Provision of health care services related to substance use disorder in southern U.S. jails

Abstract

Introduction:

The U.S. jail population has more than tripled since the 1980s, and today, one out of every three incarcerated individuals is being held in a county or city jail. Substance use disorders (SUD) are overrepresented in incarcerated populations; however, little recent research has examined the availability and quality of SUD-related health care services in jail settings. Incarcerated individuals may engage with a variety of SUD-related health care services, including: screening and withdrawal management at entry, SUD treatment or other brief health care interventions while they are being held, and overdose prevention education and reentry planning at release.

Methods:

We conducted a thematic analysis of qualitative data from 34 interviews conducted with 38 personnel from a purposive sample of jails that varied in size and rurality within a five-state study area. The goals of the analyses were to: 1) describe jail health care services for SUD and barriers to service provision, 2) compare current practices to best practice recommendations, and 3) provide context by describing factors at the jail and community level that influence service provision, such as access to resources.

Results:

Interviewees described wide variability in both availability and comprehensiveness of SUD-related health care services. Most adhered to federal guidance for supervising withdrawal from alcohol and benzodiazepines, but not opioids. Medication for addiction treatment was most widely available for pregnant women and rarely for other individuals. Roughly one third of the jails in our sample provided behavioral group or individual therapy with a licensed counselor and roughly one quarter offered self-help groups. Very few jails provided comprehensive re-entry planning and support. Jail staff reported specific barriers to providing each type of service, as well as limiting contextual factors. Despite observed increases in case volume, jail staff did not necessarily receive any additional funding or health care staff. Overall, lack of investment in mental and behavioral health care contributed to recidivism and feelings of hopelessness among staff.

Conclusions:

This study identified several areas where jails could improve SUD-related health care services. Many of the barriers to improvement—organizational buy-in, cost/budgeting, staffing, logistics—were not under the control of health care staff. Implementing changes will require support from local governments, jails administrators, private health care companies, and other local health care providers.

1. Introduction

The United States has the highest incarceration rate in the world, with more than 2 million Americans currently incarcerated (Minton et al., 2021; Widra & Herring, 2021). Since the 1980s, the U.S. jail population has more than tripled, and in 2020 one out of every three incarcerated individuals were being held in a county or city jail (Aiken, 2017; Sawyer & Wagner, 2022). Jails are short-term facilities that typically hold individuals awaiting trial and those who have been convicted with sentences of less than one year (Aiken, 2017).

Substance use disorders (SUD) are overrepresented in incarcerated populations. A national survey from 2002 found that 47% of people incarcerated in jails met criteria for alcohol abuse or dependence, and a national survey from 2007–2009 found that 63% of sentenced individuals in jails met criteria for drug dependence or abuse (Bronson et al., 2017; Karberg & James, 2005). Among the same population, the percentage self-reporting “regular” use was 39% for cocaine or crack, 19% for heroin or other opiates, 20% for methamphetamine and 21% for depressants such as benzodiazepine. Existing data also suggests that substance use at the time of arrest is common. In the 2007–2009 survey, 37% of sentenced individuals in jails reported using drugs at the time of their offense (Bronson et al., 2017). More recent nationally representative data on the prevalence of substance use among jailed persons are not available, but a recent study specific to opioids found that 14.5% of individuals admitted to local jails screened positive for opioid use disorders (OUD; Maurschak et al., 2023). Additionally, a national report of mortality during incarceration found that that from 2000 to 2018, deaths in jails from drugs or alcohol increased by 381%, from 37 yearly deaths to 178 (Carson, 2021).

Jails have some legal obligation to provide adequate medical treatment to people in their custody. However, that mandate is ill-defined and historically health care services, including those for people with substance use disorders (PWSUD), have been limited (Belenko et al., 2013; Wakeman & Rich, 2015). For example, among those who met drug dependence or abuse criteria in the 2007–2009 survey of people sentenced to jail, only 19% had received any type of drug treatment or drug-related programming (e.g., a self-help group) since their arrival at the facility (Bronson et al., 2020). Withdrawal management in jails has been even more uncommon. In a 2003–2005 survey of 100 jails, only 34% offered any type of “detoxification” or withdrawal management (Oser et al., 2009). In their study of OUD-related practices within U.S. jails, Maruschak et al. (2023) found that only 53% all jail jurisdictions and 47% of southern jurisdictions provided recommendation medications for managing opioid withdrawal (either clonidine, lofexidine, methadone, or buprenorphine).

Despite increasing rates of opioid use disorders over the past 20 years, the most effective treatment – the combination of medication and behavioral counseling, is rare in jails (Centers for Disease Control and Prevention, 2022; Wakeman & Rich, 2015). This type of treatment is referred to as Medication-Assisted Treatment (MAT) in general or Medications for Opioid Use Disorder (MOUD) for the specific case of opioid treatment (Centers for Disease Control and Prevention, 2022). A recent cross-sectional survey assessed MOUD availability for non-pregnant individuals in U.S. jails (n=836 jails, completed March 2020). The study found that 13% of jails both initiated and continued at least one type of MOUD, and 11% only continued MOUD for those already prescribed prior to arrest (Sufrin et al., 2023). The remaining jails did not offer initiation or continuation, forcing individuals to undergo involuntary withdrawal upon entry. Lack of continuation is detrimental to longer-term outcomes, as stopping MOUD for periods of incarceration can impede individuals from reengaging with MOUD following release (Fu et al., 2013). Sufrin et al. (2023) also found variation in what types of MOUD were available in U.S. jails. Only 6.7% of jails were able to continue MOUD for individuals on all three possible types of medications (methadone, buprenorphine, and naltrexone). At jails that had only one type of medication was available, naltrexone was the most common (21% of jails with MOUD), followed by buprenorphine (11.3%) and then methadone (8%). When individuals are provided with MOUD while incarcerated, they have increased engagement with community-based treatment after release, lower rates of illicit opioid relapse, lower rates of overdose (fatal and non-fatal), and reduced rates of recidivism (Malta et al., 2019; Moore et al., 2019). A recent report found that across the five states included in this study, only a few jails offered buprenorphine or naltrexone and several of these efforts were small-scale pilot programs (Weizman et al., 2021). Behavioral counseling is more accessible in U.S. jails than MAT/MOUD, but it is still not widely available. While 19% of sentenced individuals in jails who met criteria for drug dependence or abuse reported receiving any type of drug treatment or participating in a program since their arrival to the facility, only 5% had received counseling from a professional (Bronson et al., 2017).

