By Taylor Knopf
State lawmakers are making $2 million available to North Carolina sheriffs to start or expand opioid addiction treatment programs in their jails, but the money comes with a big caveat.
The $2 million grant program included in the state budget late last year specifies that the funds can be used to provide only one of the three FDA-approved medications for opioid use disorder. Some addiction experts argue that the favored medication — naltrexone, also known by the brand name Vivitrol — is the least effective of the three.
At a time when drug overdose deaths have reached record numbers, medical experts argue that people with opioid addiction need access to all three medications. Having the option to use the medication that works best for an individual improves their chance of recovery and decreases their risk of overdose death. This is particularly relevant for people in jails and prisons, where people have higher rates of substance use disorder.
Moreover, formerly incarcerated people in North Carolina are 40 times more likely than the average person to die of an opioid overdose within two weeks of their release from jail or prison. They are 74 times more likely to die of a heroin overdose, according to a 2018 study conducted by researchers working for state government along with some from UNC Chapel Hill.
When someone spends time in jail without access to treatment for addiction, their opioid tolerance invariably declines. Then, when they post bail or are released, they could return to using drugs to cope with painful opioid withdrawal symptoms or manage their drug cravings. They may use a dose far higher than their bodies can tolerate, making them more susceptible to a drug overdose.
On top of that, formerly incarcerated people are often walking into a world where the street drug supply is more lethal than ever before. Fentanyl, an opioid 100 times stronger than morphine, has become more widespread in the street drug supply since the beginning of the pandemic. It’s mixed into many drugs, including methamphetamine, cocaine, heroin, and is sometimes pressed into counterfeit pills disguised as prescription opioids. People who use drugs don’t always know if fentanyl is present or how much is in the substance they’re using, making it more deadly.
Access to medication for opioid use disorder in jails and prisons and the continuation of that treatment in the community helps prevent these kinds of deadly overdoses.
Addiction treatment in jails
In Rhode Island prisons, the first statewide system to allow access to all medications for opioid use disorder, addiction medications helped people manage withdrawal symptoms and decreased the supply and demand for illegal drugs within the prison facilities. When interviewed by researchers, incarcerated participants shared positive experiences and said they were more likely to continue their medications after their release.
After the addiction treatment program started in the state prisons, drug overdoses among formerly incarcerated people in Rhode Island decreased by 61 percent. California recently began offering addiction medications in its state prisons and saw a 58 percent drop in overdose deaths within prisons in the first year.
It’s been a long road to incorporating opioid addiction treatment in jails, as public health experts have worked to dispel the stigma around providing these medications to people with substance use disorders. And there’s still a long way to go.
In North Carolina, at least 17 of the state’s more than 100 jails have some kind of program providing one or more medications for opioid addiction, according to the state’s Opioid and Substance Use Action Plan Data Dashboard. Only five of the 17 jails are offering more than one type of medication for opioid addiction.
Most people who end up in jail in North Carolina aren’t given access to medications for their opioid addiction, even if they had a prescription in the community. Last month, the U.S. Department of Justice issued new guidance saying it is a violation of the American with Disabilities Act (ADA) to discriminate against someone taking medication for opioid use disorder.
The DOJ guidance gave specific examples of what this violation looks like, including: “A jail does not allow incoming inmates to continue taking MOUD (medication for opioid use disorder) prescribed before their detention. The jail’s blanket policy prohibiting the use of MOUD would violate the ADA,” the guidance states.
Vivitrol’s favored status
Some in the recovery community have viewed medications used to treat opioid addiction — particularly methadone and buprenorphine — as simply replacing one drug with another. Both of these medications are classified as controlled substances, but naltrexone is not.
That’s one reason naltrexone is favored by some with a more traditional view of addiction recovery, including law enforcement, according to Evan Ashkin, a UNC medical professor and founder of NC FIT, a program that connects formerly incarcerated people to health care services and other resources.
Naltrexone doesn’t activate the opioid receptors in the brain the way the other two medications do. Instead, it blocks receptors in the brain that are stimulated by opioids. While that sounds like something that a person with a substance use disorder might need, the drug does little or nothing to address cravings for opioids. And for people who still have dependence on opioids, it can provoke withdrawal.
The brand name version of the drug, Vivitrol, is an injectable medication, whereas the other two are often taken orally, though there is an injectable form of buprenorphine on the market.
