‘Doom County Jail’: Dysfunction Plagues Program for Incarcerated Opioid Users

Men locked up in the Broome County jail describe an opioid treatment program so shoddy, they risk withdrawal, relapse, and overdose.

Spencer Norris   ·   September 27, 2023
Broome County jail from the exterior
As incarcerated men struggle to get medication, a black market has emerged in the Broome County jail. | Photo: Broome County Corrections Division | Illustration: Maia Hibbett

Hell broke loose in Joshua Cottrill’s body. He could walk off the cold sweats during the day, but over nights at the Broome County jail, he couldn’t breathe. His legs and back were in pain, and insomnia kept him awake for two days straight. Withdrawal often causes opioid users to vomit and defecate uncontrollably, but Cottrill could do neither; he’d been too sick to eat for 10 days.

His peers were worried. One incarcerated man said he warned Cottrill that he could die if he didn’t force himself to hold something down.

Opioid withdrawal is torturous and occasionally lethal. The pain can be bone-deep. It’s often described as the worst illness of someone’s life.

It’s also mostly preventable. Medication for opioid use disorder — MOUD for short — is one of the only evidence-based treatment options shown to prevent withdrawal, relapse, and overdose. It is widely considered the gold standard for treating opioid addiction. Thanks to a 2021 law, New York jails are mandated to distribute it.

Nearly two weeks into his incarceration, Cottrill still hadn’t received his medication. Already in severe withdrawal, he said “they just keep saying I gotta wait, please be patient” — a common refrain from Broome County prisoners waiting on the life-saving treatment.

Cottrill’s account is one of 16 shared with New York Focus by people currently or formerly incarcerated by the Broome County Sheriff’s Corrections Division who had enrolled — or attempted to enroll — in the jail’s MOUD program. Along with community advocates, academics, family members, and attorneys, they portrayed a deeply dysfunctional treatment program.

The men described an intense fear of relapsing because they can’t get the medication they need. At least one has, even after starting the MOUD program, because his dosage was too low to stave off his symptoms. Six other men said that their treatment isn’t working and that they’re going into withdrawal every day. One of them pled with his jailers for months before he was able to receive medication, and only after a civil rights group intervened on his behalf. Some may never get on the program at all.

“I’m not trying to be in pain and fighting this addiction,” said Ryan Carney, who relapsed while on the program. “It’s definitely a good program, but I don’t think it’s being ran the way it was made to be.”

Access is so limited that some men save spit-caked, half-used doses and reconstitute them to sell to others in need. Others try to smuggle medication into the jail. They face disciplinary action if discovered, but they’re desperate enough to risk it.

“It’s definitely a good program, but I don’t think it’s being ran the way it was made to be.”

—Ryan Carney

The man presiding over all of this says he wants the treatment program to work. Sheriff Fred Akshar, a former New York state senator, voted for the 2021 law while in the legislature. When he took over as sheriff, he replaced a tough-on-crime predecessor, and some local advocates hoped for a new progressive era. Akshar touted plans to revamp the jail’s approach to addiction.

Nearly 10 months into the sheriff’s tenure, Broome County is still waiting on the transformation. The number of incarcerated individuals on the MOUD program has increased from 54 to 85 this year, according to Akshar’s office. But according to the men interviewed, little has changed in the two years since New York Focus first reported that people jailed in the county were unable to access medication.

That was before the jail was legally required to have the program. Now that it’s mandatory, advocates said that the jail is doing the bare minimum to avoid breaking the law.

KEY POINTS

  • People incarcerated at the Broome County jail are struggling to access medication for opioid use disorder (MOUD) that the jail is legally required to provide. The men interviewed frequently suffer through mild to severe withdrawal while being denied the medicine that would eliminate their symptoms.

  • As a state senator, Fred Akshar voted for this law. He's now sheriff of Broome County, which has some of the highest rates of overdose in the state. He's fighting to reform a system that was never designed to support such programs.

  • Some men reported having to wait months to start on the MOUD program. Many struggle even if they get in, receiving doses too low to manage their disease.

  • Some who haven't been able to get on the program have smuggled in medications like Suboxone. Akshar's office treats these medications as contraband — a practice that research suggests does more harm than good.

