Sun. May 22nd, 2022

What It’s Like to Be on Vivitrol, the Drug that Prevents Heroin Addicts from Getting High

What Comes After Addiction

Vivitrol, a drug designed to prevent heroin addicts from getting high, forces life into focus.
By Genevieve Smith


The first time Gabriel overdosed on heroin, he was technically homeless, crashing on a friend’s couch. One morning, the friend went out for groceries and Gabriel shot up. When the friend returned, Gabriel was blue. After coming to in the hospital, Gabriel was stunned that he’d been so close to killing himself, in such a stupid way, and he felt guilty for the pain he’d caused his father, Martin, who had not realized the extent of his son’s addiction. Gabriel decided then that he was done with heroin.

The next five times Gabriel overdosed tend to blur together. Sometimes he wouldn’t even go to the emergency room. He’d just sort of wake up someplace and someone would tell him he’d stopped breathing. Sometimes he’d stay clean for months before slipping up again. But mostly he kept using. He kept using heroin after his son, Jared, was born. He kept using after two friends overdosed at the same time and he had to administer CPR to one, then the other. He kept using after one of his best friends died from an overdose. And he kept using after he went on Suboxone, an opioid relative of methadone. He realized he could take Suboxone in the morning, quiet his heroin hunger pains long enough to go to work, and still shoot up at night. He did this for a couple of years until his doctor refused to continue filling his prescriptions.

The last time Gabriel overdosed was in September 2014. He stopped by his dealer’s house after a recovery meeting. On his way home, he went unconscious, and the car swerved into the guardrail on a bridge. The medics had to saw him out.

Martin believed there was an angel looking out for his son. How else to explain his good fortune? That he walked away from the crash with just a couple of broken ribs. That he survived all those overdoses. That when Martin called the local substance-abuse center, the nurses knew to get Gabriel in to see a counselor right away, and that just a few years earlier that counselor, Janet Brannen, had started his town’s only group-therapy sessions for opiate addicts, where he went even when he was so sick from withdrawal that he’d have to leave to throw up. That his father stayed with him during the worst of his detox. That he lived in Massachusetts, which subsidized his treatment. That he had Jared, who gave him a reason to stick it out. Not least, that his physician was one of two local doctors willing to prescribe the drug Vivitrol, which made staying off heroin possible when nothing else had, because for the four weeks the drug was in his system, he couldn’t, no matter how hard he tried, get high off opiates.

I’d been introduced to Gabriel, which is not his real name, by his half-sister, who is a friend of mine and who had told me about the treatment that seemed to be finally keeping her brother off heroin. Gabriel lives in the Berkshires, and this past spring, on the day of his fourth monthly Vivitrol injection, I went to see him. I brought with me a photographer, Graham MacIndoe, himself a former addict. With a committed girlfriend and a grown son, Graham is very much the best-case scenario of what a life after heroin might look like.

We met Gabriel in the parking lot of the clinic. It was mid-March and sunny but still cold. A third of the houses in the Berkshires are vacation homes, and in the off-season, the landscape felt particularly dormant. Standing by his car in a black fleece jacket and a Dewar’s hat, Gabriel, then 24, was built like a high-school football player, broad and tall but still soft, with a thin, sculpted goatee, short brown hair, cheeks stained pink. He had diamond studs in his ears and robin’s-egg-blue eyes laced with dark lashes, his only blemish a jagged scar down the center of his nose from a fight a few years ago. (He was drunk, not high.) He looked much healthier than I had imagined a recent junkie to look. More surprising, though, was his voice, which was so gentle it seemed to be coming from a smaller person tucked into his great body. Inside the clinic, a nurse ushered us to a small examination room. Gabriel sat on the edge of the beige exam table, legs dangling, as he waited for his doctor, Lara Setti.

The active ingredient in Vivitrol is a drug called naltrexone, which works by blocking heroin’s path. It fits the keyhole where heroin would bond to the brain’s receptors, but it won’t turn the knob. The first forms of naltrexone, released in the ’80s, had to be taken every day, which is in part why the drug never caught on as a treatment: You might not be able to fulfill the craving when on naltrexone, but the craving is still there, because for an addict, how to get high is the first thought of the day and the last. The breakthrough with Vivitrol was that four-week window of highlessness, which meant someone in recovery no longer had to keep the faith of sobriety every single day. A once-a-month re-up would suffice. Even then, it is still possible, at least theoretically, to cheat, particularly toward the end of the 28-day cycle when the drug has been partially metabolized. At that point, a committed addict could potentially do enough heroin to get a decent high, albeit a more expensive one, since he’d need enough to overpower the naltrexone lingering in his system.

