KY judge sees medical hope for opiate addicts

• Vivitrol is a nonnarcotic pharmaceutical that prevents heroin or prescription painkiller abusers from getting high..Kentucky Circuit Court Judge David Tapp is piloting its use in his drug courts and a special probation program, serving Lincoln, Pulaski and Rockcastle counties – and witnessing success, so far.
• Suboxone sales climbing on the streets: Suboxone is a synthetic opiate that’s used for heroin addicts to quell craving and stabilize the brain. The Kentucky State Police crime lab analyzed 739 submissions of buprenorphine, the generic form of Suboxone, in 2013, compared to 1,139 in 2014 – a 58 percent increase.
• Judge Tapp says he is seeing success with Vivitrol. Kentucky Administrative Office of the Courts is monitoring the program.

We all know heroin use is an epidemic in our area. But what are our local leaders and institutions doing – or not doing – to fight it? This year the Enquirer will be focusing on solutions to the region’s heroin problems.

A sliver of hope for heroin addicts could enter Northern Kentucky’s drug courts, where judges have steadfastly said no to drugs to treat them – even in the face of scientific evidence that medicine often works best.

The hope is being touted by one of their own: a Kentucky drug court judge who is successfully using the non-narcotic drug Vivitrol to help prescription painkiller and heroin addicts in his court stay clean.

Kentucky Circuit Court Judge David Tapp, who serves Lincoln, Pulaski and Rockcastle counties, was in Northern Kentucky on Monday to describe his Vivitrol program to the region’s drug court judges.

“We’ve been using Vivitrol on a very small level here,” said Tapp said from his Somerset courthouse Tuesday. “It seems to be working really well.”

What’s Vivitrol?

Vivitrol is the injectable form of non-narcotic naltrexone. The FDA approved naltrexone in 2006 for treating opiate addiction and Vivitrol for monthly injection in 2010.

It’s a pharmaceutical that blocks mu-opioid receptors so that heroin or prescription painkillers have no effect on their user. Vivitrol is prescribed by a physician, usually for patients who have had shorter-term heroin or opioid addiction. To take it safely, the patient first has to be detoxed from opioids or heroin.

Like with other medicines used to treat heroin and opioid addiction, experts say Vivitrol works best when combined with counseling, and that’s what Tapp’s participants are getting.

The Kentucky Administrative Office of the Courts began working with Tapp on piloting the Vivitrol program in his drug court about eight months ago. Now officials are beginning to discuss its potential use in drug courts throughout the commonwealth. But they say it’s too soon to make a decision.

Kentucky’s House on Friday passed a bill expanding medical care for addicts, which provides funding for hospitals to supply patients with overdose kits when they are sent home.

Since Northern Kentucky is so entrenched in the nationwide heroin epidemic, Tapp said it made sense to him to come and talk to judges in the region.

“I thought perhaps I’d enlist their support.”

The local drug court judges are just listening for now. But it’s too early for them to agree to the regimen, they say.

“I’m all for looking at it,” said Campbell County District Judge Karen A. Thomas, the county’s drug court judge.

Even that is a switch from the usual mantra in Kentucky drug courts, which require participants to remain drug-free or be tapered off of physician-recommended and prescribed medicines used to stabilize them within six months. The programs use abstinence-based recovery methods.

The Kentucky drug court policy states judges can use their discretion and allow – or forbid – the use of medically supervised detoxification or treatment for up to six months. The courts system says the narcotic treatments interfere with their drug-testing, and that experts have told them those taking the drugs can safely and medically taper off them within six months.

But the abstinence programs that have great success for alcoholism, for example, fail miserably for most heroin and opioid addicts. A startling number of those – between 95 and 98 percent – who are assigned to abstinence programs fail to remain clean.

Vivitrol is, then, middle ground for judges who want to help addicts but are opposed to synthetic opiate replacements and offering, well, no medical treatment.

Suboxone stigma,

and street sales

“Suboxone and methadone – they’re just legalized narcotics,” Campbell County’s Thomas said.

Both drugs are used – frequently with success – to keep addicts off of heroin by reducing cravings, preventing withdrawal symptoms and stabilizing them. But they come with a stigma, because they’re synthetic opiates.

Suboxone, the brand drug of the generic buprenorphine, is often prescribed in take-home doses, making it easier for addicts to live a normal life – but also fueling its illegal sales on the street.

The street sales are evident throughout the state. And buprenorphine submissions to the Kentucky State Police crime laboratory are skyrocketing, just as overdoses and deaths from heroin are climbing. The lab analyzed 739 submissions in 2013, compared to 1,139 in 2014 – a 58 percent increase in cases where officers either seized the drug or bought it during a drug investigation.

Van Ingram, executive director of the Office of Drug Control Policy, said most of the street-sales of buprenorphine are happening in regions outside of Northern Kentucky.

Some people are selling the take-home strips of Suboxone for financial gain, some are sharing the drug, some people may be getting prescribed more than they need, Ingram said. One heroin addict told the Enquirer in 2012 she was using Suboxone from the street as she tried to wean herself from heroin to temper dope sickness that comes with withdrawal.

Tapp said the courts see evidence of diverted Suboxone in drug tests for inmates, and that’s why judges don’t want it in their court programs.

Dr. Mina “Mike” Kalfas, a Northern Kentucky physician and certified addiction specialist who has been prescribing Suboxone for 12 years, said that most addicts using it illegally are trying to self-medicate to avoid withdrawal.

In fact, part of the illegal sale of Suboxone in Northern Kentucky is attributed to the fact that not enough physicians in the region prescribe the drug, leaving heroin addicts to seek it from those who do have a prescription.