  • MOUD programs in jails and prisons have been shown to reduce overdose rates in the community. But some men are released before they can get on Broome’s program, leaving them at extremely high risk for relapse and overdose.

“What very much seems to be happening is that Broome is partially complying with MOUD law, but ignoring the spirit of it,” said Antony Gemmell, an attorney with the New York Civil Liberties Union, which hailed the law as “an opportunity to save countless lives” when it passed and has since intervened to enforce it. The jail “is seemingly denying people what is necessary treatment for a life-threatening illness,” Gemmell said, “and that should be concerning to everyone.”

Through a representative, Akshar said he “respectfully but wholeheartedly” disagreed with Gemmell’s assessment. “My administration holds a dramatically different philosophy and has taken a dramatically different approach to treatment access within the Broome County Correctional Facility than the previous administration.”

State Assemblymember Linda Rosenthal, who sponsored the MOUD bill, said she would push for an investigation into how the law is being implemented.

“We shouldn’t have had to pass a law for this,” Rosenthal said. “But we did. This is just the right way to approach the epidemic. So it’s disturbing that, A, it’s not going according to the way the law specified, but B, it’s not the best practices route either. It seems very slipshod and haphazard.”

For Cottrill, the shoddy implementation meant waiting so long, his body shut down.

Cottrill’s withdrawal intensified until medical staff decided to intervene. He became so sick that when he tried to walk, he passed out, falling and hitting his head on the floor, according to Cottrill and four other people who witnessed the incident. Staff took him out in a wheelchair. He started the MOUD program the next day.

Every morning around 4:30 AM, the men on the program sit shoulder to shoulder. Medical staff go around the room, handing out their medication, pre-crushed in envelopes. They keep the powder under their tongues until it’s dissolved, then raise their hands. Staff and correctional officers check their mouths with flashlights to make sure that they aren’t “cheeking” their medication — storing it to sell to their peers. Then they go back to bed, hoping to squeeze in a few hours before they have to start the day.

For many of the men interviewed, the cravings begin around dinnertime. Restlessness. Headaches. Some have physical pain, cramps, and uncontrollable muscle contractions. One said his spasms were so bad that he was afraid of accidentally punching the wall in his cell. If they’re lucky, they sleep a little before they wake up in withdrawal in the middle of the night.

4:30 AM comes, and the cycle begins again.

All of the men interviewed who were able to get on the program said they were receiving between eight and 16 milligrams of Subutex a day. (Subutex is a brand name option for buprenorphine, one of the most common forms of MOUD.) While the majority were able to eventually access the MOUD program, they frequently reported having to wait months to get their dosages right.

“I don’t feel well at all right now.”

—Nicholas Clancy

For people with advanced opioid dependence, said Justine Waldman, a doctor of addiction medicine and CEO of the REACH Project, “eight milligrams of Subutex is not going to touch them,” especially considering the prevalence of fentanyl and the strength of opioids now available.

The prisoners agree. While some reported doing well on the program, many said that the doses aren’t enough to prevent them from getting sick every night.

“I take my medication at four o’clock in the morning. By four o’clock in the afternoon, like right now, I don’t feel well,” said Nicholas Clancy. He was clammy, aggravated, and in pain. “I don’t feel well at all right now.”

Joshua Lee, an addiction medicine doctor who has studied medication programs in New York City’s jails, said that Broome appeared to be doing what it could under the circumstances.“If they do have ready access to eight to 16 milligrams of buprenorphine, it’s hard to accuse Broome County jail of not offering adequate MOUD treatment, at least with buprenorphine.”

Yet that doesn’t necessarily equate to great care. Most of the men reported being switched from one medication to another without their consultation. Some, including Cottrill, said they were on methadone before they were incarcerated but got switched to Subutex in jail — which can be especially brutal.

“That can totally fuck people up,” Lee said. “You can have these withdrawal symptoms long-term.”

That’s if they can get on the program at all. The sheriff’s office said that incarcerated individuals are automatically enrolled in the program if they tell staff that they have used opioids when they enter the jail. But multiple men said they had to fight for months to get access and provide some kind of proof that they needed the medication.

