With Suboxone more available in Allegheny County Jail, post-release care becomes even more crucial

Elizabeth wept on an April evening as she stood on the sloped embankment of the Monongahela River, not far from the Allegheny County Jail, which had released her two weeks prior.

She was thinking of her three children, whom she hadn’t seen in five years due to her opioid use disorder . At 40, she’s suffered from the disease for nearly two decades. PublicSource is withholding her last name because identifying her could lead to negative legal consequences.

A member of the county’s Jail Oversight Board hoped for a good outcome for Elizabeth during one of his jail inspections in March: Muhammad Ali Nasir saw that she was benefiting from the jail’s recent expansion of its medication-assisted treatment [MAT] program , which qualified her to receive buprenorphine , often sold under the brand name Suboxone . It satisfies cravings for opioids, prevents withdrawal, and doesn’t cause a high when taken as prescribed.

“It was the best conversation I’d had with her,” said Nasir, known as MAN-E, who met Elizabeth a year ago through his mutual aid work with people facing addiction and housing instability. “She seemed healthier, like she was moving toward recovery.”

But Elizabeth relapsed soon after she was released — a dangerous time for people with opioid use disorder, even if they were receiving medication for the disease while incarcerated. Taking Suboxone over time will lower a person’s opioid tolerance , which puts them at risk for overdose if they take heroin or fentanyl at doses their body was previously used to.

“All they did was set me up for failure because I’m not on it now,” she said, describing her withdrawal from Suboxone and return to illicit drug use during an interview near her tent, which was located in an encampment sheltered by a bridge.

The Allegheny County Jail offers greater access to medications for opioid use disorder [MOUD] than many jails and prisons in Pennsylvania. The county reached an agreement with the U.S. Department of Justice, announced in November , that compels the jail to offer MOUD to all who would benefit, not just pregnant people or those booked with a valid prescription. One month later, it started patients on buprenorphine — a level of access even the state’s prison system doesn’t provide.

A PublicSource investigation found the program expansion is off to a rough start, but Nasir could see that it was helping Elizabeth. Her success in jail, and struggles upon release, reflect a challenging reality: No matter how care improves within the walls, it’s less likely to succeed unless it continues outside.

The county’s agreement with the Justice Department doesn’t require it to facilitate continuity of care, but it’s taken some steps to do so. It awarded a contract to Unity Recovery for non-clinical reentry services “to ensure that individuals are connected with a community provider” after they’re released, wrote Mark Bertolet, a spokesperson for the county’s Department of Human Services. The jail has referred hundreds of people to Unity, though it’s unclear how many have continued MOUD on the outside as a result.

And low-barrier clinics have seen increases in referrals from the jail and patient demand for buprenorphine. That could reflect more people seeking to continue treatment at a time when a fire at the Second Avenue Commons shelter has taken crucial health care resources near the jail offline.

What happens when continuity of care is broken

Elizabeth was working as a nurse aide in her early twenties when she hurt her back while lifting a patient. She was prescribed Percocet , an opioid pain reliever, so she could keep working to support her first child. She got into two car accidents after that, causing further injury and full-blown opioid use disorder.

Click here to view resources for recently incarcerated people

“I’m in pain constantly,” she said, noting she uses drugs to alleviate her suffering. Like so many others with the disease , she was repeatedly arrested — at least 14 times since 2008, according to court records — for theft, possession and other low-level charges.

She faced a high risk of death each time she was released from jail — the circumstance surrounding 420 of the 2,684 people who died by accidental drug overdose in Allegheny County between 2016 and 2020, according to a county report .

But each release was also a chance for the county and the region’s low-barrier health care providers to quickly intervene before Elizabeth started using again. Her discharge in April — which followed her stabilization on Suboxone — was an especially opportune time for them to act.

“There’s nothing more important than continuity of care when it comes to any MOUD,” said Dave Lettrich, executive director of Bridge to the Mountains , a street outreach organization that connects unhoused people to low-barrier health care. “Even the slightest break in that continuity of care is all it takes to quickly undermine any positive effects.”

Experts said stigma around opioid use disorder , tight regulation of MOUD and a mixed public-private health care system driven by profit keeps many providers and local governments from doing what they should.

In Pennsylvania , a person’s Medicaid coverage is suspended if they’re incarcerated for more than 15 days. Brandon Cwalina, spokesperson for the state’s Department of Human Services, said the agency can quickly reinstate coverage through an automated process for those leaving state prisons. But the process might take longer or even lead to a coverage gap for those released from county jails — a delay that could keep them from filling a prescription for buprenorphine.

