Looking out over Walsh Field Recreation Area in Belfast on June 7, the prison cells that once encased a third of Sheldon Snell’s life seemed like a cold, distant planet. Beyond the shed with rakes and cleaning supplies, Snell, 46, of Montville, paused at a chainlink fence. For nearly two decades, fences and cement walls had commanded his life. Now, he was in charge of this enclosure.
“This is what I worry about the most. This is the Little League field,” he told me.
As the groundskeeper for the seven acres of the city-owned recreation area, part of his job is to mow the Little League field at least once per week during the summer, trim the perimeter’s weeds, and make sure the pitcher’s mound slopes at a precise angle, to prevent a dangerous baseball ricochet.
Snell is alive, and in a job he cherishes, by what some might call luck, a miracle or the circumspection he developed with the passage of time.
He is here despite spending a total of 18 years in various Maine prisons and jails in the 1990s and 2000s for more than 25 nonviolent felonies fueled by alcohol and drugs. Sitting at a picnic table, he counted the number of people he knows who died from overdoses, many after their release: six. No, eight.
Some may say incarceration woke them up to the reality of their problem. But it can also have the reverse effect: continued substance use, crime and death.
There is a proven way, based on years of research, to help prevent people like Snell from cycling through state prisons and county jails again and again, if they’re lucky enough to survive that long: Treat their addiction.
Yet, with a few exceptions, Maine’s criminal justice system has floundered in its response to the addiction crisis it has helped to perpetuate.
It has largely prevented inmates from taking physician-prescribed addiction medication such as methadone, buprenorphine or naltrexone in jail — to the point of requiring that inmates with prescriptions stop their treatment when behind bars. Attempts to prevent people with substance use disorders from going to jail in the first place vary by region. And upon release there’s no guarantee a former inmate will be connected with the help he or she needs.
The BDN interviewed officials at each of Maine’s 15 county jails. Many spoke of desperately wanting to stop seeing the same people revolve through their doors, but having only nascent, underfunded, temporary or volunteer-based programs to counteract a complicated public health crisis — compounded by limited available services in the community. Just one jail allows certain inmates to take buprenorphine, commonly known by its brand name Suboxone, while another jail recently started offering naltrexone, known as Vivitrol.
“There’s a belief that we are trying to fix that problem. We aren’t. We can’t,” especially not as the jails are currently funded and operated, and given their transient population, said Cumberland County Sheriff Kevin Joyce. The issue is much larger than what one sheriff, alone, can tackle.
“There’s just no coordinated effort,” he said. “We need to act. We need to do something that’s bold.”
Others questioned whether it’s the role of county jails to tackle what amounts to a health problem.
Either way, an epidemic has fallen at the doorstep of prisons and jails. An estimated 70 percent of all inmates in local jails have committed a drug offense or used drugs regularly, and an estimated 35 percent were under the influence at the time of their offense, according to the Bureau of Justice Statistics. More Maine people are overdosing and dying at greater numbers than ever before.
When other states have continued or started people on addiction medication in jail, and facilitated the continuation of their treatment in the community after their release — or rerouted them around jail entirely, such as through drug courts — they have increased the chance people will stay in treatment, and witnessed reduced drug use and drug-related criminal behavior.
Importantly, they’ve also reduced former inmates’ risk of death.
Studies in the United States have shown that people released from prison, especially in their first two weeks out, are at a high risk of dying in general — their chances are as much as 12.7 times greater than others in the community — and are at particular risk of dying from an overdose: up to 129 times more likely than the general population.
It comes down to an absence of everything “community” stands for. Recently released inmates are often disregarded by family, employers, landlords — people who can help them fulfill the basic needs of life. They face medical and financial challenges, and often return to neighborhoods where drugs and alcohol are prevalent. Not having health insurance or a job makes it more difficult to treat a substance use disorder.
What’s more, it’s easier for people to accidentally overdose after a period of forced abstinence behind bars because they lose tolerance to the drugs.
As Snell experienced, the cycle of substance use and incarceration often repeats itself. About 54 percent of drug offenders and 57 percent of non-drug offenders in Maine are rearrested within three years of entering probation, according to research by the Muskie School of Public Service at the University of Southern Maine.