Another component of substance use treatment specific to OUD is provision of overdose education and naloxone distribution (OEND; Oser et al., 2009). OEND programs work to prevent overdose deaths by providing newly released individuals, who often have low drug tolerance, with the opioid overdose reversal drug naloxone, which can be easily administered by non-medical personnel. As of 2021, OEND programs had been implemented in jails or prisons in fourteen states. Although some have adopted state-wide OEND policies, most programs are implemented at the local or county level (Wenger et al., 2019; Wenger & Lilly, 2021).

Delivery of health services in jails can be particularly challenging as the custodial population is dynamic. The majority of jail incarcerations last a few days or weeks, while a smaller proportion, perhaps less than 25%, are incarcerated for multiple months or years (Camplain et al., 2019; Minton & Zeng, 2021; Spaulding et al., 2011). Nevertheless, in the past few years, successful lawsuits affirming the right to OUD services and published policy positions, such as that from the American College of Physicians, have highlighted the importance of providing adequate health services for PWSUD in jails (American Civil Liberties Union, 2021; Kendig et al., 2022). Provision of SUD-related healthcare services should span the entire incarceration, from entry to release. Possible SUD-related services begin with screening and withdrawal management at entry, continue with SUD treatment or other brief healthcare interventions while they are being held, and conclude with re-entry planning so that those in need of continued treatment can receive it. For OUD, OEND programs are an essential tool in preventing overdoses upon release.

This study focuses on the provision of these SUD-related healthcare services in southern jails for several reasons. Compared to other U.S. regions, the south has the highest incarceration rate (400 per 100,000), a high percentage of rural residents (24.2%), and the highest median percentage of health professional shortage areas (65%; Kaiser Family Foundation, 2022; Minton et al., 2015; U.S. Census Bureau, 2022). At the time of this study, only one state in our sample had opted to expand Medicaid to low-income persons without dependents (WV). Consequently, many individuals are uninsured prior to their incarceration and have limited access to routine community-based healthcare. Jail stays may be one of the few times that PWSUD have access to any healthcare (Gates, Artiga, & Rudowitz, 2014). Recent research has shown that, despite need for these services, southern jails may lag behind other regions in the provision of SUD-related healthcare services (particularly services for OUD). Maruschak et al. (2023) found that compared to other U.S. regions, southern jail jurisdictions were the least likely to: provide medications for opioid withdrawal, initiate behavioral/psychological treatment, initiate or continue MOUD, and provide overdose education.

1.1. Current Study

To strengthen our understanding of SUD-related healthcare in southern U.S. jails, we conducted a qualitative data analysis of interviews with jail personnel in five states, focusing on the availability of SUD-related services, barriers to SUD-related service provision, adherence to best practices, and contextual factors (e.g. staffing, morale) that can influence quality of care. The qualitative approach and choice of key informants (healthcare service providers and supervisors, jail administrators) provide unique insight into services provided in southern jails by exploring provider/administrator perceptions of care and the needs of the population (PWSUD), whereas many existing qualitative studies have focused on the experiences and perceptions of incarcerated individuals who engage with SUD-related services (Akiyama et al., 2020; Owens et al., 2018; Vail et al., 2021; Velasquez et al., 2019). Additionally, key informants were able to provide detailed descriptions of their organizational context that help frame our understanding of the landscape of care in the region. It is important that we understand not only what services are or are not provided, but also what drives decision-making surrounding SUD-related healthcare.

2. Material and methods

2.1. Parent study

The primary focus of the parent study was to understand the provision and use of healthcare services in southern U.S. jails. (Carda-Auten et al., 2022). The study conducted recruitment, interviews, and data analysis on a rolling basis. The study team identified 346 eligible jails in the study region, of which 125 were ultimately contacted. The study stratified eligible jails by population size, rurality, and geographic location within the five-state study region and then purposively sampled with the goal of creating a diverse sample based on these characteristics. At each eligible jail, the study team attempted to identify and interview the person who was “most knowledgeable” about delivery of health services. This person was primarily identified by “cold calling” each jail, but in some instances local and regional stakeholders provided suggestions. Of the 125 jails that we contacted, personnel from 34 agreed to participate, 14 declined, and 77 were unresponsive or did not complete their interview for other reasons (e.g., scheduling conflict, no-shows). After completing interviews with personnel from 34 facilities, the interview team felt they achieved saturation of themes and ceased further recruitment efforts. The study did not contact the remaining 221 jails. Interviews were conducted between August 2018 and February 2019 by two members of the research team (ED and JCA), who have 14 years combined experience in qualitative interviewing.

The majority of interviews (80%) occurred on-site in the jail and the remainder were conducted by phone. All interviews were audio recorded and transcribed verbatim. The interview guide included sections focused on health care staffing, intake processes for health care provision, internal medical resources, external medical resources, and management of drug and alcohol detoxification. See Table 1 for sample interview guide questions related to the provision of SUD-related healthcare services. Participants did not receive any financial remuneration for participating. The Institutional Review Board at the University of North Carolina at Chapel Hill approved this study.

Table 1.

Sample Interview Guide Questions

Interview question topic	Sample questions
SUD screening and withdrawal management	If there is a health screening portion to the custody intake process, can you tell me about it (or, when is the first health screening done)? What is the process to care for an inmate who is found to have immediate healthcare needs during the health intake process? (E.g., severe mental illness, suicidal ideation, on medications, substance use withdrawal symptoms) Follow-up: (If they have to wait) What happens if they need help more immediately and cannot wait? How does [NAME OF JAIL] manage inmates with acute symptoms (e.g. substance use withdrawal symptoms)? How is it decided when acute substance use care should be provided? About how long does it take for someone to receive treatment if they are found to have acute substance use disorder symptoms? Does your jail have an onsite substance use detoxification program? (If yes) Can you please describe the components of this program? (If no) How does your jail handle inmates who need detoxification services?
SUD treatment - General	What is the overall approach to managing a substance use disorder (opioid use disorder, alcoholism)? How is treatment provided to inmates found to have a chronic substance use disorder? Where is treatment for substance abuse disorders provided (i.e. on-site or off-site)? Outside of withdrawal treatment, what type of substance use disorder care, if any, is given to someone who is determined to have an addiction? A common challenge among many jails is having adequate substance use disorder treatment services. What are the struggles you commonly encounter in managing substance use disorders?
SUD treatment - MOUD	Does [NAME OF JAIL] have any programs in place for opioid use? (If yes): Please describe the program(s) in place. If someone comes into [NAME OF JAIL] who is currently prescribed Medication Assisted Treatment (MAT) or another medication for an opioid use disorder, is that medication given to them while incarcerated? Do the same rules for access and administration we discussed earlier apply to medications for substance use disorders? Does [NAME OF JAIL] initiate MAT specifically for opioid use disorder? (If yes): Which medications for assisted treatment, if any, are available? Do all inmates have access to MAT or only some groups (e.g., pregnant women, those who were on MAT prior to arrest)? Can you please describe the components of your MAT program? Where do inmates receive MAT (e.g. on-site or off-site)? Can you please describe the MAT site? What type of providers administer MAT to inmates?
Overdose education and naloxone distribution	Does [NAME OF JAIL] have any substance use or overdose education programs (for inmates) in place? (If yes) Please describe the program(s). To what extent, if at all, is overdose prevention discussed with inmates at release? Does [NAME OF JAIL] have any naloxone provision programs in place? (If yes) Please describe theprogram(s).
Linkage to care upon release	What is the typical process for releasing inmates? Is there a process to help inmates enroll in any type of benefits (Medicaid, SSI, food stamps) before they are released into the community? (If yes): Can you describe it? Who is the person that helps the inmate with enrollment? What is the typical process for releasing an inmate who is taking medication? Does your jail ever discharge inmates with a supply of medication? Does [NAME OF JAIL] communicate medical information to any outside community providers? (If yes) Please describe the process. Does [NAME OF JAIL] provide any information about or linkage to community mental health services at release? (If yes) What is the process for communicating this information?

