The twice-arrested heroin user listened nervously as the judge reviewed her record, then offered a deal he thinks could save her life.
"You're not a criminal, you're an addict," Judge Robert Peeler told Cynthia Fugate. "Something is driving you to use heroin that is beyond your control. Is that fair to say?"
"Yes, sir," she replied quietly.
Peeler, a common pleas court judge in southwest Ohio's Warren County, is among a growing number of judges and corrections officials across the country trying to combat the fast-growing national heroin problem by fighting heroin needles with treatment needles. Peeler told Fugate he could order monthly injections of the opiate-blocking drug Vivitrol if she were willing.
"I'm 30 years old. I've overdosed four times," Fugate said, her voice quavering. "I want to be clean. I really do."
The shots, the judge said, could keep Fugate from "winding up in a body bag."
Peeler began researching the drug treatment shots last year after a young woman died of a heroin overdose, at least the third heroin user who had stood before him in his courtroom who later died. Nationally, overdose deaths have risen 45 percent from 2006 to 2010. In Ohio, 680 people died of heroin overdoses in 2012, up 60 percent from the previous year.
Vivitrol has its skeptics, with some questioning whether it's effective enough to warrant the time and expense - shots can cost about $1,000 each - and suggesting it's a trendy, under-researched attempt at a quick fix. Sheriff Richard Jones in neighboring Butler County has called Vivitrol in jails "a waste of money," citing an earlier pilot program in Warren County in which only three of 12 subjects completed the program and stayed off drugs.
Peeler is among those who say the high toll of heroin-related deaths, crime and prison recidivism make it worth trying.
"To sit back and keep doing what we've been doing just isn't going to get it," Peeler said. "I want to stop people from dying."
The Warren County program is getting some $800,000 in state funding help for Vivitrol, and programs are also underway in dozens of other courts, jails and prisons in at least 21 states, from Cape Cod in Massachusetts to Lane County in Oregon. The programs are usually funded with grants, getting some help from drugmaker donations and discounts, and insurance usually will cover some shots.
Vivitrol, made by Alkermes PLC of Ireland, had been used for alcoholism. But after a Russian study showed it could be effective for users of heroin, morphine and other opiate drugs with once-monthly injections, it was approved by the U.S. Food and Drug Administration in late 2010.
Vivitrol uses naltrexone, an opioid receptor antagonist, to block heroin's effects on the brain. Unlike the widely used methadone treatment, it doesn't require clinic visits and daily doses and is unlikely to lead to trading one dependency for another, as can happen with other treatments, advocates say. Effective for a month, it eases the daily temptation of people struggling to stay off heroin.
Because Vivitrol is long lasting, it has special importance for former heroin users leaving incarceration, said Mady Chalk, a former federal official on substance abuse who is now with Philadelphia's Treatment Research Institute.
"Patients return to their community having been detoxed, their systems have been emptied of the drugs; they return to environments that trigger all the things that one would expect," Chalk said. Many are unable to resist the urge to reuse heroin and don't realize they can't tolerate as strong a dose as before.
"The body simply can't handle it, and they die," Chalk said.
Giving users an injection before they leave custody provides a month's buffer to begin post-release counseling and to focus on rebuilding their lives.
Dr. Mark Willenbring, a former National Institute on Alcohol Abuse and Alcoholism official who founded Alltyr addiction treatment center in St. Paul, Minnesota, thinks there is too little evidence of success to consider Vivitrol a panacea. "It's not a wonder drug," Willenbring recently told the Alcoholism & Drug Abuse Weekly.
Peeler doesn't order shots for anyone who doesn't want them. In his courtroom the same day as Fugate, a male drug defendant declined, saying he believed the shots were dangerous - there are potential risks including liver damage and suicidal depression - and he didn't want to go through the therapy and probation requirements of the sentencing deal that potentially allows drug defendants to avoid a conviction on their record.
But Sherry Moore believes the shots saved her.
Not long after completing a nine-month sentence for heroin possession, she began using again. She told her probation officer she didn't know what to do, that she had already been through treatments.
"I'm like, `I'm a mess,'" she recounted. "None of it worked for me."
The officer asked if she wanted to try Vivitrol. After a year of monthly injections, she said she's been drug-free since late 2012.
She and other Vivitrol advocates emphasize that counseling and a strong will to overcome addiction are needed, too. Moore, 53, also credits her return to church.
"I think God helped me with it," she said. "I think I would have died."