“We know that good people are struggling with opioid abuse every day. That doesn’t mean they’re criminal minded and filled with malice. They’re people who have an illness,” said Joel Merry, sheriff of Sagadahoc County. “Treating them like hardened criminals is getting us nowhere.”
The fact remains, however, that people are breaking the law. “We think the law enforcement side is important. It’s a crime,” said Piscataquis County Sheriff’s Office Chief Deputy Bob Young. “But also the treatment side is important, and how you balance that is what everyone is struggling with.”
‘Every means possible to find recovery’
Snell doesn’t remember many of the crimes in the Bangor area he was convicted of between 1990 and 2010 — mostly burglaries, thefts and forgeries — because he was blacked out from alcohol and drug use, he said. But he didn’t doubt what the police said he did and pleaded guilty in every case.
“When I did those burglaries, the first thing I’d go for was the medicine cabinet,” he said. Back then, his addiction was fueled mainly by alcohol, he said, and he also used prescription drugs.
Over and over, his medical condition and the criminal justice system met head on. The very definition of a substance use disorder is when someone continues to use despite negative consequences, according to the Diagnostic and Statistical Manual of Mental Disorders.
Snell attended some counseling sessions behind bars, but the real test always came when he got out. Despite the pleadings of his family, he continued to break the law to support his addiction. The court requirements compounded: He accumulated charges of failure to appear and violating conditions of his release — eliminating options to avoid jail time.
“They thought I was high risk and unable to change,” he said.
Today, Maine jails may offer Alcoholics Anonymous, Narcotics Anonymous, or group or individual counseling options, but their long-term effectiveness, especially for helping inmates with an opiate use disorder, is questionable.
A randomized trial that tracked three groups of inmates in Baltimore found that the inmates who received both counseling and methadone in prison were significantly more likely than those who received only counseling behind bars to stay in treatment long-term and significantly less likely to have a positive opioid urine screen both six months and 12 months after their release.
“Science shows that relapse rates, even for people who have strong motivation, are really, really high. People who go to a 12-step program after six months still have a fairly high rate of recurrence,” said Dr. Vijay Amarendran, a psychiatrist at Acadia Hospital in Bangor. “Clearly the science shows the best evidence, the best outcomes for people long-term, is medication-assisted treatment.”
Addiction medications block the effects of illicit opioids to help heal the brain. When that happens, the seemingly uncontrollable behavior that characterizes addiction — such as lying to family or buying heroin off the street — starts to subside. People resume their lives. They stop breaking the law.
But the idea persists that medication-assisted treatment is the same as substituting one drug for another — a major barrier to its use.
“There are many who don’t want to admit or believe that an addiction is a disease and it’s got to be treated as a disease. … I believe it is a disease, and we’ve got to find every means possible to find recovery,” said Wayne Gallant, Oxford County sheriff and president of the Maine Sheriffs’ Association. “Everybody’s recovery is different. If some need to be on certain medications to guide them along, then I think it’s important.”
Treatment policies often end up reflecting a lack of understanding of addiction. “There’s a lot of investment in ideologies that oppose the use of science-based treatment. I am not optimistic that people’s minds can be changed,” said Dr. Mark Publicker, a leading addiction specialist in Maine.
Snell took responsibility for his crimes, while understanding the factors that increased the likelihood he’d develop an addiction: early alcohol and drug use, easy access to drugs on Indian Island where he grew up, abuse as a teenager that required multiple surgeries, time in a juvenile detention center and a family history of alcoholism. Genetics can account for between 40 and 60 percent of a person’s vulnerability to addiction.
But he prefers not to dwell on the past. Today, he umpires baseball games that his former probation officer’s kids play in. He is friendly to staff from the Maine State Prison in Warren who come to the Belfast recreation area to walk their dogs. Recovery is “a lifetime battle,” he said, and requires not solely medication or counseling or a job, but all of it — the collective force of a community.
‘It’s a medical decision’
Penobscot County Sheriff Troy Morton walked through the intake room at the Penobscot County Jail in Bangor where a number of men waited to be booked June 9. On the plexi board behind the intake desk read the inmate count for the day: 184. The jail has capacity for 157.
He took a remotely operated elevator, with no buttons, to the third floor, where he opened a door that led into a narrow hallway in the area where women are held. Four women sat around a table in a common room.
