Program Component 1: Leadership and Staff Buy-In

The first essential component of a MAT program is buy-in from both leadership and facility, medical, and custody staff. The program will not be successful without support and funding from leadership or the commitment of day-to-day facility staff who are on the front lines ensuring that the program is well-run, medication is administered in a timely and appropriate way, and efforts to minimize medication diversion and misuse are consistent. As we mentioned in Part I, individuals with opioid use disorder are disproportionately represented in U.S. jails and prisons relative to the general population. Given that our facilities are on the front lines of the opioid epidemic, it makes sense that we have full access to all the tools available to help resolve this public health crisis. MAT is one of these tools and can lead to safer and healthier individuals and communities.

Prior to implementing a MAT program, a team should be assembled that includes medical and custody staff and facility leadership. Funding can be procured through various means, including legislation and state budget advocacy, government or private grants, and settlement funds resulting from legal action against pharmaceutical companies, funding must be pursued aggressively in the long term to ensure program sustainability. It is important to assess the resources available to the facility, including access to licensed providers who have the clinical expertise to run such a program, and the goals of the program, including how long treatment will be offered if continuing medication for those on medication in the community and whether the program will include medication induction for those who are screened and subsequently assessed to have an opioid use disorder (OUD) but who are not on medication in the community. Through independent research and conversations with agency representatives during planning, ensure that all applicable federal and state laws and regulations are followed.

Program Component 2: Community Partnerships

Medication-assisted treatment includes the use of Federal Drug Administration-approved medications methadone, buprenorphine, and naltrexone. Any licensed provider can prescribe naltrexone, and, in December 2022, President Biden signed the Mainstreaming Addiction Treatment (MAT) Act, which removes current restrictions around who can prescribe buprenorphine. Methadone, however, is subject to strict federal regulations and can only be dispensed by a Substance Abuse and Mental Health Services Administration (SAMHSA)-certified opioid treatment program (OTP).

This is where education is essential. It is crucial that experts are engaged to provide facility staff with information about the causes of opioid use disorder, the impact of opioid use on the brain, evidence of the effectiveness of MAT, and how social and economic circumstances and mental health issues can lead to adverse health outcomes, drug use, and involvement in the criminal justice system and also influence recovery.

After the policies and procedures are reviewed and approved by the appropriate individuals, both health and custody staff will need to receive training on the content. This can be conducted internally or concurrently with a larger educational session about OUD and MAT from outside experts. Interactive learning with multiple teaching methods (e.g., open discussion, lecture, and role playing) will enhance content retention and audience attention. Participants should take a pre- and post-training quiz to measure the effectiveness of the session and evaluate the need for further training.

Program Component 5: Implementation

Once the program processes have been determined, resources designated, and custody and medical staff trained on medication-assisted treatment, the real work begins. Historically, detention and correctional facilities have been somewhat isolated and resistant to change. As operations have evolved to direct management of inmates, the necessary knowledge, skills, and abilities of correctional staff increased dramatically. Today’s jail professionals are required to wear many hats, none more important than ensuring the life and safety of everyone they work with and those they are required to supervise.

There will initially be some staff resistance to a MAT program, as it’s different from what has always been done. There is a security risk associated with all medications in a jail environment, and this new process will potentially introduce additional opportunities for contraband. With proper custody and health staff training and effective policies and supervision, however, those risks are mitigated. The sanctity of life is an important concept, and effective MAT programs reduce the frequency of detoxification-related crises.

For medical personnel, strategies to minimize medication misuse and diversion include ensuring adequate staffing-to-patient ratios to allow for the appropriate time for and supervision of medication administration; continuous communication and regular meetings between all individuals who are involved in the program, including between custody and health staff; and randomized drug testing processes. MAT programs should be evaluated through continuous quality improvement (CQI) studies. Focus should be given to metrics that have most value for key stakeholders and may include collecting data about processes to understand how well the program is being delivered and/or outcome data that will provide information about the impact of the program.

Custody staff, supervision, and administration are key to the safe, secure, and effective implementation of any MAT program. Officers escorting nurses must ensure the medication provided is ingested and not misdirected or secreted in some way. This is especially important when methadone is being administered by a nurse in an opioid treatment program regimen. The officer and nurse must both be vigilant to ensure the medication is ingested properly. Safety and security-minded teamwork is critical to success and needs to be the focus every single time, with every individual receiving medication. Security over convenience, always.

NCCHC Opioid Treatment Program (OTP) Accreditation

Under federal law, correctional facilities looking to become a corrections-based OTP must first be accredited by a federally approved body, such as NCCHC, which has been granted accrediting authority by SAMHSA. Then, it must obtain certification from SAMHSA. The NCCHC Standards for Opioid Treatment Programs in Correctional Facilities are the foundation of OTP accreditation and the best place to begin when seeking to become a federally certified corrections-based OTP.

When preparing for accreditation, common challenges that may occur and should be proactively addressed include:

• Ineffective coordination/collaboration among correctional, health care services vendor, and/or community-based partners

• Difficulty navigating federal and state regulatory requirements

• A less than full comprehension and understanding of accreditation standards

• Insufficient documentation to support consistent compliance with accreditation standards

• Ensuring that the MAT program is an integral part of administrative/staff meetings, CQI, health record reviews, and training

It is best to apply for accreditation with at least nine months of program treatment history to show consistent compliance with the Standards. Further, it may be helpful to conduct a mock pre-accreditation review based on the standards.

Although a jail-based MAT program is a big undertaking, the work that you are doing to help an extremely vulnerable population is commendable and will make a difference in our society. It will take years-long dedication from private organizations, nonprofits, and