MOUD / MAT Delivery

MOUD / MAT Delivery Models

This section gives examples of the different arrangements that jails can have to get daily buprenorphine and methadone doses to pregnant patients. For a more detailed, step-by-step MOUD (also referred to as MAT) implementation plan (not specific to pregnancy), we recommend this Implementation Toolkit from Vital Strategies/National Council on Behavioral Health. 

(Note: The Vital Strategies resource was revised in 2023 and now reflects the removal of the X-waiver to prescribe buprenorphine. It does not reflect the updates to the DEA/SAMSHA rule on providing methadone in correctional facilities. See MOMCARE content for details on these updates.)

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MOUD / MAT Delivery Models

HOW 

  • It’s now easier than ever to dispense buprenorphine AND methadone in jail!!
    • The DEA no longer requires clinicians to obtain an X-waiver to prescribe buprenorphine. If your jail has a physician, nurse practitioner, or physician’s assistant with a DEA registration for Schedules II-V medications, all they need to do is complete the required 8 hours of training for prescribing buprenorphine. Here is a link to SAMHSA-sponsored training
    • The updated SAMHSA rule 42 CFR Part 8 now allows jails to dispense methadone if they register as a hospital or clinic with DEA form 224 and have at least one provider with a DEA license. This is easier than registering as a certified opioid treatment program (OTP). For more information, please see this FAQ sheet.
  • Consult with your health services provider and local health department to understand the options available for MOUD delivery.
  • Assess your jails’ medical coverage and expertise to determine which MOUD delivery model is best suited for your setting.
  • Determine if onsite or offsite MOUD dosing makes the most sense for buprenorphine and methadone.
  • See the MOMCARE MOUD/MAT Jail Delivery Models: Benefits and Tradeoffs table for considerations on delivery models for buprenorphine and methadone. 
  • Update your jail protocol and educate staff to align with the procedures of your MOUD delivery model.

WHY 

  • MOUD delivery in jail depends on the level and expertise of healthcare staff within the facility or on the availability and proximity of community MOUD resources.  
  • There are unique costs, staffing, time, regulatory, and safety considerations for each MOUD delivery model.
  • The delivery model will also set the foundation for needed policies and protocols that will help ensure there are no deviations from the standard of care.

KEEP IN MIND 

  • Assessing what medications (buprenorphine and methadone) are available in your community and their proximity to your jail is important to consider if offsite transport is needed.
  • Some jails do not have 24/7 medical staff coverage. A plan must be in place for getting pregnant patients MOUD or MOUD-related care during periods of no medical coverage.
  • If you dose medications onsite at the jail, a diversion protocol should be put into place. See MOMCARE Preventing and Managing Diversion.
  • Staffing and training needs depend on your MOUD delivery model.
  • Using an offsite provider for MOUD via transport or telehealth can help with continuity of care when patients leave jail.

🤰 PREGNANCY-SPECIFIC CONSIDERATIONS

  • Regardless of whether you initiate MOUD and dose MOUD for pregnant patients onsite or offsite, a plan should be in place regarding where to take patients (e.g. hospital) if a medical emergency occurs.
  • If you transport pregnant patients offsite for MOUD, they cannot be restrained per state legislation for pregnant detainees in 41 states and DC.
  • Pregnant patients may need more frequent MOUD dose adjustments than non-pregnant individuals due to how medications are metabolized in pregnancy.

HOW 

There are key pros and cons when selecting a MOUD delivery model (or combination of models) best suited for your jail to provide buprenorphine and methadone. We list the delivery models for delivering buprenorphine and methadone to pregnant patients in jail custody and provide a link to a table that has more details on the benefits and tradeoffs of each modality. Sometimes, a combination of models works best in some jails and the modality may depend on the patient’s status. Jails should identify a modality for both buprenorphine and methadone.

See the MOMCARE MOUD/MAT Jail Delivery Models: Benefits and Tradeoffs for the pros and cons of each buprenorphine and methadone delivery model that are briefly outlined below.

