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

Table of Contents

1. Introduction
2. Executive Summary
3. Section 1: Opioids, Opioid Use Disorder and MOUD
4. Section 2: MOUD Availability in Jails Nationwide and in NC
5. Section 3: NC Jails Discussion: barriers to MOUD treatment and problems with existing programs
6. Section 4: Recommendations and Resources

Executive Summary

The US and North Carolina are experiencing an overdose death crisis. Over 100,000 people in the US lost their lives to overdose in 2022[i] and North Carolina lost 3,875 family members, friends and neighbors[ii]. Opioids, primarily illicit fentanyl, are the main driver of the overdose death crisis.[iii]

National Statistics

• Nationally, opioids were involved in 80,411 overdose deaths in 2021 (75.4% of all drug overdose deaths). [iv]
• Opioids are a factor in 7 out of every 10 overdose deaths. [v]
• Opioids kill more than 136 Americans every day. [vi]

NC Statistics

• In NC, more than 36,000 people have lost their lives to overdose from 2000-2022. [vii]
• Opioids are a factor in 78.9% of all overdose deaths. [viii]
• More people die in North Carolina of an accidental drug overdose–usually an opioid–than from any other cause of accidental death. [ix]
• On average, at least five people die from opioid overdoses every day. [x]
• Those leaving incarceration in North Carolina have a 50 times greater chance of dying from an overdose than the general population in the first two weeks following release. [xi]

Nationally, in 2020, the opioid crisis cost the US close to 1.5 trillion dollars.[xii] More important than the economic cost of the crisis is the human cost. Loved ones, friends and neighbors are being lost unnecessarily to a treatable medical condition. This devastating trend does not need to continue. Opioid use disorder (OUD) is a treatable medical condition that responds well to the proven and effective medications available for opioid use disorder.[xiii]

According to the National Academy of Sciences, Engineering and Medicine, “The verdict is clear: effective agonist medication used for an indefinite period of time is the safest option for treating OUD.”[xiv] Agonists reduce opioid use and help people remain in treatment.[xv] Agonist medications such as methadone and buprenorphine have proven to be the most effective in treating OUD and are the standard of care. [xvi]

Recent studies found that agonist medications are key to treatment of OUD and preventing overdose deaths. One study compared 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 (naltrexone/Vivitrol).[xvii] Another study concluded that non-MOUD treatments provided no protection against opioid overdose death, but the risk was reduced following exposure to MOUD[xviii] – in order to stop these deaths, efforts need to expand access to agonist MOUD treatment.

These medications must be made available and easily accessible to people who need them, including those who are incarcerated.

OUD is also a disability which is protected under the Americans with Disabilities Act (ADA).[xix] In April 2022, the US Department of Justice (DOJ) provided guidance that OUD is a disability covered by the ADA, that people in jails and prisons are covered under the ADA, and that blanket policies that prohibit the use of MOUD in these facilities violates the ADA.[xx]

Recent settlement agreements in 2023 between the DOJ and jails have gone further in outlining how jails must “offer the option to all individuals with OUD booked into [the jail] to receive treatment with any FDA-approved OUD medication….including those who were not being treated with OUD medication prior to their incarceration at [the jail].”[xxi] Despite all of this, many who would benefit from these medications don’t receive them. This is due in large part to stigma and moral judgments surrounding this medical condition and the medications used to treat it.[xxii] This is especially true for those in our jails and prisons.[xxiii]

People with opioid use disorder are overrepresented in our criminal justice system, jails and prisons. It is estimated that 15% of 1.8 million people in the U.S. who are incarcerated have an opioid use disorder.[xxiv] This problem is compounded for BIPOC communities, who are more likely to face criminal justice involvement for their drug use[xxv] and are less likely to have access to evidence-based treatment.[xxvi]

Since jails are the de facto medical providers due to lack of sufficient resources in the community, these facilities have a unique opportunity to offer medical treatment that can help their communities and turn the tide on the overdose crisis. Agonist medications for OUD are associated with an estimated 50% reduction in death among people with OUD.[xxvii] This medical treatment provides stability, better retention in treatment, and better outcomes for people with OUD.[xxviii] Jails can help those in custody and their communities and comply with anti-discrimination laws by introducing MOUD to those not already in treatment and continuing MOUD for those who were already in treatment in the community.

Findings

Disability Rights North Carolina (DRNC) studied the availability of medications for opioid use disorder (MOUD) in NC Jails by contacting all 100 counties.* It is gratifying to report there has been some progress since the initiation of this project. However, North Carolina must persist in implementing changes in its jails, justice, and correctional systems and focus on improving access to treatment, not simply on punishment.

MOUD treatment	Reported
Continuation	23
Continuation and induction	11
Medication for pregnant women only	3
Vivitrol only	1
Developing a plan	7
No response	15
No program	26
Insufficient or contradictory information	6

*There are 5 counties with either no jail or less than 10 cell capacity. Bertie and Martin Counties share a regional jail as do Camden, Pasquotank and Perquimans Counties. There are 92 County jails represented in the total count.

