Of the three Food and Drug Administration-approved medications for opioid use disorder (MOUD), two have been shown to reduce rates of overdose by more than 50 percent. Evidence for the third shows that it does not reduce overdose, frequently increases overdose, and continues to be the MOUD most offered to people leaving United States prisons and jails—the moment their overdose risk goes up.
Methadone is a full agonist of the brain’s opioid receptors, while buprenorphine (commonly prescribed as Suboxone) is a partial agonist. Naltrexone is an opioid antagonist: It takes up the same space in the same receptors, but unlike agonists, it doesn’t activate them. Like the better-known opioid antagonist naloxone, naltrexone can’t get someone high.
Naltrexone is the generic name sometimes used interchangeably with the brand name Vivitrol, an injectable formulation administered once a month. Vivitrol was approved for opioid use disorder (OUD) by the FDA in 2010. Naltrexone comes in pill form as a generic, but public discussion of naltrexone usually refers to Vivitrol.
“I OD’d a whole bunch of times.”
Christian, a Washington State resident in his 40s, has lost track of how many Vivitrol shots he’s been given over the past five years. All were administered on his way out of city or county jails in the greater Seattle area; some court-ordered, some voluntary.
He didn’t know much about MOUD when his early shots were administered, so he’d ride out the cravings while he waited for the Vivitrol to suppress them the way he’d been told it would. Then after a few days, he’d go looking to cop. But when he tried the same quantities of drugs he’d been using before, nothing happened. After a while he started doubling up. Then tripling up. Then he quadrupled up, and finally got what he needed.
“I OD’d a whole bunch of times,” Christian told Filter. “Because at the beginning of the month, I’m doing a gram-and-a-half in one shot and immediately nod. But then by the middle of the month, I’m doing the same amount and OD-ing because [the Vivitrol is] starting to wear off, and I’d have to get Narcan’d.”
If he refused an offer of treatment, he’d get kicked out of his jail-alternative program and he’d have to do time.
In Vivitrol’s long-acting formulation, naltrexone has a half-life of five to 10 days. Just as opioids or other drugs wear off over the course of a few hours, Vivitrol wears off over the course of a few weeks. The harms of an opioid blocker that starts out strong, then becomes weaker and weaker over the 28 days it’s supposed to last, might seem obvious, but have nonetheless been refuted by Vivitrol manufacturer Alkermes.
Christian wanted to move off street-supply opioids to methadone or bupe, but he couldn’t access them. Since he already had opioids in his system at the beginning of each new stint in jail, staff always left him to go through forced withdrawal. Then once opioids were out of his system, they’d tell him the only MOUD he was eligible for was Vivitrol.
On a few rare occasions, he was given generic oral naltrexone rather than the shot, which meant that a large dose of street-supply opioids could get him high within a day. But mostly it was Vivitrol, and it was never up to him either way. It wasn’t making his life any safer or more stable, but he kept taking it. If he didn’t, his record would show that he’d refused treatment, he’d be kicked out of any jail-alternative program he was in, and he’d have to do time.
So the cycle continued: Get a Vivitrol shot. Get out. Get significantly larger quantities of drugs than he used to. Overdose. Get Narcan’d. Go back to jail, all while the cravings never got better.
“That was my entire experience,” he said. “Every time.”
There are places you can enter withdrawal willingly, like detox centers. The place you do it unwillingly is the floor of the county jail.
In order to start taking naltrexone, you have to stop using opioid agonists for at least a few days, probably a week; maybe two. There are places where people enter withdrawal willingly, like detox centers, but the place people do it unwillingly is the floor of the county jail.
The way jail and prison systems approach MOUD varies a lot from state to state, so we can’t see the full picture of which prescriptions are most common and where. Similarly imprecise estimates have suggested that anywhere from 25 percent to 50 percent of people incarcerated in US prisons and jails meet the criteria for OUD.
It’s good PR for corrections departments (DOC) that do provide MOUD to say so, but many aren’t as quick to volunteer whether that refers to all three, or just two, or just one. When it’s just one, it’s naltrexone.
A limited number of US jails and prisons provide methadone, but to get it you have to already be enrolled in a program. And in good standing with that program, which doesn’t always line up with the circumstances under which you’re arrested. Very, very few facilities are willing to initiate methadone for new patients.
Bupe is more common, and initiating it requires that you enter the early stages of withdrawal. But not full withdrawal, and the process shouldn’t feel anything like it does for naltrexone; bupe is actually prescribed to ease withdrawal, something naltrexone advocates are never interested in. But even with the X-waiver removed, in most places corrections staff aren’t inclined to start you on bupe unless you’ve been on it before.
Naltrexone, meanwhile, isn’t a DEA-controlled substance. Local governments aren’t trying to look too closely at how it’s prescribed, but they should.
Naltrexone and law enforcement were made for each other.
Naltrexone and law enforcement were made for each other. Of the three approved MOUD, naltrexone’s distinction as the opioid antagonist makes it the obvious choice for cops and all with thom they’re aligned: DOC; drug courts; drug warriors; abstinence-based treatment and recovery facilities.
This MOUD, so we’re told, is the one that doesn’t get you high. It’s not addictive. You can’t “abuse” it. If you really wanted to get “clean,” you’d want this one.
“I’ve seen where people were given a choice: Vivitrol, or discharge from a program that keeps them out of jail or prison,” Georgia resident Molly McCarver told Filter. “Nobody should be forced! Making it mandatory to get a shot is backwards.”
McCarver, 39, first went to inpatient treatment for OUD in 2007. It was a Narcotics Anonymous-style program, where she’d attend groups and counselors would teach her how not to use drugs. She went back six or seven times over the next few years.
