Shot in the Dark

At first, Alkermes—whose most successful strategy to date has been to market to law enforcement officials—agreed to give Cummings the first 50 injections free of charge. About 60 percent of Barnstable’s inmates enter with an opioid addiction, and Cummings knew he needed to go beyond just locking folks up. “We finally realized,” he says, “that if you take somebody and put them in jail for a year, which is about our average sentence, and then do nothing for them and send them right back into the community they came from, you’re going to see them again.”

The program Cummings designed goes beyond the drug—participants receive help with job placement, housing, psychosocial support, and MassHealth insurance to cover their follow-up Vivitrol appointments—but the shot is its linchpin. (While the list price of Vivitrol is more than $1,000 per shot, the discounted price with Medicaid is closer to $660, which is entirely covered by Medicaid.) Alkermes, for its part, kept providing Cummings’s jail the first shot for free. “We’re now up to about 300 without charge,” the sheriff says.

So far, Cummings boasts seemingly impossible success. The recidivism rate for those in the Vivitrol program, he claims, is around 20 percent (the national average for all inmates is close to 70 percent), and almost half of the people who’ve been released from jail during the program’s first three years have reported remaining sober. Numbers like that quickly got Cummings noticed. Eleven of the 12 main sheriffs’ offices have copied his program (Plymouth County has not, but Alkermes says officials there have asked about starting one), and Massachusetts, fueled by politicos such as O’Neill, has been the proving ground for Vivitrol programs across the country. The Vivitrol–correctional-facility model “kind of sprouted its own life,” according to Hunt. And Cummings, who received $500 from Alkermes for his most recent reelection campaign, has become an unofficial spokesman for the drug, traveling as far as London to espouse Vivitrol’s virtues; even his own office has referred to him as a Vivitrol “expert in chief.”

Six years after their first phone call, Hunt and Cummings stand by the drug and the program they helped launch. But, sitting in his Cape Cod office, Hunt also accepts that the opioid epidemic in Massachusetts is getting worse, not better, and that Vivitrol certainly isn’t for everyone. “The criticism of Vivitrol,” he says, “is really a criticism of the approach, of abstinence. Because the whole abstinence road is fraught with people who go through the cycle like nine times before they make it. For the people who knock Vivitrol because there’s a higher risk of overdose if somebody quits the program, I don’t disagree with that.”

The company behind it, however, feels like it’s been unfairly maligned. Nestled along the Cambridge Reservoir on the western edge of Waltham, just a stone’s throw from Costco, the U.S. headquarters of Alkermes are downright suburban. With glass walls and a neutral color scheme, the offices feel sleepy—like your dermatologist might be waiting for you just down the hall.

Over coffee at a shiny wood conference table, Alkermes spokesperson Jennifer Snyder and Jeff Harris, its government relations head, tell me how “incredibly disappointing and frustrating” the recent spate of bad press has been. The company seems shocked by the blowback. Alkermes, both Snyder and Harris tell me, is just “a small company.” Suboxone, which is made by Indivior, a spinoff of Reckitt Benckiser, and methadone, which has several long-established brand names, are both better known. With $58.5 million in sales during the first quarter of 2017, less than a quarter of what Indivior reported, Alkermes sees itself as the underdog—and its efforts to “raise awareness” about Vivitrol as akin to a public service. “There’s an awareness problem with Vivitrol,” Harris says. “People can have a cynical view of marketing, but that is actually about building awareness.”

This past summer, I met with Garrett Smart, 25, and Richard Mayo III, 24, in an empty classroom at Cummings’s jail. Both men were on deck for Vivitrol shots before their upcoming releases. For the most part, they were excited about it. “I use to get high,” Smart said, leaning back in his chair. “If I know I can’t get high, I won’t use. The only negative I see with Vivitrol is overdosing.”

It’s a concern shared by many inmates in the Vivitrol program, and for good reason. In Massachusetts, recently released opioid-addicted inmates are 56 times more likely to die of an overdose than the rest of the population. Opioid-related emergency room visits increased 87 percent in the state between 2011 and 2015, mostly due to the prevalence of fentanyl and carfentanil, drugs that are far more powerful than heroin. “People have no idea what they’re taking,” state Senator William Brownsberger told me. “And they’re coming up dead way too often.”

