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More than 130,000 Americans will go through drug courts this year. They're often charged with possessing drugs or stealing, to feed their habit. To avoid jail, they're offered treatment. And sometimes, that includes medication to treat addiction. One pharmaceutical company sees an opportunity here. It markets its drug, Vivitrol, directly to court officials, who have no medical training. And now, some courts favor the drug over other treatment options. Jake Harper of Side Effects Public Media reports.
JAKE HARPER, BYLINE: Philip Kirby started using heroin about five years ago.
PHILIP KIRBY: When I was addicted, you know, I was addicted. You can't really dabble in it.
HARPER: Late last year, he was pulled over and charged with possession. He went to jail for a few months before entering drug court in Hamilton County, north of Indianapolis. But before Kirby started the program, he says court officials pressured him to get a shot of Vivitrol.
KIRBY: They made it seem like they were forcing it upon me, like I couldn't come into the program until I got it.
HARPER: Vivitrol is a drug called naltrexone. One shot blocks opioid receptors in the brain for a month. It's one of three FDA-approved medicines for opioid addiction. But doctors warn that some patients will do better with other treatments. And it can have side effects. Kirby says he reacted badly to it, that he got a bad rash.
KIRBY: I had sinus problems, chest problems for the whole month I was on it. And I couldn't shake it.
HARPER: The drug court Kirby went through doesn't allow other medications for treating addiction. In fact, we've identified at least eight drug courts in Indiana that say they only allow participants to use Vivitrol. One reason Vivitrol is so prominent in drug courts is that its manufacturer, Alkermes, is doing something unusual. Its sales reps market directly to judges.
This is happening across the country. Drug court officials in Missouri and Ohio also said they were contacted by sales reps. Here's how this can play out. Judge Lewis Gregory heads the Greenwood City Court, south of Indianapolis. And about a year and a half ago, Gregory didn't allow participants to start on medication.
LEWIS GREGORY: And we were failing miserably with the heroin population.
HARPER: He only knew about two opioid addiction medications, and they're opioids, buprenorphine and methadone. When prescribed properly, they prevent withdrawals and help patients feel normal. But sometimes, the drugs are sold on the street and misused.
GREGORY: I was certainly not going to do a medication-assisted treatment program with drugs which people use to get high.
HARPER: But then Gregory got some Vivitrol literature in the mail and a phone call from an Alkermes representative.
GREGORY: And so we ended up meeting in the early part of 2016, and she began educating me a bit.
HARPER: He said she gave him the pitch. Vivitrol is not an opioid. It blocks opioid receptors. And that was appealing to Gregory. Six months later, his court began permitting Vivitrol. He said the sales rep even sits in on treatment team meetings. Vivitrol sales could reach $300 million this year. At an investor pitch last year, policy director Jeff Harris said that drug courts are an important market.
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JEFF HARRIS: Think about this - there are over 3,000 counties in the United States, and there are over 3,000 drug courts.
HARPER: Alkermes has said it supports the use of all medications for addiction. But in practice, it doesn't. Previous reporting from NPR and Side Effects found that the company lobbies state and national lawmakers for policies that favor Vivitrol and even, in some cases, hamper access to the other medications. And drug courts are another place the company can grow sales. But most drug companies don't market to courts.
ADRIANE FUGH-BERMAN: I have not heard of a drug company going after judges before.
HARPER: Adriane Fugh-Berman researches pharmaceutical marketing at Georgetown University. She and other experts I spoke with say that marketing to judges and criminal justice officials isn't just unique; it's inappropriate.
FUGH-BERMAN: They're not health care providers. They don't know data. They don't know research.
HARPER: Alkermes declined repeated interview requests. In a written statement, the company defended its practices by noting that judges don't actually prescribe their product. But Basia Andraka-Christou, a researcher at the Fairbanks School of Public Health, says court officials do influence treatment decisions. That's why the company is marketing to them.
BASIA ANDRAKA-CHRISTOU: The judges in these cases are actually making a lot of the medical decisions, and that should be very concerning to everyone.
HARPER: Some judges only allow Vivitrol in court-ordered treatment, and others prefer it over other medications. But they argue that they don't mandate Vivitrol. Judge Gail Bardach runs the Hamilton County Drug Court, the one Philip Kirby went through.
GAIL BARDACH: We encourage it, but we never force anybody - never have, never will.
HARPER: But faced with potential jail time, participants don't always feel like getting the shot is a choice. To be clear, even if it doesn't feel like a choice, it can work for the right patients. Jeremy Templin was arrested for theft when he was 19 and addicted to heroin.
JEREMY TEMPLIN: I don't remember any of it. I don't remember what was stolen or any of that. I was in a blacked-out stage.
HARPER: He spent a few months in jail. Then, he was offered a spot in the Hamilton County Drug Court, and he got Vivitrol.
TEMPLIN: I don't know what it would have been like without it. I can't speak for that, but I know that I did have it. And here I am today, you know. I'm still alive.
HARPER: Still, addiction experts warn that using Vivitrol as a one-size-fits-all solution is a bad idea. People who go on Vivitrol lose their tolerance to opioids. So if they stop treatment, as many people do, and go back to using drugs, they're at a greater risk of overdosing. Dan Mistak is an attorney with Community Oriented Correctional Health Services. He says courts should let doctors determine which medication is right for each patient.
DAN MISTAK: We rely on outside experts all the time in the judicial systems. We don't ask a judge to come in and be an expert in arson. And so I think for these clinical decision-makings, I think that this is a responsibility that a judge doesn't want.
HARPER: Both the federal government and the National Association of Drug Court Professionals agree, and they endorse all addiction medication options. But getting courts to follow best practices is another matter. In some areas, buprenorphine and methadone providers are hard to find. And without clear rules in place for all of the drug courts in the U.S., some courts will continue to prefer Vivitrol over other treatments.
Phillip Kirby, who you heard from in the beginning, says his probation officer kept pushing him to stay on Vivitrol until he revealed a rash covering his body, another possible reaction to the drug. I could still see splotches on his arms months later.
KIRBY: This is like scarring from it.
KIRBY: Yeah, it's all cleared up except for these scars. I don't know if they'll go away. I hope they would go away eventually.
HARPER: In May, he was kicked out of drug court when he got caught with marijuana and sent to prison. He says he wish he never took Vivitrol in the first place. For NPR News, I'm Jake Harper.
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CHANG: This story was produced in collaboration with Side Effects Public Media and WFYI.
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