The opinion
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PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 24-7049
TRACEY EDWARDS,
Plaintiff - Appellant,
v.
BENITA J. WITHERSPOON; ANTHONY PERRY; JAMES ALEXANDER;
GARY JUNKER; ELTON AMOS; LESLIE COOLEY DISMUKES; KAVONA
GILL; TAMARA BROWN; NIKITIA DIXON; TAMMY WILLIAMS; SHEIDA
BRODIE; TIANNA LYNCH; LORAFAITH RAGANO,
Defendants - Appellees.
--------------------------------------
DISABILITY RIGHTS NORTH CAROLINA; LEGAL ACTION CENTER;
NATIONAL WOMEN’S LAW CENTER; PREGNANCY JUSTICE; ADDICTION
MEDICINE SPECIALISTS,
Amici Supporting Appellant,
Appeal from the United States District Court for the Eastern District of North Carolina, at
Raleigh. James C. Dever III, District Judge. (5:21-ct-03270-D)
Argued: October 22, 2025 Decided: September 10, 2026
Before DIAZ, Chief Judge, and GREGORY and BENJAMIN, Circuit Judges.
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Affirmed in part, vacated in part, and remanded by published opinion. Judge Benjamin
wrote the opinion, in which Chief Judge Diaz and Judge Gregory joined.
ARGUED: Joseph Longley, AMERICAN CIVIL LIBERTIES UNION FOUNDATION,
Washington, D.C.; Shana Hope Khader, TYCKO & ZAVAREEI LLP, Washington, D.C.,
for Appellant. Laura Howard McHenry, NORTH CAROLINA DEPARTMENT OF
JUSTICE, Raleigh, North Carolina, for Appellees. ON BRIEF: D Dangaran, RIGHTS
BEHIND BARS, Washington, D.C.; Sarah Grady, David Howard Sinkman, Amelia
Caramadre, KAPLAN & GRADY LLC, Chicago, Illinois; Jaclyn S. Tayabji, Hassan A.
Zavareei, TYCKO & ZAVAREEI LLP, Washington, D.C.; Daniel K. Siegel, Amika
Medha Singh, ACLU OF NORTH CAROLINA LEGAL FOUNDATION, Raleigh, North
Carolina, for Appellant. Jeff Jackson, Attorney General, NORTH CAROLINA
DEPARTMENT OF JUSTICE, Raleigh, North Carolina, for Appellees. Jim Davy, ALL
RISE TRIAL & APPELLATE, Philadelphia, Pennsylvania, for Amici Addiction Medicine
Specialists. Dorianne Mason, Alison Tanner, Ma’ayan Anafi, Emily Gabos, NATIONAL
WOMEN’S LAW CENTER, Washington, D.C.; Russell H. Falconer, Kathryn M. Cherry,
Dallas, Texas, Raena Ferrer Calubaquib, Sanjay Nevrekar, Dillon M. Westfall, New York,
New York, Robert B. Watson, GIBSON, DUNN & CRUTCHER LLP, Washington, D.C.,
for Amici Disability Rights North Carolina, Legal Action Center, National Women’s Law
Center, and Pregnancy Justice.
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DEANDREA GIST BENJAMIN, Circuit Judge:
Tracey Edwards was incarcerated at the North Carolina Correctional Institution for
Women (“NCCIW”) in Raleigh, North Carolina, when she found out she was pregnant
with her second child. Edwards had a history of opioid use disorder (“OUD”) and was thus
eligible to receive medication for opioid withdrawal (“MOUD”) at NCCIW pursuant to an
internal policy that provided MOUD only to pregnant offenders. Edwards was induced
and gave birth while in state custody. She was shackled on her way to the hospital, at
various times during active labor and delivery, and while returning to NCCIW. Upon her
return, Edwards was placed in the NCCIW’s inpatient medical facility and requested to
continue her MOUD treatment but was denied because she was no longer pregnant.
Edwards sued state and prison officials, alleging Eighth Amendment violations for
the restraints used during her labor and delivery and for the denial of MOUD after she gave
birth. She also alleged disability discrimination under the Americans with Disabilities Act
and § 504 of the Rehabilitation Act for the prison’s denial of MOUD after pregnancy. The
district court granted summary judgment in favor of the defendants on all claims.
For the reasons below, we affirm in part, vacate in part, and remand for further
proceedings.
I. Background
A. Tracey Edward’s Incarceration
Tracey Edwards was convicted of a nonviolent drug offense in North Carolina and
began serving a 70-month sentence at NCCIW in May 2019. [J.A. 116.] She was
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incarcerated at NCCIW from 2019 to 2021. [J.A. 116.] NCCIW is the only state prison
under the North Carolina Department of Adult Corrections (“DAC”)1 that incarcerates
pregnant offenders. [J.A. 118.] During intake, she learned that she was pregnant with her
second child. [J.A. 117.]
Prior to her incarceration, Edwards struggled with opioid addiction and was
diagnosed with OUD. [J.A. 116.] NCCIW provides treatment for OUD to pregnant
offenders to protect the child. [J.A. 365–66, 570–72.] Because Edwards was pregnant, she
received a daily dose of Suboxone, a Food and Drug Administration (FDA) approved
medication for OUD treatment, to prevent withdrawal. [J.A. 705.] She initially received
this treatment daily at an outside clinic and was shackled while transported to and from the
clinic. [J.A. 705.] Later, NCCIW initiated its own in-house medication assisted treatment
(“MAT”)2 program where Edwards received Suboxone treatment until she was induced.
[J.A. 140, 570–72.]
B. Policy Hierarchy for the DAC
NCCIW employees, including the warden, officers, and medical staff, must adhere
to three sets of guidelines—DAC Policies, NCCIW standard operating procedures
1
At the time of Edwards’ incarceration, NCCIW was under the North Carolina
Department of Public Safety. Beginning in 2023, the North Carolina Department of Adult
Corrections began operations as a separate state agency and is currently responsible for all
state prisons, including NCCIW. [J.A. 118.] We use DAC for consistency.
2
NCCIW refers to its in-house program as MAT. MAT and MOUD are often used
interchangeably, and both include the use of FDA-approved medications for OUD
treatment, including Suboxone. [J.A. 139.] Hereinafter, we will refer to the treatment as
MOUD unless we are referring to NCCIW’s specific in-house program.
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(“SOPs”), and NCCIW post orders. [J.A. 118–19.] The three guidelines operate within a
hierarchy. DAC policies, which take precedence over other directives, are mandatory
guidance issued by the state that must be followed by all state prison facilities. [J.A. 118,
3075.] NCCIW SOPs are policy documents issued by NCCIW that instruct NCCIW staff
on the use of techniques relevant to their jobs. [J.A. 119]. Post orders are procedures
related to the specific facility where an officer is stationed. [Id.] When DAC updates a
policy, the prison warden must update any corresponding SOPs and post orders. [J.A.
3075]
DAC issued Policy F.1100 Transporting Offenders on September 6, 2018. F.1100
“outline[s] procedures governing the transportation of offenders outside of the
institution/facility.” J.A. 504.3 Section (i) addresses transportation for pregnant offenders:
(1) An offender with a clinical diagnosis of pregnancy shall not be restrained
by leg, waist, or ankle restraints. Wrist restraints may be used during any
internal escort or external transport. These wrist restraints shall only be
applied in the front and in such a way that the pregnant offender may be able
to protect herself and the fetus in the event of a fall.
(2) The following offenders should not be placed in any restraints,
including wrist restraints, unless there are reasonable grounds to believe the
offender presents an immediate, serious threat of hurting herself, staff, or
others, including her fetus or child, or that she presents an immediate,
credible risk of escape that cannot be reasonably contained through other
methods:
(A). An offender who is in labor, which is defined as occurring at the
onset of contractions;
(B). An offender who is delivering her baby; . . .
(D). An offender who is transported or housed in an outside medical
facility for treating labor and delivery;
Citations to “J.A.” refer to the joint appendix filed by the parties. The J.A. contains
3
the record on appeal from the district court. Page numbers refer to the “J.A. #” pagination.
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(E). An offender for induction once the intravenous line has been placed
and the induction medication has been started
If restraints are required, they should allow for the mother’s safe handling of
her infant. . . .
(4) Upon medical discharge, wrist restraints shall be applied for
transport back to the correctional facility. Leg restraints may be applied
when there are reasonable grounds to believe the offender presents an
immediate, serious threat of hurting herself, staff, or others, or that she
presents an immediate, credible risk of escape that cannot be reasonably
contained through other methods.
(5) Waist restraints shall not be used at any time during pregnancy or post-
delivery, to include transport back to the facility.
J.A. 510–11 (cleaned up) (emphasis added).
