This story was produced in a collaboration between Alaska Public Media and the Anchorage Daily News, with support from the journalism non-profit the Economic Hardship Reporting Project.
Lucy Tall and Roger Williams spent years living on the streets of Anchorage, camping out in parks and bathing in creeks. Last year, both Tall and Williams were suffering from health problems related to alcoholism and coronavirus was spreading.
“We realized we were getting too old for camping out in wintertime,” Williams said
The couple packed up their tent, gathered their belongings and moved into Ben Boeke Ice Arena. The city had converted the sports venue into a mass shelter to provide more space to help mitigate the virus spread.
Besides hot meals, showers and a place to sleep, the shelter offered a host of services to Anchorage’s homeless residents, such as housing and employment information, help applying for economic stimulus checks and disability payments, and access to health care.
Tall and Williams had decided they wanted to stop drinking and they asked shelter workers for help. A staffer told them about a drug that would end up changing their lives. It’s called Vivitrol.
“A slow release in the body”
Tall and Williams were among at least 1,100 people who meet the official definition of homelessness in Anchorage and the many thousands more who are semi-homeless: couch surfing, doubling up and living in cars. Alcohol abuse is a common struggle. Substance abuse experts estimate nearly 40 percent of the nation’s homeless population is dealing with alcohol dependence.
Vivitrol is an injectable medication, a once-a-month shot that helps people break addictions to alcohol or opioids. Though Vivitrol has shown to be an effective way to help people with serious addictions gain enough stability to transition into permanent housing and stay there, it isn’t widely used yet. Addiction experts cite a lack of awareness among primary care doctors of its availability and benefits, stigma around getting help for alcoholism, and lack of desire among potential patients to get sober.
But many people who work in the fields of homelessness prevention and addiction treatment think with wider use, Vivitrol has the potential to reduce the number of people living outdoors in Anchorage.
Vivitrol falls into a class of medications called opiate antagonists. The Food and Drug Administration approved Vivitrol’s use for alcohol dependence in 2006. For people with alcohol use disorder, Vivitrol offers relief by easing their cravings.
The medication blocks the brain’s dopamine reward system that gets stimulated when alcohol enters the bloodstream and reaches the brain. Vivitrol comes in a pill form as well, Naltrexone. For some patients, Naltrexone works well. For others, not so much: It can be hard to remember to take a daily pill, increasing the likelihood of relapse.
For homeless individuals, whose lives are often marked by trauma, or for the high percentage who experience mental health challenges, Vivitrol may be easier to manage. It lasts for 28 days until another shot is required.
“Remembering to take your medication is challenging. It’s even more challenging with alcohol-use disorder because cognitive functioning is impaired when they are under the influence of alcohol,” said Dr. Lorenzo Leggio, a senior investigator and deputy scientific director at the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health in Bethesda, Md.
Making it easier to stay on track is one major reason scientists were motivated to develop Vivitrol, he said.
“This is a slow release in the body. It works better for many,” said Leggio.
An older medication to treat alcoholism, Antabuse, made patients feel sick if they drank while taking the drug. Vivitrol isn’t like that. It simply reduces cravings and the feeling of intoxication from drinking alcohol.
The federal government requires private insurance to cover substance use disorders, so many health plans cover the cost of Vivitrol and associated counseling. A large portion of the homeless population is covered by Medicaid, and many treatment providers will accept Medicaid to cover Vivitrol treatment, according to the Alaska Division of Insurance. If paying out of pocket, Vivitrol is pricey. A single shot can cost upwards of $1,450, according to providers.
But given how widespread alcohol misuse is in the United States and its heavy cost to society, Vivitrol’s benefits may be well worth the price and, if anything, the medication should be more widely used, many addiction experts say.
They knew they needed help
Tall, 59, is Cup’ik, a tribal member from Chevak, a river community in the Yukon-Kuskokwim Delta where fishing and hunting drive the local economy. Many children in the region grow up bilingual, speaking Indigenous languages and English.
Things were good in Tall’s life until the arrival of adolescence, she said.
At age 15, Tall drank alcohol for the first time. Soon she watched people around her die of alcoholism while others suffered alcohol-related injuries and illnesses, both physical and mental.
As years passed, Tall’s dependence on liquor grew. She left Chevak and made her way to Anchorage, where alcohol is cheaper and more widely available, to see friends and drink.
She met Williams, 61, in Anchorage and the two became a couple in 2011. A former North Slope roughneck and house painter, Williams was also an alcoholic and a regular client of Bean’s Café.
For a decade or so, they lived outdoors when the weather cooperated. When temperatures reached deadly cold, they slept at shelters. Sometimes they bathed in Ship Creek.
