Receptivity to Jail-based medication for opioid use disorder among rural detention Administrators

ABSTRACT

Opioid-related deaths continue to rise and a sizable proportion of people who present the greatest risk for fatal overdose are admitted to local detention centers. Despite the evidence demonstrating the effectiveness of medication to address the symptoms of opioid use disorder and the recent legal decisions (Department of Justice, 2022) mandating access, this treatment is only available in about 25% of jails in the US and most of them are located in urban or semi-urban areas. The current study was designed to better understand the steps that need to be taken to implement these programs in rural detention centers. Semi-structured interviews were conducted with 19 sheriffs and jail administrators across a nine-county region in southern Appalachia to identify the best pathway toward the delivery of medication for opioid use in the detention centers. Administrators’ views of these programs fell on a continuum from being completely opposed to highly receptive. Qualitative analysis of the barriers to implementation also varied according to these positions. Effective approaches to facilitating the adoption of medication programs in rural jails must address administrators’ views, but they must also take into account the unique characteristics of the detention center and the community in which they are located.

KEYWORDS:

• Opioid use disorder
• medication assisted treatment
• perceptions
• rural jails

Introduction

The rate of drug-related overdose deaths in the United States reached an all-time high in 2021 (Spencer et al., 2022). This amounted to over 106,000 fatalities, 75% of which involved opioids (National Institute of Drug Abuse, 2023). In addition to overdose risk, people who use opioids are also more likely to be involved in the criminal justice system compared to those who do not use opioids (Winkelman et al., 2018). Estimates suggest one-quarter to one-third of all people who present indications of opioid use disorder are admitted to correctional facilities in a given year (Boutwell et al., 2007).

Jails serve as the primary entry point into the criminal justice system and according to recent estimates, nearly nine million people were processed into these detention centers in one year (Maruschak et al., 2023). Many of these individuals are taken into custody without advance notice, and for those who are opioid users, experience an immediate interruption in opioid use, increasing the likelihood of experiencing acute withdrawal at the time of admission to a correctional facility (Mitchell et al., 2009). Failure to properly manage withdrawal has contributed to a steady rise in the number of fatal overdoses that have occurred in jails, designating drug-related overdose as the third leading cause of death in these detention centers (Carson, 2021, Kaplowitz et al., 2021; Fiscella et al., 2005).

Survival of the withdrawal process during incarceration does not eliminate the risk of adverse outcomes. People with a history of recent opioid use also experience an increased risk of overdose immediately following release from the detention center. Forced abstinence during confinement is generally associated with a reduction in tolerance to opioid administration and many people return to previous levels of use following release. Evidence has shown that those who have recently been incarcerated are 30 to 40 times as likely to succumb to fatal opioid overdose compared to the general population (Larochelle et al., 2019; Merrall et al., 2010; Ranapurwala et al., 2018).

Medication for opioid use disorder (MOUD) is an established medical treatment designed to manage withdrawal and reduce cravings (Bell & Strang, 2020). This approach has been available to people involved in the criminal justice system for many years (Cornish et al., 1997; Kinlock et al., 2008; Magura et al., 2009), but the most recent wave of the opioid epidemic has renewed interest in this approach. Evidence demonstrating the effectiveness of MOUD to manage withdrawal and reduce the likelihood of post-release overdose risk specifically for people who have been incarcerated has also been growing rapidly (Degenhardt et al., 2023; Lim et al., 2023; Marsden et al., 2017; Martin et al., 2022). Despite these results and a groundswell of support for the widespread adoption of MOUD in local jails (Bureau of Justice Assistance, 2022, Department of Justice, 2022; National Sheriffs’ Association, 2022), access to this treatment remains limited in many facilities, particularly small correctional centers in rural areas.

The present study was conducted in a rural region of one southern Appalachian state to better understand views related to the adoption of MOUD among detention administrators who are responsible for providing substance-related services to people who are detained. Qualitative semi-structured interviews were conducted with 19 sheriffs and jail administrators to determine the current status of MOUD delivery in rural detention centers and to understand administrator receptivity to implementing or expanding these types of programs.

Literature review

There are over 2,800 jails in the U.S. and recent research has shown awareness of MOUD is increasing and many criminal justice agencies are working to improve access to the treatment (Substance Abuse and Mental Health Services Administration, 2019) as evidenced by a growing number of facilities providing MOUD (Scott et al., 2022). This growth is due, in part, to the continued advocacy for the expansion of access to treatment in local detention centers (Madras et al., 2020). At present, the United States Food and Drug Administration (FDA) has approved three medications for the treatment of opioid use disorder (United States Food and Drug Administration, 2017). Naltrexone, an opioid antagonist, functions by blocking the uptake of opioids in the receptors. This medication can be taken orally or administered in an extended-release injection (Sullivan et al., 2019). In contrast, two other MOUD drugs, methadone and buprenorphine, are opioid agonists which bind to receptors effectively reducing cravings and preventing withdrawal effects (Fischer et al., 1999). Methadone is primarily administered orally in a liquid form while buprenorphine can be taken sublingually or administered in an extended-release injection (Andraka-Christou & Capone, 2018).