Justin Knapp told staff that he was headed for a relapse and submitted five requests to be put on the MOUD program. He shared the slips and communications from the jail’s healthcare contractor with New York Focus.

“I would like to speak to Dr. Boot about the M.A.T. program,” Knapp wrote on one request (MOUD is often called ‘medication-assisted treatment’, or MAT). “I’ve been craving heroin and I don’t want to use but I am an addict who given the oppertunity [sic] will use heroin and I don’t want to die from heroin overdose.”

“I’ve been craving heroin and I don’t want to use but I am an addict who given the oppertunity will use heroin and I don’t want to die from heroin overdose.”

—Justin Knapp

He was denied over and over again. Months went by, and he still couldn’t get the medication he was begging for. Knapp eventually filed a grievance demanding access. The jail’s response was short and to the point.

“Your grievance denied as non grievable,” it read. “Your failure to qualify for the program proves a lack of medical necessity.”

Gemmell’s team at the NYCLU stepped in and sent a series of letters to the Broome County Sheriff’s Office demanding that the jail evaluate Knapp for the program. It’s unclear if that effort was what finally got him on MOUD, or if a desperate strategy he took paid off.

Knapp said that the jail required some kind of proof that he needed treatment: previous medical history or a positive urinalysis for opioids. So, he said, he illegally obtained Suboxone in the jail and got tested while it was still in his system. Knapp was finally able to get on the program in July — nearly six months after he was first denied.

Fred Akshar stands on NY Senate floor and speaks in April 2019.
Then-Senator Fred Akshar speaks during Senate session in Albany on April 30, 2019. | NY Senate Photo

The intense demand for the medications has created an MOUD black market in the Broome County jail.

Incarcerated men are going to exceptional lengths to obtain medication that is supposed to be free and easily accessible. Sometimes, that’s a contraband strip of Suboxone. Other times, it’s the dried-up spit and remnants of Subutex from someone who cheeked their medication.

According to the Broome County Sheriff’s Office, they’ve caught 58 instances of medication diversion since the beginning of the year — “but that only represents the instances we’ve been able to catch.”

In the cases they don’t catch, “people are bringing back half-chewed spit and letting the paste dry for a day,” said Carney. “That’s an addiction right there in itself.”

“We shouldn’t have to go through that, taking toothpaste caps full of spit and just snorting other peoples’ spit,” he added. “While we’re asking for [prescribed MOUD], being denied time after time after time.”

If medical staff suspect someone is cheeking their medication — for example, staff see a bit of powder still floating around their mouth — it jeopardizes their treatment. The first time, they have to speak with the provider for counseling; the second, their medication may be cut. The third time, they’re removed from the program altogether.

The Broome County Sheriff’s Office acknowledged the policy but denied it is punitive because corrections officers aren’t calling the shots. “Any changes to dosages are strictly made by the MAT medical provider based on the health and safety of the individual,” the spokesperson wrote.

Others try to smuggle their medicine in. In February, the Sheriff’s Office announced that it had intercepted a bundle of contraband containing marijuana, synthetic cannabis, tobacco, and about 167 strips of Suboxone, 13 of which were spliced with methamphetamine. Akshar held it out as a victory for protecting the prisoners.

“This investigation demonstrates how valuable our community members are in helping create a safer more secure environment,” Akshar said via a press release. “Our team was able to once again thwart an effort to smuggle dangerous narcotics into our facility.”

Most available research indicates that intercepting diverted medication harms more than it helps. A 2018 survey of people using diverted buprenorphine (the active ingredient in Suboxone and Subutex that prevents withdrawal and cravings) found that nearly four out of five users said they were trying to avoid going into withdrawal. Two-thirds said they were trying to remain abstinent. And because buprenorphine has a ceiling effect that limits its depressive effects on respiration, there’s very little chance of overdosing on it. In fact, one study found that access to non-prescribed buprenorphine reduces the risk of overdose.

Distributing the medications in jails and prisons is also remarkably safe. In 2016, Rhode Island established the country’s first statewide correctional MOUD program. A study conducted one year in found that no one had been hurt by diverted medications.

