The opioid epidemic has continued to worsen across North Carolina, and it has impacted all kinds of people — including people who are pregnant or will become pregnant.
Much of the fallout from the opioid crisis has trickled down to county jails and other carceral institutions, as 85% of the prison population either has or was incarcerated for a crime related to a substance use disorder (SUD), according to federal data, and that of course includes pregnant people.
There, administrators decide whether to put them through detox and force them into a state of withdrawal from the substances they were using or allow them to take medication-assisted treatment. The medical community recommends medication-assisted treatment for pregnant people with SUD, as detox or chaotic drug use puts stress on the developing fetus.
Despite research supporting medication-assisted treatment as the standard of care for all people with opioid use disorder, access to medications such as methadone and buprenorphine for people detained in North Carolina’s jails is spotty at best.
A recent study from researchers at Johns Hopkins University found that 60% of the 836 jails surveyed across the country provide medication-assisted treatment to pregnant people in their jails, which means 40% of those jails did not offer medication-assisted treatment. In North Carolina, a handful of counties offer MAT in jails, but it depends where you are.
Medication-assisted treatment for pregnant people in jails
Medication-assisted treatment helps stabilize pregnant people while preventing them from experiencing painful withdrawal, which can put stress on both them and their unborn baby, said Carolyn Sufrin, one of the paper’s authors and an associate professor of gynecology and obstetrics at Johns Hopkins University.
“To do that in a jail setting where you don’t have any control over your environment, your temperature, your ease of access to water, the toilet, it’s a pretty miserable experience,” Sufrin said.
There is not a clear-cut causal relationship between withdrawal and miscarriage, Sufrin said, but it can cause dehydration, which could affect blood flow to the fetus or cause preterm contractions.
More importantly, withdrawal, “doesn’t work, and it can be fatal” if a pregnant person returns to drug use and overdoses, Sufrin said.
“They get released from jail, and they go back into their communities and they use again,” Sufrin said. “They might use the same amount of drugs that they used before. But their tolerance is much lower than it was before they were in jail and so they’re more prone to overdose.”
The state of medication-assisted treatment in NC jails
Unlike state prisons, which are controlled by one central system, the NC Department of Public Safety, the state’s jails follow the jurisdiction of individual sheriffs.
What this means is that treatment of opioid use disorder is handled differently in each county, said Elisabeth Johnson, primary provider for prenatal and gynecologic care at UNC Horizons, a Carrboro-based program that provides medication-assisted treatment and resources for mothers.
“It’s really the luck of the draw of where you land if you are a pregnant person using opiates,” Johnson said. “If you happen to land in Durham County, it might be different than if you happen to land in Alamance or Granville.”
We reached out to all 100 counties in the state to see what kind of addiction treatment they offer in their jails and 10 responded. About half of those jails implement a detox protocol, which means they force pregnant people with opioid use disorder into substance withdrawal.
The Department of Health and Human Services previously told North Carolina Health News that at least 13 counties in the state have started programs to implement medication-assisted treatment programs in their jails. Some jails, such as in Durham County and Buncombe County, have started programs where they identify detainees with substance use disorder and prescribe them medication-assisted treatment.
North Carolina jails that do not have the resources to care for pregnant people awaiting trial also have the option to send them to the medical unit at the North Carolina Correctional Institution for Women (NCCIW) in Raleigh through the state’s safekeeper program. Safekeepers are people county jails send to state prison while they await trial for reasons ranging from medical concerns to that person being under 18 years old.
Pregnant safekeepers are housed separately from the general prison population, unless they are admitted to a medical or mental health unit.
The Department of Public Safety does not keep track of the number of pregnant safekeepers that go through NCCIW every year, according to spokesperson John Bull, but four pregnant people were being treated at NCCIW as safekeepers as of Feb. 16.
“The number of pregnant offenders varies on a regular basis and the counties that send them routinely vary,” Bull said. “I don’t know of any particular counties that obtain these safekeeper orders for pregnant offenders more than other counties.”
The possibility of being sent to NCCIW, which could be far from home for pregnant people arrested in the far eastern or western parts of the state, could be an incentive for pregnant people not to disclose their pregnancy status, said Essence Hairston, UNC Horizons program manager.
“That creates another issue because you have a pregnant patient that’s withdrawing in the jail,” Hairston said.
Difficulties upon release
If a pregnant person being held as a safekeeper at NCCIW is released from their county jail, they will be released from the custody of the prison in Raleigh, Hairston said. No one is responsible for returning them to their home county.
That might not be as much of a problem if that person is from Wake or Orange counties, but if they’re coming from the far western part of the state, it could be difficult to find a way home.
“It’s not an uncommon thing,” Hairston said. “It’s just an unsafe practice, especially when you’re dealing with individuals affected by [opioid use disorder] or any other substance use disorder.”
Pregnant people with substance use disorder may also be released and find out that their Medicaid has been paused, Johnson said. It could take 45 to 60 days for a person’s Medicaid to go back into effect, Johnson said. That means it will be difficult to get access to medication-assisted treatment — and prenatal care.
“You don’t leave with medication in hand,” Johnson said. “Hopefully you’re connected with somebody who might be able to take care of you quickly, but you don’t have insurance coverage to pay for the medication.”
Improving access to medication-assisted treatment
Starting a medication-assisted treatment program inside a county jail can be expensive — especially in smaller counties with more limited funding. Additionally, providing MAT in a jail is difficult if that facility is in a county that doesn’t have a health provider licensed to dispense MAT, Sufrin said.
“If your jail is in a community where the community doesn’t have a provider of buprenorphine or methadone, it makes it really hard for the jail to be able to provide that as well,” Sufrin said. “And to be able to provide continuity upon a person’s return to the community.”
There is also stigma still attached to medication-assisted treatment, even though it is the FDA-approved treatment for opioid use disorder.
“Some jail administrators are concerned that incarcerated individuals will divert the medications to other people and sell drugs in the jail,” Sufrin said. “And so there are those concerns that may lead some people to be hesitant to provide these treatments in their jail.”
The lack of access to medication-assisted treatment for pregnant people in jails is a product of a “combination of stigma,” Johnson said. Many providers in jails feel uncomfortable treating pregnant people, she said.
Still, Johnson said there is potential for “positive change.”
“Sometimes people’s feelings can shift when they start hearing from those of us who do the care,” Johnson said.
This article originally appeared at North Carolina Health News, an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina.