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After O'Neill was hired at Santa Rita, she worked only four hours a week providing counseling for people in methadone treatment. When she arrived there, the medical group did not yet have a license to dispense methadone, a pain reliever commonly used to treat opioid addiction, and so a contractor, HAART, was dispensing methadone in the jail. HAART's policy was to provide pregnant women with methadone treatment and maintain the treatment for anyone who was already on it. Everyone else went through medically supervised withdrawal, also known as detox.
O'Neill was troubled by this approach. "Detoxing people off that is not based in evidence," she said in an interview. "There's a lot of evidence if you sustain people in treatment there is lower recidivism, people are healthier. The practice of detoxing people was always incredibly counter to what I saw work in the community."
In her resignation letter, O'Neill would note that the American College of Obstetricians and Gynecologists "recommends methadone maintenance for pregnant women and advises against medically supervised withdrawal because relapse rates are so high and can cause negative maternal and fetal health outcomes, as well as miscarriage."
Once the medical group was licensed to dispense methadone, the company implemented a new protocol to detox all inmates off opioids, regardless of their condition or history, O'Neill said. Although the protocol made an exception for pregnant women, O'Neill wrote in a sworn statement that she saw two pregnant women in withdrawal. One had symptoms of withdrawal including vomiting and diarrhea, O'Neill said, but the medical director said she was not actually opioid dependent, despite documented history. The other had been given methadone, but only 10 mg, when an initial dose is usually around 30 mg and an average dose is 80 mg.
While she was in the jail, O'Neill also advocated that inmates at risk of opioid overdose be given naxalone when they are released. She had pushed the sheriff's office to implement the policy since 2016 and gave seven presentations to medical staff and the sheriff's office over the next three years.
"Having someone in withdrawal and with no tolerance, when they get out has a huge risk of overdose," O'Neill said. "Giving it to people who are leaving jails is a really effective intervention."
But the sheriff's office never implemented the policy until after a woman recently released from the jail was found dead of an overdose at the nearby BART station. Her death would spur a call for statewide reform on the late-night release of prisoners.
While not technically an in-custody death because it happened after she was released, the death of 26-year-old Jessica St. Louis in July alarmed observers at the jail. St. Louis was found at the passenger pickup area of the Dublin/Pleasanton BART station when it opened at 5:30 a.m. on July 28. She had reached a plea agreement and was sentenced a day prior to five days in jail, which she had already served while awaiting sentencing, and three years of probation. She was released from the jail at 1:30 a.m., well before BART started running. An autopsy determined that she had died from a fentanyl and heroin overdose.
The death of St. Louis appears to have spurred some policy changes, possibly at a statewide level. Beginning in September, a little more than a month after St. Louis's death, Santa Rita staff began providing some inmates at risk of an overdose with naxalone when they're released. It's the same policy that O'Neill had been advocating for years.
In December, state Sen. Nancy Skinner introduced legislation that would give people scheduled to be released in the middle of the night the option to either stay in the jail until daytime or get transport anywhere in the county, so people like St. Louis would not be released with no way to get home. The bill passed the Senate's Public Safety Committee in April.
"They're very vulnerable when they're released, regardless of their job, and vulnerable people are easy prey and predatory people are always seeking vulnerable people," Skinner said in an interview. Late night release is "a perfect recipe for a predatory person to take advantage of a vulnerable person," she said.
In late 2017 and early 2018, two inmates hanged themselves while held in isolation. On Nov. 28, 2017, according to a lawsuit alleging systemic failures in mental-health treatment at the jail, Edwin Villalta was found dead in his cell after hanging himself with his county-issued blanket. Villalta was not on intensive observation log, a jail protocol for people demonstrating behavioral problems or who could be suicidal. Logan Masterson was found dead on April 7, 2018, while held in administrative segregation in Housing Unit 2, the same unit where guards had allegedly subjected inmates to gassing attacks in 2016. A lawsuit filed over the latter incident highlights alleged deficiencies in the jail's treatment of inmates with suicidal tendencies.
Masterson had been arrested three days earlier, after leading Livermore police officers on a pursuit. He had allegedly stolen a car at gunpoint in downtown Livermore. According to a lawsuit filed by his family in March, Masterson was intoxicated and suicidal when he was booked into jail.