A self-assessment of opioid use disorder services at a Pacific Northwest County jail

Abstract

This study describes the delivery of opioid use disorder (OUD) services in a Pacific Northwest County jail focusing on screening, assessment, withdrawal management, and medications for opioid use disorder (MOUD). Guided by the 2023 Medicaid performance measures, self-assessment data were collected through stakeholder interviews, policy and electronic healthcare records (EHR) analyses, and a systematic survey focusing on conformity to practice, policy, and documentation. This jail provided OUD screening, assessment, withdrawal management, and MOUD supported by institutional policy and an EHR software system. Survey results confirmed strong conformity to the 2023 Medicaid performance measures, with 91.9% of required recommendations met for policy and practice domains and 87.9% for documentation. Optional (not required) recommendations achieved 80.0% conformity for policy, 93.3% for practice, and 60.0% for documentation. The findings from this self-assessment underscore the robust implementation of OUD services in one jail and can inform internal and external performance improvement goals and activities. (150 words)

Opioid Use Disorder (OUD) remains a pervasive and urgent public health crisis in the United States. In 2022, opioid overdoses claimed over 81,000 lives, according to the Centers for Disease Control and Prevention [1]. Beyond its devastating mortality rate, OUD imposes profound individual and societal burdens, including incarceration, health deterioration, economic instability, and fractured relationships [2]. Medications for Opioid Use Disorder (MOUD), methadone, buprenorphine, and extended-release naltrexone, are well-established, evidence-based, approved treatments that significantly reduce overdose risk and improve recovery outcomes [3]. Retention in methadone and buprenorphine treatment is associated with substantial reductions in overdose mortality among people dependent on opioids [4]. However, access to these treatments remains critically limited. According to the 2020 National Survey on Drug Use and Health, only 11.2% of individuals with OUD accessed MOUD in the past year, reflecting substantial treatment gaps [5].

The criminal justice system intersects significantly with the opioid crisis, disproportionately affecting individuals with opioid use disorder (OUD). Individuals involved in the criminal justice system are disproportionately affected by OUD, with an estimated 15% of incarcerated individuals meeting diagnostic criteria for the disorder [2], a markedly higher rate than the 0.6–0.9% prevalence of prescription opioid use disorder among U.S. adults aged 18 and older (DSM-5 criteria) [6]. These elevated rates reflect longstanding disparities in access to care, with many individuals encountering significant barriers to evidence-based treatment in the community. In this context, jails can serve as a crucial point of engagement for treatment—not because incarceration is inherently therapeutic, but because it may be one of the few environments where individuals can access care without the competing demands and structural obstacles present in the community. Moreover, offering MOUD during incarceration has been associated with strong protective effects against overdose following release, reinforcing its importance as a harm reduction strategy. The National Commission on Correctional Health Care has recognized the high prevalence of OUD among incarcerated populations and issued recommendations to ensure access to and continuity of MOUD as an urgent public health priority [7].

Comprehensive care models for OUD in correctional settings have been identified and endorsed by expert panels [8–12]. These models outline evidence-based best practices to manage OUD and emphasize a continuum of care that includes screening, clinical assessment, withdrawal management, MOUD initiation, and reentry services to ensure post-release continuity and positive outcomes. They also provide facility administrators and healthcare practitioners with specific directions for developing the policy and practice, and monitoring the uniformity and quality of service delivery. These models support the argument that MOUD treatment should be the standard of care in jails and prisons.

