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 4: Recommendations and Resources

Recommendations

The State, public health directors, and other community leaders need to expand public education to reduce stigma around OUD and its medications.

Stigma remains a major barrier to MOUD, undermining current efforts to increase the understanding that OUD is a medical condition and a disability, MOUD is a medication, and that MOUD is effective to save lives. Examples may include the use of print, online, radio, and TV educational advertisements, social media campaigns, and billboards.

Stigma surrounding OUD and the medications used to treat it is a major barrier to MOUD access[i] because it stops people with OUD from seeking out MOUD, interferes with MOUD being offered as a treatment, and interferes with program development and implementation in NC jails. North Carolina needs to continue to focus on OUD as a disability and MOUD as a necessary medication, rejecting the outdated notion that MOUD is simply trading one drug for another. Public education efforts on a widespread scale are needed to address this stigma. Every part of the community, not just those involved in this work, needs to be included in this educational outreach.

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.

Leaders in jail administration must promote MOUD and its effectiveness, modeling their support of the program and enforcing that the program is implemented and accessible to all those with OUD.

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.

Lower barrier access to MOUD, which limits demands placed on clients to make treatment readily available and easily accessible and without judgment, should be the focus for treatment as recommended by SAMHSA.[ii] Care should be person-centered and individualized, with consideration for the person’s unique needs and experiences.[iii] Flexibility and availability are key to successful treatment if a person comes into jail with OUD and needs treatment.[iv] MOUD should be started immediately and without unnecessary barriers, such as positive drug screens stopping a person from continuing or initiating treatment, unless there is a specific medical issue.[v] Medication type, dosage and the duration of treatment must be individualized.[vi] Additional therapy should be offered, but not required, to receive the medications.[vii]

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.

The lack of access to MOUD in jails and prisons (including the lack of continuity of care if one facility provides MOUD and the next does not) is not helping to stem the overdose crisis that plagues North Carolina. Jails have a unique opportunity to be a major contributor to the wellbeing of their community and its members by providing treatment to those with OUD and helping them to stabilize.

Some jails reported that a lack of resources, such as low staffing, lack of funding, lack of providers, or diversion concerns have prevented them from developing and implementing an MOUD program. However, these reasons do not excuse jails from compliance with the duty to provide adequate medical care, including MOUD. Other jails facing the same constraints have MOUD programs in place. There is no need to reinvent the wheel; there are sheriffs, jail administrators, and contracted medical providers available to share how they overcame these obstacles to develop a plan. Community experts are also able to help.

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.

Community leaders such as county managers, county commissioners, and public health officials must present a united front and show their support of MOUD. County Commissioners can choose to use Opioid Settlement funds for jail populations to receive treatment in the facility and supportive services on release.[viii] Public health directors can provide more education to their communities and support the use of MOUD in jails by requiring the jail medical plan to include MOUD.[ix]

Policymakers and community leaders must support programs for those with OUD who have experienced incarceration by ensuring access to treatment and re-entry programs in the community, regardless of the ability to pay. These supports must include access to housing, food, continued access to medications – and if desired, to counseling and other supportive services like case management and peer supports, re-entry programs such as Formerly Incarcerated Treatment (FIT), and access to job training/Vocational Rehabilitation.

Many people leaving jail have no access to insurance. For those entering jails who are on Medicaid, NC Medicaid should be suspended not discontinued and should be in place on release from jail.[x] Those not on Medicaid should be assisted to apply before release.

The Local Management Entity/Managed Care Organizations (LME/MCO a.k.a. Tailored Plans) that serve the county where the detention center is located should dedicate positions for staff who are knowledgeable about the needs of those leaving incarceration, coordinate with the jails, and provide services to people with OUD leaving incarceration.[xi] Prior to release from incarceration, provide warm handoffs to supports, services and treatment in the community.

Resources for Jails

Resources are available to help jails develop MOUD programs that comply with legal requirements.

  • 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
  • North Carolina Substance Treatment and Recovery (NC STAR Network) is a free resource for jails that is funded through the state. They will provide free outreach and training to both detention center staff and jail medical providers (free CME credits are available) throughout the state. Reach out to Brenda Pearson for assistance: Pearson, Brenda brenda_pearson@med.unc.edu
    From its website https://ncstarnetwork.org/:

    The NC STAR Network is a statewide initiative with an overarching goal of expanding access to addiction treatment for all citizens of North Carolina through utilization of a Hub and Spoke model. The Hubs are academic centers with a strong focus on providing addiction treatment and education. Currently, the NC STAR Network hubs are located at UNC, Mountain Area Health Education Center (MAHEC), and East Carolina University (ECU). The Hubs are strategically located in the West (MAHEC), central (UNC) and East (ECU) portions of NC which allows each to provide service to a wide range of citizens.