Despite a growing interest in MOUD programs, the most recent estimates indicate only about 25% of these facilities offer any form of MOUD, and the majority of jails that provide this treatment are concentrated in more densely populated areas (Maruschak et al., 2023). Rural areas, however, experience persistent opioid use and disproportionately high overdose rates (Post et al., 2022) and although detention centers in these communities may be well suited to MOUD programs, they must overcome several barriers prior to initiating MOUD programs.

Recent research exploring the challenges encountered during the implementation of MOUD programs in jails has identified several key factors that tend to restrict the availability of this treatment. One of the most prominent and entrenched obstacles that has been consistently observed is related to the negative perception of MOUD held by prospective program administrators and clinical staff (Ferguson et al., 2019; Mackey et al., 2020; Moore et al., 2022). These attitudes tend to reflect a moral system centered on holding individuals accountable for their inability to control what is viewed as willful drug use (Wakeman & Rich, 2018). According to this approach, the criminal justice system and, jails specifically, serve an important role as they force people who use drugs to abstain while simultaneously punishing them for their involvement in socially unacceptable behavior. Abstinence is seen as the only suitable pathway to recovery within this framework (Richard et al., 2020). Stakeholders with this view have characterized MOUD as drug replacement therapy that prolongs addiction (Matusow et al., 2013; Sharma et al., 2017), blocking the planning for MOUD programs from advancing past an initial discussion.

Beliefs regarding the role of MOUD in correctional settings are also often met with appeals to practical considerations within the agency that must be taken into account when administering MOUD in jails. Corrections administrators who hold stigmatizing views of MOUD may resist the adoption of new programs by citing the inability to overcome existing demands placed on overextended corrections officers (Grella et al., 2020). The list of job duties among custodial staff is lengthy and includes escorting people who are detained to scheduled court appearances, facilitating attorney interviews, distributing meals, completing routine head counts at mandated intervals, and filing reports. As many jails are perpetually understaffed (Blakinger, 2022), it may be challenging to incorporate the additional procedures needed to effectively deliver MOUD. Alternatively, protocols for administering medication may be adopted from other correctional facilities of similar sizes and may become more efficient as programs become operational (Krawczyk et al., 2022).

Although criminal justice practitioners tend to maintain negative views of MOUD and are likely to object to these programs, there is some preliminary evidence suggesting some may be more receptive to this form of treatment compared to others. One study focused on the perceptions of MOUD for people involved in the criminal justice system in rural settings, for instance, found program clinical administrators to be open and somewhat supportive of medication in certain supervised situations while law enforcement officers held the strongest attitudes against this form of treatment (Victor et al., 2022). These disparate views represent a significant challenge in the process to initiate MOUD programs in local jails and more work is needed to better understand the degree to which detention administrators are receptive to providing medication, particularly in less densely populated regions.

Emerging research has also found that negative views of MOUD may subside over time (Blue et al., 2023). For example, correctional staff often fear the potential for drug diversion associated with MOUD programs. They invoke the possibility that those who are intended recipients of the medication can avoid ingesting a dose and use it instead as currency in the facility’s illicit market (Pivovarova et al., 2022). There is evidence, however, that these views can change over time and officers’ fears can be assuaged. A study of correctional staff’s perceptions of MOUD diversion in seven Massachusetts jails found evidence of more neutral views of the treatment as programs become operational as officers have an opportunity to witness the benefits of the administration of the medication among patients (Evans et al., 2022).

Resistance toward MOUD may also diminish as correctional staff experience an improvement in their workplace environment that is directly connected to the availability of the treatment. Specifically, attitudes toward medications and programs in general have improved among corrections officers after realizing they no longer had to contend with the consequences of physical withdrawal among people who have used opioids (Bandara et al., 2021). Given this movement toward acceptance over time, and the potential for this beneficial outcome in small rural jails who are not currently providing access to MOUD, a deeper understanding of the views of the treatment is needed to help inform better approaches to reduce stigma and foster program implementation.

