Death by detox

It’s been more than a year since 32-year-old David Stojcevski died in a Michigan jail cell after spending more than two weeks in acute withdrawal from benzodiazepine medication and methadone. But the grueling details of his ordeal are just now coming to light as his family speaks publicly for the first time about their pending wrongful death lawsuit.

According to the complaint, which was first reported on last month, Stojcevski lost 50 pounds in just 16 days as Macomb County Jail officials repeatedly refused to give him medications he had been legally prescribed before entering the facility to serve a 30-day sentence for reckless driving. Video taken of his cell during his confinement shows that despite being clearly in distress, Stojcevski was largely ignored by corrections officers and staff from the private firm contracted to provide medical services at the jail.

The FBI is reportedly investigating the circumstances of Stojcevski’s death, and protests were held this month outside the jail.

The Stojcevski case is hardly unique. Just this week, the parents of a 25-year-old man who died while withdrawing from heroin at the Adams County Detention Facility in Colorado accused jail officials of negligence and promised to bring a suit against the facility.

Municipalities across the U.S. have quietly shelled out tens of millions of dollars to settle wrongful death suits resulting from in-custody fatalities attributed to untreated drug or alcohol withdrawal. Over the past five years alone, families in at least six states have been awarded nearly $11 million in compensation for loved ones who died while being denied routine detoxification care in local jails. This includes the largest jailhouse death settlement in Ohio history — $4 million — which was paid to the widow of R&B singer Sean Levert following his death in a Cleveland jail in 2008 from complications of benzodiazepine withdrawal.

That such tragedies occur so frequently is little wonder given the sorry state of addiction services at many U.S. correctional facilities. According to estimates, two-thirds of inmates entering jail have a diagnosable substance abuse disorder, yet few jails provide the medical standard of care recommended by doctors for patients at risk of withdrawal. Many inmates are being treated for mental health issues at the time of their arrest. This often includes the use of powerful psychotropic drugs. However, America’s roughly 3,300 municipal jails have no consistent policies on what medications they’re allowed to dispense.

A study conducted by physicians at Harvard and published in 2009 found that more than a third of people entering jail with chronic medical conditions are cut off from their medications. As a result, many inmates are deprived of drugs they’ve been on for years under conditions that defy medical best practices. While the Federal Bureau of Prisons publishes a comprehensive guide to proper treatment protocols for inmates in withdrawal, there is no such standard of practice governing the way local jails deal with detoxing inmates.

According to the National Institute of Corrections, at least 32 states have laws on the books dictating minimum standards for jails. However, most of these are voluntary, and it’s typically up to the chief administrator of each facility to set specific policies.

A study published in 2010 by The National Center on Addiction and Substance Abuse (CASA) at Columbia University found that only 11 percent of substance abusers receive any type of professional treatment in jail, and fewer than 1 percent are provided medically assisted detoxification.

In some cases, jailers who are ill-equipped to deal medically with an inmate’s withdrawal revert to disciplinary measures instead. Earlier this year, Alameda County, Calif., paid out a whopping $8.3 million to the family of a man who died after being beaten by guards at Santa Rita Jail while he was suffering from severe alcohol withdrawal. The 49-year old had a history of alcoholism and had been picked up three days earlier on a charge of jaywalking.

By almost any measure, correctional officers who allow inmates to suffer and die while detoxing from drugs or alcohol are breaking the law.

According to one recent legal analysis, denying medication-assisted drug treatment to inmates as a matter of jail policy violates both the Americans with Disabilities Act and the Rehabilitation Act.

It also happens to be unconstitutional. In 1976 the U.S. Supreme Court ruled, in Estelle v. Gamble, that “[d]eliberate indifference to serious medical needs of prisoners constitutes unnecessary and wanton infliction of pain,” and qualifies as cruel and unusual punishment under the Eighth Amendment.

The Court has clarified a “serious medical need” as one that poses “a substantial risk of serious harm,” or is “so obvious that even a layperson would easily recognize the necessity for a doctor’s attention.”