They pointed to the flickering light overhead, and told Morton the phone and TV were on the fritz. He acknowledged their complaints and then began telling them about a new program the jail would be offering to a small number of women in a month.
As a pilot project, the jail would provide counseling and then, right before their release, a long-acting medication called Vivitrol that’s injected monthly and blocks the effects of opioids and alcohol. They would be directly connected to counseling and more shots of Vivitrol in the community.
The women’s reactions were strong. It’s easy to stay clean in jail, said one woman, but then it’s easy to use again once released. She said she wanted a life with her children. She just wanted a life, period.
“I want to stay clean on the outside,” she said.
Another woman said she’d been in and out of jail many times and had never been offered help for her addiction.
“We don’t want to be a detox center, but we kind of are,” Morton told them. “If we can build from the detox out, we’ve got a chance.”
The jail’s Vivitrol project started July 10. It’s the first of its kind in the state. Up to 12 women at a time are eligible to start counseling sessions in jail with a licensed clinical social worker from Penobscot Community Health Care. The jail’s medical service then offers the women one Vivitrol shot a couple weeks before their release date.
People need to be opioid free for a minimum of seven to 14 days before getting a Vivitrol shot to prevent immediate withdrawal.
Upon their release, PCHC assumes responsibility for patient care, including providing the medication, said Dr. Trip Gardner, PCHC’s medical director of homeless health services and chief psychiatric officer. Women are offered an intensive amount of counseling: eight group counseling sessions and one individual counseling session per week for 12 weeks. They continue to see the same clinician at PCHC with whom they began treatment prior to their release.
They can also receive psychiatric and medical care, help signing up for insurance, and assistance with finding housing, education, transportation and jobs.
The case management is a fundamental part of the program because social factors play a major role in any health issue, let alone addiction, Gardner said.
Similarly, other jails across Maine may work with case managers or local organizations, or have special programs for certain populations, to make sure recently released inmates get services, including treatment, in the community. But, overall, it’s not clear how comprehensive or effective the release planning is long-term.
“When we cannot meet the cost of just keeping people safe and secure, we can’t do some of the things we’d like to do like release planning. We do some of that. I give ourselves probably a B, a B-,” said Joyce, the Cumberland County sheriff.
And services aren’t always available in the community, or people can’t afford them. Aroostook County, for instance, has no methadone clinic.
Plus, regions across the state need more avenues for people to find social support and, ultimately, long-term sobriety, such as through recovery centers and places to detox safely outside a hospital setting, said Peter McCorison, a program director of behavioral health services for Aroostook Mental Health Center.
For too long the system has only torn people down without any corresponding action to build them, and their support system, back up, said York County Sheriff William King.
“Vivitrol is a wonder drug. Methadone and Suboxone are great to stop the cravings, but I want to give people an opportunity to face their demons and to understand why they turn to that altered state in the first place,” he said.
Jails across the country have been turning to Vivitrol because it’s relatively easy to manage, doesn’t require a special license to administer, and can’t be abused or diverted for illegal use, according to the Substance Abuse and Mental Health Services Administration. A couple studies found patients on Vivitrol were more likely to be opioid-free, and to report fewer cravings, than those who got a placebo.
Addiction and public health specialists, however, are wary of favoring Vivitrol over other medications, given the limited research backing Vivitrol compared with the decades of research backing methadone, which was approved by the Food and Drug Administration in 1972, and Suboxone, which the FDA approved in 2002.
Not a single study has compared Vivitrol with the other medications. And some studies have found high dropout rates or a number of people returning to opioids while on Vivitrol or after taking it.
Then there’s the cost: about $900 per shot.
The Penobscot County pilot pays for clients’ Vivitrol shots for six months, with the first shot offered free by the manufacturer, Alkermes, Morton said. PCHC’s work is funded with a year-long $346,318 grant from the Maine Department of Health and Human Services.
In an ideal world, everyone, including inmates, should be treated with the medication that is best suited to help them manage their opioid addiction, as a doctor would do with any other disease, said Gardner, with PCHC.
“We have three medicines to treat. We need access to all three,” he said.