On February 1, 2019, NCCIW issued SOPs D.1800 Offender Restraint and H.0300
Use of Force and Restraints, which were approved by NCCIW Warden Benita
Witherspoon. [J.A. 2220.] Both SOPs require an offender in the hospital to be restrained
to their bed by one arm and one leg. [J.A. 518; J.A. 523.] Under D.1800, there is an
exception to the general policy that an offender should not be restrained outside the facility
if a “[p]regnant offender is in active labor.” J.A. 513. And H.0300 states that a “maternity
offender WILL NOT have leg restraints applied” and “shall not be restrained during active
labor.” J.A. 524. Active labor is not defined in the SOPs, but F.1100 defines “in labor” as
“the onset of contractions.” J.A. 510.
Edwards and defendants disagree about whether the SOPs conflict with F.1100 as
policies related to the shackling of pregnant offenders. [see J.A. 131.] However, in March
2021, a DAC official wrote in an email stating that the SOPs “[did] not match with red
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book4 policy in regard to pregnant offenders” and that NCCIW was notified of the issue
previously. J.A. 548. Defendants further represent that “correctional staff knew to
implement any exceptions for pregnant offenders outlined in F.1100.” J.A. 3060.
C. Warden Witherspoon’s Actions
Witherspoon was the warden at NCCIW when Edwards was incarcerated and was
responsible for ensuring all SOPs and post orders complied with DAC policies. [J.A. 722,
2220, 2258.] By April 2019, DAC’s region director and Witherspoon had at least three
phone calls to discuss community organizers’ concerns with NCCIW’s policies, including
the shackling of pregnant offenders during hospital transport and stays. [J.A. 135, 321–22,
722,]. In these calls, it was noted that such shackling violated DAC policy. [J.A. 136,
3076]. And the region director and Witherspoon discussed updating the post orders to
better comply with DAC policies regarding the use of restraints on pregnant offenders.
[J.A. 722]. But no changes were made until January 2020. [Id.].
After another pregnant NCCIW offender was shackled during labor against medical
advice, DAC issued the following directive on November 22, 2019:
Any offender in their third trimester should not be restrained. This
applies even if they are not in pre or active labor. If there is a potential
serious security concern with the offender not being restrained it should be
discussed with the Region Director prior to restraints being added . . . Please
ensure that you notify your staff of this temporary directive.
4
We understand “red book” to be a general term for DAC and/or facility policies
that are written down, often in a red book. See J.A. 2478, 2486 (discussion of “red book”
in reference to DAC policies). The reference here is to DAC policies, but the general term
was also used by NCCIW officers to refer to the physical red book where NCCIW SOPs
and post orders were written. See J.A. 1483 (Officer Tamara Brown noting that the
NCCIW red book includes its SOPs and post orders).
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J.A. 554–55; 538–39 (emphasis added).
At the time the directive was issued, Witherspoon was out of the office. [J.A. 538.]
But she requested that a direct report ensure that the directive and general prison policy
were discussed with prison staff. [Id.] That training did not take place, and Witherspoon
took no action to ensure any training was held. [J.A. 3076–77.] Witherspoon did not
update the post order for the University of North Carolina at Chapel Hill Hospital (“UNC-
CH”), where Edwards’ labor and delivery took place, until after the region director
provided an updated DAC policy in January 2020. [J.A. 722.]
A timeline of the relevant institutional policies is below:
Issuing Body Date Issued Title Key Policies
DAC September 6, F.1100 • “An offender with a clinical diagnosis
2018 Transporting of pregnancy shall not be restrained
Offenders. by leg, waist, or ankle restraints.”
(J.A. 510–11) • “An offender who is in labor …
should not be placed in any
restraints.”
• “Waist restraints shall not be used at
any time during pregnancy or post-
delivery, to include transport back to
the facility.”
NCCIW February 1, SOPs D.1800 • An offender should not be restrained
2019 Offender Restraint outside the facility where a
(J.A. 513) “[p]regnant offender is in active
labor.”
H.0300 Use of • “Maternity offender WILL NOT have
Force and leg restraints applied” and “shall not
Restraints be restrained during active labor.”
(J.A. 524)
NCCIW April 20, Post Order • “Although restraints are provided for
2019 Security the maternity offender while
Supervisor for transporting to and from the hospital
UNC-CH during pregnancy and immediately
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(later updated (J.A. 3345) post-partum the Offender will only be
in January handcuffed from the front. The
2020) maternity Offender WILL NOT have
leg restraints or waist chain applied. “
• “The Offender will not be
handcuff[sic] while holding the baby,
but will have one leg restrain[sic] per
policy.”
DAC November 22, Directive • “Any offender in their third trimester
2019 (J.A. 554–55) should not be restrained.”
D. Edwards’ Labor and Delivery
On December 19, 2019, NCCIW officers transported Edwards to be induced at
UNC-CH. [J.A. 3114–15]. Officers Shieda Brodie, Tamara Brown, Nikita Dixon, Kavona
Gill, Tianna Lynch, and Tammy Williams, and Sergeant Lorafaith Ragano (collectively,
the “Officer Defendants”) were responsible for Edwards while she was in the hospital. On
the way to the hospital, Edwards was handcuffed, and, upon arrival, one of her arms and
one of her legs were shackled to the hospital bed. [J.A. 121–22.] Brodie monitored
Edwards on December 19 from Edwards’ arrival until approximately 7:00 p.m. that
evening. [J.A. 623.] Lynch monitored Edwards overnight from approximately 7:00 p.m.
on December 19 to 6:00 a.m. on December 20. [J.A. 510, 623.] According to the Officer
Defendants’ activity logs, Edwards was induced through her intravenous (IV) line at 8:25
p.m. and given an epidural (pain medication provided to pregnant patients) at 11:15 p.m.
[J.A. 623.] According to Edwards, she was shackled by one arm and one leg even after
she was induced and until she began pushing. [J.A. 167, 624–25, 2110–11.]
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Edwards gave birth to her child at 11:04 a.m. on December 20, 2019. J.A. 117.
Ragano monitored Edwards during this time. About two hours after giving birth, Edwards
was transferred to the maternity ward where Ragano handcuffed Edwards to the wheelchair
during the transfer and then shackled one of her arms and the opposite leg to a different
bed. J.A. 625, 729–30. Dixon relieved Ragano at 7:00 p.m. on December 20 and Ragano
took over once again at 7:00 a.m. on December 21. [J.A. 168.]
While Edwards was in the hospital, she continued to receive Suboxone daily and
was prescribed Suboxone upon discharge. [J.A. 3077.]
Edwards remained in the hospital for two days where she was monitored by Ragano,
Brown, Gill, and Williams. [J.A. 610–11, 613, 616–18.] She was discharged on December
22 while Williams was on duty. [J.A. 616–18.] According to Edwards, as she was
transported back to NCCIW, Williams and one other officer5 restrained her by shackling
her ankles together, handcuffing her, and placing a belly chain around her stomach to
restrict her movements. [J.A. 123.] Prison officials did not identify Edwards to be a
security or flight risk before or during the time that she was at UNC-CH. [J.A. 3076.]
The parties dispute how long Edwards was shackled during her hospital stay, but
the district court identified times that both parties agree she was unrestrained: when
Edwards’ medical team instructed her to push, when she gave birth, for some period of
time after birth, when she went to the restroom, and on at least two other occasions during
5
During Williams’ deposition, she testified that she had another person with her
during this transport but did not remember which officer. J.A. 1992.
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her stay when she was unshackled to walk with her baby in the hospital hallway. [J.A.
3073–74.]
E. Edwards’ Post-Pregnancy Medical Treatment
When Edwards returned to NCCIW, she was placed in the inpatient medical unit.
Edwards requested MOUD, but NCCIW denied her request pursuant to its policy
restricting MOUD to pregnant offenders. [J.A. 141, 636.] Edwards was instead given an
oxycodone taper over nine days: 10 milligrams three times a day for three days, then twice
a day for three days, and then once a day for three days. [J.A. 169.] She was also given
Tylenol and ibuprofen for pain management. [Id.]
Edwards experienced withdrawal symptoms including pain, diarrhea, and vomiting
for several weeks after she gave birth. [J.A. 3128.] Edwards described the pain as “more
painful than giving birth” and alleged that she sometimes could not eat or shower due to
the intensity of her symptoms. J.A. 169. Edwards remained in the medical unit until mid-
January 2020. [J.A. 141.]
Dr. Elton Amos was the medical director at NCCIW during Edwards’ incarceration.
[J.A. 46.] Amos supervised nine medical providers responsible for direct patient care and
provided clinical oversight, including the drafting of NCCIW’s MAT provider handbook.
[J.A. 353, 635–36.] The MAT handbook includes the policies and procedures for
NCCIW’s MAT program and notes that Amos was responsible for preliminary approvals
of MOUD medications for pregnant offenders. [J.A. 636.] Dr. James Alexander was the
healthcare facility health treatment administrator at the time and was responsible for
reviewing NCCIW policies, such as the MOUD policy, to ensure compliance with
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statewide policies. [J.A. 568, 737.] Dr. Gary Junker was the behavioral health director for
DAC from 2015 until 2020. Junker was responsible for mental health policies across state
prisons and provided oversight for medical directors, including Amos. [J.A. 732, 1032,
2219, 2340.]
