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(Editor’s note: This is the first in a three-part series about local opioid addiction treatment efforts. The other two stories will run during the next few weeks.)

When Tacoma-based doctor AJ Shergill established a part-time addiction medicine practice in 2015, he did not foresee eventually opening a suboxone clinic in Longview.

But shortly after he switched to full-time opioid addiction treatment about a year ago, an influx of people from Cowlitz County started showing up desperate for help.

“They were bumming rides,” he said in a recent interview. “A whole bunch of them were relying on one person with a big van to bring them up there. Sometimes they’d make it, sometimes they wouldn’t.”

Shergill, 41, runs Medtriq, a medication-assisted opioid addiction treatment clinic that opened in Longview with little fanfare last November. Since then, the humble clinic has quickly grown to become the largest suboxone prescriber in a county with the third-highest opioid-related death rate in the state. After just six months, Shergill’s Longview clinic is now busier than his Tacoma practice.

Suboxone is a prescription medication that eliminates cravings for painkillers and opioids such as heroin by partially blocking the brain’s opioid receptors. Many people struggling with opioid use disorders will travel for hours to get a prescription. Scientific studies have found medication-assisted treatment can significantly reduce chances of relapsing and overdosing.

Shergill, who lives three hours from Longview, said it’s not particularly convenient for him to drive south to consult with patients here. But his motivation is simple: When patients can’t make it into treatment, they start withdrawing — and often relapse.

Last summer, Shergill said 11 people from Cowlitz County missed appointments on the same day because they were stranded along Interstate 5. The old van they relied on had broken down.

“That’s why I decided to just come down here and open a clinic,” Shergill said. “To make it easier for them to be seen. If you’re going to make a difference, you have to go where the need is.”

At first, Shergill rented a small office on Third Avenue in Longview. He soon was swamped with patients.

Word spread quickly throughout the community, and by the third week his waiting room was overflowing. Some people were forced to wait for up to seven hours, and Shergill met with patients late into the night. About a month and a half later, he started staying in a hotel room on Wednesday nights and meeting with patients on Thursday mornings.

“It was probably the busiest time I’ve ever had in my professional life,” Shergill said.

During the fall and winter, Shergill added about 10 to 15 patients per week simply through word-of-mouth referrals. He soon was forced to relocate from his Third Avenue location due to neighbors’ complaints about groups of destitute-looking patients standing outside smoking cigarettes.

Now his clinic — located at 1318 Washington Way next to the Verizon store — serves more than 100 patients. It is open Monday, Wednesday and Thursday. New patients are welcome on all three days, but Shergill said he prefers first-time visits on Mondays.

Shergill also opened a clinic in Centralia last month, which relieved some of the pressure placed on the Longview clinic by patients coming from Lewis County. That clinic is also open three days per week.

‘I’m healthy enough to fight my demons’

Christina was 11 years old when she found her father dead from a heroin overdose at a residence in Longview. She called an ambulance, but the paramedics were unable to resuscitate him.

“That was a really hard thing for me,” she Wednesday in an interview at Medtriq. “Finding my dad dead caused a lot of trauma in my life.”

Throughout her adolescence, Christina repeatedly witnessed her aunts and uncles injecting heroin. But she vowed to never use it.

When Christina was 15 years old, however, she was diagnosed with a painful kidney disease. Her doctor prescribed oxycontin. Over time, she developed a resistance to the highly addictive pills.

“Slowly I became addicted to pain medication, physically and then mentally,” she said.

She eventually went from taking her pills orally to crushing and snorting them, which led her to a dark place.

Seeking help, Christina tried for months to gain entry into PeaceHealth St. John Medical Center’s suboxone program. But every time she called, staff told her the the clinic was full. With only one doctor prescribing suboxone, space was extremely limited. The Kaiser Permanente Medical Clinic in Longview also employs a doctor who prescribes suboxone, but Christina was told the clinic does not accept Medicaid. So with no local alternatives, Christina continued to take painkillers.

Then another traumatic event in her life — which she declined to disclose — prompted her to do the unthinkable.

“I started smoking heroin,” she said.

Christina’s life quickly deteriorated even further, but after about 45 days she decided to seek treatment again.

This was around the time Shergill opened his Longview clinic. Christina tried to see Shergill on one of his busiest days last fall, but she was told to come back the following week due to six-hour-plus wait times. So she returned a week later — and to her relief, she was seen.

Christina, now 30 years old, has been off her painkillers for six months. She no longer needs to take three different nausea medications daily, and her cravings are gone.

Instead, she takes suboxone twice daily and meets with a counselor regularly. Color has returned to her face.

Like most of the clinic’s clientele, Christina has health insurance through Apple Health — Washington’s version of Medicaid. The program covers the cost of her clinic visits and medication. Unlike private insurance, Medicaid patients do not need to wait for prior authorization to fill prescriptions and there is no limit on how long they can stay enrolled in chemical dependency programs.

Christina recently started a part-time job, and her fiance is also in Shergill’s program.

“I’m ready to conquer the world,” Christina said. “I’m healthy enough to fight my demons.”

‘We don’t mistreat anyone’

How did a doctor from Tacoma establish the busiest opioid addiction treatment clinic in Cowlitz County seemingly overnight?

