This is the third article in Rewire’s Women, Incarcerated series. You can read the other pieces in the series that have been published so far here.

Tracy Lee Veira had been in jail for seven days when she was finally allowed to have visitors. Popular in her hometown of Orange City, Florida, Veira had a web of friends eager to see her, as well as two young children who were restless for their mother.

For years Veira had skirted the law, possessing cocaine, violating probation. Once, Veira was pulled over by the local sheriff for driving without a license for the third time in a row. According to her mother, Donna Mullins, Veira threw her keys on the hood and said, “Please, take my keys! I have a problem with driving!”

Most recently Veira had been arrested for “doctor shopping”: requesting the same Oxycodone prescription from three different doctors.

But Veira was also trying to remake her life. In early September 2009, she had turned herself in to the Volusia County Jail for an outstanding warrant, wanting to put her trouble behind her, according to her mother.

When she entered the jail, Veira told officials she had been taking Oxycodone, a highly addictive opioid pain medication, every day, even as recently as that morning.

But the medical staff at the Volusia County Jail did virtually nothing with that information. They did not document what she said, did not speak to her former doctor or outside pharmacy, did not make any plans to continue her medication, and did not order any follow-up care, according to a lawsuit later filed by Veira’s estate against the correctional health-care company that manages most of Florida’s corrections facilities, Corizon Health.

After three days in jail, Veira was feeling nauseous and scared. She couldn’t keep anything down. She was transferred to a solitary confinement cell, closer to the guards who were ostensibly monitoring her deteriorating health.

For the next few days, Veira tried to get the guards to help her. By the seventh night, Veira was so ill that Patty Blair, a childhood friend who was also at the jail while Veira was there, could hear Veira’s cries.

“It was frightening to hear her beg them, because you could hear in her voice that she didn’t feel good,” Blair told Rewire. Blair says the correctional officers told Veira to lie down, that she simply had a leg cramp and needed to rest.

In fact Veira was undergoing a dangerous detox.

On September 16, 2009, Veira was found dead in her cell. No one on the jail staff made any announcement; inmates whispered stories from cell to cell about who had died and why, according to Blair and another woman we spoke to who was at the jail with Veira. An autopsy later determined that Veira’s digestive system shut down due to severe dehydration. During her week in jail, she had lost 20 pounds.

In an interview with Rewire, Mullins recalled lifting Veira’s 7-year-old son onto her knee later that night. He was supposed to have visited Veira that day. Instead, Mullins told him that his mommy had gone to Heaven. “He just looked at me, and asked, ‘Why?’”

A Corizon spokesperson told Rewire that the company was not able to comment specifically on Veira’s case because of ongoing litigation. The spokesperson added in an email, “It is our standard policy to document all available medical history, including current prescriptions, of our patients when they enter our care.”

A Volusia County Jail spokesperson had “no comment involving the matter.”

Veira is one of thousands of women who have struggled with drug addiction behind bars. And she is not the only one who has died from poor treatment. During a five-month review of more than 200 lawsuits, and interviews with lawyers and public health experts, Rewire found that drug treatment for incarcerated women is inconsistent and inadequate—and in some incidents, like Veira’s, it is fatal.

Incarcerated women have extraordinarily high rates of drug dependency: A recent report from the Bureau of Justice Assistance of the U.S. Department of Justice found that 82 percent of the women they surveyed had a serious substance use disorder—a much higher rate than their male peers, who report a rate of 44 percent. It is no coincidence that incarcerated women also have high rates of mental illness and past trauma.

Like Veira, two-thirds of women in prison are incarcerated for non-violent crimes, often related to mental illness, poverty, abuse, or addiction. In 2010, more than 25 percent of female prisoners in state and federal facilities were there for drug crimes.

The petty nature of the crimes in some of the cases we examined made the poor treatment of women’s drug dependencies even more striking. Christina Ackerman, for example, was arrested for stealing DVDs from a Blockbuster in 2003. She died from dehydration related to withdrawal after five days in a county jail in Pennsylvania. She was 21 and had a three-year-old daughter, according to a lawsuit filed on her behalf.

When correctional officers found Ackerman lying on the floor in her own vomit, they notified a nurse, who said, “What do you want me to do about it?”

Savannah Sparks met a similarly grim fate when she went to jail for shoplifting in 2012. She died from complications related to withdrawal after six days in a county jail in Kentucky, according to Prison Legal News. During Sparks’ incarceration, she vomited continuously, sweated profusely, and was unable to eat or drink. But still, no one at the jail took her condition seriously.

Instead, the on-duty prison nurse told WDRB.com: “She had a bad detox. I mean, we have those all the time. It wasn’t something that made me feel like, you know, ‘Oh my god, I need to tell somebody else!’”

Medical and public health experts told Rewire that corrections facilities urgently need to improve the way they address inmates’ drug dependency.