F. Procedural History
In April 2022, Edwards sued DAC officials under 42 U.S.C. § 1983, alleging Eighth
Amendment violations for shackling her during labor and postpartum and denying her
MOUD after birth, as well as disability discrimination because of her OUD under the
Americans with Disabilities Act (“ADA”) and § 504 of the Rehabilitation Act (“RA”).6
Edwards moved for partial summary judgment and all of the defendants moved for
summary judgment in full. The district court denied Edwards’ motion for summary
judgment and granted Defendants’ motion for summary judgment, thereby dismissing all
of Edwards’ claims.
Edwards now appeals. She challenges the district court’s decision on three grounds:
(1) the district court’s grant of qualified immunity to Witherspoon and the Officer
6
Edwards named the following defendants: James Alexander, the NCCIW
healthcare facility health treatment administrator, in his personal and official capacities;
Elton Amos, the NCCIW medical director, in his personal and official capacities; Todd
Ishee, the secretary of the DAC, in his official capacity; Anthony Perry, the current NCCIW
warden, in his official capacity for the purpose of injunctive relief; Gary Junker, the then-
behavioral health director, in his personal and official capacities; and Benita Witherspoon,
the former NCCIW warden, in her personal capacity. Edwards also named the seven
Officer Defendants in their personal capacities. Pursuant to Federal Rules of Civil
Procedure 25(d), defendants Ishee and Perry were substituted for their predecessors, former
secretary Eddie Buffaloe and former warden Claudette Edwards (as of September 2025,
Michelle Carlton is warden at NCCIW).
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Defendants for Eighth Amendment violations, specifically her shackling during pregnancy,
labor, and postpartum recovery; (2) the district court’s finding that there was no
constitutional injury committed by DAC medical officials Alexander, Amos, and Junker
for denial of postpartum MOUD; and (3) the district court’s conclusion that Edwards was
not discriminated against under the ADA or RA after being denied postpartum MOUD.
[J.A. 3097]. We address each in turn.
We have jurisdiction under 28 U.S.C. § 1291.
II. Standard of Review
We review the district court’s summary judgment and qualified immunity decisions
de novo. Aleman v. City of Charlotte, 80 F.4th 264, 283 (4th Cir. 2023). Summary
judgment is proper “ ‘if the movant shows that there is no genuine dispute as to any material
fact and the movant is entitled to judgment as a matter of law.’ ” Id. (quoting FED. R. CIV.
P. 56(a)). All facts and reasonable inferences drawn therefrom must be viewed in the light
most favorable to the nonmoving party.” Id. at 283–84.
III. Eighth Amendment Shackling Claim
A. Background on Shackling
The shackling of pregnant offenders is controversial and dangerous. The United
Nations explicitly prohibits the use of restraints “on women during [labor], during
childbirth and immediately after childbirth” in its rules for the treatment of prisoners. The
United Nations Standard Minimum Rules for the Treatment of Prisoners, United Nations,
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at 15 (Dec. 2015). This is for good reason. The American College of Obstetricians and
Gynecologists explains that “[p]hysical restraints interfere with the ability of clinicians to
safely practice medicine by reducing their ability to assess and evaluate the pregnant patient
and the fetus.” Reproductive Health Care for Incarcerated Pregnant, Postpartum, and
Nonpregnant Individuals, Comm. Op. No. 830, at 30 (July 2021) [https://perma.cc/P2J9-
2N8H]. The National Commission on Correctional Health Care notes an increased risk of
falls, pain during labor, and complications in postpartum from shackling pregnant
prisoners. Nonuse of Restraints for Pregnant and Postpartum Incarcerated Individuals, at
2 (Dec. 2025).7
Consequently, by 2018, 22 states, the District of Columbia and the federal
government had enacted legislation prohibiting or limiting the use of shackling during
labor.8 Ginette G. Ferszt, et al., Where Does Your State Stand on Shackling of Pregnant
Incarcerated Women?, 22 Nursing for Women’s Health 17, 18 (2018). And the Sixth,
Eighth, and Ninth Circuits condemn the practice of shackling pregnant offenders who do
7
Edwards’ expert cites to an earlier version of this position statement from 2020
concluding the same, which is reaffirmed in the 2025 version cited here.
8
As of 2025, 40 states have enacted legislation restricting the use of shackles on
incarcerated pregnant women. Veronica Brawley & Emma Kurant-Thoma, Use of
Shackles on Incarcerated Pregnant Women, J. of Obstetric, Gynecologic, & Neonatal
Nursing, Oct. 2013, at 87, https://www.jognn.org/action/showPdf?pii=S0884-
2175%2823%2900247-2 [https://perma.cc/F53K-CL4W]. Relevant here, in 2021, North
Carolina passed the Dignity for Women who are Incarcerated Act, which restricts DAC
employees from restraining “a pregnant female incarcerated person during the second and
third trimester of pregnancy, during labor and delivery, and during the postpartum recovery
period.” N.C. GEN. STAT. § 153A-229.2 (2021).
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not present a security or flight risk. See e.g., Villegas v. Metro. Gov’t of Nashville, 709
F.3d 563, 572 (6th Cir. 2013); Nelson v. Corr. Med. Servs., 583 F.3d 522, 534 (8th Cir.
2009); Mendiola-Martinez v. Arpaio, 836 F.3d 1239, 1252–55 (9th Cir. 2016).
B. Edwards’ Shackling is a Constitutional Violation
With this background in mind, we begin with Edwards’ shackling claim. The
district court granted qualified immunity for Witherspoon and the Officer Defendants
because it found one’s “right to be free from shackling” while pregnant, during labor, and
postpartum was not clearly established. J.A. 3087. It did not discuss the constitutionality
of the underlying conduct. We address both issues, starting with whether shackling
Edwards violated the Eighth Amendment.
“[T]he qualified immunity analysis consists of two prongs: (1) whether a statutory
or constitutional violation occurred, and (2) whether the right was clearly established at the
time of the violation.” Benton v. Layton, 139 F.4th 281, 288 (4th Cir. 2025) (internal
quotation marks omitted) (quoting Aleman, 80 F.4th at 284). Courts may address the
inquiry “in whichever sequence ‘will best facilitate the fair and efficient disposition of [the]
case.’ ” Pfaller v. Amonette, 55 F.4th 436, 444 (4th Cir. 2022) (quoting Halcomb v.
Ravenell, 992 F.3d 316, 319 (4th Cir. 2021)).
The Eighth Amendment’s prohibition of cruel and unusual punishments extends to
“the treatment a prisoner receives in prison and the conditions under which [s]he is
confined.” Helling v. McKinney, 509 U.S. 25, 31 (1993); U.S. CONST. amend. VIII. The
Eighth Amendment “imposes [] dut[ies] on prison officials to ‘provide humane conditions
of confinement . . . [and] ensure that inmates receive adequate food, clothing, shelter and
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medical care.’ ” Scinto v. Stansberry, 841 F.3d 219, 225 (4th Cir. 2016) (quoting Farmer
v. Brennan, 511 U.S. 825, 832 (1994)). To make out an Eighth Amendment claim in this
context, a plaintiff must make two showings. First, that the confinement conditions inflict
an “objectively, sufficiently serious” harm that “deprives prisoners of ‘the minimal
civilized measure of life’s necessities.’ ” Thorpe v. Clarke, 37 F.4th 926, 933 (4th Cir.
2022) (internal quotation marks omitted in first quotation) (quoting Farmer, 511 U.S. at
834). Second, that the officers acted with a culpable state of mind showing “ ‘deliberate
indifference to inmate health or safety’ because they knew of but disregarded the inhumane
treatment.” Id. (quoting Farmer, 511 U.S. at 834).
1. Shackling of Pregnant Offenders is Objectively Serious
To satisfy the objective prong, a deprivation must be “objectively ‘sufficiently
serious.’ ” Strickler v. Waters, 989 F.2d 1375, 1379 (4th Cir. 1993) (quoting Wilson v.
Seiter, 501 U.S. 294, 298 (1991)). The plaintiff must produce evidence of “ ‘a serious or
significant physical or emotional injury resulting from the challenged conditions,’ or ‘a
substantial risk of such serious harm resulting from . . . exposure to the challenged
conditions.’ ” Scinto, 841 F.3d at 225 (alteration in original) (quoting De’Lonta v.
Angelone, 330 F.3d 630, 634 (4th Cir. 2003) (De’Lonta I)). “Only an extreme deprivation”
meets this burden. De’lonta v. Johnson, 708 F.3d 520, 525 (4th Cir. 2013) (De’Lonta II).