Kentucky courts aren’t the only ones that spurn the use of Suboxone and methadone. Ohio’s Hamilton County Drug Court is another court adhering to abstinence for participants. Warren County Common Pleas Court, on the other hand, has been allowing Vivitrol for some inmates.

‘Hard-nosed’ judge

welcomes Vivitrol

Tapp describes himself as a “hard-nosed” judge and says even he was a skeptic when he first heard about Vivitrol.

But Tapp learned last spring about how it could be used in Kentucky’s courts system. By summer, he had put protocols in place for its use in his drug court, along with requirements for use in a special probation program. By Sept. 16, 2014, Tapp found his first candidate for the medicine.

Deedra Shipp, 25, of Stanford, says she started using drugs when she was 14.

“Her record was horrible. She’d been in jail several months. I had her tested, right there, and she was positive for everything – opiates, marijuana. She was using in jail,” Tapp said.

Her attorney made an argument to keep her out of prison, and Tapp thought: “Maybe she’s a good person to start with Vivitrol.”

He had Shipp transported from Lincoln County to Pulaski County, where a doctor met with her and decided she was, in fact, a good candidate for the pharmaceutical.

She’s been getting a Vivitrol injection once a month. And she hasn’t fallen back into illegal drug use.

“Since I’ve been on Vivitrol, I’ve been sober on my own for the first time in 11 years,” Shipp said.

“She’s been drug-tested 12 to 14 times a month. She’s had zero positive drug screens. She is employed,” Tapp said, ticking off one success after another for the young woman and concluding with a chuckle, “She’s doing good!”

Tapp said defendants and their attorneys who enter his court may ask about Vivitrol as an effort to stay off drugs and out of prison. Some are people who no longer want to be on Suboxone, he said. Others have repeatedly relapsed from abstinence-based therapy.

“We provide them with literature and make arrangements for them to meet with a physician,” Tapp said.

“It’s always a medical decision.”

Kenton County Circuit Judge Gregory Bartlett, a drug court judge, was out of town when Tapp visited but met with him a couple of weeks ago at a circuit court judges meeting.

“I don’t know a whole lot about Vivitrol,” Bartlett said. “I’m interested in looking into its use.”

Likewise, Boone County Circuit Judge James Schrand, who heads that county’s drug court, said he found Tapp’s experience with Vivitrol interesting.

“With the way the epidemic is, we want to look at all of our options,” Schrand said. But again, he said it’s too soon to say the Northern Kentucky drug court judges are even considering its use.

But there is interest in Vivitrol elsewhere in Northern Kentucky.

Campbell County Judge-executive Steve Pendery, whose county is designing plans for a substance abuse program for its jail, has invited Tapp back to Northern Kentucky to meet with the county jail staff.

“I’m interested in hearing his experience with Vivitrol,” Pendery said. “We have to learn more so that we can create a program that offers the hope of success,” Pendery said.

One county over, Kenton County Judge-executive Kris Knochelmann expressed interest in Tapp’s program after hearing the judge was in Northern Kentucky last week.

“Any movement in this area is good,” he said.

Tapp said the cost of his program isn’t much, despite the fact that Vivitrol shots cost about $1,000 per month. The medicine is covered under Medicaid and some private insurance companies. The court helps participants enroll for insurance, and the makers of Vivitrol have provided the first dose free for now to drug-court candidates.

The court pays for a single pill dose of naltrexone, at about $5 per pill, for each Vivitrol candidate to ensure they are detoxed before starting the injections.

Does Vivitrol work?

Every heroin addict is different, and every treatment plan should be individualized.

Kalfas said he’s had about a 30 percent to 50 percent success rate with Vivitrol, and he uses numerous factors to decide whether a patient is a good candidate for the drug. The odds of success go up to about 70 percent when the person remains sober for the first three months they’re injected with it, he said.

Dr. Adam Bisaga, professor of psychiatry at Columbia University Medical Center’s Department of Psychiatry Division on Substance Abuse, said the effectiveness of office-based Vivitrol is similar to that of office-based Suboxone, with 50 percent of patients still in treatment at six months. But success, he noted, “really depends on many factors.”

Like with other medicines for opiate and opioid addiction, the length of use of Vivitrol varies depending on the addict’s need. The Enquirer has interviewed patients who remained on it for a year before going without it successfully. Some physicians say Vivitrol should be used for at least three months, but some patients are on it for a few years.

Tapp made it clear he isn’t touting Vivitrol as the answer to the heroin epidemic.

“There’s no one magic bullet. I just don’t think there’s only one solution,” the judge said. “What we need are different arrows in the quiver.”

Vivitrol: A nonnarcotic pharmaceutical that blocks mu-opioid receptors so that opiates such as heroin or opioids will not provide any effect. Generally prescribed for patients who have had shorter-term heroin or opioid addiction. It is given by injection monthly.

Suboxone: A synthetic opiate that partially fills the brain’s mu-opioid receptors. It reduces cravings and prevents withdrawal symptoms. It also blocks euphoric effects of opiates such as heroin and opioids such as prescription painkillers. Generally used for individuals who’ve had shorter-term heroin or opioid addiction. It is prescribed by physicians and can be taken in a pill or dissolving film form.

Naloxone/Narcan: Naloxone is the generic form of Narcan, a drug that is injected or sprayed into the nostrils to revive people who have overdosed on heroin or opioids. It causes almost immediate withdrawal and restores normal breathing in the patient, reviving him or her.

Methadone: A synthetic opiate that completely fills the mu-opioid receptors in the brain. It reduces cravings and prevents withdrawal symptoms. It is regulated in the body to stabilize the patient so he or she functions well without euphoric effects. Generally used for individuals who’ve had long-term heroin or opioid addiction. It is provided in a highly structured and federally regulated clinic setting in a liquid form.