This article originally appeared on Tonic.
When Beth Thompson was picked up by the San Antonio police on a forgery charge last December, she knew she was in for an unfathomable amount of pain.
Thompson had committed the crime to help fund her addiction to heroin. She knew that getting arrested likely meant she would be cut off from the drug, which would guarantee excruciating withdrawal symptoms. Only five detention centers in the United States currently induct people into medication-assisted treatment for opioid addiction, and Bexar County Adult Detention Center, where Thompson was booked, isn't one of them.
"I was on the floor in a ball, throwing up," Thompson recalls. She spent her first three days without heroin in a general booking area—an enclosed space furnished with sparse bunk beds and a communal metal toilet. The space has a large plexiglass veneer through which the guards could watch them as was shared with what she estimates were 15 or 20 other women, some of whom were also sick from withdrawal. By the end of her first 24 hours, withdrawal symptoms had set in.
But Thompson couldn’t get any kind of medicine before she was processed, which took three days and included a crucial appearance before a magistrate—an appearance she barely got through without vomiting. Her body trembled and ached as she tottered into the small hearing room, she says, her jaw set so hard it burned. She was trying to hold back the bile bubbling up her throat. Anxiety frenzied in her chest. She couldn’t stop thinking about the hit of heroin she’d been after when she got arrested—and the few extra hours of delicious relief it would have granted her.
After her arraignment, she was transported to another building, where she was shuffled between concrete pods for various booking processes. The last of these was a medical exam. By then, she was in the thick of withdrawal. Her entire body felt like a giant, aching bruise. The blood pressure cuff choked her sweaty, track-studded arm. When she was asked whether she was in drug withdrawal, she gave an ardent yes—hoping for some kind of medical relief.
Instead, she was sent to a "detox tank” in yet another building, a space that housed about 25 other inmates who were either withdrawing along with her or experiencing acute symptoms of mental illness. She remembers being awake for the full four days she spent in the segregated area, with bright lights drilling into her throbbing skull, surrounded by the sounds and smells of other physically or mentally ill patients. "You'll have someone throwing up next to someone who seems ot be in schizophrenic psychosis," Thompson says. "It's not good."
What she remembers most is the smell, she says. The small, communal toilet was in the corner of the pod, enclosed by a short stall that did nothing to keep the smell of diarrhea, vomit, and blood from overtaking the unit. The women were given basic cleaning supplies and Thompson says the least sick among them did the floors and toilet three times a day.
Thompson only had the energy to remove and fold her sheets (required for getting them washed) once during that time, so she spent most of her detox writhing in sticky, sweat-drenched sheets. Her blanket was never replaced, even when she was through with the physical withdrawal.
While in the detox tank, Thompson was given clonidine, a blood pressure medication that is sometimes prescribed for opioid withdrawal in hospital emergency departments, and in some—but not all—correctional facilities. Clonidine can help alleviate some of the physical symptoms of withdrawal, like chills and agitation. It does not, however, treat the underlying addiction.
Tonic contacted Bexar County’s Sheriff’s department to ask about Thompson’s experience. A public information officer, Johnny C. Garcia, replied with a statement declaring their inmates’ healthcare to be a priority, citing the HIPPA-related restrictions regarding discussing a former inmate’s health, and this:
“[Thompson] was screened and referred to Classification for housing in a detox unit. While in detox, she was followed by a provider to ensure she was clinically stable. The detoxification program does not include methadone maintenance unless the individual is already on that treatment prior to incarceration. Even when individuals are already on methadone maintenance, we taper them off because that is a highly addictive medication that is primarily used for patients that have continued access to drugs—individuals in jail do not have that access and are not as equally affected.”
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"Addiction care [in the US prison system] doesn't meet community standards," says Sarah Wakeman, assistant professor of medicine at Harvard University and an addiction medicine physician at Massachusetts General Hospital. This is especially notable because, in the United States, prisoners are legally entitled to healthcare equal to community standards—meaning that, while incarcerated, people should have access to the evidence-based care they would be granted outside. While clonidine is "better than no medicine," it is "inexcusable" that some facilities are not offering people with opioid dependencies methadone and buprenorphine, she adds, considering the overwhelming data confirming their efficacy in the treatment of opioid use disorders.
Wakeman also notes that “there continues to be confusion and spreading of the myth that people who use [medication treatment for addiction] are not really in recovery, and that myth is really strongly held and believed in correctional facilities.” For example, contrary to Garcia’s statement about the addictive quality of methadone, it's a World Health Organization- and FDA-approved treatment for opioid use disorder that does not usually cause addiction. (I reached out, by email, to Bexar County’s Sheriff’s department for comment on this and did not receive a response at the time of publication).
This clash of the Bexar County’s Sheriff’s department and Wakeman's stances represent a larger ongoing tension in the US today concerning the opioid epidemic. There are strong disagreements between law enforcement and many medical professionals about whether methadone-assisted treatment is the best way to help people fight and recover from addiction, though there's a lot of promising research about how effective and underutilized addiction recovery drugs are. While a minority of correctional facilities maintain patients on methadone or buprenorphine if they were prescribed it before their incarceration—current estimates say fewer than 40 out of about 5,000 facilities let patients remain on the treatment—most only provide medications like clonidine or nothing at all.
Thompson continued to experience withdrawal symptoms for two weeks. She says she was not offered treatment or recovery services while incarcerated (when asked about this information, the Bexar County’s Sheriff’s department responded that all inmates have “unencumbered access to medical care.”)