There are significant ethical considerations for the humane treatment of people who are detained, illustrating the necessity of implementing these programs. Clinicians have argued the imposition of forced withdrawal equates to punishment in the absence of conviction (Fiscella et al., 2018), and stigma surrounding MOUD has been identified as one of the most prominent factors involved in preventing health-care providers in correctional settings from acting in a patient’s best interest, perceived as a violation of the pillars of bioethics (Brezel et al., 2020). These ethical considerations have led to the establishment of a legal precedent and a corresponding growth in the number of lawsuits to increase access to medication in many states (Longley et al., 2023; Toyoshima et al., 2021) and encourage expanded use of these programs.

An implementation science framework for MOUD adoption in rural jails

The emerging area of implementation science may be useful for understanding jail administrators’ receptivity to MOUD delivery. Implementation science takes an interdisciplinary approach to studying how research and clinical interventions can be translated into practice. In the criminal justice system, there is often a gap between what is known about an effective treatment through research and the implementation of that practice (Abramsky & Fellner, 2003). Recently, criminal justice researchers have begun to argue that implementation science has useful applications for understanding how evidence-based programs and policies can become criminal justice practice (Zielinski, Allison, Brinkely-Rubenstein, Curran, Zallar, & Kirchner, 2020).

Given that implementation science provides a lens through which to understand the components of the process by which new programs and procedures are integrated into criminal justice practices, delivering MOUD may be able to be understood within this framework. MOUD delivery in local detention centers is contingent on several domains surrounding a proposed program. According to implementation science, developing an effective implementation process requires fully understanding 1) the characteristics of the intervention, 2) the characteristics of individuals involved in the program, 3) interorganizational factors, and 4) the larger social context in which the program operates (Damschroder & Hagedorn, 2011). These four components of the program implementation process may provide an understanding of receptivity of MOUD programs among rural jail administrators.

When applying this guiding framework to the development of MOUD programs in rural jails, delivering medication inside the correctional facility is the intervention. To determine whether delivering medication inside of a facility is possible, practitioners must assess the degree to which the facility is equipped administer it. They must determine whether there are adequate staff, a medical provider to administer the medication, and a sufficient space within the jail to provide the treatment. Second, the characteristics of individuals involved with the program must be examined to foster successful adoption. As the main programmatic decision makers for the local jail, sheriffs and detention administrators must support MOUD implementation before a program can begin. If these key stakeholders do not approve, the program cannot advance past the planning phase. Third, interorganizational characteristics will also play a role in the likelihood of a rural jail delivering MOUD. Senior leadership must clearly communicate to line staff their endorsement and expectations of a program to maximize buy-in. Failure to emphasize objectives and timelines to achieve goals may be interpreted by those in lower-level positions as though the program is not important. In such cases, there is likely to be weak adherence and minimal commitment to program implementation. Finally, the larger social context must be considered. In rural areas, negative views of opioid use and medication as an acceptable treatment option are informed by tight knit social networks that are often rooted in strong connections to local churches (Thomas & Grafsky, 2021). The sociopolitical environment in rural areas also tends to favor anti-drug use programs, increase stigma toward people who use drugs, and foster a high degree of reluctance to seek treatment (Richard et al., 2020).

The current study

Although there is growing concern about drug-related overdose in jails, increased awareness about forced withdrawal, and high rates of fatal overdoses among recently incarcerated individuals, MOUD availability is lacking, especially in small detention centers in rural areas. These opioid-related concerns have been observed in rural communities (Rigg et al., 2018), making it important to study these views in local detention centers as they influence access to MOUD. Prior research has made significant advancements in identifying the key barriers to MOUD delivery in correctional settings, but a significant gap remains in what is known about the views of this treatment among the primary decision-makers responsible for operationalizing these programs in small rural jails.

The present study seeks to understand the process by which MOUD programs are implemented in rural jails by extending the existing literature on perceptions of and receptivity to MOUD by achieving three objectives: (1) to assess the extent to which rural Sheriffs and jail administrators are receptive to jail-based MOUD, (2) to identify the primary challenges of MOUD delivery relative to Sheriff and jail administrators’ degree of receptivity to the treatment, and (3) to develop evidence-based recommendations to address the most prominent MOUD-related challenges for jails. A deeper understanding of these views is needed to address barriers and objections to jail-based MOUD programs in rural settings.

