Editor’s note: This story discusses suicide. If you know someone in crisis, resources are available here.
GOLDENDALE, Klickitat County — When he was growing up, Ivan Howtopat dreamed of being a famous skateboarder. Playing college basketball. Buying his mom a house.
More recently, he told her that he wanted to go to opioid treatment. Maybe he’d start to learn a trade.
Ivan was still just at the beginning of his life when drugs came into the picture — about 20 years old, said his parents, Melissa and Donovan.
And he was only 24 when he died last May after hanging himself in the Klickitat County Jail, in the midst of fentanyl withdrawal — the symptoms of which can be brutal on the body and mind.
The jail doesn’t provide any of the three medications approved by the U.S. Food and Drug Administration to treat opioid use disorder.
Fentanyl is the most ubiquitous opioid available without a prescription and the cause of record-breaking overdose deaths across Washington. Fentanyl is 50 times more powerful than heroin, and opioid treatment experts say that access to medications like methadone and buprenorphine is more important than ever to help people stay alive.
Ivan’s death points to how some jails, especially smaller ones in rural areas of the state, lack a key tool in fighting the crisis. While an influx of state money is poised to help more jails provide medications to treat opioid use disorder, there have historically been significant barriers, including costs and a shortage of health care providers.
This year, state legislators agreed to add nearly $7.4 million to the state’s budget to maintain and grow a program that pays for the medications in jails.
Gov. Jay Inslee, who requested the funding in his proposed budget late last year, said medications administered inside the jail can be effective at setting people up for success when they leave.
“They’re shielded from the influences of the street,” Inslee said.
Lawmakers also passed a bill requiring jails to inform people who are being released from custody of treatment options.
But Melissa Howtopat isn’t sure if that would have helped her son.
“I feel like he needed help as soon as he got there,” she said.
Why don’t all jails have this treatment?
As the fentanyl crisis tightens its grip in Washington and across the country, there is growing agreement in the public safety sphere that people in jails and prisons would benefit from medications to treat opioid use disorder.
But logistical and bureaucratic barriers still exist.
Methadone and buprenorphine can help people in the throes of withdrawal manage their symptoms, such as nausea, vomiting and anxiety, but also are used for long-term treatment of opioid use disorder. A third drug, naltrexone, can be used for long-term treatment but does not help with withdrawal symptoms.
A 2021 study conducted by researchers at the University of Washington found that 29 out of 47 Washington jails that responded to the survey offered buprenorphine to treat withdrawals, but no jails offered methadone, which is a more tightly regulated drug.
Researchers said “additional efforts are needed to provide these lifesaving (medications), including increased funding for staff and medications, administrative and legal support.”
Those in most Washington jails are allowed to continue medications to treat opioid use disorder if they had already been prescribed them before entry. In 2022, the U.S. Department of Justice said that people who were prescribed medications to treat opioid use disorder were protected by the Americans with Disabilities Act.
But starting someone on the medications while in jail is less common.
In 2019 guidance to states, the federal Substance Abuse and Mental Health Services Administration said misconceptions about the drugs, concerns that they could be diverted in prisons and jails to those who weren’t prescribed them, state regulations and the lack of health care providers in communities were all barriers to providing opioid use disorder treatment in the criminal justice system.
Cost is one of the most significant barriers.
Coverage by Medicaid — the government health care program that covers poor Washingtonians and other qualifying groups — stops when you are incarcerated. That means jails pay for the costs of medical care, and those who’ve been treated are sometimes billed after the fact.
Washington has been working to try to fill that gap through a state Health Care Authority program that provides money to jails to cover the cost of the medications. The state also sought a waiver from the federal government to allow those who are eligible for Medicaid to receive certain Medicaid services for 90 days before their release, including medications to treat opioid use disorder. That coverage is set to begin in July 2025.
Shawn Davis, chief of corrections for the Stevens County Jail in northeastern Washington, says the jail pays medical costs out of pocket, to the tune of nearly $300,000 per year, when the overall budget for the jail is about $2 million.