2.2. Study sample

The sample of 34 participating jails included 11% of all county jails in AL, 6% in GA, 13% in NC, 9% in SC, and 18% of regional jails in WV. The participating jails represented small, medium, and large facilities located in both metropolitan and non-metropolitan areas. Most jails (91%) contracted with private companies to provide healthcare. Jail demographics are described in Table 2. Each facility identified the individual who they felt was most knowledgeable about health care delivery within that facility as an interviewee. Interviewees included nurses, regional health supervisors, and non-clinical jail administrators. Four facilities had two participants (e.g., nurse and jail administrator) who were jointly interviewed. Interviewee demographics are described in Table 3.

Table 2.

Jail Demographic Characteristics

Characteristic	n	%
Jail location (state)
Alabama	7	21
Georgia	9	26
North Carolina	12	35
South Carolina	4	12
West Virginia	2	6
Jail size (capacity)
Large (999+)	7	21
Medium (100–999)	20	58
Small (0–99)	7	21
Metropolitan status
Metropolitan	19	56
Non-metropolitan	15	44
Healthcare entity
Private medical company	31	91
Community clinic	2	6
County	1	3

Table 3.

Interviewee Demographic Characteristics

Characteristic	n	%
Role
Regional manager	4	11
Local nurse/healthcare administrator	30	79
Jail administrator	4	11
Years in current position
Less than 1 year	5	13
1 to 5 years	17	45
6 to 10 years	6	16
More than 10 years	7	18
Missing	3	8
Gender
Female	33	87
Male	5	13
Race
Black	7	19
White	21	55
Missing	10	26
Age
<35	5	13
35–55	16	42
>55	6	16
Missing	11	29

2.3. Secondary analysis

We used a reflexive thematic approach to analysis (Braun & Clarke, 2006; Braun & Clarke, 2013). Our first goal was to describe jail-based healthcare services for PWSUD, barriers to service provision, and adherence to existing best practice guidelines. Our second goal was to provide context for the descriptive findings by exploring relevant factors at the jail and community level that may influence the provision of healthcare services for SUD. Prior to this analysis, BR read the parent study transcripts to familiarize herself with the data. Transcripts from the parent study had been de-identified and coded for a previous qualitative analysis (Carda-Auten et al., 2022). BR, ED, and JCA identified relevant codes and data matrices from the existing analysis related to the provision of healthcare services for PWSUD. Relevant codes included: Health intake and screening; substance use treatment (acute); substance use treatment (chronic); Medication Assisted Treatment (MAT), Medicaid/Medicare (screening for enrollment or eligibility); challenges to provision of healthcare; healthcare staffing (challenges); and release. For this analysis, BR created two new data matrices, one for release/reentry services and one organizing the available services for PWSUD by jail to better understand individual cases. These code reports and matrices guided the initial descriptive analysis of healthcare services (Results sections 3.1–3.4). To meet the second goal of this analysis, BR created a new subset of codes that focused on the context surrounding service provision for PWSUD within the jail system and completed secondary coding of the transcripts using Dedoose software. Codes included: liability concerns, organizational policies, jail resource constraints, community resource constraints, logistical challenges, the changing landscape of care, stigma, and staff burnout. Ultimately, some codes only represented barriers to one specific health service, for example organizational policies regarding controlled substances preventing MAT programs. We dropped these codes as we moved forward with refining themes that aligned with our second goal. The study grouped other codes into themes that represented overarching contextual issues within the jail health care system. Final themes were named and presented in this manuscript (Results section 3.5). Illustrative quotes are included throughout to substantiate the analytic findings, and the number of facilities providing certain types of services is included where it is informative for understanding the diversity of services or service availability across the sample. To provide context for the illustrative quotes, we also provide the interviewee’s gender, race, and age (if provided) and the associated jail’s size and metro status. The study defined metro/non-metro status using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties (Ingram & Franco, 2014).

3. Results

In this section, we first describe available SUD-related healthcare services and barriers to service provision within the study jails as reported by staff interviewees. These services include screening and withdrawal management, behavioral therapy and counseling, MAT and MOUD, OEND programs, and reentry planning. We then describe overarching themes that provide context for the current healthcare landscape for PWSUD in jails.

3.1. Screening and withdrawal management

Interviewees reported that upon entering the jail, the first SUD-related health care services incarcerated individuals engaged with were general health screening and withdrawal management (if required). When screening for substance use, most jails relied on self-report (n=12), or a combination of self-report and vital signs plus visual inspection for signs of recent substance use (e.g., pupil size; n=3). However, one large metro facility conducted drug testing upon entry to confirm substances use and inform the subsequent treatment protocol. Interviewees also identified challenges related to screening. Several stated that incarcerated PWSUD were generally hesitant to disclose their substance use at intake screening due to fear of possible consequences. Healthcare staff reported having better success with disclosure when they (1) assured new arrivals that they would not be prosecuted for disclosing substance use, (2) pointed out that withdrawal would inevitably cause noticeable physical symptoms, and (3) emphasized the need to disclose which substances they had used so the healthcare staff make informed decisions about how treat withdrawal symptoms. One interviewee recounted,

“I had a guy detoxing and he was terrified to tell us what he’d taken, because he thought he was gonna get charged. I said, “Listen. You’re already in jail. I don’t care what you took. I just need to know what you took so I can take care of you.” Even the officer that arrested him happened to be there, and he said, “Listen, buddy. There’s no drug charges on you. Tell this lady what she needs to know.” (White female, 50; Jail 14, medium non-metro)