And some providers turn away opioid use disorder patients, forcing low-barrier clinics to pick up the slack.

Prevention Point Pittsburgh operates mobile medical vans staffed by Allegheny Health Network clinicians in overdose hotspots throughout the city. Patients don’t need health insurance to receive and fill buprenorphine prescriptions, but they should call ahead to make sure the vans have capacity. Staff noticed a recent uptick in patients seeking Suboxone after jail time, partly fueling the overwhelming demand for care.

Prevention Point still takes patients who are “dumped on us” by providers who refuse to treat them, said Executive Director Aaron Arnold. It receives at least one new patient every week that way.

“There are people who tell me point blank they will never, ever prescribe” buprenorphine, he said, attributing the rejections to stigma and lower profit margins for addiction treatment.

Elizabeth felt she didn’t get what she needed to continue her recovery.

“The jail gave me a fucking list of numbers,” she said. The cell phone she shared with her wife was stolen shortly after she was released, which left her unable to make or receive phone calls to providers.

The ideal discharge process

The average jail stay is 61 days, according to a county dashboard . Patients often need to stay on buprenorphine in the long term to avoid relapse, which is why advocates are fighting for seamless continuity of care.

Lettrich, Eric Hulsey of Vital Strategies and other experts told PublicSource what discharge planning for incarcerated people with opioid use disorder should look like. Staff should:

• Make an appointment with a provider who prescribes MOUD, ideally scheduled on a patient’s release date
• Ensure the cost of the appointment and prescription fill is covered, via Medicaid, commercial health insurance, or free or low-cost health care options in the community
• If a patient’s Medicaid was suspended during incarceration, help them reinstate it before their release, or as soon as possible afterward
• Provide a take-home supply of buprenorphine that will “bridge” the patient to their appointment with a prescribing provider
• Provide a naloxone kit , known by the brand name NARCAN, that will quickly reverse an overdose
• Connect the patient with wraparound services , such as counseling, housing assistance, transportation and job training.

They acknowledged the ideal discharge is hard to do in a jail environment, where releases happen on short notice and staff are stretched thin .

How the jail facilitates continuity of care

The jail follows some, but not all, of those best practices: It doesn’t make medical appointments for people about to be released from custody.

Those who had a prescription when they were booked “know where to go and typically don’t need additional assistance,” said spokesperson Jesse Geleynse. But the jail will send dosing information to their provider if the patient gives written consent.

Patients get a NARCAN kit in case of overdose and a three-day supply of buprenorphine, which Geleynse said should be enough to tide them over until they get a prescription — even if they’re released on a Friday. Lettrich said Friday releases could lead to overdoses because fewer clinics are open on weekends. He’d like to see patients leave the jail with a seven-day bridge prescription.

Geleynse didn’t answer a question about how the jail communicates with the state Department of Human Services to reinstate suspended Medicaid plans. But he said Three Rivers Youth , a local recovery organization, helps recently incarcerated people enroll in Medicaid through a contract with the county.

Jail officials acknowledged that patients who were first prescribed buprenorphine while incarcerated need more support to prepare them for release. “We know that starting someone on a medication comes with giving them resources to then continue the medication,” said Renee Madden, deputy health services administrator of behavioral health.

The jail refers those patients to the Rethinking Incarceration and Empowering Recovery [RIvER] Clinic — an AHN program that provides free health care, including buprenorphine, to recently incarcerated people. Because AHN is the jail’s contracted health care provider , RIvER Clinic staff can meet with referred patients in the jail and read their electronic health records, gaining insight into the care and wraparound services they’ll need in the community. Almost 90% of the clinic’s patients have opioid use disorder and need bridge prescriptions for buprenorphine.

Staff follow up with them soon after they’re released, offering care to a group of people who disproportionately experience poverty, mental illness and homelessness , said Co-Director Thomas Robertson , an internal medicine doctor.

“We’re very, very low barrier,” he said. “You don’t have to lie to us. You don’t have to be scared about coming here. We are here for you, for the good, the bad, the ugly.”

Demand surged after the jail expanded access to MOUD, which Robertson said may have contributed to a more than 30% increase in patients coming to the clinic. But staff are doing fewer buprenorphine inductions and treating more patients who’ve been stable on the drug for some time — a sign that expanded access in the jail is helping.

Peer support to prevent overdoses

Research shows that support from “ peers ” can help prevent overdoses. They’re in recovery from opioid use disorder and are licensed to guide others through the process.

