Family of man who died in Klickitat County Jail questions facility’s medical care

Editor’s note: This story contains descriptions of suicide and self-harm. If you or someone you know is considering self-harm, support is available 24 hours a day at the national suicide crisis lifeline. Just call 988 to talk to a trained listener or text HELLO to 741741.

Melissa Howtopat, left, hugs a friend in Klickitat County on Aug. 19, 2022. Howtopat and her husband are raising questions about the Klickitat County Jail after their son died while enduring fentanyl withdrawal.

Troy Brynelson / OPB

Melissa Howtopat picked up a call from her son in the Klickitat County Jail in May. He expected to spend the next 15 days in jail, and he wanted his parents to meet him when he got out.

“He was like ‘Can you pick me up? Or can dad pick me up? Because that way I won’t go to the drug house,’” Melissa Howtopat recalled her son saying from the jail phone, worried he would return to fentanyl.

Days later, Ivan Howtopat died in jail by suicide. Melissa and her husband Donovan have since been grappling with how their 24-year-old son ended up dead and questioning whether the Klickitat County Sheriff’s Office properly cares for inmates feeling the pangs of drug withdrawal.

They argue Ivan Howtopat should have been taken to the hospital, where he could be supervised while his body fought the effects of the powerful opioid.

“When he was arrested, my dad told the arresting officers that he needed help because he was severely addicted,” Melissa Howtopat said. “You can’t just throw him in there and forget about him.”

Klickitat County Sheriff Bob Songer, who oversees the jail, did not respond to requests for comment.

Melissa Howtopat, right, pictured with her son Ivan Howtopat in an undated photo. Melissa Howtopat and her husband are raising questions about the Klickitat County Jail after their son died while enduring fentanyl withdrawal.

Courtesy of Melissa Howtopat

The family has hired a law firm but has not filed any official complaints in court. However, the attorneys said that jail staff did nothing to help Ivan Howtopat detox even though they were aware he was a fentanyl user.

“Ivan’s death is tragic, but especially so because it was preventable,” wrote Corinne Sebren in a statement.

Klickitat Sheriff’s deputies arrested Ivan Howtopat on May 15 in the town of Goldendale. He had fentanyl in his system, records show, when the deputies attempted to stop him while he was riding a bicycle.

Arresting deputies actually mistook Howtopat for a different man with a felony warrant. They didn’t learn who he was – or that he, too, had a felony warrant — until after they arrested him. Howtopat had fled on his bike, crashed it, and ran into a backyard where he was arrested.

The deputies cited him for his warrant and for resisting arrest, records show.

According to records, jail staff couldn’t book Howtopat into the jail right away because he was “hard to wake” and “not cooperative.” A screening noted he had a dependency on fentanyl.

Fellow inmates later told investigators that Howtopat was reeling from withdrawal and expressing intense discomfort. At one point, Howtopat asked a fellow inmate to break his arm so he could go to a hospital.

“I’m looking at him like, dude, they’re not going to let you out of here. They’re going to bring you right back,” John Raczykowski told investigators. “He’s like, ‘I just can’t take it in here.’ And I said, ‘Dude, just calm down, your worst enemy is your mind.’”

Raczykowski also recalled Howtopat crying during a card game and asking about methods of suicide.

Klickitat County Sheriff Bob Songer speaks at a public meeting Aug. 1, 2023.

Troy Brynelson / OPB

“I asked him, like, ‘You’re not going to do anything?’ And he said, ‘I’m tired,’” Raczykowski said.

Howtopat spent five days in jail by the time corrections deputies found him dead in his cell on May 20. Video footage shows about an hour elapsed between checks by deputies. A medical examiner said his injuries were consistent with someone hanging for nearly that long.

A 2019 investigation into Northwest jail deaths by OPB and the Northwest News Network found that around 40% of the deaths happen within the first week someone is incarcerated. The analysis of a decade of data also found nearly half of all jail deaths were the result of suicide.

To family members, jail staff should have flagged Howtopat immediately and ensured he received medical treatment. They question whether jail staff followed best practices.

“They weren’t qualified, I guess. I feel like they weren’t qualified at all to even take him into their jail,” Melissa Howtopat said.

County jails often look to outside organizations to help implement care for inmates with substance abuse disorders. It was not immediately clear what policies Klickitat County has in place at its jail.

Sebren, the family’s attorney, raised a number of concerns with Howtopat’s time at the jail. She said the family had to fight to get a copy of his medical test in jail.

Sebren argued the medical test has multiple discrepancies. It wasn’t conducted by a medical professional, but rather the same corrections deputy who said Howtopat couldn’t be woken up at his arrival.

Another discrepancy: The medical test said Howtopat never “attempted or seriously considered suicide.” Records provided by the jail show he had many run-ins with the law over the years, including multiple instances described as a “suicide attempt.”

Sebren contended jail staff should have looked at Howtopat more closely on intake.

“These are all red flags where people should have said, ‘Hey, do they need to check him out? Do they need to ask other questions?’” Sebren said.

The sheriff’s office did allow Donovan Howtopat to perform a cleansing ceremony within the jail cell. And Melissa Howtopat said the family is now trying to raise money for a headstone.

