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

Section 3: NC Jails Discussion: barriers to MOUD treatment and problems with existing programs

Barriers to plan development

As DRNC collected information about the availability of MOUD for OUD in NC’s jails, several barriers to developing MOUD plans and issues that impact the provision of MOUD in facilities with existing MOUD plans were identified.

• One major barrier to developing an MOUD plan is a firmly held belief that abstinence is the right way to address OUD. This belief appeared to be held by various people in the facility, sheriffs and jail staff, third party medical providers, and abstinence only based community providers who serve these facilities. People in custody also confirmed that this is a barrier.
• A lack of support from third party provider medical staff at the facility for the use of MOUD was especially problematic as they are viewed as experts and deference was given to their opinion. At some facilities our staff heard directly from medical providers, both doctors and nurses, that they did not support the use of MOUD, because they believe that withdrawal and abstinence are the best way to address OUD. Many of these medical providers shared their belief with us that the use of MOUD was simply trading one drug for another (a belief also shared by some sheriffs and jail administrators). Another issue was abstinence only community service providers that worked in the facility who advocated for this viewpoint with jail staff. These providers are also viewed as experts in OUD and their opinion was given weight in the decision not to provide MOUD. This deference is misplaced as it is contrary to the standard of care of experts in the community as well as legal obligations.[i] While abstinence may work for some, this model has not proven to be effective in the overdose epidemic.[ii] Too many facilities are relying on outdated detox/withdrawal protocols which are contrary to the standard of care and legal requirements.[iii] This is also an example of a blanket policy that is prohibited under the ADA.[iv]
• Some sheriffs and jail administrators expressed that they would not allow opioids in their facilities. However, this blanket denial ignores the fact that MOUD is safe, effective and FDA approved. Many other jails across the U.S. and in North Carolina are providing MOUD successfully. In fact, providing MOUD can make the facility safer for both those in custody and jail staff.[v]
• Another barrier encountered is that some facilities have developed or are developing Vivitrol-only programs. While developing an MOUD program is a positive step, developing an injectable naltrexone only program is problematic for several reasons. Naltrexone is the least effective of the three types of FDA approved medications for OUD.[vi] Providing only naltrexone likely violates the ADA, especially for those coming into the facility who are taking a different medication, as the decision of what medication to provide should be based on an individualized assessment and not based on a blanket policy.[vii] Recent settlement agreements reached with the U.S. DOJ reject offering Vivitrol only because it is an inadequate MOUD program.[viii]
• Limited medical provider hours, facilities that only have medical staff available a few hours a day or a few days per week in the jail, were also cited as a barrier to developing a plan and providing MOUD. However, a number of small facilities with limited medical staff hours have been able to work around this limitation. As seen in the current NC jail data in this report, facilities of all sizes are able to offer both continuation programs and continuation/induction programs. Facilities should work with their Public Health Director in their county to find solutions to this barrier. If and until there is a resolution, the facility should arrange transfer to another facility that can provide MOUD. A related concern is that in some places there are no MOUD providers in the county. Transfer to another facility that can provide the treatment is an option already in operation by other NC counties facing this issue.
• Waiting for an external event to occur is another barrier to MOUD program development. Some counties indicated that they are waiting for a new facility to be built before they will initiate a program. There are other jails who are also waiting on new facilities; however, these counties have already started an MOUD program. An MOUD program does not require a new facility. MOUD is a medication, like other medications. Other counties told us they recognized that they will need to develop an MOUD program, but they are waiting on the state to mandate the provision of this service. Unfortunately, both reasons ignore the legal requirements that currently exist to provide appropriate treatment-the constitution and the ADA.[ix]

Problems with existing programs

Problems were identified when our staff examined existing MOUD programs that are important to highlight as they interfere with the provision of appropriate OUD care. Most of this information was reported by the facilities themselves, but our staff also gathered information from other sources such as community partners and from the experiences of people with OUD who were incarcerated in jails.