We can consider the consensus of experts to prove that a prison official’s conduct poses a
risk of “serious or significant physical or emotional injury.” Scinto, 841 F.3d at 225
(quoting De’Lonta I, 330 F.3d at 634). We also may take into consideration the
“contemporary values concerning the infliction of a challenged sanction” as the Eighth
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Amendment “ ‘must draw its meaning from the evolving standards of decency that mark
the progress of a maturing society.’ ” Villegas, 709 F.3d at 572 (quoting Gregg v. Georgia,
428 U.S. 153, 173 (1976)).
Edwards claims that two sources of evidence are sufficient to meet the objective
prong.
First, she points to a growing consensus within the medical community and amongst
policymakers that the shackling of pregnant offenders is dangerous and harmful. Edwards
adduces evidence from the United Nations Committee Against Torture, the American
Medical Association, American College of Obstetricians and Gynecologists, the National
Commission on Correctional Health Care, and others condemning the practice of shackling
pregnant women, specifically during labor, and identifying the harms that can result from
the practice. See e.g., J.A. 174, 180–81; see also Villegas, 709 F.3d at 572–75 (relying on
a similar set of sources to find that shackling “poses a substantial risk of harm”). Edwards’
expert, maternal fetal medicine specialist Dr. Alison M. Stuebe, characterized the use of
restraints on a pregnant woman as “psychologically devastating, dehumanizing, and
painful.” J.A. 173. Steube noted that, as pregnancy impacts a person’s balance and
mobility, shackling “directly increases” the risks of falls and injury to both the pregnant
offender and the baby and “can cause skin breakdown, nerve damage, and fractures.” J.A.
175. Stuebe continued that shackling “interferes with medical care” as the ability for
medical staff to maneuver a patient, like Edwards, is delayed by restraints putting both the
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women and the baby’s lives at risk. Id. She also assessed that shackling increases the risks
of fatal blood clots postpartum because of a reduction in movement. J.A. 175–76.9
Second, Edwards points to her labor and delivery experience. Edwards states that
she was shackled by one leg and one arm for hours, even after medical staff induced her,
leaving her skin “raw and red.” J.A. 167. She was unable to move around even while
experiencing contractions and the shackles were only removed once doctors told her to
start pushing. Id. All told, her testimony supports that she was shackled by her hand and
foot for at least twelve hours from the time she was induced at 8:25 p.m. until shackles
were removed so that she could push and gave birth at 11:04 a.m. the next day. J.A. 117,
623. She then says that she was again shackled with both legs together and one wrist
handcuffed within an hour of giving birth as she was moved from a delivery to recovery
room. J.A. 168.
9
Defendants argue, citing Williams v. Branker, that Edwards’ testimony and expert
report do not rise to the level of an objectively serious injury or medical need because any
discomfort from Edwards’ shackling in the hospital was just an aggravation of a preexisting
condition that resulted from incarceration. See 462 F. App’x 348, 354 (4th Cir. 2012)
(“The fact that the conditions to which Williams was subjected aggravated his mental
illness is an unfortunate but inevitable result of his incarceration.”). But there is a key
difference between Williams and the case before us. Williams centered on allegations that
the plaintiff-inmate’s mental health suffered due to solitary confinement conditions that
included isolation and behavioral restrictions. Id. at 354. The court concluded that where
the conditions of confinement meet the minimal standards required by the Constitution,
any impacts on the inmate’s mental health were an “unfortunate but inevitable result of his
incarceration” that do not violate the Eighth Amendment. Id. Not so here. As we explain
below, shackling a pregnant inmate during labor and post-partum, without justification, is
an Eighth Amendment violation.
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While this court has not opined on this exact issue, other courts condemn shackling
of pregnant offenders who do not present a security or flight risk. See Women Prisoners v.
District of Columbia, 877 F. Supp. 634, 668 (D.D.C. 1994), vacated in part, modified in
part by 899 F. Supp. 659, 668–69 (D.D.C. 1995) (holding that the District of Columbia
Department of Corrections’ policy of shackling pregnant women prisoners in the third
trimester and immediately after delivery was “inhumane” and “violate[d] contemporary
standards of decency”); Nelson, 583 F.3d at 525–27, 529 (reversing qualified immunity
where officials in the Arkansas Department of Corrections shackled Nelson during her
third trimester and labor, including shackling her by both legs to the hospital bed and only
removing the restraints immediately before Nelson delivered her child); Brawley v.
Washington, 712 F. Supp. 2d 1208, 1219–20 (W.D. Wash. 2010) (noting that “[c]ommon
sense, and the [Department]’s own policy, tells us that it is not good practice to shackle
women to a hospital bed while they are in labor”); Villegas, 709 F.3d at 566–67, 574
(finding that there is a qualified “right to be free from shackling during labor” in case where
prisoner was shackled to a hospital bed by one leg); Mendiola-Martinez, 836 F.3d at 1252–
57 (finding issues of fact remained as to whether officers violated Mendiola-Martinez’s
Eighth Amendment rights by handcuffing and using ankle shackles on her during her
transport to and from jail to the hospital as she was in active labor).
This right to be free from shackling during labor is not unqualified. These same
cases note there are common sense exceptions for the safety of the prisoner and others and
for those determined to be an escape risk. See Villegas, 709 F.3d at 574 (noting that
professional organizations, including the United Nations, and other courts have exceptions
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where there is clear evidence that the offender is a security or flight risk); Women
Prisoners, 877 F. Supp. at 668 (“The [c]ourt understands that the Defendants may need to
shackle a woman prisoner who has a history of assaultive behavior or escapes.”); Nelson,
583 F.3d at 534 (“[A]n inmate in the final stages of labor cannot be shackled absent clear
evidence that she is a security or flight risk.”).
Taken together, the well-documented condemnations of shackling from
professional and human rights organizations, the testimony of Edwards and her medical
expert, and the consensus among other courts show that shackling “offends contemporary
standards of human decency” and presents a substantial risk of serious harm. See Villegas
709 F.3d at 574. We hold that, without clear evidence of a security or flight risk, shackling
a pregnant offender during labor and immediately postpartum poses an objectively serious
risk of harm under the Eighth Amendment.
2. Defendants Were Aware of the Subjective Risk of Harm
Next, we consider whether Edwards has shown that defendants had actual
knowledge of the harm or risk of harm. The subjective prong requires that a prison official
act with deliberate indifference. The standard is “akin to criminal-law recklessness.”
Pfaller, 55 F.4th at 445. “It requires that a prison official actually know of and disregard
an objectively serious condition, medical need, or risk of harm.” De’Lonta I, 330 F.3d at
634. “[T]he official must both be aware of facts from which the inference could be drawn
that a substantial risk of serious harm exists, and he must also draw the inference.” Farmer,
511 U.S. at 837. In other words, the official must have “actual knowledge” of the harm or
risk of harm. Iko v. Shreve, 535 F. 3d 225, 241 (4th Cir. 2008).
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Whether a defendant possesses the requisite knowledge often requires we look to
circumstantial evidence. See Women Prisoners, 877 F. Supp. at 669 (noting that the
[d]eputy’s statements that “he would not shackle a third trimester woman” “suggests that
he recognizes the risk”). We can presume an officer’s knowledge of the rules governing
the officer’s conduct. See Harlow v. Fitzgerald, 457 U.S. 800, 818–19 (1982) (“[A]
reasonably competent public official should know the law governing his conduct.”). And
we can infer “this subjective state of mind . . . from the fact that the risk of harm is
obvious.” Brawley, 712 F. Supp. 2d at 1220 (citing Hope v. Pelzer, 536 U.S. 730, 738
(2002)).
The subjective prong presents a “high bar for recovery,” Iko, 535 F. 3d at 241, but,
on the record before us, a genuine dispute of fact remains as to whether Witherspoon and
four of the Officer Defendants—Brodie, Lynch, Williams and Ragano—were deliberately
indifferent.
a. Warden Witherspoon Can Be Liable for Failure to Update Prison Policies
We start with Witherspoon. As warden at NCCIW, Witherspoon was on notice that
NCCIW policies did not comply with DAC policies. Yet Witherspoon made no
meaningful effort to bring NCCIW policies into compliance or ensure her staff was
adequately trained. Recall that, by September 2018, DAC policy placed significant limits
on when and how prison officials could restrain pregnant offenders. F.1100 provided that
a pregnant offender “shall not be restrained by leg, waist, or ankle restraints” unless there
are “reasonable grounds to believe the offender presents an immediate, serious threat” or
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there is a “credible risk of escape.” J.A. 510–11. Further, “waist restraints [were] not [to]
be used at any time during pregnancy or post-delivery.” J.A. 511 (emphasis added).
Yet, Witherspoon did not bring NCCIW policy into compliance. The DAC region
director met with Witherspoon on three occasions in April 2019 to discuss concerns with
NCCIW’s practice of shackling pregnant inmates. And in November 2019, another
pregnant offender’s shackling prompted communications from DAC and state officials
about NCCIW’s policies. The DAC region director issued a directive on November 22,
2019, that any offender in their third trimester should not be restrained, even if they are not
in pre or active labor. Still, Witherspoon took no action to ensure that NCCIW staff were
updated or trained on this new directive. She did not update NCCIW’s SOPs or post orders
at UNC-CH until January 2020, two months after Edwards gave birth.10
Witherspoon’s knowledge of DAC policies that restricted the use of restraints and
her failure to align NCCIW policies accordingly is plausible evidence of deliberate
indifference.
Defendants suggest that Witherspoon did not know of the risk of harm because the
NCCIW and DAC policies were not actually contradictory. Appellees’ Br. (ECF No. 64)
at 46–47 (hereinafter “Response Br.”).11 However, that is not right. “[A]t least two SOPs
at NCCIW”—H.0300 and D.1800—did not match DAC policy “in regards to pregnant
10
The record shows that she only updated the post orders, but not the SOPs. See
J.A. 836 (noting that the only policy that changed while Witherspoon was warden was the
post order issued on January 20, 2020).
11
Page numbers for citations to ECF documents utilize the page numbers in the red
header on each document.
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offenders” and had not for some time. J.A. 548 (email requiring that the wording be
updated “ASAP” and noting that NCCIW was directed to make changes previously but
“apparently didn’t get it done”). As a result, a jury should decide whether Witherspoon’s
failures constitute deliberate indifference.
b. Some Officer Defendants Can Be Liable for Shackling Edwards During Labor
and Delivery
Next, we must determine whether the Officer Defendants acted with deliberate
indifference. Edwards contends that there is a question of fact for the jury as to the risk of
harm each Officer Defendant was aware of when they shackled her. Appellant’s Br. (ECF
No. 33) at 61 (hereinafter “Opening Br.”). We agree that a triable issue of fact exists as to
the state of mind of four of the seven officers who shackled Edwards: Brodie, Lynch,
Williams, and Ragano. While the claim against Witherspoon relies on her inaction in the
face of explicit directives, the claims against the Officer Defendants hinge on the actions
each took while Edwards was under their care.
A reasonable juror could find that Brodie, Lynch, Williams, and Ragano acted with
deliberate indifference. Brodie was the officer on shift on December 19, 2019, when
Edwards arrived at the hospital and was shackled by one arm and one leg to the hospital
bed. [J.A. 623.] Lynch was on duty the evening of December 19, and shackled Edwards
by one arm and one leg while she was induced and in active labor. Williams was the officer
on duty when Edwards was discharged on December 22 and transported Edwards back to
NCCIW using leg restraints and a belly chain. And Ragano was the officer on duty while
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Edwards remained chained by one arm and one leg immediately before giving birth and in
the hours following birth as she was moved to the recovery room.
Moreover, Ragano, Brodie, Williams, and Lynch admitted that they had been
trained on the DAC policy, F.1100 Transporting Officers, prohibiting their very conduct.12
[J.A. 726–27 (Ragano); J.A. 747–49 (Brodie); J.A.752–54 (Williams); J.A. 758–59
(Lynch)]. Williams specifically stated that, even at “that time” in 2019, a pregnant offender
should “never ever, ever, ever” wear a restraint during active labor. J.A. 1986–87. A jury
could conclude that each of these four officers, given that they had been trained on the risks
to pregnant women posed by their conduct, had disregarded that risk when they shackled
Edwards. See Women Prisoners, 877 F. Supp. at 669 (the officer’s statements that “he
would not shackle a third trimester woman” “suggests that he recognizes the risk”); see
also Harlow, 457 U.S. at 818–19 (“[A] reasonably competent public official should know
the law governing his conduct.”).
We reach a different conclusion as to the remaining Officer Defendants—Nikita
Dixon, Kavona Gill, and Tamara Brown. The DAC and NCCIW policies that these three
officers were trained on distinguish between acceptable and prohibited conduct based in
part on whether the offender was in “active labor.” See J.A. 510 (defining active labor as
the onset of contractions). So, it is relevant when each officer monitored Edwards. These
three officers monitored her on December 20 and 21, after she gave birth to her daughter
but not while she was immediately postpartum. [J.A. 610, 611, 616.] While Edwards was
12
This was despite Witherspoon’s failure to update NCCIW policies and to ensure
all officers received training. See Section III.B.2.a.; see also Section I.C.
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shackled and unshackled at various times during their shifts, she was not in active labor,
immediately postpartum, or being transported between the hospital and NCCIW. As a
result, we cannot conclude that their conduct was deliberately indifferent—instead it was
closer to “mere negligence.” Farmer, 511 U.S. at 835. And as the subjective prong
requires “something more than mere negligence,” id, summary judgment was appropriate.
* * *
Because the record would permit a reasonable jury to find that Witherspoon, Brodie,
Lynch, Williams, and Ragano violated Edwards’ Eighth Amendment rights, the district
court should not have dismissed Edwards’ claims against those five defendants on
summary judgment. See Taylor v. Riojas, 592 U.S. 7, 9 (2020) (“And although an officer-
by-officer analysis will be necessary on remand, the record suggests that at least some
officers involved in Taylor’s ordeal were deliberately indifferent to the conditions of his
cells.”). However, we affirm the grant of summary judgment for Edwards’ claims against
defendants Dixon, Gill, and Brown.
C. Shackling Edwards While She Was in Active Labor Was Clearly Wrong
1. Thorpe
We now address whether Witherspoon, Brodie, Lynch, Williams, and Ragano
violated a right “ ‘clearly established at the time of the challenged conduct.’ ” Lewis v.
Caraballo, 98 F.4th 521, 530 (4th Cir. 2024) (quoting Carroll v. Carman, 574 U.S. 13, 16
(2014)).
“A right is clearly established if, at the time of the alleged offense, ‘the contours of
the right allegedly violated were sufficiently clear that a reasonable official would
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understand that what he is doing violates that right.’ ” Id. at 534 (alterations omitted)
(citing Anderson v. Creighton, 483 U.S. 635, 640 (1987)). A clearly established legal
principle “must be settled law, which means it is dictated by controlling authority or a
robust consensus of cases of persuasive authority.” Feminist Majority Found. v. Hurley,
911 F.3d 674, 704 (4th Cir. 2018) (quoting Wesby, 583 U.S. at 63). We consider “decisions
of the Supreme Court, this court of appeals, and the highest court of the state in which the
case arose” to be controlling authority. Franklin v. City of Charlotte, 64 F.4th 519, 534
(4th Cir. 2023) (internal quotation marks omitted) (quoting Owens ex rel. Owens v. Lott,
372 F.3d 267, 279 (4th Cir. 2004)).
However, the cases do not have to be identical; “officials can still be on notice that
their conduct violates established law even in novel factual circumstances.” Hope, 536
U.S. at 741. And “[q]ualified immunity does not protect knowing violations of the law.”
Thorpe v. Clarke, 37 F.4th 926, 930 (4th Cir. 2022) (citing Ashcroft v. al-Kidd, 563 U.S.
731, 743 (2011)). If there remains a genuine dispute as “to an official’s deliberate
indifference” that “if established, [would] necessarily include an awareness of the illegality
of the defendant’s actions,” Pfaller, 55 F.4th at 448, then there is no reason to also
undertake the traditional clearly established inquiry. See Thorpe, 37 F.4th at 934.
In Thorpe, the court affirmed the denial of qualified immunity because, on the facts
alleged, the prison officials’ conduct amounted to an intentional Eighth Amendment
violation. There, the prisoner-plaintiffs alleged that their Supermax prison’s solitary
confinement policy violated the Eighth Amendment. Thorpe, 37 F.4th at 930. The
defendants responded in part that, regardless of any potential constitutional violations, they
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were entitled to qualified immunity because it was not clearly established in 2012 that the
solitary confinement program was unconstitutional. See id. at 930, 935. However, the
district court denied qualified immunity at the motion to dismiss stage. Id. at 932.
The court affirmed because “qualified immunity does ‘not allow the official who
actually knows that he was violating the law to escape liability for his actions.’ ” Id. at
933–34 (quoting Harlow, 457 U.S. at 821 (1982) (Brennan, J., concurring)). To the
contrary, where “ ‘plaintiffs have made a showing sufficient to’ demonstrate an intentional
violation of the Eighth Amendment, ‘they have also made a showing sufficient to overcome
any claim to qualified immunity.’ ” Id. at 934 (quoting Beers-Capitol, 256 F.3d at 142
n.15). And “[d]ismissal . . . remains improper so long as the officers’ mental state remains
genuinely in issue.” See id. at 934.
Applying this principle, the court reviewed the “circumstantial evidence” and
“direct evidence of [the defendants’] consciousness of risk.” Id. at 935–36 (cleaned up).
