Inmates leaving the Harris County jail in Texas will soon be offered monthly Vivitrol injections to help them combat heroin and opioid addiction. The innovative pilot program has sparked some criticism, but defenders say the treatment can help keep addicts out of the justice system.
When Kristina Davis walked into her daughter’s parent-teacher conference high on heroin, it was a moment of truth. She knew things had to change.
The 31-year-old had tried to get sober before, but nothing stuck. So on Wednesday, she tried something new.
Sleepy-eyed but hopeful, Davis arrived at the Texas Clinic before 7 a.m. for her first injection of Vivitrol, a drug administered once a month to combat addiction.
“Honestly, I just want to live,” she said. “I’m tired of dying every day.”
The shot is an innovative treatment option that soon will be available for inmates leaving the Harris County Jail. The state’s largest county lockup has launched a pilot program that will begin offering the treatment in coming weeks to soon-to-be-released prisoners in hopes of preventing relapse and reducing recidivism.
It is believed to be the first county jail in Texas to offer the drug.
“It’s really pretty exciting for us,” said Dariel Newman, the jail’s head nurse of quality improvement. “We see so many folks in here that their addiction is either the reason they were arrested or a factor.”
The medication is designed to combat opioid and alcohol cravings, but it’s not as well-studied as some of the alternatives, experts caution. The marketing practices of the drugmaker, Alkermes, have sparked criticism in recent months, including a sharply worded letter from U.S. Sen. Kamala Harris, D-Calif., calling for an investigation into “treatment manipulation.”
But amid a rising tide of heroin addiction, the Harris County Sheriff’s Office is optimistic about the drug’s possibilities.
“We’re trying to be more innovative as an agency,” said Sheriff Ed Gonzalez. “Incarceration only is not an effective solution.”
‘A Big Step’
Vivitrol is non-addictive, non-narcotic and has no street value—three traits that have made it appealing to jails and corrections departments, some of which may not be comfortable with other treatments like methadone or buprenorphine, one of the drugs in Suboxone.
The monthly shot is a long-acting version of naltrexone, which works by covering opioid receptors so heroin can’t reach them. That means patients on Vivitrol aren’t able to get high and may have fewer cravings.
But unlike Vivitrol, which is a non-narcotic “antagonist,” buprenorphine and methadone are agonists. Known as maintenance treatments, the drugs latch on to the opioid receptors and prevent the heroin from attaching but at the same time deliver a bit of their own painkilling effect.
The U.S. Food and Drug Administration approved Vivitrol shots in 2006 for use in alcohol dependence treatment. But as the opioid epidemic ramped up, the medication became another tool in the fight against heroin.
Because it’s a long-lasting shot, patients don’t have to take a pill or pick up a methadone dose every day. But it requires that patients get off heroin before they can start the first shot, or they risk making the painful detox worse.
It’s also pricey: more than $1,000 per shot. Drugmaker Alkermes has donated enough Vivitrol to cover the initial doses for everyone in the Harris County Jail’s 20- to 30-person pilot program, and after that block grant funds, Medicaid or private insurance are expected to cover the rest.
Over the coming year, the jail’s medical staff will help select inmates for the program, looking for medically and psychologically fit candidates with a strong desire to stay sober.
“Are you addicted to opiates? Are you addicted to alcohol? Because if so, we will help you,” Newman said.
Participation is voluntary, and there’s no incentive in terms of reduced sentences. And only inmates set to be released – not those headed to state prison – are eligible to take part.
“This is a big step for the jail,” said Katharine Neill Harris, a researcher with Rice University’s Baker Institute for Public Policy.
Although the drug is a new offering for Harris County inmates, it’s already been locally available through the Texas Clinic Healthcare System, which has partnered with the jail to administer the program.
Just before their release, selected inmates will get one 380-mg shot. After their release, they’ll come back once a month for shots, with additional visits for counseling.
