Justin Davenport, Jake Moses and Brandin Riehle are best friends, the closest friends each of them has had in their entire lives.
The three are in their 20s: Davenport is 28; Moses, 27; and Riehle, 24. Like all friends, they have quite a bit in common. They enjoy playing basketball and other sports.
Most importantly, they’re recovering from heroin addiction together.
The three young men are all in Clackamas County’s Corrections Substance Abuse Program, or CSAP, a pilot program exploring the integration of medication-assisted treatment into its drug treatment programs for parolees.
The opiate crisis is in full swing in Oregon, as it is in the rest of the country. State and local health departments for Clackamas, Multnomah and Washington counties report that medical emergencies and fatalities from opiate addiction are a daily occurrence. Between a dozen and five dozen people overdose each week. One hundred four people died from opiate overdoses in the first six months of 2017, on par with 2016.
As the population of inmates and parolees who struggle with opiate addiction in Oregon grows, county jail systems are examining to what extent medication-assisted treatment can be integrated into their services to prevent painful withdrawal, relapses and overdoses.
As the name suggests, medication-assisted treatment involves taking a drug to recover from using another drug, rather than relying on behavioral treatment alone. And studies indicate the treatment drugs produce better results in preventing relapse.
Riehle, who most recently served a two months in jail for drug possession charges, has been in the CSAP program for five months.
Moses served a three-month jail sentence for robbery and burglary charges. He came straight to the CSAP program after his sentence finished, and he has been in it for eight months.
Davenport served a 45-day sentence for parole violations.
They all started using drugs as teenagers, as early as the age of 12, first drinking and smoking weed, then using prescription opiates like Oxycontin or Percocet, which gradually led to heroin addiction.
Davenport, Moses and Riehle emphatically believe they would not be sober and their lives would be completely different were it not for the CSAP program.
“It’s given all three of us our families back, the lives that we deserve to live,” Davenport said.
The CSAP program began integrating the medical-assisted-treatment program within the county’s existing residential treatment facility six months ago.
Twenty-four women and 32 men participate in the program. Capt. Jenna Morrison, director of Clackamas County’s parole and probation programs, expects the program to expand to 50 men and 30 women by July. Program participants are screened by probation officers to qualify.
Clackamas joins corrections programs across the country that have begun incorporating medication-assisted treatment into their residential re-entry programs, following a recommendation from the U.S. Attorney General’s Office. Programs were pioneered in a handful of counties along the East Coast as early as 2014. Last year, Rhode Island became the first state system to offer a range of medicines to treat addiction.
In medication-assisted-treatment programs, one of three drugs are used to treat opiate addiction.
Methadone, the most well-known and commonly prescribed drug, is an opiate and controlled substance that is given to patients in prescribed doses, creating a controlled high that prevents withdrawal.
Buprenorphine, also known as Subutex, or Suboxone when combined with naloxone, is also an opiate and controlled substance that is a time-released drug and relieves pain and cravings.
Naltrexone, also known as Vivitrol, can be taken in pill form each day or injected every 28 days. The drug blocks the brain’s opiate receptors, thus reducing cravings, and reduces, if not entirely eliminates, the body’s physiological desire for opiates.
The CSAP program uses Vivitrol via injection. Morrison said the program chose Vivitrol because there are fewer federal regulations regarding how the drug is prescribed and administered.
Medication-assisted treatment isn’t without its detractors. Historically, there has been resistance to medication-assisted treatment from those who argue that the only, or best, way to recover from drug addiction is abstinence. And methadone is “shrouded in stigma and controversy,” said Dr. Alison Noice, the deputy director of CODA, an Oregon drug treatment agency, because it is, like heroin, a controlled substance.
Morrison said she was one of those people.
“Twenty years ago, when I was a baby parole officer, I thought, ‘No way. With methadone, you’re getting high,’” Morrison said.
But studies suggest it is more effective than quitting cold turkey.
An October 2015 article published in the Journal of Substance Abuse Treatment analyzed the relapse rates of 52,000 people who were in drug treatment for opiate addition between 2004 and 2010 and who received methadone or buprenorphine as part of their treatment.
