Troy Garver, who was addicted to prescription pain medication, went to prison for selling morphine pills in 2014. Now he's trying to rebuild his life. As a part of his recovery he takes monthly shots of Vivitrol, a drug that may revolutionize the treatment of opioid addiction. (Zoeann Murphy/The Washington Post)

On July 29, Troy Garver woke early, changed out of his jail-issued jumpsuit and rode in a van with seven other inmates to the circuit courthouse in Hagerstown, Md., to hear a judge decide his fate. His outfit — a neatly pressed button-down shirt tucked into dark jeans — had spent eight months folded tightly in a paper bag in the Washington County Detention Center, ever since his conviction for selling morphine pills. His scholarly gold-rimmed glasses clashed with the Ozzy tattoos decorating his fingers. Though he knew what to expect, he was still afraid it wouldn’t happen.

After a short hearing, Judge Dana Moylan Wright released Troy back into the community, with a stiff 10-year prison sentence hanging over his head if he slipped up. “This is a one-shot deal,” she told him.

“I didn’t think she was going to let me go,” Troy said later. “In jail, I heard she’s the hanging judge.”

As part of his four-year probation, Troy, a 42-year-old Westminster, Md., native, is not allowed to consume drugs or alcohol and must attend two Alcoholics Anonymous meetings a week. If he fails, he will pay a steep price: Ten years is six times as long as his original sentence.

“They came down hard on me,” he said. “I’m always nervous. I’m nervous I won’t be able to do it. I got 10 years over my head. I can’t mess up.” He is a father of eight, three of whom live with him and his longtime girlfriend, and he was thinking of his children.

For many addicts, this could be the start of a revolving door, cycling between drugs and incarceration. But Troy had a better chance than most. Through a trailblazing jail substance-abuse program, he was taking a medication called Vivitrol, a drug some experts think can revolutionize the treatment of heroin and prescription opioid abuse.

Troy Garver, when he was in the Washington County Detention Center for selling drugs. He jumped at the chance to try a new medication called Vivitrol, which could potentially revolutionize the way heroin and prescription opioid addiction is treated in this country. (Michael S. Williamson/The Washington Post)

In 2003, Troy had a good-paying gig at a fertilizer plant when he slipped and fell down a shaft, breaking his neck. He said he spent six months in a coma, then underwent surgery and recovery at a hospital, paid for by the company that had placed him in the temporary job. He hasn’t been employed since. “I lost everything: my job, my car, my strength,” he said. “I was never the same again.”

Troy had worked since he was 16, when his mother had signed the papers necessary for him to leave high school and enter the real world. “Money was more important than school,” he said. He moved to Columbus, Ohio, from Westminster for a framing job and met his first girlfriend; they had four children in quick succession before breaking up.

Troy then started a relationship with Barbara Dow, and they would go on to have four children together as well, three of whom were disabled. He continued to work in construction, and in the off-months, he worked in factories.

But after his accident, he couldn’t work at all, and he was in pain. Every month, he went to the doctor, and every month, the doctor would prescribe more pills: Oxycodone, then Percocet, then morphine. The addiction crept up on Troy. “My body just got used to [the pills] after so many years of taking them,” he said. “I didn’t even know I was addicted.”

Troy and Barbara lived on her income from a part-time job at a self-storage company, along with one year of worker’s comp for Troy and, starting in 2010, his disability payments. In 2007, after social services was alerted that the family couldn’t take care of son Domanick, who has autism and Down syndrome, they lost their parental rights for him. Domanick, 15, lives with a foster family in Ohio. “I think about him every day, but we couldn’t do it,” Troy said.

In 2010, the couple moved to Hagerstown with the three other children so Troy could be closer to his mother. He took care of the children while Barbara was at her part-time job in the flooring department at Lowe’s. By then, he had become aware that he had a drug problem: He would run out of his monthly prescription within two weeks.

“I was supposed to be taking four pills a day; instead I would be taking eight pills a day. The last two weeks would be spent stressed and angry,” he said.

“There was tension and arguing all the time,” said Barbara, 39.

He tried to kick the addiction by attending Narcotics Anonymous meetings. But in fall of 2013, he was arrested for selling his morphine pills to an undercover informant he met in downtown Hagerstown after one of those meetings.

