Local government, jail administrators, correctional officers, and health care professionals play key roles in developing policy and procedures that detect and properly manage substance withdrawal among individuals in jails. By establishing clear guidelines, jail staff can save lives and promote the well-being of adults who are at risk for SUDs and withdrawal.

Withdrawal Management Process

Custody and health care staff are the foundation for an effective withdrawal management process. These individuals should be conducting regular and active observation that begins the moment an individual arrives at the jail. All individuals should be screened for risk of withdrawal, regardless of their length of stay in the jail. Screening helps to identify individuals who:

• need immediate clinical assessment,

• have used alcohol or sedatives recently, regularly, and/or heavily,

• have a history of complicated withdrawal,

• are pregnant and screen positive for alcohol or opioid use.

Should an individual screen positive for withdrawal risk, they then move onto the next stage of the withdrawal management process: the clinical assessment. The initial clinical assessment addresses whether swift action is needed to avoid critical biomedical or psychiatric issues due to withdrawal. The results of the clinical assessment will determine whether an individual’s needs can be addressed and care for within the jail or if they must transfer to a higher level of care.

Different jails have different levels of health care capacity. A larger jail with more staff has greater access to resources than a smaller jail would. In this case, jail administrators must consider whether onsite withdrawal management or external transfer is best for the patient. If onsite withdrawal management is appropriate, the treating clinician will provide specific guidance for ongoing monitoring and care during withdrawal. Custody staff who are trained or qualified health care staff may monitor vital signs and assess withdrawal symptoms. If the jail does not have the capacity to manage the patient safely and effectively during the withdrawal process, the patient should be transferred to a higher level of care.

Screening for Withdrawal Risk

Several factors contribute to withdrawal symptoms and severity, including duration, usage, prior episodes of withdrawal, and the presence of other medical conditions. These conditions will influence the severity of withdrawal, which is why screening is critical for identifying those who are at risk for withdrawal so staff can take the appropriate measures. Screening tools are used to gauge risk for withdrawal and identify those who should be monitored by correctional staff and those who should be referred for immediate clinical assessment. Screening usually includes documenting what type of substance the individual used, routes of use, amount used, frequency and recency of use, and any prior withdrawal history.

Jails that do not have expertise in substance use withdrawal, withdrawal management, or overdose risk should establish relationships with local experts, which may include local public health organizations and state substance use treatment institutions. Jails should have a twenty-four hour, on-call clinical support staff or individual. Jail administrators may consider remote coverage, telehealth services, onsite health care staff, or a combination. Further, while it is not the responsibility of custody staff to diagnose symptoms, they should be trained to identify when a patient appears "unwell" to a lay observer to make an immediate referral to medical staff.

Custody staff may be trained to screen for withdrawal risk and follow the established protocols to ensure patients at risk for withdrawal receive the necessary medical services. If need be, custody staff may be trained to administer withdrawal severity tools, which may include observing and collecting vital signs and coordinating with on-call medical staff when health care staff are not available. Custody staff who conduct screenings or administer withdrawal severity tools should be trained by a qualified health care professional. Any staff that conducts these screenings should be assessed yearly to ensure competence, safety, and reduce liability. The assessments should ensure that staff is able to address misconceptions and stigma surrounding SUD, treatment, and the medications that can be used to treat OUD. Refer to Table 2 to identify what action custody and health care staff should take after a clinical assessment.

Reentry

Reentering the community can be a challenging time for any inmate, especially those facing substance use withdrawal. Reentry plans should be individualized based on the patient’s ongoing need for managing withdrawal, and includes treatment engagement, overdose prevention, and recovery support. These plans should include:

• Assertive referrals

• Sharing health records as authorized by state law

• Establishing insurance coverage

• Provide information on where individuals can follow up in the community upon release to obtain withdrawal management treatment services

• Where possible, provide medication to sustain the individual until their next appointment