The Last Shot

Amid a surging opiate crisis, the maker of the anti-addiction drug Vivitrol skirted the usual sales channels. It found a captive market for its once-a-month injection in the criminal justice system.

Now Alkermes had beaten its competitors to an extended-release form of naltrexone. Administered by a shot in the buttocks, it blocked the patient from getting high for 28 days.

.. The judges say they don’t force anyone to take a particular medicine. But in effect, they give addicts a choice: the shot, or jail.

.. Thanks in great part to these judges, and to an explosive epidemic that only seems to be accelerating, some 30,000 people are now receiving Vivitrol shots. In the first quarter of 2017, sales totaled $58 million, a 33 percent increase over the year before. The company is ramping up manufacturing capacity, enough so that it could soon handle $800 million in annual sales, which it projects it will reach by 2020.

.. Leading the way in sales is Ohio ..

.. Last year the state’s Medicaid program alone paid for more than 30,000 doses of Vivitrol at a cost of more than $38 million

.. Pennsylvania and other states are giving inmates shots just prior to release, to serve as protection for their first few weeks on the street.

.. Many question whether the criminal justice system is rushing headlong into a solution that’s too good to be true, not recognizing that Vivitrol should be only one option

.. “In what other medical situation do judges prescribe specific treatments from the bench?” asked Mark Willenbring, an addiction psychiatrist in St. Paul, Minnesota. “If you get in a car crash because you’re diabetic, do they prescribe a specific medication from the bench? This is the only area in medicine or health care where judges think they know more than doctors.”

..  the judges (who were often elected) tended to reflect local cultural biases about addiction, viewing it as moral weakness that called for tough paternalism.

.. opiate addiction is a chronic condition — that the damage done to the brain may require at least several years of maintenance on methadone or buprenorphine

.. But these medications faced resistance in some quarters. Many 12-step-based treatment programs viewed them as a crutch and disdained those who depended on them for falling short of true abstinence.

.. To cover this cost, many took to selling some of their Suboxone on the side to people who lacked legal access to it.

..  the “antagonist” naltrexone acts like a glove over the synapses, preventing any opioid from reaching them. And it seemed more punitive in nature: Instead of providing a substitute high, it functioned as a roadblock, denying any high at all.

.. It has spent $19 million on lobbying in Washington in the past seven years

.. It became a member, at the second-highest tier of corporate donor, of the American Legislative Exchange Council, or ALEC, the corporate-backed group that promotes conservative ideas for state and local policy.

.. The company has made more campaign contributions in Ohio than in any other state, with top beneficiaries including Gov. John Kasich

.. “Why treat people who have a drug problem with another drug?”

..  “Courts are a good place to do” drug treatment, state Sen. Dave Burke, a Republican, told me. “You have a black robe and the threat of jail time.”

.. Since most of the drug courts were opposed to buprenorphine and methadone, or located in places that lacked access to them, the vast majority of the counties put their funding toward Vivitrol-based programs.

.. “We’re not forcing anyone into Vivitrol that doesn’t want it — it’s just one of our options,” Blackburn said. But, he added, “I’m a little more comfortable probably not sentencing someone to prison that wants to go on Vivitrol.”