The last thing Lizabeth Loud, a month from giving birth, wanted was to be forced into treatment for her heroin and prescription painkiller addiction.
But her mother saw no other choice, and sought a judge's order to have her committed against her will. Three years later, Loud said her month in state prison, where Massachusetts sent civilly committed women until recent reforms, was the wake-up call she needed.
"I was really miserable when I was there," the 32-year-old Boston-area resident said. "That was one bottom I wasn't willing to revisit again."
An Associated Press check of data in some key states has found that the use of involuntary commitment for drug addiction is rising. And in many places, lawmakers are trying to create or strengthen laws allowing authorities to force people into treatment.
But critics, including many doctors, law enforcement officials and civil rights advocates, caution that success stories like Loud's are an exception. Research suggests involuntary commitment largely doesn't work and could raise the danger of overdose for those who relapse after treatment.
And expanding civil commitment laws, critics argue, could also violate due process rights, overwhelm emergency rooms and confine people in prisonlike environments, where treatment sometimes amounts to little more than forced detox without medications to help mitigate withdrawal symptoms.
At least 35 states currently have provisions that allow families or medical professionals to petition a judge, who can then order an individual into treatment if they deem the person a threat to themselves or others. But the laws haven't always been frequently used.
Wisconsin Gov. Scott Walker signed a law last year allowing police officers to civilly commit a person into treatment for up to three days. In Washington state, legislation that took effect April 1 grants mental health professionals similar short-term emergency powers. In both states, a judge's order would still be required to extend the treatment.
Related bills have also been proposed this year in states including Pennsylvania, New Jersey and Massachusetts, where involuntary commitment has emerged as one of the more controversial parts of Republican Gov. Charlie Baker's wide-ranging bill dealing with the opioid crisis.
Massachusetts already allows for judges to order people to undergo up to three months of involuntary treatment, but lawmakers are considering giving some medical professionals emergency authority to commit people for up to three days without a judge's order.
The proposal is a critical stopgap for weekends and nights, when courts are closed, said Patrick Cronin, a director at the Northeast Addictions Treatment Center in Quincy, who credits his sobriety to his parents' decision to have him involuntarily committed for heroin use almost 15 years ago.
But giving doctors the ability to hold people in need of treatment against their will, as Massachusetts lawmakers propose, will burden emergency rooms, which already detain people with psychiatric problems until they can be taken to a mental health center, said Dr. Melisa Lai-Becker, president of the Massachusetts College of Emergency Physicians, an advocacy group.
"We've got a crowded plane, and you're asking the pilots to fly for days waiting for an open landing strip while also making sure they're taking care of the passengers and forcibly restraining the rowdy ones," Lai-Becker said.
Baker's administration stressed the proposal wouldn't take effect until 2020, providing time to work out concerns.
Even without the state legislative efforts, use of involuntary commitment for drug addiction is rising, according to information the AP obtained from states that have historically used it the most.
Florida reported more than 10,000 requests for commitment in both 2016 and 2015, up from more than 4,000 in 2000, according to court records.
Massachusetts reported more than 6,000 forced commitments for drug addiction in both fiscal years 2016 and 2017, up from fewer than 3,000 in fiscal year 2006.
In Kentucky, judges issued more than 200 orders of involuntary commitment for alcohol or drug abuse in the last calendar year, up from just five in 2004, according to court records. The state has so far reported nearly 100 such commitments this year.
But researchers caution there hasn't been enough study on whether forced treatment is actually working. And many states don't track whether people are being civilly committed multiple times, let alone whether they get sober for good, the AP found.
In Massachusetts, where fatal overdoses dropped for the first time in seven years in 2017, state public health officials don't credit increased use of civil commitment, but rather better training for medical professionals, tighter regulations on painkillers, more treatment beds, wider distribution of the overdose reversal drug naloxone, and other initiatives.
A review published in the International Journal of Drug Policy in 2016 found "little evidence" forced treatment was effective in promoting sobriety or reducing criminal recidivism.
Another 2016 study by Massachusetts' Department of Public Health found the involuntarily committed were more than twice as likely to die of an opioid-related overdose than those who went voluntarily, but those findings shouldn't be viewed as an indictment of the process, argues Health and Human Services office spokeswoman Elissa Snook.
"Patients who are committed for treatment are among the sickest, most complex and at the greatest risk for an overdose," she said. "Involuntary commitment is an emergency intervention, to help individuals stay alive until they are capable of entering treatment voluntarily."
Most states send the civilly committed to treatment facilities run or contracted by public health agencies. The costs generally fall on patients, their families or insurance providers.
Massachusetts stands out because, until recently, it sent those civilly committed for drug addiction to prisons. That decadeslong practice ended for women in 2016, but many men are still sent to the Massachusetts Alcohol and Substance Abuse Center, which is housed in a minimum-security prison in Plymouth, near Cape Cod.
Patients wear corrections-issued uniforms and submit to prison regulations like room searches and solitary confinement. They also aren't given methadone or buprenorphine to help wean off heroin or other opioids, as they might in other treatment centers.
Michelle Wiley, whose 29-year-old son David McKinley killed himself there in September after he asked her to have him civilly committed for the third time, said she isn't opposed to expanded use of the practice as long as those with addiction aren't sent to places like Plymouth.
In the days before he hanged himself in his room, Wiley said, her son had complained to her about dirty conditions, poor food and not enough substance abuse counselors while he went through withdrawal.