Methods

Data were gathered from May 2022 to December 2022 through semi-structured interviews with 19 administrators in nine detention centers across nine counties throughout a region in South Central Appalachia. The communities across the region vary in population size, remoteness, and population demographics. According to the most recent version of the National Center for Health Statistics (NCHS) Rural-Urban Classification Scheme for Counties, most participating detention administrators are located in areas classified as noncore (U.S. Department of Health and Human Services, 2014). One of the facilities is located in an area categorized as medium metro. The most sparsely populated community included in the project has a population of just over 11,000. Eight of the counties have fewer than 60,000 residents, while the one with the largest detention center has a population of approximately 260,000. Most of the detention centers in the region are small in size with a maximum capacity of less than 150. One facility included in the study exceeds this limit and is classified among those that can hold over 200. Only one of the nine facilities offers MOUD to detainees.

Recruitment was conducted by the primary researcher and involved contacting sheriffs and jail administrators directly by e-mail or telephone. Additional participants were gained through a snowball sampling technique where participants who had completed interviews provided contact information for administrators who held similar positions in other counties. Recruitment was complete when administrators began recommending new participants who were already included in the sample, and no new suggestions or recommendations were made. All administrators who were contacted agreed to participate. To achieve the specific objectives of the study, the researchers developed an interview protocol (see Appendix A) that consisted of questions relating to the respondent’s views of MOUD, potential obstacles to implementation, factors that would be required to operate a program, and the results that would be generated from a successful program. Interviews were conducted in-person at each detention center and lasted approximately 45–60 minutes. Each participant received an informed consent document prior to the interview, and all were asked permission to record. Those who agreed to participate were assigned pseudonyms to ensure their anonymity. These procedures were approved by the Institutional Review Board (protocol #1956431–1) of the researchers’ affiliated organization.

The final sample consisted of 19 sheriffs and jail administrators from detention centers distributed across the nine counties in the region. There is only one facility in each county; therefore, in some counties, more than one administrator was interviewed from each jail. Four participants were sheriffs, seven held the title of jail administrator, and the other eight all held high administrative positions that report directly to the sheriff. All of the interviews were recorded, except for two. In these instances, participants refused audio recording but allowed the interviewer to take handwritten notes.

Following the completion and transcription of the interviews, researchers followed an inductive grounded theory approach (Charmaz, 2006) to identify salient themes. Two trained researchers worked independently to thematically code interviews, meeting regularly to compare their codes and iteratively refine the coding scheme to ensure inter-rater reliability. This process continued until reaching a point of saturation and meeting the goal of identifying prominent views of MOUD, particularly as a treatment in the administrator’s own detention center. This process ultimately led to the development of a framework for classifying administrators views according to their receptivity to MOUD program implementation as either low, moderate, or high receptivity. Although interviewees were not explicitly asked their level of receptivity to MOUD, the researchers were able to apply this low, moderate, or high receptivity continuum to the participants’ views based on the degree to which the administrator spoke about MOUD as a viable treatment in a correctional setting and did not stigmatize MOUD treatment or patients. Although there is some overlap between categories, low receptivity is characterized by ardent stigma, moderate receptivity is associated with a wide range of procedural and cultural concerns about implementing MOUD, and high receptivity demonstrated an ability to overcome barriers while exhibiting little to no stigma toward these treatments. Specifically, the low receptivity end of spectrum represented counties that do not provide MOUD and spoke about being resistant to implementing MOUD in their jail, discussed MOUD in a way that was rooted in stigma, held preconceived notions about MOUD patients, or held misinformation about how the treatment works. The higher end represented facilities that have embraced MOUD by having already implemented MOUD programs and initiating MOUD for those who meet certain eligibility criteria or who recommend patients who are admitted to the facility for MOUD post-release. Respondents who were categorized as moderately receptive, did not stigmatize the treatment or MOUD patients, but cited other barriers and logistical concerns as the reason why their facilities have not yet implemented MOUD programs. The researchers made determinations of which administrator fit into which category based on the themes that emerged during data analysis, and each category was associated with slightly varied themes. In addition, the researchers made determinations of where the administrator fell on a scale of highly unlikely to highly likely to adopt MOUD in the facility they represent. These determinations were based on a variety of factors related to how the administrator spoke about plans (or lack thereof) to implement MOUD programming. Administrators from counties that already have MOUD programs or are in the early stages of planning for future implementation them were placed higher on the continuum, while those who were absolute in their belief that MOUD was not an option for their facility were placed lower. Some respondents explicitly stated the likelihood of MOUD implementation, and in cases where it was not stated outright, likelihood was inferred by the researchers based on how positively or negatively the administrator spoke about MOUD within the context of their own facility.

