GREAT FALLS, Mont. (AP) — Late last August, Ryan Haman was ordered to spend a week in a cell at the Cascade County Detention Center. As an opioid addict, it definitely wasn’t his first time in jail, but hopefully it would be his last.
Haman would walk out of the jail clean after detoxing, as always.
“I couldn’t stay sober for more than a week.”
But this time, instead of relying on sheer force of will to keep his urges to inject himself with drugs like oxycodone or heroin at bay, Haman had an appointment to receive a shot that had the potential to change his life.
The Vivitrol injection
Haman received a Vivitrol injection. Vivitrol is the brand name for extended-release naltrexone, an opioid antagonist, a drug that blocks opioid receptors in the brain from being activated. That means the patient can’t feel the euphoric and pain-relieving properties of opioids if they use after receiving their monthly injection.
“Relapse rates are so high,” said Shelley Andrus, a psychiatric mental health nurse practitioner with Benefis Health System. “It’s dismal.”
She said most medical studies place the relapse rate for an opioid addict around 96 percent.
“The brain has been profoundly affected,” Andrus said. “It’s like not being able to feel happiness anymore.”
In fact, Andrus has known opioid addicts so disconnected with cause and effect they’ve injured themselves, even broken their own bones, to gain access to prescription medication.
Haman called his experience with the Vivitrol shot “amazing.” He said he could feel how the drug was changing his brain.
“Having a clear brain for a month makes a big difference,” Andrus noted.
That “clear brain” can then be reprogrammed, so to speak. It starts functioning normally again, allowing patients to feel good without pills or heroin.
“That’s the beauty of this medicine,” Andrus added.
Therapy becomes effective as the patient can develop new thought processes and coping skills.
The therapeutic aspect of a treatment program is vital. In fact, Vivitrol can only be prescribed as part of a treatment plan that includes addiction counseling.
The need for Vivitrol will only increase as the opioid epidemic grows.
Opioid addiction is on the rise nationwide. According to data from the 2012 National Survey on Drug Use and Health, nearly 1.9 million people started using opioid pain relievers for non-medical use in 2012, with 2.1 million reporting opioid dependence or abuse. That same study shows heroin use has been on the rise since 2007 with 669,000 reporting past-year use in 2012.
Haman, 27, received a three-year deferred sentence in August 2014 for writing false prescriptions for opiate pain medications. It was the first time he’d ever been in trouble with the law, despite a long history of substance abuse that started with marijuana use in sixth grade.
Haman said his drug use was about the “party life” and peer influence. He had a “normal” childhood with no major trauma, but Haman did note alcoholism was present in his family.
By eighth grade, Haman said he was getting drunk on a regular basis. Then he started experimenting with mushrooms after starting high school. He tried cocaine and methamphetamine by his junior year. He started selling drugs, too.
“I always had a big supply,” he said.
Haman said he was 20 or 21 when he started taking pills. That habit started with a doctor who would write him prescriptions for opiate pain medications like oxycodone or methadone.
But eventually those prescriptions weren’t enough.
“I was an addict. I always needed more.”
So Haman started writing his own. He started selling extra pills, too.
Haman stopped this behavior briefly in 2009, the year his daughter was born. He found a good job. He used methadone to “hold himself over,” but eventually things fell apart.
Haman was arrested in October 2013 after a local pharmacy called the police about a suspected forged prescription for Oxycontin. He was charged with fraudulently obtaining dangerous drugs, a felony.
In exchange for Haman’s guilty plea, the charge was amended to criminal possession of dangerous drugs, a felony. At his sentencing hearing, District Judge Greg Pinski warned Haman his addiction, if left untreated, could kill him.
“There were times I wanted to stop before I got in trouble,” Haman said. “I just couldn’t.”
The thought of going to prison was scary for Haman, but it was nothing compared to the cravings and the misery of withdrawal.
“I figured I was going to get revoked, and I still couldn’t stop.”
Haman figured right. He suspected the authorities knew he was selling pills, and in December 2014, court documents say he showed up for an illegal drug buy with a Great Falls police detective. The detective and adult probation and parole searched his car. They reported finding four clonazepam pills, a syringe and a spoon. Haman tested positive for oxycodone.
Haman’s probation was revoked, and he was sentenced to complete the 8th Judicial District Adult Drug Treatment Court. But after several months, many sanctions and at least 11 drug tests positive for oxycodone, Haman was on the verge of being terminated from the program.
“He couldn’t stay sober,” said Haman’s addiction counselor, Jeff Fauque of Gateway Community Services. “He was so close to going to prison.”