“Ultimately, the jail is a place of punishment, and I think that they view people who are incarcerated as bad people,” said Kevin Revier, a professor of criminology at Arcadia University who did his doctoral thesis on the Broome County jail. “I thought it was interesting that the sheriff would be so excited about catching people smuggling in necessary medication.”

“I’m like a potential overdose waiting to happen.”

—Keith Keefer

Akshar’s office doesn’t see it that way.

MAT is not smuggled into the jail. MAT is prescribed by a medical provider,” read the sheriff’s written response. “The illegal contraband smuggled into the facility was not prescribed based on medical assessment, included substantial amounts of methamphetamine, marijuana and synthetic cannabis. This was a criminal act with potentially fatal consequences.”

Gemmell, the NYCLU director, said, “I hope to the extent that Broome County is investing time in putting press releases out about diverted medications, that they put equal effort into ensuring that those medications are available to the people whose lives depend on it.”

When they get out, the men held in Broome County Corrections will be released into one of New York’s communities hit hardest by the opioid crisis. The county now has the fourth-highest rate of overdose death in the state. Opioids have torn its social fabric to shreds. Some of the men in the jail grew up together and watched one another follow the same trajectory.

It’s a recipe for disaster. People recently released from incarceration have a dramatically higher risk of dying from an overdose. After months of restricted access, their tolerance is often at an all-time low. Upon reentry, they will have access to the most lethal drug supply in the history of the opioid epidemic, owing to the deluge of fentanyl and the tranquilizer xylazine.

Jail MOUD programs have been shown to interrupt this pattern. Back in Rhode Island, post-incarceration overdose deaths dropped 61 percent in the program’s first year alone.

Through his press representative, Akshar acknowledged that the jail has had some difficulties getting incarcerated people on MOUD, but he denied that there were significant delays. “I can say with full confidence that if someone enters our facility and the screening process shows they are in need of MOUD under our care, they are immediately put into the program.”

Some of the men interviewed for this story said they believe Akshar is personally invested in the program’s success. One man expressed his gratitude for jail staff, who resuscitated him after he overdosed in his cell. (He still had to wait about two months to access the MOUD program.)

Akshar is facing an uphill battle. For the better part of a decade, the Broome County jail has struggled to deliver medical care of any kind. At least 10 people died in custody from 2011 to 2022, often following medical neglect. Under the previous sheriff, one man who was jailed for a drug court violation died after going 13 days without medical attention for an aggressive brain tumor. The incidents have earned the facility the moniker “Doom County Jail,” according to Revier.

“It’s a structural problem with jail medical delivery,” said Andrew Pragacz, a professor in Binghamton University’s sociology department. “Good healthcare delivery is predicated on being able to advocate for yourself and being able to have some say in your care. It’s a power relationship.”

“They just keep saying I gotta wait.”

—Joshua Cottrill

Akshar said that his office is doing everything it can to get the men incarcerated in Broome County ready to leave. He said the jail provides at least seven days of medication for anyone on the MOUD program upon release, even if they were cut off for diversion, and connects them with local providers on the way out. But that only helps the folks who were able to get on the program in the first place.

Keith Keefer almost dreads the possibility of release. He said he was prescribed methadone for pain while he was free — after a 2010 accident that shattered several bones in his torso — and taken off of it while incarcerated in Broome County. When he spoke with New York Focus, he still hadn’t been able to get on the MOUD program, more than four months after he entered the jail.

Months off the methadone, Keefer’s cravings are intense. He’s never used heroin or fentanyl, he said, but without the MOUD, he’s afraid of what he’ll do to stop the feeling.

“I’m scared to death because I want to get high,” Keefer told New York Focus. “I’m in so much pain, the urge to get high is tremendous.” He said his family moved to be closer to him — and make sure he doesn’t try to buy for the first time when he gets out.

“I’m like a potential overdose waiting to happen,” Keefer said. “I don’t want to end up with a drug problem that I didn’t come here with.”

Spencer Norris is a reporter at New York Focus investigating drug policy with a focus on the state’s addiction treatment facilities. He was previously the investigative data reporter at the South Florida Sun-Sentinel, where his coverage of sex trafficking won statewide awards and… more
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