On a warm spring day in 2015, Sarah Blair was stranded at a Safeway in Thornton with no car and a dead cell phone. Her plan to get more heroin had fallen through. She felt sick and agitated. Withdrawal was setting in. Inside the grocery store at the checkout lane, she grabbed a woman’s purse out of her cart. She matched the keys to a car in the parking lot and slid behind the wheel. But when the woman came running out, Blair said she just sat there. She was exhausted. It was nearly her 21st birthday and she had been using heroin for three years.
“I gave her her purse,” Blair said during a recent interview at her home in Colorado Springs. “I just sat there and lit a cigarette and waited for the cops to come get me.”
Over the next several days, she went through withdrawal in the Adams County jail. She was throwing up on her cell floor. She remembers not eating or sleeping for days. The officers gave her Gatorade, but she couldn’t hold it down. She was dehydrated, underweight, and restless, she said. Barely able to walk, she went to go see the nurse because her fingers on each hand were clenched together like claws.
Blair said the nurse told her she was about to have a heart attack. Not long after she was in an ambulance heading to the hospital.
She survived. But, over the last five years, at least four people suffering from drug and alcohol withdrawal have died in Colorado’s county jails. While each death has its own particulars, together they can also be seen as the result of a confluence of larger factors.
The first is that Colorado is grappling with an opioid crisis that claimed a record number of lives in 2017. So far this year, nearly two people have died every day from an opioid overdose.
The second is that the number of people with a substance use disorder spending time behind bars is disproportionately higher than the general population; the state doesn’t collect data on the health conditions of jail inmates, but in the state’s prisons, about three-quarters of inmates are addicted to drugs or alcohol when they begin incarceration, according to state data.
The third is that county jails were not set up to treat people with addictions and so they are often put through forced withdrawal, which not only increases medical risks, but is also one of the least effective ways to ensure someone stays clean and sober. Blair said she was shooting up within two days of her release.
These factors together put Colorado’s sheriffs on the front lines of a public health crisis they are currently ill-equipped to handle.
The state Office of Behavioral Health spent about $5.2 million this fiscal year to help jails provide drug addiction treatment. But of the state’s 57 jails, only five received money specifically for medication, according to the state. And only two of these jails routinely provide medication to ease withdrawal symptoms. Jails instead can use this money for other services to treat inmates with opioid use disorder, such as helping them find housing when they are released.
As lawmakers now regroup in Denver for the 2019 legislative session, high on the priority list for some is better medical treatment for those facing withdrawal in the state’s prisons and county jails.
On Friday, the first day of the session, lawmakers made their first-ever attempt at a bill that would require jails receiving this state money for drug addiction treatment to allow medications including methadone, buprenorphine or naltrexone in their jails. All these medications have been shown to reduce cravings and help people move past their addictions to stronger, illegal opioids like heroin.
Lawmakers say that giving inmates access to meds may help drive down the odds of relapse and costly reincarceration.
“We want to make sure that when people are in the criminal justice system that they are getting access to the medication-assisted treatment that they need,” said Rep. Chris Kennedy, a Democrat from Lakewood who is sponsoring the legislation.
Added Kennedy, “If we help people get sober, when they get out then they will not be as likely to commit new crimes and end up back in jail or prison.”
Taxpayers spend nearly $40,000 per prison inmate per year in Colorado, according to the Department of Corrections. Seventy-four percent the state’s 20,200 prisoners are addicted to drugs or alcohol when they begin their incarceration. The number of prisoners is expected to rise in coming years, in part due to the growing number of people arrested and charged with drug crimes.
‘We are basically setting them up for failure’
Blair says she was never that good at managing her addiction to heroin. Few people are, she acknowledges. But some people, she said, can hold a steady job and learn how to parcel out their heroin for later use. She couldn’t, she said.
She said her addiction started shortly after she dropped out of University of Colorado Denver during her first year. She remembers feeling lost and having panic attacks and not sleeping much. She was also drinking heavily, she said. She started smoking painkillers with her friend, and then moved to heroin. Her family has a history of addiction, she said, but getting hooked never crossed her mind. The first time she started feeling withdrawal symptoms, she thought she had the flu. And when she again felt the effects of withdrawal, another friend told her she should stop. She didn’t.
Eventually, she said, she needed heroin first thing in the morning. She couldn’t hold a steady job, often calling into work late and leaving early. Without the money to support her $100-a-day habit, she started returning pants she stole from Walmart for cash. She said she pawned her mother’s engagement ring. Heroin, she says, was the first, if not the only, priority in her life.
Most medical experts view addiction more as a disease than a choice. And in Colorado, there is not nearly enough treatment available for those addicted to opioids such as heroin, experts say. About half of Colorado’s 64 counties do not have a treatment provider that can dispense medications such as methadone or buprenorphine, according to recent reports by the Colorado Health Institute, a nonpartisan health policy research group.
“Our treatment system is both underdeveloped and not easy to access or understand,” said Robert Valuck, a clinical pharmacy professor at the University of Colorado Anschutz medical campus.
Arrests for drug charges have been on the rise in the last five years, according to an analysis of state data. So, too, have the number of people sent to prison for possession and selling of drugs that include heroin and methamphetamine, a powerful stimulant. Many of these people spend time in jail on bond awaiting their trial. Those who return to jail multiple times are sometimes referred to as “frequent fliers.”
Their odds of recovery would be much higher, Valuck argues, if people addicted to drugs had access to medication and therapy while serving time behind bars. People with high blood pressure and diabetes receive medication in jail, he said, and so should people with an opioid use disorder.