MOUD/MAT Jail Delivery Models
BUPRENORPHINE METHADONE 
  • Correctional clinician provides buprenorphine onsite – the jail in-house medical provider prescribes and doses buprenorphine onsite. Other variations exist including performing all inductions offsite then continued dosing at the jail. Per DEA regulations, the provider will need DEA license and to complete the required 8 hours of training.

** New DEA regulations make this a relatively easy and feasible option for jails.**

  • Onsite medication administration by an external provider – External provider comes to jail to provide buprenorphine to patients under the external provider’s license (can include inductions)
  • Telehealth – The jail uses telehealth (outside providers) to provide buprenorphine onsite. Telehealth must have video, not just audio per SAMHSA/DEA guidelines.
  • Mobile MOUD unit – Mobile MOUD unit travels to the jail. Patients are escorted outside where they see an external provider who provides buprenorphine.
  • Offsite medication administration for buprenorphine – Patients are transported offsite to community OTP, hospital, or other medical provider for daily buprenorphine dosing
  • Correctional clinician provides methadone onsite – The jail registers as a hospital/clinic per the new SAMHSA/DEA regulations and the jail in-house medical provider prescribes and doses methadone. Other variations exist including performing all inductions offsite then continued dosing at the jail. For more information, please see this FAQ sheet 
  • Onsite medication administration by an external provider – External provider comes to jail to provide methadone to patients under the license of the external provider (can include inductions).
  • Telehealth – The jail uses telehealth (outside providers) to provide methadone onsite. Telehealth must have video, not just audio per SAMHSA/DEA guidelines.
  • Mobile MOUD unit – Mobile MOUD unit travels to the jail. Patients are escorted outside where they see an external provider who provides methadone.
  • Offsite medication administration for methadone – Patients are transported offsite to community OTP, hospital, or other medical provider for daily methadone dosing.
  • Methadone is either picked up by jail staff or delivered to the jail by OTP and the correctional clinician administers methadone – Could be used for initiation or continuation of methadone.
  • Jail becomes an OTP – The jail obtains an OTP license to dispense

Update to SAMHSA Rules on Methadone in Correctional Settings

In April 2024 SAMHSA, in conjunction with the DEA, updated the final rules of 42 CFR Part 8 to make it easier to provide methadone correctional facilities – especially for pregnant patients! Here are some key points:

  • If the jail is registers as a hospital or clinic (which they can do if they have at least one health care provider with a DEA license), they can dispense methadone onsite as treatment for OUD to patients who have another primary medical diagnosis besides OUD.
    • All pregnant patients fall under this! Pregnancy counts as their primary diagnosis.
  • Registering as a hospital or clinic is much easier than registering as an OTP, and can be done online (DEA form 224, found here).
  • Methadone dispensing includes giving up to a three-day (72 hour) take-home supply for patients upon release.
  • A patient can be started on methadone via telehealth if it includes video (audio-only not allowed).
    • If they were already taking methadone through an OTP before coming to jail, they can just be continued on their verified dose without a visit.
  • This rule does not impact buprenorphine prescribing/dispensing.

For more information, please see this FAQ sheet on the updated SAMHSA methadone rules.

🤰 Jails should consider these questions to assess your capacity and comfortability with providing MOUD services to pregnant patients onsite: 

  • Does your jail have adequate medical staff coverage? What is their level of expertise regarding pregnancy AND addiction medicine?
  • Continuation and ongoing MOUD (pregnant patient on it pre-jail, or started while in jail):
    • Is there medical staff available to provide daily doses of methadone and buprenorphine onsite?
    • Is there medical staff who can assess when a pregnant patient needs a dose adjustment?
  • Initiation of MOUD in pregnancy:
    • Does your jail have 24/7 access to clinicians with obstetrics AND addiction medicine expertise who are onsite, available by telehealth, or by phone consultation?
    • Are jail medical staff trained to counsel pregnant patients on the risks and benefits of MOUD and withdrawal in pregnancy?
    • Jails without these criteria should do all pregnancy MOUD inductions offsite at the hospital or local OTP.
  • What is available in the community—do you have a methadone-providing OTP? Do you have a buprenorphine provider?  
  • Speak with your healthcare provider/contractor to discuss their ability to deliver these services.

If your jail does not have the medical expertise to perform all or some of these tasks, alternative options should be considered like either having an external provider come to the jail, utilizing telehealth, or transporting the patient offsite.