• A major issue was the use of drug screens on intake into jails. These drug screens, used to screen for evidence of illicit substance use, are used to block people from participating in MOUD programs. This refusal to provide MOUD happens even when the community provider of MOUD is aware of a positive test result and said the MOUD should continue. Issues like false positive drug screens, refusing to retest, or look at alternative explanations for positive results were reported by people who experienced this during incarceration. In addition, this practice of using intake drug screens to discontinue access to MOUD violates the ADA. Although people using illicit substances are generally not protected by the ADA,[x] there is a health care exemption to that exception in the ADA[xi] explained in the DOJ guidance.[xii] Jail medical providers are part of that health care exemption. Medical providers are not allowed to deny services to people with an OUD on the basis of current illegal use of drugs, who are otherwise eligible to receive that service.[xiii]
• DRNC received several complaints about this practice of denying MOUD because of positive drug screen on intake in the jail. One person that they had been stable on MOUD in the community for years yet when they entered the jail, the nurse at the facility told them they tested positive and took them off their medications. Another person reported that when they complained about not being allowed to continue MOUD.

“[T]he nurse said, ‘what is crazy, what is BS, is people being on this medication for 8-9 years’… but I had been on the medication less than 6 months…. I started to have drug dreams again.” 

• People entering jail who are already prescribed MOUD can experience long delays while waiting for drug screen results and on the facility’s follow up confirmation of current treatment from community providers. This can lead to unnecessary withdrawal and someone having to take a much lower dose than they might have been prescribed in the community – requiring people to slowly titrate back to the dose that works for them.  Staff received numerous reports from people who have experienced this. One individual described jail medical staff waiting 3-4 days before contacting the methadone provider, and not only did they have to go through withdrawal, but they also had to start on a lower dose than they were taking in the community.
• Use of only one type of medication or only allowing one set dosage for everyone was another problem frequently reported. This included changing the amount/type of medication that a person received from what they received in the community. One person reported a different set dosage for women and men, based only on gender, not the needs of the individual. One community provider reported that people were all put on the same dose and schedule regardless of what they were taking in the community. Another individual had to go through withdrawal for 7-8 days then was put on a different medication, with a very low dose so withdrawal symptoms continued.
• Unnecessary punitive measures, such as putting someone in segregation to avoid the risk of diversion of medication to other inmates, were also reported. There are many ways of addressing concerns of diversion that medical providers can put into place. Putting someone in segregation because they take MOUD out of fear of diversion should not be one of those methods.
• One client reported a delay in getting their methadone, so they went through withdrawal; once they began to receive methadone again, they were then put in segregation due to fear of diversion of methadone. Going through withdrawal followed by being placed in isolation to receive medication had a terrible impact on their mental health.
• One county did not provide MOUD if a person was housed in segregation. People in segregation should receive their medications as prescribed. This relates back to the stigma that exists toward this medical condition and the medications used to treat it.[xiv] MOUD is a medication, not a reward or punishment. This would be an unacceptable practice for medications such as insulin and hypertension medications, etc.
• Some facilities have no formal plans but provide some form of MOUD. While it is encouraging to learn that at least some people are provided with MOUD, with a formal plan in place there is less chance for inequitable practices that can creep in when there are no formal procedures in place.
• Lack of transparency of a jail’s policies/practices is a major problem, especially for those with disabilities in the jail’s custody. People with disabilities are overrepresented in jails.[xv] People in jail must rely on the jail to provide for their medical care. Inspections of jails are infrequent.[xvi] Not sharing information on the practices/policies for health-related matters does not allow any community or expert input if there are problems with the medical treatment that people in custody receive. There should be transparency in the care that people with disabilities receive in a detention facility.
• Lack of data is problematic for similar reasons. If the facility does not gather and keep aggregate data on the people entering their facility who have OUD, they will not have a clear understanding of the problem in their community. If data is not kept, they are also unable to evaluate any MOUD program and determine if changes to the program need to be made. Data is also important when asking for grants and increased money for medications/programming, etc.

Related Issues

Lack of continuity of care

Interruptions in MOUD occur when individuals go to one facility for a time then are transferred to another jail or prison that does not offer MOUD. Some facilities will not continue or initiate people on MOUD if they are going to be transferred to another facility without MOUD. Others may continue, then taper the dose to lessen withdrawal. Some keep the MOUD dose the same without tapering, which forces the person to go through withdrawal at the next location.

Ignoring court orders for continued treatment. Facilities did not often report receiving court orders to continue treatment/medications. However, even with a court order, sometimes people are still not receiving their medications.