“Everybody deserves medical care while they are incarcerated, and if we don’t do that, we are basically setting them up for failure,” he said.
As more county sheriffs come to terms with their role in managing a growing opioid epidemic, some are finding themselves woefully underprepared and without the means to take on the responsibility.
‘See you in two weeks’
In the Alamosa County jail, located in Colorado’s rural San Luis Valley, Sheriff Robert Jackson estimates the vast majority of inmates are addicted to opioids and methamphetamine. But, he says, he doesn’t have the resources to pay for medication, let alone find the qualified medical staff to administer it.
Little of the money the state provides to jails for drug addiction treatment has made it out to the rural Western Slope, Jackson said, where opioid treatment providers are few and far between.
As a result, Jackson said he closely monitors people in his jail who are going through withdrawal. And he said it “looks like something out of a scary movie.”
Often, he said, he puts men and women in roughly 10-by-10-foot holding cells with nothing but a hole in the floor and mat to sleep on. He monitors them with a ceiling-mounted camera. He gives them paper “uniforms” to wear and a paper blanket so they don’t commit suicide by choking themselves.
“These people are circling the drain. They are at the end of the world,” Jackson said.
Vomiting, diarrhea, sweats and seizures are common symptoms of alcohol and drug withdrawal, he said. The paint on the inside of a door in one of these holding cells has been etched and scraped mostly bare by those locked inside, a lieutenant said. In 2016, one woman who Jackson says was going through methamphetamine withdrawal gave birth in one of these concrete cells. She sued Jackson and several of his deputies for allegedly denying her what she says was her constitutional right to medical attention.
Jackson said if he had the money, he would have a program to give people methadone and other medications, though he also believes there is the potential for people to abuse the privilege by selling the drugs to other inmates. Medicaid doesn’t cover the cost of medication for incarcerated people, so the burden is on counties, he said. Plus, he said, he has overcrowding to deal with.
“My plan would be to start treatment in-house now. These people are in a pretty vulnerable position. They are sober. We can rationally discuss this stuff to them. This is the perfect place to have that conversation,” Jackson said. “Right now, we just kick people out. See you in two weeks.”
‘Paying for the consequences of addiction’
Some jails across the Front Range are expanding their treatment. Boulder, El Paso and Arapahoe counties offer medication to certain inmates going through withdrawal. Larimer County is starting a program. The Denver County jail, through a partnership with Denver Health, recently started giving anyone booked into the jail who is addicted to opioids a three-day Suboxone plan to make withdrawal more comfortable. Suboxone is a brand-named buprenorphine medication designed to curb cravings. Others who are undergoing methadone or buprenorphine treatment before their arrival in jail have access to a similar treatment plan during their sentence, according to Sasha Rai, the jail’s director of behavioral health.
Rai, a psychiatrist, acknowledges Denver’s program is unique and that not all counties have the resources to have similar programs. (Denver’s program is funded through state and private grants and the city’s budget.) But, he said, if counties can get grant money from the state, set up a program and prove it works, then their local governments might be persuaded to chip in and help cover additional costs.
Counties, he said, end up paying for addiction one way or the other.
“If you don’t treat the addiction when they’re in the jail, then you have to treat it when they go to the ER, when they get arrested, when they break the law for addiction. You’re still paying for the consequences of addiction,” he said.
Nathan Evans, a 27-year-old from Denver, was working at King Soopers lifting boxes when he developed two hernias. When doctors stopped prescribing him meds, the pain didn’t go away, he said. He said he was previously addicted to Percocet painkillers and fentanyl. And when the meds ran out for his hernias, he turned to heroin, which led to his second run with addiction. He was eventually arrested for theft and possession and booked into the Denver jail. He said he can’t imagine having to go through withdrawal without any medication.
“The human will do almost anything to stop pain. And that’s basically all withdrawing is. It’s just pain,” he said during an interview at the downtown Denver jail.
Without the addiction meds, he said, his odds of relapse would be much higher. When he gets out, he said, his first stop will be to go pick up Suboxone and continue his treatment. Caseworkers at the Denver jail help inmates transition into treatment after their sentence.
This transition is key for maintaining treatment, experts say.
‘You need something bigger’
Blair, who now helps people recovering from addiction find housing with Oxford House, a sober-living organization, said she doesn’t hold a grudge against the officers at the Adams County jail. She said at the time they didn’t take opioid withdrawal seriously, in part because they didn’t understand it.
Today, she has mixed feelings on giving inmates access to medications like methadone and buprenorphine. She said it can work well for some people, especially if there is a plan to taper off of it. But, she said, some people may view it as another way to get high.
Medication in jail is only one step toward improving treatment for people addicted to drugs, said Terri Hurst, a lobbyist with the Colorado Criminal Justice Reform Coalition, a nonprofit criminal justice reform advocacy group.
“We can invest in treatment in both jails and prisons, but if there is no provider willing and able to help that person in the community — to engage and continue their treatment — then it is still going to be this revolving door,” Hurst said.
That outside help proved critical for Blair. Medication did not help her, she said. Instead, she entered rehab and continues to rely on a 12-step program. It took a suicide attempt to give her the resolve to achieve sobriety.
Waking up after her attempted suicide, “I had this distinct thought that kinda said, ‘You’re not getting off that easy.’ It was no longer a choice. I was going to get sober. It was that moment of surrender.”
She re-entered rehab.
“I’ve been sober ever since,” she said. She recites the date like a turning point in her life. “September 9th, 2016.”