It pointed to independent expert studies showing the severe and permanent damage caused
by solitary confinement, the defendants’ knowledge of a Human Rights Watch report
finding human rights violations in the state prisons, defendants’ knowledge of a United
States Department of Justice investigation examining the prison’s use of isolation, and
judicial precedent going back to 1890 all to show that the prison officials had the “requisite
knowledge of a substantial risk.” Id. at 936. The court determined that plaintiffs presented
“more than a mere suggestion to the contrary” that the officers were aware of the substantial
risk of harm. See id. at 936 (noting that the evidence was “sufficient to defeat summary
judgment”).
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The court expanded on the principles from Thorpe in Pfaller v. Amonette, 55 F.4th
436 (4th Cir. 2022). There, the court held that a prison doctor’s failure to provide timely
medical treatment was an intentional violation of the Eighth Amendment. Pfaller, 55 F.4th
at 446. Pfaller concerned the death of an inmate from liver cancer while incarcerated. Id.
at 441. The inmate’s primary doctor regularly tested the inmate’s blood to review for liver
cancer but, on two occasions, failed to refer the inmate for additional testing against
Virginia Department of Corrections medical guidelines. Id. at 443. He also misattributed
the inmate’s other symptoms to other causes. Id. The doctor eventually referred the inmate
for further testing, and the inmate was ultimately diagnosed with untreatable liver cancer.
He died a month later. Id. at 443. His estate filed a § 1983 claim alleging the inmate’s
Eighth Amendment rights were violated due to inadequate medical care. Id. at 441.
The court explained that, in Eighth Amendment cases, “not all disputes of material
fact as to deliberate indifference will freeze our application of qualified immunity;” rather
such cases “exist on a spectrum of intent and harm.” Id. Where the violation “inherently
include[s] [a] knowing disregard for the law,” Thorpe applies. Id. But where “there may
be more attenuation between the risk of harm and the defendant’s knowledge that his
conduct is constitutionally deficient, . . . a defendant is less able to ‘use his own “state of
mind” as “a reference point” to “assess conformity to the law.” ’ ” Id. at 446–47 (quoting
Thorpe, 37 F.4th at 939).
Ultimately, “Thorpe most neatly applies to . . . a prison guard, who doesn’t need case law
to tell him he can’t abuse an inmate.” Id. at 446. So, the court need not separately
determine whether the constitutional right at issue was clearly established if there remains
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a genuine issue of material fact as to an official’s deliberate indifference, because that
potential deliberate indifference would, if established, necessarily include an awareness of
the illegality of the defendant’s actions. Id. at 448.
As to the primary care doctor, the court then reasoned that “[the doctor] was on
notice that he was violating [the inmate]’s constitutional rights.” Id. at 452. The court
ultimately upheld the district court’s denial of qualified immunity. Id. at 454.
2. Edwards’ Shackling Warrants Application of Thorpe
As discussed above, we find that the conduct of Witherspoon, Brodie, Williams,
Lynch and Ragano constitutes “potential deliberate indifference,” id. at 448, such that
summary judgment was inappropriate. So, the remaining issue is whether their conduct
was clearly constitutionally deficient such that Thorpe applies. We hold that it was.
Collapsing the inquiries is appropriate because the risk was obvious and Witherspoon and
the four officers were “on notice of the full volley of harms their [shackling] practices
created.” Thorpe, 37 F.4th at 936.
As in Pfaller, 55 F.4th at 446, it is a matter of common sense that you should not
shackle a pregnant offender while they are in active labor. Giving birth carries risks for
both the pregnant offender and baby under any circumstances; between 2019 and 2023,
North Carolina reported 29.8 pregnancy-related deaths per 100,000 live births, ranking
34th in the United States for maternal mortality. America’s Health Rankings, Maternal
Mortality in North Carolina, United Health Found.,
https://www.americashealthrankings.org/explore/measures/maternal_mortality_c/NC (last
visited Aug. 3, 2026) [https://perma.cc/P6QC-ZXM6]. It is obviously wrong to compound
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these risks by shackling a pregnant offender during labor and immediately after. The
obviousness of the harm is only compounded by the consensus of experts decrying the
practice and the DAC policy explicitly prohibiting the actions of the relevant defendants.
See Brawley, 712 F. Supp. at 1219–20 (“Common sense, and the [Department]’s own
policy, tells us that it is not good practice to shackle women to a hospital bed while they
are in labor.”).
Witherspoon and the four officers’ non-compliance with DAC policy and the
November directive further support collapsing the inquiry. While a policy violation alone
does not support a constitutional claim, see Davis v. Scherer, 468 U.S. 183, 195 (1984),
the existence of such policies can support the conclusion that a reasonable correctional
officer “would have known” of the constitutional infirmity. Hope, 536 U.S. at 741–42.
Like the physician in Pfaller, Witherspoon and the four officers ignored DAC guidelines
concerning the shackling of pregnant offenders even though they were aware of the
guidelines and had been trained on them. See Pfaller, 55 F.4th at 449 (noting “a reasonable
inference that [the primary doctor], as a staff physician, was aware of those Guidelines”
and that he “acknowledged” that “he understood that the Guidelines set the standard of care
for the treatment of patients with chronic hepatitis C”). An unconstitutional harm to
Edwards resulted. Thus, we can and will collapse the qualified immunity inquiry.13
13
Defendants say Thorpe is inapplicable because it involves a motion to dismiss
rather than summary judgment. Response Br. at 36. But, whenever “the officers’ mental
state remains genuinely in issue,” disposing of the case is improper. Thorpe, 37 F.4th at
934.
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* * *
Accordingly, we hold that there is a genuine dispute of fact as to whether defendants
Witherspoon, Brodie, Lynch, Williams and Ragano violated Edwards’ Eighth Amendment
rights when she was shackled before, during, and after her labor and delivery while in the
custody of NCCIW. Further, we vacate the district court’s finding that these defendants
are entitled to qualified immunity on the shackling claim.14 The decision as to defendants
Dixon, Gill, and Brown is affirmed.
IV. Eighth Amendment MOUD Claim
A. Background on Opioid Use Disorder
Opioid dependence is a chronic medical condition and “ ‘extraordinary public health
crisis that started at least two decades ago and has accelerated over the past decade.’ ”
Spurlock v. Wexford Health Sources, Inc., 175 F.4th 232, 239 (4th Cir. 2026) (quoting City
of Huntington v. AmerisourceBergen Drug Corp., 96 F.4th 642, 647 (4th Cir. 2024)); see
also Preventing Opioid Use Disorder, Ctr. for Disease Control (May 8, 2024),
https://www.cdc.gov/overdose-prevention/prevention/preventing-opioid-use-
14
While we find that the clearly established analysis folds into the discussion of the
constitutional violation, the district court’s reliance on Fain v. Rappahannock Regional
Jail, No. 3:12-cv-293-JAG, 2013 WL 3148145 (E.D. Va. June 19, 2013), to say that this
right is not clearly established, is separately unavailing. See 2013 WL 3148145, at *5–6.
Fain, an unpublished district court order, is not controlling authority for clearly established
purposes, which is limited to “decisions of the Supreme Court, this court of appeals, and
the highest court of the state in which the case arose.” Franklin v. City of Charlotte, 64
F.4th 519, 534 (4th Cir. 2023) (internal quotation marks omitted) (quoting Owens ex rel.
Owens v. Lott, 372 F.3d 267, 279 (4th Cir. 2004)).
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disorder.html [https://perma.cc/27TE-DXLH]. “OUD is a progressive brain disease
characterized by uncontrollable cravings for and/or dependence upon opioids.” Spurlock,
175 F.4th at 239. In one study of 24 carceral settings, 26% of pregnant people admitted to
state prisons and 14% to jails had OUD. Chris Ahlbach et al., Care for Incarcerated
Pregnant People With Opioid Use Disorder: Equity and Justice Implications, Obstet
Gynecol., 2 (Sep. 2020), https://pmc.ncbi.nlm.nih.gov/articles/PMC7483637/
[https://perma.cc/9MES-YKLU].
The accepted evidence-based standard of care for OUD is prescribing MOUD. See
Christian Heidbreder et al., History of the Discovery, Development, And FDA-Approval Of
Buprenorphine Medications for the Treatment of Opioid Use Disorder, Drug and Alcohol
Dependence Reports, 2 (2023), https://pmc.ncbi.nlm.nih.gov/articles/PMC10040330/
[https://perma.cc/DT83-2CTQ] (describing MOUD as the “gold standard for OUD
treatment”). The FDA first approved MOUD medication for use in treating OUD in 2002.
Heidbreder, supra at 1, 5. As noted in Spurlock, “[t]he World Health Organization,
National Institute on Drug Abuse, Substance Abuse and Mental Health Services
Administration, National Sheriffs’ Association, Centers for Disease Control and
Prevention, American Medical Association, and the American Academy of Pediatrics all
recommend that medical providers [screen for OUD and prescribe MOUD where needed].”