The jail brought in Unity Recovery, a peer-run organization, to help with discharge planning as it expanded access to MOUD in December. Unity’s peers have served 380 people through 2,257 peer engagement sessions to date, according to Bertolet, the county Department of Human Services spokesperson. Elizabeth was among those referred to Unity, though it’s unclear if she’s used its services.

Unity was launched in Philadelphia in 2019 by Robert and Arielle Ashford, who are both in recovery from substance use disorder. It expanded into Pittsburgh and opened a recovery house in 2022 on the South Side , where nearly 50 peers offer 24/7 support to people in crisis.

Executive Director Robert Ashford said Unity receives the jail’s referrals in real time as people test positive for opioids during booking. If a person consents, a Unity peer will meet with them in the jail to plan their reentry as soon as possible — an effort to get ahead of an unpredictable release date. Step one: Come to the recovery house.

“Get a meal, take a shower, get your bearings about you [and then] let’s talk about medication,” Ashford told PublicSource in May.

Unity doesn’t provide medical care, but it connects people to the RIvER Clinic for bridge prescriptions. Robertson said the clinic’s social worker and nurse navigator do outreach on Tuesday mornings at Unity’s recovery house, including patient intake and on-the-spot telemedicine if they need immediate care.

‘If I don’t make it, I’m going to sleep in a tent’

Nasir, County Councilor Bethany Hallam and other mutual aid workers distributed supplies outside Unity’s South Side recovery house on a Sunday afternoon last month.

PublicSource surveyed about 30 people who gathered to receive food, tents, menstrual products and other necessities. Only one — a 30-year-old man who asked not to be named — said he was referred to Unity while receiving Suboxone in the jail.

“They’re really doing something great here as far as how they’re helping the homeless people,” he said, describing the food, shelter and harm reduction supplies Unity gave him after he was released in May. But he was unsure of his housing prospects at the time.

“If I don’t make it, I’m going to sleep in a tent,” he said.

Geleynse said the jail referred 403 people to Unity as of June 13, but couldn’t specify how many of those referrals resulted in continuity of care. “The jail has no mechanism to track this information and is not permitted to work with or contact patients after they are released from custody,” he wrote.

While the jail may not be able to, the county can track prescription fills that were paid for by county funds or Medicaid, said Hulsey, a former manager of behavioral health analytics for the county’s Department of Human Services who left in 2019, and is now with the public health advocacy group Vital Strategies. Ideally, he said, it should determine if people are regularly filling prescriptions over 180 days — the standard for continuous MOUD treatment .

“Did the person remain in treatment long enough for it to be effective?” he asked.

The county is developing a dashboard that will show the public health outcomes of the jail’s expanded MAT program, said Bertolet. Asked if it will track continuity of care, he said, “We’re still determining what will be included in the tool, based partly on the frequency and accuracy of the information that we get.”

Ashford said Unity sees between 80% and 90% uptake on the jail’s referrals and collects data on health outcomes among participants. He didn’t respond to multiple requests for specific figures.

‘People are falling through the cracks’

Janice Kochik steps in when traditional health care fails people with opioid use disorder. She’s a street outreach nurse practitioner for Central Outreach Wellness Center , which provides low-barrier care to LGBTQ+ and other marginalized people.

On a Saturday afternoon in June, she was distributing pillows, blankets and other supplies in an encampment along a section of the Three Rivers Heritage Trail. Earlier that week, a fire ripped through Second Avenue Commons and displaced 188 people from the county’s main low-barrier shelter. She saw that more tents — from eight to at least 30 — had been pitched there since the blaze took the shelter offline.

Kochik helped several people who said they were released from the jail without a supply of Suboxone. She checked a state-run database to make sure they didn’t have the drug, then wrote bridge prescriptions and connected them to the RIvER Clinic or Prevention Point.

“People are falling through the cracks,” she said, expressing concern over what those patients told her. “They’re discharged and they’re standing outside the jail and they have no idea where to go. Their choices are back by the railroad tracks or in a camp.”

Robertson, of the RIvER Clinic, said the jail’s discharge planning “can be rushed or disjointed” because staff don’t always receive notice before a person is released, which could lead to the mistakes Kochik’s patients described.

“We try our best to capture every referral,” he said, though the shelter fire has complicated that effort.

The RIvER Clinic treats patients at a location on the North Side, and used to do so on Monday mornings at the UPMC Second Avenue Commons Health Center . That clinic is based at the shelter — just a short walk from the jail. Neither UPMC nor AHN providers have been able to treat patients there since the June 4 fire. County officials said it could take months to reopen the shelter.