The next steps vary based on the delivery model you selected; they may include:

  • The jail adds buprenorphine to their formulary and the jail clinician completes the DEA-required 8 hours of training needed to dose Buprenorphine. Here is a link to SAMHSA-sponsored training, which can be done online.
    • All licensed practitioners who hold a DEA registration with Schedules II-V authority can prescribe buprenorphine. No additional waiver/license is needed. They have to attest to having completed the training.
  • The jail registers with SAMSHA as a hospital or clinic to dispense methadone onsite.
    • The jail must have at least one practitioner with a DEA license.
  • The jail sets up a telehealth program with a community buprenorphine or methadone provider.
  • The jail establishes a relationship with their local hospital for MOUD inductions and pregnancy emergencies.
  • The jail establishes a relationship with a certified community opioid treatment provider (OTP) and discusses the best method of getting MOUD to pregnant individuals in custody.
  • The jail puts policies and procedures in place that correspond with your delivery model. For example, if you transport patients offsite for dosing, you must avoid using restraints on pregnant individuals. If you dose MOUD onsite, you must have a diversion protocol. See MOMCARE Policies and Procedures for more details on what a comprehensive policy should entail.
  • The jail trains all staff on the basics of your unique MOUD program. Train key staff (custody and health care) on the nuances and details of delivering MOUD to pregnant patients.

This webinar explains the essential elements for developing a jail-based telehealth program and shares lessons learned from a telehealth program in several Michigan jails.

Dose Logistics

Dose Logistics

This section describes MOUD dosing logistics in a correctional setting. It provides information on medication formulations and options for onsite dosing protocols in jails for methadone and buprenorphine. When dosing occurs offsite, the community provider will be responsible.

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HOW

  • There are many different modalities for dosing MOUD in a jail setting.
  • MOUD can be dosed all at once, in a small group, or individually
  • MOUD can be dosed in a separate pill call or together in the general pill call
  • Medical and security staff must work together to get dosing done sufficiently and properly to prevent diversion. Each medication type requires special steps to prevent diversion.
  • Dosing can be administered in the medical unit, general housing, or designated MOUD area
  • There are some supplies jails should buy to assist with dosing MOUD and adhering to DEA regulations, including a safe, pill crusher, and MOUD dose record logbook.

WHY

  • Comprehensive dose administration protocols help ensure pregnant patients receive their MOUD promptly, jails comply with DEA regulations and minimize diversion.
  • Dosing protocols should account for the role of the medical staff, security staff, and patients receiving MOUD.

KEEP IN MIND

  • Devise a daily dosing protocol that fits your jail’s needs and capacities.
  • While dosing protocols should include strategies and vigilance to minimize diversion, it is important to maintain a respectful and trustful demeanor with patients. Take extra care not to stigmatize patients for being on MOUD.
  • Dose timing should be consistent for each day so patients acclimate to a schedule. If possible, consider split dosing (i.e. dosing twice per day) to ensure medications do not wear off before the next dose. This may be needed for pregnant patients.
  • Jails should consider patients regarding the time of day for MOUD dosing. Early morning dosing may be ideal logistically but may cause unintended effects on patients like the dose wearing off before the day is over.
  • If a patient has court or another offsite obligation, ensure they get their MOUD dose before they leave the facility.
  • If someone is caught diverting, they should be referred to medical to discuss their dosing needs and treatment goals. However, they should not automatically be discontinued from MOUD. See MOMCARE Preventing Diversion for more details.

🤰 PREGNANCY-SPECIFIC CONSIDERATIONS

  • Pregnant patients can be dosed in the same group as non-pregnant patients
  • Nausea and vomiting during pregnancy may be an issue for people taking methadone since they need to swallow it (it’s not an issue with buprenorphine since it is not swallowed). Consider giving crackers and an anti-nausea medication (e.g. promethazine or, if 2nd or 3rd trimester, ondansetron) before dosing methadone.
  • Pregnant patients may need frequent dose increases. While they should also have regular dose assessments with a clinician, they may tell the pill-call nurse about cravings or withdrawal symptoms. The nurse should convey this to the MOUD clinician in a timely fashion so that dose changes can be made.