The controversial methadone clinic in Kelso — which prescribes and dispenses medication — took nearly two years to obtain permits from eight different state and federal agencies. But Shergill was able to sidestep the red tape.

Because Shergill only meets with patients and writes prescriptions, he simply needs to meet the criteria for any other type of basic medical clinic.

With a background in business, Shergill also possesses the right skills for adjusting a clinic to accommodate a surge in demand. Shergill received his medical training at Kansas City University of Medicine and completed his residency in internal medicine at Legacy Health Systems in Portland. While in Kansas City, he also earned a dual masters in business administration degree.

He never considered addiction medicine a calling, but when he opened his part-time Tacoma practice he quickly found he enjoyed solving logistical problems to help people in need.

Since he first opened his Longview clinic, Shergill has hired two new providers who are licensed to prescribe suboxone.

“It’s important to keep extending days and adding more providers to make sure people aren’t waiting too long,” he said.

Many patients who have been stabilized have jobs, so the idea is to make the process as convenient as possible.

“I don’t want people to be out of work, missing work or having trouble at work because of these appointments,” he said.

The providers also dial in remotely to conduct televisits via webcam. Patients need to come into the clinic to track blood pressure and give urine samples to ensure they are taking the suboxone and not using any other drugs. But the providers can be anywhere, and the televisits also are covered by Medicaid.

Televisits are especially crucial in rural communities where it’s a challenge to find providers who are licensed — and willing — to prescribe suboxone.

“Longview is a pretty small town, so it’s hard to find providers,” Shergill said. “But in Seattle, Tacoma, Bellevue … it’s no problem.

Shergill also recently agreed to partner with a Spokane-based provider of telepsychiatric services. About three-quarters of his clinics’ patients have co-occurring mental health disorders, he said.

“You can’t treat addiction if you don’t treat their depression, anxiety, PTSD,” he said. “Those are big drivers of their continued use. I’ve learned over time that addiction treatment really requires behavior change.”

The Longview clinic electronically routes prescriptions to the Rite Aid across the street, and Medtriq also runs its own lab so staff are not relying on drug test results from a different facility.

“Many places where people have gone before, they’ve had a poor experience. They just don’t feel treated very well, and there might be a lot of reluctance because of that,” Shergill said. “Once they’re in here they realize it’s just a different kind of clinic. We don’t mistreat anyone.”

Even with a rapidly growing practice, Shergill said he isn’t in it for the money.

About 98 percent of his patients are on Medicaid, which has the lowest reimbursement rate among all insurers in the state.

“That’s why many of these patients don’t have treatment options,” he said. “Nobody’s even taking their insurance, so they can’t go anywhere.”

Lucrative practices usually limit patient populations to around 10 percent to 15 percent Medicaid patients or charge cash, he said.

“When I focus on addiction and mental health only, then I can create an efficient practice and from a business perspective I can still make it work,” he said.

‘You relapse when the situation isn’t working’

Nohelani Garcia got hooked on opioids after a complicated childbirth. The 29-year-old Kelso resident was prescribed painkillers after her delivery, and she turned to the streets for more pills when her supply ran out.

When the mother of two decided to get clean, she couldn’t find a local clinic that would accept Medicaid, so Garcia’s mother started driving her to Rebound Behavioral Health in Vancouver.

She is glad she doesn’t need to make the costly and time-consuming drive down south anymore.

After meeting with Shergill for the first few months, she was slightly apprehensive when she learned her next appointment would be through the clinic’s televisit station with a Tacoma-based nurse practitioner.

“At first, I was skeptical because I was like ‘How is she going to assess me if she’s not even in the same room as me?’ “ she said in an interview.

But the visit went well, and now she prefers meeting with the female nurse practitioner over the web.

“I was like ‘Oh yeah, this is pretty cool,’ “ Garcia said. “It’s just like if she was in the room.”

Garcia’s friend Tonya Kovach also traveled down to Vancouver for methadone doses until she learned about Shergill’s clinic.

The 30-year-old Kelso resident, who paid out of pocket, said she would spend more than $400 per month on medication and transportation costs.

She relapsed several times when she ran out of money for the medication or could not arrange for transportation.

“You relapse because the situation’s not working,” she said.

Kovach is now focusing on her recovery, and Garcia is studying business management at Lower Columbia College.

“I’ve been wanting to go back to school for a couple of years, but when I started using I kept putting it on the back burner,” Garcia said. “When I got on suboxone, I finally got the ball rolling.”

Local partnerships

With wait times down and the clinic running smoothly, Shergill said he is looking to deepen partnerships with local health care providers.

Many of his patients receive primary care at Family Health Center, and he has approached the clinic about installing televisit stations for pregnant women to use.

He also is getting referrals from the Cowlitz County Drug Court and Awakenings, the local substance abuse treatment center.

“We share the same goal of getting everything taken care of around the addiction,” he said.

And Shergill is already scouting for more locations in underserved areas around rural Southwest Washington. A clinic in Klickitat County could be next, he said.

“We’ve kind of validated our practice model,” he said. “In any location, really, we can make it work. The goal is to set up smaller clinics, wherever they may be, and just get going.”

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