Though each person’s circumstances should be considered when prescribing, methadone would likely be the most scalable option if the state expanded the use of any medication, given practical considerations of cost, medical evidence for effectiveness and availability in the community upon release, Publicker, the addiction specialist, said. Inmates don’t qualify for health insurance in jail or prison, so medical costs are borne by taxpayers.
“Doing the wrong thing is worse than doing nothing. Everything that is being proposed in the state is wrong. It’s perhaps well-meaning, but it will be ineffective and waste whatever small amount of resources are available,” he said.
Currently, jails only allow pregnant women to receive methadone because of the risk detoxing poses to the fetus.
Knox County Jail in Rockland is the only jail in Maine that dispenses Suboxone to inmates. The jail’s medical vendor makes the determination, verifies prescriptions and limits the medication to those in custody for only a short while, said Knox County Sheriff Donna Dennison.
“They can have a family member bring [the Suboxone] in. Then we’ll lock it up, and they’ll get it as is prescribed,” Dennison said. “It’s a medical decision.”
‘Everything’s pushing back against you’
The nation’s first and largest jail-based opioid treatment program sits within New York City’s main jail complex, Rikers Island. Here, at a facility that dominates headlines for its violence and dysfunction, is also where a model program has existed since 1987 to provide inmates with medication-assisted treatment, most often methadone, and connect them to community-based treatment upon their release.
Called the Key Extended Entry Program, it treats several thousand people a year whether they came in having received medication before or not, and has seen documented success. The program has resulted in up to 80 percent of people continuing treatment in the community and reduced reoffense rates. Additional studies have found that people receiving addiction medication during incarceration had a 47- to 73-percent reduction in needle sharing, which lowers the risk of Hepatitis C and HIV transmission.
Rikers also started offering Suboxone in July 2015. It plans to triple prescribing of Suboxone and double prescribing of methadone by 2018, said Dr. Lipi Roy, the former chief of addiction medicine for New York City Jails.
Corrections facilities generally hesitate to provide methadone and Suboxone to inmates because they are narcotics in their own right, though they don’t produce a high when taken as prescribed. “That’s our biggest concern, is just control of the drugs,” Merry, the Sagadahoc sheriff, said.
To prevent diversion at Rikers, Roy said, nurses and corrections officers directly observe people taking their doses: methadone in liquid form and Suboxone as a sublingual film. Inmates wait, sitting on their hands or with hands behind their back. Their mouths are checked before they leave.
The way Roy sees it, treating more inmates will help reduce the number of people smuggling in heroin and Suboxone for illicit use.
In Maine, the vast majority of people who are arrested and brought to jail have their addiction medication stopped. That was the case with Nick St. Louis of Otis. He had taken Suboxone for his opiate addiction for several years before he was arrested in December 2008 at age 26 for drinking a small amount of alcohol, which was prohibited under his conditions of release.
At Penobscot County Jail, St. Louis’ anxiety set in first. Knowing he wouldn’t receive his addiction medication made it worse.
“All I do is think about why I’m not getting it,” he said. Then came the symptoms of withdrawal: the chills, a stabbing headache, dry heaves.
But the worst part was knowing he could be taking a step back in his recovery. “You’re doing so well, and everything’s pushing back against you again,” he said.
At the end of June, Joshua Sprague, 38, of Bangor was arrested on a charge of unpaid fines and fees and spent six days at Penobscot County Jail where he had no access to his regular dose of methadone. “It’s extreme anxiety. It feels like you can’t breathe,” he said.
After his release, the last thing he remembers is sitting out on Kenduskeag Avenue in Bangor with his hand up, and a car stopping. He had spent the night vomiting, alternating between hot and cold sweats. He could barely hold himself up. He doesn’t know who drove him, but he ended up at Acadia Hospital where he passed out and had a seizure.
“They should have methadone in jails, period. Methadone and Suboxone. If you have a disease, you should be treated for it,” he said. “If Acadia is not medically able to just take you off it, then how can they?”
The blatant signs of withdrawal — nausea, insomnia, muscle and bone pain, cold flashes, diarrhea — usually subside within several days, but some people have shown persistent withdrawal symptoms for months. Plus taking away people’s addiction medication puts them at higher risk of relapse.
“It destabilizes their recovery completely,” said Amarendran, the Acadia doctor.
