UKIAH, 9/19/21 –– Every morning, Captain Timothy Pearce, Mendocino County jail’s commander, arrives at the facility where he has worked for the last 18 years and reads a coded dashboard, prepared by the jail’s medical staff, which tracks those in custody on detox monitoring who have tested positive for opiates or alcohol. On July 30, when Pearce spoke with The Mendocino Voice, seven people had tested positive for opiates.
Over the past two years, at least 16 people at the Mendocino County jail have overdosed while in custody. The jail, on the frontlines of the opioid epidemic, has turned towards medication-assisted treatment for opioid users, a progressive departure from previous policies. The fact that people with opioid use disorder are receiving treatment for their addiction in a county jail might be surprising, but what’s alarming providers are the risks of not treating substance use, including high overdose rates, both in jail and once those prisoners are released.
The jail has experienced a recent wave of overdoses – at least seven so far in 2021, according to press releases issued by the Mendocino County Sheriff’s Office (MSCO). No one has so far died this year, likely thanks to Narcan, a life-saving medication that can reverse an overdose from opioids. MCSO staff have used Narcan for the last two years.
Pearce says people in custody who are withdrawing from alcohol and opiates are the “most dangerous people in custody, more fragile than the rest. And I’m concerned if they somehow slip through the cracks or something happens.”
Jails and prisons are dangerous environments for substance-dependent people. In the United States, an estimated 65.8% of individuals in local jails had a substance use disorder, according to a report from the Center on Addiction. Some may have life-threatening withdrawals if they cannot access adequate medical care. Those who have started treatment outside jail could relapse if they cannot continue treatment in jail. And a decreased tolerance and lack of treatment during incarceration have made drug overdose the leading cause of death after release from prison, especially among women.
“When they leave here and there are drug dealers waiting for them, they go right back to the usual amount of heroin [or other drugs] that they were using prior to coming in, and more often than not they die from that,” Pearce says. The California Department of Health Care Services (DHCS) says “individuals leaving prisons and jails are 40 times more likely to die of an overdose in the first two weeks compared to California’s general population.”
Until recently, MCSO’s policy in the jail concerning substance use was limited to a tapered detox with buprenorphine to ease withdrawal, with no further treatment. A 2018 report published by the National Sheriffs’ Association on jail-based medication-assisted treatment programs noted, “correctional withdrawal alone actually increases the chances the person will overdose following community release due to loss of opioid tolerance.”
In June, MCSO’s medication-assisted treatment (MAT) jail program was launched through a DHCS grant to expand access to MAT in county jails, managed by Health Management Associates. MCSO, Mendocino County Behavioral Health and Recovery Services (BHRS), and Naphcare, a private company currently contracted by Mendocino County to provide medical services in the jail, are partnering with Mendocino Coast Clinics in Fort Bragg and Mendocino Community Health Clinic (MCHC) in Ukiah to continue treatment outside the jail. Within three weeks of starting the program, nine people were already participating.
Diseases of despair: Addiction as a disease, not a choice
Dr. Lin Taylor is the case manager of Mendocino Coast Clinics’ (MCC) MAT program and a MAT provider receiving patient referrals from the jail. Taylor says she has seen the number of her MAT patients grow to 118, and referrals are increasing. The jail referred one patient the week she spoke to the Mendocino Voice. “I definitely have job security here,” she says.
Dr. Taylor compares treating addiction to treating any other disease. “If someone has high blood pressure they get medication for their high blood pressure. We look at addiction as a disease.” Taylor says. “Suboxone keeps a patient from going into withdrawal. It’s not a high…it just keeps the high highs and the low lows from being such an impasse where you can’t function. It also takes away their cravings so their mind isn’t a spinning wheel of ‘When can I get the next drug?’”
One of the primary distinctions of MAT programs is the coordination of behavioral health and social services in addition to medication, says Dr. Taylor, who holds weekly group meetings exclusively for her MAT patients.“What we find so important is that we’re able to integrate behavioral health,” says Taylor. “[Patients] get therapy and counseling along with their treatment. We can give them the medicine, but what happens is that their emotions and trauma rise to the surface, which they have been numbing with the drugs. And so they’re still dealing with that, and those emotions can be triggers for relapse.”
For Dr. Taylor’s patients, the impact has been overwhelmingly positive. “It changes their life,” she says. “That’s the best part of my job. They’re able to function again. They’re able to go back to work, get jobs. They get their children back. They get to repair their relationships.”
Dr. Taylor and other behavioral health services providers long viewed the jail as an untapped opportunity to get people into treatment and prevent overdose deaths. Dr. Jenine Miller, director of BHRS, says the first discussions about medication-assisted treatment started seven or eight years ago. Funding and stigma were obstacles that needed to be overcome.
“It wasn’t that [MAT programs] weren’t used, but it was obscure for us in our little community,” Miller says. “I think it’s a mindset change. Not just in the jail, [but] for the whole community. We still haven’t as a society grasped that [addiction] is a disease, and that it has to be treated at a different level.”
