Jail-Based Medication-Assisted Treatment (MAT):
Keys to Successful Implementation
Fred Meyer, MA, CJM, CCHP, and Claire Wolfe, MPH, MA, CCHP
Over the past year, we have connected with facilities across the country in an effort to understand the unique challenges and benefits of jail-based medication-assisted treatment (MAT) programs. This article explores the keys to successful implementation and is informed by our experiences, as well as lessons learned from both county and state agencies. While each facility is unique, learning from the experiences of others and connecting with those who have overcome implementation barriers are important tools to assist in the creation of a successful MAT program. The following topics came up frequently in our site visits and conversations. It’s our hope they will be useful in your efforts to move forward and create an efficient and effective MAT program in your jail.
Institutional Culture
Our nation’s jails are some of the most individually and societally impactful portions of the criminal justice system. Each part of the cycle of arrest, incarceration, and return to the community involves some portion of your jail operation. The intersection between corrections and substance use disorders, generally, but opioid use disorder, more specifically, is large1. The high disease burden among incarcerated populations requires public health intervention to avoid further diminishment of health during incarceration or more dire outcomes such as death, both during incarceration and post-release3. In jail operations we have worked with, this is one critical area that implementing MAT addresses directly.
Correctional culture, to include correctional medicine, is often insular and resistant to change. Security is of utmost importance and adding any new form of treatment may be met with skepticism and doubt. Some health and custody staff may initially resist a MAT program because it is different from what has traditionally occurred in most jail environments. There may be questions related to the introduction of contraband, the reasoning behind offering MAT, and additional workloads for staff. This is where custody, health leadership, and communication come into play. They are both critical to success.
We have encountered multiple custody administrators and medical directors who have not worked with or been exposed to MAT in a jail environment. Some medical leadership personnel reported that they preferred to “detox” all incoming individuals and some jail administrators agreed, suggesting the current process was working well. Through meetings and discussions about improving health care and security, the concerns and resistance to change are overcome and operations can be improved.
A MAT program must be well-run to ensure that those who need treatment receive it in an evidence-based and clinically informed way, to minimize diversion, and to provide resources for incarcerated individuals when they are released. For this to happen, individuals in leadership positions must first champion the provision of MAT. This includes custody and medical leadership, to include the agency chief executive who has the power to pursue and ensure ongoing funding, enact the policies and procedures to support the program, and to drive institutional and culture change.
Breaking Down Barriers
There may be concerns expressed regarding the introduction of new medication into any correctional environment, especially when that medication has the potential for abuse. When an individual does not ingest prescribed medication but uses it for another purpose, or provides it to another, it is referred to as medication diversion. This is a challenge you will face, and it is typically overcome by training and appropriate oversight of medication delivery by health and custody staff. Supervisory audits of the process on a regular basis will help ensure we “inspect what we expect” and keep the facility secure. Institutions that have active MAT programs actively manage this concern with success.
During familiarization training related to MAT, questions may arise from health and custody staff about additional work and time needed to ensure safety and security. It is true that focusing on security can take time, but security over convenience is a concept that is hard to refute. When strict oversight is employed during medication pass, the benefits of MAT far outweigh any additional time demands required to ensure the medication cannot be used as contraband.
Medical leadership, to include physicians, may have no experience with MAT and some may initially oppose changes to the current process of “detox,” or withdrawal, only in the jail. They may also be concerned about an additional workload on them and other medical staff. Once the benefits are identified and communicated (e.g., reduced morbidity and mortality, helpful for those with co-occurring mental illnesses, and may reduce criminal recidivism) perceptions change. When consulting with industry experts and other jail administrators currently utilizing MAT, the new standard of care will eventually be accepted and adopted. This requires strong leadership from medical and custody.
In our travels, we have encountered agencies that have found it helpful to initiate MAT by continuing those on active treatment that are arrested and brought into the jail. Once the initial screening process is effective in identifying those in need and those already on active treatment, it is a simple step to introduce MAT medications. Add in mental health resources and community providers and the positive impacts snowball, improving jail operations in the process, and resulting in improved care and outcomes.
With the support of leadership, custody and health staff should be provided with tools to develop their own support and understanding of MAT. To garner buy-in and support, successful strategies include providing training on MAT to existing custody and health staff and to new employees and hosting sessions between staff, leadership, and the facility’s medical provider or opioid treatment program (OTP) partner where concerns and questions can be heard and addressed. Safety and security must always be the number-one priority, and this culture of openness is crucial, as is having buy-in from individuals who will be working directly with and adjacent to the MAT program. We recommend a proactive approach to garnering buy-in and quelling concerns right from the start.
It is important to maintain the sustainability of the program year-over-year, further underscoring the need for leadership support and a champion of the program. Legislative and policymaker support can ease funding burdens that facilities will face in providing MAT. However, grant funding may also be available to your facility. Funding is needed not only for the medications, but for adequate staffing and discharge planning. Your facility may benefit from dedicated MAT coordinators and a discharge planner.
If securing funding is proving to be difficult, a pilot program using a targeted population can be conducted. An evaluation of the pilot that details specific outcomes can be used as evidence of effectiveness to secure additional funding and support.
Jail Benefits
As a result of the improved care associated with an effective MAT program, jail staff and inmates benefit in several ways. First, by providing an increased standard of care, the risk of adverse medical events in the jail environment decreases. It is likely you will see fewer emergency transports and potentially fewer deaths. With fewer individuals actively going through detoxification, you may see fewer disciplinary issues, fights, and attacks on staff. These harm reductions may also result in fewer injuries and complications for custody and medical staff. All of this may also result in fewer budgetary expenditures.