“It’s a huge loss any way you cut it,” Robertson said, noting many of the patients the RIvER Clinic treated at the shelter came from Renewal Inc. , which houses formerly incarcerated people with substance use disorders. His team is working with Renewal and doing more street outreach to mitigate that loss.

UPMC staff are now operating a temporary walk-in clinic, on a reduced schedule, inside the county Department of Human Services building Downtown. The clinic will move to a location in Uptown on Aug. 1.

“We were devastated by the fire at Second Avenue Commons and are working as quickly as possible to … resume normal hours,” the clinic’s medical director, Anita Leon-Jhong, said in a statement.

The outlook for continuity of care

There could be changes on the horizon for health care after incarceration.

For years, state and local governments couldn’t use federal funds to cover the cost of health care for incarcerated people, but a new policy aims to change that: States can request a federal waiver allowing Medicaid to pay for MOUD, counseling, case management and a month’s supply of all prescribed medications upon release.

Such waivers could help prevent deaths from all causes after imprisonment, according to a briefing by the Prison Policy Initiative , which studies mass incarceration.

Some states have already been approved , while Pennsylvania’s application is still pending. “We are hopeful for federal approval by fall 2024,” wrote Cwalina, the  Pennsylvania Department of Human Services spokesperson. The state General Assembly would then have to approve funding for the programs outlined in the application .

The county is searching for a licensed provider to start patients in the jail on methadone by October. The drug can be more effective than buprenorphine for some patients, but is more strictly regulated and continuation on the outside could be complicated. It also pledged to find 500 deeply affordable housing units in 500 days for unhoused people, who suffer from substance use disorders at higher rates .

These are good policies, but they don’t address the problem “on the front end,” said Emily Kaltenbach, senior director of state advocacy and criminal legal reform for the Drug Policy Alliance , which advocates for ending the drug war .

“We should be asking ourselves whether individuals who have a substance use disorder, or who had been caught with possession of substances, should belong in jails and prisons to begin with,” she said.

In April, Elizabeth hoped to get back on methadone, which kept her abstinent for four years. She dreamt of getting into a trade school to become a welder.

She was arrested again in June in Westmoreland County. The charges are theft, use and possession.

Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at venuri@publicsource.org or on X, formerly known as Twitter, @venuris .

This story was fact-checked by Jordana Rosenfeld.

This reporting has been made possible through the Staunton Farm Mental Health Reporting Fellowship and the Jewish Healthcare Foundation.

Resources for recently incarcerated people

If your Medicaid was suspended during incarceration, call the Pennsylvania Department Human of Services to reinstate it at 1-877-395-8930. If you’re in Philadelphia, call 215-560-7226 or the local county assistance office.

This isn’t an exhaustive list and many other resources are available in our community.

Low-barrier health care

• RIvER Clinic, based at AHN’s Center for Inclusion Health , 1307 Federal St., Suite 301, in Central Northside, 412-260-2436, riverreferrals@ahn.org , clinic hours from 8 a.m. to 5 p.m. on Tuesdays and 8 a.m. to 12 p.m. on Thursdays, telemedicine clinic available from 8 a.m. to 5 p.m., Monday through Friday
• Prevention Point Pittsburgh , multiple locations in Pittsburgh listed here (buprenorphine prescriptions available at mobile sites Tuesday through Friday, but not at East Liberty office site on Sunday), patients should call 412-247-3404 before seeking treatment
• Central Outreach Wellness Center , 127 Anderson St., Suite 101, North Shore, 412-322-4151
• UPMC Second Avenue Commons Health Center , now at a temporary location in the Allegheny County Department of Human Services building, 1 Smithfield St., Downtown, accepting walk-ins from 12 p.m. to 4 p.m. Monday, Wednesday and Friday through July, will move on Aug. 1 to a Pittsburgh Mercy facility at 905 Watson Street, Uptown
• UPMC Toxicology Telemedicine Bridge Clinic , virtual care only, schedule appointments here
• The Squirrel Hill Health Center , multiple locations in Allegheny County listed here , call 412-422-7442 for medical and behavioral services, and 412-697-7997 for dental services

Peer support and shelter

• Unity Recovery , 801 Bingham St., South Side, 412-586-5372, contact@unityrecovery.org
• Za’kiyah House , peer support and supportive housing in Homewood and North Braddock, call intake at 412-727-2158 from 12 p.m. to 6 p.m. Monday through Thursday and 9 a.m. to 3 p.m. Friday through Sunday, zakiyahhouse@gmail.com

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