Results

This study seeks to assess the extent to which rural sheriffs and jail administrators are receptive to implementing jail-based MOUD programs. This is done through examining MOUD receptivity through the lens of implementation science to understand the characteristics of MOUD interventions, characteristics of those making the decisions to implement programs, interorganizational factors, and the social context in which MOUD programming would be implemented. Taken together, administrators demonstrated varying degrees of receptivity, categorized according to low, moderate, and high receptivity. As shown in Figure 1, participants were distributed relatively evenly across the receptivity spectrum. Based on the researchers’ classifications, six participants from three counties fell on the lower end, eight participants from four counties fell approximately in the middle, and five participants from two counties fell on the higher end of the spectrum.

Figure 1. Spectrum of MOUD receptivity.

Respondents within the middle and higher end of the spectrum were supportive of MOUD in jails, however they varied in their level of stigma and hesitancy toward implementation.

Low receptivity

Participants who strongly opposed the implementation of MOUD frequently stigmatized the harm reduction strategy itself, touting abstinence-only strategies as the only beneficial way to curb substance use disorder. These respondents shared concerns about the validity of medication as a treatment for addiction, tending to view MOUD programs as replacing one drug with another. For example, Interviewee 6 stated:

I don’t know that the benefit outweighs the non-benefit aspect of it … For one, we’re a non-narcotic facility here. So, if we’re taking the dependency and putting it on another that’s a narcotic, then we’re not necessarily helping with the addiction part of it. We’re just curbing that addiction or enabling that addiction, in my opinion, from one drug to another long enough to get them out of jail. And then as soon as they get out, are they gonna go back to their narcotic drug?

Interviewee 19 also maintained an abstinence-only position, arguing that medications only served as “replacements” for illicit substances.

Stigmatizing MOUD by emphasizing abstinence only approaches tended to stem from the larger social context in which the jails operate, with beliefs characteristic of the rural communities where the jails are located. This cultural stigma was one of the most prominent obstacles for those in low receptivity communities and was viewed as being closely linked with the predominant conservative political ideology in these areas. Ignoring the ingrained sociopolitical environment these jails operate within is difficult, especially among those administrators who hold elected positions. This makes policies and programs that are viewed as contrary to conservative ideologies unpopular, and unlikely to be implemented. Interviewee 8 explained this concept:

If you want to refer to it as a political ideology that says, “we are absolutely going to do this or we’re absolutely not going to do this.” I think throughout [region], and I can speak for [county], you got pretty politically conservative folks that you’re dealing with not only culturally but in the local governments. Maybe not so much in the larger towns and cities, but definitely in the majority of [region] and in the rural counties. And when you’re dealing with detention, most of your county commissioners, most of your sheriffs, are overwhelmingly pretty conservative when it comes to political ideology. So, I think, I think your biggest obstacle is probably that where folks just overall just say, “absolutely not, we’re not going to do.” [MOUD]

Even when the respondents themselves support MOUD, they do not go against public opinion. Three respondents from one county explained that they themselves are supportive of implementing MOUD in their facility; however, county representatives and the community itself are not receptive. Interviewee 14 stated, “Since [jail captain] ain’t here, I’ll just be honest that we [peer support and jail administrator] support it, we want it … but we’ve been told before, it ain’t gonna happen” explaining the resistance stems from the county’s preexisting abstinence-based rehabilitation service. Interviewee 14 shared that those involved with the community rehabilitation service will often shame individuals who use or want to use MOUD during their treatment process. Furthermore, Interviewee 14 claimed that the stigma against MOUD within the community would be difficult to overcome.

In addition to the role that the social context plays in MOUD resistance in low receptivity counties in the form of stigma and lack of support from the community, respondents in the low receptivity category expressed concern over organizational factors related to the logistics of implementing a MOUD program. Notably, Interviewee 6 highlighted several logistical concerns for how the treatment protocol itself would work within structural barriers related to jails operate:

I think one of the other drawbacks would be time. Is it [for] somebody that’s just, you know, disorderly conduct or had a warrant and is high as a kite when you find them? Okay, they make bond in two days. How do we continue that treatment? We’ve given [MOUD] to him for two days, but what do we do now if it’s a 30-day supply? What do you do with the supply? … Is it on hand? Where’s it kept here? Because heaven forbid that get out into the wrong hands. … There’s a lot of unanswered questions, but if you could ever get in a good protocol and do it, would it work? Maybe, maybe not.

In addition to the social barriers to implementing MOUD programs, low receptivity counties also struggle to see how MOUD programs can overcome the constraints of short jail stays, storing MOUD medications, and fears about drug diversion.

Moderate receptivity

The eight respondents who fell along the middle of the spectrum indicated that they had begun to move past the stigma and began to have a more positive perception of MOUD. For example, Interviewee 2 stated, “Any kind of addiction … there’s a lot of risks with just stopping cold turkey, not to mention, just the physical misery of it … [MOUD] would definitely help ease the pain of people that have issues at hand” illustrating greater openness to seeing the benefits of MOUD compared to those in the low receptivity category.

