Evolving to Deliver Compassionate Care to a Vulnerable Population
Dr. Yong Ki Shin inhabits two worlds. It just so happens that these worlds coexist in a small rural town in southwestern Washington. Their close proximity makes it easy for Dr. Shin to pass from one into the other and back again, often several times in the same day.
Dr. Shin launched his private practice in Montesano, Washington, in the late 1990s. About eight years ago, the county asked him if he would be willing to provide urgent care at the local jail. Grays Harbor County Jail’s nurse practitioner—and only care provider—had decided to move on. “My practice was across the street, so I figured it would be easy for me to go over and take care of the inmates,” says Dr. Shin. “That’s how I got started.”
But providing care to geriatric patients isn’t the same as providing care to the incarcerated. Dr. Shin admits he didn’t know what he was getting himself into, and lacked the training to understand the standard of care in a correctional environment. “The first three years, I was mostly providing urgent care,” says Dr. Shin. As he watched and learned more about the health needs of the inmates, he began taking steps to improve the quality of the jail’s care, especially in the way it treated inmates with addictions.
ADDICTION IN CORRECTIONAL SETTINGS
Dr. Shin soon came to understand that practicing correctional medicine consists primarily of treating addiction.
That wasn’t always the case. Christened by President Richard Nixon in 1971, the War on Drugs would become a decades-long crusade against the trade and use of certain controlled substances. Aggressive enforcement and harsh mandatory sentencing became commonplace for simple possession, taking precedence over prevention and treatment.
The federal government increased its budget for the control of illicit drugs eightfold during the 1980s. Over the same period, the frequency of arrests for drug offenses rose 126 percent. By 2013, nearly half a million people per year were being incarcerated for drug-related crimes.
Research from the National Center on Addiction and Substance Abuse (CASA) at Columbia University demonstrates an unmistakable link between drug and alcohol use and the rapid growth of the country’s prison population. Of the more than 2.3 million people currently held in U.S. prisons and jails, two-thirds meet clinical criteria for substance abuse or addiction.
Many incorrectly assume that incarceration—time spent in a restrictive environment with limited access to substances to abuse—can help addicts kick their habits. On the contrary, long stints spent among other addicts under highly stressful circumstances, layering additional traumas onto already-fraught lives, make the odds of an addict relapsing after release extremely high.
Death from overdose is another significant danger, particularly when it comes to opioid addicts. A 2007 study of a population of more than 30,000 former inmates in Washington found that their risk of death from overdose after release was roughly 3.5 times higher than the general population’s. The days immediately following a prisoner’s release are the most dangerous. In the first two weeks, the study found, the risk of death by overdose was 12.7 times higher than it was for the average Washingtonian. The most effective approach to mitigating these risks is to provide inmates with substance-use disorder treatment during incarceration, and to continue that treatment uninterrupted upon release. However, according to another CASA study, only 11% of inmates with substance-use disorders have access to treatment while incarcerated.
CONFRONTING ADDICTION IN JAIL
A lot can change in eight years. “Our community has changed. I have changed,” says Dr. Shin. “Opiate addiction has become significantly worse.”
Before accepting his new role at the Grays Harbor County Jail, Dr. Shin had only encountered patients with addictions in inpatient settings. His impressions were generally negative. “I hadn’t been trained to treat addicts. I found them difficult and demanding, and I didn’t know what to do with them," he recalls. As Dr. Shin began caring for inmates, his views of addiction began to change. Gradually he stopped seeing it as an issue of self-control. When people put addictive substances before their freedom and health—and in the most extreme cases, before their lives—they are clearly no longer thinking rationally. “Once I started looking at it that way,” says Dr. Shin, “I wanted to do whatever I could to take away that destructive craving.”
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“Our community has changed. I have changed. Opiate addiction has become significantly worse.”
—DR. YONG KI SHIN
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Experiences with people visiting his clinic also influenced Dr. Shin’s feelings toward addiction. Many of his elderly patients struggle not only with their own health issues, but also with raising grandchildren as the children’s parents battle addiction—in many cases in the jail across the street.
A couple of years ago, local leaders came together to develop a community-based strategy for coping with the problem. Public health officials, the sheriff’s department, and the prosecutor’s office all contributed to the conversation. Among the highest priorities they identified was bringing treatment services into the jail to reduce criminal recidivism and improve the odds of recovery.
To that end, the county formed a partnership with Evergreen Treatment Services (ETS), a nonprofit that has provided substance-use disorder services in Western Washington since 1973. ETS has since taken on multiple roles in treating the jail’s addicts. As a first step, the county had ETS addiction specialists come to the jail on a daily basis to provide methadone to patients who had been using it successfully before their incarceration.
ETS has also helped Dr. Shin identify suitable candidates for treatment with Suboxone, a highly effective medicationassisted therapy combining buprenorphine and naloxone. Dr. Shin sought training and obtained the necessary certification to provide Suboxone to prisoners himself, which he has been doing for nearly two years. However, funding for addiction treatment has been limited: while Medicaid does pay for Suboxone therapy, that coverage ends when a Medicaid recipient becomes incarcerated. Upon releasing these inmates back into the community, the jail does a warm handoff, driving them to the local ETS center where they can begin the process of continuing their care outside of the penal system. “We wanted to remove some of the obstacles these patients have to establishing long-term addiction treatment, and reduce the incidence of overdoses,” says Dr. Shin.
TRAINING A NEW GENERATION
Dr. Shin has no illusions that efforts like his will solve the problem of addiction in rural communities like Montesano. Incarcerated addicts, often at the lowest point in their lives, present the poorest odds of recovery of any addicted group. Still, when communities fail to address these needs among the incarcerated, it reveals the troubling yet common conviction that addiction is a personal failure rather than a public health crisis—an attitude that undermines efforts to prevent and treat addiction in the first place.
“Many doctors have done much more than I have to treat inmates with addiction problems,” says Dr. Shin. “I wasn’t trained to treat addiction, but I saw a need in my community and evolved.”
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“We’ve reached a point where we can no longer rely on
addiction specialists to deal with the problem.”
—DR. YONG KI SHIN
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Other physicians need to evolve as well, Dr. Shin maintains. The problem is not that we lack the knowledge and tools to prevent and treat addiction, but that there are not enough doctors willing and able to work with addicted patients, regardless of whether they’re incarcerated.
“We’ve reached a point where we can no longer rely on addiction specialists to deal with the problem,” says Dr. Shin. “Our program would not have been possible had ETS not been providing services in the community.” In other words, overdependence on organizations like ETS is a real obstacle to communities’ ability to fight addiction effectively. Medical schools have begun incorporating addiction and correctional medicine into their curricula, so there is hope that the next generation of doctors will be better equipped. Dr. Shin, who serves on the faculty of the School of Medicine at the University of Washington, enjoys teaching students and residents about correctional medicine and the use of Suboxone. “I’m just so heartened when doctors-intraining, both students and residents, show interest in learning how to care for the incarcerated.”
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