During the past year, about 1,600 people have been offered medications such as buprenorphine to assist with their opioid use disorder and withdrawal symptoms while they’ve been in the Clackamas County Jail, according to county officials. That’s 11% of the 14,500 intakes during that time frame.
This was made possible after Clackamas County won a grant in April 2019, allowing it to expand on what began as a pilot project in 2017.
The foundation Arnold Ventures, in conjunction with the U.S. Department of Justice and the Bureau of Justice Assistance, awarded the county — along with 14 other jurisdictions nationwide — $720,000 to create a plan for offering treatment medications, with the aid of a team of substance use disorder experts. Clackamas County was the only jurisdiction in Oregon to receive the grant.
In addition to helping people stave off cravings for opioids, medications can also soften the blow of painful withdrawals.
Andrew Swanson can attest to the pain. Swanson underwent numerous surgeries for injuries incurred on his job as a racecar driver, and his chronic pain is what got him hooked on opiates — first ingesting pills, then smoking heroin, then injecting it. But Swanson described the physical pain he experienced while going through opiate withdrawals as the worst pain of his life.
Withdrawal symptoms include diarrhea, an elevated heart rate and blood pressure, trouble sleeping and anxiety — as well as muscle cramps and abdominal pain.
Before Swanson got sober in November 2016, he was arrested twice for offenses connected with his addiction to heroin — once in Los Angeles and once in Mexico.
Neither time was he given medication to help him cope with withdrawal, though in Lose Angeles, jail staff offered anti-diarrheal medication and blood pressure medication to manage the symptoms.
Other correctional facilities, including both of Multnomah County’s jails, have offered some form of medication-assisted treatment for opioid use disorder for years.
“What makes our program unique is our ability to start new clients on (medication-assisted treatment) prior to release from the jail and the case management that accompanies all (those) clients, rather than focusing solely on medically-supervised withdrawal, which is typically the focus within the correctional setting,” said Melanie Menear, health services director at Clackamas County Jail.
Clackamas County’s program is larger in scope and has made buprenorphine far more accessible than programs at other Oregon jails, including in Multnomah County. It has also applied to the state for special certification to prescribe methadone. That application is still in the approval stage, but the ability to prescribe methadone will be unique to Clackamas County Jail and the clients it serves, should prescribing ability be granted.
Methadone, developed in 1937 by German doctors seeking to address an opium shortage, is the oldest and perhaps the best-known drug used to treat opiate use disorder.
It’s also controversial due to higher toxicity and chance of overdose, and it is a Schedule II controlled substance — a classification it shares with fentanyl, Ritalin and oxycodone.
“In general, historically, because jails can’t prescribe methadone, if a person was incarcerated that needed methadone, you needed an opiate provider to bring methadone to the jail,” said Alison Noice, executive director of CODA, which partners with Clackamas County to provide treatment to inmates who have methadone prescriptions.
Now, Noice said, jail staff assess individuals at the time they’re taken into custody and, in some cases, transport an inmate to CODA’s clinic for assessment. For the duration of a person’s time in jail, a CODA nurse takes methadone to a nurse on staff at Clackamas County.
“It’s the first time we were able to get a corrections health team to say, ‘That makes sense,’” Noice said.
Noice added that CODA is working with Washington County to provide similar access.
Multnomah County is not a licensed methadone provider, said Dr. Michael Seale, deputy director of Corrections Health at the Multnomah County Health Department. But, like Clackamas County, Multnomah County offers bupenorphrine, also known as Suboxone. It was already being offered when he started working there five years ago, Seale said. Last year, roughly 1,080 orders for bupenorphine were placed on behalf of people housed within Multnomah County's jails.
It some cases, via an emergency provision, Mutlnomah County has the limited ability to prescribe methadone for 72 hours.
Multnomah County staff have become increasingly more liberal in their use of bupenorphine, however, not just honoring prescriptions for inmates who come in with them, but assessing inmates’ history and withdrawal symptoms as they come in and offering new prescriptions.
Clackamas County officials started using medication-assisted treatment for two reasons, said Eric Anderson, corrections manager with the Clackamas County Sheriff’s Office.
One was because it was “the right thing to do,” Anderson said.