From the website:

Funded by NC DHHS Division of Mental Health, The North Carolina Technical Assistance Center (NC-TAC) is a statewide initiative to provide technical assistance to programs that support individuals at risk of incarceration and overdose. We provide tailored, evidence-based, technical assistance with a harm reduction approach. Our goal is to improve access to resources for people who use drugs and are impacted by the legal system, in North Carolina. Our services are available to any North Carolina non-profit, private, or government entity that provides services to people impacted by the legal system.

We have specific expertise in the following areas:

    • Harm reduction (Drug user health, engaging key populations)
    • Supporting release from incarceration (Reentry)
    • Diversion/Deflection, including Law Enforcement Assisted Diversion (LEAD)
    • Jail-based Medication for Opioid Use Disorder (MOUD)
    • Naloxone access and distribution
    • Program evaluation
    • Data management

Information on grants/funding and grant writing:

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

Jump to Page Numbers

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[i] See 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); 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/.

[ii] SAMHSA, Advisory: Low Barrier Models of Care for Substance Use Disorders 1 (2023), https://www.med.unc.edu/fammed/justicetateam/wp-content/uploads/sites/1256/2023/12/SAMHSA-Low-barrier-models-SUD_dec-2023.pdf.

[iii] Id. at 1–4.

[iv] Id. at 3–4.

[v] Id. at 4–5.

[vi] Id. at 1,4.

[vii] Id. at 4–5.

[viii] North Carolina Opioid Settlements, Data Dashboard—Local Spending Plans, CORE-NC, https://ncopioidsettlement.org/data-dashboards/spending-plans/ (last visited Feb. 13, 2024).

[ix] 10A N.C. Admin. Code 14J .1001(e).

[x]The Governor has also made this a priority, see N.C., Exec. Order No. 303: Sec. 4 Part B i–ii, Establishing a Unified Approach to Improving Education, Rehabilitation, and Reentry Services for Incarcerated and Formerly Incarcerated People in North Carolina (Jan. 29, 2024), https://governor.nc.gov/executive-order-no-303/open. The Governor’s order reads in part, “[t]he North Carolina Department of Health and Human Services (“DHHS”) shall: i. Work with the Centers for Medicare & Medicaid Services with the goal of securing approval for the NC Section 1115 Demonstration Waiver to allow certain eligible people to receive certain Medicaid services prior to release. ii. Create mechanisms to allow people to be pre-screened before leaving prison for federal and state benefits (e.g., TANF, SNAP, Medicaid, and LIHEAP) including ensuring processes exist for people preparing for release who are otherwise eligible for Medicaid to receive Medicaid services immediately upon release.” Id.

[xi] Id. at B.iii. (“Ensure released people who are diagnosed with Serious Mental Illnesses (SMIs), Substance Use Disorders, Intellectual or Developmental Disabilities (I/DD) or Traumatic Brain Injuries (TBIs) are engaged in the appropriate behavioral health services upon release from state prisons and county jails.”).

[xii] S.B. 105, Gen. Assem. Sess. 2021, S.L. 2021-180 (N.C. 2021), Competitive Grants to Sheriff’s Offices for Addiction Treatment in Jails. (Sec. 19A.10(f) reads, “[t]he working group created under subsection (e) of this section shall establish the operational criteria and application process for the grant program created by this section and shall communicate information regarding the grant program to all sheriffs’ offices in the State. The working group shall evaluate applications for each of the categories under subsection (b) of this section and may award lower amounts than requested to individual sheriffs’ offices in order to assure broader access to funds. The working group may establish protocols for the allotment of funds to assure that funds can be expended efficiently.”). See also H.B. 259, Gen. Assem. Sess. 2023, S.L. 2023-134 (N.C. 2022) (specifically Sec. 19F.3(a) which rewrites the 2021 senate bill to add, “[t]he working group shall ensure all Federal Drug Administration (FDA)-approved drugs for the treatment of opioid dependence through Medication-Assisted Treatment (MAT) in jails be considered as options for treatment, including, but not limited to, long-acting, injectable medication regimes.”).

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Appendix A

Appendix B

 

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