Many NC jails violate legal requirements by skipping meds for opioid use disorder
By Rachel Crumpler
For almost six years, R struggled with addiction. He said he tried to quit using opioids and benzodiazepines more than 50 times — mostly “cold turkey” — but it never worked.
In 2020, he got arrested. When he got out of jail on bond a few days later, R said he knew he needed to do something different so his life wouldn’t be cycling in and out of jail.
That change came on March 14, 2020, when he started taking Suboxone. The medication containing buprenorphine and naloxone is one of the most effective known treatments for opioid use disorder.
“I gave it a shot, and it worked,” R said. “Ever since I started taking Suboxone, I haven’t craved. I haven’t slipped up. I haven’t gone back or thought I want to do drugs again. I think I’m past that.”
Medication that cuts opioid craving is often part of the rehabilitation process of people seeking recovery from substance use disorders. Photo credit: Liora Engel-Smith
R said taking Suboxone helped him “get a grip” on his life. He went back to school. He got a job.
R typifies how treatment for opioid use disorder that includes one of three U.S. Food and Drug Administration-approved medications (buprenorphine, methadone and naltrexone) — paired with counseling — is considered best practice. The medications suppress withdrawal symptoms, reduce drug cravings and decrease the risk of overdose death.
But in August 2023, R needed to return to jail to serve a total of 30 days for the 2020 offense. While there, he was forced to go off his medication after taking it for more than three and a half years. That’s because jail staff said they would not administer his prescription in the facility.
As a result, R went into withdrawal while serving his first seven days in jail. R said he sweated profusely. He felt nauseous and in constant pain. He was restless and anxious.
“It just got worse every day,” R said. “After like four or five days I actually called the nurse and I was like, ‘Hey, I can’t do this.’ I need something.’ They offered me a Tylenol, and I had to pay like $20 to see the nurse to get the Tylenol.”
His experience of being forced off his medications for opioid use disorder shouldn’t have happened. Jails have a legal responsibility to provide those medications because people with opioid use disorder are protected under the Americans with Disabilities Act. Guidance from the U.S. Department of Justice issued in April 2022 states that it is a violation of the ADA if correctional facilities do not continue an individual on the medications to treat their addiction that they were receiving in the community before incarceration.
The DOJ has the authority to investigate potential ADA violations if an individual files a complaint, and it can also initiate its own compliance review if it receives information about a potential violation. Based on the findings, the DOJ does have enforcement authority.
NC Health News is withholding R’s full name and the name of the central North Carolina jail that denied him his medication because he still has days left to serve on his sentence and does not want to risk retaliation.
R said he even went to the jail with an informational pamphlet on the legal requirements, but jail staff, including a nurse, dismissed it and told him he would just have to deal with the withdrawal.
It was not the response he expected. He thought he would be able to continue taking his medications while serving his time — just as people are continued on insulin and heart medication while in custody.
Many North Carolina jails have yet to meet these legal requirements. Only about one-third of 92 jails provide medications for opioid use disorder in their facilities, according to a report released last month by Disability Rights North Carolina.
Detoxification and withdrawal like R experienced are the most common outcomes for people with opioid use disorder when they enter jails. Slowly, though, more detention centers in the state are starting to provide medications for opioid use disorder — not just because it’s best practice, but because it’s now a legal imperative.
Didn’t have to be withdrawal
If R had been at one of the 34 local jails across the state that Disability Rights NC found were continuing people on medications while in custody, his experience serving his sentence could have gone much differently.
After that experience of withdrawal, R still had more days to serve to complete his 30-day sentence. But he knew he could not endure going through withdrawal again — or the disruption to his treatment.
For years, he had been doing well on the medication and built routines. R said going home after that seven-day stint felt like “starting over.” He said he had to build back up to his proper dosage at the clinic where he was getting substance use treatment.
R worked with his probation officer. He has served the rest of his sentence in 24-hour stints in jail so he does not have to go off his medications again. He said he’s glad about that, but this means completing his sentence is slow going.
“It’s holding me back,” R said. “I’ve been trying to get another job, and I can’t because I have to be free once a week to go. And it’s really hard to work that out with employers.”
R expects to complete his sentence this summer. He said he would have preferred to serve longer stints of time if he could have continued his meds.
“I got unlucky because of where I live,” R said. “If I lived like a county over, I could have been fine. You would think everybody follows the same rule.”
Building momentum
For many years, medical providers and others have been advocating that medications for opioid use disorder be accessible to incarcerated people, in particular because people with addiction are overrepresented in the state and nation’s criminal justice system. It’s estimated that 15 percent of the 1.8 million people incarcerated in the U.S. have an opioid use disorder.
Studies show that providing these medications in correctional settings decreases opioid use, criminal activity after release and the spread of infectious disease. Studies have also found that overdose death rates after incarceration are lower when people receive medications for their addiction in custody. That’s a good thing because a study in North Carolina found that formerly incarcerated people are 40 times more likely than the average person to die of an opioid overdose within two weeks of release from jail or prison.
Recognizing these benefits, the National Commission on Correctional Health Care and the National Sheriffs’ Association recommend that jails provide access to and continuity of medications for opioid use disorder — to save lives and fight the opioid epidemic.
The North Carolina Sheriffs’ Association has not issued a statement on the subject, but Executive Vice President and General Counsel Eddie Caldwell said the group does not issue positions on various issues.
“Each sheriff works with their local community health folks, as well as whoever provides medical care in their jail, to determine what medical care is appropriate in what circumstances for what type of inmate,” Caldwell said. “That is done on an individual county-by-county basis, and the association has no role in that. We don’t advise sheriffs, one way or the other, on that.”
Even with mounting evidence about the effectiveness of the medications, implementation in jails has moved slowly and at the discretion of each county sheriff.
But in the past two years, there’s been more movement.
In 2022, NC Health News reported that 19 of the state’s county jails had some kind of program providing one or more medications for opioid use disorder. Now, that number has grown, according to Disability Rights’ assessment, with about 37 percent of jails in the state providing the medication.
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