Despite the existence of these care models, the full potential of correctional facilities as intervention sites remains largely unrealized. About 7% of all carceral systems in the U.S. with high OUD mortality offered all three FDA-approved medications, while 92% of these jails offered some form of MOUD [8]. Only 20% of these jails treated all individuals assessed with OUD and 72% of facilities reported offering post-release continuity of care. This limited access perpetuates cycles of relapse, overdose, and re-incarceration, particularly during the high-risk period following release. In another study, 8.1% of arrestees were diagnosed with OUD in four jails with MOUD programs, with 31.3% of these diagnosed arrestees receiving medication [11]. Similarly, a qualitative study of formerly incarcerated individuals in a state prison system highlighted substantial variability and barriers in access to MOUD, underscoring how systemic limitations and policy inconsistencies continue to obstruct evidence-based care in carceral settings [13]. Surprisingly, not all pregnant incarcerated women with OUD in the U.S. appeared to have access to essential medications and standard medical care [14]. A few examples of administering MOUD in jails have demonstrated success. A randomized, open-label trial by Rich and colleagues in 2015 [15] demonstrated that continuing methadone treatment during incarceration significantly improves post-release treatment engagement and reduces relapse compared to forced withdrawal. Moore and colleagues in 2018 [16] found that continuing methadone maintenance treatment during incarceration is feasible and effective compared to forced withdrawal. A comprehensive program evaluation of expanding access to MOUD in jails conducted by Pourtaher and colleagues in 2024 found a reduction in overdose deaths immediately after release and relatively high adherence to filling their first prescription of buprenorphine [17]. The Hennepin County Jail in Minnesota documented a program that effectively integrated methadone, buprenorphine, and extended-release naltrexone for incarcerated individuals with moderate-to-severe OUD [18]. Innovative approaches, such as telemedicine and streamlined protocols during the COVID-19 pandemic, enabled one program to meet healthcare demand and maintain standards, including the elimination of the “X-waiver” permitting the prescription of buprenorphine by physicians like any schedule 3 medication [19]. An economic evaluation of OUD in a Massachusetts jail found that a strategy of offering MOUD during incarceration was cost-effective and associated with fewer overdose deaths [20].

The impact of MOUD implementation in carceral settings is evident. MOUD administration throughout the period of criminal justice involvement reduced mortality and recidivism [21], all-cause mortality and specific causes of death [22], and improved post-release outcomes [23] among incarcerated individuals with OUD. A modeling study estimated that sustaining interventions like MOUD, naloxone distribution, and safer prescribing could reduce opioid overdose deaths by 13–46% across four U.S. states, highlighting the lifesaving impact of continued public health efforts [24]. Similarly, methadone and buprenorphine treatment during incarceration reduced overdose mortality risk by 80% in the first-month post-release [25]. A randomized clinical trial of methadone treatment of arrestees found that initiating methadone treatment in jail was effective in promoting entry into community-based addiction treatment [26] but the impact was not sustained at long-term follow-up [27].

To address the gaps in the availability and implementation of OUD clinical best practices, jails need evaluation, training, technical assistance, and funding to improve the clinical capacity to administer MOUD and reduce the risk of opioid-related overdose during incarceration and following release [8, 28]. A qualitative study conducted in seven Massachusetts jails found that successful implementation of legislatively mandated MOUD in jails was associated with systematic reviews and evaluations of policy, resources, implementation, training, and education [29]. Jail-based programs that effectively screen and provide MOUD have the potential to reduce opioid-related deaths in this high-risk population, especially with post-release treatment engagement and retention [30].

The National Commission on Correctional Health Care (NCCHC) released standards for treating OUD or any other health conditions among patients in jails and prisons in 2016, and a recent report published by Viaduct Consulting LLC in 2023 recommended a comprehensive list of best practices for OUD services in jails and prisons that could be reimbursed through the Medicaid Sect. 1115 waiver [7, 31]. When applied to jails, this waiver can support innovative programs to address health care needs and improve care transitions for incarcerated individuals, including those with opioid use disorder (OUD) or other chronic conditions. Recent findings by Berk et al. [32] further underscore the impact of such programs, demonstrating that initiation of MOUD during incarceration and linkage to community-based care at release significantly reduced overdose risk and improved continuity of care, reinforcing the value of integrated OUD treatment models in correctional settings. These findings support promising avenues for expanding access to Sect. 1115 waivers, including state-level policy reforms, cross-agency collaborations, and federal incentives that encourage broader adoption of jail-based MOUD programs.

Current study

This self-assessment study describes the cascade of opioid use disorder (OUD) services, including screening, clinical assessment, withdrawal management, and medications for opioid use disorder (MOUD), delivered in a Pacific Northwest County jail operated by a national correctional healthcare provider. The primary aim was to evaluate the jail’s OUD-related policies, practices, and documentation using the 2023 Medicaid performance measures as a framework for internal quality improvement. The study is intended to serve as a replicable model that other correctional facilities can use to guide internal assessments and inform system-wide enhancements.

