Everyday Chaos: Opioid Addiction Treatment at Cook County Jail

As of April 3rd, A.B., a female detainee who wished to only be identified by her initials, had been in Chicago’s Cook County Jail for 139 days. For 114 of those days, she had been part of Thrive, the jail’s recovery program for women working to overcome opioid addiction. “It’s everyday chaos, like jail is,” A.B. says, “but if you dial in, you’ll get what you need out of it.”

She’s one of many detainees fighting addiction at the largest single-site jail in the country. Cook County Jail (CCJ) houses approximately 100,000 detainees each year, and spans ninety acres of land, encompassing eight city blocks. According to Dr. Connie Mennella, the Chairperson of the Department of Correctional Health at Cermak Health Services, the health care provider for Cook County detainees, “more individuals [in the county] die right now from opioid overdose than from motor vehicle accidents and gun violence.”  

On a national level, over two million people are dependent on or abuse opioids. In 2016, there was an average of 116 deaths resulting from opioid overdose every day nationwide. In 2017, the US Department of Health and Human Services declared a nationwide public health emergency. That same year, Cook County sued a group of pharmaceutical companies alleging responsibility in the opioid epidemic. The Cook County Sheriff’s office tracked inmates who were addicted to opioids from 2014 to 2015 and found that more than 40 died due to overdosing, almost half of them within two weeks of release.

The jail has become a treatment center for those working to overcome addiction. For many detainees, it is the first time they get any form of substance abuse counseling, and may even be their first time having health care. Dr. Nneka Jones Tapia, the former Executive Director of the Cook County Department of Corrections, laughs when describing the jail’s role as a treatment center. “Of course, the jail didn’t set out to become a health care facility,” she says, “but two things are at play that we had no control over.” First, she explains, “correctional institutions are the only area where health care is required, and second, there was a growing lack of community health care resources due to closures of city facilities and budget constraints.” As a result, Cook County Jail has become one of the largest opioid addiction treatment centers in the county.

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Dr. Jones Tapia, a clinical psychologist, and the other jail staff knew that as more resources in the county were shut down, those who may have previously been able to receive treatment would be coming to the jail. “We really didn’t have a choice in the matter,” she reflects. “Just the sheer number of individuals that we were getting in our custody that had those complex medical, mental health, and substance use problems, was something that we were ill-prepared to deal with.”

The jail offers the full spectrum of health care services, from check-ups for pregnant detainees and dental health to mental health treatment in the jail’s innovative  Mental Health Transition Center, which Jones Tapia founded. These services are offered through a partnership between the Cook County Sheriff's office and Cermak Health Service, which is part of the Cook County Health and Hospital System. With a limited budget, the jail has to be strategic about what services to outsource and what to keep in house.

Despite the many services the jail has had to take on due to an increased demand in recent years, there has been no budget increase. “I wish!” Jones Tapia says. Instead, the sheriff’s office worked to paint a picture for the community of the complexities of running the jail and what life was like for detainees inside, so they better understood the situation. Following these efforts, there was an increase in community agencies volunteering to come into the jail to offer services, once they “realized the crisis” that the jail was dealing with.  This information campaign was accompanied by a reworked budget and cuts to other services in order to provide the health care services necessary to serve the population.

“Community, state, local government: when they cut, they cut social service programs. We cut security staff,” Jones Tapia says. The jail banked on the idea that there would be less of a need for security staff if they were able to create better citizens, and that’s where programs like the Mental Health Transition Center came into play. This past fiscal budget year, the jail had a few hundred million dollars to make up in its budget, and the staff knew significant cuts would be necessary. Cook County Sheriff Tom Dart was pushed to cut social service programs, but refused to in favor of reducing law enforcement staff. “I’m glad that when the chips fell, we stood true to what we had been saying for years,” Jones Tapia says.

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The Thrive program is a result of both the need to cut back on costs and the jail’s focus on internal programming. Substance abuse counseling for male detainees, who make up the vast majority of the jail, is provided by an outside provider called WestCare. The program for male and female detainees used to be the same, until the jail had to cut costs. “It was so expensive,” describes Jones Tapia, “one of those tough decisions we made was to cut the contract for the women,” and offer the services internally. “To be very frank, we weren’t happy with the treatment provider we had for the women. We were marginally happy with the treatment provider that we had for the men.”

A.B. is from the north side of Chicago. She leads the morning meditation program for women living on her tier, a position to which she was elected by popular vote of her fellow inmates. It’s one of the numerous elected roles in the Thrive tier, like house representatives, and phone and microwave coordinators. A.B. says these roles help prevent too much chaos from arising in the community. “We don’t have to like each other,” she states, “but we do have to respect each other.”

