CHEHALIS, Lewis County — John Lininger met with his doctor in a windowless exam room, the clinic separated by two thick metal doors from the 240 or so other inmates of the Lewis County jail.
Lininger, a 46-year-old carpenter, has been in and out of this jail repeatedly over the past nine years on charges that he says are driven by his opioid addiction. Past jail visits meant excruciating withdrawals: nausea, bone-deep pain and overwhelming cravings for opioids.
This time is different. He sits calm, alert, without a thought of using heroin.
He’s taking buprenorphine, a synthetic opioid medication, under the supervision of Dr. AJ Shergill, who consults with Lininger and a jail nurse via a video link from his Bellevue office, checking to see if Lininger is experiencing withdrawals.
Before Lininger started the pills, all he could think about was heroin. Buprenorphine allows other thoughts the space to enter his brain.
“It doesn’t have a feeling every time,” he said. “It just keeps this feeling of not being encaptured.”
As Washington continues to struggle with an opioid epidemic, jails across the state are increasingly on the front lines. With more than half of people abusing prescription opioids or heroin reporting contact with the justice system, according to a national 2018 study, jails are exploring providing what’s known as medication-assisted treatment.
A state-funded study last year found that 14 of the 33 Washington jails surveyed provided some kind of medication, including King County, with most offering buprenorphine. Washington’s state prison system is also expanding its efforts, prescribing medication before release at three facilities.
Some have moved to ensure that they can continue existing prescriptions. Others have adopted buprenorphine to treat messy, potentially deadly detox and protect inmates from post-release overdoses, to which reduced tolerance can make them 40 times more vulnerable.
A few, such as Lewis County, work with providers to offer prescriptions in an effort to address an epidemic that left 742 people dead statewide in 2017 and has trapped many in a cycle of incarceration.
Lewis County patients continue the prescription for their whole stay, once or twice a day sitting on their hands on a clinic bench or in plastic chairs in front of security cameras, closely watched while the tablets dissolve under their tongue. On release, jail staff coordinate their transition to a community provider, covering the cost of a bridge prescription.
Before the program began in March, John Ackerman, the jail’s health-services administrator, saw the same people cycle through jail without their addiction being addressed. “What we’ve been doing for so long is not working,” he said.
Opioid medication programs are popping up at jails big and small, rural and urban, across the state, and report few issues. However, some have been reluctant, citing concerns about cost, abuse potential or the difficulty of finding local medical providers, resulting in an uneven rollout statewide.
“People say they feel normal”
When Clallam County sheriff Bill Benedict saw a presentation on the effectiveness of buprenorphine treatment in 2015, it just made sense to him, making his jail, he believes, the first statewide to offer it behind bars.
“I knew running a jail that at least half my inmates were users,” Benedict recalls.
From 2006 to 2012, Clallam County received the most prescription pain pills per capita in the state, according to a Washington Post analysis. In the following four years, it had the highest opioid-related overdose rate.
Benedict says he received little pushback on the idea, a fact the self-described “numbers guy” credits in part to sharing UW students’ study results that showed striking success, particularly when compared to those not in the program.
“I don’t know any one of them who got off heroin” who weren’t in the program, Benedict said.
While methadone is more commonly known and necessary for some, buprenorphine is less strong, safer and easier to prescribe. It costs only a few dollars per dose and has a record of effectiveness. A Swedish study found buprenorphine effective at keeping people in treatment, with three-quarters of participants remaining in treatment a year later, compared to none of the participants tapered off it.
Over time, opioids trick the brain into associating them with survival, stimulating rewards systems in a reconfiguration of the brain’s priorities that causes users to continue self-destructive behavior.
“[The brain] becomes permanently damaged,” said Richard Ries, addiction treatment director at Harborview Medical Center in Seattle. He thinks detox treatment alone should be banned for opioid addiction because of the deadly relapse potential.
“It just doesn’t work,” he said. “Even those folks who do everything right relapse.”
Buprenorphine binds strongly to receptors, but activates them more weakly than other opioids, preventing withdrawal without creating a high. Patients describe a relief from overwhelming cravings.
“It’s almost universal; people say they feel normal,” said Lucinda Grande, a buprenorphine prescriber and co-author of a study on opioid medication in jails.
A patchwork landscape
While many jails say they’re working toward providing opioid treatment medication, there are hurdles.
Smaller jails often don’t have on-call medical staff to prescribe buprenorphine, and there’s no consistent funding source. Medicaid shuts off while a person is incarcerated, so jails cover costs out of pocket, or seek funding from grants — like Lewis County did.
Their grant started at $80,000 but has increased since due to the success of the program. The program figured for a 20-patient average, but Ackerman estimates fully meeting demand would quadruple its size.
Before they started, Lewis County jail chief Chris Sweet heard jail staff and the community concerns around bringing opioids into jail, and the idea that buprenorphine was replacing one addiction with another.
However, several jails with buprenorphine programs, including Lewis County, say they haven’t seen major issues with theft or misuse thanks to preventative measures such as urine tests. Further, officials say, buprenorphine is not a particular concern because behind bars all drugs — even baby aspirin — are desirable.
“I think their intentions are good, but I think the risks are overblown compared to the benefits,” said Marc Stern, Washington’s former top prison doctor and a national expert on prison health.
At King County jail, nursing supervisor Sean Dumas said the main concern among staff was the extra work involved, but they are supportive overall. By the end of the year they hope to start people on buprenorphine, in addition to continuing prescriptions. The jail also plans to use buprenorphine to treat withdrawal, although the timing is uncertain.
As for replacing one addiction with another, Ries at Harborview says addiction not only creates dependence, but displaces healthy behavior. Buprenorphine allows people to integrate with society in a healthier way, like an antidepressant does.
Even if buprenorphine doesn’t always lead to immediate change, it’s worth trying, says Andrew Saxon, a UW School of Medicine professor of psychiatry and behavioral sciences.
“If we’re keeping them alive, we’re keeping them in treatment, they may have a chance to get better,” he said.
In Lewis County, once Sweet explained the science behind the drugs and how addictive opioids were, people were won over, he said.
“I want to live”
Last month, a federal judge approved a settlement between the ACLU and Whatcom County over claims it had violated the Americans with Disabilities Act by not providing buprenorphine to two jail inmates previously prescribed it in the community.
“The settlement in the Whatcom County case should absolutely send a message to other jails,” said Mark Cooke, policy director for ACLU of Washington’s smart justice campaign. He says the organization will focus on educating jails about the case before pursuing further legal action.
The state Legislature this year considered requiring all jails to provide opioid medication by 2021, although the provision didn’t make a final bill.
For Lininger, he plans to continue his buprenorphine prescription once he’s released. Not constantly craving opioids has given him time to find a reason to stay sober — he’s seen too many people die as the result of opioids.
“I want to live,” Lininger said.
Staff reporter Vianna Davila contributed to this report.