Logistically, a monthly shot of Vivitrol is easier for jail administrators than giving out daily doses of a medication. Many operators of addiction rehabs and jails cite the risk of diverting the controlled substances taken orally. The concern is that someone will put the medication in their mouth, hold it in their cheek and pass it to someone else for whom it wasn’t intended.
In the state budget, the $2 million grant program to offer opioid treatment in jails is written two ways. The state budget bill states that the funds “shall be used to provide competitive grants to sheriffs’ offices to assist in establishing, maintaining, or expanding Medication-Assisted Treatment (MAT) programs for alcohol or opioid addiction for jails.”
However, there’s a second budget document known as the “money report” which can provide extra details on a budget item. It states that the funding “provides competitive grants to sheriffs’ offices to assist in expanding, maintaining, or establishing medication-assisted treatment (MAT) of non-opioid, long-acting, injectable medication regimes as treatment for alcohol and/or opioid dependence as part of reentry programming in county jails.”
Vivitrol is the only opioid treatment medication that matches that description.
Meanwhile, the drug company that makes Vivitrol — Alkermes — has been busy. The company’s Congressional lobbying expenditures went from almost nothing to more than $4 million in the last decade, according to data collected by Center for Responsive Politics. Over the past six years in North Carolina, Alkermes has spent roughly $370,000 to retain lobbyists with McGuireWoods out of Fayetteville, according to reports filed with the N.C. secretary of state’s office. Vivitrol sales continue to increase. Alkermes’ first quarter revenue report this year highlights $84.9 million in sales of Vivitrol compared to $74.5 million for the same period the prior year — an increase of 14 percent.
An investigation by NPR and Side Effects Public Media found that Alkermes has aggressively promoted Vivitrol to lawmakers across the country while sometimes making it harder to access other, more effective medications for opioid addiction and adding to the stigma around using those medications.
“So law enforcement likes [naltrexone] because it has no potential for diversion,” Ashkin said. “It is not a controlled substance. And it doesn’t push this stigma button of ‘you’re replacing one addiction with the other’ and that’s, sadly, a widely held view even in the recovery community.”
“I think the really important missing piece for a lot of people is, if we’re trying to reduce death from overdose, Vivitrol has not been shown to do that,” he continued. “So long-acting naltrexone has scant to no evidence that it prevents overdose deaths.”
Issues with Vivitrol
Vivitrol works differently than the other two medications for opioid use disorder — methadone and buprenorphine — in that it requires patients to fully detox from opioids for it to be effective. Because of this, some experts are hesitant to use it, saying it puts people at higher risk of overdose death.
“There’s this kind of false sense of parity between buprenorphine, methadone and naltrexone, like all three were equally good and could be used interchangeably, but definitely not the case,” said Nabarun Dasgupta, drug and infectious disease researcher at the UNC Gillings School of Global Public Health.
He said there’s decades of research and understanding of how buprenorphine and methadone work and the overall number of patients who have taken them is much higher than naltrexone. There is also some concern around the authorization of naltrexone in the U.S., especially after more than half the participants dropped out of the initial study trial conducted in Russia.
“I think naltrexone is really good for a certain kind of patient,” Dasgupta said. “And those are usually patients with strong motivations to not use [drugs] with a lot of social and family support.”
Because naltrexone blocks opioid receptors, it could prevent someone from overdosing if they used a certain amount of an opioid drug. They will not feel “high” from using heroin if Vivitrol is in their system, Dasgupta explained. But because it’s a month-long injectable dose, it will wear off toward the end of the month. And someone would be more likely to overdose if they went back to using street drugs, especially as the supply is contaminated by fentanyl.
“So it’s the kind of drug that a lot of people are interested in at first because it’s intuitively appealing to block the effect of street drugs,” Dasgupta said. “In practice, what happens is it may prevent them from getting high but doesn’t really help them take care of their cravings in a way that frees up their time and energy to build up the rest of their lives and address the fundamental reasons why they were using drugs in the first place.”
At about $1,000 per monthly injection, another issue with Vivitrol is affordability. If a jail program starts someone on a medication they cannot afford to continue in the community, they’re setting them up for failure, explained Carlyle Johnson, clinical psychologist and Alliance Health’s lead representative on opioid projects, who works with Durham and Orange counties’ detention centers on their addiction treatment program. He explained that many people who pass through jails are uninsured or on Medicaid and because of the way funding in the community works, it’s easier to connect them to methadone or buprenorphine.
“It really ought to be people’s choice,” Johnson said. “The gold standard would be you have a choice of any of the three medications.”