HOW

How can MOUD be dosed in a jail setting?

  • All MOUD patients at once, in groups of 5 or less, OR individually
  • If only MOUD patients, some jails have security officers remind patients of protocol with a standardized script (i.e. expectations of being on MOUD at the facility)
  • A security officer checks hands and mouth before the nurse doses
  • Have the patient take a sip of water to make sure the mouth is moist enough for absorption (important for buprenorphine)
  • Some strategies to reduce diversion:
    • Barber cape, place it around the patient and have them sit in a chair.
    • Shirts with no pockets
    • Barber cape
  • Clinical providers should log all dosing in a standardized log book.

The table below provides some nuances for each MOUD type and formula.

Methadone
Buprenorphine tablets (e.g. Subutex, Zubsolv):
Buprenorphine film (e.g. Suboxone)
  • Dosed as a liquid
  • Have the patient swallow
  • There is no need to wait for it to absorb
  • Dosed as a tablet that must be dissolved under the tongue, NOT swallowed
  • While generally not recommended to crush, because not all of the dose may be delivered, this is a reasonable step to prevent diversion.
  • Crush tablets, then place them under the patient’s tongue.
  • Do not talk, chew, or swallow anything until the dose is dissolved. This takes 5-10 minutes in most cases.
  • Dosed as a film that must be dissolved under the tongue.
  • Do not talk, chew, or swallow anything until the dose is dissolved. This takes 5-10 minutes in most cases.
  • Have the patient drink water after to get rid of any residual. Some jails also give crackers after this just in case there is residual.

When should MOUD be dosed in a jail setting?

There are two options for dosing MOUD in jail:

  1. Separate MOUD-only pill call
    • Requires a dedicated MOUD dosing team (nurse and security officer)
    • PROS: Consistency in who administers the dose, does mouth checks, and messaging/instructions can mean less diversion; staff can focus on appropriate handling and logging of MOUD per DEA requirements
    • CONS: Can tie up security staff for a while depending on the number of patients
    • Some jails find staffing for this easier on the night shift, in the early morning. This is very early for patients, however.
    • Some jails find staffing for this easier on the day shift.
  1. MOUD pill call that is integrated into regular pill call
    • PROS: Medical and security staff already doing pill call with mouth checks, does not require staff to leave usual assignments; more efficient if there are only a few patients on MOUD
    • CONS: Potentially less consistency, more opportunities to deviate from DEA-required protocols, may be more difficult to observe after dose

Who should dose MOUD in a jail setting?

A nurse or other licensed health professional who can administer medications at your jail AND a security officer who works with patients to prevent diversion

Where should MOUD be dosed in a jail setting?

There are a few options for where MOUD dosing usually takes place in a jail facility:

  1. Clinical unit
  2. General housing units where patients reside
  3. Designated MOUD housing unit
  4. Another area with adequate space for observing patients after the dose

What supplies are needed to dose MOUD in jail?

Supplies you might need for dose administration, in addition to methadone and buprenorphine itself, include:

  • Gloves
  • Water & cups for before and after dose
  • Pill crusher if using tablets
  • Safe, (DEA-approved) for storing methadone
  • Logbook to record dosing
  • Barber’s cape (so that you can easily see that hands are not maneuvering to divert dose)
  • Crackers

For clinical details on dosing initiation and titration protocols, please see this quick guide to buprenorphine initiation in pregnancy. For methadone information, see The ASAM National Practice Guideline for the Treatment of OUD (p. 51-52 for pregnancy dosing information)

WHY 

MOUD helps people who use opioids get to a state of feeling normal so they can function without pain and cravings. Having thorough, comprehensive dose administration protocols will ensure that pregnant patients receive MOUD dosing promptly, that jails comply with DEA regulations, and that diversion is minimized.

Many jail staff are understandably concerned about diversion—that a patient taking buprenorphine or methadone by mouth will not actually absorb the dose, but will hide it and then take it back to their cell with them—where they may save it to take at a different time or to give/sell to another individual.  Having a dosing protocol where medical staff, security staff, and the patient are partners together will build trust and ensure smooth, safe dosing.