Tall was in and out of the hospital for alcohol-related problems, including a broken hip and multiple rounds of pneumonia. She and Williams mourned the deaths of their friends. They knew they needed help.
A disturbing portrait
According to 2019 statistics from the National Institute on Alcohol Abuse and Alcoholism, nearly 26 percent of Americans ages 18 or older reported having engaged in binge drinking during the prior month. About 95,000 people die from alcohol-related causes annually, and the economic burden of alcohol misuse in the United States in 2010 totaled $249 billion, according to the institute.
In Alaska, the statistics suggest an even more disturbing situation. The rate of alcohol-related deaths nationwide in 2017 was 9.6 per 100,000. In Alaska, it was more than double that, at 19.8 per 100,000. For Alaska Natives, the rate was a staggering 67.9 per 100,000, according to CDC numbers.
While alcohol use disorder is common, the number of people who pursue medication-assisted treatment like Vivitrol is minuscule. Nationally, it’s about 4% of alcoholics or problem drinkers, according to Leggio.
If doctors failed to prescribe life-saving medications to such a tiny portion of patients with other serious conditions like diabetes, cancer or hypertension, society would be aghast.
“It would be unacceptable clinically, ethically, even legally,” he said.
On-demand treatment services are critical
Vivitrol treatment is available at a number of clinics around Alaska. It’s also available to inmates with opioid or severe alcohol dependence at seven Alaska correctional facilities.
“They receive a shot just prior to release and are connected to treatment providers in the community for follow up,” said Sarah Gallagher, Department of Corrections spokeswoman.
Bean’s Café, which operates the mass shelter at Sullivan Arena next to Ben Boeke, hopes to see Vivitrol offered at the medical clinic inside the facility in the near future. Medication-assisted treatment for addiction to opioids like heroin is currently offered at the clinic. But if a client wants to quit drinking with the help of Vivitrol, Bean’s will refer them and provide transportation to a clinic offering the treatment.
Having Vivitrol available at the shelter clinic would save time and expand the number of clients served, said Bean’s Café executive director Lisa Sauder.
“The more services we can deliver on-demand, in real time, then the people we are going to be able to help,” Sauder said.
One of the challenges of helping homeless alcoholics is catching them at the moment they are ready for treatment.
“To be able to connect our clients directly to a provider who can do that the same day is really critical to the success of it,” she said.
Vivitrol has helped several clients stay sober while at the Sullivan, she said. The medication has also shown success among homeless residents staying in federally funded hotel rooms during the pandemic. Once on Vivitrol they are less likely to allow drinking buddies into rooms or host liquor-fueled benders.
Not every alcoholic is a candidate for Vivitrol. The patient must have proper liver function and meet among other medical criteria. But mostly they must be ready to move beyond heavy drinking. Dolores Van Bourgondien, an advanced nurse practitioner who administers Vivitrol in Juneau, has seen many homeless clients turn it down. For a time earlier in the pandemic she nursed homeless residents staying at a COVID isolation center in the capital city. Many were chronic alcoholics who were offered the option of medically-assisted treatment.
“Not one of them was open to going on the medication,” said Van Bourgondien. “You have to meet the patient where they are. People have to be ready.”
“It’s just a mindset”
After Williams and Tall told a shelter worker they wanted to get sober and into housing, she steered them to Ideal Option. The outpatient clinic for alcohol and opioid addiction treatment on East Tudor Road is one of several locations including Wasilla, Fairbanks, Juneau, Kenai and Ketchikan. Van Bourgondien works at the one in Juneau.
The couple rode a bus to the East Anchorage clinic and sought out Vivitrol.
“We jumped on the bandwagon,” Williams recalled.
After public transportation ground to a halt during a citywide hunker-down mandate, they continued their recovery, cold turkey. They had just two injections of Vivitrol, but it was enough to set them on a path of recovery they plan to sustain.
They’re living in permanent supportive housing now at Karluk Manor, sober. They play a lot of cribbage and just celebrated their first anniversary of not drinking, said Williams.
“We’re happy,” Tall said.
The couple said they are committed to their sobriety.
“It’s just a mindset,” said Tall.
Chami Krueger is Bean’s Café medical navigator who helped the couple get connected with a Vivitrol provider. Watching Tall and Williams move from shelter to Karluk Manor “was the most rewarding day of my job,” said Krueger, her voice catching.
“I’m so incredibly proud of them.”
This story was supported by the journalism non-profit the Economic Hardship Reporting Project. Paula Dobbyn can be reached at pauladob@gmail.