Once the jails screened individuals, jails varied in where people experiencing withdrawal were housed, the frequency of monitoring, and their protocols for medical management of withdrawal. About half of the interviewees (n=16) specifically mentioned relying on validated scales (e.g. the Clinical Institute Withdrawal Assessment for Alcohol “CIWA-Ar” and the Clinical Opiate Withdrawal Scale “COWS”) to assess symptoms and to guide their protocol once an individual disclosed substance use or entered withdrawal. Three others stated that they had a protocol in place but did not identify or describe it. Most commonly, jails reported that individuals experiencing withdrawal were kept in a dedicated medical observation area (n=14). Some had a room or cell with a camera where healthcare staff could monitor the individual. Jails with dedicated medical areas tended to report more intensive monitoring by healthcare staff compared to other facilities. For example:

“And we actually have a nurse that’s in that [detox] housing unit with them 24/7. So that nurse is over there. She’s taking their vital signs. She’s doing assessments on ‘em every day, twice a day. She’s making sure that they stay hydrated. We have two medical officers over there in that unit. We’ve outfitted it to all of our low bunks.” (Female, race and age not provided; Jail 1, large metro)

Generally, interviewees expressed a desire to keep individuals in withdrawal separate from the general population until they were in more stable condition. Among jails that did not have a dedicated medical observation area, roughly half (n=7) reported that they keep individuals in withdrawal in booking, evaluation, or holding cells near the officers for easier observation. One stated, “We have a withdrawal protocol. The first step is to keep them back there in the booking area where they’re visible and you can watch ‘em, keep eyes on them.” (White female, 59; Jail 7, small metro) The remaining jails (n=5) reported that individuals go into the general population – either in all cases or unless they qualified as “a really severe” case. Jail staff reported various reasons for this decision. For example,

“We won’t put ‘em separate unless we feel like it’s not safe. A lot of times they’re safer down there [in general population] with somebody because if something starts happening, somebody will watch out for ‘em...They don’t like to be up front because the cops are in and out and there’s always an officer up there. They don’t have the TV that they have down there. They really don’t like to be up front. It stresses ‘em out even more.” (White female, 35; Jail 20, medium non-metro)

Slightly more than half of the jails (n=19) in this sample described monitoring protocols for PWSUD. All jails with a protocol in place reported that healthcare staff saw individuals in withdrawal one to three times per day to assess symptoms and take their vital signs, with three times per day as the most common protocol. In between visits with health care staff, officers were often responsible for checking in with PWSUD. Two facilities reported that officers conducted wellness checks every 15–30 minutes, while others did not specify the frequency of monitoring. Ten facilities stated they provide individuals in withdrawal with extra fluids, including pitchers of water and Gatorade. Many interviewees cited the importance of both hydration and regular monitoring during withdrawal.

“If we believe that they’re going to dehydrate, we put them in a medical unit so we can keep an eye on that. There was a story about another facility…They didn’t check on [a man] for eight hours, and he died. We’re lucky enough to have officers and health working together tightly to make sure that doesn’t happen in our facility, where we have a death due to neglect or just oversight.” (Male, race and age not provided; Jail 3, medium metro)

Several staff described a hierarchy of withdrawal severity by substance used. Staff generally agreed that “alcohol trumps everything,” and one told us that “opiates are probably the easiest drug to come off of.” The study found considerable homogeneity across protocols for alcohol and benzodiazepine withdrawals, and health care staff considered these cases to be the most high-risk. Interviewees stated, “Your alcohol and your benzos are the most dangerous to the person,” and “Alcohol and benzos are the two you can die from.” All jail staff who discussed their protocol for alcohol withdrawal (n=21) were consistent in their use of the CIWA-Ar scale, a chlordiazepoxide (Librium^®) taper, and thiamine supplements. Similarly, all jails that discussed their benzodiazepine protocol (n=12) administered a benzodiazepine taper using clonazepam, diazepam, or Librium. Staff mentioned treating individuals with alcohol use disorders as quickly as possible, with the intention of managing the symptoms early and mitigating the chance of a later emergency room visit. One said,

“The town drunk that’s homeless that gets brought to jail all the time… I would walk in and say, “What cell is he in?” I would run upstairs and grab all the medicine that he’s gonna be on and go get it in him, because if I didn’t, we’d end up in the hospital.” (White female, 50; Jail 14, medium non-metro)

For other substances, jails generally reported following federal guidance for supervising withdrawal (Table 4). However, protocols for managing opioid withdrawal often deviated from clinical guidelines. The recommended best practice is to provide an opioid agonist taper to manage withdrawal. While jails typically adhered to this guideline for pregnant individuals (described in more detail below), they rarely provided tapers to other PWSUD. Among jails that described specific opioid withdrawal protocols for the general population (n=19), only one facility reported providing an opioid agonist taper (Suboxone^®). The remaining facilities provided symptom management to varying degrees. Four provided clonidine, while an additional four provided a different anti-anxiety medication (hydroxyzine or Librium^®). One jail supplemented clonidine treatment with dextromethorphan (Robitussin^®), which has been shown to further reduce symptom severity (Malek, Amiri & Habibi Asl, 2013). Eight jails only provided medications to treat nausea, gastrointestinal cramping, diarrhea, and pain. Jails used a variety of medications for symptom management, including Phenergan^®, Imodium^®, Zofran^®, Bentyl^®, and Tylenol^®. One facility sent PWSUD out to the emergency department or a nearby detoxification center for withdrawal management of any symptoms considered to be severe.

Table 4.

Federal Bureau of Prisons’ Clinical Guidance for Medically Supervised Withdrawal

Substance	Screening and monitoring	Primary treatment	Hospitalization guidance
Alcohol	Use CIWA-Ara scores, taken frequently	Lorazepam and thiamine supplements	Transfer if actively seizing, showing signs of delirium tremens, or CIWA-Ar > 20
Benzodiazepines	Use vital signs, taken three times per day for three days	Clonazepam taper	Transfer if actively seizing, showing signs of delirium tremens, hallucinating, or profoundly agitated
Opioids	Use vital signs, taken daily (more if using clonidine) and COWSb scores for symptom severity	Opioid agonist taper, symptom management	Usually not necessary
Cocaine	Use vital signs, as needed	Symptom management only	Usually not necessary

^aClinical Institute Withdrawal Assessment Alcohol Scale Revised

^bClinical Opiate Withdrawal Score

3.2. Medication assisted treatment

Interviewee reports indicated that only a few jails were following best practice guidelines for SUDs by implementing an evidence-based treatment plan once withdrawal management was complete. For alcohol and opioid disorders, MAT may be indicated. Medication for addiction treatment was most commonly available for pregnant individuals with OUD, and facilities reported having a separate treatment protocol in place for these cases. Health care staff described the separate protocol as being “for the baby.” One stated, “The reason that we give pregnant females MAT is to protect the baby. You don’t want the baby to withdraw.” Most jails that provided MOUD for pregnant individuals described transporting them to local clinics, where methadone (n=4) or the choice between methadone and buprenorphine (n=1) was available. Two jails reported that their contracting physicians were able to prescribe buprenorphine (Subutex^®) for pregnant women on-site; although in one case, medication was only provided until they could arrange care through the local methadone clinic. Additionally, two interviewees described careful use of benzodiazepines to medically manage severe alcohol use disorders for pregnant individuals. In one of these cases, pregnant individuals were required to sign a consent form acknowledging that they had been made aware of the potential teratogenic effects of the medication.

