Medication-assisted treatment (MAT), including Federal Drug Administration (FDA)-approved medications buprenorphine, methadone, and naltrexone, and commonly referred to as medications for opioid use disorder (MOUD) when discussing treatment for opioid use disorder, is considered the standard of care and has been demonstrated to improve the in-custody environment and post-release outcomes when provided effectively during incarceration (1,2). However, challenges to providing these medications in jail persist for many agencies. Some of the most pressing issues commonly include medication diversion, insufficient medical and correctional staff, and lack of buy-in from staff, among others. These are daunting challenges that all facilities offering MAT must overcome in order to have a successful program.
We can learn methods of doing so by seeking out and listening to those who have made such improvements and overcome common challenges. In this spirit, we asked the Director of Hudson County Correctional Center in New Jersey, Becky Scott, to share insights into their MAT program. MAT has been available at the Hudson County Correctional Center since 2016. Below is a summary of our communication, with Director Scott answering predetermined questions in writing.
Health as a Priority, not a Mandate
Director Scott’s over-arching message is that jail leaders need to critically analyze the purpose of their facility. Jails are required by law to provide health care to individuals in custody and exist to promote public safety, however, we must examine the systemic factors that impact who end up in custody and align services to best support rehabilitation. “Jails must redefine themselves. The largest barrier resides in what County Corrections is designed to be, in contrast with the needs of those most often inhabiting the jail. Local corrections can accept the needs of the population it serves and redefine itself in a way that addresses the underlying systemic clinical issues, which is the motivation driving behavior,” she says. “Or corrections can continue to provide public safety by segregating an individual for an abbreviated period of time from society and then hope the clinical world will be waiting for the person upon release.”
Buy-in from correctional and county leadership is essential in achieving the former. Once government, custody, and medical leadership buy in and are supportive, the resources needed to implement MAT, including medical staff, training, and outside expertise, are more likely to be provided in the long-term. Correctional staff will carry out the vision of their leadership and, if a program is well run and communication is effective at all levels, you will see the benefits first-hand. In Hudson County, correctional staff have begun to believe in the program after experiencing positive outcomes.
Director Scott further recommends, prior to implementing a MAT program, reading the research and understanding the evidence base behind the treatment, and taking the time to sit with medical staff to understand and address concerns and to foster collaboration and communication.
Preventing and Managing Medication Diversion
The specific strategies used to minimize diversion of buprenorphine and/or methadone will vary depending on the facility, however, there are general steps that can be taken to minimize diversion while achieving a therapeutic versus strictly punitive environment. Diversion can take place prior to, during, and after medication administration. Guardrails should be in place at each step of the process.
Prior to
All staff, including medical and correctional, should receive training on diversion (contraband) risks and the diversion control policies of the facility. Training should provide background information on the risks associated with diversion of controlled substances, the importance of safe handling of medications, how to determine when diversion may be taking place, and what to do about it. Further, patients should be educated that jail staff are effective at catching attempts at diversion to minimize attempts (3).
Access to medication should be restricted to authorized personnel. Strict protocols for handling and storing medications should be implemented. Regular audits and inspections of medication storage areas, administration processes, and documentation are important in identifying irregularities and correcting any processes that are vulnerable to medication diversion.
During
Strict supervision of medication administration by both medical and correctional staff is crucial. Further, says Director Scott, “Surveillance technology, such as video monitoring and electronic medication tracking systems, to oversee medication distribution and administration, and to detect any irregularities or potential diversion activities,” is a useful tool.
The means and relative ease of diversion will vary depending on the formulation of MAT in use. Patients may “cheek” oral formulations, e.g., film or tablets. We should be clear that the role and responsibility of a nurse conducting mouth checks is different from that of the officer. The role of the nurse is to ensure patient safety and effectiveness of treatment. As such, discovery of cheeking should result in a clinical intervention and never a disciplinary one. Even sharing of the information with the medication officer would be a breach of patient confidentiality. Further, medical staff becoming involved in discipline erodes patient trust and confidence in health care staff, which is a disservice to the patient and the facility. Patients may be directed to sit on their hands and drink water before and after medication administration. In many facilities, it is standard for the dosing of methadone and buprenorphine to be done separately from other medications.
An adequate staff-to-patient ratio for supervision of medication administration is necessary to catch attempted diversion (3).
After
It is crucial to cultivate a culture where custody staff feel comfortable, are encouraged, and have a clear protocol for reporting and investigating suspected medication diversion. Routine searches of housing units, monitoring of phone calls for mention of diversion or substance use, and urine testing results are recommended (3).
Despite these efforts, medication diversion may occur or be attempted. Often, we hear that a patient should be punished and discontinued on MAT if they are caught diverting medication. This may not always be the most effective solution. Instead, Director Scott recommends that a combination of investigative, disciplinary, and supportive measures is used.
First, the extent of diversion should be investigated. Policies and procedures should be in place to gather evidence and to determine the extent of the diversion. Efforts should be made to determine the reason for diverting medications. Depending on the reason, for example, coercion or euphoria, the response should be tailored (3).