The analysis found that people who received medication-assisted treatment had a 50 percent lower risk of relapse than those without the medicines. Health care expenditures were also $153 to $233 cheaper for each patient each month.
“The science tells us that using medications as part of addictions treatment has tremendous, positive impacts on patient outcomes,” Noice said.
CSAP participants are given the first injection the day before they are released from jail. They are taken to a transition center when released, and a staff member of the CSAP program then picks them up and takes them to the residential facility, in Milwaukie.
Within the next couple of days, they’re taken to a doctor’s appointment, where, among other things, another appointment is made 28 days out, for the next Vivitrol shot. Every 28 days, participants go to the doctor for the month’s Vivitrol shot.
The program is intended to last between a year and a year and a half, and participants live in the facility for six months to a year.
Morrison said the program’s creation was spurred by the fact that nearly all county parolees with addictions abuse heroin, “a huge difference in what we saw even five, seven years ago,” she said, when methamphetamine, alcohol or marijuana tended to be more common.
Noice, with CODA, said incorporating medication-assisted treatment into the county jail system ensures that treatment goes uninterrupted for people serving brief jail sentences.
“We don’t want them to disconnect from treatment,” Noice said. “When we focus on not disrupting the medication, we in turn have a much better chance of keeping a patient in treatment.”
The jail sentences people serve are often short, anywhere between a few days to a couple of months. Still, Noice and others said there is a very high potential for treatment to be negatively impacted in jail. Not providing any medical service to opiate addicts in jail can bring on the danger of withdrawal.
“It’s really traumatizing … (and) increases the risk for relapse,” said Dr. Andrew Mendenhall, the senior medical director for substance use disorder services at Central City Concern.
A person can experience nausea, vomiting, diarrhea, cold sweats and hot flashes, and body aches.
“No appetite,” Davenport said.
“Hard to eat, hard to keep stuff down,” Riehle said, adding that he also experienced muscle spasms and restless leg syndrome when he withdrew.
“It’s horrible,” Davenport said. “That’s what drives the whole addiction part of it. You know you’re going to be sick, so the only way you can feel somewhat normal is having those drugs.”
Jail complicates recovery on many levels. People may refuse to start drug treatment knowing that they’re about to start a short jail sentence and could go into withdrawal. In other cases, people are released from jail without any connection to a treatment program and immediately go back to using drugs.
That happened to Riehle, and it almost killed him.
Riehle, who used heroin for 6 1/2 years, relapsed as soon as he finished a two-month sentence for possession of heroin, which he served at the Clackamas County Jail.
Three days after his release, he overdosed on heroin and passed out. He later found out that a nearby homeowner had seen him and called the police.
An officer revived Riehle with Narcan, or naloxone, the powerful drug that reverses the effects of heroin on the brain.
“They found me just laying by the river. I don’t remember any of it,” Riehle said.
Morrison said the CSAP program is designed so that the transition from jail to the treatment program is as seamless as possible, to prevent someone from having the slightest desire to leave and start using drugs again.
“I was told I had to come (to the CSAP program). I’m glad that’s what happened. I don’t think I would have come,” Davenport said, conceding he would have started using heroin again.
Riehle used heroin for 6 1/2 years, Davenport for seven, Moses for 10. Now that they’ve been taking Vivitrol, the three say they have no cravings for heroin.
“I don’t even think about it,” Riehle said.
The CSAP program – where medication is central to treatment and used in combination with therapy, counseling and other programming – is reflective of how great a challenge treating opiate addiction is compared to treating addictions to meth or cocaine.
Clackamas County’s residential treatment program had been abstinence-based, Morrison said, meaning the residential program provided therapeutic and behavioral services to discourage drug use. But she and others said abstinence is completely impractical for an addiction as difficult to detoxify and recover from as opiates.
Mendenhall said it takes only a couple of days to two weeks to detoxify from drugs like alcohol or methamphetamine. With opiates, detoxification can take weeks to months.