Instead, Haman spent the seven days in jail and got his Vivitrol shot.
Medically assisted addiction treatment
Vivitrol is the newest development in medically assisted drug addiction treatment. It was approved by the FDA in 2010. It also is used to treat alcoholism. Medical providers continue to prescribe naltrexone to patients in pill form.
“The problem with a pill is you can choose not to take it,” Fauque said, explaining why he’s excited about Vivitrol as a treatment option. “You want to use the word miracle.”
Haman said he likely would have skipped doses of naltrexone if it had been prescribed to him.
Taking a pill every day also can be a trigger for patients who are addicted to pills.
There are other medications prescribed to opioid addicts. The medically assisted treatment of such addictions stretches into history, much like the use of substances such as heroin.
Methadone clinics have been used since the Vietnam War era, when some soldiers returned home addicted to heroin. The clinics were slower to come to less-populated areas. Andrus said Montana was one of the last states to adopt their use.
Andrus touts the benefits of Suboxone, a combination of buprenorphine and naloxone, which was approved by the FDA in 2002 to treat opioid addicts. The drug stimulates the same receptors in the brain as an opioid, but also includes an antagonist component to block some of the euphoric effects.
It is a narcotic and a controlled substance. Fauque didn’t want Haman to use it. He said clients of his replaced their addiction to oxycodone with an addiction to Suboxone.
Andrus noted that like any other medication, Suboxone can be abused or over-prescribed. But she’s seen success stories from some of her patients.
“Many of the people I’ve treated would be dead without Suboxone.”
Challenges for Vivitrol patients
Medically assisted addiction treatment, like addiction itself, carries a certain stigma. That stigma makes finding a medical provider to prescribe Vivitrol, naltrexone or Suboxone challenging.
Andrus estimates there is only one medical doctor prescribing Suboxone in the Great Falls area and only a handful of providers prescribing Vivitrol. She said for the most part, only providers specializing in addiction and mental health are providing medically assisted drug addiction treatment nationwide.
“It’s a difficult population to treat,” Andrus said.
Finding a provider isn’t the only challenge for those who might benefit from the Vivitrol shot. The injection is typically administered once a month for six months. Each injection can cost between $500 and $1,200, depending on health care coverage and co-pays.
Many of the Treatment Court participants have lost everything, including decent jobs that provide affordable health insurance. Andrus noted that Medicaid expansion and the Affordable Care Act have helped, but co-pays can still be impossible for a patient to afford.
Haman said Medicaid covered the five injections he received, but that process was made easier by his “high relapse risk.”
Michelle Koppany is a case manager contracted by the Drug Treatment Court program. She’s been working with the program for seven years. She’s reached out to Vivitrol’s regional representative to help expand availability and learn the best language for providers to use to get the injection covered by medical plans. The drug representative is scheduled to make a visit to Great Falls in early March and give a presentation about Vivitrol to medical providers in hopes to increase accessibility.
Koppany says she wants to get Vivitrol prescriptions for every qualified client.
She’s already seeing road blocks. Koppany said that Medicaid denied coverage for a client with a Vivitrol prescription, saying that person needed to fail on oral naltrexone before the injection could be covered.
“Why are we asking people to fail one more time?” she asked, adding that one more relapse could be a client’s last.
“I’m tired of watching people die,” she said.
The risk of overdose death increases in a patient who relapses after receiving medically assisted treatment, Andrus said. She explained that the body “resets,” so if the person intentionally skips a dose or injection appointment, their body may not be able to handle the doses they were taking before treatment.
Andrus said Vivitrol has some side effects, including liver problems, increased depression or upset stomach. The patient also must completely detox before receiving the injection or withdrawal symptoms will start immediately.
That’s why Haman spent the week in jail before his first shot.
He said he felt “sick” at first, as he adjusted to the medicine. His cravings were gone after two weeks, allowing him to focus on treatment and get a job. Haman has maintained steady employment since receiving his first Vivitrol injection.
“Being on the shot, I got my life back,” he said.
Haman is in the third of five phases of Treatment Court.
“I’ve had to change.”
He attends Alcoholics Anonymous meetings three to four times per week.
“They really make me feel better,” he said.
Haman continues to see Fauque on a regular basis, along with a probation officer, and he completes weekly court check-ins with Pinski and is frequently drug tested.
Haman’s daughter lives with his parents. He says he sees her every day.
He is staying away from contacts from his life as a drug user, but says it’s hard to live in the same city that he considers his “old stomping grounds.” Haman said he might move away after completing Treatment Court, but his main focus now is maintaining his sobriety.
“This life is way better than where I was a year ago,” he said.