Twenty-one-year-old Briona Davis has been in and out of jail ever since she turned 18, and using heroin since she left her home in Frederick to move to Taneytown in 2013.
"I met a guy there, I was 17 at this time, and he sold heroin so I started using," she said. "I liked the high, it was a good way for me to cope with everything, a good way for me to numb everything I was going through."
By March 2016, Davis, who had been incarcerated at the Carroll County Detention Center, was living at the W House in Hagerstown, a halfway house where she relapsed for what she now hopes was the last time.
"I started using again, and it just wasn't the same. It's not fun anymore, it doesn't give you that high, it doesn't numb anything. It actually makes everything much worse," she said. "I was actually hoping to just fade, you know? I knew that I was either going to get locked up or I was going to die."
With her relapse, it was the lockup and not the grave that awaited Davis — a good thing in her estimation, not only because she is alive, but because it allowed her time to reconsider her life and decide on a new course. As her official release date of Dec. 26 approached, she learned of an optional treatment that might help her do things differently this time around: She could receive an injection of naltrexone, brand-name Vivitrol, a long-acting opioid blocker that would prevent her from getting high even if she relapsed and used heroin upon her release.
"The Vivitrol is an opiate blocker and alcohol blocker that you get monthly, so it will reduce cravings," Davis said. She will get a monthly injection of Vivitrol from the Carroll County Health Department, as well as attend intensive outpatient addiction counseling.
"Every time I was released [before] I never took any precautions, never cooperated with treatment, and this to me is kind of an open doorway to a new, you know, a new life," Davis said. "I am definitely hopeful and optimistic."
A case for evidence-based treatment in jail
Supporting a heroin habit of $300 to $400 a day is hard. It's hard on the body, it's hard on loved ones and it's hard on the wallet — there is a well-documented and perhaps common-sense connection between addiction, crime and incarceration. Davis, for one, was first arrested in 2014 on a theft charge.
Here in Carroll County, as in much of the rest of the country, this means many people are arrested who have an active, untreated addiction to heroin or other opioids, and find themselves in the detention center. This, in some sense, can be a golden opportunity, according to Dr. Marc Fishman, the director of Maryland Treatment Centers, which manages both the Shoemaker Center and Recovery Support Services at Mountain Manor in Carroll County.
"People with criminal justice involvement have much higher rates of addiction than the [general] population, and people with addiction, including opioid addiction, have much higher rates of criminal behavior," he said. "All the data say that if we can reduce addiction in the criminal justice population, we decrease recidivism, we decrease crime, we decrease reincarceration and we increase public safety."
The best way to do that, the data and Fishman suggest, is to use the best evidence-based medical approach to treating opioid addiction, which is the use of one of three medications — methadone, buprenorphine/Suboxone or Vivitrol — in conjunction with intensive counseling and therapy. This has long been the standard of care outside of prison walls, and Fishman said there is mounting evidence that it should be so behind bars as well.
"There is very clear, high-quality scholarly research for all three of these medications introduced in the criminal justice system, during incarnation: methadone, buprenorphine and extended release naltrexone," he said. "They increase rates of connection to treatment post-release, decrease rates of relapse, decrease rates of overdose and improve outcomes."
A study published in the November issue of The Journal of Substance Abuse Treatment, for instance, found that men who were arrested while in a methadone treatment program and were allowed to remain on methadone while in jail were more likely to return to treatment upon release, and less likely to be arrested again, than men who were forced to detox while incarcerated.
Perhaps even more important, Fishman notes, is that studies have shown people with addiction who have been kept on methadone or buprenorphine/Suboxone while in jail are less likely to die due to an overdose when released.
"The first 30 days post-release from detention for someone who has a history of heroin addiction is an enormous time of risk," he said. "In fact, some people who have measured it, it looks like the risk goes up 10-fold in the first 30 days after release from incarceration."
Being incarcerated might force someone to go without drugs, but addiction is more than physical dependence, according to Fishman: Being forcibly abstinent in jail "doesn't mean they have developed relapse prevention or recovery skills, it doesn't mean that they have had considerable behavioral change, it just means that they had a dry spell."
When released, they might go to use again without counting on the fact that their tolerance to the drug has changed, use the dosage they are accustomed to, and then overdose. This is one reason why Fishman prefers the term "relapse prevention medications" over "maintenance drugs."