“[I] was not only misled, but was promised–through vocal and formal statement–by the judge of my case that I’d be able to receive treatment which was untrue, I was made to feel as if my OUD and symptoms were meaningless.”

When a facility does not provide MOUD many people will suffer withdrawal. Withdrawal protocols, often of the third-party medical providers, that only provide minimal care for those going through withdrawal were identified. The symptoms of withdrawal are terrible: vomiting, diarrhea, nausea, pain and muscle cramps, etc. Withdrawal is especially problematic if there are underlying health issues, both known and unknown. DRNC staff received information from many who reported they did not receive any care while being forced to go through withdrawal.

One person reported that they informed the nurse that they were taking buprenorphine from a community provider, which the facility would not allow, so they would be going through withdrawal. The nurse said they would give them medications to try to help with the discomfort, then failed to leave a note instructing that the person be provided these medications, so the person never received any medications to help them. When the nurse returned days later, it was reported that the nurse said ‘oh, well you are already through the worst of it, kind of pointless to put you on anything.’ 

Withdrawal symptoms can also happen at facilities that do provide MOUD but take too long to get the person back on their medications.

“I was forced to go through withdrawal for 7-8 days, I was not given anything to help with withdrawal-not even Gatorade” another said, “I was miserable, couldn’t sleep or eat for days, my blood pressure was so high I was seeing Nat’s [sic] and about passing out every time I stood up my breathing was ragged and I felt as if I was having trouble breathing. I was easily agitated and highly irritable. After about 2 weeks I was feeling some better but still never got to feeling normal again until I got out. It was a horrible and scary situation; they just don’t care about your medical health in there….”

People who are not provided with MOUD while incarcerated experience ongoing problems after release

In addition to the unacceptable increased risk of overdose death following release, people who do not receive MOUD in jail are less likely to return to their treatment[xvii] and are more likely to return to use.[xviii] Destabilizing people by discontinuing medications, or not taking the effort to stabilize people by starting medications while they have the opportunity to provide treatment in jail, is harmful to our citizens and communities. Unless changes are made, the overdose epidemic will continue. DRNC identifies recommendations and resources to help in the next section.

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[i] See Nat’l. Comm’n. on Corr. Health Care (NCCHC), Opioid Use Disorder Treatment in Correctional Settings (2021), (Mar. 11, 2021), https://www.ncchc.org/position-statements/opioid-use-disorder-treatment-in-correctional-settings-2021/; Jennifer J. Carroll, Effective Treatment for Opioid Use Disorder for Incarcerated Populations, NACo (Jan. 23, 2023), https://www.naco.org/resources/opioid-solutions/approved-strategies/incarcerated-pops.

[ii] See e.g., Mallory Locklear, Treating Opioid Disorder Without Meds More Harmful Than No Treatment at All, YaleNews (Dec. 19, 2023), https://news.yale.edu/2023/12/19/treating-opioid-disorder-without-meds-more-harmful-no-treatment-all (citing 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. 111040 (2024)); 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.

[iii] See Nat’l. Comm’n. on Corr. Health Care (NCCHC), Opioid Use Disorder Treatment in Correctional Settings (2021), (Mar. 11, 2021), https://www.ncchc.org/position-statements/opioid-use-disorder-treatment-in-correctional-settings-2021/; Jennifer J. Carroll, Effective Treatment for Opioid Use Disorder for Incarcerated Populations, NACo (Jan. 23, 2023), https://www.naco.org/resources/opioid-solutions/approved-strategies/incarcerated-pops.

[iv] 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 at *2 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[v] Nat’l. Sheriffs’ Ass’n. & Nat’l. Comm. on Correctional Health Care, Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field  5 (2018), https://www.sheriffs.org/jail-based-mat or https://www.ncchc.org/jail-based-mat/ ; See also NCCHC Foundation, From the General Public to America’s Jails: MAT Saves Lives 11 (2021), https://www.ncchc.org/wp-content/uploads/From_the_General_Public_to_Americas_Jails_-_MAT_Saves_Lives-_Indivior.pdf (providing MOUD agonist medications methadone and buprenorphine reduce the overall use of illicit drugs in jails and reduces disciplinary problems).