Not losing sight of substance use as a chronic, relapsing mental illness is important; addressing underlying mental health issues, substance use, or unmet health care needs may be crucial to reducing diversion. Mental health staff should be involved in the response to provide support to, and an assessment of, the individual, ensuring that appropriate care is provided. If discipline is deemed appropriate, loss of privileges and other sanctions may be considered, as opposed to medication discontinuation. Adjustment of dosage or discontinuation of medication should never be a custody decision. Medications should only be adjusted or stopped on the order of a prescriber and only with documented clinical justification.
Partnerships
Partnerships are crucial. Jails are not designed to be health care facilities yet serve the same purpose in many ways. Director Scott says, “MAT is not a magic wand; it is a tool.” While medication alone has been demonstrated to be effective in reducing overdose deaths postrelease1,4, Hudson County has found that MAT is most successful when ancillary behavioral health and support services are also provided and utilized by patients. This includes substance use treatment from a state-certified treatment provider operating in the jail.
Jail leadership places a high value on re-entry services, understanding the vulnerability that those released from jail often experience. This includes utilizing County-provided services and partnerships through the County Welfare Agency to ensure that individuals released from the jail do not experience a disruption in health care and have access to systems of support, including housing. Additionally, a Medicaid application is completed prior to release through an outreach manager who visits the jail and meets with individuals to assess their needs.
Positive outcomes
A MAT program is complex and requires a number of intersecting components, including dedicated leadership, trained staff, effective policies and procedures, open communication, and continuous quality improvement, among others, in order to be successful. When challenges emerge, and they likely will, it’s imperative to look at the program and identify areas of improvement and then systematically work across disciplines to implement corrective action. Only through this process will the most profound positive impacts materialize.
Director Scott says, “MAT programs can foster a more positive and cooperative relationship between custody staff and incarcerated individuals, as the provision of evidence-based health care services demonstrates a commitment to addressing the health needs of the population under custody.” Other positive outcomes cited include improved behavioral and mental health stability, reduced substance use
and withdrawal symptoms, improved compliance with medical protocols, and potentially a reduction in recidivism. She says, “It’s important to note that the successful implementation of a MAT program in correctional facilities often requires a comprehensive approach that includes proper training for staff, access to quality health care services, on-going monitoring and evaluation, and collaboration between health care providers, correctional staff, and external stakeholders.”
By emphasizing the human aspect of substance use and treating the disease during incarceration, we can improve safety in our facilities and, by extension, our communities.
Thank you to Director Scott for her invaluable insights and for taking the time to provide her input.
_______________________________________
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 work on improving access to 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.
Fred Meyer, MA, CJM, CCHP has 27 years of experience working in county jails. Starting in an Illinois jail in 1996 then moving to Las Vegas in 1999, he has professional knowledge in all areas of safety, security, management, and leadership. In 2018, Fred was appointed as deputy chief with the Las Vegas Metropolitan Police Department (LVMPD) where he was responsible for the largest jail operation in the state of Nevada. Fred retired from the LVMPD in 2022 and currently leads the consulting arm of the National Commission on Correctional Health Care. He is an instructor and graduate of the National Jail Leadership Command Academy, graduate of the Jail Executive Development Program, is a Certified Jail Manager, and sits on the AJA Board of Directors in the role of Parliamentarian. For more information, he can be contacted at fredmeyer@ncchcresources.org.
Sources:
1. Martin, Rosemarie A., Alexander-Scott, N., Berk, J., Carpenter, R.W., Kang, A., Hoadley, A., Kaplowitz, E., Hurley, L., Rich, J.D., Clarke, J.G. (2022). Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study. The Lancet Regional Health—Americas, Volume 18, 100419. https://doi.org/10.1016/j.lana.2022.100419
2. Brinkley-Rubinstein, L., Peterson, M., Clarke, J., Macmadu, A., Truong, A., Pognon, K., Parker, M., Marshall, B.D.L., Green, T., Martin, R., Stein, L., Rich, J.D. (2019). The benefits and implementation challenges of the first state-wide comprehensive medication for addictions program in a unified jail and prison setting. Drug and Alcohol Dependence, Volume 205, 107514. https://doi.org/10.1016/j.drugalcdep.2019.06.016
3. Evans, E.A., Pivovarova, E., Stopka, T.J., Santelices, C., Ferguson, W.J., Friedmann, P.D. (2022). Uncommon and preventable: Perceptions of diversion of medication for opioid use disorder in jail. Journal of Substance Use and Addiction Treatment, Volume 138, 108746. https://doi.org/10.1016/j.jsat.2022.108746
4. Lim, S., Cherian, T., Katyal, M., Goldfeld, K. S., McDonald, R., Wiewel, E., Khan, M., Krawczyk, N., Braunstein, S., Murphy, S. M., Jalali, A., Jeng, P. J., MacDonald, R., & Lee, J. D. (2023). Association between jail-based methadone or buprenorphine treatment for opioid use disorder and overdose mortality after release from New York City jails 2011-17. Addiction, 118(3), 459–467. https://doi.org/10.1111/add.16071