“On average, people stay on Vivitrol about 6 to 12 months,” said Farrukh Shamsi, Texas Clinic Healthcare System president and CEO. The Fulton Street clinic, which has been offering medication-assisted treatment since the 1980s, started doling out the monthly shots about two years ago, and since then, Shamsi said, he’s seen some notable success stories.
Stopping the Cravings
“We had a patient who switched over from buprenorphine and wanted to be off everything,” he said. “The first shot, he said, ‘Everything is going fine and I don’t have any cravings.’ And the second shot he said he noticed this color on the side of his house that he never noticed before.”
That’s the sort of testimony that made the shot an attractive option to Davis. She’d tried Suboxone and didn’t like it.
“I felt over-medicated,” she said.
So this time when she went into rehab in October, she asked about other options, and the program director told her about Vivitrol. Her recovering peers were skeptical, Davis said, but she wanted to try it anyway.
“It sounds promising,” she said, minutes before receiving her first injection. “I’m always willing to try some new avenue.”
After 15 years of battling her addiction, it feels like it’s about time, Davis said.
The Houston native started using hard drugs in her mid-teens, a move she now attributes to untreated childhood trauma.
“The rig was the only thing that accepted me, and I didn’t have to worry about anything else,” she said. But despite her descent into addiction, Davis managed to keep up appearances. For years, she held a job at a local oil change company. She took community college classes and, as a single parent, raised her 7-year-old daughter.
She had periods of clean time, but in the end she always returned to the needle. Now, she thinks maybe those four trips to rehab and two jail stays could have been avoided if she’d been able to get naltrexone before.
“I would have been clean a long time ago,” she said.
Although the drug is appealing to health care providers uncomfortable with the idea of maintenance treatments, it’s also been a source of some controversy. A ProPublica investigation over the summer raised questions about the relative lack of research showing efficacy and the ethics of (Vivitrol’s) coercive use in drug court programs.
Earlier this month, Sen. Kamala Harris announced an investigation, saying Alkermes had purposely contributed to misconceptions about other medications to boost its sales.
“Alkermes has taken unethical drug promotion to new depths by enlisting judges, law enforcement personnel, and legislators to favor Vivitrol over proven treatments,” Dr. Adriane Fugh-Berman of Georgetown University Medical Center said in a release at the time.
Alkermes fired back, saying it had “dedicated itself to addressing the scourge of opioid addiction” and agreeing to cooperate.
Just a few days later, a large-scale study helped bolster some of the drugmaker’s claims, but experts still see some cause for concern.
“There is much more data showing long-term effectiveness of methadone and buprenorphine, including studies from other countries showing that when offered during incarceration, these medications decrease mortality after release from incarceration,” said Dr. Aaron D. Fox of Montefiore Medical Center. Although the new study boosts claims about the drug’s efficacy in fighting cravings, there’s still more research on the life-saving effects of older treatments.
“I’m sure that Vivitrol can be helpful for some people,” Katharine Neill Harris said. “But I would caution against the rush to Vivitrol to the neglect of other medications that we do have evidence help people.”
Harris County Sheriff’s Maj. Mike Lee, who oversees the jail’s mental health programs and diversion strategies, said he’s open to exploring other options.
“We’re doing it with great intention, and we have every hope that it succeeds,” he said. “But I think we’re willing to say if this approach doesn’t work, then let’s try another.”
Lee also said the sheriff’s office “would consider” giving out the overdose-reversing drug naloxone to inmates before their release. And non-medication interventions may be on the table, too, including a detox center or Law Enforcement Assisted Diversion, or LEAD, program.
“There have been discussions occurring at the county level about possibly diverting some other low-level drug offenders,” he said. “What that would look like, we’re still having discussions.”
But whatever effects these programs have inside the jail, Davis hopes she never finds out— at least not from the inside.
“I’m trying to make sure that once I hit two years clean I can work at a treatment center and give back,” she said. “I want to do recovery coach training. That’s my goal.”
Kerri Blakinger is a staff writer for The Houston Chronicle. This story was one of her projects as a participant in the 2017 John Jay/Koch Texas Justice Reporting Fellowship program. Her original story can be accessed here. She welcomes readers’ comments.