175 F.4th at 240. Studies from 2007, 2016, and 2020 show “MOUD combined with
psychosocial interventions is the most effective treatment option,” while other studies from
2000, 2010, 2014, and 2019 note that “MOUD has been shown to be associated with
positive outcomes for reducing drug use [and] criminal activity.” See Heidbreder, supra
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at 8 (citing these studies and characterizing the results). The MOUD medication,
Suboxone, works by blunting the effects of the opiates and preventing cravings in users
such that it helps users effectively transition away from addiction. Peter Grinspoon, 5
myths about using Suboxone to treat opioid addiction, Harvard Health Publ’g (Aug. 8,
2024), https://www.health.harvard.edu/blog/5-myths-about-using-suboxone-to-treat-
opioid-addiction-201803201556 [perma.cc/VD8T-3KVV]. Researchers have described
prescribing MOUD to pregnant prisoners as “essential for their health, dignity, and well-
being.” Ahlbach, supra at 5.
In contrast, withdrawal from opioids, or detoxification, is considered
“fundamentally unethical” and “horrifically painful,” as it can lead to injury, death, and
increases the risk of relapse, especially for pregnant prisoners. Id. at 4. Those with OUD
also become more prone to overdose as their tolerance is reduced while abstinent in prison.
Id. “For those already prescribed MOUD, sudden cessation of the medication can cause
withdrawal symptoms similar to opioid withdrawal itself.” Spurlock, 175 F.4th at 240.
B. Denial of MOUD is a Constitutional Violation
The district court granted summary judgment to Amos, Alexander, and Junker on
Edwards’ claim that denial of MOUD upon her return to NCCIW violated her Eighth
Amendment rights. According to the court, Edwards did not make a prima facie showing
of an Eighth Amendment violation because she did not show “that any defendant
subjectively knew that she faced a substantial risk of serious harm and disregarded that risk
by discontinuing MOUD after she have birth.” J.A. 3084. We disagree with the district
court’s decision regarding Amos and Alexander but agree with its grant of summary
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judgment to Junker. We first discuss the Eighth Amendment violation. Then, because we
conclude there is a plausible Eighth Amendment claim, we also address whether the right
is clearly established.
A prison official’s “deliberate indifference to serious medical needs of prisoners
constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the Eighth
Amendment.” Estelle v. Gamble, 429 U.S. 97, 104 (1976) (citation omitted) (quoting
Gregg v. Georgia, 428 U.S. 153, 176 (1976)). To establish a claim for deliberate
indifference to serious medical needs, a plaintiff must prove two familiar components:
“ ‘(1) that the deprivation . . . [is] objectively sufficiently serious, and (2) that subjectively
the officials act[ed] with a sufficiently culpable state of mind.’ ” De’Lonta II, 708 F.3d at
525 (second alteration in original) (quoting De’Lonta I, 330 F.3d at 634).
Here, Edwards produced evidence sufficient to create a genuine dispute of fact as
to whether medical officials violated the Eighth Amendment in denying her MOUD
postpartum. We address the objective and subjective prongs in turn.
1. Edwards’ OUD was Objectively Serious
The objective prong for a medical needs claim requires demonstration of
“ ‘officials’ deliberate indifference to a ‘serious’ medical need that has either ‘been
diagnosed by a physician as mandating treatment or . . . is so obvious that even a lay person
would easily recognize the necessity for a doctor’s attention.’ ” Scinto, 841 F.3d at 225
(quoting Iko, 535 F.3d at 241).
Here, Edwards was formally diagnosed with OUD prior to her incarceration. The
court has recognized that a “ ‘serious medical need’ is ‘one that has been diagnosed by a
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physician as mandating treatment.’ ” Iko, 535 F.3d at 241 (alteration omitted) (quoting
Henderson v. Sheahan, 196 F.3d 839, 846 (7th Cir. 1999)). Edwards’ official OUD
diagnosis is sufficient to meet this prong.
2. A Triable Dispute of Fact Remains as to Whether Prison Officials Were
Deliberately Indifferent to Edwards’ Serious Medical Need
The subjective prong “requires proof of the official’s ‘actual subjective knowledge
of both the inmate’s serious medical condition and the excessive risk posed by [the
official’s] action or inaction.’ ” Scinto, 841 F.3d at 226 (quoting Jackson v. Lightsey, 775
F.3d 170, 178 (4th Cir. 2014)). This can be met through direct evidence of an official’s
“actual knowledge or circumstantial evidence tending to establish such knowledge.” Id.
This includes evidence “that a prison official knew of a substantial risk from the very fact
that the risk was obvious.” Makdessi v. Fields, 789 F.3d 126, 133 (4th Cir. 2015) (quoting
Farmer, 511 U.S. at 842). “[A] prison official’s ‘[f]ailure to respond to an inmate’s known
medical needs raises an inference [of] deliberate indifference to those needs.’ ” Scinto, 841
F.3d at 226 (alterations in original) (quoting Miltier v. Beorn, 896 F.2d 848, 853 (4th Cir.
1990), overruled in part on other grounds by Farmer, 511 U.S. at 837).
Nor does an official’s strict adherence to a blanket policy relieve them of their
constitutional obligations. See Gordon v. Schilling, 937 F.3d 348, 361 (4th Cir. 2019). In
Gordon, the court reversed a grant of summary judgment where the prison official enforced
a policy that categorically denied hepatitis C treatment to inmates who were within two
years of release. Id. at 361. In addition to noting the official’s awareness of the seriousness
of hepatitis C, the court held that “a factfinder could determine that the categorical
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postponement of medical care . . . evinced a disregard for the wellbeing of those inmates.”
Id. Even where the official offers a medical justification, there may remain genuine
disputes of fact as to the “sufficiency of those justifications.” Id.; see id. (citing a
recommendation from a national medical organization as sufficient for creating a genuine
dispute of fact as to the official’s explanation). It is even more suspect when the protocols
are applied categorically as “prison officials still must make a determination that
application of the protocols result in adequate medical care.” Roe v. Elyea, 631 F.3d 843,
860 (7th Cir. 2011); see also Gordon, 937 F.3d at 361 (citing Roe for the same proposition).
Here, there is sufficient evidence to create a genuine dispute as to whether Amos
and Alexander knew of the substantial and obvious risk of harm when they enforced
NCCIW’s policy denying MOUD to all non-pregnant offenders, including those with an
OUD diagnosis or who had previously received MOUD treatment. See Makdessi, 789 F.3d
at 133. As NCCIW’s medical director, Amos was responsible for direct patient care and
drafted the handbook prohibiting MOUD to non-pregnant offenders. Yet, Amos himself
conceded that OUD is a serious and potentially deadly condition, J.A. 360, the “clinical
standard” of treatment is medication, J.A. 362, and “treatment in the postpartum period
would not be different than [OUD] in the pre-pregnancy period.” Id. And Alexander, who
reviewed and signed off on NCCIW’s MOUD policy, was a board-certified physician in
public health with 10 years of experience treating women at NCCIW navigating pregnancy
and/or OUD. See J.A. 1198–1200. Amos and Alexander’s backgrounds and testimony
lead us to conclude that a reasonable jury could find that they were “subjectively aware of
the risk” associated with discontinuing MOUD while creating NCCIW’s policies. See
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Brawner v. Scott Cnty., Tennessee, 14 F.4th 585, 599 (6th Cir. 2021) (determining that a
jail nurse’s experience could point to her subjective awareness of the risk of harm of
suddenly discontinuing a prisoner’s medications, including Suboxone.).
Defendants contend that the prison officials acted based on NCCIW policy that only
provides MOUD to pregnant offenders. But, as the court has noted, simply following
policy does not defeat a constitutional claim. See Gordon, 937 F.3d at 361. There is an
expectation that officials will still make individual determinations as to the level of care
required. Roe, 631 F.3d at 843. This expectation was echoed in Alexander’s understanding
of NCCIW policy. He acknowledged that the facility’s SOPs outlined that offenders
should be “evaluated by a provider” who “makes the determination on who needs the
therapy based on their clinical judgment.” J.A. 1201–02. Yet, there is no evidence that
medical staff independently assessed whether Edwards still needed MOUD after giving
birth. And the MAT handbook authored by Amos categorically denies non-pregnant
offenders such treatment. J.A. 636. This policy represents the type of “categorical
postponement” we understand to “evince[] a disregard for the wellbeing of . . . inmates.”
Gordon, 937 F.3d at 361; see also Brawner, 14 F.4th at 599 (finding a prison’s blanket ban
on controlled substances insufficient to defeat a constitutional claim because “[the] abrupt
discontinuation of substances that could lead to withdrawal symptoms and potential
seizures [] pose constitutional problems”).