Pacific Northwest Contracted jail

A national correctional healthcare services, technology solutions, and administrative services company contracted jail was used for this self-assessment. Given the higher prevalence of OUD in the western parts of the country [33, 34], a jail located in the Pacific Northwest was selected for this self-assessment. This jail was also the companies first established, long term, and most experienced MOUD program dispensing FDA-approved drugs of buprenorphine, methadone, and extended-release naltrexone for OUD.

Cascade of Services for OUD

Figure 1 presents an overview of the cascade and types of OUD services at this jail for screening, assessment, withdrawal management, and MOUD. All individuals who voluntarily consented to receiving healthcare services at this jail were screened during detainment for OUD to determine the need for assessment, withdrawal management, and/or MOUD. OUD screening and clinical assessments pertinent to OUD present in the EHR software system are shown in Table 1. The procedures of OUD screening, clinical assessment, withdrawal management, and MOUD services at this facility are described below.

Fig. 1.

Cascade and types of OUD services

Table 1.

OUD screening and clinical assessments

Receiving Screening/Arresting Officer Questions (RS-AR)

Arresting officer aware arrestee was under the influence of drugs or alcohol (yes, no, NA).

Observation or demonstration of intoxicated, in withdrawal, slurred speech, unsteady gait, stupor, tremulous, sweating, anxious, abnormal breathing, or hyperventilating (affirmative, negative).

Receiving Screening/Substance Use Assessment (RS-SU)

History of risk of alcohol or drug withdrawal (affirmative, negative).

Recent use of illegal drugs or prescription pain medication (affirmative, negative).

Most recent use of alcohol, sedative (e.g., Xanax, Klonopin, Valium, Ativan), or opioids (e.g., heroin, oxycodone, Lortab, methadone) (affirmative, negative).

How recent was alcohol, sedative, or opiate use (5 days or less, 6 days or greater)?

Mental Health Screening/Substance Use Questions (MHS-SU)

Used illegal drugs or abused prescription drugs (ever) (affirmative, negative).

Abused alcohol or sedatives (ever) (affirmative, negative).

Experienced significant alcohol or drug withdrawal, including any history of withdrawal seizures (ever) (affirmative, negative).

Been in inpatient or outpatient detoxification or had any hospitalization related to substance abuse (affirmative, negative).

Urine Drug Screen (UDS)

Opioid (OPI), methamphetamine (MET), amphetamine (AMP), benzodiazepine (BZO), cocaine (COC), methadone (MTD), oxycodone (OXY), marijuana (THC), barbiturates (BAR), buprenorphine (BUP), 3,4-Methyl​enedioxy​methamphetamine or “ecstasy” (MDMA), and phencyclidine (PCP) (Quick Test Cup™) (negative, presumptive positive for each).

Separate FYL-U11 tested for fentanyl (FEN) (Rapid Test Strip) (negative, presumptive positive).

Opiate Withdrawal Screening (CDS-OPI)

Is the patient currently exhibiting opiate withdrawal symptoms (sweating, restlessness, dilated pupils, bone/joint aches, tearing, GI upset, tremor, yawing, irritability, gooseflesh skin) (yes, no)?

Last opiate use (3 or fewer days ago, 4 or more days ago).

Number of days (opioid) use per week (3 or fewer days, 4 or more days, daily).

Clinical Opiate Withdrawal Scale (COWS)

Resting pulse rate, Sweating, Restlessness, Pupil size, Bone or joint aches, Runny nose or tearing, GI upset, Tremor, Yawing, Anxiety or irritability, Gooseflesh skin (severity ratings of 0–4 or 0–5 for each symptom; decision criterion - total score less than 6 vs. 6 or more).

Screening

The purpose of the screening phase is to identify patients who are at risk of opioid withdrawal and who might need clinical assessment, withdrawal management, or MOUD. The screening phase utilizes Receiving Screening (RS) and Urine Drug Screening (UDS) questions (see Table 1). The RS procedure has two parts: Receiving Screening /Arresting Officer Questions (RS-AR) and Receiving Screening/Substance Use Assessment (RS-SU). The RS utilizes observations and interview questions specific to opioid use to document recent or past opioid use and history of opioid withdrawal or medically assisted detoxification. Observations of intoxication or withdrawal symptoms are documented by the arresting officer and qualified healthcare professional and screening questions are administered by a qualified healthcare professional, specifically an emergency medical technician or a nurse. A urine drug screen (UDS) for opioids (and other drugs) is administered to individuals at risk of opioid withdrawal and verify recent opioid use, resulting in a presumptive positive or negative result. Recent or past opioid use based on observations of intoxication or withdrawal symptoms or self-reported use of opioids (last use of opioids within the past 5 days), history of opioid withdrawal or medically assisted detoxification, or a presumptive positive UDS, prompt a clinical assessment.