Still, Vivitrol was a welcome improvement. In the past few years, as it has caught on as a treatment option, drug-court judges have incorporated it into their prison-alternative arsenal, and reentry programs have started giving injections to prisoners before they return home to all the old temptations and triggers. It has been fantastically successful in both keeping prisoners clean and reducing recidivism, though one clinician told me most ex-junkies will try to get high at least once before really understanding what they’ve signed up for.

Doctors treating the general population have been slower to prescribe the drug, in part because it requires a high level of management. Vivitrol must be kept refrigerated and administered in the office. Getting insurance approval is a nightmare. Without insurance, it’s wildly expensive — $1,500 for a single dose. But heroin has increasingly become a white suburban drug — 90 percent of new users are white; 75 percent live outside cities. With that shift has come greater political attention and greater pressure to find solutions that don’t involve jail time. In October, President Obama made expanding access to medically assisted opioid-addiction treatments like Vivitrol a cornerstone of a new $133 million federal program to combat heroin use.

But it’s not just access that has kept Vivitrol unpopular. It has another problem: You have to get heroin out of your system before you can take it. Most addicts Gabriel knew were too terrified of withdrawal to consider going on Vivitrol. You had to want to get clean badly enough that you were willing to wade through seven to ten days of pure physical anguish—fevers, vomiting, a hurt that penetrates every ounce of your body. The pain is more bearable if you think you deserve to suffer, if you see suffering as penance for six years of fucking up.

Photo: Graham MacIndoe

The shot would come at the end of the doctor’s visit. It was the easy part, a jab in the hip. Before that, Setti tried to treat everything else. Heroin leaves behind a lingering emptiness, like a stain. The feeling even has a technical name: excessive anhedonia. It’s such a pleasing sound for a phrase that means the inability to experience pleasure. The theory goes that opiates flood the brain with so much dopamine that the sober addict becomes numb to the joys of regular life — a beautiful day, a delicious meal, a meaningful conversation. Janet, Gabriel’s counselor, had told him to expect it to take two years before he’d be able to fully enjoy himself like a normal person. It was a fact Gabriel repeated often, a way of reminding himself that it wouldn’t be like this forever.

Setti was good-naturedly no-nonsense, his coach and cheerleader as much as his doctor. She handed Gabriel a set of dog tags that he was to wear in case he had an accident and lost consciousness. “If you needed a narcotic and they gave you a narcotic, it wouldn’t work,” she said. “You could be writhing in pain, and they wouldn’t understand.” She asked Gabriel about his new job, and his son, and whether his antidepressants seemed to be working. She wanted to know how often he was exercising and whom he was hanging out with and whether he was lonely and if he was drinking. It was clear she’d invested in Gabriel, which made sense, since he was her only patient on Vivitrol. None of the others had been willing to go through withdrawal.

She examined Gabriel’s depression questionnaire. “So this is interesting,” she said. “This is the best you’ve ever done.” It was true. Four months into his treatment, he felt like Jared could tell how much more present his father was. His life had taken on a certain rhythm, one meant to keep him out of trouble: work-gym-home. He had a job at a factory making potter’s clay. His new landlord had let him slide on the rent until he got settled, and now he was finally caught up. He was going to the gym six days a week. He was in the best shape of his life. He was even thinking of quitting smoking.

Still, he had trouble answering the question about friends. He had a few close ones and a gym buddy, but most of his old gang he knew he couldn’t see, because even if he couldn’t do opiates, he could do other things. Alcohol in particular was tricky. Vivitrol blocks the same receptors that make drinking feel euphoric. Gabriel could still get the physical effects of drinking — slow response time, poor motor skills, reduced inhibition — but there was no warm, happy glow, at least not for the first few weeks after his injection. Toward the end of the cycle, he could enjoy a drink, but when he did, he felt his resolve melting a few beers in. He thought he should probably just not drink at all, but he didn’t really want to do that either. He asked about upping his dose of antidepressants.

Martin, who is slight, with a short white beard and a muss of white hair, was dressed head-to-toe in denim. If you ask Martin where he’s lived, he quotes Beckett. In the morning, he wakes up early and feeds the birds in the field behind his apartment, then he writes for three hours. He writes poems. He writes about what he reads. He quotes Emerson to explain this habit. He will tell you this in a voice barely above a whisper. It’s that voice that connects father and son, though Gabriel’s is loud by comparison.