New Alzheimer’s Drug Raises Hopes — Along With Questions

The FDA has approved Leqembi, the first disease-modifying treatment for early-stage Alzheimer’s and a precursor condition, mild cognitive impairment. Medicare has said it will pay for the therapy. Medical centers across the country are scrambling to finalize policies and procedures for providing the medication to patients, possibly by summer’s end or early autumn.

It’s a fraught moment, with hope running high for families and other promising therapies such as donanemab on the horizon. Still, medical providers are cautious. “This is an important first step in developing treatments for complex neurodegenerative diseases, but it’s just a first step,” said Ronald Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center in Rochester, Minnesota.

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Unanswered questions abound as this new era of treatment begins for mild cognitive impairment and early-stage Alzheimer’s. Will Leqembi’s primary benefit — a slight slowing of decline in cognition and functioning — make a significant difference to patients and family members or will it be difficult to discern? Will its effects accelerate, decelerate, or flatten out over time?

Will demand for Leqembi (the brand name for lecanemab), a monoclonal antibody that requires infusions every two weeks, be robust or restrained? How many older adults in their 70s and 80s will be able and willing to travel to medical centers for infusions twice a month and have regular MRI scans and physician visits to monitor for potential side effects such as brain bleeds or swelling?

Even with Medicare coverage, how many people will be able to afford the suite of medical services required, including cognitive tests, infusions, doctors’ appointments, MRI scans, genetic tests, and spinal taps or PET scans to verify the presence of amyloid plaques, a hallmark of Alzheimer’s and a precondition for receiving this therapy?

Will primary care physicians start routinely screening older adults for mild cognitive impairment, something that doesn’t happen currently?

These questions aren’t surprising, given that these dementia treatments are opening uncharted territory. Here’s some of what people should know:

Leqembi basics. Leqembi is very effective at removing amyloid plaques (a protein that clumps between neurons) from people’s brains. But it doesn’t reverse cognitive decline or prevent future deterioration.

In a briefing document, Eisai, the company that makes Leqembi, said clinical trials showed a 27% slower rate of decline for people taking the drug. But when raw scores on the cognitive scale used to measure results are considered (4.41 for the Leqembi group at the end of 18 months versus 4.86 for the placebo group), the rate of improvement was 9%, according to Lon Schneider, a professor of psychiatry, neurology, and gerontology at the University of Southern California’s Keck School of Medicine.

Benefits may be hard to detect. Research suggests that patients notice a “clinically meaningful” change in cognitive performance — a noticeable alteration in their ability to think, remember, and perform daily tasks — when scores rise at least 1 point on an 18-point scale used to measure Leqembi’s impact. But the change detected after 18 months for patients taking this medication was only 0.45%.

“That’s a minimal difference, and people are unlikely to perceive any real alteration in cognitive functioning,” said Alberto Espay, a professor of neurology at the University of Cincinnati College of Medicine.

Petersen has a different perspective since many patients have told him they’d be happy to put off getting worse. “If they can keep these patients stable for a somewhat longer period of time, that’s meaningful,” he told me.

Side effects are common. The drugmaker reported 17% of patients taking Leqembi experienced swelling in the brain and 13% had brain bleeds. Most of these side effects occurred during the first three months of treatment and resolved without serious consequences four months later.

In slightly more than 1 in 4 cases, there were also infusion-related side effects — chills, aches, nausea, vomiting, a spike or drop in blood pressure, and more.

A little-discussed side effect is a reduction in brain volume associated with Leqembi and other anti-amyloid therapies. “We don’t know what this will mean to patients long term, and that’s concerning,” Espay said.

Because people with the APOE4 gene variant, which raises the risk of Alzheimer’s, are also at higher risk of Leqembi side effects, physicians at major medical centers will recommend genetic testing as they evaluate potential patients.

Not all patients will qualify. “I’m very carefully selecting the patients I think will be appropriate, focusing on people with mild cognitive symptoms who are otherwise healthy,” said Erik Musiek, an associate professor of neurology at the Washington University School of Medicine in St. Louis.

He has about 20 patients ready to start treatment once Washington University starts offering Leqembi, perhaps by early autumn. Delivering this therapy “is going to be challenging, and I think they need to err on the side of caution,” he said.

In Los Angeles, UCLA Health has set up a multidisciplinary group of specialists, similar to a cancer tumor board, to undertake comprehensive reviews of patients who want to take Leqembi, said Keith Vossel, director of UCLA’s Mary S. Easton Center for Alzheimer’s Research and Care. They will disqualify people with evidence of more than four microbleeds on brain MRIs, those taking blood thinners, and those with a history of seizures.

At the Mayo Clinic in Minnesota, a new Alzheimer’s therapeutics clinic will carefully assess potential patients over three to four days and treat only people who live within a 100-mile radius. “We’ll start with patients who are fairly healthy and follow them very closely,” Petersen said.

At Mount Sinai School of Medicine in New York City, Mary Sano, director of Alzheimer’s Disease Research, is concerned about older patients with mild cognitive impairment who want to take Leqembi but don’t have evidence of amyloid plaque accumulation in their brains. “We’ll only treat people who are amyloid-positive, and I’m afraid this could lead to people feeling like we’re not taking care of them,” she said. About 40% to 60% of patients 58 and older with mild cognitive impairment are amyloid-positive, research indicates.

