Judge Harry Powazek agreed to have his picture taken for this story only if it could be shot near the wall of photos in his office of his drug-court graduates.
"Read some of what they wrote," he says, gesturing to the mat portion of the framed pictures where graduates signed their names and included words of thanks. Powazek knows each person's story—why they ended up in jail and what they went through during drug court's rigorous 18-month program, which promises a clean slate in exchange for showing up for counseling programs, finding a job (or performing community service) and staying off drugs.
In a year or so, there will be faces on the wall whose stories are quite different from the others—10 people who, each month since early fall, have received an injection of Vivitrol, a drug that nullifies the effects of opiates like heroin and Oxycontin.
Initially used to treat alcohol addiction, in 2010, the U.S. Food and Drug Administration (FDA) approved Vivitrol's use for opiate addiction. It's what's referred to as an opioid antagonist, meaning that it blocks the receptors in the brain that give an opiate addict a high. One injection of Vivitrol lasts roughly 30 days.
What it does, Powazek says, is free people from the compulsion to start using again—what's the point of shooting up if nothing's going to happen?—and helps them focus on getting their lives together.
"It's not like penicillin—you take it and you're done," Powazek says. "For most people, the cravings are diminished substantially where they're at a stable place emotionally to take on the benefits of the counseling, the meetings and the structure this program has to offer. They don't feel they need to run out and use."
For now, the Vivitrol pilot is limited to Powazek's North County Drug Court program in Vista. The drug is expensive—a single dose costs around $1,100—so participation in the program is capped at 10 people. San Diego's is currently one of a number of Vivitrol pilot studies, says Jennifer Snyder, a spokesperson for Alkermes, the pharmaceutical company that manufactures the drug. A program in Maryland is using Vivitrol to help drug-addicted jail inmates transition back into the community. So, too, are pilots in Massachusetts, Pennsylvania and New York's Rikers Island jail, all of which are hoping to see a decline in recidivism.
Powazek says he first heard about Vivitrol at a conference. "I've been going to the drug-court conventions every year, and they've always talked about medication that would help in the transition, not as a cure, but as a supplement to the therapy," he says. "We've talked about it, and most of my counselors are kind of open to it, but there's always a reluctance to begin to use another pill or another shot, so we had to balance that, but, ultimately, we had no money."
He invited folks from Los Angeles County's Department of Public Health to San Diego to discuss a pilot study they launched in 2009 involving 399 addicts. The results of the study were so promising that, in 2011, the Los Angeles County Board of Supervisors agreed to allocate $3.4 million to fund Vivitrol for three years.
Powazek also invited Susan Bower, San Diego County's director of alcohol and drug services, to the meeting.
"After they were done with the presentation, lo and behold, the county said maybe we can come up with some money," Powazek says.
Bower agreed to allocate $184,000 to the pilot—$150,000 for the medication and $34,000 for a two-year study by the San Diego Association of Governments' Criminal Justice Research Division, says Craig Sturak, spokesperson for the county's Health and Human Services Agency; the county's three other drug-court locations are serving as control groups for the study. As for what'll happen with the pilot project's over, "I think that's something that would be looked at after the evaluation's done, to see what the results were," Sturak says.
Choosing participants for the pilot project "was incredibly difficult," Powazek says.
"We've been having, especially up in North County, a large influx of convicted felons who are 18, 19, 20, 21. They went straight from Oxycontin to heroin, or they started stealing. We're having fits with them because they've not hit bottom, they don't have a great deal of focus and all they want to do, generally speaking, is run.
"So we thought, This is great. Let's give them a shot and if anything's going to prove how well Vivitrol will work—."
But they ran. Drug Court requires that participants show up to counseling sessions and, initially, come to court weekly. Many of the first Vivitrol recipients never showed up.
"They wouldn't stay to get the counseling; they would just run," Powazek says. "Or they decided to use barbiturates. It was incredibly difficult."
So, Powazek and his team decided to modify the requirements. In order to be in the Vivitrol program, a person had to show up for scheduled counseling and court dates for a month.
"You have to show a commitment that you're willing to address your addiction issue," Powazek says, "show that you're going to the meetings, you're willing to work, you're not going to take off, that type of thing.
"So, we made those changes, and we rarely have people taking off. And the feedback that we've gotten—they say that they don't have the cravings, at least as bad. They are able to focus in on the counseling and the behavior modification," he says.
"The Vivitrol," he adds, "is not a cure. It's just something to help them get by. The behaviors, the cause for the addiction—whether it's mental health or whatever— until you address that you're not going to be successful."
Vivitrol, of course, isn't the first drug used to combat addiction. Methadone has been used to treat opiate addicts since the 1960s. And, prior to Vivitrol was Naltrexone, a daily pill approved by the FDA in 1984 for alcohol dependence and later approved for opiate addiction.
Medication-assisted treatment says Elinor McCance-Katz, medical director for the state of California's Department of Alcohol and Drug Programs, is considered the standard in treating addiction.
"Opiate addiction is very, very difficult to treat," she says. "We have medication treatments that are FDA approved and are shown to be effective....
"We now know that substanceabuse disorders, particularly addiction, is a brain disease," she adds. "It's not a matter of bad behavior and bad character and all of those negative things that we attribute to people with addiction."
Currently, San Diego County forbids medication-assisted treatment in the programs it funds, making it the only one of California's 13 largest counties with such a policy. That makes the Vivitrol pilot unique, though it doesn't indicate a change in the county's position, Sturak says.
"The general consensus here is that Vivitrol is different from methadone, and this is a very small pilot."
It's a start, says Margaret Dooley-Sammuli, senior policy advocate for criminal justice and drug policy for the San Diego & Imperial Counties ACLU.
"It's good," she says, "because it's actually health treatment that they're thinking about."
Vivitrol, compared with other addiction medicine, is different in that it doesn't require a daily dose and doesn't have street value.
"Probably the most attractive from the criminal-justice perspective is that it's non-divertable—in other words, no one's going to take this needle and sell it on the street. No one wants a drug that's going to take away the effect of their drug," says Kathy Jett, a policy consultant with the government-reform nonprofit group California Forward, who most recently headed up addiction and recovery services for the California Department of Corrections and Rehabilitation.
"And the other piece is, it's nonaddictive," Jett says. "It's up to the individual to go back for that second shot. And if they choose not to, there's no medical problem, there's no detoxification. It just simply wears out after 30 days."
As attractive as Vivitrol may seem, there are two issues that need to be worked out, Jett says— the cost and the question of who's best-suited for the drug. Pilots like San Diego County's will help answer the latter question.
"This is not a sort-of one-sizefits-all drug," Jett says. "It really is another tool in our toolbox to work with addicts. It's extremely promising with addicts who are coming out of institutions where we stabilize them and they're now reentering back into the community where they'll get all the stimulus to use again."
As for cost, states and counties are tapping into a range of sources, from federal grants to, in California, funding made available through AB 109, legislation that diverts nonviolent offenders away from prison and into county jails. Private health insurance covers Vivitrol, as does Medi-Cal. And, increased use of the drug is a way to address cost, too, Jett says.
"Until the drug is expanded in the public sector, like all new medications, it's going to have a high price tag. This is not an easy medication to make."
There's also the argument that the cost of treatment is cheaper than incarceration.
"If you think about it in the long run, my people are not in jail—so there's not the cost of jail. They're not committing crimes," Powazek says. "There is this theory that it's just cheaper to give them a shot. I'm not sure I buy into it—giving them a shot without the psychological support I don't think is a solution, but it's certainly cheaper than housing them. It's cheaper than this revolving door."