“As a physician, I see drug addiction as a health-care issue,” Dr. Carolyn Sufrin, an OB-GYN at Johns Hopkins Hospital, told Rewire. “Without appropriate drug treatment, people are being punished for their struggles with addiction.”

Best Practices for Drug Treatment Rarely Followed

If serious drug addiction is common for women prisoners, high-quality treatment is not. A report by the Bureau of Justice Statistics indicates that between 2000 and 2011, female jail inmates were nearly twice as likely as males to die of drug or alcohol intoxication while in custody.

Detoxing from drugs and alcohol can be a dangerous process that requires physician oversight, experts told us. While coming off opiates can leave patients susceptible to death from associated dehydration or other conditions, abruptly stopping alcohol consumption can itself be fatal, due to the effects that such chemical changes can have on the brain.

Roughly one million arrestees per year may be at risk for untreated alcohol or opiate withdrawal, according to a 2004 study published in the American Journal of Public Health.

The National Commission of Correctional Health Care (NCCHC), which accredits prison health-care programs, publishes standards for how to treat opioid and alcohol withdrawal in correctional settings.

For opioid withdrawal, the NCCHC advises that all inmates be carefully evaluated when they enter the jail; those that test positive for withdrawal risk should be treated with methadone or buprenorphine, both FDA-approved drugs for detoxification.

But many incarcerated people simply don’t receive that treatment.

“In a well-run prison or jail that’s providing adequate care, someone who’s detoxing would be potentially provided with some medication to ease the withdrawal symptoms, and he or she would be watched for suicide or accidental death. This requires personnel and entails costs,” Brad Brockmann, the executive director of the Center for Prisoner Health and Humans Rights at the Miriam Hospital in Providence, Rhode Island, told Rewire. “The best practices, which are out there, are rarely followed.”

The quality of drug treatment can vary widely between federal prisons, state prisons, and county jails.

The Federal Bureau of Prisons (BOP) has a detailed drug treatment program, outlined in a 2012 report to Congress. The program includes drug abuse education at all 118 BOP facilities, as well as non-residential and residential drug abuse treatment programs at many facilities. In 2012, there were residential drug treatment programs at ten federal prisons for women (out of 27 total federal prisons for women). That year, 47,087 inmates participated in non-residential, residential, and community transition drug treatment programs in federal prisons.

There is strong evidence that offering drug treatment to prisoners has tangible benefits to society. In a three-year study published in 2000, the BOP found that female inmates who participated in residential drug abuse treatment programs were 18 percent less likely to recidivate than similarly situated female inmates who did not participate in treatment.

But for women in county jails—waiting to be sentenced or serving time for misdemeanors—drug treatment can be disorganized and insufficient.

Hope Wulliman, a former director of nursing at the Manatee County Jail in Florida, said inmates going through withdrawal at her jail were sent to a separate medical unit for “basic treatment” that fell far short of what such patients required.

“They basically got comfort measures, like Imodium [used to treat diarrhea],” she told Rewire. She said she had seen many people go through withdrawal at the jail, with “lots of different symptoms: hallucinating, jumping off the toilet, kicking at the air.”

Wulliman had never worked in corrections before she took the job in 2009.

“There wasn’t really a whole lot of training at all,” she told Rewire.

“Some of it was just common sense … nursing is nursing.”

Like most of Florida’s prisons and jails, health care at Manatee County’s facility is provided by Corizon Health, a national company with a deeply troubled record when it comes to patient care.

Inga Jones, a nurse who worked at the Volusia County Jail from 2005 to 2010—where Tracy Veira died—said in a court filing that poor drug treatment at the jail was common.

“Drug and alcohol withdrawal protocols were routinely not followed,” she said in court papers obtained by Rewire. “We worked three days on and two days off, and many times I recall returning to duty to find a patient in full-blown detox.”

When asked about their policies or procedures for inmates with drug dependency, a Corizon spokesperson said in an email, “We are always working to improve policies and procedures in the interest of our patients. We change protocols as needed and on an ongoing basis in accordance with annual NCCHC reviews.”

Florida’s problems with Corizon and its other private provider, Wexford Health Services, have been so severe that the state has announced it is seeking to renegotiate the $1.4 billion in contracts it has between the companies.

“Their Substance Abuse Treatment Just Ended”

Even at the level of state prisons—which, in contrast to jails, usually house inmates for longer periods and often for more serious crimes—drug treatment can be limited, and programs can end abruptly.

In Illinois, for example, the nonprofit Wells Center offers drug and alcohol treatment to a number of correctional facilities.

The center, which gets funding from state contracts, currently provides gender-specific and trauma-informed care modeled off cognitive behavioral therapy for about 180 women in Illinois.

The need is much greater than that. Bruce Carter, the executive director of the center, estimates that if he had enough funding, staff, and space, he could easily have three times as many patients.

Women inmates are especially eager for drug treatment, Carter told Rewire.