The women in the Thrive tier, comprised of two levels of cells surrounding a central common space called the dayroom, come from varied backgrounds. According to Jones Tapia, the jail houses around 400 women at a time in total, making up only a small sliver of the jail’s total average daily population of 7,500. As of April 3rd, 57 of these 400 women were in Thrive.

 Women in the Thrive program participate in individual and group therapy, which comprises most of the treatment. The program also involves alumni meetings, which are now in the early phases, through which past participants voluntarily return to the jail post-release. The participants in Cook County’s substance abuse program are there because of court orders, but the jail is exploring how to allow for individuals to participate without a court order. Dr. Jane Gubser, the Chief of Programs for the Cook County Sheriff’s Office, oversees Thrive. She describes it as “a holistic program for women who are incarcerated,”  which includes a curriculum that is designed by Stephanie Covington, a leading thinker on gender-specific substance abuse programs. In addition to the core focus of the program, there are sessions on domestic violence, health education, interpersonal issues, communication, and parenting, addressing the many factors the jail believes contribute to recovery for a woman with a history of substance abuse.

Thrive is only one component of the treatment options for detainees suffering from opioid addiction. Any person who comes into custody at CCJ is evaluated at intake by both security and Cermak Health Services using a medical screen, a mental health screen, and a security screen. “If someone comes in with diabetes or needs immediate care for any medical issues, they're going to be given some type of ‘M’ alert,” which signifies a medical condition that will dictate where they are housed in the jail. The same applies to people with mental health issues.  “If anyone comes in with an opioid addiction, and they’re going through detox, they’re immediately flagged,” Gubser says, and then they are housed in the detox unit where they are monitored by medical staff.

However, not everyone who comes in with a detox alert gets prolonged substance abuse treatment beyond the immediate medical care, because the programming aspects of recovery are court-ordered. Thrive, in its current state, is the largest it has ever been since the sheriff’s office took over the programming from the outside provider. The men’s program, still provided by the outside provider, used to have more than 600 people in it at any given moment. Gubser says that due to financial restrictions with the county budget, “we modified to the program, so we only have 145 individuals” in the men’s program at any given time now, which was also shortened from 120 days to 90 days. “That’s what we can afford.”

Jones Tapia credits the Health and Hospitals System for doing an “amazing” job screening individuals admitted to the jail for any addictive drugs that they may have taken. Of the substances people are screened for, use of opioids and alcohol are the most common. “Then they can start their treatment regimen at the point of intake, which is almost unheard of in other correction institutions,” Jones Tapia states. “Most other correctional institutions, you don’t even get evaluated, so for them to have people at the point of intake is incredible.”

Once someone is identified and tagged with any drugs in their system, they are put on a regimen of medication to help taper them off usage. All patients entering Cook County Jail with opioid use disorder are offered a medically-supervised detoxification “at a minimum,” Mennella says.

Beyond detox, eligible individuals who enter the jail already participating in medication-assisted treatment for opioid use disorder are given the option to continue their medication with supported linkage back to their community provider upon their release, after they’ve been medically cleared and assessed. This treatment includes FDA-approved medications for treating opioid use disorder, like methadone, buprenorphine, and naltrexone, which can help reduce the effects of withdrawal. On a pilot basis, Cermak Health is also able to begin medication-assisted treatment for interested and eligible individuals.

Since Cermak began the pilot program to offer medication-assisted treatment in the spring of 2017, there has been a steady increase in patient interest. In 2017, approximately 100 people were treated through a medication-assisted treatment pilot program at the jail. In the first three months of 2018, an additional 175 people received methadone or buprenorphine for treatment through Cermak Health Services, and around 50 have received extended-release naltrexone in the last twelve months. We “strive to meet this demand whenever possible,” Mennella explains. “We carefully counsel patients regarding the three medication options, so they can make an informed decision regarding which medication will best suit their individual needs” upon release.

Jail officials emphasize these linkage services and post-jail care opportunities. Every participant in the Thrive program is given a case manager with whom they work to identify their needs post CCJ. “Any linkages that we can do in terms of trying to assist people with transportation, medication, getting them hooked up with a doctor,” explains Gubser, from housing to searching for inpatient treatment centers in the community. Some judges in Cook County specifically send people to jail for 90 days of treatment in either the WestCare or Thrive programs, and won’t let them leave the jail unless a caseworker from an organization like the community provider TASC is there to pick them up and take them to an outside recovery program upon release. Some detainees are then taken to a two year recovery program, and if they complete it, their records are eligible for expungement. However, only a limited number of detainees have access to this type of program. “I think it is a very thoughtful design,” Gubser reflects, “and I think that’s what we need to be seeing more of.”