Moderately receptive respondents also shared a variety of practical concerns that they believed would need to be addressed prior to implementing a MOUD program in their jails. Factors such as access to community services (n = 7), availability of funding (n = 5), sufficient staff (n = 7), access to mental healthcare (n = 4), and potential liability issues (n = 6). Access to community treatment services was of particular concern as several respondents explained that their facilities do not want to initiate MOUD if there is no guarantee of continuation after release. Many perspective MOUD patients live in small, rural communities that lack substance use disorder treatment services, leaving jail as their only potential option for treatment. This was noted by Interviewee 11, “In the community, we definitely need more treatment centers, like long term treatment centers in this area, because there’s nothing long term.” Similarly, Interviewee 4 explained:

Services for people who are drug addicted, outside of a jail setting, are hard to come by especially in rural communities like ours … Of course, there’s got to be a “want to” [seek treatment] on the part of the user, but there’s not a whole lot of those avenues to get them the help they need outside of the jail and so, they end up just dumping everybody in the jail. And a large percentage of our people that are in the jail are drug addicted and then, you know, we’re not set up to provide services that they need to help combat their addiction. Then they end up dying in our custody sometimes and we’re kind of helpless and then it looks like to us, from an administrative standpoint, like we didn’t do anything for these people, but nobody’s given us the tools to help.

Moderately receptive respondents were adamant about the need for a “warm handoff” from the detention facility to an outside support system to make jail-based MOUD programs worthwhile. For example, Interviewee 5 explained:

The main obstacle that I have had as the Sheriff comes from the fact that if we introduce medication to our inmates, once they walk out of our doors, be it they are bonded out by someone or by family or if they plead to their case and their case is over. Once they leave, where are they going to continue to be able to get the medical assisted treatment? Because it’s not free. There has to be someone waiting on them and picking them up once they walk through our doors into the outside world, to support them as they continue walking through this process of rehabilitation. If we had someone inside that could walk them to the doors and then do a really warm handoff to our providers outside and start getting them treatment as well as classes and anything else that a doctor would recommend.

Respondents were supportive of MOUD as long as the intervention was characterized by care that continues into the community, something that is not currently possible in a majority of these communities.

Another source of hesitancy among those who are moderately receptive to MOUD programming was availability of funding and medical resources in the facility. Interviewee 7 summarized this barrier, “Every service that we provide in our county, in law enforcement and many others, it comes down to funding.” With the implementation of MOUD in jails comes the potential need for additional staff to monitor the program. Additionally, the majority of jails in this region contract out their medical care which means would renegotiating with their providers, a complex process explained by Interviewee 13, “Contractors typically will say, yes, we will do it, but … in the functional reality it’s under resourced, under supported, under trained, under producing. Over promise/under deliver has been my experience.” Interviewee 5 echoed this sentiment:

I feel that that we would be ready to have that conversation with our medical contract companies. But until we get [treatment] on the outside … I don’t really want to get back into the negotiations and dealing with our medical provider, because they do a really great job doing what we pay them to do. But the fact of the matter is, they don’t want to feel responsible and be responsible for something that is not in their contract. From a civil liability standpoint, I’m sure, and I understand that.

For the facilities that do not have medical contracts, they are required to transport detainees to local clinics or hospitals for treatment. Interviewee 15 shared that their facility has begun transferring detainees with pressing medical needs stemming from withdrawal to another detention center. They further explained:

We’ve had a few that I have sent up there just for that reason [withdrawal], because they have an onsite nurse and they’re able to get some relief … I ain’t gonna let somebody sit back there by ‘emself [to detox], I’ll try to figure something out. So far, I’ve worked with another center where I’ve been able to send them, and they got onsite nurses that are able to kind of get them through the first couple weeks. We’re very limited on what we can do as far as medications and any kind of help like that, our hands are tied.

The lack of medical services also applies to mental health services. Half of participants in the moderate category shared concern over the limited mental health treatment available to detainees. Much like with community services, detention facilities are hesitant to implement MOUD programs if they cannot provide the full spectrum of care. For example, Interviewee 19 shared, “That’s the only way it’s gonna be successful, is having [mental health] components to it. Because it’s so much more than just putting medication in your mouth.”

Some moderate receptivity participants were concerned about the possibility of diversion. Four respondents stated that diversion was a huge concern while four respondents explained that it was highly unlikely to occur given the strict rules regarding medication distribution. For some, such as Interviewee 11, diversion is always a concern:

We really have to watch. We’ve got a couple of them that will crush their pills now because they save them and they pass them out. And it’s usually stuff like anxiety meds, because they figured out they can get a little bit of a high off of that. So, they save their anxiety medicine and share it and snort it.

Similarly, Interviewee 6 stated that diversion was a significant source of hesitancy, “if we don’t ensure that that medication was taken like it should have been, then it becomes a bartering tool. And then not only are we enabling them, but now are they getting somebody else addicted.” Other respondents moderately receptive to MOUD are not worried about diversion because they do not think the risk is different from what they face with any other medication.

Overall, moderately receptive respondents had begun to move past the stigma against MOUD projected by those who completely opposed this form of treatment; however, they still express concerns related to factors involved in implementing and managing a successful program. These respondents stated they would like to see further research on MOUD in jails before they would consider it for their own facilities.

High receptivity

Highly receptive respondents spoke about MOUD with little to no stigmatizing language. The five respondents in this category focused on the benefits of MOUD rather than the morality associated with the treatment. For example, Interviewee 13 shared:

If people are getting treated for their conditions appropriately, they do not have as many internal and external struggles mentally, emotionally, physically with their time while they’re here. And they are certainly less likely to overdose when they leave the building if they’re continuing their treatment, and more effectively able to re-engage in life in the community because their addiction needs are being addressed.

Based on these responses and others similar to them, it appears the focus shifted from the medication to the health and well-being of detainees.

Furthermore, while highly receptive respondents were still concerned about many of the barriers discussed in the previous section (i.e., drug diversion, funding, and access to mental health resources), they were more confident in their ability to overcome them. Interviewee 13, from the one facility that has already successfully used grant funding to implement MOUD, shared their experience overcoming the many challenges of implementing an MOUD:

If you’re utilizing grant funding, you’ve got this dynamic promise of funding, release of funding and collapse of funding, and that implicates staffing and everything in between. So that is a significant challenge. Obviously, buy-in and support from the decision makers and gatekeepers [are challenges]. In our county at the onset, the sheriff was the one who said “we’re doing this” … but all of detention leadership wasn’t necessarily on board. And so, he had to do a lot of management of those roles and relationships in regards to making sure that the program was able to continue in development. And he had to address some things very specifically with individuals’ roles … to ensure that [the program] was moving forward … And then medical providers. There have been a significant amount of educational training and stigma issues with the medical staff directly and then also with security staff.

Even when a county is receptive to the point of already having implemented and MOUD program, a number of logistical challenges and barriers present themselves.

Highly receptive participants were also less concerned about diversion of the medication than administrators in the low and moderate receptivity categories. Highly receptive respondents indicated that diversion concerns could be tempered through the implementation of strict guidelines for medication distribution. For example, Interviewee 19 explained that their only diversion incidents occurred because an officer overlooked or missed a step in the process. They shared:

One of [the cases of diversion] was, we suspected, was maybe being strong armed … . the other [case of diversion] was cheeking … But the thing with that is if you have policies and procedures, and you follow them to a tee, diversion is almost impossible … The three incidents we’ve had, it’s because we didn’t follow our procedures. And somebody overlooked this step, or that step got missed.

In summary, individuals in the high receptivity category are primarily focused on the benefits of the program rather than views of the medication itself. These respondents shared some of the concerns of those in the moderate category; however, they clearly articulated the processes that helped them overcome any resistance that may have been present.

Discussion

After speaking with sheriffs and administrators who are the key decision makers when it comes to facilitating the startup of MOUD programs in the detention centers they operate, an interconnected set of themes emerged related to characteristics of the MOUD intervention itself, characteristics of those participating in MOUD, interorganizational factors, and the larger social context in which MOUD program implementation may occur. Participants’ receptivity to providing the treatment in the jail informed the prominence of certain barriers that must be addressed prior to program adoption. Prior work has identified similar themes related to stigma toward MOUD, lack of staff, logistical challenges, and funding as primary obstacles (Krawczyk et al., 2022; Victor et al., 2022), but the objections do not appear to be universal and tend to vary according to the extent to which administrators are willing to embrace a medication-based treatment program.

The varied stages of preparation to deliver MOUD among sheriffs and jail administrators in the studied region reflect the diversity of views of the treatment that are typical of different rural and mostly rural communities. Prior research has demonstrated significant heterogeneity in opioid-related concerns in less densely populated areas (Rigg et al., 2018), and the elected officials responsible for addressing these needs, including sheriffs, are likely to support the consensus of certain segments of the community (Zoorob, 2022). This was evident in the responses referring to the political composition of the county, which makes the implementation of MOUD in jails operated by those who present the greatest resistance and a high level of stigma contingent on some assurance that the community will respond positively to the adoption of the program.