Aside from withdrawal management protocols, MOUD was rarely available to other individuals within the jail. Only one jail had the capacity to initiate MOUD (buprenorphine) for non-pregnant individuals within their facility. Three jails allowed non-pregnant individuals to continue their MOUD by transporting them out to a local clinic (for methadone or Suboxone^®) or by reporting to the jail healthcare staff daily to receive their medication (Suboxone^® only). Additionally, four facilities were researching or planning to implement some form of MOUD in the future. A few specific barriers to offering MOUD were reported. The first barrier was the Drug Enforcement Administration Drug Addiction Treatment Act (“DEA-X”) waiver requirement for providers interested in prescribing buprenorphine, which has since been removed. The remaining barriers were specific to implementing an extended release injectable naltrexone (Vivitrol^®) program. The interviewee said,

“It’s a long process to do [Vivitrol] correctly. You have to have outside community involvement. You have to have outside doctors. You have to have a way to administer it in the future. We’ll give you the first shot, but after that, it’s up to you. You have to go through mental health.” (Male, race and age not provided; Jail 3, medium metro)

In addition to lack of a properly licensed healthcare provider, interviewees identified the following treatment barriers: lack of community MAT/MOUD clinics (if sending out for treatment), logistical challenges of sending patients to community providers, the custodial population’s high turnover, organizational policies prohibiting storage of controlled substances, and cost. One interviewee described a case they managed in the past to illustrate issues related to transiency and controlled substances:

“[I have someone] in here on a simple, second-degree trespass. So she’s not sure if she’s gonna get out. I’m gonna start her on a detox protocol. Okay? I go ahead and I order her medicines, I do the paperwork, and I give her [the] first dose. I’ve packed up another couple of days’ worth to make sure that she’s ready to go, and during the night, somebody comes and bonds her out...Technically then, when you get in the next day and find out she’s gone, you have to throw that medicine out...So, we watch what we order, how we order, when we order, why we order. You just don’t automatically order medication for somebody.” (White male, 65; Jail 15, small non-metro)

At one facility where newly admitted PWSUD could continue MOUD while incarcerated, the interviewee described concerns with logistics saying,

“I haven’t had anybody that [the nurse practitioner] continued [yet]. That would be an even bigger issue because that would be somebody that had to go somewhere every single day. It’s expensive. You paying the officers. You paying the gas. The time. That would be a headache.” (White female, 35; Jail 20, medium non-metro)

Logistical challenges were not limited to only the jails. Another interviewee described challenges imposed by their local methadone clinic saying,

“That would be ideal…If they would allow the jail to [pick up] seven days’ worth [of methadone] while they’re in here, then [afterwards they could] go back to their daily. We would be doing it, but that would be up to the methadone clinic. Some will work with you, some will not.” (White female, 63; Jail 31, medium non-metro)

3.3. Behavioral therapy and counseling

Behavioral therapy and counseling may serve as an alternative method of SUD treatment in facilities where MAT/MOUD is unavailable. Jails reported several types of available therapy or counseling including one-on-one sessions with a licensed counselor (n=12), group therapy with a licensed counselor (n=4), and Narcotics Anonymous (NA), Alcoholics Anonymous (AA), or faith-based groups (n=9). Some offered both one-on-one and group options. A single jail reported using a novel brief intervention model for SUD. That facility runs a 30-day county-funded program that offers substance use treatment and transitional case management services for incarcerated PWSUD, as well as some supplemental services like anger management and parenting classes. Five facilities did not offer any type of behavioral therapy or counseling and one interviewee was unsure. The remaining interviewees did not mention therapy or counseling while describing health services for PWSUD.

For those with one-on-one counseling, either the jail’s mental health provider was available to speak with individuals about SUD or an outside agency came in to offer services. At some jails, anyone who experienced withdrawal was automatically referred to mental health, but for others, responsibility for seeking care within the jail fell to the individual. Two facilities had a provider available, but he or she would only see patients regarding other mental health conditions. In those cases, the provider did not offer any formal counseling for SUD. Notably, three jails who offered groups or counseling through outside agencies also planned for continuity of care upon release. Agencies began working with individuals while they were incarcerated and later moved them into their SUD programs in the community. One interviewee described their partnership, stating

“The secretary actually goes through the records and identifies people or sometimes they self-identify and want [to work with our mental and behavioral service providers]...[The providers] come in and they collect their information, what’s wrong with them, start seeing them, start putting the resources to work for them.” (Male, race and age not provided; Jail 4, medium non-metro)

Interviewees also described barriers to providing behavioral therapy. Some identified overwhelmed community SUD programs as the main barrier, describing “seven-month waitlists” and insinuating that programs were not available to partner with the jail to provide services because they were already inundated with patients from the community. Jail staffing shortages were a barrier to offering NA and AA, as groups would have to be canceled if not enough officers were free to supervise on a given day. Additionally, two interviewees identified jail policies related to background checks as a barrier. One stated,

“The people who teach [NA and AA] are usually [former] addicts. Lots of them have criminal backgrounds. Well, they’re not allowed in the jail if they have a criminal background...They don’t pass [the background check], so then they can’t come. Then the classes end up not happening. That’s a big barrier right there.” (White female, 54; Jail 16, medium metro)

3.4. Release planning/reentry services

The final SUD-specific healthcare services individuals may engage with within the jail system are those provided upon release: overdose prevention programming and linkage into community-based care. Overall, the amount of resources devoted to reentry services varied among our sample. The most common reentry service provided was linkage to treatment for SUD. As described in the previous section, three jails worked with local providers to provide counseling during incarceration and referral services. One of those providers was also available to act as a court advocate for individuals in need, supporting them as they navigated their trial and connecting them to local SUD services. Two jails had a social worker who would take the lead on discharge planning for PWSUD, and three jails reported that their own staff provided discharge planning specific to SUD. Jail health care staff were relieved when someone else was available to “get the ball rolling” for individuals who needed referrals. One, whose jail had temporarily lost their mental health social worker said,

