County Jails Struggle With A New Role As America's Prime Centers For Opioid Detox06:09

With his sleepy eyes and loose-fitting clothes, Chavez looks younger than his 23 years – a little like a teenager in baggy pajamas. But the bright hunter-orange of everything he's wearing, down to the plastic Crocs, all signify he's in the San Mateo County jail's infirmary in Redwood City, Calif., where he gets his regular dose of methadone.

Still, Chavez is one of the lucky ones here. Because he was in a local methadone program before he got arrested — again — he has been allowed to keep using that synthetic opioid substitute in jail. Methadone and a couple other drugs help jailed opioid users like Chavez temper cravings and, in theory, stay off more powerful and destructive opioids.

"It's all about if you want to get clean or not, you know," Chavez says. "The methadone is just there to help, you know. I mean, you've got to dedicate to the methadone. Because you got to start somewhere."

With the methadone treatment he says, "I just feel more normal — like a normal person."

Jail as an "opportunity to intervene"

Doctors who treat people in jails say a challenge — and an opportunity — in expanding the use of methadone or another medical treatment is that it's not clear, at first at least, how big a role opioid addiction is playing in an inmate's troubles; their drug use is often intertwined with mental health problems.

"The opiate part of the problem is usually not part of the charging documents, so it's hard to tell," says Dr. Robert Spencer, San Mateo County's correctional health medical director. Addiction, mental health and crime "are so intimately connected," Spencer says. "It's often a form of self-medication, an attempt by them to modify their symptoms. This gives us an opportunity to provide an intervention and a possible way forward."

More research is needed to confirm the long-term benefits of treating addiction in jail, addiction specialists say. But, so far, studies have shown that medication-assisted treatment works well in reducing fatal overdoses, relapse and in reducing the spread of infectious diseases, such as HIV.

Still, this kind of medication-based approach is relatively new in San Mateo — as it is for many jails across the country. For nearly a quarter century, San Mateo's flagship addiction treatment program has been an abstinence-based approach called Choices. So far, only a dozen or so of the jails' roughly 1,000 inmates are undergoing some sort of medication-assisted treatment.

Correctional health director Morales wants to expand those numbers. But he has lingering worries about costs, effectiveness and safety. He says inmates can hoard — and then sell, trade or abuse — some of the opioid treatment drugs, which are among the most top contraband items in jails today.

In addition, prison reforms in California to reduce overcrowding and reclassify some sentences has resulted in county jails housing more inmates for longer periods.

That, Morales says, has increased a kind of recidivist merry-go-round: a growing number of inmates with multiple bookings and short jail stays; people who aren't getting the treatment they often need.

"I don't think our script is good yet," he says. "We don't explain it well [to inmates], and we have to get better at advocating that someone use medicated-assisted treatment — and to get the protocol right, so that it's not isolated folks that are doing it."

Jails need to build the momentum of routine treatment by getting staff and inmates who have been helped talking about the success of this approach, he says. "And frankly, we're not scaled up enough. Those are the challenges that we're facing."

It's a similar story nationally, where the number of jails offering medication for inmates who are addicted is small.

Only 10% to 12% of the nation's 4,000 jails are trying some form of addiction medication as part of treatment.

"Although this number is not the majority of jails, five years ago it was zero," says Klein. "And the number is increasing every week."

Some are offering access to the opioid substitute drugs buprenorphine and methadone, which can help opioid users detox and then temper cravings. Long term, in theory, those drugs can help people who have become addicted to opioids stay off of destructive and potentially deadly street versions.

But the majority of jail-based medication-assisted treatment programs today are limited to injectable naltrexone, given upon an inmate's release.

Also known by its brand name Vivitrol, naltrexone is an injectable drug that could trigger withdrawal symptoms in someone who is physically dependent on opioids; but it also blocks the brain's receptors for opioids and alcohol for 28 days.

Inmates who have been addicted to opioids are at far greater risk for overdose upon release, as their tolerance for street drugs is often greatly reduced after a stint of abstinence. Suddenly, a dose that got them high in the old days could now be fatal.

Liability concerns and the need to improve withdrawal management are also driving the increase in medication-assisted treatment. About 80%

. of all detoxification for drugs and alcohol happen in jails and prisons. And nationally, in the last 10 years, counties and states have paid out well over $70 million for addiction withdrawal-related deaths of inmates, according to a tally by Klein. More than 50 similar lawsuits are still pending.

Klein says the challenge is far broader than jails for a public health system that has yet to catch up to the opioid crisis. "MAT is totally underutilized in the community, much less in jails," he says.

The problem is particularly hard for jails in more rural and semi-rural counties, which often have limited access to medications, to physicians who will administer it, and to follow-up programs that inmates can tap into upon release.

To provide methadone, for example, a jail has to either be certified as a methadone clinic or partner with a community clinic.

"Even if [rural jails] wanted to provide medication-assisted treatment within the jails, there may not be a methadone clinic for 60 miles," says Carrie Hill, director of the National Sheriffs' Association's center for jail operations. "It's a huge issue."

Or a county may not have a doctor with the necessary licenses to provide treatment medications, Hill says.

Most rural areas "don't have a single doctor who is certified to even prescribe buprenorphine," says Klein. "So it's very difficult for a jail to even find a doctor who can prescribe it to an inmate who may need it. Most rural and suburban counties in this country don't have any methadone clinics they can rely on."

Hill says the sheriffs in her group are working on ways to expand treatment and recovery support services to rural areas, including city-rural treatment partnerships; additional funding to greatly expand telemedicine and broadband services; and mobile anti-opioid addiction units that could deliver treatment drugs to hard-to-reach jails.

The group is in conversation with its federal partners to get the necessary medical waivers to do that.

Advocates for expanding MAT say the medications are saving lives. "In jail, [when] we have somebody stabilized — off street drugs — they can begin to calm down and [we can] find out if we can help them with medication," Klein says. "What a tragedy if we miss that moment."

The legislature in Massachusetts, with Koutoujian's encouragement, has given the green light for a seven-county pilot program of the best evidence-based opioid treatment in jails. Starting this August, the jails will offer all forms of medication-assisted treatment and carefully track data on efficacy — including rates of drug relapse, overdose and recidivism.

While he supports MAT in general, Koutoujian, the sheriff, says he's wary that medications alone will solve the inmate addiction treatment problem. That kind of thinking, he says, got us into this crisis in the first place.

"Medication-assisted treatment is very important but people have to remember if you do the medication without the treatment portion — the counseling and the supports — it will fail. And we will just fall prey to another easy solution that just simply does not work."

"We have to make sure, if we are going to use medication-assisted treatment," Koutoujian says, "that when they leave our facility they will have access to medication. Do they have health insurance to cover that medication? Do they have access to counseling and treatment services and navigators to help them through this most difficult time period? If they don't have that, then in many ways we could be setting them up for greater failure."

Meanwhile, in San Mateo's jail, inmate Felipe Chavez says he wants to serve his time, reconnect with an infant daughter he barely knows and try "to live a different life."

"I mean, I know everyone says that while they're in here," Chavez says. "But, you know, I'm really trying to just get my family back together. Change the way of life."

To do that, Chavez says, for now he wants to stay in the jail's fledgling medication-assisted treatment program — to help him stay off fentanyl and stay alive.

Copyright NPR 2022.