health and Human Services, NC Association for County Commissioners, the NC Association of Local Health Directors/NC Alliance for Public Health Directors, and many others support the use of MOUD in jails. In addition, the NC Legislature has provided funding for all three types of MOUD in jails and the NC DOJ has included support for MOUD in jails using opioid settlement funds. The National Sheriff’s Association, National Commission on Correctional Healthcare, Substance Abuse and Mental Health Services Administration (SAMHSA), National Association of Counties,[21] the U.S. Department of Justice, and many others support MOUD as the standard of care. Your facility is a vital link in this movement to save lives and again, failing to provide MOUD is a violation of the law.

There are many resources available to help you develop your MOUD program and comply with the law. Other jails have successfully implemented MOUD programs, including here in NC. There is a wealth of available resources on staffing and administration, diversion concerns, policy development, and more. We have included some of those resources and community resources at the end of this letter. Offering MOUD saves lives and money, makes the jail a safer place for staff and people in custody, and helps strengthen your community. Providing MOUD in your facility will help make it more likely that people continue in recovery and treatment after release. You do not have to reinvent the wheel to implement MOUD in your facility, there are many resources and experienced players who can help you.

Sincerely,

Disability Rights North Carolina

Resources

Vital Strategies

Elijah Bazemore

Major Bazemore worked in the Durham Sheriff’s Office for over 30 years and successfully implemented a MOUD program in the detention facility. He is now a consultant with Vital Strategies and his focus is to help NC Sheriffs implement MOUD in their facilities.

ebazemore.consultant@vitalstrategies.org
(919) 421-4942

NC DHHS State Opioid Treatment Authority (SOTA)

The SOTA’s mission is to reduce the impact of opioid use disorder in NC communities and promote excellence in opioid treatment programs (OTP). They are familiar with OUD and MOUD resources.

Smith Worth, LCSW, LCAS
Email: smith.worth@dhhs.nc.gov

Or

Anna Stanley, LCMHCS, LCAS, CCS
NC State Opioid Treatment Authority Coordinator
anna.stanley@dhhs.nc.gov
Division of Mental Health, Developmental Disabilities and SA Services, NC DHHS
3004 Mail Service Center
Raleigh, NC 27699-3004
Phone: (984) 236-5124
Fax: (919) 715-3604

Local Resources:

Toolkits/Webinars:

Webinar Series MAT in Jails Series: Legal, Medical, Community, and Security Considerations:

Information on grants/funding and grant writing: 

DOJ Guidance, recent actions, and related information on positive drug screens:

Jail Resources:

Links to BJA/NIC publication: Guidelines for Managing Substance Withdrawal I n Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals located at:

or at the Jails and Justice Support Center:

References

  • [1] National Sheriffs’ Association & National Commission on Correctional Health Care, Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field  5 (October 2018) at https://www.sheriffs.org/jail-based-mat or https://www.ncchc.org/wp-content/uploads/Jail-Based-MAT-PPG-web.pdf (accessed 5/8/2023); See also:  National Center for Correctional Health Care Foundation, From the General Public to America’s Jails: MAT Saves Lives 11 (2021 White Paper December) (evidence suggests providing MOUD agonist medications methadone and buprenorphine reduce the overall use of illicit drugs in jails and reduces disciplinary problems) at https://www.ncchc.org/wp-content/uploads/From_the_General_Public_to_Americas_Jails_-_MAT_Saves_Lives-_Indivior.pdf (accessed 5/16/2023).
  • [2] SAMHSA, Medications for Substance Use Disorders (4/25/2023) at https://www.samhsa.gov/medications-substance-use-disorders  (accessed 5/12/2023).
  • [3] Ranapurwala SI, Figgatt MC, Remch M, et al. Opioid overdose deaths among formerly incarcerated persons and the general population: North Carolina, 2000–2018. Am J Public Health. 2022;112(2):300–303.
  • [4] See National Commission on Correctional Healthcare, Opioid Use Disorder Treatment in Correctional Settings (Mar. 11, 2021 Position Statement) at https://www.ncchc.org/opioid-use-disorder-treatment-in-correctional-settings (accessed 5/19/2023); see also National Institute on Drug Abuse, Criminal Justice DrugFacts (June 2020), at https://www.drugabuse.gov/publications/drugfacts/criminal-justice (accessed 5/19/2023).
  • [5] SAMHSA, Medications for Substance Use Disorders (4/25/2023) at https://www.samhsa.gov/medications-substance-use-disorders  (accessed 5/12/2023).
  • [6] Id.
  • [7] National Academies for Science and Engineering, Medications for Opioid Use Disorder Saves Lives 2 (2019), at https://www.nap.edu/catalog/25310/medications-for-opioid-use-disorder-save-lives (accessed 5/19/2023); see also id. at 1 “OUD is a life-threatening condition associated with a 20-fold greater risk of early death due to overdose, infectious diseases, trauma, and suicide.”
  • [8] Id. at 3-4.
  • [9] SAMHSA, Medications for Opioid Use Disorder for Healthcare and Addiction Professionals, Patients, and Families, Treatment Improvement Protocol Tip 63, at ES-2 (“Withholding or failing to have available all classes of FDA-approved medication for the treatment of opioid use disorder in any care or criminal justice setting is denying appropriate medical treatment.”) at https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document/PEP21-02-01-002 (accessed 5/19/2023).  See also National Academies for Science and Engineering, Medications for Opioid Use Disorder Saves Lives 3 (2019) at  https://www.nap.edu/catalog/25310/medications-for-opioid-use-disorder-save-lives  (accessed 5/19/2023).
  • [10]  See e.g., Weiss RD, Sharpe Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. (2011.) Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid use disorder: A 2-phase randomized controlled trial. Archives of General Psychiatry 68(12), 1238-46. (showing up to 90% relapse rate); National Institute on Drug Abuse, How do Medications to Treat Opioid Use Disorder Work? (December 2021) at https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work (accessed 5/19/2023).
  • [11] National Academies for Science and Engineering, Medications for Opioid Use Disorder Saves Lives 5 (2019), at https://www.nap.edu/catalog/25310/medications-for-opioid-use-disorder-save-lives (accessed 5/19/2023); U.S. Food and Drug Administration, Information about Medication Assisted Treatment (MAT)(5/10/2023) at: https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat (accessed 5/12/2023).
  • [12] See e.g., National Academies for Science and Engineering, Medications for Opioid Use Disorder Saves Lives 5-6 (2019) (found that people taking long term methadone or buprenorphine are up to 50% less likely to die from overdose) at https://www.nap.edu/catalog/25310/medications-for-opioid-use-disorder-save-lives (accessed 5/19/2023); Sarah E. Wakeman, et al., Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder, 3 JAMA NETWORK OPEN 1, 8 (2020) (found only methadone and buprenorphine were associated with reductions in overdose and need for serious opioid acute care, other treatments such as Naltrexone or withdrawal/abstinence did not offer that protection)  at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032 (accessed 5/17/2023); Cates, L., Brown, A.R. Medications for opioid use disorder during incarceration and post-release outcomes. Health Justice 11, 4 (2023). https://doi.org/10.1186/s40352-023-00209-w. at  https://rdcu.be/dcOju (accessed May 23, 2023).
  • [13] NIH National Library of Medicine MedlinePlus, Opioid Misuse and Addiction Treatment (October 8, 2019) at https://medlineplus.gov/opioidmisuseandaddictiontreatment.html (accessed 5/19/2023).
  • [14] Id.
  • [15] See e.g., The National Sheriff’s Association and National Commission on Correctional Healthcare, Jail-Based Medication-Assisted Treatment Promising Practices, Guidelines, and Resources for The Field 9 (Oct. 2018) at https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf .
  • [16] See e.g.,  Pesce v. Coppinger, 355 F. Supp. 3d 35 (D. Mass. 2018) (Held that it likely violates ADA and 8th Amendment to deny MOUD without individual assessment and contrary to treating provider’s recommendation); Smith v. Aroostook Cty., 376 F. Supp. 3d 146 (D. Me.), aff’d, 922 F.3d 41 (1st Cir. 2019)(Court granted preliminary injunction and held that it likely violates ADA to deny incarcerated person access to MOUD without an individualized assessment of the need for medication); Rokita v. Pa. Dep’t of Corr., 273 A.3d 1260 (Pa. Commw. Ct. 2022) (Court denied Commonwealth’s preliminary objection holding that refusal to provide plaintiff with access to a physician who could prescribe MAT allowed plaintiff to make out a claim that the DOC acted with deliberate indifference under the 8th Amendment and also violated ADA by having policy prohibiting MAT for the general population); P.G. v. Jefferson County, No. 5:21-CV-388-DNH-ML (N.D.N.Y. Sept. 7, 2021) (Court held that it likely violates Title II of ADA and 14th Amendment of the Constitution to deny pre-trial detainees access to medically necessary methadone treatment); M.C. v. Jefferson Cty., No. 6:22-CV-190, 2022 U.S. Dist. LEXIS 87339 (N.D.N.Y. May 16, 2022) (Court granted class certification and preliminary injunction and held that the facility’s policy to only provide MOUD to pregnant detainees and forcing others to go off of their MOUD without individualized assessments by a medical professional likely violates Title II of the ADA as well as the 8th and 14th Amendments).  