Medication-assisted treatment was cited in a 2018 U.S. Surgeon General report as an evidence-based, “gold standard” treatment for opioid use disorder. The program prescribes U.S. Food and Drug Administration (FDA)-approved medications — buprenorphine, methadone, naltrexone, or Suboxone, a combination of buprenorphine and naloxone — to a patient with wrap-around counseling and behavioral therapy. These medications are opioid antagonists, blocking and reversing the effects of opioids on a person’s nervous system, and preventing the euphoria and addictive qualities of opioids. Multiple studies have found buprenorphine and Suboxone to be safe for those seeking treatment during pregnancy.
Miller says an initial DCHS grant in 2018 to identify how to streamline access to MAT in the jail, paired with funding to equip MSCO with Narcan, jump-started discussions again about a MAT program in the jail. “That really started changing the perception [and brought] everyone to the table,” she says.
With a raging drug epidemic and success stories streaming in from jails across the country about the MAT model’s impact, what seemed progressive in the past now looked like common sense.“Law enforcement here has definitely always been open to implementing strategies that will reduce recidivism,” says Rendy Smith, BHRS substance abuse program and services manager. “The numbers speak for themselves. The facts don’t lie. As the nation as a whole has started moving toward this treatment approach and embracing medication-assisted treatment, our local law enforcement really started to see that there’s been successes, and that there’s been forward movement in implementing these things in the jails here, and in their daily practices.”
Captain Pearce says while reducing recidivism is a major motivation for MCSO, “the biggest reason is to save people’s lives. We’re trying to prevent deaths and also trying to get people help so they don’t get involved in the justice system.”
Two worlds collide – Correctional facilities as gateways to treatment
Jails have acted as de facto detox centers for a long time, and as a revolving door for people struggling with substance use disorders. Between 24 and 36% of opioid-dependent adults are estimated to cycle in and out of jails each year, according to a 2016 study.
Correctional facilities historically have not been tasked or equipped to address certain healthcare needs, such as treatment for substance use disorder and mental health. Yet, the opioid epidemic has put jails even more squarely on the frontlines. While providers treating addiction have long viewed jails as a unique opportunity for treatment, stigma and funding have in the past stood in the way. Perhaps because of the pervasiveness of the opioid crisis, those attitudes are changing. The U.S. drug epidemic has taken the lives of at least 94,134 people, according to provisional data from the Centers for Disease Control and Prevention. Deaths from synthetic opioids, like fentanyl, made up 60% of drug overdose deaths in the United States in 2020, an increase of 32% from the previous year.
“It’s really been a culture shift, and for the most part, [MSCO has] been on board,” says Smith. “It’s definitely a different way of thinking and doing things. Sometimes there’s a little bit of a resistance to change, but when you see the successes, when you see the numbers decreasing because of certain implementations and strategies, then it makes people want to try those strategies, try those implementations, and see if it doesn’t help here in the community.”
Through the California MAT expansion project, MAT programs have expanded in the past few years and now operate in more than 35 counties statewide, including Mendocino. As of June 2020, 6,500 jail detainees in California have received MAT during incarceration, according to the project.
Once released, challenges can seem insurmountable without proper coordination
COVID-19 protocols and the recent spike in cases in the jail have made meeting in-person for counseling and group sessions erratic in an environment where people don’t stay for very long. Stacey Holden is NaphCare Health Services administrator at Mendocino County jail. “A lot of times when people are arrested, they don’t stay very long.” Holden says. “So sometimes we will [treat] them, but they’re gone before we can get them a referral to the community [provider]. But we’re trying our best to catch them.”
A transitional plan and proper coordination for someone reentering the community after incarceration is essential, but a lack of fluidity between jail, providers, insurance and other social services can fail a formerly incarcerated person who has basic needs like housing and healthcare — or, particularly in rural areas like Mendocino County, needs transportation to continue treatment. Existing funding mechanisms for this care can also create challenges. Medi-Cal covers MAT treatment, however, Medi-Cal coverage is not active while someone is incarcerated, which can cause gaps in accessing health care and life-saving medication once a person is released. Once a release date is known, BHRS can assist the transition of each MAT patient to a provider in the county. Medi-Cal can be reactivated if the person is in jail for less than one year, though there have been problems reported in other parts of the state and by local providers about delays affecting access to timely treatment, putting patients at risk for relapse or other serious health needs after they are released from jail.
Geography is another issue. BHRS is applying for grants to cover the cost of transportation to the two clinics coordinating with the MAT jail program, located in Ukiah and Fort Bragg. In the past, Smith says BHRS staff would get people into residential treatment programs, but the person seeking treatment would have no way to get there after being released from jail.
Pearce says the goal is to have providers across the county, where there are more than 50 MAT providers, though he noted the county’s mountainous geography “often stalls a lot of progress. So we wanted to make sure that the coast was included. As we roll this thing out and perfect it, we want to have connections to each and every clinic in Mendocino County.”
The program is also looking into how to use a similar model to treat alcohol use disorder. Currently there are no medications to treat methamphetamine use beyond behavioral therapy, a drug Pearce says is a big concern in the jail.
For now, the fledgling MAT jail program is finding its footing and has become as Rendy Smith puts it, “a labor of love.”
To find out more about MAT treatment and other resources available for treating substance use disorder check out our resource guide here.
Dana Ullman reports on health-related stories for The Mendocino Voice with the support of the USC Annenberg Center for Health Journalism This article was produced as a series for the 2021 California Center for Health Journalism Fellowship.