Last time, it took Arielle Holmes less than an hour to relapse on heroin after she was released from prison.
Probation violations and other crimes led her back to Hiland Mountain Correctional Center, where she sat in yellow inmate clothing last week.
"The second I got to Anchorage, I ran to a friend and wanted to get high," said the 28-year-old. "It's just an instant trigger. I forgot that I was clean. I forgot that I had plans to go somewhere."
This spring, with her release date approaching, Holmes volunteered for another kind of shot: a medication that would chemically lock away her ability to get high.
Vivitrol is an injectable form of naltrexone, an opioid blocker. After Holmes got the shot, she'd not be able to get high for a month — even if she took opioids. The drug also reduces the incessant craving for opioids that addicts feel.
Drugs have created trouble in her life for 15 years. For others close to her, they had cost them life. She doesn't want that to be her story.
"I don't want to die and I don't want to live here," she said. "I'm tired of being here."
A revolution in treating opioid addiction?
Around the country, public health officials see Vivitrol as a potentially revolutionary tool for tackling the deadliest public health crisis since AIDS.
Over the past five years, the medication has been used in dozens of state drug courts and correctional systems, such as Massachusetts and New Hampshire, to fortify people newly clean from heroin against relapse, keeping them from returning to jail.
Initial results have been promising: In one of the pioneer programs, at Barnstable Country Correctional Facility in Massachusetts, about 82 percent of inmates who took Vivitrol have stayed out of jail.
In Alaska, the medication is quickly becoming the prevailing approach for treating the many addicts caught up in the criminal justice and penal systems.
Public health officials describe Alaska's opioid epidemic as a series of deadly, destructive waves: First, prescription painkiller deaths increased a decade ago. Then six years later, heroin hit hard. Synthetic opioids like fentanyl are a newer worry, according to Dr. Jay Butler, chief medical officer of the Alaska Division of Public Health.
The number of heroin-associated deaths in Alaska quadrupled between 2009 and 2015.
Here, as in other states, opioid addiction and incarceration are closely intertwined.
In Alaska, nearly 70 percent of people who leave jail go back within five years, according to state statistics. Opioid abuse is a driver of recidivism, state Department of Corrections Commissioner Dean Williams said, though there has been no study to see how significant it is.
The state says at least 80 percent of inmates have a drug or alcohol addiction.
Many addicts say they relapse as soon as they leave jail, as Holmes did.
"You lose them in the first day or two," said Williams. "That's why the behind-the-walls approach (to giving Vivitrol shots) is a step in the right direction for us."
This month, the department launched a pilot program at Hiland to give inmates who volunteer a shot of Vivitrol before they even leave jail. If the program is a success, DOC says, Vivitrol could eventually be offered in jails all over the state.
'Someone had to do something'
Just a year and a half ago, Vivitrol was barely used in Alaska, according to nurse practitioner Jyll Green of MyHealth Clinic in South Anchorage. But it is exploding.
"Statewide they were maybe giving 30 shots per month, and now it is hundreds per month," she said.
In her own primary care practice, three to seven people get Vivitrol injections each day, she said.
Its popularity has exploded in part because of buzz around a pilot project Green took on last year with Partners for Progress, an Anchorage nonprofit that helps people restart their lives after prison.
In early 2016 "we had a couple people overdose and die" just after getting out of jail, said Cathleen McLaughlin, the director of the organization's Partners Reentry Center, a downtown drop-in center designed to be a first stop for people newly released from jail. "We thought, if only they could have gotten out with Vivitrol under their belts."
McLaughlin and Green came up with a plan: As soon as people were released they'd be taken to Green's clinic to get a shot, which can be given by a nurse practitioner. That meant even meeting inmates in the parking lot of the jail, in case they get picked up by their dealer.
"I'm not embarrassed to say we didn't really study it for two years or anything," said McLaughlin. "Someone had to do something."
Of the 180 people offered Vivitrol, 95 said they'd take it, according to McLaughlin. Of the people who refused Vivitrol, nearly every one ended up back in jail within six months.
About 27 percent of the Vivitrol takers went back to jail — mostly for what McLaughlin described as technical probation violations like not showing up for a meeting rather than a new crime committed.
Richlynd Ketah-Guest had a longer and deeper history of addiction than many of the people being offered Vivitrol.
Ketah-Guest has a soft voice and a neck illustrated with tattoos. Her eyeliner is immaculate, her hair worn in a soft, strawberry-blond bob. She grew up in Southeast and says she became a ward of the state as an adolescent.