Clinical assessment

The purpose of the clinical assessment phase is to determine the medical necessity for opioid withdrawal management or MOUD among arrestees, expected to be at risk for opioid withdrawal during screening. Validation of pregnancy and prescribed use of opioid maintenance treatment before detainment are documented at this phase. There are two clinical assessments: The Comprehensive Detoxification Assessment (CDA) and Clinical Opiate Withdrawal Scale (COWS).

The CDA and COWS (see Table 1) are administered by qualified healthcare practitioners trained to use these clinical assessments. The CDA is an interview-based assessment that evaluates the presence of opioid withdrawal symptoms, last opioid use, and frequency of opioid use. If the CDA indicates symptoms of withdrawal, opioid use in the past three days, or regular use (e.g., four or more days per week), the COWS is administered to evaluate the severity of withdrawal. The COWS is a validated scale [35] ranging from 0 to 36, with higher scores indicating more severe symptoms. A COWS score of 6 or greater, based on policy, prompts the initiation of a buprenorphine/naloxone taper if one has not already been started. All patients undergoing detox monitoring are also considered eligible for MOUD, and the decision to initiate MOUD is based on clinical judgment and patient consent. Clinical documentation of withdrawal risk prompts appropriate withdrawal management, including comfort medications and hydration, ordered by a qualified medical clinician as indicated.

Withdrawal management

Withdrawal management is implemented to ensure the safety and reduce the physiological distress of individuals undergoing opioid withdrawal. Supportive medications are prescribed by a physician to manage common symptoms associated with opioid withdrawal, including acetaminophen or ibuprofen for pain or muscle aches, loperamide for diarrhea, and ondansetron for nausea or vomiting. These medications may also be used to treat similar symptoms unrelated to withdrawal (e.g., viral gastroenteritis or headache). Fluid and electrolyte replacement, such as oral rehydration with electrolyte beverages, is also provided to address dehydration. Clinical Opiate Withdrawal Scale (COWS) assessments are conducted regularly during this stage to monitor symptom progression, adjust supportive medication use as needed, and inform decisions regarding the initiation of MOUD.

Medication for opiate use disorder (MOUD)

MOUD is a treatment approach that uses the FDA-approved medications buprenorphine, methadone, and extended-release naltrexone to treat OUD. Under an all-inclusive MOUD contract, resources were not a barrier to care delivery. Patients meeting medical necessity for withdrawal management, defined by clinical judgment or a Clinical Opiate Withdrawal Scale (COWS) score of 6 or greater and more than 12 h since last opioid use, or those still monitored by COWS after 24 h were eligible for either a 5-day buprenorphine/naloxone taper or induction into the jail’s MOUD program. This determination was based on clinical judgment and patient preference. MOUD was automatically continued for individuals receiving treatment prior to incarceration. Pregnant patients meeting criteria were placed on MOUD per policy. While buprenorphine and methadone were the most commonly used medications, extended-release naltrexone was available in accordance with clinical indications and patient preference.

Conformity to the 2023 medicaid performance measures

Overview and design

This study evaluated the implementation of 52 best practice recommendations for opioid use disorder (OUD) care in a jail setting; refer to the 2023 report titled “Recommendations for Medicaid Coverage of Opioid Use Disorder Services in Jails and Prisons” [31] for specific recommendations. These recommendations were organized into three domains of care: Screening, Clinical Assessment, and Medication for Opioid Use Disorder (MOUD). The screening domain included nine recommendations, the clinical assessment domain included seventeen, and the MOUD domain included twenty-six. Of the total fifty-two recommendations, thirty-seven were designated as required and fifteen as optional. For the purposes of analysis, each recommendation was treated as a standalone item, even if it contained multiple components. The implications of this unit-based approach are addressed in the study’s limitations.

The aim of the screening phase was to identify individuals at risk for opioid withdrawal who might require further assessment or MOUD initiation. The clinical assessment phase was intended to determine medical necessity for treatment or withdrawal management among individuals identified during screening. MOUD was defined as a treatment approach involving any of the three FDA-approved medications for OUD: buprenorphine, methadone, and extended-release naltrexone.