Defendants also argue that they were not deliberately indifferent because NCCIW
officials provided the oxycodone taper to lessen Edwards’ withdrawal symptoms.
Response Br. at 53–54. But the court has expressly held that providing “some treatment”
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as an alternative is not de facto constitutionally adequate. See De’Lonta II, 708 F.3d at 526
(“[J]ust because Appellees . . . provided [plaintiff] with some treatment consistent with the
. . . Standards of Care, it does not follow that they have necessarily provided her with
constitutionally adequate treatment.”); see also Pfaller, 55 F.4th at 454 (“[The doctor] was
on notice that providing some care—even if unreasonable or deficient—does not clear the
constitutional bar.”). For example, prison officials cannot provide a deaf inmate an
interpreter but fail to ensure that interpreter is fluent in American Sign Language and then
hope to survive constitutional muster. See Heyer v. U.S. Bureau of Prisons, 849 F.3d 202,
211–12 (4th Cir. 2017) (noting such care was not “constitutionally adequate”).
The same logic controls here. The court noted recently that opioid “withdrawal can
cause significant suffering” and “increase[] risk of relapse, overdose, and death.” Spurlock,
175 F.4th at 240; see id. (further noting that the “process of withdrawal from opioids, also
known as detoxification, is not even considered to be a medical treatment for OUD”).
Edwards says she experienced this suffering, alleging that her withdrawal symptoms were
“more painful than giving birth.” J.A. 169. A reasonable factfinder could conclude that
the oxycodone taper was far from “constitutionally adequate treatment.” De’Lonta II, 708
F.3d at 526.15
15
Defendants point out that NCCIW officials could not offer MOUD post-
pregnancy as the prison was not licensed as an opioid treatment facility and officials did
not have prescribing authority. Response Br. at 53; Oral Argument at 30:35 -33:00. But
this lack of licensure does not negate the state’s responsibility to provide adequate medical
care. See Estelle, 429 U.S. at 97. The prison could have explored care alternatives, like
utilizing the outside facility it used previously, rather than categorically denying MOUD.
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Defendants also suggest that we must base our decision on the standard of care at
the time of the prisoner’s treatment. Oral Argument at 29:25–30:30, Edwards v.
Witherspoon, et al., No. 24-7049 (argued Oct. 22, 2025),
https://www.ca4.uscourts.gov/oral-argument/oral-argument-audio-files. The court has
never stated that such temporal adherence is necessary, and such a restriction does not aid
their argument. Suboxone received FDA approval for opioid treatment in 2002 and studies
spanning the 2000s and 2010s highlighted MOUD as the most effective treatment for OUD.
See Heidbreder, supra at 5. Additionally, in 2019, there was a growing legal consensus as
cases across the country addressed MOUD access. See Pesce v. Coppinger, 355 F. Supp.
3d 35, 47–48 (D. Mass. 2018) (holding that it likely violates ADA and Eighth Amendment
to deny MOUD without individual assessment and contrary to treating provider’s
recommendation); Smith v. Aroostook Cty., 376 F. Supp. 3d 146, 159–61 (D. Me. 2019),
aff’d, 922 F.3d 41 (1st Cir. 2019) (granting a preliminary injunction and holding that it
likely violates the ADA to deny incarcerated person access to MOUD without an
individualized assessment of the need for medication).
Accordingly, there are genuine disputes of fact as to Amos’ and Alexander’s
subjective knowledge of the harms that could result from denying MOUD.
We reach a different conclusion as to Junker. While Junker was Amos’ supervisor,
he was primarily responsible for the DAC’s mental health care procedures rather than OUD
policy. See J.A. 732, 1031–32, 2219. He specifically testified that he did not work on
OUD policy, and Edwards produced no evidence contradicting this testimony. J.A. 1031–
32, 1037. Thus, we cannot conclude that Junker had “actual knowledge” of the risk of
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harm to Edwards, nor does “circumstantial evidence” point to that conclusion. Scinto, 841
F.3d at 226.
C. The Right to Access MOUD is Clearly Established
Whether the defendants violated Edwards’ clearly established rights turns on the
how we define the “precise right at issue.” Tarashuk v. Givens, 53 F.4th 154, 162 (4th Cir.
2022). In the medical needs context, we routinely define the right as “the right of prisoners
to receive adequate medical care and to be free from officials’ deliberate indifference to
their known medical needs.” Scinto, 841 F.3d at 236. In so doing, we acknowledge that
this right has been clearly established by “the Supreme Court and this [c]ircuit since at least
1976.” Id.; see also Iko, 535 F.3d at 243 n.12.
And the Eighth Amendment qualified immunity analysis does not require additional
granularity. See Pfaller, 55 F.4th at 453. Pfaller is again helpful to our discussion. In
Pfaller, the court expressly rejected efforts to define an Eighth Amendment right more
narrowly. 55 F.4th at 445, 453. A primary physician wanted to define the right at-issue as
“whether it would have been clear to [the physician] that he was providing inadequate
medical care in violation of the Eighth Amendment by failing to schedule a specific type
of follow-up test (fibroscan) for Pfaller until July 2018.” Id. at 452. But the court held that
requiring that level of specificity would transform qualified immunity into absolute
immunity. Id. at 453. The court instead applied the right from Scinto and found that the
doctor was “on notice that he could not refuse necessary medical care to Pfaller.” Id.
Defendants seek to define the right with similar granularity, arguing that “the
constitutional right to receive MOUD has not been clearly established.” Response Br. at
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50. However, in accordance with our caselaw, we reject the defendants’ attempt to “define
the rights at issue in accordance with the ‘very action[s] in question.’” Pfaller, 55 F.4th at
453 (quoting Scinto, 841 F.3d at 236).
It is undisputed that Edwards was denied MOUD upon her return to NCCIW
pursuant to prison policy to only provide MOUD to pregnant offenders. We hold that
Edwards’ constitutional right to receive adequate medical care and to be free from officials’
deliberate indifference to their known medical needs was clearly established. As such,
there is a genuine dispute as to whether that right to adequate medical care and freedom
from prison officials’ deliberate indifference to her medical needs was violated by
defendants’ conduct. And because that right is clearly established, Amos and Alexander
are not entitled to summary judgment.
V. ADA and RA Claims
Title II of the ADA provides that “no qualified individual with a disability shall, by
reason of such disability, be excluded from participation in or be denied the benefits of the
services, programs, or activities of a public entity, or be subjected to discrimination by any
such entity.” 42 U.S.C. § 12132; see Reyazuddin v. Montgomery Cnty., 789 F.3d 407, 419–
21 (4th Cir. 2015). Section 504 of the RA provides that “[n]o otherwise qualified
individual with a disability . . . shall, solely by reason of her or his disability, be excluded
from the participation in, be denied the benefits of, or be subjected to discrimination under
any program or activity receiving Federal financial assistance.” 29 U.S.C. § 794(a). Due
to the similar statutory language in the ADA and the RA, courts generally construe both
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acts to impose the same requirements. See Seremeth v. Bd. of Cnty. Comm’rs, 673 F.3d
333, 336 n.1 (4th Cir. 2012). Further, courts now consider substance abuse and OUD as
disabilities pursuant to the ADA and RA. See Smith, 376 F. Supp. 3d at 159; Taylor v.
Wexford Health Sources, Inc., 737 F. Supp. 3d 357, 376 (S.D. W. Va 2024).
The district court granted summary judgment on Edwards’ ADA and RA claims
because there was “no genuine dispute that Edwards failed to qualify for NCCIW’s MOUD
program after giving birth” because she was no longer pregnant. J.A. 3093. As a result,
the district court found no discrimination based on any disability. However, the district
court misinterpreted Edwards’ claims. She alleges statutory violations based on her OUD
diagnosis rather than her pregnancy. Viewed in that light, Edwards may well have
cognizable ADA and RA claims because of the growing recognition that substance abuse
and OUD are disabilities. See Smith, 376 F. Supp. 3d at 159; Taylor v. Wexford Health
Sources, Inc., 737 F. Supp. 3d at 376. The mere absence of discrimination based on
pregnancy does not disprove discrimination based on Edwards’ OUD diagnosis.
As the district court did not correctly evaluate the nature of Edwards’ claims, we
vacate and remand for further proceedings on the question of whether Edwards has viable
claims under the ADA or RA for the prison’s denial of MOUD.
VI. Conclusion
For these reasons, we vacate the grant of summary judgment as to defendants
Witherspoon, Brodie, Ragano, Lynch, and Williams on Edwards’ shackling claim. And
we vacate summary judgment as to defendants Amos and Alexander on her MOUD claims.
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We remand the claims against these defendants for further proceedings. We also vacate
and remand on the question of whether Edwards has viable claims under the ADA and RA.
All other decisions of the district court are affirmed.
AFFIRMED IN PART,
VACATED IN PART, AND REMANDED
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