The displayed data is generated from the many jails that responded to DRNC’s outreach efforts to learn more about the status of MOUD treatment and resources. Attempts were made to obtain other reliable information to determine what each NC jail offered people in their custody. However, some jails showed a lack of transparency in their policies and practices when we reached out for clarification of information received. Other counties failed to respond to any of our staff’s outreach efforts, including public records requests. Based on these findings, DRNC developed recommendations to improve access to MOUD in NC jails.

Recommendations

• The State, public health directors, and other community leaders need to expand public education to reduce stigma around OUD and its medications.
• Community medical professionals who specialize in OUD and the use of MOUD should provide ongoing education to law enforcement, jail staff, and detention facility third party medical providers. This education should focus on OUD as a disability, the effectiveness of MOUD, and proper access to MOUD. This education should be continuing, not a one-time offering.
• Barriers to access of MOUD in jails and prisons should be removed. MOUD should be available and easily accessible for people with OUD. Stop the use of drug screens on intake to deny MOUD and other rigid rules around access (e.g., do not force someone to engage in therapy to receive medication), do not discontinue access to medication as a punishment, and remove arbitrary limits to medication types and dosages – this needs to be assessed individually.
• The State must require that MOUD, including agonist medications, be made available to those with OUD in all NC jails and prisons. If the facility does not have the ability to provide MOUD, anyone who needs MOUD should immediately be transferred to another facility.
• Community leaders and policymakers need to support the use of MOUD in carceral settings and efforts to help those released re-integrate into their community by publicly supporting and improving funding for these programs, and providing guaranteed continued access to MOUD to people who are uninsured when they leave the facility. This must include assistance from the Local Management Entity/Managed Care Organization (LME/MCO) to make sure that all people with OUD who are leaving the facility are connected with services.

Jump to Page Numbers

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[i] Provisional Drug Overdose Death Counts, Ctrs. for Disease Control and Prevention (CDC),  https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (Jan. 7, 2024). For all overdose deaths nationally—not limited to only opioids—over 100,000 people lost their lives to overdose in 2022. Id.

[ii] Opioid Substance Use Action Plan Data Dashboard, N.C. Dep’t. Health Hum. Servs. (NCDHHS),  https://www.ncdhhs.gov/opioid-and-substance-use-action-plan-data-dashboard (last visited Feb. 15, 2024). Provisional 2022 data indicate that over 11 North Carolinians died each day from a drug overdose, not limited to opioids; and the rate is 38.5 deaths per 100,000 people. Id. (data pulled from the “Welcome” tab and the “Metrics” tab along the top of the dashboard).

[iii] Nat’l. Ctr. for Injury Prevention, Understanding Drug Overdoses and Deaths, CDC (May 8, 2023),  https://www.cdc.gov/drugoverdose/epidemic/index.html.

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

[v] Opioid Epidemic: Addiction Statistics, Nat’l. Ctr. for Drug Abuse Stats. (NCDAS), https://drugabusestatistics.org/opioid-epidemic/ (last visited Feb. 15, 2024).

[vi] Id.

[vii] Overdose Epidemic: Combating North Carolina’s Opioid Crisis, NCDHHS, https://www.ncdhhs.gov/about/department-initiatives/overdose-epidemic (last visited Feb. 15, 2024).

[viii] Opioid Epidemic: Addiction Statistics, NCDAS, https://drugabusestatistics.org/opioid-epidemic/ (last visited Feb. 15, 2024) (N.C. state data).

[ix] Attorney General Josh Stein, Opioid Crisis, N.C. Dep’t. Just. (NCDOJ), https://ncdoj.gov/responding-to-crime/opioid-epidemic/ (last visited Feb. 15, 2024).

[x] Id.

[xi] 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 mortality immediately after release from incarceration. See Commonwealth of Mass. Dep’t. 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).

[xii] Ahmed Aboulenein, Opioid Crisis Cost U.S. Nearly $1.5 Trillion in 2020—Congressional Report, Reuters (Sept. 28, 2022, 1:08 PM), https://www.reuters.com/world/us/opioid-crisis-cost-us-nearly-15-trillion-2020-congressional-report-2022-09-28/.

[xiii] Nat’l. Acad. Sci. Engineering Med. (NASEM), Medications to Treat Opioid Addiction Are Effective and Save Lives, But Barriers Prevent Broad Access and Use Says New Report, (Mar. 20, 2019), https://www.nationalacademies.org/news/2019/03/medications-to-treat-opioid-addiction-are-effective-and-save-lives-but-barriers-prevent-broad-access-and-use-says-new-report; NASEM, Medications for Opioid Use Disorder Save Lives 38 (2019),  https://nap.nationalacademies.org/catalog/25310/medications-for-opioid-use-disorder-save-lives [hereinafter NASEM, Medications for Opioid Use Disorder Save Lives].

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

[xv] Id.

[xvi] William C. Goedel et al., Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States, 3 JAMA Network Open 1, 7 (2020), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764663 ; see also Substance Use Prevention and Treatment Project, Opioid Use Disorder Treatment in Jails and Prisons, PEW (2020), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2020/04/opioid-use-disorder-treatment-in-jails-and-prisons.

[xvii] 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  .

[xviii] 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.”).