It’s hard to imagine how the peril facing someone in Stojcevski’s condition could go unnoticed. But in practice, entrusting subjective medical assessments to untrained personnel without the benefit of written protocols makes it easy for inmates in distress to fall through the cracks. In some cases, jail employees are ignorant of the potentially fatal side effects of being abruptly deprived of certain substances. In other cases, they just don’t care, or else defer to the opinion of the privately contracted medical professionals used by most jails.

The extent to which these private contractors contribute to the problem is hard to ascertain. However, numerous press reports have documented a link between private medical services and subpar health care in American prisons and jails.

Nashville-based Correct Care Solutions — the private company contracted to provide medical services at Macomb County Jail, where Stojcevski died — has been the subject of dozens of federal lawsuits since 2007 alleging inadequate medical treatment. Some are clearly frivolous. But my review of more than 30 cases filed in federal courts in Tennessee and Illinois reveals a number of credible accounts of inmates being denied access to medications they’d been taking before being jailed.

In one case, from 2012, an inmate claims to have gone more than three weeks without his medications, including the benzodiazepines Klonopin and lithium and the powerful anti-psychotic Seroquel. The plaintiff says he suffered paranoia and hallucinations and lost 30 pounds as a result of being denied his medications.

It’s impossible to know how many other inmates with similar experiences choose to suffer in silence. One expert in the field has estimated that one million arrestees a year may be at risk for untreated alcohol or opiate withdrawal alone, and other drugs would push that number higher.

While the suffering caused by withdrawal is widespread, the number of actual deaths is small. Exactly how small, however, is anyone’s guess.

According to the most recent survey data from the Department of Justice, 967 inmates died in the custody of local jails in 2013 — mostly from chronic illnesses such as heart disease. Yet while the DOJ’s survey questionnaire includes a category for death caused by drug or alcohol intoxication, it provides no option for reporting deaths caused by complications from withdrawal.

Even if it did, it would not capture all detox-related deaths. In the case of opioids, for instance, many detox deaths are officially attributed to underlying illnesses that were exacerbated by the presence of withdrawal symptoms.

Suicide has been the leading cause of death in jails every year since 2000. How many of these suicides are a result of mental anguish caused by untreated withdrawal symptoms is unknown, but we know that at least some of them are.

For example, in February, 31-year old Richard A. Kempf killed himself while in the custody of Washington County jail in Pennsylvania. In May, his family sued the facility, claiming that despite exhibiting severe symptoms of drug withdrawal, Kempf’s repeated requests for medical treatment were ignored by his guards.

The tragic circumstances of these deaths are compounded by how little it would cost jails to avoid them. The most common drug for treating opioid withdrawal, methadone, wholesales for about a dollar a dose. And generic versions of lorazepam and clonazepam — the two drugs listed in federal prison guidelines as most favorable for treating alcohol and benzodiazepine addiction — can be bought in bulk for pennies a pill. Even at retail prices, America’s jails could treat every detoxing inmate in their custody today for a fraction of the average cost of settling one wrongful death suit.

But penny pinching doesn’t account for how an inmate can spend weeks writhing in pain naked on a concrete floor without eliciting a modicum of compassion. Rather, decades of drug-war messaging has promoted an attitude that considers addicts and their medical complaints with skepticism at best, contempt at worst.

After his Senate confirmation hearing in February, President Barack Obama’s new director of national drug control policy, Michael Botticelli — himself a recovering addict — reiterated his position that addiction is a medical issue deserving of the same evidence-based best practices as any other life-threatening condition.

“Standard medical care does not allow a diabetic to enter kidney failure before offering insulin,” he wrote. “Yet untreated substance use disorders routinely proceed unchecked until they have reached such levels of emergency.”

It’s time for America’s jails to internalize that message, and make it known to staff that callous indifference to needless suffering and death will no longer be tolerated.