In 2016 she was working at a recovery center, where her supervisors didn’t know she was managing her cravings with kratom. It didn’t show up on her drug screens and did help somewhat, but she could feel herself getting closer to using illicit opioids. When she asked about getting on bupe, she was told that it wasn’t allowed because it made you “feel different.”
Her supervisors offered Vivitrol. She didn’t want to do anything to lose her daughter, or her job. So she took the shot.
Vivitrol didn’t suppress her cravings; it made them worse, because all it did was dull the effects of the kratom. For 45 days of “absolute misery,” she kept showing up for work and white-knuckling her cravings, before she finally went to go fix them.
“I’d see these people leave detox because of these shots. They felt like they were tortured.”
In 2021, she started working at a detox center. The nurses would give some patients their first naltrexone shot on their way out the door, so McCarver never saw how it went. But some patients were given a shot on their first day—in a place that didn’t provide bupe, staff somehow thought that naltrexone could be given to someone in withdrawal.
Precipitated withdrawal, the state those patients entered upon getting injected with naltrexone while their opioid receptors were already occupied, is sometimes mistermed as withdrawal, or mischaracterized as being a similar experience. It is not.
Regular withdrawal comes on gradually, worsening over a period of hours. Precipitated withdrawal is the same symptoms but suddenly and all at once. And then, when you do what you normally would in order to get well, you can’t.
An FDA review found that some people sent into precipitated withdrawal after receiving naltrexone required treatment in intensive care units.
“I’d see these people leave detox because of these shots,” McCarver said. “They felt like they were tortured.”
She never saw what happened to those patients, either. But it’s not hard to imagine what they might have done next. They’d come in sick and left even sicker. They were going to find whatever would make them well.
In 2019, the FDA issued a warning letter to Alkermes after the company released a misleading print ad. Not for being overly generous about Vivitrol’s efficacy, but for explaining its safety to prospective patients without making clear that Vivitrol could kill them.
“Fatal outcomes have been reported in patients who used opioids at the end of a dosing interval, after missing a scheduled dose or after discontinuing treatment,” the letter stated. “Furthermore, there is also the possibility that a patient who is treated with Vivitrol could overcome the opioid blockade effect of Vivitrol. Patients should be told of the serious consequences.”
Why do people keep prescribing naltrexone for OUD? It isn’t safe for people with a tolerance to opioids. Or people who recently used opioids. Or people who recently stopped using opioids. Or people who might use opioids again.
Research supporting naltrexone has relied on undercounts of fatal overdose associated with it. Many prospective participants aren’t unable to complete the required seven-to-10-day withdrawal period. Many who do end up discontinuing early.
So a lot of people with more severe OUD are removed before the data collection starts. Those included might have milder cravings, or more of an interest in abstinence. And still, early discontinuation of naltrexone treatment is a well-documented phenomenon.
Stakeholders still pitch naltrexone as a product that brings results, despite its disproportionate expense relative to other MOUD, so it’s worth that cost so long as providers are willing to keep paying.
It would make sense if DOC liked naltrexone because it helped them cut costs. But it doesn’t. It’s several times more expensive to administer in institutional settings than either methadone or bupe.
Naltrexone does nothing to reduce use or overdose in the longterm, but studies usually only follow someone’s progress (urine drug screens) for a few weeks or months. Law enforcement and other stakeholders get to say naltrexone is shown to increase abstinence. Later patients may end up using four times their former dose, lose their housing, die—but that’s after the data collection period ends.
“On Vivitrol … I’d get dopesick hard and fast. So I’d spend most of my time high, trying to stay ahead of it.”
“On Vivitrol I’d be using a gram-and-a-half a day for a week, and then if on Day 8 I couldn’t buy, I’d get dopesick hard and fast,” Christian said. “So I’d spend most of my time high, trying to stay ahead of it.”
Before Vivitrol, his regular dose of street-supply opioids might not have brought the stability he wanted, but at least he was functional. For however long the Vivitrol was in effect, he couldn’t find enough work to keep him afloat, and he was spending a lot more on drugs. He lost the room he was staying in because he couldn’t make rent.
“I couldn’t think straight. Couldn’t get a job,” Christian said. “I couldn’t even talk to people without opioids in my system.”
Pauli Crawford, a prisoner in Washington Corrections Center where I’m also incarcerated, keeps getting caught using or bringing in fentanyl, but he doesn’t want to keep doing this any more than the corrections officers want him to. In late 2023 he sent in a request for MOUD, but Washington State DOC only considers requests from prisoners in the final six months of their sentence. Crawford still has four years to go.
“I’m just trying to manage my cravings,” he told Filter. “[But] they won’t give me Suboxone with this much time.”
MOUD isn’t just about overdose prevention. What a lot of people want most from it is stability.
Almost all public discussion around MOUD access is in the context of overdose prevention. But for Crawford, and many others at risk of overdose both inside and outside prison, the thing they want most from MOUD is stability.
Relief from the cravings that plague him would allow Crawford to stop breaking the rules and focus on other things. But each time he gets an infraction, he loses a a little more of his “good time,” and his sentence gets a little longer.
Even when he reaches the final six months, Crawford said, “I’m afraid they’ll give me Vivitrol instead.”
By the end of 2021, McCarver had quit the detox and got on Suboxone. In 2022, she got on methadone. These are the MOUD she credits for helping her enter long-term recovery. They provided a stable foundation she used to start a career, go to school, get married, be in her daughter’s life full-time.
When Christian last spoke to Filter, he was only a couple of days out from his release date. “Just got the shot. I’m hoping to stay sober,” he said with a short laugh. “But that’s probably not gonna happen.”
Top image via District Attorney General’s Office of Knox County, Tennessee. Inset image via Food and Drug Administration.
R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.