By Rachel Crumpler|North Carolina Health News
Nearly eight out of 10 people entering the North Carolina state prison system in fiscal year 2021-22 had a substance use disorder in need of treatment, according to a report from the Department of Adult Correction.
Those numbers come from screenings done as people were coming into the system. But there’s a chance those numbers are even higher because, though the prison system screens most people for substance use problems, some people can be missed due to behavior issues, mental acuity and language barriers.
Of the 11,986 people prison staff screened in fiscal year 2021-22, 9,315 people indicated a need for intermediate or long-term substance use disorder treatment — a rate of 78 percent.
The prison system only has the treatment capacity to meet a fraction of the growing need. Year after year, the gap between supply and demand keeps growing, said Wrenn Rivenbark, N.C. Department of Adult Correction’s Alcoholism and Chemical Dependency Programs clinical director.
Since fiscal year 2012-13, the annual percentage of people screened entering prison with a substance use disorder has increased 17 percentage points — from 61 percent 10 years ago.
Only a little over 1,000 beds are available for prison-based, cognitive-behavioral substance use disorder treatment programs, which range in length from 90 days to a year. With beds turning over about every three to four months, Rivenbark explained that he can provide about 3,000 treatment episodes per year.
This means there are enough beds to meet about a third of the incoming treatment need, he said. That rate is actually even lower because of a backlog of incarcerated people who entered prison in previous years and are still awaiting treatment.
“Exponentially it just adds on every year,” Rivenbark said. “Those that didn't get treatment this year are still there even with a new ‘incoming class,’ as I call it. Every year I get further behind in how many treatment beds we can actually accomplish for these folks coming in.”
The outcome: more people returning to communities without having had treatment.
It’s a reality that the state prison system has been aware of for years — stated bluntly in annual reports to the General Assembly’s Justice and Public Safety Appropriations Committees going back to at least 2008.
“Without additional resources, the chasm between the chemically-dependent treated offender and the chemically-dependent untreated offender will grow ever wider — resulting in increasing numbers of offenders returning to our communities without treatment,” prison officials wrote in a March 2008 report to state lawmakers.
A similar statement has appeared in every annual report since.
Prison officials’ predictions have been borne out by the numbers. It’s a supply and demand problem that doesn’t have an easy solution, Rivenbark said, adding that treatment gaps have been an issue throughout his 30-plus-year career in providing substance use disorder treatment — both in the community and in the prison system.
“I have no reason to think [demand] will decrease,” Rivenbark said.
Rivenbark said he and his team are continuously looking for ways to use their resources to better serve incarcerated people with substance use disorder, such as using electronic tablets for lessons and information, providing medications for opioid use disorder and reintroducing peer support.
Treatment offered
The need for substance use disorder treatment within the prison population is significant. Department of Adult Correction Secretary Todd Ishee said at an October prison reform conference that 63 percent of the more than 30,000 people who make up the state’s prison population have a problem with drugs or alcohol.
The Department of Adult Correction’s Alcoholism and Chemical Dependency Programs work to provide substance use disorder treatment to as many of these incarcerated people as they can, given limited resources.
According to the 2021-22 annual programs report, 10 prisons offered a total of 569 beds for intermediate treatment programs lasting 90 days. Another eight prisons offered a total of 556 beds for long-term treatment programs ranging in length from 120 to 365 days.
The prison-based treatment programs are grounded in cognitive-behavioral interventions that reflect best practices from the federal National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration. Rivenbark said treatment includes lectures, group counseling and individual counseling designed to get people introduced to the concepts of recovery-based thinking and actions.
People are generally placed in a treatment program as they near the end of their prison sentence, not at the beginning, Rivenbark said.
“There's great debate about that, and I could argue either point,” Rivenbark said. “We are internally, even now, trying to look at how we can do both — maybe intercept you more robustly when you enter but also make sure we are dealing with you around your recovery status and tools as you get ready to go home.
“If I had to pick one, I would pick trying to prepare you to return to the community because that's where you're going to leave the somewhat structured environment of prison and return home where all of the opportunities for drug involvement are going to be freely open to you again.”
Rivenbark said placement in a treatment program is primarily based on bed availability, facility transfers and the overall needs of an incarcerated person. In some circumstances, he said, people will not be referred to a treatment program when they have sentences that are too short for them to complete an available treatment program. Others may not receive treatment because they need other services.
Often, the problem is that there are no available treatment beds.
The prison system requires people identified as needing substance use disorder treatment to go through the mandatory program orientation period in which staff members confirm that need. After orientation, however, incarcerated people are free to leave the treatment program.