“She was a big help in accessing those communities, facilities and groups...If somebody wanted to [go to residential treatment] she would be the one that would start the initial process for that form and give ‘em the paperwork. She was a great facilitator for that...I can hardly wait to get her back.” (White male, 65; Jail 15, small non-metro)

Three additional types of reentry services for PWSUD were described. An interviewee from one jail reported having a relatively new peer mentoring program to help PWSUD reenter society and in another jail, staff worked with a small local organization to arrange housing for PWSUD. The interviewee said, “She will house anybody, whether it’s an alcoholic or a drug user. We’ve placed a lot of people there.” The third jail was the only facility with a OEND program:

“One of the big initiatives that we have is getting Narcan out into the community… What happens is people will have a time when they’re not using. They’ll go back out and think they can use the same amount, and they’ll have overdoses. We put Narcan in their property just in case.” (Black female, 45; Jail 11, medium metro)

Two jails had well-established linkage to care programs, but only for PWSUD who also belonged to certain sub-populations – specifically HIV-positive individuals and veterans. Notably, sixteen jails devoted very few resources to reentry planning and linkage to care for PWSUD and described various barriers to providing these services. Although some provided newly released individuals with a written list of community resources, connecting with providers was described as the responsibility of the individual, their family, their probation officer, or the court. As one stated, “As far as setting them up in a long-term treatment facility, that’s not something we do. Occasionally, the court will order it, but then when the court orders it, it’s up to the—generally speaking, that’s a probation deal.” (White male, 46; Jail 34, medium metro)

Jail staff identified several challenges to discharge planning and linkage to care in the community. One interviewee described a lack of capacity to provide linkages to care saying,

“If somebody says I want to go [to residential treatment], tell your attorney ‘cuz I don’t have the contacts and I don’t have the time to sit down and do all that stuff. There’s 69 others I’m still having to take care of.” (White male, 65; Jail 15, small non-metro)

Another interviewee described the disconnect between administrative and health staff at their facility at the time of release, saying, “We don’t do anything like that [linkage]. Yeah, usually, on my level, I don’t even know they’re leaving. Usually, it’s like they’re walking out the door. I look and I say, “They’re leaving?” I don’t even know.” (White female, 41; Jail 10, medium metro) Finally, some interviewees described a lack of accessible community resources for PWSUD as the main barrier to the provision of reentry services. When asked if any local programs for SUD existed, one interviewee described their frustrations saying,

“Not in this county. We try to get them the resources. Now, there are some rehab hospitals. That’s another thing. It’s fee for service. If they’ve got $100 to go get a fix or $100 to go see a doctor, where you think they’re gonna go?” (White female, 50; Jail 14, medium non-metro)

The burden of seeking care for recently released PWSUD was also frequently mentioned as a barrier. One interviewee said,

“They actually need help. You know, they don’t understand to call this number, to go to this place. They don’t have the resources for that. They can’t even get a bus to go home. [Much] less trying to get all the way across the city to go to an appointment.” (Female, race and age not provided; Jail 01, large metro)

Several staff members identified reentry services as an area where they would like to see their jail improve. Healthcare staff wanted to provide better continuity of care, but they did not personally have the capacity. One described discharge planning and reentry services as “the social work side of things.” Several staff felt that having a social worker, case manager, or other community liaison who could help recently released individuals find housing, enroll in Medicaid, and connect to mental health care would ultimately help reduce recidivism.

3.5. The Context of Care for Incarcerated PSWUD

Jails described two key issues within their healthcare system that affected their ability to provide services for PWSUD. The first was an increase in the volume of individuals needing care without an increase in resources to meet their needs. Interviewees acknowledged the changing landscape of care within the jail, describing longer periods of incarceration, an increase in individuals who have mental health and substance use disorders, and a shift towards younger and sicker populations. One recalled,

“Then drugs and alcohol, I remember where it used to be few and far between when you had somebody come in—and they’re stayin’ in jail longer... Now, the jail is having to do long-term things because people are stayin’ in jail so much longer.” (Black female, 45; Jail 11, medium metro)

Another stated, “You’re seeing younger people with serious health conditions. Getting 20-year-olds having had open heart surgery, valve replacement from shooting up, all kinds of stuff. They have endocarditis. I mean, just all that stuff. It’s cardiac related. They’re just killing themselves.” (White female, 50; Jail 14, medium non-metro)

Despite the increase in case volume, jail staff did not necessarily receive any additional funding or staff. Lack of available correctional officers to assist with mental health and SUD patients was cited as a barrier across the spectrum of services. It affected healthcare staff’s ability to provide transportation for necessary appointments (including MAT) and to hold group therapy, as well as time management in general. As one interviewee stated,

“We have only set times we can actually see people anyway because there’s lunches and then officer lunches. That takes up two hours. That’s lunchtime gone. Then in the afternoon, it’s headcount and things at 4:30 or 5:00. Then they’re getting their evening meal. You’ve only got these set times you can actually do your—see people and do your work.” (Female, race and age not provided; Jail 5, large metro)

Shortages of medical, mental health, and social work staff were described as a barrier to providing comprehensive services, particularly linkage to care. Additionally, several healthcare staff described feelings of burn out and their desire for additional medical hires to relieve them. One said,

“I have been the only nurse and it’s always been eight hours a day. There was a want and a need last year to add an additional nurse eight hours a day, a second shift from maybe 3:00 to 11:00, but the budget just—they just couldn’t allocate the money in the budget. Of course they’re talkin’ about it again for the upcomin’ fiscal year, but who knows? I don’t know if they’re gonna spend the money or not. I could use it.” (White male, 46; Jail 34, medium metro)

Several interviewees felt that staffing was not a budget priority within their facility, saying that the administration was content with the “bare minimum.” Nurses described long shifts and high caseloads. One told us, “I’m on call 24/7. I can’t take a vacation because I don’t have anybody to sit in my seat.” (Female, race and age not provided; Jail 6, large metro).

Interviewees described several potential changes their facilities could make to enhance their ability to provide comprehensive healthcare services for PWSUD, including improved medical spaces (i.e. padded cells for mental health patients), increased funding for mental health and healthcare staffing, dedicated officers to assist with monitoring and patient transport, and improved teamwork between administrative, correctional, and medical staff.