Expert selection and domain definitions

A panel of six subject matter experts was recruited, with two experts representing each of the three domains: policy, clinical practice, and documentation. All experts were internal to the healthcare service infrastructure associated with the jail, selected to ensure familiarity with the site-specific operations, record systems, and institutional mandates. While external experts might have increased generalizability, internal reviewers were chosen to enhance contextual validity and practical relevance.

Each domain was defined as follows. The policy domain referred to formal institutional rules or protocols that govern care delivery, including eligibility criteria, service mandates, and procedural timelines. The clinical practice domain captured the actual delivery of care by medical providers within the jail setting, focusing on observable service behaviors and adherence to evidence-based standards. The documentation domain encompassed the infrastructure of the medical record system, particularly its ability to structure and support accurate recording of clinical processes and decisions.

Rating procedures

Each expert independently rated the fifty-two recommendations using a four-category scale: present, partially present, not present, or not applicable. Experts were instructed to base their ratings on domain-specific materials, such as written policies, clinical protocols, electronic medical records (EMRs), provider behavior, and their own professional experience. Upon completing their independent assessments, the two experts within each domain met to reconcile discrepancies and submitted a final, consensus-based set of ratings.

In the policy domain, a recommendation was rated as present if it was explicitly and fully addressed in written policy, including any relevant timelines or qualifiers. A partially present rating was used when policy language referenced the recommendation but lacked specificity or applied only to a limited population. If the recommendation was not addressed in policy at all, it was rated as not present. Recommendations deemed inapplicable due to legal, structural, or operational constraints were rated as not applicable. Importantly, this domain assessed only the written policy and did not consider actual implementation.

In the clinical practice domain, experts rated recommendations as present if the service was delivered consistently to at least 80% of eligible individuals, as observed or reported in the past year. Services delivered inconsistently, to subgroups only, or in ways that did not meet timing benchmarks were rated as partially present. A rating of not present was given when no implementation could be identified. Recommendations that could not be reasonably implemented due to structural or mandate-related limitations were rated as not applicable. This domain focused on actual service delivery rather than policy intent.

In the documentation domain, a recommendation was rated as present when the jail’s EMR contained a designated field, module, or form corresponding to the recommended action. Partially present indicated that documentation fields were insufficient or unstructured, such as when notes were used instead of templates. A rating of not present was used when the system offered no documentation mechanism. Not applicable was used when the recommendation did not require documentation due to its irrelevance to the services provided. This domain assessed the structural capacity for documentation rather than the actual recording of actions.

Operational thresholds

To ensure consistency across domains, rating thresholds were defined in advance. A recommendation was rated as present when there was reliable evidence of support, implementation, or documentation affecting the majority of eligible individuals, typically defined as 80% or more. Partially present was used when evidence existed but was incomplete in clarity, scope, or execution. Not present indicated that no support, implementation, or documentation was evident. Not applicable was reserved for recommendations that could not be evaluated due to structural infeasibility.

This structured, domain-specific, and threshold-guided methodology enabled a robust and replicable evaluation of OUD-related services in jail settings. The use of internal domain experts further enhanced the assessment’s contextual relevance, while the three-domain approach ensured that findings reflected not only policy intent, but also clinical implementation and documentation.

Standardized definitions for expert evaluation of OUD treatment practices

To promote consistency in interpretation and enhance the reliability of expert evaluations regarding opioid use disorder (OUD) treatment practices, the following standardized definitions were provided. OUD is defined as the use of opioids resulting in physical dependence, cravings, and continued use despite adverse consequences, excluding cases of physical tolerance or dependence arising from properly managed pain treatment. OUD withdrawal refers to the constellation of symptoms that occur following the discontinuation of opioids in physically dependent individuals, including pain, chills, nausea, vomiting, and malaise. OUD treatment encompasses any therapeutic approach to managing the disorder, including medications for opioid use disorder (MOUD), behavioral therapies, substance abuse treatment programs, peer support groups, or a combination of these modalities. MOUD specifically refers to treatment programs that provide FDA-approved medications, buprenorphine, methadone, and extended-release naltrexone, to individuals meeting clinical criteria for OUD, encompassing both the initiation of treatment and continuation for those already engaged in MOUD prior to incarceration. MOUD treatment includes either starting or maintaining these medications. MOUD initiation involves beginning one of the three medications for a patient with OUD, whether in withdrawal (in the case of buprenorphine and methadone) or meeting diagnostic criteria for OUD, with the intent to maintain the patient on the medication per clinical standards of care. MOUD continuation refers to the ongoing administration of these medications for individuals who were receiving treatment in the community before incarceration. MOUD initiation for withdrawal management specifically denotes the use of methadone or buprenorphine to alleviate acute withdrawal symptoms while simultaneously initiating ongoing OUD treatment, distinguishing this approach from short-term opioid agonist tapers that are used solely for symptomatic relief without long-term treatment intent.