While Gabriel lifted weights, Martin told me about his guilt at missing all the signs of trouble when his son was a teenager, how he believed Gabriel when he explained away the needle Martin found. He admitted he often doesn’t understand his son and wonders if his own interiority is partly to blame for Gabriel’s problems. Martin had studied the methods of Rudolf Steiner, the mystic philosopher. He met Gabriel’s mother in Wales, where they were both working as caregivers in a Camphill community, a self–sustaining village for the developmentally disabled inspired by Steiner’s work. Gabriel was born there. When he was 3, the family moved to another Camphill community in the Hudson Valley. There were no boys his age, so Gabriel often played alone. He hated it, even more so when his mother, who is Dutch, decided to return to the Netherlands. He lived with her for a few years before coming back to live with his father, who had by then moved to the Berkshires.

Martin looked out at the countryside and saw utopia, saw the ability to work with one’s hands, saw a way to live well with little. His son looked out and saw guns and ATVs and boredom. He saw Marlboros and trucks. He saw heroin. “Gabriel’s thing is four-wheelers, bulking up,” Martin said. “I said to him, ‘Who the hell is your father? Who was your mother with?’ ”

Martin was hopeful but cautious about his son’s future. “He seems stable now,” he said. “You just have to trust that he’s committed to the path he’s on, but there’s always that possibility. So you live with a kind of shadow.” He talked about Gabriel’s “heartforce,” that goodness in him that Martin believed would carry him through. To his addiction, Gabriel had given the years when most of us begin to figure out who we are and what we want. He had talked to his dad about maybe wanting to be a plumber, though so far it was only talk. “He is a young 24,” Martin said. “I’ve told him, What do you really want to do? Who are you? ‘What is it you plan to do with your wild and precious life?,’ as Mary Oliver said.” He grew quiet and looked away. When he started speaking again, there were tears in his eyes.

The clinic where Janet works is housed in an old Victorian. She met us at the door with hugs. “I remember the most striking thing was your eyes,” she said to Gabriel. “Fear, sadness, desperation, but also a kind of finality. Sometimes I see folks and I think they’re not ready yet. He was ready to get clean.”

Janet was full of stories, wisdom handed down from addicts. There was the addict who told her that heroin was the answer to all of life’s problems, so why should he quit? And the one who wanted to get high so badly he paid someone to cut out his naltrexone implant—an alternative to the injectable Vivitrol that’s released via a microchip embedded in the skin. She talked about how the Vivitrol shot “catapults the person into the possibility of being able to get to who you are really and what you want, because it literally stops you from thinking I can go do heroin.” One patient told her how he didn’t know what to think about with his morning coffee now that he didn’t have to think about how to score that day.

Gabriel nodded. Heroin for him, too, had been a revelation. “There’s nothing for me like that experience of instantly being wiped free of any pain,” he said. “It’s unnatural. So once you experience it, what are you supposed to do with that? It’s not something that’s supposed to be experienced.”

Sometimes Gabriel could go a few weeks without thinking about heroin, then it would just pop into his head. Things could be going beautifully, and the thought would cross his mind how much more beautiful they’d be if he were high. Or he’d be driving and he’d see someone he used to get high with or someone who was clearly high at that very moment, and it would hit him — first, a pang of jealousy. Then, slowly, he’d work to remind himself of all the shit that came with the joy.

In those early months, the craving was physical. Now it was contained mostly to his brain, so he could talk his way down more easily. But there were times he’d toyed with the idea of shooting up, especially toward the end of the month, when the drug had partially worn off. “It’s weird,” he said. “It’s sort of like there are two halves of my brain. One is, This shit’s bad, my life is good. I might struggle sometimes but blah, blah, blah … And there’s the other half that’s like, I love heroin. This shit is amazing. Don’t worry about anything else.

Maybe if you had grown up in a town where the main industries seemed to be real estate and antiquing; maybe if you’d never been good at school or at least not very interested; maybe if your dad believed so strongly in the sanctity of childhood and the goodness he saw in you that he pretty much let you roam free and feral; and maybe if your mother was 4,000 miles away and you never stopped missing her; maybe if you’d always felt a little insecure; maybe if as long as you could remember you’d been curious about drugs, you’d wanted to feel big and warm and expansive and confident; maybe if you’d already tried marijuana and cocaine and LSD and mushrooms and oxycodone and MDMA and crack and basically everything you could get your hands on; maybe it wouldn’t seem like a big deal to shoot heroin. Maybe you would have done it, too.

And maybe you would have felt like Superman from the moment the needle pricked the skin and that itchy burn like liquid Red Hots spread through your veins; maybe you’d feel invincible; maybe you’d finally feel like you could breathe.