See also, Kortlever v. Whatcom Cty. (D. Wash. 2018) (Class action which settled with agreement to provide MOUD on class wide basis, including maintenance and induction primarily of buprenorphine); Finnigan v. Mendrick, No. 21-CV-341, 2021 WL 736228 (N.D. Ill. Feb. 24, 2021) (Jail allowed Plaintiff access to her medication and made plans to implement a policy to provide MAT); Sclafani v. Mici (D. Mass. 2019); Smith v. Fitzpatrick (D. Me. 2018).
  • [17] U.S. Dept. of Justice, The Americans with Disabilities Act and the Opioid Crisis: Combating Discrimination Against People in Treatment or Recovery (4/5/2022) at: https://archive.ada.gov/opioid_guidance.pdf  (accessed 5/4/2023).
  • [18] See e.g., U.S. Dept. of Justice, ADA Settlement Agreement between The U.S.A. and Big Sandy Regional Jail Authority (November 29, 2023) at https://www.justice.gov/d9/2023-12/settlement_agreement_executed_and_signed.pdf (jail facility required to make policy changes to both continue and initiate medications for opioid use disorder and they will not deny access to MOUD on the basis of an individual’s current illegal drug use)(accessed 12/14/2023); U.S. Dept. of Justice, Settlement Agreement between The U.S.A. and Allegheny County (11/30/2023) at https://www.justice.gov/d9/2023-11/us_and_allegheny_county_settlement_agreement_accessible_copy_for_web_posting_0.pdf (requiring the facility to provide Methadone, not only continue pregnant women, and any other FDA approved MOUD, including initiation and continuation.)(accessed 12/14/2023);   U.S. Dept. of Justice, Statement of Interest in Strickland v. Delaware County, 21CV4141 Eastern District of Pennsylvania (December 11, 2023) (Categorical jail policy to not continue Methadone for a person in custody violates ADA) at https://www.justice.gov/media/1328001/dl?inline (accessed 12/18/2023); U.S. Dept. of Justice, Agreement to Resolve the Department of Justice’s Investigation of the Cumberland County Jail (May 17, 2023 filed in Case 1:23-cv-02655 U.S. v. Cumberland County) at https://www.justice.gov/opa/press-release/file/1584086/  (accessed 5/18/2023); Dep. of Justice, Settlement Agreement Between U.S. and Massachusetts Trial Court (Mar. 24, 2022) at https://www.justice.gov/d9/press-releases/attachments/2022/03/24/us_v._massachusetts_trial_court_-_settlement_agreement_0.pdf   (Courts violated ADA by discriminating against those with OUD by requiring they stop MOUD without individualized assessment.) (accessed 5/19/2023). Pesce v. Coppinger, 355 F. Supp. 3d 35 (D. Mass. 2018) (Held that it likely violates ADA and 8th Amendment to deny MOUD without individual assessment and contrary to treating provider’s recommendation); Smith v. Aroostook Cty., 376 F. Supp. 3d 146 (D. Me.), aff’d, 922 F.3d 41 (1st Cir. 2019)(Court granted preliminary injunction and held that it likely violates ADA to deny incarcerated person access to MOUD without an individualized assessment of the need for medication); Rokita v. Pa. Dep’t of Corr., 273 A.3d 1260 (Pa. Commw. Ct. 2022) (Court denied Commonwealth’s preliminary objection holding that refusal to provide plaintiff with access to a physician who could prescribe MAT allowed plaintiff to make out a claim that the DOC acted with deliberate indifference under the 8th Amendment and also violated ADA by having policy prohibiting MAT for the general population); P.G. v. Jefferson County, No. 5:21-CV-388-DNH-ML (N.D.N.Y. Sept. 7, 2021) (Court held that it likely violates Title II of ADA and 14th Amendment of the Constitution to deny pre-trial detainees access to medically necessary methadone treatment); M.C. v. Jefferson Cty., No. 6:22-CV-190, 2022 U.S. Dist. LEXIS 87339 (N.D.N.Y. May 16, 2022) (Court granted class certification and preliminary injunction and held that the facility’s policy to only provide MOUD to pregnant detainees and forcing others to go off of their MOUD without individualized assessments by a medical professional likely violates Title II of the ADA as well as the 8th and 14th Amendments).  See also, Kortlever v. Whatcom Cty. (D. Wash. 2018) (Class action which settled with agreement to provide MOUD on class wide basis, including maintenance and induction primarily of buprenorphine); Finnigan v. Mendrick, No. 21-CV-341, 2021 WL 736228 (N.D. Ill. Feb. 24, 2021) (Jail allowed Plaintiff access to her medication and made plans to implement a policy to provide MAT); Sclafani v. Mici (D. Mass. 2019); Smith v. Fitzpatrick (D. Me. 2018).
  • [19] Substance Abuse and Mental Health Services Administration (SAMHSA), Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings. HHS Publication No. PEP19-MATUSECJS Rockville, MD: National Mental Health and Substance Use Policy Laboratory. 3 Substance Abuse and Mental Health Services Administration (2019) at https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matusecjs.pdf (accessed 5/19/2023).  See also:  National Center for Correctional Health Care Foundation,  From the General Public to America’s Jails: MAT Saves Lives 2 (White Paper December 2021) at https://www.ncchc.org/wp-content/uploads/From_the_General_Public_to_Americas_Jails_-_MAT_Saves_Lives-_Indivior.pdf (accessed 5/16/2023).
  • [20] Ranapurwala SI, Figgatt MC, Remch M, et al. Opioid overdose deaths among formerly incarcerated persons and the general population: North Carolina, 2000–2018. Am J Public Health. 2022;112(2):300–303.
  • [21] National Association of Counties, Effective Treatment for Opioid Use Disorder for Incarcerated Populations (January 23, 2023) at https://www.naco.org/resources/opioid-solutions/approved-strategies/incarcerated-pops (accessed 5/23/2023).