"None of them are perfect, none of them are curative, none of them are the next penicillin for addiction, but they keep people from dying," he said.
As to which of the medications are best, Fishman is agnostic — whatever works for the person in recovery is what is best for them, and "it's good to have options."
In the Carroll County Detention Center, there are at present only two options — Vivitrol and forced abstinence. The detention center does not offer Suboxone or methadone for people with substance abuse disorders, with an exception made for pregnant women, according to Sheriff Jim DeWees.
He said he's been approached about the idea of bringing methadone or Suboxone into the jails, but he has chosen not to pursue the option.
"I'm very well aware and understand that methadone and Suboxone are maintenance drugs that are given in small doses to wean someone off, but I'm not ready right now to look at it in our jails," DeWees said.
The sheriff is of the mindset that methadone, Suboxone or Vivitrol are not a lifetime cure, and it's better to detox. The jail offers several intensive programs, including a drug treatment program, and everyone with a substance abuse disorder goes through detox, DeWees said.
When Brittany Sabock was a 16-year-old student at North Carroll High School, she never could have imagined that within two years she would go from sipping beer at a party to using heroin to landing in rehab for the first time.
The detention center also offers its own abstinence-based drug program, but it has limitations, according to Warden George Hardinger. There are only 16 beds in the housing unit where the drug treatment program is run, so there is usually a waiting list for the program and women aren't able to participate.
For women, numbers and spaces make it harder to have a drug treatment program. As of Dec. 13, there were 30 women in the jail.
DeWees acknowledges that recovery is not a short-term process, but he said the long-term solution is not through opioid maintenance drugs.
Hardinger shares DeWees' view, noting that while his staff will bend over backward to enable a pregnant woman on methadone to get her daily dose, detoxing other inmates has always seemed like the more responsible course.
"For me in particular, I see it as we do have an opportunity to really get people weaned off of the maintenance drug," Hardinger said. "Not everyone agrees with me, but it may be the one and only opportunity that someone has."
The science behind addiction
Fishman, of Maryland Treatment Centers, respectfully disagrees with DeWees and Hardinger. It takes a bit of background in the neuroscience of opioids and opioid addiction, however, to understand why.
"God gave us opioid receptors in our brains, they do all sorts of interesting nuanced things — the regulation of pain, the regulation of reward — a whole host of very interesting things, in small amounts, in complicated circuitry," Fishman said.
When a person regularly uses powerful opioid drugs like heroin, "They are a sledgehammer that hijacks the system, overpowering the small amounts, the nuanced balance of what normal brain chemistry is like and for many people it's just irresistible."
Long-term use of opioids, in other words, scrambles the brain's normal circuitry for dealing with stress, managing pain or even feeling happy, such that further drug use is a person's only means of coping with life's stresses, according to Fishman.
"Some people are so transformed by addiction that they've got no other coping button to push," he said.
This is a chemical imbalance, a persistent "thirst" for drugs in response to stress that lingers long after drug use stops, according to Fishman. The three medications are a way to compensate until the natural balance in the brain can be restored: methadone by replacing the stimulation of opioids at opioid receptors, Suboxone by partially replacing that stimulation, and Vivitrol by blocking the opioid receptors from opioids and their effects while somewhat decreasing cravings.
"For some people that restoration may come quickly, for some people that restoration may come slowly and for some people that restoration may be currently beyond our ability to know how to achieve," Fishman said. "As far as we can tell, when people ask, 'How long should I stay on?' the answer is, the longer the better."
Weaning someone off methadone or Suboxone is not a worthy or effective goal in itself, and is in most cases contrary to the evidence, according to Fishman. The goal should be recovery, which he said starts with abstinence from drugs of abuse, and is fully compatible with relapse prevention medications such as methadone.
"Recovery might come with medicines, might come with other tools such as counseling, social supports and reconnecting with the world," Fishman said, "But recovery takes time, and none of those other active ingredients are accomplished if a person is caught up in an endless loop of using and withdrawing, and medicines can help interrupt that cycle.'"
Open minds and open questions
Hardinger said he hasn't completely ruled out introducing methadone to the jail, if he gets the right pitch. The problem is he hasn't been approached by someone in 15 years, he said.