It is much easier to tell the story of addiction than of what happens after. Addiction is the stuff of movies: self-destruction; brushes with death; villains; the chance of rescue, redemption, salvation. But for those who make it out, the rest of the narrative, the long, hard work of putting together a life — it’s much less compelling stuff. It’s what the rest of us do every day in one way or another. And it is mostly boring and exhausting and not so much fun, or else the fun is at the margins of the tedious, the brief moments between work and bills and child care and doctors’ appointments and grocery shopping and cooking and laundry. The bigger meaning is in there, someplace, but it can be hard to find. Adulthood can sometimes feel like an endless series of administrative tasks, of just getting by, even when we are not grappling with our demons, even when our demons are not particularly menacing.

Photo: Graham MacIndoe

At dinner, Graham and Gabriel discussed the oldest addicts they’d known, the agony of withdrawal. We talked about more mundane things, too, like child-rearing, but the conversation had a way of snaking back toward heroin. Gabriel had said he loved movies, and when I asked about his favorites, he told me he really likes ones about drugs, which prompted a discussion of which films and shows were the most realistic. (Requiem for a Dream got the desperation of wanting to cop right; the dealers in The Wire were spot-on.) I asked Gabriel what he thought he might like to do with his life.

“People always ask me that,” he said. “ ‘What do you want to do when you grow up?’ I’ve been so caught up in just going through all this stuff that I haven’t even had … I always thought it would be awesome to be in film, to be part of creating something. Something like Graham’s doing. You love photo. And that’s what you do for a living. I’d love to find something I really love to do.” I didn’t say then that even if you are lucky enough to do something you love, you will still, from time to time, look at your life and find it lacking. You’ll bang around the rooms of your mind, knocking over furniture, grasping for the exit.

As we finished our burgers, Gabriel talked about missing the social part of his old life, the way his friends would run around together on a mission to get fucked up. “A lot of things are boring, and that life is exciting and you’re taking risks,” he told me. “Getting up and working a normal job, that shit is lame.” And yet it was exactly that banality that he aspired to. “You gotta put in your time to earn a living, to pay your bills, to take care of all your responsibilities,” he said. “It’s almost like I was in a bad accident, and I had to relearn how to talk and walk and stuff.”

The first time Gabriel got high while on Vivitrol was two weeks after his seventh injection. In Janet’s telling, a friend who was also on the drug discovered that he could get a decent high just a few weeks into the monthly cycle, and he convinced Gabriel to join him. (Percy Menzies, whose addiction-treatment clinic in St. Louis has treated more than 6,000 patients using Vivitrol, told me that it’s exceedingly rare to successfully get high before day 21 of the drug’s 28-day cycle.) Then his insurance lapsed, and he couldn’t afford to pay for the $1,500 injection out of pocket. Soon after, Janet said, his car broke down and the girl he’d been seeing moved to Florida. And just like that, he was using heroin regularly again, even though he hated it and hated himself for doing it. He came to Janet’s office in tears, because he’d failed and because he didn’t think he could go through the ten days of detox again. Janet helped get him into a methadone program. Even getting him to that first appointment felt to her like a minor miracle. Gabriel had driven to the clinic dope-sick, and his GPS had gotten him lost. He missed his time slot and was told to come back a week later. He called Janet panicked. “There was so much bad heroin going around he was terrified he was either going to overdose and die or get arrested,” Janet told me. She managed to get him in to see the doctor, and he texted her later: “I got it. I’m ok. I’m alive.” I could hear her voice crack as she recounted the story on the phone. “It was like a car chase, life and death,” she said. “I can’t even talk about it. I’m too close to it still. These kids are fighting for their lives.”

When I asked Gabriel why he relapsed, he was dismissive at first. “I’m no good. I’m an addict. That’s why.” A little later, he was more circumspect. “It’s hard to explain how I hate it so bad and yet why can’t I just say no? It’s just a wild thing to fathom, you know? It breaks my heart to be going through this.” He suggested that maybe he wasn’t ready for Vivitrol. “With the methadone, you’re still sort of feeding that hunger for the opiates. The Vivitrol is like a full-blast kick to nothing. I think that was good for me, but it also panicked me in a way.” But he said he was grateful for those eight drug-free months. “It allowed me to get a taste of what life was like completely sober. It was the happiest I’ve ever been.”

That night back in March, over dinner, Gabriel had told a story he’d heard about euphoric recall. A term from substance-abuse literature, it describes the way addicts will remember their highs, all of the good parts and none of the bad. One guy in Gabriel’s group therapy who had been sober a long time now, who had the wife and the career and the stability, said that at the beginning, his memory of the high was an inch from his face, so close he could feel it, but slowly it receded, until it became like the moon. It hangs over him still, but he wouldn’t know how to touch it if he tried.




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