While individuals should not have to become incarcerated to receive adequate treatment for opioid use disorder, this is an area where we can lead change. Time served in jail can provide an opportunity for stabilization and treatment while the individual is segregated from the community. This requires that the facility and those working within it recognize the operation as a key component of justice and health care, providing a service to individuals with physical, mental, and behavioral health issues. When an individual is released, the jail can facilitate continuity of care and a continuation of treatment in the community.
Building Partnerships and Reentry
Federal guidelines dictate that methadone can only be administered by an accredited and Substance Abuse and Mental Health Services Administration-certified (SAMHSA) OTP. Further, continuity of care upon release is necessary to maximize the effectiveness of MAT provided during incarceration. These two factors, among others, make partnerships with community organizations extremely beneficial, and often essential, for correctional facilities. Community partners come with a wealth of expertise and, working together with jail staff, can help to provide a high standard of care to patients in ways that a correctional facility may lack the resources to provide alone.
If an area has a shortage of OTPs, as is common in rural areas4, community-based providers who are willing to prescribe buprenorphine to incarcerated individuals with OUD can also be excellent partners. Recent changes to buprenorphine prescribing regulations may enhance this resource in the community in the future5,6. While such restrictions undoubtedly exist, efforts should be made to ensure that access to all three medications used for MAT is provided to allow patient preference and provider expertise to guide care. If lack of community providers is a problem, your facility may want to explore becoming an OTP. The National Commission on Correctional Health Care (NCCHC) accredits correctional facilities looking to become an OTP and can provide more information on this process.
One of the most important and potentially challenging aspects of providing MAT is ensuring individuals have continuity of care following release. It is important that they have access to medication and care in the same capacity that they did during incarceration. Discharge planning must begin at intake given the often unpredictable nature of release from the facility. Having an established relationship with a community-based OTP can help ease this transition and allow for continuity of care with the same provider and organization that the patient experienced during incarceration.
As the MAT program matures, there are tremendous opportunities to add educational and psychosocial programming, as well as reintegration support with social necessities such as housing. Partnerships with organizations in the community can facilitate this and support meaningful change for individuals following release. Jails are pieces of a larger disjointed health care and social services network. Jail staff can provide information and referrals to the community care network, likely having achieved a better understanding of patients than in the community, so that the system is informed enough to provide adequate rehabilitative support following release.
Program Evaluation
Success will often lead to more support and approval of the program. We have heard that, over time, the environmental benefits to staff of having a MAT program, including fewer fights, a culture more aligned with healing, and less contraband, become clear and lead to support even from some of the most ardent detractors. The NCCHC Standards for Health Services in Jails require at least one continuous quality improvement (CQI) study annually. CQI studies that analyze metrics on screening for the MAT program, program participation, and continuity of care processes and outcomes are helpful in measuring the impact of the program and identifying areas of improvement. Consistent monitoring through an external partner may be a useful option given limited staff resources. Listening to the lived experiences of staff also provides important feedback on the program. As mentioned above, the implementation of MAT programs can lead to a more therapeutic and healing environment overall, where the facility is generally perceived as a more enjoyable place to work. Feedback on such factors is important to collect and report.
While implementing a MAT program comes with challenges, one that is well-run will have a significant impact on patients while minimizing security risks. Overall, the top advice we received includes: find a champion, secure funding, provide education to staff, meet with staff to enlist buy-in, and embrace time served in jail as a unique opportunity for stabilization for patients.
There is nothing more important than life, safety, and security in any jail operation. Effective MAT programs have the potential to improve health care for the individual, reduce risk of violence and disorder inside the jail, and make the environment safer for everyone.
Our final article in this series will focus specifically on discharge planning and continuity of care.
Thank you to Frank Mazza, Lauranne Howard, and all others who contributed for your invaluable input.
Fred W. Meyer, MA, CJM, CCHP, is managing director of NCCHC Resources, Inc., the consulting arm of the National Commission on Correctional Health Care. A retired deputy chief, he has more than 25 years of experience in corrections and is a graduate of the National Jail Leadership Command Academy and Jail Executive Development Program. He holds a master’s degree in criminal justice from the University of Nevada, Las Vegas. He can be reached at fredmeyer@ncchcresources.org
Claire Wolfe, MPH, MA, CCHP, is a program manager at NCCHC Resources, Inc. She holds a Master of Public Health in Epidemiology and has focused her research on opioid use disorder treatment in jails. Previously, she worked for the philanthropic arm of a multi-national IT consulting company and as the chief of staff for a New Jersey State Assemblyman. She can be reached at clairewolfe@ncchcresources.org.
References
1. Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings. Substance Abuse and Mental Health Services Administration. (2019). Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Retrieved February 21, 2023, from https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matusecjs.pdf
2. Bronson, J., Stroop, J., Zimmer S., Berzofsky M. (2017). Drug Use, Dependence, and Abuse Among State Prisoners and Jail Confined Persons, 2007–2009. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Retrieved February 21, 2023, from https://bjs.ojp.gov/content/pub/pdf/dudaspji0709.pdf
3. Ranapurwala, S. I., Shanahan, M. E., Alexandridis, A. A., Proescholdbell, S. K., Naumann, R. B., Edwards, D., Jr, & Marshall, S. W. (2018). Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015. American journal of public health, 108(9), 1207–1213. https://doi.org/10.2105/AJPH.2018.304514
4. Havens, J. R., Walsh, S. L., Korthuis, P. T., & Fiellin, D. A. (2018). Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment. Current HIV/AIDS reports, 15(4), 315–323. https://doi.org/10.1007/s11904-018-0402-3
5. Rosenblatt, R. A., Andrilla, C. H., Catlin, M., & Larson, E. H. (2015). Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Annals of family medicine, 13(1), 23–26. https://doi.org/10.1370/afm.1735
6. Removal of DATA Waiver (X-Waiver) Requirement. (2023, March 29). Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement