When people are released from prison or jail, the weeks and months afterward can be a dangerous time, especially for those addicted to opioids, such as prescription pain pills, heroin or fentanyl. Drug overdose is among the top causes of death when people funnel back into communities with diminished drug tolerance and often little support to help keep them from using again.
That’s why Maryland lawmakers passed a bill in 2019 requiring all local correctional facilities to screen people for opioid use disorder and offer three types of medications to stem cravings and prevent debilitating withdrawal symptoms. Lawmakers sought to address an opioid crisis that has worsened with the rise of fentanyl and during the pandemic.
The first-in-the-nation law required all Maryland jails to have opioid treatment programs in place by January, but fewer than half of the affected local governments — 11 counties and Baltimore City — were fully compliant as of late February, according to the Governor’s Office of Crime Prevention, Youth and Victim Services.
Officials in the remaining 13 counties, including Harford and Frederick, are working with the state to meet the requirements for treatment and counseling, said Joseph Cueto, a spokesman for the state crime prevention office.
The missed deadline has riled some lawmakers, including state Sen. Chris West, a Baltimore County Republican who co-sponsored the measure. He noted that it had broad support in the legislature and the backing of then-Gov. Larry Hogan, a Republican.
“I must admit that I am appalled to learn that this bill, which was carefully negotiated, has simply been ignored,” West said.
West said that local officials need to follow the law or explain to the legislature why they can’t and seek guidance. “I plan to inquire whether any such briefing and inquiry ever occurred in this case,” he said.
Jail administrators and experts say a number of factors have contributed to the delay. They include inadequate funding, a stigma against opioid addiction treatment, staffing issues and strict regulatory hurdles surrounding medications. Also, some local officials have bristled at the state mandate.
Frederick County Sheriff Chuck Jenkins said his jail is working toward meeting the law’s requirements, but said he believes the best way to treat addiction is through the “hard steps of withdrawal” without help from medication — contrary to what research has shown about the effectiveness of medication-assisted treatment, or MAT.
“These people sit down there and pass laws in Annapolis and expect these things to happen in the snap of a finger. It just doesn’t,” said Jenkins, a Republican.
Others, such as Margaret Chippendale, director of Howard County’s corrections department, say they have seen the benefits of medication first-hand: “I believe in MAT, I believe it works. Only time will tell how many people are saved by it.”
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The COVID-19 pandemic has taken a toll on many, with overdose deaths in Maryland hitting record levels at about 2,800 each in 2020 and 2021, though numbers trended down slightly last year. Opioid overdose deaths across Maryland now average about seven a day. That gives urgency to the crisis, said Brendan Saloner, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.
“We have one of the most volatile, unpredictable drug supplies on the streets of cities like Baltimore right now, and we have people in crisis and we’re not helping them,” said Saloner, who serves on a steering committee set up last year to discuss challenges in establishing jail treatment programs.
An estimated seven out of 10 people incarcerated at local detention centers in Maryland are diagnosed with a substance use disorder, according to a 2016 state report.
“People who have been incarcerated are hugely overrepresented in the overdose death numbers in the state, so if we want to get those numbers down as a stated public health priority, we need to focus on helping people who are at the greatest risk of overdose,” Saloner said. “The people who are cycling in and out of jail or prison are one of the main priorities the state needs to keep their focus on.”
Missing the deadline
The 2019 state law requires jails to offer all three medications approved by the Food and Drug Administration for treating opioid addiction — methadone, buprenorphine and naltrexone — along with counseling and peer recovery services. Jails are also required to report data to the state and connect people with medication and other services after release.
The medications work by binding to or blocking opioid receptors in the brain, lessening cravings and withdrawal symptoms like intense stomach and muscle aches and anxiety. This allows patients to focus on work, school and other parts of their life instead of looking for the next high. People who have developed a tolerance to opioids do not experience a euphoric high from medications. For some, the goal may be to wean off medication, a process that can take months or years. Others may stay on medication-assisted treatment indefinitely.
The law set up staggered deadlines for counties, with all supposed to be in compliance by January. According to Cueto, the Maryland jurisdictions that had met the requirements of the law as of late February included Baltimore City and the counties of Allegany, Anne Arundel, Baltimore, Carroll, Charles, Dorchester, Howard, Montgomery, Prince George’s, St. Mary’s and Washington.
Officials in some jurisdictions that have met the requirements acknowledge that their programs are a work in progress. Cueto said the state crime prevention office is in the process of determining compliance by reviewing surveys, data and performance measures. The office will send its next report to the General Assembly in November, he said.
Compliance with the law is a “great starting point,” Saloner said.
“I hope that even those facilities that come into compliance are encouraged and given resources to ensure that medications are available to 100% of the people who meet eligibility requirements,” he said. “I am concerned that methadone in particular will be hard to provide universally if the state does not support more jails to do things like starting people on methadone who come to jail without a history of treatment in the community.”
Harford County Warden Daniel Galbraith said his jail is trying to establish an opioid treatment program by April or May. Galbraith said the county has been working with its contracted medical provider for about a year to begin offering methadone and buprenorphine, but troubles with hiring and funding have contributed to delays, along with setbacks contracting with a doctor to prescribe buprenorphine, which until recently was highly restricted.
Currently, few people can get access to methadone or buprenorphine while in the Harford County Detention Center — not even to maintain ongoing treatment, Galbraith said. Only those who are pregnant can continue treatment medications. A few years ago, the jail began offering naltrexone to people before release to prevent highs and ease cravings for weeks at a time.
Galbraith estimated it would cost $814,000 to start the program, in addition to the jail’s $5 million contract with a provider for mental, medical and dental health care. The contractor has to hire nursing staff, behavioral health counselors and peer recovery specialists, he said.
Funding has been a major challenge for some counties. Harford wasn’t prepared to apply for a $7.5 million round of grants for the programs last year from Maryland’s Opioid Operational Command Center. Sixteen detention facilities received grants ranging from $200,000 to $879,000.
Howard Ashkin, past president of the Maryland Association for the Treatment of Opioid Dependence, questioned whether the state grants provided sufficient funding for 24 jurisdictions, especially as the pandemic drove up labor costs. It’s unclear whether additional funding will be available, said Teresa Heath, deputy director of the Opioid Operational Command Center.
Millions of dollars in legal settlements with drug manufacturers are coming into the state and may be used for treatment programs in jail, she said. States across the country, including Maryland, have sued prescription opioid manufacturers for their role in fueling the opioid epidemic.
The state is also exploring other sources of funding.
In Frederick County, the jail began providing medications recently, but only for individuals who have already been prescribed them, said Jenkins, the sheriff. He expressed frustration at the mandate for complicated, expensive changes.
“We do the best we can to take care of these folks, [but] jail is not the place to deal with these problems. … Unfortunately, this is what happens,” Jenkins said.
Harford County Sheriff Jeff Gahler is among those with misgivings about medication-assisted treatment. He prefers abstinence-based treatment to medications that he believes substitute one addiction for another. Experts at the National Institute on Drug Abuse and elsewhere, however, say that medications do not get people with opioid use disorder high and can be essential to recovery.
“I’m not a supporter of the program, but I’m going to follow the law,” Gahler said.
Medication-assisted treatment for opioid use disorder is at least twice as effective as treatment without medication, research has shown. Medications decrease opioid use, overdose deaths, criminal activity and spread of infectious diseases while increasing social functioning and the likelihood that someone will stay in treatment, according to the National Institute on Drug Abuse.
Such treatment in correctional settings has been proven effective. In 2016, Rhode Island began providing medications in its prison and jail system, resulting in a more than 60% decrease in the number of post-incarceration deaths.
Stigma is “a huge issue” when it comes to medications for opioid use disorder, said Michael Gordon, a senior research scientist at Friends Research Institute, which is overseeing a study of naltrexone and extended-release buprenorphine in Maryland facilities. It’s important to educate and train people, particularly corrections administrators, on the importance of supporting medications for opioid use disorder behind jail and prison walls, he said.
Other correctional administrators have embraced the research and the program, even as they face logistical hurdles, said Ashkin, whose advocacy group represents opioid treatment programs.
Ashkin cited industry-wide problems with attracting and retaining staff, delays created by the pandemic and the web of regulations for buprenorphine and methadone, which are classified as controlled substances. Federal authorities consider methadone, in particular, to have a higher risk of misuse and overdose, and tightly restricts how it is stored and distributed. It’s normally handed out on a daily basis rather than as a prescription to people starting the medication.
However, there have been recent calls from researchers and clinicians to loosen the rules around methadone, which they say are keeping people from accessing needed treatment and disproportionately affect Black and Latino communities.
“I’m going to assume … they’re discovering that it’s far more complicated than they may have thought,” Ashkin said.
‘We’re saving lives, we’re improving the quality of life’
Though the state and some localities have begun collecting data, it’s too early to say if medication-assisted treatment at jails has had a demonstrable effect on recidivism and post-release overdose rates.
Local corrections administrators overseeing established programs reported mostly positive impressions.
“I believe anything we can do to help an offender to kick the habit, so to speak, is a benefit. … We’re saving lives, we’re improving the quality of life,” said Chippendale, of Howard County, who noted that staff members tend not to see people returning to jail if they received treatment services before release.
In Anne Arundel County, officials report all medication-assisted treatment participants have been connected with further treatment upon their release. Officials point to the apparent downward trend in the number of overdose deaths in the county as a sign that the program is working as intended.
“The naloxone training, that’s a piece of it. Education is a piece of it. I think we’re part of the overall solution,” said Christopher Klein, superintendent of detention facilities in Anne Arundel County. Naloxone is a drug that can reverse opioid overdoses.
From a security standpoint, medication-assisted treatment also appears to have other benefits.
“MAT keeps them stabilized,” said Renard Brooks, deputy director for programs and services for the Baltimore County Department of Corrections. “When it comes to misbehaving or acting out on a housing unit, when they get treatment, it’s calmer on that unit.”
However, jail staffers worry about diversion of medication to unintended recipients. In the Allegany County jail, people are monitored to make sure they’re not spitting their pills into pockets or throwing them up later, said Capt. Dan Lasher.
“It has its uphill battles from time to time but [is] still worthwhile,” Lasher said, adding that the jail has seen better results from medication-assisted treatment than just providing counseling for drug treatment.
“Whether it’s considered a crutch or not, we’re seeing better numbers of them at least not using something that’s going to kill them,” he said.
Many jail administrators and sheriffs are still in the process of hiring more peer specialists and counselors, stepping up their re-entry efforts or trying to expand the capacity of their programs, which experts say are too limited to meet the treatment demand.
A string of deaths at the Baltimore City jail complex, some of them overdoses, has raised questions about whether the flow of illicit drugs contributed to the problem.
Dr. Michael Fingerhood, a Johns Hopkins addiction specialist who treats those with substance use disorders at a mobile clinic outside the city jail, said the number of people accessing treatment behind bars seems to be “way below the need.”
“It’s an urgent situation, if people are overdosing in jail,” Fingerhood said. “We would have less of that if we had more treatment.”
A handful of health care workers were staffing the mobile treatment center on a recent Thursday afternoon. It was a cloudy and warm day, and a few people who had just been released from the Baltimore Central Booking and Intake Center walked up.
Standing outside the clinic, Deborah Agus, executive director of the Behavioral Health Leadership Institute, scanned those coming up to the RV unit for familiar faces. The team tries to move patients to brick-and-mortar treatment clinics due to capacity concerns, but those have been filling up too, she said.
Agus’ nonprofit has run the mobile treatment center for nearly six years. She said the new law hasn’t really altered their approach.
“We were already here,” Agus said.
Her next step is to send staff inside the jails to ensure people have a smooth transition to treatment upon release.
Opportunities to reduce barriers
In December, President Joe Biden made it easier for physicians to prescribe buprenorphine by eliminating certain training requirements and removing a cap on how many patients a health care provider could treat, which federal authorities said was meant to curb trafficking of the medication.
That could make a big difference for jails looking to establish opioid treatment programs, said Sachini Bandara, an assistant professor in the mental health department at the Johns Hopkins Bloomberg School of Public Health. The requirements had previously been a major barrier in finding physicians to prescribe buprenorphine.
Another recent development could make an even bigger difference, Bandara said. Earlier this year, the U.S. Centers for Medicare and Medicaid Services approved a request from California allowing Medicaid to pay for certain re-entry services, including medication-assisted treatment, for eligible individuals in state prisons, county jails and youth correctional facilities. Typically, Medicaid is prohibited from paying for most services provided during incarceration.
Now more than a dozen other states are seeking the same permission, and Bandara urged Maryland to join them.
Saloner, the health policy professor, agreed that Maryland should seek the permission, adding that state officials should also ask the U.S. Drug Enforcement Administration for more flexibility with regulations restricting methadone access.
He added, “I think that it takes energetic leadership from the state to try to help each of the jails come into compliance with the law.”