Around that time she started using drugs.
A familiar tale unfolded from there: time in prison for stabbing a man. Time in jail followed almost immediately by relapse on drugs. Attempts at treatment.
She had tried everything from Narcotics Anonymous to antidepressants to get off drugs by the time she was in her early 30s. Her addiction alienated her from family members.
"I still talk to my grandmother at least once a day on the phone, though," she said.
When she was released from prison in March, things soured quickly. First she got kicked out of her post-prison transitional housing. Then she found herself walking down Gambell Street in Anchorage late at night. A car pulled up and a driver made her an offer she found hard to refuse.
Next thing Ketah-Guest knew, she was holed up in a room at a grimy Fairview motel, doing heroin again.
A week later, the 32-year-old had a reckoning.
Ketah-Guest, who is transgender, was tired, essentially homeless and probably on her way back to a men's prison again if she got caught using — the same bleak cycle that had eaten up most of her adult life while costing the state of Alaska untold dollars in incarceration fees.
"I said, 'If anything can help me, it's Vivitrol,' " she said in an interview a week after she'd taken her first shot.
For her, saying yes to Vivitrol meant she was really ready to say goodbye to heroin — she knew the drug wouldn't let her get high.
Ketah-Guest's probation officer helped her get an apartment at an Anchorage sober-living program for ex-inmates called New Life Development. There, she had to tough out five days of detox before she could get her shot.
Vivitrol can't be used until the person is clean from opioids for at least a week. If opioids — including long-acting ones like methadone and Suboxone — are still in the user's system, an injection of Vivitrol will send the person into immediate, painful withdrawal.
With only a handful of inpatient detox beds in Anchorage, many people try to do it on their own. Ketah-Guest said she did just that, taking hot baths and reading the Bible and an Alice Hoffman novel while holed up in her room.
Diana Palin, the operations manager for New Life Development, wasn't sure if Ketah-Guest would stay. She stopped by Ketah-Guest's room often, wondering if she would still be there.
"There are no locks on these doors," said Palin. "She could have left."
When Ketah-Guest tested clean, Palin drove her to get her first injection of Vivitrol.
A week later, at the beginning of April, Ketah-Guest sat on the bed of her apartment in New Life Development's transitional housing complex, a former hotel near the Seward Highway.
She was bubbly and excited about her daily to-do list: She was thinking about a job she wanted to apply for at a laundromat and planning a trip to Value Village to shop for khakis and a polo shirt, a switch from her usual leather jacket and high-heeled boots.
"I want to appear work-ready," she said.
What she was not thinking about, for once, was heroin, she said.
The Vivitrol hadn't fixed her life, she said. There was a lot more to do. But it had made it possible, for these weeks, to think about something other than the overwhelming desire to get high.
A new form of an old drug
Vivitrol is a new use for an old drug, naltrexone, used for decades to treat addiction — with varying success.
Taken as a daily pill, naltrexone is not considered effective for most opioid addicts, according to studies on medication-assisted treatments.
It's hard to get addicted people to comply with taking a daily pill to keep themselves from getting high, said Aryeh Levenson, an Anchorage psychiatrist who has worked in addiction treatment for decades.
"It's the psychological effect," Levenson said. "Every day is a possible failure."
The monthly injectable form takes choice out of the equation for much longer.
An opioid blocker, it represents a departure from the two major medications already used to medically treat opioid addiction, methadone and Suboxone — both of which are opioids themselves and can be addictive.
In addition to rare but serious side-effects, cost is a frequent criticism.
Vivitrol is by far the most expensive medication treatment for opioid addiction. A single dose costs around $1,200, compared to roughly $350 a month for methadone or $400 for Suboxone.
Alaska's Medicaid expansion made it much easier for people to qualify, said Jyll Green of MyHealth clinic: The program covers Vivitrol with no preauthorization and no limit on how many shots a person can get.
People who receive Vivitrol in jail will also get help applying for Medicaid so they can continue the shots after release, according to DOC.
The pharmaceutical company Alkermes has given DOC roughly 1,200 "sample shots" of the drug at no cost, said Williams. Other clinics, like MyHealth, also fill coverage gaps with samples.
But in some cases, people off heroin because of Vivitrol have struggled to patch together where their next monthly dose will come from.
Troy Buckner, the head of New Life Development, said one client who made too much money in the construction industry to qualify for Medicaid, but didn't have insurance, ran out of ways to pay for the shot after a few months.
The man went back to using, Buckner said.
