Though many jail inmates have addiction problems, facilities lack treatment services
Measure 110 drew a bright line between law enforcement and drug addiction treatment.
People found with small amounts of drugs could avoid a trip to jail and access treatment. Three years after voters approved the measure, one reality remains: People with serious drug addictions continue to flow into Oregon jails.
Yet many Oregon jails that house people awaiting trial on misdemeanor or serious felony charges, sometimes for months or longer, do not have consistent drug addiction programs. Unlike other health care providers, jails cannot receive Medicaid funding because inmates are not eligible. As a result, local and state governments must pick up the tab, whether it’s for diabetes, stitches or opioid addiction treatment.
Clackamas County Jail stands apart from many in its treatment for addiction, with a full-time dedicated health care professional that oversees treatment for inmates.
But in rural areas, programs are not as well developed, even though Oregon’s drug addiction crisis continues. An Oregon State Sheriffs’ Association survey of 24 jails found 11 of them lacked a medication-assisted treatment program to treat opioid addiction.
Many facilities are working to implement the programs as soon as funding is available, and some could start as soon as January, the survey found.
Jails are forced to rely upon a patchwork of funding to address drug addiction. Measure 110 funding, which comes from cannabis revenue, has pumped $265 million into addiction services, treatment and harm reduction, state data show. But none of it goes directly to jails because the Measure 110 is designated to bolster much-needed community services.
Rep. Pam Marsh, D-Ashland, hopes to fix that. She is working on a bill to help jails provide more addiction treatment and services. While some are well-equipped, others “simply have no ability to do anything,” Marsh said in an interview.
Her proposal, which is still in the works, would allow jails to apply for grants to provide medication treatment, screenings and mobile services for jails without addiction treatment staff, for example, or to serve several jails. The amount is not yet set, but it could range from $5 million to $10 million for the rest of the budget cycle, which ends in June 2025.
The nine-member governor-appointed Criminal Justice Commission, which is tasked with improving state and local justice systems, would oversee the program.
Marsh said it’s important to stabilize and treat people both in and out of jails.
“We need to build all parts of the substance use treatment system,” Marsh said. We have to concentrate on that period of time.”
In the long-term, Marsh said she hopes to see federal Medicaid funding go to jails for addiction treatment through Oregon’s Medicaid waiver, a plan that allows exceptions to typical coverage. State and federal officials are still negotiating that, she said.
“Our program is: Let’s get things up and running and look for ways to bring in federal funding in an ongoing way,” Marsh said.
Clackamas County’s system
In researching the issue, Marsh is looking at systems in her own Jackson County district and elsewhere. Experts consider Clackamas County a model: It hosts a comprehensive program offering all three federally approved options for treating opioid addiction. The program has a full-time coordinator who works with inmates with drug addictions and other medical staff with other duties assist too. The program has been in existence since 2019 thanks to a federal grant.
Hundreds of inmates have received addiction medication in Clackamas County, and demand is going up. In 2022, 351 people were treated among the nearly 11,000 people who were booked in the jail that year. So far this year, 521 people have received addiction medication in the jail.
The Food and Drug Administration has approved essentially three medicines for opioid addiction treatment – methadone, buprenorphine and naltrexone. Both methadone, which is considered the gold standard, and buprenorphine are controlled substances that could be used to get high but they’re not a drug of choice for most people. They prevent withdrawal symptoms and blunt the highs associated with opioids, while naltrexone blocks the euphoric feeling from taking opioids.
Though many drug users take more than one illicit drug, fentanyl, a powerful opioid, is driving the current epidemic. In Oregon, 955 people died of opioid overdoses in 2022, up from 280 in 2019, state data show.
The jail has three ways for people to start treatment, said Melanie Menear, health care administrative services manager at the facility.
If they enter the jail and are already on an opioid addiction medication, they’re continued on them while incarcerated. Inmates can also request to start on medication if they have a history of an opioid addiction. Drug court case managers, attorneys, judges or even family members also can request treatment on behalf of inmates.
The medications come with regulatory complications. Methadone, for example, is tightly controlled, which means a provider in the jail cannot simply write a prescription. Medical staff need to work with an outside opioid treatment program, pick up the medication and dispense it in the jail.
There’s a small window for success. At the Clackamas County Jail, the average stay is just under 11 days, said Capt. Lee Eby, commander of the jail.
But it’s worthwhile to give people the chance to start treatment, in hope they’ll continue their journey after they exit, he said.
“They may have never had that option, or even been in the right state of mind where we can approach them and say, ‘Hey, that’s maybe the best way to move forward,’” Eby said.