[vi] 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; see also Taylor Knopf, Strings Attached to New State Funds for Addiction Treatment in Jails, N.C. Health News (May 10, 2022), https://www.northcarolinahealthnews.org/2022/05/10/strings-attached-to-new-state-funds-for-addiction-treatment-in-jails/ (expressing concern with the use of Vivitrol as an MOUD plan due to problems with effectiveness and prohibitive cost.).

[vii] See Pesce v. Coppinger, 355 F. Supp. 3d 35 (D. Mass. 2018) (holding that it likely violates ADA and 8th Amendment to deny MOUD without individual assessment and contrary to treating provider’s recommendation); 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 at *2 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[viii] See e.g., 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.

[ix] 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 at *2 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[x] 42 U.S.C. § 12210(a); 28 C.F.R. §§ 35.131(a)(1), 36.209(a)(1); 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 at *3 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[xi] 42 U.S.C. § 12210(c); 28 C.F.R. §§ 35.131(b)(1), 36.209(b)(1).

[xii] 42 U.S.C. § 12210(c); 28 C.F.R. §§ 35.131(b)(1), 36.209(b)(1); 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 at *4 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf.

[xiii] See 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 at *3–4 (Apr. 5, 2022), https://archive.ada.gov/opioid_guidance.pdf. Since jails are the medical health care providers to the people in their custody and care, the illicit drug use exception from ADA protections does not apply due to the medical provider exemption, so jails and jail medical providers may not deny medications if the person with an OUD tests positive on an intake drug screen, if they are otherwise entitled to medical care/services. Id.

[xiv] Julia Dickinson-Gomez et al., “You’re Not Supposed to be on it Forever”: Medications to Treat Opioid Use Disorder (MOUD) Related Stigma Among Drug Treatment Providers and People Who Use Opioids, 16 Substance Abuse 1, 2 (2022).

[xv] Nat’l. Jud. Task Force to Examine State Cts. Response to Mental Illness, State Courts Leading Change: Report and Recommendations 9 (2023), https://www.ncsc.org/__data/assets/pdf_file/0031/84469/MHTF_State_Courts_Leading_Change.pdf (“[M]ore than 70% of people in American jails and prisons have at least on diagnosed mental illness or substance use disorder, or both.”).

[xvi] N.C. Gen. Stat. § 153A-222, Inspections of local confinement facilities (“(a) Department personnel shall visit and inspect each local confinement facility at least semiannually. The purpose of the inspections is to investigate the conditions of confinement, the treatment of prisoners, the maintenance of entry level employment standards for jailers and supervisory and administrative personnel of local confinement facilities as provided for in G.S. 153A-216(4), and to determine whether the facilities meet the minimum standards published pursuant to G.S. 153A-221. facilities as provided for in G.S. 153A-216(4), and to determine whether the facilities meet the minimum standards published pursuant to G.S. 153A-221.”); see also 10A N.C. Admin. Code 14J .1301 (“All jails shall be visited and inspected at least twice each year, but a jail shall be inspected more frequently if the Department considers it necessary or if it is required by an agreement of correction pursuant to 10A NCAC 14 .1304.).

[xvii] See e.g., Lara Cates & Aaron R. Brown, Medications for Opioid Use Disorder During Incarceration and Post-Release Outcomes, 11 Health Just. 1,2 (2023) (finding that most studies have shown that MOUD provided during incarceration increased community based treatment engagement post-release); PEW, Opioid Use Disorder Treatment in Jails and Prisons 5 (2020),  https://www.pewtrusts.org/-/media/assets/2020/04/caseformedicationassistedtreatmentjailsprisons.pdf  (“The preponderance of evidence suggests that people who are incarcerated and started on medication and counseling in jail or prison are more likely to engage in treatment post-release than people who do not receive medication while incarcerated.”); Rural Health Information Hub, Considerations for People Who Are Incarcerated When Implementing MOUD Programs (2019), https://www.ruralhealthinfo.org/toolkits/moud/4/population-considerations/incarcerated (people who are incarcerated and receive MOUD prior to release are more likely to engage in treatment after release, engage in treatment sooner, and stay in treatment longer).

[xviii] Lara Cates & Aaron R. Brown, Medications for Opioid Use Disorder During Incarceration and Post-Release Outcomes, 11 Health Just. 1,2 (2023).