Colorado shepherded in major shift in opioid treatment in jails

All jails in Colorado are now required to offer the gold-standard opioid treatment to inmates who need it, expanding a proven intervention to one of the front lines of the state’s deadly overdose crisis.

At least half of Colorado’s jails were not offering full medication-assisted treatment — the use of medications like methadone plus counseling — before a statutory requirement kicked in on July 1. Amid broader debate about how to handle record-breaking overdoses here, experts have hailed the requirement as among the most consequential policies to come from last year’s controversial fentanyl bill. While several expressed concern about how the state would monitor jails’ compliance in the years to come, the change means a required expansion of treatment for hundreds of the state’s most vulnerable drug users.

“You want to save lives? You need MAT in jails,” Rob Valuck, the executive director of the Colorado Consortium for Prescription Drug Abuse Prevention, said, using the shorthand for medication-assisted treatment.

Colorado is now one of a handful of states to require that its jails screen inmates and offer the medications like methadone or Suboxone if necessary. That’s been a shift among law enforcement in recent years, informed by stark data: People recently released from prison or jail face far higher risks of overdose than the general public, with their tolerance for drugs wiped out during incarceration. One 2008 study out of Washington state found recently released inmates were 129 times more likely to fatally overdose within the first two weeks of their release. A 15-year study of North Carolina inmates put the risk at 40 times higher.

Simultaneously, national research indicates as much as 63% of the jail population has a substance-use disorder.

Some jails — like Denver — have offered the treatment for years. But many Colorado jails were offering only a limited version of the treatment before the fentanyl’s bill passage, and a few weren’t offering it at all. Previous state law required only that jails have a policy for medication-assisted management, and experts said a jail’s policy could simply be that they didn’t offer it at all.

Jails in small and large counties alike didn’t fully offer the treatment to all patients, a stance that experts said likely violated federal law and was akin to denying insulin to a diabetic. Officials from Weld County, which offered only one type of medication treatment to pregnant women in jail before the law changed, declined an interview request, but a sheriff’s department spokesman told the Greeley Tribune last year that they hadn’t embraced the treatment because of a “philosophical difference of opinion.”

The fentanyl bill change wiped away those philosophical disagreements, and jails that hadn’t fully embraced the treatment — like Weld and Jefferson counties — are now offering the required treatment, state and local officials said. In its first month, Weld County’s program enrolled 41 patients into its jail program, according to information obtained via a records request.

Expanding medication treatment in jails is not the sole solution to the state’s opioid crisis, experts said. But it offers a proven intervention for a high-risk group of people. In 2018, the National Sheriffs’ Association issued guidance arguing that the medications increase “the likelihood of successful treatment” for opioid addiction, while reducing mortality and recidivism for those in the criminal justice system.

Without the medications, withdrawal is agonizing and staying sober is far harder: A 2008 study, for instance, found inmates who received methadone and counseling were “significantly more likely” to continue treatment and avoid future incarceration in the first three months after their release than those who only received counseling.

“In public health, you want an effective intervention in a place where you find a lot of people with that condition. And jails are perfect,” said JK Costello, a physician and consultant who has championed the treatment in jails. “We know there’s tons of people with opioid use disorder there, and we know something that works. And it’s just that alignment of population. We’ve got enough people to do a program, with a program that we know works.”

Surrender and embrace

A couple of months after the fentanyl bill passed and was signed into law last year, Jose Esquibel, the associate director of the drug abuse prevention consortium, helped pull together jail administrators and experts to ease the transition. Jail leaders now praise that group as vital to ensuring compliance and for treating what several called an “unfunded mandate” as a collaborative process.

Eventually, as the reality of the requirement set in among leery Colorado jails, resistance wore down.

“What we thought was a surrender was an embrace,” said Jeremy Dubin, the medical director for the Front Range Clinic, which provides medication-assisted treatment services in some jails. “There was resistance, then all of a sudden — surrendering and then embracing it. It wasn’t this white flag going up – it was more like, ‘OK, we get it, now come help us do it.’”

The advisory group coordinated technical assistance, shared best practices and helped evangelize the program. Grant money was available for smaller jails in need of resources, though experts say funding is a concern going forward. The grim breadth of the overdose crisis helped to whittle away at age-old stigma about methadone and similar medications.

“Even in rural and frontier areas, these deputies and sheriffs and deputies — they’ve been touched by fentanyl,” Dubin said. Fentanyl is a synthetic opioid that’s cornered the drug market and sent overdose rates in Colorado surging. “They’ve been touched with their patient-inmate populations, with their families, with their friends, themselves.”

Jails here have had a checkered history of dealing with opioid withdrawal, a torturous process for users. In 2015, a 37-year-old mother died from withdrawal symptoms in the Jefferson County jail. That same year, a father in heroin withdrawal died of dehydration and other withdrawal symptoms  in the Adams County jail. The two counties would later pay millions to the families. Capt. Jamison Brown, of the Colorado Jail Association and Denver Sheriff Department, said people continue to overdose inside jails “at an alarming rate.”

“They have an addiction that is a medical condition,” said Denver Sheriff Elias Diggins. He likened it to treating people with high-blood pressure. “An addiction is something that someone can’t control, so it is our duty to help them.”

Some law enforcements’ embrace of the program has helped change resistance among their peers, and the National Sheriffs’ Association has thrown its support behind medication-assisted treatment in jails. Mesa County has had a medication-assisted treatment program since 2019, said Capt. Jeff Byrne. The jail’s various treatment and transition programs have been so successful — Byrne said the jail’s population has dropped “pretty significantly” in recent years — that the sheriff’s department is now seeking to open its own methadone clinic, the only such program in the state.

Before the bill passed, the Jefferson County jail — which had nearly 1,000 people in custody as of late July — offered “continuation” of the medications, meaning it would continue providing medications to inmates who were taking them before they were arrested. But it didn’t offer new prescriptions.

The program’s now expanded, and since July 1, 50 inmates are receiving the treatment, said Polly Abernathy, the jail’s detention services manager. She said the program’s going well so far and that the jail is continuing to educate its staff. The program has the potential to “change the trajectory of (inmates’) lives.”

“Obviously we’re going through an opioid epidemic, and anything we can do to help those people in the community that deal with it, we’re obligated to do that,” she said. The jail is expecting more inmates to participate as the program gains momentum.

For larger jails in more populated areas, partnering with existing providers or expanding existing but limited services made the shift easier. Given the number of people who live and are incarcerated in those counties, the impact of improved treatment access is far-reaching. The barriers were often philosophical, officials said: Medication-assisted treatment is still stigmatized, even within parts of the medical community.

The state’s new requirement forced jails to leap-frog past those philosophical concerns. But in more rural settings, where the nearest methadone provider may be hours away, jails faced more base-level challenges. Budgets are small, and manpower — both in the jails and in the nearby health care workforce — is thin.

In rural Costilla County, for instance, plans to bring a mobile clinic to the jail whenever it housed a qualifying inmate fell through, said Sheriff Danny Sanchez and jail administrator Monique Trujillo. The plan now is to use telehealth, but it all might be moot anyway: Sanchez said county officials are discussing whether to close the jail because of staff shortages and infrastructure costs.

“I’m not saying (the treatment is) a bad idea, but it just puts a lot of extra work and a lot of money that our rural counties don’t have,” he said.

Oversight and money

Despite the apparent adoption of the treatment by Colorado’s jails, several providers and experts said changes and oversight are needed to ensure jails continue offering the treatment going forward.

No state agency is charged with ensuring that jails continue to provide the treatment, several officials said, nor is there oversight to ensure they’re providing the treatment in the correct way. There’s also no penalty in state law if a jail pulls the plug. Several officials said it would likely take a lawsuit and a judge to ensure compliance, should a facility change its mind.

When the Behavioral Health Administration was checking to see if all jails were compliant, for instance, state officials couldn’t confirm the status of two, in Costilla and Jackson counties, said Joy Hart, the BHA’s division director of statewide programs. Sanchez, the Costilla County sheriff, told the Post his jail was compliant. Messages sent to Jackson County’s sheriff were not returned, but other officials confirmed the county was also now able to offer medication-assisted treatment.

Rita Torres, whose nonprofit Health Care Partners Foundation provides treatment in the Los Animas and Huerfano county jails, said resources will be the largest strain for small facilities going forward. The County Sheriffs of Colorado declined an interview request, but executive director Amy Nichols said in a statement that, while sheriffs recognized the treatment’s utility, the requirement “came with no resources to implement these programs and to provide the mandated services.”

Torres said small jails were competing against each other for grants and that there wasn’t enough state money to cover the costs long term. Larger jails can more easily absorb new requirements, though they, too, have said they don’t know how much the programs will cost in the years to come. Abernathy, from Jefferson County, said her jail had declined additional state money and were using their own general fund dollars. In southern Colorado, Torres said she usually expects her payment to be late.

Hart said the National Commission on Correctional Health Care’s standards include offering the treatment and that should act as an incentive for jails. But accreditation from the organization is voluntary, and officials with the commission told the Denver Post that their standards require that jails have a policy about medication-assisted treatment, but they don’t require that jails provide it to all inmates who qualify for it. The commission is in the process of updating their standards, officials said.

Two legislative committees — one overseeing the opioid response, the other studying jail standards — may both consider taking steps to more tightly oversee the requirement, legislators told the Post this week. Valuck, of the consortium, said his group had specifically asked the opioid the do so.

For now, though, the requirement represents a tangible step forward in combating the fentanyl-fueled overdose crisis in Colorado, which has killed thousands of residents in the past few years alone. Jails had slowly begun to offer the treatment, but the requirement fast-tracked that process.

“This does create a little bit of a paradigm shift, a philosophical shift that’s supportive of a society that’s bringing everyone along,” Dubin said. “It would’ve happened, but it would’ve happened much slower, and we would’ve had a lot more deaths in the meantime.”

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