“They will experiences months of fatigue, depression, lack of energy and really severe cravings,” Mendenhall said. “People are not going to feel good.”
Opiate addicts also need to stay in a treatment and recovery program much longer, for a year to a year and a half. The standard recovery from meth, on the other hand, averages between six months and a year.
Morrison said it will be at least another six months before enough data is collected to show whether cravings are substantially reduced and if participants stay in the program for the full course of treatment.
“We’re hoping that with Vivitrol, people are able to move through our treatment program a bit quicker” than if they were taking methadone or buprenorphine, she said, both of which have side effects and lengthen the time it takes to recover.
Jake Moses, who has been in the CSAP program for eights months and used heroin for 10 years, said being on Vivitrol has helped him enormously.
“There’s no side effects,” he said. “It takes away the cravings. It takes away the anxiety. It gives my brain a chance to concentrate on things important in my life.”
With the medication dealing with physical cravings, anxiety and other symptoms of opiate recovery, Davenport and his fellow CSAP participants are able to focus on the rest of the CSAP program, a combination of classes on interpersonal and life skills, group therapy and other programs that help them build the skills and resiliency they need to not rely on drugs.
Davenport calls it “life college.” He, Moses, Riehle and other participants are in classes from 8 in the morning until 4 in the afternoon. The range of classes they take include anger and stress management, mindfulness, coping skills, morality and accountability, and group therapy.
Participants also go on trips, watching motorcycle races at the Portland Raceway and crabbing at the coast.
“They show us that we can have fun without drugs,” Davenport said.
Davenport said he’s learned how to cope when he feels triggered to use drugs; he’s also learned how to be kind to himself.
Moses said he can hardly start to explain how much he has changed since being in the program. Among other things, he’s learned how to use the word “love.”
“I had a hard time saying that in the past,” he said. “I used to be a not nice person.”
Other jail systems are starting to incorporate less robust services for those recovering from opiate addiction.
Over thep two years, the Multnomah County Jail has started prescribing buprenorphine more often to inmates with opiate addictions to blunt the symptoms of withdrawal.
Dr. Mike Seale, the director of the county’s corrections health programs, said health staff “taper down” the amount of buprenorphine over the course of a week as an inmate’s withdrawal symptoms lessen.
CODA and the jail system have been working more closely together in instances where a patient of CODA who is about to start a jail sentence in Multnomah County and is taking buprenorphine is able to continue taking the same prescription.
But, Seale noted, “jail is not a treatment facility.”
Approximately 100 people are booked into Multnomah County’s jail each day, Seale said. He estimated that a third “have some substance-use issue.”
The short duration of the sentences, the fact that an inmate’s bail can be quickly paid and other factors make it difficult to have “the therapeutic relationship with the patients,” Seale said.
“We don’t have a lot of time for that case management.”
Noice, for her part, would like to see the services offered in Multnomah County’s jail become more robust, even creating a way to administer methadone in the jail.
Methadone is strictly regulated by the federal government, Noice said, and “a clear chain of custody” would need to be created, which would involve a CODA staff member traveling to the jail with the methadone doses.
“We’ve had lots of conversations about it,” she said. “It takes some real logistical planning.”
Morrison said Clackamas County is also exploring whether to integrate buprenorphine into the CSAP program. But there are federal regulations mandating that a medical doctor have a particular license to prescribe the drug, and they are also only able to write a certain number of prescriptions.
“I support medical-assisted treatment,” she said. “It’s trying to figure out the best way to integrate it into our population. Vivitrol is not the answer for everything,” especially if someone in the CSAP program decides to leave and the medication wears off.
As jails continue exploring how to start medication-assisted-treatment programs for their inmates and parolees, “it’s important to (remember) we have three medications,” Noice said. “They’re all equally valuable.”
And it is a reminder that there is no silver bullet to the opiate epidemic – that each person’s recovery is a personal victory, a mysterious combination of drug treatment, therapy and medical services, and social support.
“This is not about solving it and winning this battle,” Morrison said. “Right now, it’s about harm reduction.”