Research has also shown stigma toward MOUD is associated with a misunderstanding about how the medication functions to treat substance use (Madden et al., 2021). One way to reduce negative views of MOUD, particularly the belief that using medication serves to prolong addiction by substituting one drug for another, is through training and education. A study of informational sessions specifically designed to reduce stigma toward this treatment and other public health-oriented initiatives among corrections officers have found this approach to be an effective method to change these perceptions (Friedman et al., 2015; McCuller & Harawa, 2014). This may be the most logical first step toward gaining support for jail-based MOUD programs, but special consideration must be made for clinical providers who possess local knowledge and have an established relationship with detention administrators to deliver these sessions (Curcija et al., 2020).

Community-oriented solutions to expanding MOUD access in rural jails could evolve in a number of ways. At the very least, the most effective options will account for the unique characteristics of a particular county with a thorough assessment of county leaders’ positions on the issue. One recommendation explored in recent work is the development of a community advisory board that includes representatives from local law enforcement agencies, clinical providers, and municipal or county leaders (Lister et al., 2020). This group can be responsible for facilitating educational sessions, strategic planning, implementation, and evaluation of the local jail-based MOUD program.

Counties characterized by moderate receptivity to jail-based MOUD programs appear to be focused on logistical factors as the most pressing items requiring attention prior to implementation. This position represents a slightly more advanced stage in the planning process, but the review of many of the procedures and protocols for delivering medication in the facility must be developed prior to reaching the point of startup. Medication administration practices are likely to vary from facility to facility, and this stage of the planning process will require jail-specific information (Matsumoto et al., 2022). Detention administrators will benefit from the assistance of their peers that are operating similar sized facilities and who have started MOUD programs, but adaptation will be necessary to ensure medication delivery is effectively integrated into current practices.

Administrators who are highly receptive to MOUD and have taken the initiative to implement a program currently represent the minority of detention centers in the studied region. However, this group is also in the best position to share their experiences as they relate to learning the best practices of medication administration in local jails. In addition to providing insight related to effective implementation methods, administrators in this category might improve their current approaches by concentrating on strategies to expand MOUD delivery while conducting research on the effects of these programs in the detention center as well as in the community.

The present study provides a better understanding of rural detention administrators’ experiences and views regarding jail-based MOUD, but the findings should be considered according to several limitations. Information was collected from administrative decision-makers, most of whom were responsible for operating facilities that do not provide MOUD to people who are detained. Although the representation of rural jails without MOUD programs resembles the current national landscape of limited availability of medication in small detention centers across the country, these results may not apply to similarly sized facilities in other geographic areas that have not adopted MOUD for reasons that were not addressed in these interviews. Additional work is needed in other regions to understand whether these challenges are universal, particularly for small detention centers in rural areas. Future work should also document the implementation process from inception to maturation to assess the changes in administrators’ views of MOUD over time. This information could be informative for administrators who are searching for examples from other detention centers to help facilitate the adoption of these programs. In addition, the current study did not directly assess the factors that were most likely to promote receptivity to MOUD, which highlights another important area warranting attention.

Calls to action to deliver medications to treat opioid use disorder in correctional settings are beginning to resonate (Canzater & LaBelle, 2020), but small rural jails are likely to be among the slowest adopters. These facilities vary significantly with regard to administrators’ receptivity to MOUD, and this feature influences various elements of the implementation process. A significant amount of coordination is required to begin the administration of medication in local jails, and this must take into account the unique characteristics of the facility and community to maximize the likelihood of success (Fiscella et al., 2005).

Acknowledgments

This work was supported by the Dogwood Health Trust.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/23774657.2023.2278195

Additional information

Funding

This work was supported by the Dogwood Health Trust.

Appendix A

Interview Protocol

1. Can you please describe your position in the Sheriff’s Office/detention center and your role in determining how MOUD may be delivered to people who are incarcerated?

2. How beneficial is MOUD as a treatment for opioid use disorder for people who are incarcerated?

3. What are some of the obstacles that must be overcome to successfully deliver a MOUD program in the detention center?

4. How might MOUD administration affect inmate behavior?

5. If your agency were to adopt a MOUD program, what training would be required to successfully implement this program?

6. Can you anticipate any increased demands on staff to administer the program? For example, would you need additional personnel to monitor medication diversion within the facility?

7. To what extent is drug diversion a concern when thinking about a MOUD program?

8. What kind of results would you like to see from a MOUD program?

9. What advice would you provide to Dogwood Health Trust about the adoption and maintenance of a MOUD program in a county detention center that the organization might not currently be aware of?