The second issue affecting service provision for PWSUD was a pervasive lack of investment in mental and behavioral healthcare that was evident across counties and states. This contributed to recidivism and feelings of hopelessness among healthcare staff. Throughout their descriptions of healthcare services for PWSUD, interviewees expressed frustration with the inadequacy of available community resources and issues with continuity of care. This was especially true for those who also needed mental health services. One interviewee referred to the mental health crises as “a big elephant in the middle of the room, and everybody’s dealing with everything but the elephant.” Interviewees felt that newly released individuals were not set up for success. In communities where SUD and mental health resources existed, individuals still needed help meeting their basic needs and with navigating the health system. As one interviewee stated,

“They don’t understand to call this number, to go to this place. They don’t have the resources for that. They can’t even get a bus to go home, so you see a lot of ‘em walking. Much less trying to get all the way across [the city] for an appointment.” (Female, race and age not provided; Jail 01, large metro)

Another interviewee felt that not enough time was spent within the jail to make a difference for the average PWSUD, expressing feelings of futility. “Well, here, they’re not here long enough to really get ‘em clean. Really, you just take it away for a few days and they go back; they’re gonna go right back to it.” (White female. 35; Jail 20, medium non-metro) Some staff members expressed doubt regarding PSWUD and their motivation or ability to recover. For example,

“There has to be some desire. A lot of ‘em, they don’t care… I can treat ‘em. I can get ‘em clean. They’re in jail for six weeks and they’re clean. The minute they get out, they’re gonna do drugs again and they’re gonna come back. It’s just a revolving door.” (White male, 65; Jail 15, small non-metro)

Finally, interviewees were frustrated with high rates of turnover and the limits of jail-based health care. As one said,

“The sad part about it is soon as they step foot in the door, they’re ours and they’re our responsibility, but as soon as they step foot out, they’re no longer ours. So it’s like care stops right there and that’s always been a big issue that we’ve all discussed. There’s no discharge. They just leave.” (White female, 49; Jail 2, large metro).

Another said they felt as though their facility was constantly “just throwing people out the door.” Working to provide effective and efficient healthcare for PWSUD and individuals with mental illnesses was draining for some interviewees. They struggled to provide services in broader community systems that ultimately did not provide adequate support for their patients. This led to a pessimistic outlook towards PWSUD and their potential health outcomes. After discussing the lack of mental health care and community resources for PWSUD at length, one interviewee concluded by saying,

“It’s really sad. You see these people get out of jail and out of prison, and they don’t stand a chance. Unless they have a huge family support, which most of them don’t, the chance of their survival out there is just not very good.” (White female, 54; Jail 16, medium metro)

4. Discussion

Overall, we found that jails in the southern United States varied widely in both availability of SUD-related healthcare services and in their adherence to recommended best practices. At entry, 16 of 34 jails (47%) reported some form of screening for SUD (self-report, checking medical records if available, visual inspection for signs of substance use, drug testing), while the rest did not report SUD-specific health screening protocols. This finding is slightly lower than expected based on existing literature regarding SUD screening in jails. Taxman et al. (2007) found that roughly two thirds of jails screened for SUD at intake. More recently, Bunting et al. (2023) completed a content analysis of jail intake forms (n=63) and found that 3 in 4 jails included SUD-specific screening questions.

We found that most jails were following federal guidance for supervising withdrawal from substances that caused symptoms that were perceived as potentially life-threatening, such as seizures. They had a sense of urgency surrounding the treatment of alcohol and benzodiazepine-dependent individuals and tapered medications for withdrawal management were provided promptly. In sharp contrast, most jails did not provide evidence-based medical management for opioid withdrawal, which was considered less hazardous. Yet incarcerated individuals have died from dehydration, severe electrolyte imbalances, or from secondary conditions (e.g. a perforated ulcer or history of seizures) that were overlooked or ignored amid other withdrawal symptoms (Baumgartner & Brookes, 2018; Bureau of Justice Assistance, 2022). A study of deaths in US jails from 2000 to 2013 found that while alcohol was involved in 76% of withdrawal-related deaths, opioids were implicated in the remaining 24% (Fiscella et al., 2020).

Our results supported existing evidence that MOUD in jails is most widely available for pregnant individuals (Belenko et al., 2013; Friedmann et al., 2012; Knittel et al., 2022; Sufrin et al., 2022). However, pregnant individuals with OUD represent a very small segment of the jail population in need. A recent study estimated that only 3% of all individuals entering jails are pregnant, and even fewer (14% of those who are pregnant) also have an OUD (Sufrin et al., 2020). See Knittel et al. (2022) for full report of the data from this study pertaining to jail health services for pregnant individuals. Only one jail (3% of the sample) provided MOUD to non-pregnant individuals/the general population, but an additional four (12% of sample) were planning to implement some form of MOUD. These statistics are roughly what we would have expected to find in a non-representative sample based on the existing literature. Maruschak et al. (2023) found that 16% of southern jails could continue MOUD for the general population and 11% could initiate MOUD. The main barriers to MOUD provision were cost, logistics/security concerns, and lack of a properly licensed provider, which was also consistent with the existing literature (Friedmann et al., 2012).

Roughly one third of the jails in our sample provided behavioral group or individual therapy with a licensed counselor and roughly one quarter offered self-help groups. Availability of counseling services was higher than reported in older studies (Karberg & James, 2005; Taxman et al., 2007). However, this sample was not representative and services were still limited to once per week in many jails. Interviewees were not asked to provide any details on the therapeutic approaches taken by their mental health professionals (e.g. cognitive behavioral therapy). Regardless of the treatment approach taken, widespread agreement exists in the literature that planning for continuity of care after release is essential for effective intervention (Bahr et al., 2012; Belenko et al., 2013; Chandler et al., 2009; Peters et al., 2017). While some jails in our sample had implemented innovative and evidence-based protocols for reentry, many offered minimal or no reentry services.

We recognize that jail size and urbanicity/metro status may influence their ability to provide certain SUD-related services. For example, some non-metro interviewees reported a lack of local MAT/MOUD providers to partner with for continuation or initiation of treatment. In this sample, small jails were least likely to offer MOUD in general (i.e., for pregnant individuals and general population). However, MOUD for non-pregnant individuals was similarly limited across all jail sizes. Small jails were also least likely to offer group therapy and re-entry services (both for the general population and PWSUD specifically). In comparing metro and non-metro jails, non-metro jails were less likely to offer MOUD in general, to have Narcan available on-site, and to offer re-entry services in general. While fewer re-entry programs existed overall (e.g., for the general population, specific sub-populations like veterans), a large disparity in SUD-specific reentry services did not exist; 27% of non-metro jails provided SUD-specific re-entry services compared to 32% of metro jails.

It is worth noting that the most of the services where disparities were observed are the most resource intensive, either in terms of monetary investment or staff required (e.g., officers to transport to MOUD, officers to monitor group therapy sessions, protected time for a staff member to create re-entry plans). Small and non-metro jails were comparable to larger and metro facilities in their use of lower-resources practices such as screening for SUD and monitoring PWSUD in withdrawal using either dedicated medical areas or holding/booking cells near officers.

