Like many states, Maine has two incarceration systems – a state prison system and 15 county-run jails, which historically took different approaches to treating opioid use disorder. While the state prison has provided medication for opioid use disorder (MOUD) since 2019, counties took diverse approaches until an initiative led by Penobscot County Sheriff Troy Morton, president of the Maine Sheriff’s Association, worked with the state Department of Corrections to develop a medication-assisted treatment (MAT) model now used by all county jails.
The National Academy for State Health Policy (NASHP) recently spoke with Morton, who started the first jail-based MAT program in his jail in 2015, about how the self-described “old drug cop” worked with state leaders to develop the innovative county jail model, an initiative supported in Maine’s Opioid Response Strategic Action Plan.
How did the program get started?
Our state has embraced a three-pronged approach – enforcement is still critical, but we’ve also got to provide education and treatment. Initially, we decided to model our program off of the approach taken in Barnstable County in Massachusetts. At the time, they were using naltrexone, and that’s how we started here. Naltrexone [an antagonist, non-opioid replacement therapy] seemed to be the ideal treatment option in a correctional environment where the main concern is diversion [unauthorized use of MOUD]. I met with the former governor outside of my official capacity as sheriff and asked him why Maine wouldn’t try this as well. Here am I, an old drug cop, insisting that this might really work. Ultimately, the governor agreed, and we worked with the Department of Health and Human Services commissioner to coordinate funding using the state’s federal opioid grant dollars, and then [received initial naltrexone doses free of charge from the pharmaceutical company]. We were the first county jail in the state to provide MAT. Now, across the state, MAT at all county jails is supported through similar grant funding. At our facility, Penobscot Community Health Center (PCHC) contracts with the state to provide our residents with counseling services, and we receive state grant funds to pay MedPro Associates, our health care provider, to provide medical services. Moving forward, we need to think about sustainability as a state if we’re going to maintain these programs.
How did you structure your program to be successful?
At first, we started by interviewing women at our facility who had been in recovery prior to being re-incarcerated and asked them what had helped them to be successful in recovery. Their responses were all pretty similar: “I had just gotten out of jail, so I was clean; my family came back to me because I was clean; I got a job because you guys connected me with opportunities.” We really started to see some success with our program when we provided MAT in our facility and removed all the other barriers to treatment when people were released. We found funding for transportation and housing and we connected people with jobs, so there was no excuse to not stay in treatment.
We recently began drilling down into our booking processes. Previously, we relied on a process that did not really focus on SUD [substance use disorder] or mental illness. From a corrections perspective, people come to us for committing robbery or aggravated assault, not for their opioid addiction or their schizophrenia. Recognizing this, we worked with MedPro Associates and PCHC to develop better screening questions to ask new arrestees. Now we ask individuals whether they have ever been treated in an MAT program, whether they have a substance use disorder, etc. Interestingly, if a correctional officer asks new arrestees if they have an SUD, 26 percent of the time the answer is yes. An hour later, our medical staff asks the same question, and 47 percent of the time the answer is yes. Based on this, we do our best to remove correctional staff from the program screening process – our medical staff determines program eligibility and gets services started.
How do county jails provide health care services?
At our jail, we contract to provide medical services, including MAT, on site. The same provider contracts with five other county jails across the state. But, there are still county jails in Maine that do not have medical units. They rely on a local hospital to provide medical care. When an individual enters the facility and presents as being potentially eligible for the program based on a screening tool similar to what we use, they call the local hospital who will then send over a provider. But generally, all 15 facilities are providing similar services to their incarcerated populations. Some jails only start people on MAT if they’ve been on it prior to incarceration, while some will allow anyone who has an OUD to be induced. For the people who are not eligible to start medication while in our facility, we do offer counseling services through PCHC. Upon release, these individuals are entered into our Bridge Program, through which they can start MAT at PCHC as well.
What role did your relationship with the state play in developing your model policy?
Our initial program was starting to gain some traction and show preliminary success, and the male population wanted to join in. Immediately after the lawsuit in Aroostook County, there was some discussion about changing jail policy around MAT, but there were concerns about providing treatment in jail settings and about the perennial funding issue. Because our jails look different and provide services differently across the state, we realized that we couldn’t take a one-size-fits-all approach when expanding the program. That’s when we reached out to Dr. Lisa Letourneau [MD, MPH, FACP s], the Department of Health and Human Services Senior Advisor for Policy and Community Engagement, and Ryan Thornell, Maine DOC Deputy Commissioner, about developing a model MAT policy for county jails through a collaborative process. [Maine DOC currently provides naltrexone and buprenorphine to incarcerated individuals]. We did not want to have folks enter one of our jails and start in our treatment program only to hand them off to a prison that did not sync with our system. We also wanted to ensure a soft handoff to a program on the outside. Our program participants have told us that we got them healthy before releasing them without a safety net. They end up right back where they were – no apartment, hanging out with the same people, eating poorly, not sleeping, no job. People need that structure in place before they leave our facilities.
By bringing together our health care providers and corrections staff and working with the state and DOC, we were able to address concerns across the board and create a model policy that worked for everyone, medical and corrections alike. But we treated it as just that – a model policy – and encouraged each facility to adapt the policy to meet its particular needs.
Have you considered expanding treatment to include methadone?
Currently, we address requests for methadone on a case-by-case basis. If an individual comes to us and has been on methadone for years, we do not want to interfere with that person’s treatment. We defer to our medical provider and the individual’s community provider to determine what is best for that individual and make a treatment plan accordingly. At our facility, we are beginning to discuss forming a partnership with a methadone provider, but we are still in the preliminary stages of that discussion.
How do you measure success in your program?
We are beginning to generate some solid data about programmatic outcomes at this point. At the one-year anniversary of our program, of those program participants who had been released, not a single person had overdosed within that first year. How many people did we save? I don’t know precisely, but I believe that our handoff to a community provider was the key to that success.
How do you see your approach to SUD evolving?
We are in the process of training every deputy to understand and recognize someone who is in crisis and detoxing. We are realizing that we don’t need to arrest them because they are under the influence – we need to give them the opportunity to change their lives if they want to. We are also working with Community Health and Counseling Services (CHCS), our mental health provider, to provide SUD clinicians to ride with deputies to respond to those overdose situations. If someone survives an overdose, the SUD clinician can help them navigate immediate next steps and make a plan for the future. People need that assist when they survive an ordeal like that, just like they need supports like housing, employment, and transportation when they get out of jail.
