A sweeping bill that seeks to address the fentanyl crisis in Colorado would do little to improve a key treatment option in jails, experts said last week.

Meanwhile, sheriffs said that if legislators want to improve the program, they should be prepared to pay for it.

Under the bill, jails who receive behavioral health funding from the state would be required to develop protocols for medication-assisted treatment, or MAT, a program that uses prescriptions and therapy to curb opioid cravings and stave off withdrawal symptoms. But, as written, the bill does not require jails to actually offer it to inmates who need it.

Advocates say the legislation changes little from the status quo.

The legislation comes amid heightened attention to the drug's increasingly deadly impact in Colorado. Fatal overdoses involving the drug have skyrocketed since 2015, the product of shifting economics and priorities within the illicit drug trade and accelerated by the pandemic.

Nearly 900 Coloradans died after ingesting fentanyl in 2021, according to state data. That represents a roughly 66% increase from 2020 and quadruple the number of deaths from 2019.

Two sheriffs who have implemented MAT programs said they opposed the state requiring counties to offer it without paying for it. Both of those sheriffs — Justin Smith in Larimer County and KC Hume in Moffatt County — said they depended upon grant funding to pay for MAT services in their facilities.

According to a 2019 report by the Substance Abuse and Mental Health Services Administration, the odds of being arrested and becoming involved in the criminal justice system is 52% for those using opioids and 77% for those using heroin. Between 17% and 19% of state prison and jail inmates reported regularly using opioids, and as many as 45% suffered withdrawals upon being incarcerated, according the report. 

What's more, recently released inmates are 10 to 40 times more likely to fatally overdose from opioids than the general population. An older study put the risk at 129 times higher. In incarceration settings, inmates don't have access to the opioids they were using previously. When they're released, they may use the same dose they had been before. With their tolerance wiped out, that dose is more likely to be lethal.

It's why public health officials and harm reduction advocates support using medications, such as methadone or buprenorphine, in combination with therapy, to treat inmates. They said the drugs help avoid withdrawals while curbing cravings. Ideally, once that person is released, there's a clean handoff to an MAT clinic and provider waiting for them, and, research shows, they're less likely to die or reenter the justice system.

A 2019 analysis in the Journal of Substance Abuse Treatment, as well as the federal report from the same year, both noted MAT's efficacy in jail settings.

Currently, Colorado jails are required only to have a policy on MAT. That could mean describing a detailed plan for screening inmates, getting them started or continuing treatment, and how the service will continue upon release. But it could also mean a jail merely saying it won't offer MAT at all, experts said, or in limited settings — for pregnant women, for instance, or for people who were already on MAT when they were incarcerated. 

JK Costello, a consultant who advocates for MAT in jails and is working on suggested amendments for the fentanyl bill introduced by the Colorado Legislature last month, said the bill could be more prescriptive and it needs to have teeth. There's no penalty, in the bill or in current law, for jails who don't have a policy or protocols at all, let alone one with specifics, he and others noted.

Terri Hurst, a policy coordinator with the Colorado Criminal Justice Reform Coalition, called the bill's language on MAT in jails "a bit disappointing."

Ideally, both said, the bill would require MAT for qualifying inmates or at least continuing the treatment for those already on it. Hurst said she is pleased that the bill requires jails give inmates at least three doses of Naloxone — an opioid overdose antidote — upon release, though Costello noted that Naloxone comes in packs of two, making a three-dose requirement logistically tricky.

Rob Valuck, the head of the Colorado Consortium for Prescription Drug Abuse Prevention, regularly likens the concept of denying MAT to qualifying inmates as being akin to preventing diabetics from receiving insulin. It's an approved — and successful — course of treatment for a medical condition, he said, adding he's shocked no facility in Colorado has been sued for not providing MAT.

Courts in at least two other states ruled against jails who didn't provide MAT services to inmates with prescriptions, and the U.S. Justice Department issued guidance last week indicating that the Americans with Disabilities Act protects people in jails receiving MAT services for opioid use.

The bill also requires jails provide referrals for MAT services to interested or qualifying inmates upon release.

But sheriffs Hume and Smith said funding and resources are primary obstacles for rural jails.

Of the counties in the state who don't have MAT programs, most are in sparsely populated counties, according to a list provided by the Department of Human Services. The notable omission from the list is Adams County, home to more than 8% of the state's population and the site of 192 opioid-related overdose deaths in 2021.

Hume said his MAT program in Moffatt County costs roughly $60,000 annually, which he wouldn't be able to afford without grant support. He said staffing concerns — not only in distributing the medications but in ensuring they're taken by the right inmate — are also paramount. 

The bill would give jails $3 million to help them establish the protocols, but no money for ongoing funding. 

Smith said that "MAT is the best out there right now by a lot of measures."

But he said that could change, complicating any push for the legislature to prescribe this exact program going forward.

Sheriffs understand the importance of offering MAT, Smith said, adding he wants the legislature to say the state would provide the service to jails, rather than the jails providing it for inmates.

"That puts the shoe on the other foot, when they have to provide it," he said, referring to funding. "The big thing in correctional medical care is standards of care. The courts hold us to providing what's essentially the standard of care in my community. For me, that's different than rural Colorado. The challenge to this bill the way it's currently written — it's setting a standard of care statewide that's unattainable."

"Like on most things," Smith added, "they'd find us a lot more supportive if they'd fund the things they demand of us."

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