Additionally, all detainees who entered the jail with a history of opioid use or who are currently struggling with addiction are trained by Cermak to use naloxone, a life-saving medication to reverse an overdose that is often administered through a nasal spray. All of these detainees are given their own naloxone kit upon release, with the idea that it might be able to later save them or someone they know. The jail has distributed over 2,000 kits since the campaign began in August 2016, and 3,000 people have received education relating to using naloxone. “It’s not just for that person,” Jones Tapia says of the medication, "but for anyone in their immediate circle that may be overdosing.”

The jail faces challenges in providing both the medication-focused and the programming-centric treatment methods. There is a high turnover rate of detainees since many in custody are just waiting for trial before being released or moved to a more long-term prison. “We can have someone who comes into our custody, and then they could bond out,” Gubser says, “so we’re not able to fully give them those services—the reentry planning services—that we’d intend to, but they’re free to leave if they can bond out.”

The jail has limited staff, and the relationship between the sheriff’s office and Cermak Health Services has changed in recent years since the sheriff’s office took on a larger role in programming. For the Thrive program, currently serving 57 detainees, there is one lead case manager. They are assisted by three to five social work interns, depending on the school cycle. The sheriff’s office is working on developing a system so that people who report that they were using opioids in the past, but who don’t enter the jail while detoxing or using, can still be part of the medication-assisted treatment program run by Cermak. “What we’re trying to do is work on a referral source so that they can get screened, and see whether or not they’d be a good candidate,” Gubser says. However, “we don’t have the best working relationship necessarily,” she says, in reference to the sheriff’s office working with the Cook County Health and Hospital System, of which Cermak is a part.

“We’re working on collaborating as much as we can...I think there is this idea that the sheriff’s office is just the sheriff’s office, right? And they don’t necessarily see that we have clinicians who work here, and things like that,” Gubser says, referencing challenges like dealing with HIPAA regulations. “There’s a resistance to share information about clients, and if we can work on fixing that, which we are working on, I think that would help for much more thoughtful and smooth reentry plans,” she argues. “I think it’s just important to note that historically the sheriff’s office never was a provider...it’s natural that there’s some of that resistance, because historically patient information was never shared with custody.”

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Despite challenges, the jail has received positive feedback from detainees about the opioid addiction treatment provided.  Reflecting on her time as Executive Director, Jones Tapia says “It’s important to walk around and just see what’s happening, not just hear about it in meetings. When I would walk around...I would say the Thrive program tier was one of the best mannered tiers, and the ladies would always talk about how they felt supported, and they felt like the counselors were genuine.”

“You don’t always have that with a contracted care provider,” she remarks, “so to have staff that really showed heart and compassion and not just the skill set to deliver the program, but actually the heart behind it, that was rewarding.”

“The men, too, the men love their treatment program,” Jones Tapia reports. When the program was reduced to 90 days “to try to keep the program, because we were in a budget crunch...the men were in an uproar. They were really upset with us.” However, as time went on, she says that the male detainees realized they were still receiving quality programming. Jones Tapia says the participants “seem to love it.”

Dr. Gubser describes a similar reaction from detainees with whom she has worked. “I would say that the majority of the individuals who go through the program mostly say this changed my life,” she says. Many, Gubser recounts, say things like “I had to come to jail in order to get sober again.”  

“We’ve also had people in our custody who have said, ‘I can’t go back out into the community. This is the first time I’ve ever been clean for 20 days, or 90 days, or whatever, and I’m too afraid to go in the community because I’m still likely to use.’” This type of feedback is what is most challenging about jail-based treatment in Gubser’s perspective, “because it can be the best treatment in the world, or the worst treatment, but you have this factor where they’re isolated, as opposed to if you’re doing treatment in the community.” As much as there are “a lot of barriers to treatment while you’re incarcerated,” there are fewer potential triggers and less access to opioids while within jail walls.

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A.B. had been to drug treatment programs “on the outside” before Cook County Jail, but she feels that based on her experiences in the Thrive program she can now “walk away saying that I have more tools than I ever have had in my life before.  It taught me things that I never even had heard in previous treatment classes before,” she says. “If you’ve been in jail and you’ve also been in treatment, you respect the combination...if you want to really change, you’ll get what you can out of it.”

She feels that treatment in jail is harder than treatment outside. She recounts that personally “even though I was forced here, I don’t feel that I was forced here because no one is forced to go to treatment...If you want to change, then you’ll do what it takes.”

“I’ve been to several treatments on the outside, and it’s voluntary. You can always walk out of it. You can’t walk out of here.”