Until now, Smart’s longest sober period came from when he was on Suboxone, which is used to gradually wean people off their addiction or to simply stabilize it, removing the many harmful behaviors associated with illicit drug use. But he said he still found ways to get high. Vivitrol won’t allow for that, and his tolerance will plummet. If he misses a Vivitrol shot and decides to use, his risk of overdosing will be high. Another risk for Smart, an admitted cocaine and Molly abuser, is what’s called “punching” or “breaking” through—when people on Vivitrol try to either beat or go around the drug with non-opiates. Knowing he’ll have to resist that kind of urge, “that does scare me,” Smart said.

Mayo was also trying to prepare himself. He had received Vivitrol once before, after his previous stint in the jail, and the drug had left him with increased anxiety. As he fidgeted in his chair, he told me this time was going to be different. Back then he lasted five to seven Vivitrol shots before he started missing his appointments. Preparing to leave again, he seemed to be bracing himself for life on the outside, where things, as he saw them, were getting worse. “Every other week someone you know dies,” he said. “And you’re not really strong enough when you go out there.” Vivitrol, he hopes, “will give me a chance.”

Despite the hype, most of what we know about Vivitrol is driven by anecdote and opinion—which means we don’t know much at all. “The amount of studies that have been done on Vivitrol could fill a manila envelope,” Robertson says. The largest study to date was performed in Russia, and didn’t compare Vivitrol outcomes with those of either methadone or Suboxone. The first real study comparing all three was expected any day at press time.

So far, the anecdotes we do have are decidedly mixed. Robertson says Vivitrol tends to work better “for people who have a lot of support and motivation already.” If those factors aren’t there, he says, “you’ve taken away this person’s coping mechanism. You’ve taken away their greatest source of relief, and in place of it there’s not a whole lot. You’ve set someone up for disaster.”

Lise King says she’s seen just what that looks like. The coproducer of an HBO documentary about heroin on Cape Cod, she tells me Vivitrol “doesn’t change either the underlying conditions that are causing addicts to want to get high—anxiety, depression, whatever those things are. And it doesn’t change the behavioral patterns that come along with the ritualistic nature of doing drugs.” King witnessed one woman who was “so uncomfortable with how she felt” on Vivitrol that she ended up shooting speedballs—cocaine and heroin—to deal with those feelings.

Others have pushed back on the claim that Vivitrol users are really drug-free—one of the company’s most appealing claims. That’s a “fantasy,” Daniel Wolfe, the director of international harm reduction development at the Open Society Foundations, wrote in Stat this summer. “Vivitrol patients, who require a monthly injection, are not drug-free, and the medication’s price tag is many times that of methadone and buprenorphine.” King agrees. Pharmaceutical companies “made money addicting people, and now they’re saying, ‘Oh, don’t take this drug. Take this one,’” she says.

Cummings has his own stats to fall back on: He says only one of the 281 inmates in his program who have received Vivitrol has died from an overdose. But in our interview Cummings only cross-referenced data from Barnstable County, which meant that if any of his program’s patients overdosed off the Cape, they weren’t counted here. Still, Vivitrol has, undoubtedly, done well for some in the fight against opioid addiction. One recovering addict told me, “It is literally the best thing that ever happened to me.” Nick, the first volunteer for the Vivitrol program, is still sober, and no longer relies on monthly shots.

Maybe Vivitrol’s greatest benefit will be getting its boosters to take their own advice and use all of the tools available to them. That’s what Lee, the doctor who sparked Hunt’s interest back in 2011—and who happens to be running the new Vivitrol study—tells me. “If I were the world’s prison warden, I’d make all of these options available, especially around the time of [an inmate’s] release,” he says. “If a jail is serious about helping people, then it makes complete scientific and public health sense that these medications would be available.” And there’s some hope there. Recently, the state Department of Public Health announced grant money that will be used by the Franklin and Hampden county correctional facilities to expand their ability to offer Suboxone. Even better, Rhode Island recently became the first state to offer all three medications to inmates.

Without options, we’re left with a hammer and with every addict looking like a nail. These days, even Cummings has a hard time identifying who is an ideal candidate for Vivitrol. Sitting in his office, he tells me it’s either someone in jail for the first time, or someone so early in their addiction they haven’t been in jail at all. But many of the inmates in his program are clearly past that point. “We don’t just give it to anyone,” he tells me, before cracking a sheepish smile. “Well, I guess now we do kind of just give it to anyone who wants it.”

Update 11/2/17: In mid-October, after this article went to press, the first-ever study directly comparing Vivitrol to Suboxone was published. The 12-week study by a professor at the Norwegian Centre for Addiction Research at the University of Oslo, Norway compared results in 159 patients with opioid dependence and found the drugs produced similar short-term outcomes. A longer-term study funded by the National Institute of Health is expected later this year. You can read more about the Norwegian study here.