Baltimore jail officials lost track of nearly 92,500 methadone pills — controlled substances that carry a high street value — over a three-month period, investigators with the U.S. Drug Enforcement Administration found during an audit earlier this year.

The audit of the Baltimore Central Booking & Intake Center cited findings by DEA “diversion investigators,” according to a “memorandum of agreement” reviewed by The Baltimore Banner, suggesting that employees at the jail could have stolen some of the pills.

The document appears to have never been made public, but the agreement has major implications for the jail’s struggling health care system and the incarcerated people who rely on it. The agreement saddled Central Booking employees with additional reporting requirements for the next three years, and state officials could face fines if the terms aren’t met.

The Maryland Department of Public Safety and Correctional Services, which runs city jails, declined to answer questions about the agreement. A spokesperson for the department wrote in an email, “due to the complexity and nature of your request, this has some investigative implications.” The DEA declined to comment.

Investigators from the DEA found shortages of several different medications used to treat opioid use disorder at Central Booking, including 87,572 methadone 10-milligram tablets and 4,914 methadone 5-milligram tablets, according to the agreement. The department was also missing 460 films of buprenorphine/naloxone films and 4,456 buprenorphine/naloxone tablets of varying strength. The jail was short about 60 buprenorphine tablets.

The DEA agreement represents a significant enforcement action by federal officials after numerous warnings over similar violations at the same facility dating back to at least 2012, according to other documents reviewed by The Banner.

Jim Crotty, former deputy chief of staff at the DEA, said these types of agreements are “pretty rare.”

“They’re generally only taken and reserved for the most serious offenses and violations,” Crotty said. “They’re not taken very lightly, particularly given the context of this being a department of corrections facility and recognizing the importance of medication-assisted treatment during the opioid crisis.”

Studies have shown that people released from jail face an outsized risk of a fatal opioid overdose, prompting Maryland lawmakers to pass a bill in 2019 requiring local detention facilities to offer the medications. In Baltimore, the overdose death rate was nearly double that of any other major American city, The Banner and New York Times reported earlier this year.

Dr. Michael Fingerhood, a Johns Hopkins addiction specialist who often treats people recently incarcerated at Central Booking, said he frequently hears from patients that they did not receive treatment for their opioid-use disorder while detained there. He called the audit’s findings “alarming.”

Fingerhood, who does not work with the jail in any official capacity, said that as far as he can tell, its treatment program is “minimally running.”

“Maybe it’s minimally running because they’re diverting all the medication that should be for the people who need it,” Fingerhood said.

What the agreement means for Baltimore’s jail

The DEA audit found that jail officials failed to keep accurate records and document correct quantities of the controlled substances it ordered. Officials not only failed to record accurate data about its inventory, but also about when and how providers dispensed the medications.

The resulting three-year agreement sets forth several “obligations” that the corrections department and its private medical vendor, Centurion Health, must follow, or will otherwise face fines. Those obligations include performing quarterly audits, inventories, and reporting to the DEA “any professional, civil or criminal actions pending or taken against the respondent, a member on its board of directors, or any employee by any state, federal or professional agency or governing body.”

Regina LaBelle, a Georgetown University professor and former acting director of the White House Office of National Drug Control Policy, said state courts are increasingly establishing that jails must provide opioid use disorder medications to people who need them in order to have constitutionally adequate health care.

LaBelle, whose research focuses in part on expanding access to opioid use disorder treatments for incarcerated and recently incarcerated people, said the DEA is likely walking a fine line between enforcing the Controlled Substances Act and preserving the rights of people incarcerated there to access the treatments.

Even with the medications continuing to flow into the jail, LaBelle said the DEA enforcement action could have a “chilling effect” on the jail’s medical provider and make staffing medical professionals there more challenging, given the increased oversight at the facility.

“People may be thinking, ‘If I have a choice between going to a criminal justice health care system that works, why would I choose this one?’” she said.

Taken by surprise

Fingerhood and others who work to provide opioid use disorder treatment to recently incarcerated people were taken aback by the news of the DEA audit when contacted by The Banner.

So was Corene Kendrick, deputy director for the ACLU’s National Prison Project, which has been entangled in a yearslong legal fight with the corrections department over health care and mental health services at the jail.

When told about the quantities of pills missing from the jail, Kendrick responded, “Holy f---.”

The attorney cited the reports by former independent medical monitor Dr. Michael Puisis, who resigned late last year. Puisis had repeatedly dinged the department in his reports for its shoddy electronic medical records, including the medication administration records, Kendrick said.

“They had these massive three-ring binders, and the nurses would walk around and try to write notes in them as they handed out pills,” Kendrick said. “Supposedly, they were supposed to go back and reconcile things, but it was always a compete mess.”

Still, Kendrick said it was “hard to fathom” how so many pills could be diverted.

“The state is spending millions of dollars on these medications that are supposed to be highly controlled and regulated,” she said. “It wasn’t just a few pills here and there — 87,000 pills is staggering.”