Because it was Troy’s first felony arrest (he had been convicted of disorderly conduct more than a decade earlier and had been to court for paternity and traffic issues), the court agreed to a modified sentence. He would serve 18 months in jail, instead of the prosecutor’s suggested four years in state prison, with the possibility of an early release if he completed drug treatment.

Troy wanted that early release. “My family needs me,” he said.

Troy in a pensive moment. “I have so many people I want to prove I can do this,” he said. (Michael S. Williamson/The Washington Post)

The abuse of opioids — which include prescription drugs (Troy’s issue) and heroin — has risen across the country and locally. In the Washington metro region, 0.61 percent of residents reported opioid drug dependence from 2011 to 2013, according to the Substance Abuse and Mental Health Service Administration, or about 28,000 people. That was triple the number from 2008 to 2010. Meanwhile, heroin deaths more than doubled in each jurisdiction.

Fatal opioid overdoses on the rise: From 2003 to 2013, prescription opioid deaths rose 92 percent and heroin deaths rose 300 percent nationwide. Heroin deaths rose 60 percent in the District from 2011 to 2014, 88 percent in Maryland from 2011 to 2013 and 113 percent in Virginia from 2011 to 2013.

Sources: Centers for Disease Control and Prevention; District Office of the Chief Medical Examiner; Maryland Department of Health and Mental Hygiene; Virginia Department of Health

Once an area of rolling hills dotted with red barns, Washington County has experienced a population explosion — from 147,000 residents in 2010 to a projected 171,000 in 2020 — because of its open spaces and relatively easy commutes to Baltimore and Washington. Hagerstown, the county seat, is wedged between major highways traveled by East Coast drug runners. Both factors have led to a rise in narcotics abuse. In 2013, more than 60 percent of the jail’s almost 2,000 inmates were there on drug charges, and the county had 25 fatal heroin and prescription drug overdoses.

“I didn’t see it coming,” said Rebecca Hogamier, director of the county’s Division of Behavioral Health Services.

It was Hogamier who spearheaded bringing the Vivitrol program to Hagerstown. Unlike opioids such as methadone, which produce a limited buzz to control cravings, Vivitrol dulls the brain’s receptors so users don’t feel cravings and won’t get a high even if they take opioids. Also, unlike methadone, Vivitrol is not a controlled substance; it cannot be abused and there is no illegal market for it.

But the greatest excitement surrounds how it’s administered: as a monthly shot. Vivitrol is a new form of an old drug — naltrexone — that was developed in daily pill form in the 1970s and never caught on. It wasn’t until researchers created an injectable, long-acting version that clinical studies showed the drug’s promise. “It was just like, ‘Wow, this medication is a magic bullet for treating opiate dependents,’ ” said Sandra Comer, a neurobiology professor at Columbia University who led a 2006 clinical trial for injectable naltrexone users. Taking a monthly shot can be a godsend for addicts who find it difficult to wrestle daily with the decision to swallow a pill to stay clean.

Local jails have proved to be excellent testing grounds for the new drug. They house a high number of drug offenders, provide a place for addicts to detox before receiving Vivitrol and are populated with people who are likely to have Medicaid or Medicare to help pay the costs. At up to $1,000 per shot, Vivitrol is the most expensive option for treating opioid addiction (see comparison below). About 40 jails, out of the nation’s 3,000-plus, run Vivitrol programs.

The Washington County Health Department has given 246 shots to 83 people in the program’s 3 1 / 2 years (it pays $523 a shot because of the state’s purchasing power, and it received initial funding through a Justice Department grant). The results have been gratifying: Only two patients have used illegal drugs or alcohol while receiving the medication. To the best of the department’s knowledge, the 81 others have remained clean.

“I’ve been getting calls all over the place from different detention centers wanting to use it,” Hogamier said. “The big question is, How do you pay for it?” So far, Harford County, Md., is the only other jurisdiction in the region to establish a detention center program. The District certifies individual doctors or private clinics as providers of substance use disorder services; it is up to the provider whether he or she chooses to prescribe Vivitrol. In Virginia, only private-practice doctors dispense the drug.

But some addiction psychiatrists have cautioned against the rising excitement.