Evaluation survey findings

Tables 2 and 3 present the frequencies and percentages of expert ratings by domain (policy, practice, and documentation) and OUD service section (screening, assessment, and MOUD) for required recommendations and optional recommendations, respectively. For required recommendations (Table 2), 91.9% of all (Overall) recommendations were rated present for policy and practice domains, and 87.9% of all recommendations were rated present for the documentation domain, excluding not applicable ratings. All required recommendations for screening and assessment sections were rated present or partially present across all three domains. There was only one required recommendation for Policy/MOUD and one recommendation for Documentation/MOUD rated not present. For recommendations that were optional (not required) (Table 3), 80.0% of all (Overall) recommendations were rated present for policy, 93.3% were rated present for practice, and 60.0% were rated present for documentation domains. All optional (not required) recommendations for screening were rated present across all three domains. Two optional (not required) recommendations for Policy/Assessment, two for Documentation/Assessment, and one for Documentation/MOUD were rated not present. Identification of specific recommendations is reserved for internal quality enhancement purposes.

Table 2.

Results of 2023 expert ratings by domain (Policy, Practice, and Documentation) and OUD service section (Screening, Assessment, and MOUD) for required recommendations

	Policy		Practice		Documentation
Ratings	n	%	n	%	n	%
Section 2: Screening (7 recommendations)
Present (P)	6	85.7	6	85.7	5	83.3
Partially present (PP)	1	14.3	1	14.3	1	16.7
Not present (NP)	0	0	0	0	0	0
Not applicable (NA)	0	-	0	-	1	-
Section 3: Assessment (9 recommendations)
Present (P)	8	88.9	8	88.9	6	85.7
Partially present (PP)	1	11.1	1	11.1	1	14.3
Not present (NP)	0	0	0	0	0	0
Not applicable (NA)	0	-	0	-	2	-
Section 4: MOUD (21 recommendations)
Present (P)	20	95.2	20	95.2	18	90.0
Partially present (PP)	0	0	1	4.8	1	5.0
Not present (NP)	1	4.8	0	0	1	5.0
Not applicable (NA)	0	-	0	-	1	-
Overall (37 recommendations)
Present (P)	34	91.9	34	91.9	29	87.9
Partially present (PP)	2	5.4	3	8.1	3	9.1
Not present (NP)	1	2.7	0	0	1	3
Not applicable (NA)	0	-	0	-	4	-

Table 3.

Results of expert ratings by domain (policy, practice, and documentation) and OUD service section (screening, assessment, and MOUD) for optional (not required) recommendations

	Policy		Practice		Documentation
Ratings	n	%	n	%	n	%
Section 2: Screening (2 recommendations)
Present (P)	2	100	2	100	2	100
Partially present (PP)	0	0	0	0	0	0
Not present (NP)	0	0	0	0	0	0
Not applicable (NA)	0	-	0	-	0	-
Section 3: Assessment (8 recommendations)
Present (P)	6	75.0	7	87.5	4	66.7
Partially present (PP)	0	0	1	12.5	0	0
Not present (NP)	2	25.0	0	0	2	33.3
Not applicable (NA)	0	-	0	-	2	-
Section 4: MOUD (5 recommendations)
Present (P)	4	80.0	5	100	0	0
Partially present (PP)	1	20.0	0	0	1	50.0
Not present (NP)	0	0	0	0	1	50.0
Not applicable (NA)	0	-	0	-	3	-
Overall (15 recommendations)
Present (P)	12	80.0	14	93.3	6	60.0
Partially present (PP)	1	6.7	1	6.7	1	10.0
Not present (NP)	2	13.3	0	0	3	30.0
Not applicable (NA)	0	-	0	-	5	-

Limitations

While the internal expert raters of the conformity survey were qualified and knowledgeable, they were still at risk of subjectivity and positivity bias despite efforts at improving interrater reliability. While internal experts are commonly used for self-assessments, external experts could be used for increased objectivity, but at a more significant financial cost and lack of awareness of the intricacies of the system.

