Jail-based treatment for opioid use disorder in the era of bail reform: a qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative.

BACKGROUND: Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge. METHODS: In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services. RESULTS: Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January-September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails' limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic. CONCLUSIONS: Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.

Adaptations to jail-based buprenorphine treatment during the COVID-19 pandemic.

Correctional facilities are among the highest-risk settings for the spread of COVID-19. Prior to the COVID-19 pandemic, the Hennepin County Jail in Minneapolis, Minnesota, offered short-term methadone maintenance, buprenorphine initiation and maintenance, and naltrexone initiation and maintenance to all jail residents with moderate to severe opioid use disorder (OUD). In response to the pandemic, the jail reduced its population by 43%. The reduced jail census and relaxed federal telemedicine regulations in response to the COVID-19 public health emergency declaration allowed the jail to institute modifications that permitted individuals to start buprenorphine without an initial in-person visit with a clinician. The jail also instituted a buprenorphine taper to bridge individuals to maintenance or provide withdrawal management, depending on patient preference. With a decreased jail census, the use of remote visits, and modifications to the buprenorphine treatment program, clinicians are able to meet the OUD treatment demand. Some jails may need additional funding streams to offset pandemic-related health treatment costs.

Employee input and health care cost-containment strategies.

Health insurance premiums have risen steadily in recent years, and many employers are coping by increasing employee premium contributions. The danger with cost shifting is that a substantial number of employees will refuse offered insurance because of the escalating contribution required of them. The authors surveyed employees regarding what aspects of their insurance benefits they would be willing to give up if their policies were to be substantially trimmed. The responses were varied and influenced by income, education, current contribution to premium, and health status. Interestingly, few employees outside of unions strategize with their employers about how best to structure health insurance benefits to keep them affordable.