“Naltrexone buys you a month, but if you stop taking it and you haven’t developed coping strategies you may relapse,” said H. Westley Clark, a retired former director in the Substance Abuse and Mental Health Services Administration. “People do recover from opioid dependencies, but often to do so they also need to deal with other issues in their lives.”

Troy had a lot of issues, and coping with them was on his mind as he awaited his release.

After detoxing for a month following his January 2014 sentencing, Troy received his first shot in April. By May, he had been incarcerated for five months and clean for four. He had learned inmate tricks such as making hooch by fermenting orange juice and sugar, applying tattoos by dipping a safety pin in ink, and subsisting on a diet of commissary-bought ramen noodles and Snickers bars. And he was slowly coming out of the fog of addiction and turning his thoughts to the future.

Speaking through a glass partition, he said he was beginning to feel clearer and “in more control. ... I stopped feeling the cravings in my mouth. I’m not so drugged out; I’m not drooling over myself, either.”

Still, he knew it wouldn’t be easy. He likened it to being “stripped naked” before being sent back to the real world. The things he relied on to help him get through the hardships of his chaotic life — alcohol and his pills — would be taken from him. And he wouldn’t have much in the way of money, education or options to help him regain his footing.

Troy with Allen after being released from jail. (Michael S. Williamson/The Washington Post)

Troy greets his youngest child, Chase. (Michael S. Williamson/The Washington Post)

After his July release, Troy made several stops that would establish the rhythm of the rest of his life: accountability, family, work.

First, he walked to the probation office a few blocks from the courthouse, where he would have to report once a week. Then Barbara, who had attended his hearing, drove him home to see their kids. The family had moved to Falling Waters, W.Va., 13 miles from Hagerstown, for cheaper housing, more space and distance from the temptation of drugs. “I have to avoid all the things, people and places, like liquor stores and pharmacies, that got me in trouble in the first place,” Troy said.

It was the first time in months that Troy had touched his children. His eyes welled as he watched 13-year-old Lexi, who has cerebral palsy, walk down the three front steps using hot-pink crutches. She had practiced while Troy was in jail. She gave him a big hug and told him how she had missed him. It was difficult to tell how 17-year-old Allen, who has autism, felt. Chase, 12, gave his dad a hug but hung back a bit. Troy kissed the tops of their heads and stroked their hair.

Troy kisses his daughter Lexi, as Barbara looks on. (Michael S. Williamson/The Washington Post)

“I’m not going back,” he vowed that afternoon as he rode with a reporter to visit his mother’s small horse farm halfway up a mountain in Smithsburg, Md. “I have so many people I want to prove I can do this. I have my family, my mother, half the health department. They all look at me and ask me how I am doing.”

Though their relationship has been difficult at times, Troy’s mother is fully vested in his recovery. A firecracker who is married to her fifth husband and doesn’t like idle hands, Phyllis Kline says her son “wasn’t raised” to be a drug addict or dealer. She thought she had a cure: He would work part time at the farm, mucking out the barns, brushing the horses, painting the sheds and mowing the grass. These were chores Phyllis couldn’t do, especially with an aging husband to care for, and they might substitute for the physical therapy Troy couldn’t afford.

Troy and Phyllis went out to the barn where the farm’s five horses live. They shooed the horses out, and Troy started sweeping. Every once in a while he stopped and smoked a cigarette, looking out at the grassy fields. “I feel most at peace when I’m here,” he said.

“Keeping him busy will keep him on the straight and narrow,” Phyllis said.

Troy on his mother’s horse farm, where he is working part time. (Michael S. Williamson/The Washington Post)

It wasn’t that easy. Each day was fraught with uncertainty as Troy and Barbara struggled to balance the demands of his recovery against the actuality of their lives. Though the Vivitrol helped, Troy still wanted drugs at first. “I just tried to fight the cravings,” he said. “I went to a lot of meetings, sometimes four meetings a week even though I only had to go to two.”

Even when his cravings subsided around the six-month mark, there was still the pain, so he took three Aleves every day, along with Lyrica (which is not an opioid), for relief.