“We were seeing increases with the rate of people coming into custody, going through withdrawals. They had little or no support,” he said.
The other reason was litigation, Anderson said.
Last year, the American Civil Liberties Union filed multiple lawsuits against local jurisdictions and the federal Bureau of Prisons demanding medication-assisted treatment for non-pregnant inmates — and won three settlements to get treatment for inmates.
The first of those suits was filed against Whatcom County, Wash., and it was settled in April 2019, the same month Clackamas County received the Arnold Ventures Grant.
The Whatcom County lawsuit was a particular wakeup call for Clackamas County officials, Anderson said.
“We wanted to basically do what was right and also avoid any litigation that might come down the road in terms of case law or litigation that might come against us,” he told Street Roots.
All medications used for opiate use disorder work by binding to the opiate receptors in the central nervous system, reducing cravings and relieving symptoms of withdrawal, said Menear.
In addition to methadone and suboxone, Clackamas County staff also offer Vivitrol, a long-acting form of naltrexone that can reduce cravings for about a month, for some inmates suffering from opiate use disorder.
“(Buprenorphine) alleviates symptoms very quickly,” said Seale, of the Multnomah County Health Department. “It seems to be a much more humane and kind process going through withdrawal.”
In addition to offering medication, Clackamas County has hired a coordinator to help inmates create a transition plan to ensure continued access to treatment, Anderson said.
“When somebody requests our services and asks to start the program, we make an appointment (with a treatment provider) when they leave the program,” Menear said. “We are giving them a number of days’ worth of medication to get them through so that they can continue the follow-up medication when they’re released.”
Identifying an accessible clinic and treatment pathway is logistically tricky, Menear said.
But Noice said the fact that Clackamas County has worked to smooth the transition to life outside of jail has made a huge difference.
“What I hear over and over from corrections staff is I’m not comfortable prescribing these medications to people if they’re not going to get treatment on the outside,” Noice said.
That connection is something that might have helped Swanson after his arrests. Once he was released from jail, the pain and cravings of opiate withdrawal led him right back where he was before he got in.
“I got out, and obviously my No. 1 priority was getting more drugs,” Swanson told Street Roots.
Swanson now works as policy and advocacy director for Oregon Recovers, which advocates for more comprehensive treatment options in Oregon.
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He went through addiction treatment at Hazelden Betty Ford Addiction Treatment Center in Minnesota. He stayed in the in-patient program for two weeks and then lived in Minnesota to continue outpatient treatment for about a year. He took Suboxone for 14 months under medical supervision until tapering off.
He described his stint in Minnesota as a “last chance” at sobriety after he was beaten up trying to break into a car, which aggravated an old shoulder injury to a degree that required surgery.
Buprenorphine, along with methadone and naltrexone, has the secondary effect of relieving pain while getting the patient high, and it’s increasingly prescribed to patients who’ve abused opioids to treat chronic pain.
Prior to entering treatment, Swanson said, he overdosed regularly and carried naloxone, an opioid antagonist that can reverse an overdose, and knew he was going to die if he didn’t make a change.
Jail staff in Clackamas and Multnomah counties keep naloxone on hand and are trained in administering it.
Menear said there have been no overdose deaths since she started working at Clackamas County last spring, and there have been fewer overdoses, though they still happen.
Anderson also said that while it’s not something jail staff can easily track, he’s hopeful offering medication will reduce the amount of contraband drugs people bring into jails.
“It usually happens with drugs they admitted to taking as they were arrested or just after they were arrested,” Menear said.
Swanson now does yoga and mindfulness exercises to manage his pain, and he is careful to avoid physical activities that might trigger his injuries.
He doesn’t believe medication-assisted treatment, or MAT, is a silver bullet, but he applauds any move that treats drug addiction as a medical issue rather than a moral failing.
“I was somebody who was very skeptical of MAT maintenance. I didn’t think it was really recovery. I thought it was switching from one drug to another. But it saved my life,” Swanson said. “I promise you I would not be here if it were not for that full process.”
CORRECTION: An earlier version of this article erroneously stated that Clackamas County prescribes methadone to people housed at its jail. It has applied for that ability, but it has not yet been granted.