[xix] The Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12131–12134 (1990) (citing Title II, protecting individuals from discrimination in government programs); 42 U.S.C. §§ 12112, 12132, 12182 (prohibiting discrimination on the basis of disability); 42 U.S.C. §12102(1)-(2) (defining disability). For facilities that accept federal funding, there is also a potential claim under Section 504 of the Rehabilitation Act of 1973. See e.g., Taylor v. Wexford Health Sources, Inc., No 2:23-CV-00475, 2024 U.S. Dist. LEXIS 1187, (S.D. W.Va. Jan. 3, 2024) (citing 29 U.S.C. §§ 701, 794; Wicomico Nursing Home v. Padilla, 910 F.3d 739, 750 (4^th Cir. 2018); Halpern v. Wake Forest Univ. Health Scis., 669 F. 3d 454, 461 (4^th Cir. 2012)) (comparing claims under the ADA and the Rehabilitation Act and holding that claims are plausible under both laws).

[xx] U.S. Dep’t. of Just. C.R. Div., The Americans with Disabilities Act and the Opioid Crisis: Combating Discrimination Against People in Treatment or Recovery (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[xxi] U.S. Atty’s. Off. E.D. Ky., U.S. Attorney’s Office Announces Agreement to Ensure Access to Medications for Opioid Use Disorder at Big Sandy Regional Detention (Dec. 4, 2023), https://www.justice.gov/usao-edky/pr/us-attorneys-office-announces-agreement-ensure-access-medications-opioid-use-disorder; see also U.S. Dep’t. of Just. Off. Pub. Affs., Justice Department Secures Agreement from Pennsylvania Jail to Provide Medications for Opioid Use Disorder (Nov. 30, 2023), https://www.justice.gov/opa/pr/justice-department-secures-agreement-pennsylvania-jail-provide-medications-opioid-use; U.S. Atty’s. Off. D. Mass., U.S. Attorney Rollins Announces Correctional Facilities Statewide to Maintain All Medications for Opioid Use Disorder (Apr. 1, 2022), https://www.justice.gov/usao-ma/pr/us-attorney-rollins-announces-correctional-facilities-statewide-maintain-all-medications

[xxii] NASEM, Medications for Opioid Use Disorder Save Lives 12 (2019).

[xxiii] Id.

[xxiv]Ashish P. Thakrar, G. Caleb Alexander, & Brendan Saloner, Trends in Buprenorphine Use in US Jails and Prisons From 2016 to 2021, 4 JAMA Network Open 1, 1 (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8672225/.

[xxv] Johns Hopkins Bloomberg Sch. of Pub. Health, Principle #4: Focus on Racial Equity,  https://opioidprinciples.jhsph.edu/focus-on-racial-equity/ (last visited Feb. 15, 2024) (“Black individuals represent just 5% of people who use drugs, but 29% of those arrested for drug offenses and 33% of those in state prison for drug offenses. Additionally, American Indian and Alaska Native (AI/AN) people are overrepresented amongst incarcerated populations. However, inconsistency in data collection for this population does not provide an accurate estimate on the percentage of AI/AN incarcerated for drug offenses. Communities of color are also more likely to face barriers in accessing high-quality treatment and recovery support services.”).

[xxvi] Harv. T.H. Chan Sch. of Pub. Health, Substantial Racial Inequities Despite Frequent Health Care Contact Found in Treatment for Opioid Use Disorder (May 10, 2023), https://www.hsph.harvard.edu/news/press-releases/substantial-racial-inequalities-despite-frequent-health-care-contact-found-in-treatment-for-opioid-use-disorder/ (citing Michael Barnett et al., Racial Inequality in Receipt of Medications for Opioid Use Disorder, 388 New. Eng. J. Med. 1779 (2023)); Mara A.G. Hollander et al., Racial Inequity in Medication Treatment for Opioid Use Disorder: Exploring Potential Facilitators and Barriers to Use, 227 Drug Alcohol Depend. 1, 8–14 (2021); Oluwole Jegede, Chryell Bellamy, & Ayana Jordan, Systemic Racism as a Determinant of Health Inequities for People with Substance Use Disorder, JAMA Psychiatry Online (Jan. 17, 2024), https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2814162.

[xxvii] NASEM, Medications for Opioid Use Disorder Save Lives 39 (2019) (citing Louisa Degenhardt et al., The Impact of Opioid Substitution Therapy on Mortality Post-Release From Prison: Retrospective Data Linkage Study, 109 Addiction 1306 (2014); Marc R. Larochelle et al., Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association with Mortality: A Cohort Study, 169 Annals of Internal Med. 137 (2017); Jun Ma et al., Effects of Medication-Assisted Treatment on Mortality Among Opioids Users: A Systematic Review and Meta-Analysis, 24 Molecular Psychiatry 1868 (2018); Matthias Pierce et al., Impact of Treatment for Opioid Dependence on Fatal Drug-Related Poisoning: A National Cohort Study in England, 111 Addiction 298 (2016); Luis Sordo et al., Mortality Risk During and After Opioid Substitution Treatment: Systematic Review and Meta-Analysis of Cohort Studies, 357 BMJ j1550 (2017)).

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