The jail helps people prepare for their exit from the facility. Based on where the person plans to live, caseworkers set up appointments with community organizations, and provided the exiting inmate agrees, they share the information with probation officers, offering another chance for the system to keep them on the path to recovery.
“There are some people who are very tight with their probation officers who have very strong relationships with them, and they share everything with a probation officer,” Menear said.
The person leaves the jail with medication. But the resources and community services that serve people outside jail can vary from region to region across the state. That means the final responsibility for sticking to treatment rests with the person leaving the system.
Success varies. About 50% of people who exit the jail don’t show up for their first appointment with an outside community provider, Menear said.
Jackson County Jail
Another well-developed program is in Jackson County where the jail commander, Capt. Josh Aldrich, is part of Marsh’s workgroup looking at the issue.
County deputies ask questions when they screen new arrivals at the jail and alert its medical staff when someone is addicted to opioids. But the system faces challenges, like funding to pay for everyone who could benefit and safety with the medication.
“There’s a lot of diversion concerns with the meds in jails,” Aldrich said. “If you give a portion of your population this controlled substance to help them with their opioid use disorder, then are they going to try to divert that for profit or whatever to the other people in your jail who would like to use it just to get high? And so there’s concerns surrounding that.”
There isn’t enough staff to administer medication to everyone who could benefit from the treatment, he said.
“We could afford a little bit,” he said. “We couldn’t fund it at a level that would have a drastic impact to the community.”
Communities throughout Oregon need to discuss treatment for people in the criminal justice system and the appropriate involvement of law enforcement, he said.
“There’s still a lot of stigma in our communities in our state around what’s the appropriate level of help that law enforcement should be providing and its role,” he said. “That conversation is going to have to continue.”
The public also needs to realize that drug abuse is not just a problem on the streets, he said.
“People who are addicted, regardless of the criminality of drugs, still end up coming to our jail,” Aldrich said. “And so we want to be able to be included in our conversation.”
OHSU-led study finds treatment gaps
A national study shows people with opioid addiction fall through the cracks when they are in jail – both while incarcerated and when they leave.
Led by Oregon Health & Science University, it surveyed nearly 3,000 people in rural areas spanning 10 states, including Oregon, who use illicit drugs, including fentanyl, heroin and other opioids.
Overall, 42% were in prison or jail within the past six months. And within that group, nearly 85% reported opioid use within the past 30 days. But only about 18% of recently incarcerated people surveyed reported that they received medication for opioid use disorder.
The gap represents an opportunity to treat people, according to the study’s lead author, Dr. Dan Hoover, an assistant professor of medicine at OHSU.
“Incarceration could be a chance to be starting people on these evidence-based medicines, and we’re basically missing that chance,” Hoover said.
Withdrawal symptoms can start within the first 24 to 48 hours, and they can be deadly without proper management, Hoover said.
“It’s not at all harmless to have withdrawal,” Hoover said. “And that’s just immensely common in all of our jails that folks are booked in and then start having withdrawal in the first 24 to 48 hours.”
Outside jails, clinics like Community Medical Services in Salem treat people with an opioid use disorder – before and after they enter jail. Community Medical Services opened in Salem in November and has a presence in other states, including Ohio.
When someone walks into the clinic, they get a visit with a counselor and medical provider and an assessment that includes blood and urine tests. If they want to, they can start medication treatment the same day. This is important because it reduces the time between the moment of the patient’s strongest motivation to change and the start of treatment, said Dr. Moxie Loeffler, Oregon medical director of Community Medical Services.
Loeffler, also the past president and public policy chair of the Oregon Society of Addiction Medicine, is aiding Marsh’s workgroup.
“Oregon is focusing on improving health care for incarcerated people and building a system that can receive patients when they’re very vulnerable to overdose,” Loeffler said.
Though often fatal, opioid addiction is a treatable condition.
“Some of the people who are the most vulnerable to overdose are the people being released from prisons and jails,” Loeffler said.
There also are health concerns that people can have when they enter jails while using drugs and don’t receive help. In a matter of days, they can lose their drug tolerance, which is how people get used to higher doses of a drug in their bodies over time. Due to the loss of drug tolerance, the body loses its ability to break down the drug and serious health problems are likely to emerge when the drug is re-introduced, including respiratory problems, depression and overdoses.
“The cravings and withdrawal make people seek the drugs when they get out of jail, and they might be released in the middle of the night, or when there is no appointment available at a clinic or the pharmacy’s closed,” Loeffler said.
That can spur them to return to the streets for drugs.
But Loeffler said Oregon is working toward solutions and that the bill would help jails and clinics learn how to work together to take care of people with addiction.
“Then their lives can improve over time so that when they’re released from jail, they are healthier, happier and safer than they were before they were incarcerated,” she said.