Rivenbark has seen people opt out of treatment for many reasons. For example, someone may be settled at another prison with a work release assignment when their opportunity for treatment comes up, and they may not be interested in letting that work go. Others just aren’t motivated.
“Offenders can sign out, and it's not held against them if they're not ready yet for what we have,” Rivenbark said.
Challenges of providing care
Despite the overwhelming need, program slots aren’t always filled. Rivenbark explained that beds can sit empty as people are moved to the appropriate facility. Over the past few years, program utilization rates also fell due to COVID mitigation protocols.
During the 2021-22 fiscal year, 1,798 individuals were enrolled in intermediate treatment programs, resulting in an overall capacity utilization rate of 59 percent. Another 1,241 people were enrolled in long-term treatment programs for a utilization rate of 45 percent. Before COVID substantially affected prison operations, utilization for both types of treatment programs were up around 80 percent.
Getting someone into treatment and getting them through it are two different issues. Sometimes they voluntarily withdraw from treatment, or have disciplinary infractions and disruptive behavior that push them out.
Program evaluation data show that people who completed a treatment program returned to prison less frequently than those who began a treatment program and did not finish it. Questionnaire results also found that people who completed treatment programs said they had more confidence in their ability to resist the urge to drink heavily or use drugs.
Other support
Although the prevalence of people with substance use disorder has continued to rise over the years, resources to meet the demand haven’t kept pace.
While Rivenbark said he’d certainly take some money to expand prison-based treatment program bed capacity, he doesn’t think that’s necessarily the solution because he wouldn't have the staff to operate them.
“If I could triple the size of my clinical team, I could certainly triple the number of people I could see and maybe take care of that 9,000 in one year, but I don’t know that that’s a realistic ask,” Rivenbark said. He said it’s hard to hire qualified people given the healthy competition in the state for clinicians and counselors.
Besides the formal treatment programs, the prison system offers other support to help people inside prison with substance use disorder.
In fall 2021, the prison system launched an initiative called Recovery Road Services, a way to reach more people at select facilities with relapse management, medication-assisted treatment education, connecting them to mental health treatment and reentry planning. The goal is to help people prepare for the transition to the community.
“We're putting this Recovery Road team in place so if you get in a little crisis,” Rivenbark said. “Let’s say you get involved in some use of illegal substance in prison, we can send a counselor into that environment and try to do a simple intervention at that point even though we're still waiting for the official formal treatment bed to be available.”
The prison system also launched a pilot project in April 2021 providing medication-assisted treatment to people with opioid use disorder who are incarcerated at Orange Correctional and North Carolina Correctional Institution for Women in partnership with the Mountain Area Health Education Center and the North Carolina Formerly Incarcerated Transition Program. Originally announced in 2019, the project was postponed amid the pandemic and hit its stride in mid-2022 when referral, screening and initiating people on medications increased sharply.
To date, 267 people have enrolled in the program, and 213 of them have received treatment medications before release, according to data provided to NC Health News by the Department of Adult Correction. The program also links participants to medications for opioid use disorder in the community through NC FIT or other providers.
Evan Ashkin, who leads NC FIT and works with the Department of Adult Correction on the pilot, said he’s glad the prison system is offering this treatment. He pointed out how these folks are 40 times more likely to die of an overdose in the first two weeks after release than someone in the general population.
“I've had patients in previous years who were not started prior to release and even in the couple of days between release and when they got in the clinic, they had used and overdosed,” Ashkin said. “I'm very hopeful and optimistic that this will grow and expand and people will be protected from overdose post-release.”
Department of Adult Correction spokesperson John Bull said staff plan to provide medications for opioid use disorder at additional prison facilities, though the locations haven’t yet been selected.
Furthermore, Rivenbark said he and his team are using technology to reach more people. Over the past few years, electronic tablets have been distributed throughout the state’s prisons and are available to every incarcerated person. Hope University, the prison system’s online catalog of educational material that launched in facilities in April 2022, includes evidence-based drug and alcohol recovery programs that people can tap into until a treatment slot opens at a formal prison-based program.
“Are we effective for everyone?” Rivenbark asked before answering his own question with, “No.”
“Most folks go to treatment four times before it has an impact,” he continued. “We hope that even though we may not be proving beyond a doubt that no offender will come back to prison, that we're setting up the stage for their next treatment episodes. When they go home — if they still get in trouble with substances — that they'll know where the resources are so that they can go and get some continued intervention rather than coming back to prison.”
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