“Women will oftentimes have an additional motivation of wanting to get better because they’re the primary caretakers of their kids.”

According to Carter’s numbers, the treatment works. Forty-eight percent of women who have not participated in the program recidivate within three years, while women who complete treatment are far less likely to go back to prison, with a recidivism rate of only 22 percent.

But three of the five programs that Wells offered to women prisoners in Illinois have closed in the past five years.

Carter says he received a call in 2012 saying that the drug treatment program at Decatur, a minimum-security prison for women, would be shut in a week. He had to ask to keep it open for 30 days, so he could give his staff notice.

“For those inmates who were scheduled to finish their treatment in 30 days, they were able to,” Carter told Rewire. “For everyone else, their substance abuse treatment just ended.”

States Sending Pregnant Women to Jail for Drug Use

The broader political context of patchy, poor, or nonexistent drug treatment for women prisoners is this: States are increasingly jailing pregnant women because of their drug use.

In Tennessee, legislators passed a pregnancy criminalization law in 2014, making it possible to prosecute women who use illegal drugs while pregnant. The bill allows women to be charged with aggravated assault, which carries a maximum penalty of 15 years in prison. As Imani Gandy has noted, the law will disproportionately affect Black women.

And as Jessica Mason Pieklo reported last year, South Carolina and Alabama have both made various criminal laws applicable to pregnant women, while Minnesota and South Dakota have altered their laws to include a special process for putting pregnant women in jail if they are deemed a risk to their fetuses. Just last month, the North Carolina Senate introduced a bill that would make it a criminal offense for a woman to use drugs while pregnant.

In other words, these laws are sending women to jail for drug use, even though county jails and state prisons are often not equipped to handle serious drug addiction.

Allison Glass, state director of Healthy and Free Tennessee, says laws that send pregnant women to jail for drug use—but do not require improved drug treatment in jails—hurt women.

“The legislators’ concern really is not about helping women, or helping the fetuses that they say they care so much about,” she told Rewire.

“It’s really about punishing women who are struggling with a health-care issue.”

A County Is Compelled to Improve Drug Treatment for Pregnant Prisoners

In Montana, a lawsuit over the failure to provide drug treatment to a pregnant inmate has resulted in county-wide reform.

The settlement of the case also reveals how difficult it is to make systemic change to incarcerated women’s drug treatment since it is fragmented by state and county lines.

Before entering the Lake County Jail in Polson, Montana, in March 2009, Bethany Cajúne was doing well. As part of a yearlong opiate addiction treatment program, she was attending weekly counseling sessions and taking Suboxone, a medication that prevents withdrawal. She was studying for her GED, taking care of her five children, and working to be sober, according to a lawsuit filed by the American Civil Liberties Union (ACLU) on her behalf.

When she turned herself in to the county jail for outstanding traffic violations, she was about four months pregnant.

She arrived at the jail with her Suboxone in hand. Both her drug counselor and her doctor said she should stay on the prescription while in the jail.

There is a general medical consensus that it is dangerous for a woman to stop taking Suboxone while pregnant. Stopping the medication increases the risk of miscarriage or preterm labor; it also causes a pregnant woman to go through withdrawal, which threatens the health of her and her fetus.

But at Lake County Jail, the doctors and nurses would not give Cajúne her Suboxone. She asked repeatedly for the medication, and filed medical complaints. Her doctor called the facility multiple times, warning the sheriff and the jail’s doctor that Cajúne and her fetus were at risk.

Judy Beck, a spokesperson for the Montana Department of Corrections, told Rewire that she could not speak to Lake County Jail’s policies, since the Montana DOC doesn’t have control over county jails.

But in an email, she said, “Suboxone is not on the MT DOC’s formulary list. There is a process for approving use of non-formulary medications. That process is the same for inmates whether they are pregnant or not.”

Without the medicine, Cajúne quickly went into withdrawal. Dehydrated and anxious, she started vomiting and having diarrhea. At one point she fainted in her cell. After nine days at the jail, Cajúne lost about ten pounds.

Instead of giving her Suboxone, guards put Cajúne in solitary confinement, referred her to a psychiatrist, and told her to “tough it out.”

She was still pregnant, but scared that her untreated withdrawal would cause her to miscarry.

Finally a public defender intervened on her behalf, and she was released from the jail. Severely dehydrated, she went to the emergency room, where she was rehydrated and put back on her Suboxone.

The case was settled in 2011; part of the settlement involved a provision that other pregnant women at the county jail would be protected from similar treatment.

“A different case could have implications beyond the specific jail,” Andrew Beck, staff attorney at the ACLU Reproductive Freedom Project told Rewire. “The harm was caused by this jail, and the solution was to tell this jail to fix its policies.”

Even at the county level, though, the case made an impact, according to Beck.

“Because the jail agreed to this policy, and we haven’t heard of any other cases, we have every reason to think that this has made an important difference.”