"You think it's going to be helpful until you hear what it's like," she said. "If I had to do it over, I wouldn't send him to that place."
The corrections department has since taken steps to improve conditions, including more frequent patrols by prison guards and extended hours for mental health professionals, department spokesman Jason Dobson said.
As for Loud, the Massachusetts woman civilly committed while pregnant, she said she has found peace.
After briefly relapsing following her son's birth, she has been sober for about a year and a half. She focuses her energies on raising her son, attending regular support meetings and pursuing a passion sidelined by her addiction: competitive Muay Thai fighting. Her fourth bout is in July.
Loud has also reconciled with her mother. The two now live together, along with her son.
"It took me a long time to understand what she was going through," Loud said. "She was just trying to save her daughter."
On opposite sides of the county jail, a mother and her son chat about school, girls, birthday gifts — and their future together. They aren't allowed to see each other face-to-face, so the inmate and the fifth-grader connect by video.
"Hi, Mommy," 10-year-old Robby says to Krystle Sweat, clutching a phone in the visiting room as he looks at his mother on a screen, sitting in her cell.
Robby hasn't hugged her since Christmas 2015, just before Sweat wound up back behind bars. He shifts his weight from one leg to another and says that on the day she's released, he wants to show her how he can ride no-hands on his bike.
For years now, Sweat has cycled in and out of jail, arrested more than two dozen times for robbery and other crimes — almost all related to her drug addiction that culminated in a $300-a-day pain pill habit. She's tried to quit, but nothing has worked. Now she says she's ready to make the break when she's paroled, possibly this summer.
"I'm almost 33," she says. "I don't want to continue living like this. I want to be someone my family can count on."
Tucked in a remote corner of Appalachia, the Campbell County Jail offers an agonizing glimpse into how the tidal wave of opioids and methamphetamines has ravaged America. Here and across the country, addiction is driving skyrocketing rates of incarcerated women, tearing apart families while squeezing communities that lack money, treatment programs and permanent solutions to close the revolving door.
Women in jail are the fastest-growing correctional population in America. The numbers rose from 13,258 in 1980 to 102,300 in 2016, according to the Bureau of Justice Statistics. Between 1980 and 2009, the arrest rate for drug possession or use tripled for women, while it doubled for men. Opioid abuse has exacerbated the problem.
More than a decade ago, there were rarely more than 10 women in the Campbell County Jail. Now the population is routinely around 60. Most are arrested on a drug-related charge. Many also are addicted. They receive no counseling, and eventually are released into the same community where friends — and in some cases, family — are using drugs. Soon they are, too.
And the cycle begins anew: Another arrest, another booking photo, another pink uniform and off to a cell to simmer in regret and despair.
Sarai Keelean is back in for violating probation for possessing meth; she'd been using the drug and also selling it to buy opioids. Locked up for almost three years, she longs for freedom but is terrified, too. "You're afraid that you're going to mess up," she says.
Blanche Ball, who has been using, cooking or selling meth for 15 of her 30 years, has been in jail several times. "I know I could have done something more with my life," she says, but: "Once you're like this for so long, you don't know another way to be."
Her two oldest children are being raised by family, and she doesn't want to see them until she's confident she'll remain in their lives. The two youngest were adopted. "That wound is so bad," she says, "I try to block it out all the time."
In 2015, Campbell County had the third-highest amount of opioids prescribed per person of all U.S. counties, according to the Centers for Disease Control and Prevention. That amounted to more than five times the national average.
Mayor E.L. Morton blames the pharmaceutical industry and doctors, and two lawsuits against opioid makers are pending on behalf of the county and its 40,000 residents. Meth is also a problem.
"Throw a rock, hit a house, and there's drugs," says Keelean, the 35-year-old inmate.
The county has struggled for decades. Its tobacco farms and once-flourishing coal industry disappeared long ago, wiping out jobs and solid incomes. Some factories remain, but more than 1 in 5 residents are poor. Nowadays, as much as 90 percent of the crime in a five-county district that includes Campbell is connected to drugs, the local prosecutor says.
Tennessee doesn't have enough psychiatrists, social workers, counselors and nurses or residential drug treatment in rural areas — and Campbell County has no such programs, says Mary-Linden Salter, director of the Tennessee Association of Alcohol, Drug & Other Addiction Services. "It's unrealistic for people to travel 700 miles for treatment because that's where there's an open bed," she adds.
Salter also says drug treatment is often costlier and more complicated for women because many have experienced trauma and abuse as children or adults and may be slower to seek help because they fear losing their children.
"Women are the caregivers of their families," she says. "They get blamed and shamed for not taking care of their children. But they get blamed and shamed for not being in recovery. It's a horrible choice."
There are roads to recovery here. A drug court, which provides supervision for up to two years, has a 70 percent graduation rate. And a new program just for women, begun last year, takes offenders jailed on misdemeanor drug charges before sentencing and moves them into short- or long-term residential treatment. In both cases, treatment takes them to other counties or out of state.
Krystle Sweat says that when she's paroled, she wants to enter a faith-based recovery program. Her parents, who have raised Robby since he was about 3, have promised to help.
As Robby's visit ends this day, he and his mother blow each other kisses.
"I'm so thankful that he still loves me," she says, returning to her bunk where she keeps a photo of her son. "He's disappointed in me. .... He doesn't say that he is, but I know he is."
AP Photographer David Goldman contributed to this report.