It's 7 a.m. in the library of the Franklin County Jail, and nurse Jennifer Maillet is preparing addiction medications for eight men.
She mixes methadone with water and crushes buprenorphine. She puts the medication in each man's mouth as correctional officers stand watch. Every five minutes, Maillet checks each mouth with a flashlight. After three checks the men are taken to a washroom to rinse their mouths, eat a Saltine cracker, rinse again, and wash their hands.
Methadone and Suboxone (the brand name for buprenorphine) ease opioid cravings and withdrawal symptoms. Forty-four of the estimated 200 people incarcerated at the Frankin County facility receive addiction medications on this day.
That includes 30-year-old Rafael Ramirez. Until he was incarcerated, he had never taken addiction medication before.
"I've been to jail about four other times and I would go cold turkey," he says. "I would be in a cell throwing up, not sleeping, not eating for four or five days. When I came in I was sick for two days, but I started Suboxone and I'm fine. It's like I didn't even take heroin."
Each person coming in to the jail is screened for drug use and withdrawal symptoms. They're asked if they've been prescribed medication and if they want it. About half say they're addicted to heroin.
Correction officer Lee Terrell says providing medications has helped the jail.
"I think it's working," he says. "I think violence in the facility has gone down. We used to get a lot through the mail; there used to be a lot of contraband. That has come to minimal, if anything."
Many correction officials have refused to provide all three addiction medications that are available. Officials have been more open to providing naltrexone, which goes by the brand name Vivitrol and typically is given right before someone is released to block the effects of opioids. The other two medications, buprenorphine or methadone, are opioids, and many correction officials say those medications are too easily diverted for illicit use.
But Ramirez says that's not true.
"The process we do here, it's almost impossible," he says. "There's no way. I mean if you attempt it you're just dumb."
Three years ago the Franklin County Jail, in Greenfield, became the first in the state to offer buprenorphine, largely because of Sheriff Christopher Donelan.
"We don't judge and we don't punish; the judge punishes," Donelan says. "Our job is to treat people with dignity and respect and to keep people safe and to do our best to make them better because no one is serving a life sentence here, so they're all coming back to our communities."
"If they're sick with kidney or heart disease, we give them the treatment and medication. If they're sick with addiction, we should give them the treatment and medication for that."Franklin County Sheriff Christopher Donelan
Donelan says his approach has reduced recidivism. He thinks all jails should focus on treatment.
"I was determined when I became sheriff that this was going to be a locked treatment facility," he says. "If somebody is sick, we take care of them. If they're sick with kidney or heart disease, we give them the treatment and medication. If they're sick with addiction, we should give them the treatment and medication for that."
Recently Donelan accomplished another first: Rather than hire an outside provider, his jail is now the only one in the state licensed to provide methadone itself. By law, methadone must be distributed by a federally licensed facility and comply with myriad regulations.
Franklin County jail medical director Dr. Ruth Potee cites one requirement: a safe to store the methadone. She says after they spent $10,000 on the safe, federal regulators wanted it to be wired to the local police department.
"I said, 'No way, we're a jail with armed guards. I'm not wiring to the police station, that makes no sense,' " Potee says. She says it took almost two dozen phone calls for the federal Drug Enforcement Agency to allow the jail to bypass the safe-wiring requirement. "The number of hoops you have to go through to provide medical care is absurd," she says. "Nobody made this easy for us, and we wanted to do it."
Franklin County is among seven jails in the state that will receive about a half million dollars each to participate in a new pilot program to provide all three addiction medications. Not only does that mean that half of the state jails are doing this, but they all are now also licensed by the state Department of Public Health. DPH will collect data on outcomes in the hopes of reversing the grim statistic that the opioid overdose death rate in Massachusetts is 120 times higher for those recently released from incarceration, compared with the rest of the adult population.
It's a statistic that's very real to Rafael Ramirez.
"This is my only hope," he says. "I was addicted to heroin for probably like four years. This pretty much saved my life because if I didn't come to jail, I would probably be dead."
Those held in Massachusetts jails or houses of correction are either awaiting sentencing or serving sentences of up to two-and-a-half years. Those with longer sentences go to prisons run by the Department of Correction. The same law that established the jail pilot program also required four of the 16 DOC-run facilities to provide all three addiction medications. The DOC has not yet contracted with a methadone provider.
While treating addiction as a disease may represent a shift in correctional thinking, some say medication is just one piece of addiction treatment that should also include counseling and social supports. Franklin County jail assistant deputy superintendent Levin Schwartz says that's going to require another shift.
"If the goal is to not die, this is effective," Schwartz says. "But if the goal is to not return to jail and live a life of meaning and purpose, now we're talking about something different, and a pill is not going to help that. It may be part of the picture but it has to be a larger constellation. "
State health officials hope to outcome data from the pilot program in two years.
Correction: A previous version of this article incorrectly described Franklin County Jail as the first jail to be a licensed provider of methadone in the US. It is the first jail to be a licensed provider of methadone in Massachusetts. The post has been updated and we regret the error.
This segment aired on November 12, 2019.