The jail receives money from the Health Care Authority to pay for the cost of providing opioid addiction medication buprenorphine.
“Otherwise, we couldn’t afford to do it,” he said.
Davis said the lack of insurance coverage for people in custody compounds problems they already had before they came to jail. The jail won’t bill for medical costs afterward. He could send the bills to collections , but that would just be “messing up their credit and making things more difficult.”
Barriers to treatment in rural areas
Ivan Howtopat once told his mom that he would do “almost anything” to get fentanyl. He was “so afraid to be sick” from withdrawals, she said.
He was getting sick of using the drugs, too.
“That’s what he kept telling me, ‘I’m so tired of this life,’ Melissa Howtopat said. “Of always having to find a way to get the drugs.”
She says he was “this close” to getting into treatment. He went to a detox facility once, but it didn’t provide medications to help with withdrawal — and he ran away from the facility.
The lack of access to treatment in the county jail is just one slice of the broader problem in accessing effective drug treatment in Klickitat County, in the southern part of the state hugging the Columbia River Gorge. While medications to treat opioid use disorder are available in the county, there is no opioid treatment program licensed to offer methadone.
The Washington Association of Sheriffs and Police Chiefs — composed of the state’s law enforcement leaders — which helps jails get the Health Care Authority money, has been focusing on filling the gap in smaller and more rural jails, where local access to medical providers has historically been an issue on top of costs, says the association’s executive director, Steve Strachan.
Strachan said that providing medication to treat opioid use disorder treatment can smooth an incarcerated person’s path to reenter society.
“Most people are going to get out of whatever facility they go into, whether it be a jail or prison,” he said. “And the better job we do with reentry, the less chance they have of negatively impacting public safety.”
While health care providers are working hard to shore up local resources and peer counseling for people grappling with addiction, the closest inpatient treatment center for people living in the county seat, Goldendale, is in Yakima, about an hour’s drive north on U.S. 97.
“People who are addicted in Goldendale are kind of SOL, unless you’re a tribal member and you ask for help,” Melissa Howtopat said. “And you mean it.”
Ivan was a member of the Yakama Nation. In recent years, Native Americans have had the highest rate of deaths from synthetic opioids of any race or ethnicity in Washington, according to state Department of Health data.
After Ivan died, behavioral health workers from the Yakama Nation came to the Howtopats’ home offering services. Melissa told them that she wanted her three other kids to go to treatment; she couldn’t lose another child. And all three agreed.
Her oldest son, who struggled with alcohol, is now doing well. Her younger two children, a 26-year-old son and 23-year-old daughter, have relapsed since they sought treatment.
A vulnerable population
It is currently hard to know the extent of impact fentanyl withdrawal has on those being held in Washington jails.
As of 2019, Washington’s county jails had among the highest death rates in the nation. Suicide has been the leading cause of death in the state’s jails and in jails nationally.
Ivan Howtopat’s family is now preparing to sue Klickitat County, alleging the jail failed to screen him for medical and behavioral health needs adequately and to treat his withdrawal symptoms, and that jailers put him in a cell by himself that had an air vent with an uncovered grill in it, increasing his risk for dying by suicide.
A legislative task force looking at issues in the state’s jails recommended late last year that the state form an independent oversight body to monitor jails.
Supporters of providing the medications say that those who need the treatment are not only vulnerable in custody, they’re also vulnerable when they leave jail or prisons. A 2007 study that compared people released from prison in Washington with the general population found that people released from prison faced a much higher risk of fatal overdoses in the first two weeks after getting out, and that drug overdoses were the leading cause of death among formerly incarcerated people.
While in jail or prison, the absence of the drug may lower their tolerance for it. If they are released and use the same amount they were used to before they were incarcerated, that can lead to overdose — sometimes fatal.
“This is one of our major concerns, is we want (medication-assisted treatment) in every jail,” said Rep. Roger Goodman, D-Kirkland, “Because upon release from incarceration, that’s when people die.”