After considering our findings, we have several initial recommendations for improving access to effective, evidence-based healthcare services for SUD in jails. While healthcare staff may be unable to overcome institutional barriers to administer a full or partial opioid agonist taper to manage opioid withdrawal (such as policies prohibiting storage of controlled substances), use of a clonidine taper could improve withdrawal symptoms. Clonidine is an α-2- receptor agonist used to reduce noradrenergic hyperactivity seen in opioid withdrawal, which is related to many symptoms. Clonidine is an affordable (average wholesale price $0.63 per 0.3 mg tablet) and non-scheduled medication that has often been used off-label for management of opioid withdrawal symptoms and has shown to be effective in improving symptoms in at least one small study set in a county jail (Fresquez & Fogger, 2015; Kosten & Baxter, 2019; Kuszmaul, Palmer & Frederick, 2020).

Jails have historically resisted implementing MAT/MOUD programs for a variety of reasons such as concerns that MAT is “substituting one drug for another,” fear of unauthorized and illicit use, cost, or the need for a licensed provider (Friedmann et al., 2011; Grella et al., 2020). However, jails administrators should begin strongly considering processes and procedures to allow for MAT, as trends in case law suggest that jails may soon be required to offer continuation. In recent court cases involving both prison and jail-based healthcare, judges have ruled that denying MAT to individuals already participating in a treatment program is a violation of their rights under the Americans with Disabilities Act (American Civil Liberties Union, 2021). Laying the groundwork for continuation may lead to improved perceptions of MAT among staff and the opportunity expand the MAT program into other areas as resources allow, such as medical management of opioid withdrawal. In the absence of MAT, jails might consider implementing more regular behavioral therapy or other different types of brief interventions that include a referral into treatment in an attempt to reduce recidivism (Chandler et al., 2009).

The lack of re-entry planning and support, including linkage to care and overdose prevention services, was a particularly large gap in services among our sample. Re-entry planning may not be feasible for individuals with short/average jail stays, but it could greatly benefit individuals with longer incarcerations. In a scoping review of reentry interventions for PWSUD, Grella et al. (2023) evaluated case management, peer or patient navigation, initiation of MOUD or linkage to a community-based MOUD provider, and motivational enhancement approaches. Of these, the more “assertive” approaches, such as intensive case management, had the strongest evidence for facilitating successful transitions to community-based care. Brief motivational enhancement interventions (a “passive” approach) did not have a significant effect (Grella et al., 2023). These more assertive approaches are more resource-intensive in terms of both monetary investment and duration of engagement. Based on the barriers reported by our interviewees, improving the quality of reentry services will likely require administrative commitment to hiring additional nursing or social work staff. A staff member at the jail must have protected time to screen individuals, assess their needs, begin planning for treatment, and coordinate with community-based organizations to create a transition plan (Osher et al., 2003). Our findings regarding barriers to reentry planning support other recent studies. Bandara et al. (2021) and Matsumoto et al. (2022) also found that unanticipated release, along with lack of inter- (within jail) and intra- (between community partners) agency collaboration, were major barriers to successful planning. Identifying effective strategies for reentry planning for short and/or unpredictable jail stays is an important area for future research.

In the meantime, jails may look to incorporate OEND programs as a first step towards protecting PWSUD post-release. Although only one jail offered an OEND program, ten others already kept naloxone in their facility in case of an overdose and were trained on emergency use. Recently released individuals are at higher risk of dying from an opioid overdose compared to someone in the general population (Joudrey et al., 2019; Ranapurwala et al., 2022). OEND programs can greatly impact rates of fatal overdose after release, and they may be easier to implement for jails that lack other local resources. A variety of national and state-level partners can help to fund OEND programs and that offer discounted purchasing programs for naloxone. Clear, existing guidance also indicates how to implement programs within local jails (Wenger et al., 2019).

Implementing changes to improve available healthcare services for PWSUD will require buy-in from local governments, jails administrators, private healthcare companies, and other local healthcare providers. Most of the barriers to improvement– organizational buy-in, cost/budgeting, staffing, logistics – were not under the control of healthcare staff. Staff expressed the will to improve services, but lacked the resources and administrative support necessary to make changes. This lack of investment led to low morale among the staff, as they struggled to meet need with few resources. As government-run institutions (typically managed by counties), jails vary in the per capita tax revenue allotted to them and in how much of their own budget they allocate towards healthcare services. High turnover of the jail population leads to unpredictable case volume and treatment needs in any given week, and jails have reported great difficulty appropriately budgeting for healthcare costs (Huh et al., 2018). Additionally, most of the jails in this sample contracted with private healthcare companies who could exert control over how healthcare resources were allotted and which services were provided (Carda-Auten et al., 2022).

Counties must find the means to invest more heavily in facilitating access to mental and behavioral health, particularly for justice-involved populations, if they want to reduce recidivism among PWSUD and improve public health overall. To that end, public and private funding initiatives are increasingly available to support local jails in their efforts to improve access to mental health care, behavioral health care, and reentry services (Huh et al., 2018). Counties could also ease the burden of care by investing in strategies that focus on early diversion and decreasing the number of people in jail for low level drug offenses. These strategies include specialized crisis intervention teams and Law Enforcement Assisted Diversion (LEAD) programs, which focus on redirecting low-level offenders to supportive community-based programs and services instead of jail.

4.1. Limitations

This study had limitations. As a qualitative study with a non-random sample, the results are not broadly generalizable. Additionally, our interviews may have missed important perceptions or contextual factors necessary to fully understand services for PWSUD, and interviewees may have been reluctant to disclose some perceptions that they deemed reflected negatively on their jails. Finally, our interviews did not incorporate views of incarcerated PWSUD.

5. Conclusion

This study provides a contemporary portrait of SUD-related healthcare within county jails in the southern region of the US. In summary, jails could make several relatively low-barrier changes to decrease mortality and improve health outcomes for incarcerated PWSUD, such as implementing evidence-based withdrawal management protocols, screening and brief intervention with referral to treatment approaches – which may be implemented despite short jail stays, and OEND programs. Other more extensive changes, such as hiring additional healthcare staff to provide behavioral healthcare services or coordinate reentry services, may require more intensive implementation processes and engagement with a variety of internal and external stakeholders. The lack of investment in behavioral and mental healthcare across all sectors, from the national government to the county jail administration, contributes to recidivism and remains a consistent barrier to providing effective healthcare services and improving outcomes for PWSUD who have been incarcerated.

Highlights.

• Qualitative study of healthcare services for PWSUD in southern jails.

• Services included withdrawal management, SUD treatment, and reentry planning.

• Availability of services and adherence to best practice varied across jails.

• Staff reported increased case volume, as well as problems with staffing and budget.

• Lack of administrative support/investment in behavioral healthcare are barriers.