"If there is information out there, that says it's better to continue the methadone than to go through the detox to wean them off of it, I'm certainly receptive to hearing that," Hardinger said. "We use best practices, it can't be like 'Oh, gee, this is the way we've done it for years.' That's craziness."
One reason that the warden heard from Vivitrol but not methadone advocates might be that while methadone is now a generic medication, Vivitrol is a relatively new creation, according to Fishman, and "the people who manufacture extended release [Vivitrol] are doing a dang good job" of marketing it. In a bit of irony, Alkermes Inc., the maker of Vivitrol, donated the first doses of the shot to the Health Department for free.
Opinions aside, the logistics of the Carroll County Detention Center can make the possibility of methadone or Suboxone treatment in the jails difficult.
The first is the cost of methadone and Suboxone: If the opioid-maintenance medications were available in the jail, DeWees predicts a large part of the jail's population would be on it. A part of the jail's budget is already dedicated to other medications for inmates, and DeWees questions where the money would come from if he were to provide methadone or Suboxone.
There are other jails, such as Anne Arundel County's detention center, that have introduced the maintenance drugs, and DeWees said he'll watch how it goes.
There are 50 slots in the Drug Treatment Court, but Hecker said he wants to create up to 25 more by hiring a part-time case manager. It requires grant money, he said, and he might find that money through Gov. Larry Hogan's office.
There are also security concerns. The smuggling of Suboxone, which is available in a thin film like a Listerine breath strip and is easily concealable, is already a major concern at the Detention Center, and preventing inmates from somehow pretending to take their prescribed dose of a medicine and then smuggling it back to a housing unit for trade with other inmates — or stockpiling doses of it to get high — are real concerns, according to Hardinger, albeit concerns that could be alleviated with careful planning.
Fishman, for his part, acknowledges all of these worries. Methadone and Suboxone are not perfect medicines, and they can be abused. Implementing and scaling their use inside a corrections environment that was never designed to do drug treatment is also a true challenge. He merely points out that the data are clear that finding a way to use these medications in the incarcerated population will reduce crime and addiction in the community.
But what the data do not show — not yet, according to Fishman — is a clear indication that it is worthwhile for a jail to take a portion of limited resources already dedicated to a successful Vivitrol program and use those resources to initiate parallel methadone and Suboxone programs. Vivitrol is better than nothing, and for Carroll County, for now, it might prove better to invest more in that program.
"That they are doing something is miraculous, and I am all for it," Fishman said.
The Carroll County Health Department first received a grant for offering the Vivitrol shot to qualifying detention center inmates in August 2015, according to Lisa Pollard, a care coordination manager with the Health Department. The grant covered an initial shot given before the person was released from jail and six months of follow-up shots.
"We administered 13 doses by the end of December  to inmates prior to their release, and they were educated to come to Access Carroll upon release to schedule follow up," Pollard said. "Of that 13, we gave nine second injections, eight third injections, seven fourth injections, five fifth injections and three their sixth injection."
In 2016, 20 inmates have received the Vivitrol shot — not including Davis, the 21-year-old, who received hers on Christmas Eve — of which four received second injections, two the third injection and fourth injections, and one completed the fifth and sixth injections, according to Pollard. The fallout from the program indicated by the statistics doesn't necessarily reflect a treatment failure, however, she said.
"Some of them never connected with Access Carroll for follow-up after the initial injection, so we don't know if they moved, changed their mind or what," Pollard said. "One moved and some switched medications for a number of reasons but have still been successful in their recovery."
Fishman notes that the element of patient choice when it comes to selecting which relapse prevention medicine to use is an important and empowering aspect of recovery. In that sense, the availability of only Vivitrol in the Carroll County Detention Center might align with the choice some inmates have already made: Davis is adamant about avoiding methadone or Suboxone.
"Drugs like Suboxone or methadone, me myself, I feel like those are a way to get high without the legal consequences," she said.
Vivitrol is Davis' choice, and it's one she feels good about. She is looking forward to counseling, getting her GED and going to Carroll Community College, where she hopes to follow her love of writing and study English — to getting back to living without the shadow of cravings hanging over everything.
"I'm taking a step I never took in the past — I'm willing to change," she said. "I've felt worthless in the past, like I was incapable of doing so; this time I'm very well prepared."