Some worry about just how attractive the idea of a "miracle shot" could be to policymakers desperate to tackle Alaska's opioid epidemic, and that the shot's effectiveness could be overstated — and whether it would be misused if not offered in conjunction with treatment.
Alkermes, the drugmaker itself, says Vivitrol "must be used with counseling."
"It gives you a sense of having control over your addiction," said Buckner. "That's where we see the failures, with people not getting the second or third doses."
"The problem is people will look at it alone as a solution. And they may cut corners," said Levenson.
Part of the success of Vivitrol has been its makers' ability to market the drug as a policy solution, not just a medication.
Alkermes markets its product directly to correctional and justice system officials, as well as the legislators who control the money. The company has had a registered lobbyist in Juneau for the past two sessions. (The maker of Suboxone also had a lobbyist in Juneau during the 2016 legislative session.)
In Alaska, officials — from judges to probation officers to nonprofit leaders — cite Michael Eldridge, Alkermes' pharmaceutical representative in Alaska, as a driver of the rise of Vivitrol in Alaska.
"He has a role much larger than that of a (typical) pharmaceutical rep," said Green of MyHealth Clinic.
Eldridge declined an interview for this story.
The state isn't currently spending any money on Vivitrol, because the doses being used in prisons are either samples donated by Alkermes or paid for by Medicaid.
"We know it isn't a panacea," said Williams of DOC.
Jennifer Stukey, the chief operations officer for Anchorage's oldest methadone clinic, the Center for Drug Problems, says the rapid embrace of Vivitrol comes at the expense of people who can be helped by other opioid replacement therapies, like methadone.
Not everyone will be helped by Vivitrol, she said. But other treatments, like Suboxone and methadone, are "being demonized" by Vivitrol proponents.
"There's a place for all of them," she said.
While Vivitrol's use is just beginning to take hold in Alaska prisons and re-entry programs, it has been a tent pole in an Anchorage therapeutic court program for several years.
Suboxone and methadone are technically allowed, but since 2013, just about everybody in Anchorage Superior Court's lauded wellness program has been on Vivitrol.
The program offers felony offenders with underlying addiction problems a chance to complete an intense treatment program, with the promise that their charge will be dismissed it they graduate.
"It has been a game-changer," Anchorage Superior Court Judge Catherine Easter said.
For anyone medically cleared to take it, Vivitrol is a requirement of the program.
Easter credits it for helping the court keep defendants with long, serious histories of drug abuse in the program and drug-free.
Defendants are often resistant to taking a shot that will lock away their ability to get high for a month, she said. And they usually think they're ready to quit the shot before the real-life changes that will keep them clean have been made.
"Pretty much on a weekly basis, someone tells me they want to stop taking their Vivitrol," Easter said.
Mario Valdez Jr. has been in wellness court and on Vivitrol for eight months. A 44-year-old in a crisp button-down shirt, Valdez is trying to make up for time lost to drugs.
He says he started using drugs at the age of 10, huffing gasoline, before landing in a treatment facility before he was a teenager. All told, he's been in 26 treatment programs.
When he got into wellness court, he agreed to go on Vivitrol. The eight months he has been clean represent the longest stretch of sobriety of his adult life.
Vivitrol tamps down his cravings, he said.
"I could always tell at the end of the 28 days when the shot was beginning to wear off a little bit — the urges and even the dreams about (heroin) would start to come back."
He thinks he is almost ready to go off the medication and be clean on his own. For now, he works as a server at the Village Inn restaurant. Valdez said he wants to help take over a family pizza franchise chain.
Valdez's girlfriend, Jennifer McBride, is one step further down the road.
The 35-year-old is in her first month off Vivitrol after taking the shot for 11 months. She had been a pill and heroin addict since her teenage years, and dropped out of high school.
McBride survived two near-fatal ODs before she took her first injection of Vivitrol, a requirement of the wellness court program she is also part of.
The shot alone will not be enough to keep an addict away from opioids, she said.
"The shot is very important in early recovery. But the skills you get from a treatment center — that's what's going to make or break you."
Vivitrol, she said, buys you time.
"In those 30 days you get a taste of what life is like without drugs," she said. "You get a glimpse of how your life could be."
Editor's note: As of Friday, Richlynd Ketah-Guest had stopped checking in with her probation officer, a violation of her terms of probation. A warrant would be issued for her arrest. But her probation officer was optimistic that Ketah-Guest would resume her treatment and return to her responsibilities. "We'll get her back," she said.
Marc Lester of Alaska Dispatch News contributed reporting to this story.