Rating the conformity of jail OUD services to the 2023 Medicaid performance measures was sometimes challenging when a recommendation contained multiple criteria or requirements. Most ratings of partially present were due to this limitation. Furthermore, the lack of consensus about definitions of some OUD service terms was initially challenging and could have compromised the validity and reliability of conformity ratings. To counter this limitation, the authors created and used a standardized list of definitions of OUD screening, assessment, and treatment terms for expert ratings.

A recommendation conspicuously absent from the 2023 Medicaid performance measures but available at the contract jail was the implementation of UDS. UDS are used regularly to validate questionable self-reports, determine medical necessity for OUD withdrawal management or MOUD, and for the research the nature and extent of substance use among a U.S. arrestee population utilizing healthcare services [29].

While the findings of this self-assessment are valuable as a strategy and for internal quality improvement, they are primarily qualitative. The accuracy of screening and assessment methods in predicting OUD withdrawal management and MOUD service utilization and outcomes cannot be determined without more quantitative research. Diagnostic accuracy analysis, including receiver operating characteristic analysis, predictive validity analysis, and error analysis of screening, assessment and treatment services, is needed. These analyses will assess how well an instrument or screening/assessment strategy identifies or differentiates specific conditions or outcomes, providing critical insight into their reliability and practical utility, which is presently underway by the authors.

Discussion

This self-assessment evaluated the extent to which a Pacific Northwest county jail adhered to 2023 Medicaid performance measures for opioid use disorder (OUD) services, including screening, assessment, withdrawal management, and medications for opioid use disorder (MOUD). The findings revealed high conformity to required best practice recommendations across policy (91.9%), clinical practice (91.9%), and documentation (87.9%) domains, with particularly robust implementation of MOUD services. Optional recommendations also demonstrated strong performance, especially in practice (93.3%). These results highlight the feasibility of delivering comprehensive, evidence-based OUD care in carceral settings and illustrate how structured self-assessment can support continuous quality improvement, inform replication in other facilities, and align correctional healthcare delivery with evolving Medicaid standards and funding opportunities.

The choice of the 2023 Medicaid performance measures for this self-assessment is one example of OUD best practices in jails. While this is not the only comprehensive care model for OUD, these standards are current and relevant to eligibility for potential Medicaid coverage for OUD services in jails. While Medicaid is beginning to cover certain OUD services for individuals transitioning out of incarceration in select states, comprehensive Medicaid coverage for OUD services during incarceration in all States is not yet in place. Ongoing policy discussions and pilot programs continue to explore the potential for expanding such coverage in the future [32, 36, 37, 38].

Methodologically, the choice of the Pacific Northwest county jail for this self-assessment was strategic. This facility represented an established MOUD program, with experienced staff, and set the bar for the quality of OUD care for other jails. The findings of this study could be appropriate for other facilities, inside or outside of the contract network, interested in starting a MOUD program or interested in meeting best practices standards.

Although MOUD is established as a standard of care in carceral and non-incarcerated settings, it has yet to gain widespread adoption in all correctional facilities. Several critical barriers remain to broader adoption, including funding limitations, stigma, insufficient training, resistance to harm-reduction approaches, and custody-related challenges. Economic feasibility remains a key issue, and further exploration is needed into the availability and application of financial incentives to make MOUD programs sustainable in carceral settings. Medicaid funding and reimbursement opportunities for MOUD through the Medicaid 1115 waiver are expanding, yet not all states are fully leveraging these resources (32). This raises the question of whether state and federal mandates are necessary to ensure broader implementation.

The treatment efficacy of MOUD, demonstrated by its ability to reduce overdoses and save lives, should serve as a strong motivator for adoption. However, education and training for healthcare providers and correctional staff remain critical to overcoming barriers. Training efforts should focus on delivering MOUD, managing withdrawal symptoms, and preventing overdoses. Furthermore, all jails, even those without MOUD programs, should at least provide adequate screening, assessment, withdrawal management, MOUD for pregnant patients, and MOUD continuation services for individuals with OUD.