Each day started with an alarm at 5. Barbara and Troy got their children ready for the school bus, which came at 6:45. Several times a week, Barbara would drive with Troy to her job in Hagerstown. From there, Troy, who had lost his license eight years ago because of a child support dispute with a former girlfriend, would ride his bike seven miles to the health department to attend an outpatient therapy group three times a week. Afterward, he might have individual or group therapy. Then he would ride back to the mall to meet Barbara. They’d go home and play with the kids, help with homework, do the dinner-bath-and-bedtime routine. All the kids attend special schools and require medication (the youngest for ADHD). They are also enrolled in after-school programs and have many medical appointments, increasing the stress on Barbara as the only driver.

After work once or twice a week, Barbara would take the kids out to meet Troy at the farm. The kids would pet the horses and feed them carrots and molasses treats. These moments, Troy and Barbara said, are the happiest ones in their lives.

Troy saw his probation officer once a week and attended at least two AA meetings a week. The stories of relapse and redemption comforted him.

“I’m stressed out all the time,” Troy said. “I worry about my bills and getting to my meetings on time, seeing my probation officer, attending my outpatient group. But at least I’m not getting high.”

Barbara trusted Troy. She grew up in foster care, and Troy and her children are her only family. “We depend on each other,” Barbara said of Troy. “I know he’s not perfect. But I am willing to do what I can when I can. And anything is better than where he was.”

And Barbara was seeing a difference. “There is less arguing in the house now. He’s not as agitated. Troy thinks about things first instead of flying off the handle. From all this, something good must come.”

Troy receives his first shot on the outside, after staying clean and attending all his meetings. He celebrated his first full year of sobriety in January. (Michael S. Williamson/The Washington Post)

Before receiving his first Vivitrol shot outside jail, Troy had a full day of appointments with various counselors and professionals.

First, he met with his counselor, Laura Sheffield, and went through pages of paperwork. “There are a lot of people depending on you,” she noted, going down the list of his family members.

“I’m trying,” he said. “I’m really trying.”

After the session, Troy scheduled his meetings for the rest of the week. He had group, then an individual session, then trauma therapy to address his mental health issues. He arrived at the health department for the final appointment of the day. The nurse, Angie Bowers, took him to the back room to check his vitals and test his urine to see if he was clean. With just 8,000 patients taking the drug, it’s probably too soon to tell if Vivitrol will change the trajectory of opioid addiction. Yet Bowers was optimistic.

“It’s been a miracle, a miracle for so many of my patients,” she said. “But it can’t only be about the shot,” she added, wagging her finger at Troy. “It’s about recovery. You have to build your life around recovery.”

“I know,” he said. “I’m working on it.”

She turned back to Troy as she announced that he had passed his drug test. He had made it through the critical first four weeks.

He stood up and walked down the hallway where the doctor was waiting to give him the shot. “All clean and ready to go,” Troy said.

As of mid-February, six months after his first shot on the outside, more than a year since he detoxed, Troy remained clean. “In the beginning I was nervous and really worried, but now that I’ve gone so far it’s easier just to do things and cope with stuff,” he said.

The family marked Troy’s first year of sobriety on Jan. 26 by seeing the movie “Guardians of the Galaxy.” They ate popcorn and drank soda, and when laughing at the goofy parts, their troubles seemed far away. While he still struggles with depression and stress, little by little Troy has been thinking of trying new things, getting his GED, maybe painting cars or welding.

“I think my luck is changing,” he said. “It’s amazing what can happen when you are sober.”

Cara Tabachnick is deputy director of the Center on Media, Crime and Justice at the John Jay College of Criminal Justice, a think tank.

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Treatments for opioid addiction

Methadone: Opioid. Habit-forming. Controlled substance. Taken at specially licensed clinics. Daily pill. Cost: About $150 per month.

Buprenorphine: Opioid. Habit-forming. Controlled substance. Must be prescribed by doctor who receives a DEA waiver. Pill often taken every other day. Cost: About $300 per month (generic).

Buprenorphine/naloxone (Suboxone): Daily film placed under tongue. Habit-forming. Controlled substance. Must be prescribed. Requires DEA waiver. Cost: About $450 per month.

Naltrexone shot (Vivitrol): Opioid blocker. Not habit-forming. Non-controlled. Must be prescribed. Does not require waiver or registration with DEA. Monthly injection. Cost: About $1,000 per month.

Sources for costs:; Darius Rastegar; Johns Hopkins School of Medicine; Alkermes