Still, A.B. says that others in the program don’t always feel the same way. From A.B.’s perspective, this is just part of the challenge of being within a jail and the group of participants who are there for different reasons and have different levels of interest in the programming. “It seems like some of them really don’t want to change. They’re kind of just there flying by, just to get through their time. I can’t say I didn’t feel that way at one point too. But you’ve really got to sit down and look at things, that’s a bigger picture.”

One of the most important lessons that A.B. has gotten out of the programming is “to utilize people more,” she reflects, “not shove them away. Tell people your problems, talk about things. Let things go.” She remarks that one of her major takeaways was “Don’t carry everything with you, let them go, and you’ll be more free inside,” and “that people can’t make you mad. Only you can make yourself mad.”

“I would say there’s no real negative about the programs themselves,” she says, “just the jail part sucks.”

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Jail officials acknowledge that the treatment options still have room to grow. Recently Sheriff Dart announced a new program that will increase treatment for court-ordered detainees who will soon be released or are on bond. The program will assign selected detainees a caseworker upon release, but there is still much to be done. Mennella says that increasing program capacity, both within the jail and in the greater community, would serve patients well. She reports that Cermak is working to expand behavioral health support for individuals receiving medication-assisted treatment for maintenance while they are at the jail, and that they have recently hired health educators trained in alcohol and drug counseling to provide more tailored individualized support.

Jones Tapia points to working with “community partners to have a more thoughtful resource network,” as a next step in expanding opioid treatment at the jail. “I think we have some incredible people that are doing work in the communities, but I think we’re repeating services, and then we have gaps...If we had a more thoughtful system where we made sure all of the gaps are covered, and we could work together collaboratively, I think that’s going to be the next step. And we’re well on our way there.”

Both Cermak and CCJ administrators emphasize that these duties should not fall on Cook County Jail entirely, if at all. Mannella argues that to prevent more deaths, the jail and community need to increase opportunities for individuals to access treatment that includes buprenorphine and methadone, both of which have been shown to reduce opioid-related mortality. She says that this should be done first in the community, with the goal of diversion from incarceration.  “Access to these medications and behavioral health support needs to be easy, affordable, timely, and in the community.”

Outside of Cermak, Cook County Health and Hospital System offers medication-assisted treatment at ten of its health centers around the county, and Mennella reports that these offerings will continue to expand. She also advocates for increased access to naloxone, which can reverse an overdose, and further work to “promote best practices around safe opioid prescribing and pain management.” In terms of long-term strategy, she underscores the need to involve community and public sector partners in upstream efforts to address social determinants, such as housing and education. By doing so she believes the individual, family, and societal harms associated with opioid use disorder can be reduced.

Gubser feels that more is falling on the jail’s plate than should be. “If you look back, it starts to stem from when the community mental health centers started being closed down throughout the city of Chicago,” she says. “I think there was a push for insurance to cover preventative treatment, and to try to help people early on in the game, and to cover substance abuse services,” but now, “that’s not necessarily continuing the way I think it had the potential to do with the last President. I’m not going to try to get political,” she says, “but it’s just that... there are not enough services in the community to treat the individuals who need it.”

Jones Tapia argues that the public health sector, legislators, and individuals responsible for financial planning should “understand that it’s more cost effective and prudent to offer quality mental health, medical, and substance use services in the community.” Simply put, she thinks that opioid treatment should not need to happen in a jail. She also notes that there are a number of “quality universities” in Chicago, and that she doesn’t see them “being tapped to offer services to the community that they’re in.”

According to Dr. Jones Tapia, there is a misperception about the people CCJ serves. “This is not a violent person that we’re seeing coming in and out of our doors. Granted, we have those people too, and that’s where they belong. But these are people that are suffering. These are people that are here because they are economically impoverished, or people that are here because they are addicted to drugs.” She argues that it’s critical to remember that these people will be released and that they will “be our neighbors...and so it behooves us to again create better citizens.”

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When interviewed, A.B. was scheduled to be released the following day. She is confident about continuing her treatment after leaving the jail. “I’m still going to continue to be in recovery and in treatment and stuff like that,” she says. “When you’re in recovery, you stay in recovery forever. You’re always an addict, but you’re either an active addict or an addict in recovery.” The jail has worked with her to develop a plan for treatment once she leaves. “They all worked together with the courtroom and the counselors, and everybody works together to make sure that you have a good active plan when you leave.”

“Recovery is a lifelong thing. You’re always in recovery and you always have to keep it lively, with groups and all that stuff,” A.B. says. “You’ve got to do something, because if you just let it fade then you could turn back to your own ways.”

The featured image is courtesy of Martin Niese, and licensed under Creative Commons 2.0. The original can be found here.