Three days before his release from the Barnstable County Correctional Facility, Ryan Lonergan received a powerful injection, intended to change his life.
He took the shot willingly, because he knew that for 28 days afterward, the drug, Vivitrol, would make it impossible to get high on the Percocet that had been his life's downfall. Now, Lonergan would not have to decide each day whether to use drugs. Vivitrol made the decision for him, and cleared a path to recovery.
Barnstable County started offering Vivitrol to inmates in 2012, among the first jail operators in the country to do so. Since then, jails and prisons throughout Massachusetts, and about 100 others nationally, have embraced Vivitrol as a new tool to keep people off of drugs and out of prison.
The adoption of Vivitrol for departing inmates illustrates the intensity of concern about an epidemic of opioid use that resulted in more than 1,200 fatal overdoses in Massachusetts last year. Although private doctors have been slow to adopt the medication, criminal justice authorities view it as a powerful weapon to combat both opioid abuse and high incarceration rates.
Unlike other drugs to treat addiction, Vivitrol is long-acting, shielding newly released inmates from their own impulses during the critical first days of freedom. Unlike methadone and buprenorphine (often referred to by its brand name, Suboxone), Vivitrol doesn't produce a high and can't be diverted to street use.
And the requirement to be opioid-free for seven to 10 days before starting Vivitrol, a difficulty for some outside prison, isn't an issue for those who have had to detox behind bars.
Vivitrol blockades the receptors in the brain where opioids and alcohol attach, preventing the pleasure that addicts seek.
But the drug itself may not be the real game-changer, said Dr. Barbara Herbert, president of the Massachusetts chapter of the American Society of Addiction Medicine. More crucial, she said, are efforts by the manufacturer, Waltham drug maker Alkermes, to push prisons to link departing inmates with services on the outside, measures often lacking in the past.
"Its reputation on the street is that it's a silver bullet," Herbert said of Vivitrol. "But there is no way to heal from addiction without doing the psychological work of recovery."
Alkermes provides all prisons and jails in Massachusetts with free samples for the first Vivitrol injection before release, and Medicaid or other health insurance typically covers most or all of the $1,000-a-dose monthly shot outside prison. The company emphasizes that Vivitrol's effects must be bolstered by counseling and other behavioral interventions, forcing prisons and jails to forge relationships with treatment centers.
Vivitrol has a different purpose than Narcan, a widely mentioned medication for addicts. Narcan is used on an emergency basis to reverse the effects of an overdose.
After Lonergan received his Vivitrol shot in 2013, he left prison with an appointment at a treatment center near his home, a religious mentor in the community, and plans to return each month for Vivitrol.
The son of a nurse and a police detective, Lonergan started taking OxyContin after graduating from Sandwich High School. He was introduced to the opioid painkiller by his roommates before switching to another opioid, Percocet.
At the time, he said, he was lost; he'd rejected college but had no idea what to do with his life. Pills quieted his turmoil. "I wanted to feel that extreme nothing," said Lonergan, now 30 and living in Walpole. "I liked not having to worry."
Caught stealing from a house where he was doing carpentry, Lonergan was sentenced to a year at the Barnstable County Correctional Facility. There, he joined a Bible study group, and today he attributes his sobriety to God.
But Vivitrol, he said, provided an insurance policy. "If ever I was weak, or I bumped into the wrong people, I could say no," he said.
He took Vivitrol 11 months. By the time he stopped, he was working as an electrical apprentice and had become engaged.
And now he has a daughter, Ashtyn, born Nov. 13. In a recent interview, he cradled the infant with gentle expertise, feeding her from a bottle as he described his new life.
"I've been offered opiates since I stopped," he said. "There's not a second I even contemplate taking them."
Lonergan was among 178 Barnstable inmates who have agreed to a Vivitrol shot.
"About 45 to 50 percent are still clean and sober, some for up to three years," Barnstable County Sheriff James M. Cummings said. "That's kind of significant. Usually the relapse rate is 85 percent."
One in five returned to jail, compared with the national recidivism rate of three in five.
But those 178 who volunteered to take the initial Vivitrol shot represent only about 9 percent of inmates released from the Barnstable jail, and the statistics, while encouraging, don't prove Vivitrol made the difference. Perhaps those who took it were a highly motivated minority already more likely to succeed. Or they could have benefited chiefly from better links to services in the community.
The active ingredient in Vivitrol, naltrexone, has been available in pill form for two decades, originally used to treat alcoholism. But for the drug to work, the patient has to take the pill every day.
In Vivitrol, naltrexone is encased in microscopic beads that slowly dissolve, releasing the medication gradually over a month. Vivitrol was approved to treat alcoholism in 2006. When it won FDA approval for opioid addiction in 2010, it became only the third drug available to treat an affliction affecting millions. Nationwide, some 15,000 people take Vivitrol.
"We had so many people telling us to abandon it, it's for a stigmatized population, it would never be commercially feasible," said Richard F. Pops, the CEO of Alkermes.
Vivitrol can damage the liver. But possibly the biggest hazard is that someone could try to override the drug by taking huge quantities of opioids, which could lead to death.
Dr. Kelly Clark, chief medical officer of CleanSlate Addiction Treatment Centers, a chain of office-based practices in Massachusetts and Pennsylvania, said she uses Vivitrol in her practice but often finds buprenorphine more effective.
Clark and Herbert, of the addiction medicine society, said their patients feel normal on buprenorphine, but many don't like the way Vivitrol affects their brains. The drug blocks nearly all the opioid receptors, which means the brain's natural opioids, which induce feelings of pleasure from life experiences, can't latch on, either.
But people on Vivitrol can still experience pleasure through other pathways in the brain, said Dr. David R. Gastfriend, a former Alkermes executive now with the Treatment Research Institute in Philadelphia. Gastfriend coauthored a study showing that long-term Vivitrol users were still enjoying music, sex, reading, and food.
Clark said there is still more to learn about Vivitrol. There is no guidance, for example, on how long a person should take the drug. "The data we have on how well buprenorphine works is excellent. Same for methadone," Clark said. "Vivitrol is promising but not proven at that level."