Also of concern are patients who have moderate Alzheimer’s or early-stage cognitive impairment due to vascular dementia or various metabolic causes. They, too, would not be able to take Leqembi and may well be disappointed, Sano noted.

Costs could be considerable. Costs for Leqembi are difficult to calculate since Medicare officials haven’t announced what the government will pay for services. But the University of Southern California estimates that a year’s worth of care, including the $26,500 cost of the medication, could total about $90,000, according to Schneider.

A separate analysis by the Institute for Clinical and Economic Review suggests that all the medical services necessary to administer the drug, monitor patients, and undertake needed testing could total an average of $82,500 yearly on top of Leqembi’s direct cost.

Assuming a patient copayment of 20%, that would mean at least $18,000 in out-of-pocket spending. While many older adults have supplemental insurance (a Medigap plan or employer-sponsored retiree coverage) to cover these costs, nearly 1 in 10 Medicare beneficiaries lack this type of protection. And it remains to be seen what policies private Medicare Advantage plans will put in place for this medication.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

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Anti-magnetizing-vaccine doctor loses medical license

Sherri Tenpenny, the Ohio anti-vaccine doctor who made national headlines for claiming in viral testimony that COVID-19 vaccines make people magnetic, has lost her medical license.

The state medical board indefinitely suspended her license Wednesday, saying she refused for over two years to cooperate with the board's investigation of over 350 complaints against her, which suggested possible violations of state medical regulations.

In a hearing on Wednesday, board members suspended and chastised Tenpenny for failing to cooperate or answer a single question from the regulators. "Dr. Tenpenny, neither you nor any doctor licensed by this board is above the law, and you must comply with the investigation," Dr. Jonathan Feibel, an orthopedic surgeon and medical board member, said, according to Cleveland.com. "You have not done so, and therefore, until you do, your license will be suspended."

Dr. Amol Soin, a pain management specialist and board member, told Tenpenny that obtaining a medical license and practicing medicine is a privilege that requires one to consent to "reasonable things."

"And a reasonable thing you consent to... is to cooperate when someone complains about you. In this case, 350 complaints. It is a very reasonable thing to cooperate in that scenario," he said.

According to a report from the board, when investigators repeatedly attempted to ask Tenpenny questions, beginning in July 2021, she consistently failed to respond. That included failure to respond to an investigator's email and office visit, provide written responses to subsequent questions, appear at a subpoenaed deposition, and appear at an investigative office conference.

A letter sent to the board by Tenpenny's lawyer indicated that she "will not participate in the Board’s ongoing illegal fishing expedition."

If she had cooperated with the investigation, the board intended to ask Tenpenny about her recommendations and administrations of vaccines, and whether any of her patients had contracted vaccine-preventable illnesses. They also had questions about the evidence she had to support various eyebrow-raising public claims, including those:

regarding COVID-19 vaccines causing people to become magnetized or creating an interface with 5G towers; … and regarding some major metropolitan areas liquefying dead bodies and pouring them into the water supply.

The questions came shortly after Tenpenny provided viral testimony to state legislatures on June 18, 2021, which was chock-full of anti-vaccine rhetoric and conspiracy theories.

"I'm sure you've seen the pictures all over the Internet of people who have had these shots and now they're magnetized," Tenpenny said in the testimony. "You can put a key on their forehead—it sticks. You can put spoons and forks all over and they can stick because now they think there is a metal piece to that."

She also made claims of an "interface—yet to be defined" between elements of vaccines and "all of the 5G towers."

According to the Ohio Capital Journal, Tenpenny wrote a follow-up email to the lawmaker who had invited her to testify, saying, in part:

We’re on to something here… and the LOUDER they scream, the more they are trying to hide. I stand by everything I said today. I put out FACTS and HYPOTHESIS (points to ponder).

God Wins,

Dr. Sherri Tenpenny

Beyond the moment of fame, Tenpenny has established herself as an active anti-vaccine advocate, making media appearances with the likes of Alex Jones and authoring a book titled, Saying No to Vaccines: A Resource Guide for All Ages.

The board rejected Tenpenny's legal reasonings for not cooperating with the investigation and noted that she took no action in court to challenge the board's subpoena or request the ability to withhold answers. The board also noted that it is "statutorily required" to investigate the complaints against her, which suggested regulatory violations.

"In short, Dr. Tenpenny did not simply fail to cooperate with a Board investigation, she refused to cooperate. And that refusal was based on her unsupported and subjective belief regarding the Board’s motive for the investigation. Licensees of the Board cannot simply refuse to cooperate in investigations because they decide they do not like what they assume is the reason for the investigation," the board's report concluded.

Tenpenny's license is now suspended, and the board issued her a civil fine of $3,000. To get her license back, she would have to reapply, pay the fine, comply with the investigation, and submit a written statement certifying compliance. If more than two years pass in the meantime, the board may also require her to provide additional evidence of "her fitness to resume practice."