Within the last year or so, another corrections entity in Maine has started embracing a fuller range of treatment. The Maine Coastal Regional Reentry Center in Belfast, which prepares county and state inmates for their transition back to the community, has started referring inmates to methadone clinics and Suboxone providers upon their release.
“We saw guys who did everything right in re-entry. They had good jobs. They had a good solid place to live. Their relationships were set. They had community supports,” said Jerome Weiner, the program manager. “But I believe the pull of an opiate is much stronger than any drug we’ve ever dealt with. And some people just need some help.”
Some corrections officials argue that inmates shouldn’t need addiction medication after a long prison sentence, but medical experts disagree since the stress of release can trigger relapse and overdose.
Maine’s state-funded prisons do not offer medication-assisted treatment, said Lindsey Smith, a research associate with the Cutler Institute for Health and Social Policy at the University of Southern Maine.
As of January 2017, the prison system was offering residential programs that emphasize “routine, structure, and peer-accountability,” according to Maine’s Office of Program Evaluation and Government Accountability, along with several different outpatient programs, including its primary curriculum, Cognitive Behavioral Interventions for Substance Abuse.
An evaluation of that program found that 29 percent of participants in Kansas reoffended after one year, compared with 36 percent for a comparison group; it acknowledged the need to follow up after a longer period of time.
Jody Breton, deputy commissioner at the Maine Department of Corrections, did not return two phone calls and two emails over more than a month asking about policies concerning addiction treatment in Maine prisons and the Southern Maine Women’s Re-entry Center.
‘I felt her pain’
Deciding to stop using drugs or alcohol is one thing. Staying off them is another.
Snell’s jolt to quit came at one of his court hearings in 2010, when a Bangor woman got up to speak. She described the horror her daughters experienced when they returned home from school to find Snell in their house. They were having nightmares about him, Snell recalled her saying, and needed therapy.
For some reason her words reached him.
“I never really experienced what a victim goes through when someone’s terrorizing their home or invading their privacy, but that day I found out all about it. I felt her pain. It completely turned me right around,” Snell said. “She’s going to be a part of my heart for the rest of my life.”
He had always done well when he wasn’t using. At Penobscot County Jail, he volunteered to clean the facility. He became an advocate who attended disciplinary hearings in the prisons. He visited suicidal inmates at Maine State Prison. At Downeast Correctional Facility in Machiasport he recalled talking down a male inmate who had cornered a female guard by holding a chair above his head to hurl at her.
But could he sustain the behavior outside cement walls? The day Snell was released from Maine State Prison in 2013 “was the most anxiety-filled day of my life,” he said.
He struggled. His anxiety flared up in crowded indoor places. He didn’t have a license. He didn’t have a place to live, so he moved in with his Alcoholics Anonymous sponsor. He needed two surgeries for a shoulder injury.
Then, at the beginning of 2017, he developed shingles on his back and neck, and was prescribed oxycodone, followed by hydrocodone, to manage the painful rash. The painkillers hooked him. He descended toward relapse.
But this time, instead of doing what he had done in similar situations over the past 30 years, he saw a doctor who made sure he got an addiction medication, along with regular counseling. The cravings may never go away fully, he said, “but the medication has eased it.”
And he became a part of a community.
He organizes the Belfast Soup Kitchen’s annual holiday dinner, and works two jobs in the spring and summer months. He passed the major milestone of completing three years of probation. He bought a car. He helps recently released inmates navigate their new reality.
He also talks frequently about the people who helped him along the way — people like former Waldo County Sheriff Scott Story who supported his recovery and brought him to a local shoe store to buy him pair of shoes; Juliane Dow, a Belfast resident “whose door is always open” to him, he said; and Norm Poirier, director of Belfast Parks and Recreation, who hired him for the groundskeeping job.
“It’s a two-way street. We get a great employee,” Poirier said, and “it gives him something he can be proud of.”
No one can know what Snell’s future holds. Relapse at some point is not just possible but likely for people with substance use disorders. But he feels like he’s finally settling into a place where people see more than his criminal history. “I’ve never come to a more welcoming community, that’s for sure,” Snell said.
He bent to pick up some gum wrappers and a penny. I asked if it was heads up, a sign of luck. It wasn’t. But he wasn’t concerned. These days, he’s figuring out how to make his own.
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to firstname.lastname@example.org.