深夜福利

This  first appeared on  and is republished here under a Creative Commons license.

During his 20 years in the field of substance use disorders, Eric Morse has seen countless patients forced off their (MAT) 鈥� a treatment that鈥檚 often working 鈥� while incarcerated.

Morse is an addiction psychiatrist in Raleigh and president of , which provides medications for opioid use disorder to approximately 1,800 patients at eight locations across the state. He said it鈥檚 about a weekly occurrence to have a patient get detained and face the dilemma of whether or not they will be able to continue MAT in jail.

Generally, the answer has been no. But the odds of continuation should be increasing now that the U.S. Department of Justice has gotten involved.

People getting MAT receive one of three U.S. Food and Drug Administration-approved medications 鈥� methadone, buprenorphine or naltrexone 鈥� along with counseling to treat opioid use disorder. This treatment option suppresses withdrawal symptoms, reducing drug cravings. MAT is considered for treating opioid use disorder and has been proven clinically effective.

However, the use of MAT in jails across the state is inconsistent at best, . The more common protocol is detoxification and withdrawal.

In North Carolina, at least 19 of the state鈥檚 more than 100 jails have some kind of program providing one or more medications for opioid use disorder, according to the state鈥檚 .

New from the U.S. Department of Justice released in April, paves the way for MAT in jails to be accessible to, at least, individuals receiving the treatment in the community prior to incarceration. The DOJ guidance explains how the (ADA), a federal law that covers all activities of state and local governments regardless of federal funding, protects people with opioid use disorder who are in treatment or recovery from discrimination in a number of settings, including correctional facilities.

鈥淥ur goal here is to ensure that people with opioid use disorders who are in treatment or who have completed treatment are not facing unnecessary and discriminatory barriers to recovery,鈥� said Katherine Armstrong, an assistant U.S. attorney for the Western District of North Carolina, during an on providing MAT in jails.

Morse and others have been advocating for this MAT access and continuity of care for years. It鈥檚 a major shift that puts legal pressure on jails, which have been slow to adopt MAT, to provide medications to continue incarcerated people鈥檚 treatment. If they don鈥檛, they could be open to liability and lawsuits.

鈥淓ventually, you don't have an excuse,鈥� said Shuchin Shukla, a family physician focused on substance use at in Asheville who prescribes buprenorphine.

鈥淟ike you can't say, 鈥業 don't have a MAT program.鈥� That's like saying, 鈥業 just don't have insulin.鈥� You got to get insulin. This person is under your care. That is what a jail does,鈥� he said. 鈥淚t鈥檚 just like providing them with food and water. If you are a jailer and you had someone in your custody, even if they did a terrible crime, you're liable to give them food, water and medicine.

鈥淭his is a medicine 鈥� treatment for substance use disorder.鈥�

Shelly Weizman, project director of the Addiction and Public Policy Initiative at the at Georgetown University Law Center, said the recent guidance makes it 鈥渃rystal clear鈥� that opioid use disorder is considered a disability under the ADA.

According to the guidance, it is a violation of the ADA if a jail does not allow incoming inmates to continue taking medication for opioid use disorder prescribed before their detention or has a blanket policy prohibiting MAT altogether.

Additionally, a blanket policy mandating people be on one specific form of medication, rather than allowing for individualized medical care, is also a violation of the ADA, said Cassie Crawford, an assistant U.S. attorney for the Middle District of North Carolina, during the August webinar.

The DOJ guidance does carve out an exclusion to ADA protections for 鈥渋ndividuals engaged in the current illegal use of drugs.鈥� But Crawford cautioned against jails automatically refusing MAT if someone tests positive for an illegal drug as people are still entitled to medical care under the three-decades-old federal law.

鈥淵ou couldn't prohibit someone from receiving insulin because they tested positive for marijuana at intake in a correctional facility,鈥� Crawford said during the webinar. 鈥淵ou similarly can't deprive someone of legally prescribed medication for opioid use disorder just because a drug test result shows illegal use of a different drug.鈥�

The DOJ has the authority to investigate potential ADA violations if an . The Department of Justice can also initiate its own compliance review to look into an issue if it receives information of a potential violation. Based on the findings, the DOJ does have enforcement authority.

鈥淥ur first priority is trying to work out a settlement or agreement,鈥� Armstrong said, noting that鈥檚 usually what happens. 鈥淚f that fails, and the department finds a violation, we do have enforcement authority to go to court to seek the appropriate relief.鈥�

Information about filing an ADA complaint with the Department of Justice is available .

The DOJ guidance comes on the heels of several lawsuits across the country, including in , , and , where settlements favored plaintiffs continuing their medication for opioid use disorder while incarcerated.

Historically, MAT has been inaccessible to incarcerated individuals, even as federal statistics show of people in U.S. jails and prisons have a substance use disorder.