Long-acting injectable buprenorphine (e.g., extended-release depot formulations) offers a promising yet underutilized option in carceral settings, particularly in jails where short lengths of stay and high turnover complicate daily dosing [40, 41]. Although the upfront cost of long-acting buprenorphine in the U.S. can exceed $1,500 per monthly dose, significantly more than daily sublingual formulations, these costs may be offset by operational efficiencies. Specifically, the injectable formulation reduces the need for daily medication dispensing, minimizes the risk of diversion, and decreases staff time required for administration and observation. These advantages are particularly relevant in resource-constrained facilities. Despite its high initial cost, long-acting buprenorphine may represent a cost-effective strategy when considering the total burden of care and logistics in jail settings, particularly for individuals with short stays or high risk of treatment discontinuity.

While urine drug screening (UDS) in jail settings can support critical objectives, including identifying individuals in need of withdrawal management, informing harm reduction strategies, initiating evidence-based treatment, and contributing to epidemiological surveillance, its implementation is not without risk. As highlighted by Chan and colleagues [39], UDS programs, particularly when tied to punitive responses, may produce unintended harms that undermine their public health intent. These include discouraging individuals from disclosing substance use or seeking treatment, reinforcing abstinence-based approaches that conflict with harm reduction principles, and incentivizing shifts toward more dangerous substances with shorter detection windows. Furthermore, the routine use of UDS without clinical context or linkage to treatment may contribute to stigma and mistrust, potentially deterring engagement with healthcare services during incarceration. A more balanced approach to UDS, one that prioritizes clinical utility over surveillance and aligns with harm reduction, may better serve the goals of overdose prevention and treatment continuity in correctional settings.

In conclusion, the findings from this self-assessment can inform a series of future performance improvement activities, including reflection on and prioritization of areas requiring improvement, the establishment of goals and development of a quality enhancement action plan, the implementation of targeted changes, the documentation of outcomes, the solicitation of feedback, and ongoing monitoring and reevaluation to ensure sustained progress.

Abbreviations

BT

Buprenorphine Taper

C

Continuation

CDA

Comprehensive Detoxification Assessment

CDS-OPI

Opiate Withdrawal Screening

CM

Comfort Medication

COWS

Clinical Opioid Withdrawal Scale

Do.

Documentation

FR

Fluid and Electrolyte Replacement

HER

Electronic Health Record

I

Initiation

Medicaid

2023 Recommendations for Medicaid Performance Prisons

Performance

Measures for Opioid Use Disorder Services in Jails and

Measures

Prisons

MOUD

Medication for Opioid Use Disorder

NCCHC

National Commission on Correctional Health Care

OUD

Opioid Use Disorder

RS

Receiving Screening

RS-AR

Receiving Screening/Arresting Officer Questions

RS-SU

Receiving Screening/Substance Use Assessment

UDS

Urine Drug Screen

Author contributions

J.E.S. (study conceptualization, literature review, description of OUD service cascade, development of survey methods, analysis and interpretation of survey findings, preparation and editing of the manuscript, and project administration); S.A.B. (study conceptualization, literature review, description of OUD service cascade, development of survey methods, conduct of policy survey, analysis and interpretation of survey findings, preparation and editing of the manuscript); A.A. (study conceptualization, description of OUD service cascade, development of survey methods, conduct of documentation survey, analysis and interpretation of survey findings, preparation and editing of the manuscript); A.G.G. (study conceptualization, literature review, development of survey methods, analysis and interpretation of survey findings, preparation and editing of the manuscript); P.R.C. (study conceptualization, literature review, development of survey methods, analysis and interpretation of survey findings, preparation and editing of the manuscript); E.R.M. (study conceptualization, literature review, description of OUD service cascade, development of survey methods, analysis and interpretation of survey findings, and preparation and editing of the manuscript); and B.J.K. (conceptualization, review and editing, resources, and project administration).

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Salus IRB (Case ID #23472; Date of Determination: December 04, 2024) determined that the activities of the referenced protocol do not constitute regulated research involving human subjects, and no formal IRB review is required at this time.

Consent for publication

Not applicable. All the material in our manuscript is the original work of the authors and does not require permission to publish.

Competing interests

The authors declare no competing interests.