In February 2018, about two months after she was arrested, Thompson was transferred to Lucile Plane State Jail in Dayton, Texas. By then, the acute withdrawal had ended; because heroin is a short-acting opioid, withdrawal begins fast and hard, but doesn’t usually last more than seven days. Psychological recovery, however, can take much longer. By the time Thompson was transferred, she was beginning to feel the onset of a severe depression. Spending Christmas in jail and then learning her father had been diagnosed with cancer did not help. But she says that when she tried to participate in a recovery program at Lucile Plane, she was not allowed to join because she was told it required three months of participation and she was slated for release in April, which would happen before she had been able to complete the program.
Jeremy Desel, director of the public information office at the Texas Department of Criminal Justice, says (when reached for comment) that he is not aware of a program having any such restrictions. Regarding inmate access to recovery services, he says that it is part of their mission to “ensure that offenders who we oversee are prepared for reentry into society upon their release. An important part of that rehabilitation is the administration of various substance abuse programs. There are currently six major substance abuse programs that are administered by TDCJ to more than 9,000 offenders who have a range of sentence lengths.”
Depressed about being in jail and worried about her father’s health, Thompson tried to get mental health counseling at Lucile Plane. After six weeks of waiting, she was able to talk to a counselor, but was released shortly thereafter.
Thompson’s life is significantly different now from how it was before her 2017 arrest. But she doesn’t credit that to her forced detox in jail. In fact, though she managed to stay sober for several months on her own, she eventually relapsed. Instead of letting her addiction consume her life, however, she decided to do what she couldn’t while incarcerated—get into methadone treatment. Now, she lives with her high school sweetheart, who she reconnected with over Facebook this past summer. They are engaged, and live in a small trailer out by the oil rigs in Midland, Texas. I can hear the smile in her voice when she tells me over the phone that they are expecting a baby next April.
“I’m finding myself again,” she says. “It’s nice to have the time to remember what I like to do. I like painting, I like scrapbooking. It’s nice to have the aloneness. All those months in jail, you’re never alone.”
But Thompson also recognizes that many addicted people who get released after withdrawing in jail don’t get the same opportunity—and that she could have easily missed the chance herself. "Every other time I've gotten out of jail [in the past] I've overdosed the same day," she says. "Everybody overdoses when they get out."
This observation is broad but grimly realistic. Without treatment options or comprehensive social support, former inmates tend to return to the same environments in which they were living before incarceration, often loaded with the same stressors and triggers. A meta-analysis of several studies conducted in the United States, United Kingdom, and Australia found that the first two weeks after release pose an especially high risk of fatal overdose, and that risk remains elevated through the fourth week.
So this isn’t just a problem of discomfort while in jail. Opioid-addicted people who are given evidence-based pharmacotherapy like methadone, buprenorphine, or naltrexone (a non-psychoactive opioid blocker) while incarcerated relapse less, stay in treatment longer, and are less likely to overdose after being released. But without these interventions, many people who are forcibly detoxed in jail end up immediately using illegal drugs again once they get out.
Not infrequently, that relapse is fatal. Part of the reason for this increased risk is that, once a person has been detoxed from opioids, they lose the tolerance developed during active use, making it difficult for someone who relapses to accurately gauge a safe dose. One of those people was Philip Kramer of Las Vegas, a 26-year-old father of two.
Last September, a few months after relapsing on opioids and cocaine, Kramer was arrested and booked for a traffic violation. His mother, Donna DeStefano-Miller, says that after the infraction (that happened while he was intoxicated) he begged to go to a medically supervised rehab. Instead he was detained at the City of Las Vegas Detention Center for a little under a month, and detoxed without any kind of treatment aside from a low-grade pain reliever, and no follow-up care.
"My son and I would go out and feed the homeless together," DeStefano-Miller says. "I remember one time there was this kid that was sunburned from head to toe out here, wearing just a tank top...Philip brought him food, then he took off his shirt and gave it to him."
Kramer’s kindness was coupled with addiction and mental health issues. DeStefano-Miller says her son was bullied as a kid in school, and ended up developing depression. Eventually, he began self-medicating with drugs and alcohol. He battled addiction and chemical dependency through his teens and twenties, cycling in and out of various rehab facilities in the Las Vegas area. His longest stretch of sobriety after he first started taking drugs, according to his mother, was three years.
This time, which would be the last time, Kramer's incarceration lasted barely longer than the withdrawal period, serving only to lower his opioid tolerance before sending him back into the same environment he had left. (A rep from this facility confirmed that Philip Kramer was detained at their facility briefly last year but declined any further comment at this time.)
After his month at the City of Las Vegas Detention Center, he was transferred to a nearby facility for a few days and then released. Within days, he overdosed. He was revived at a nearby hospital, but was unable to secure a bed in a treatment center and was sent home.
A few days later, he overdosed again. This time, he did not wake up. Kramer was put on life support on October 28, 2017. On November 6, after doctors had tried dialysis and other measures to no avail, DeStefano-Miller signed a do-not-resuscitate order, and had her son taken off life support. Kramer passed away on November 6, 2017 at 12:01 pm, leaving behind his young daughter and stepson.
When asked how correctional facilities can help prevent circumstances like the ones that lead to Kramer's death, Wakeman of Massachusetts General says, "Ideally you would give [former inmates] naloxone [the drug that can reverse an opioid overdose] upon release." She also adds, "but it's not enough to just give out naloxone. Ideally, we would start them in treatment."
"I used to talk to my son several times a day. We would fight and then he'd call back and say, 'I love you mom,'" DeStefano-Miller says, grief palpable in her voice. "He didn't get the help he really needed."