The past five years have brought increased concern around overdose rates and who鈥檚 most at risk. Weizman said that鈥檚 got more correctional facilities taking an interest in MAT.

that providing medications for opioid use disorder in criminal justice settings decreases opioid use, criminal activity once released and the spread of infectious disease. Studies have also found that overdose death rates following incarceration are lower when inmates have received medications for their addiction. In North Carolina, a study found that formerly incarcerated people are than the average person to die of an opioid overdose within two weeks of release from jail or prison.

Recognizing these benefits, the issued a recommending that jails and prisons take action to provide access to and continuity of medications for opioid use disorder in order to save lives and fight the opioid epidemic.

The is in agreement. The organization released a statement , saying 鈥渏ails are on the front lines of this epidemic, and they are also in a unique position to initiate treatment in a controlled, safe environment.鈥� The has not issued a statement on this topic, but Executive Vice President and General Counsel Eddie Caldwell said that鈥檚 not unusual because the group does not issue positions on various issues.

鈥淚f it's required by law or by federal regulation, then the sheriffs and their jail administrators and the local medical provider that's administering their local medical plan that they're all required to have, I'm sure they're going to follow the law so there's really not any kind of statement that would be appropriate or necessary,鈥� he said.

The intersection between substance use disorders and incarceration has been well documented. Even with that, and with the mounting evidence about the effectiveness of MAT, implementation in jails remains slow, and at the discretion of each county sheriff.

鈥淵ou wouldn鈥檛 stop somebody on hypertension medicine so why would you stop somebody that鈥檚 taking medication for substance use disorder?鈥� asked Elijah Bazemore, who retired as a major from the Durham County Sheriff鈥檚 office last December after more than 30 years and helping in 2019. 鈥淚t鈥檚 still an illness. They would need continued treatment.鈥�

Weizman expects the DOJ guidance will accelerate the pace of MAT implementation in detention centers.

Morse is already starting to see signs of it. After the guidance was released, he had about five counties reverse their medical decisions regarding MAT and reach out to partner with Morse Clinics. Forging such partnerships is the easiest way to bring MAT into a jail.

Morse worked with the jails in Durham and Chatham counties before the DOJ guidance but Alamance, Randolph, Franklin, Vance and Nash counties have also now opened up to MAT in order to be compliant with the ADA, he said.

Willingness to implement MAT in jails is a mixed bag across the state, Bazemore said.

鈥淵ou鈥檝e got some agencies that are going to embrace it,鈥� he said. 鈥淪ome are going to tell you they need more information and can be swayed to go forward.

鈥淭hen you鈥檝e got some that are just simply not going to be supportive.鈥�

Money from the state helps too. State lawmakers to help local jails start or expand their MAT programs. Originally, the specified the funds could be used to provide only one of the three FDA-approved medications for opioid use disorder 鈥� naltrexone 鈥� but the to include access to all three.

After retiring from work at the Durham County Detention Center, Bazemore became a consultant specializing in jail-based opioid use disorder treatment with , a public health organization working with governments to advance local policies and practices. He says it鈥檚 his goal to eradicate the stigma that's attached to substance use disorder to get more jails on board with providing MAT. His job makes him available to provide free support to detention facilities in North Carolina wanting to implement a MAT program.

If there鈥檚 the desire, Bazemore said a jail could have the logistics worked out within six months to comply with the DOJ guidance.

鈥淭he more jails that do it, the more it's going to shine a spotlight on the fact that the other jails are depriving people of this medicine,鈥� said Evan Ashkin, director of the and a MAT provider. 鈥淚 think we're going to cross a tipping point at some level where there's going to be quite a few jails doing it and the ones that aren't are going to really stand out and be vulnerable to criticism, to lawsuits.鈥�

Ben Powell, a physician assistant at , a nonprofit opioid treatment program providing daily dosing of methadone and buprenorphine in the Triangle, said many of their clients are in and out of jail on a regular basis. He said it鈥檚 highly destabilizing for patients to be forced off their medication during incarceration.

鈥淚 can tell you it's rare that someone comes back on the day that they're released,鈥� Powell said. As a result, he said, there鈥檚 鈥渁lmost always a return to use.鈥�

Powell said maintaining stabilized treatment during incarceration is a pivotal shift that will decrease relapses.

鈥淲e're going to decrease the burden on the criminal justice system because it's going to decrease recidivism,鈥� Powell said. 鈥淲e're going to decrease the burden on the healthcare system because we're going to have fewer overdoses. We're going to increase continuity of care to decrease relapses, increase patient satisfaction and keep people from dying.鈥�

The knowledge that MAT will be continued in jail could also lead more people to seek treatment, Ashkin said. In the past, he said fear of painful withdrawal if a patient ends up in jail has deterred them from being willing to even start MAT.

鈥淭he fact that they can stay on their meds even if they wind up in the Orange County Detention Center is enormously positive because they stay on treatment,鈥� he said. 鈥楾hey're not frightened of this withdrawal.鈥�

Correction: The quote from Eddie Caldwell in this story has been updated to reflect that he said 鈥渏ail administrators,鈥� not 鈥渄aily administrators.鈥�

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at .