Malachi Castner, 23, said he didn’t always sleep on the Blue Line train to avoid the cold and rain. He didn’t always start his day early by shooting up. He was once a teenager on his high school’s wrestling team.

But it was after he tweaked his back while wrestling an opponent as a junior in high school and a doctor prescribed him OxyContin that he descended into addictive patterns that stuck.

He sat inside West Suburban Medical Center last Tuesday morning, scarfing down a sandwich and using shaking hands to open cartons of apple juice. He said he felt chills, his nose was running and his body ached. Over the next few hours, he was just anticipating worse withdrawal.

“I was tired of being on the streets,” he said as he waited. “So today, I decided I wanted to do my hustle and get some better drugs.”

By better, Castner means drugs that may put him on the road to recovery.

Cook County recorded the deadliest year for opioid overdoses in 2022, according to the Cook County medical examiner’s office. Last year, there were 2,000 deaths, surpassing 1,935 deaths in 2021 — a large majority involving fentanyl, a synthetic opioid that is 100 times more potent than morphine and 50 times more potent than heroin. For comparison, nearly 3,000 people died in the 9/11 attacks, memorialized on Monday.

To respond to the increase, a new program at PCC Community Wellness Center and West Suburban Medical Center called Project LIFE, which stands for Long-acting Injectable for Ending Overdose, is offering injectable medication to patients in an emergency room setting. The injectable drug — a 28-day treatment called Sublocade, or buprenorphine — helps patients manage cravings and withdrawal symptoms of opioid use disorder.

“Administering long-acting injectables in the emergency room, immediately after people have had an overdose or are in severe withdrawal, can have lifesaving implications,” said Dr. Ruchi Fitzgerald, service chief of inpatient addiction medicine at PCC Community Wellness Center.

Withdrawal symptoms — nausea, vomiting, a runny nose, anxiety and more — occur as the body responds to the absence of opioids. Though less serious than alcohol withdrawal, the initial phase of opioid withdrawal begins eight to 48 hours after the most recent drug use, and can lead to serious health complications.

Stanford psychiatry and behavioral sciences professor Keith Humphreys said this is the first time he’s heard of the long-lasting injection medication being administered in an emergency room setting to help patients.

“In the chaotic lives of people who are addicted, every step you make them go through to get to some kind of care, you lose people,” he said. “We have medications that work really well, but most people who are addicted to opioids don’t get them.”

[ Cook County records deadliest year for opioid overdoses in 2022 ]

Injectable buprenorphine is expensive and needs to be refrigerated, and many hospitals don’t have the resources to purchase or store it. It is typically administered in small orange strips under the tongue, under the brand name Suboxone.

Mistead Sai, a social worker for Project LIFE, said oral treatment can be hard for patients to keep track of or can be lost or stolen.

“Some patients aren’t taking (the oral sublingual). The long-acting injectable gives them protection for that monthslong period to have that in their system while they’re in the hospital,” he said.

The medicine is expensive. PCC provides Project LIFE as a consultation service to West Suburban Medical Center using grant money from the Substance Abuse and Mental Health Services Administration and the state.

The Project LIFE team prides itself in providing continuity of care to their patients. They have a chemical dependency clinic, so some of the same care providers work with people in both inpatient and outpatient settings. They partner with Haymarket Center, a nonprofit organization in the West Loop that provides substance use disorder treatment.

Castner started using in 2017, after his wrestling accident. At the time, his doctor prescribed painkillers to help him cope with extreme back pain.

“The injury was mild, but the pain was pretty bad, and it persisted. Now, the pain isn’t there anymore. It ended up going away, but the pills didn’t go away. The addiction was there,” Castner said.

Peer support specialist Darryl Clark, who worked with Castner after he checked himself in Tuesday morning, said Castner’s situation isn’t unusual. Many doctors who prescribed painkillers around that time lost their jobs, he said.

“They overloaded medication on individuals,” Clark said. “But the sad part is that when you cannot find that medication on the street, you go to the next best thing. That’s what happened with Malachi.”

Castner said he typically wakes up with a shot of heroin. Then he’ll take a train with a friend to see if he can find a “pass-out” or a free supply of drugs by members of gangs trying to advertise their products.

If they don’t find anything, they’ll start their daily hustle by “boosting” — stealing and selling merchandise — or “panhandling” — begging for money with a sign.

“It takes time to get money,” Castner said. “We’ll go out on the West Side, get some drugs and do it all over again.”

Castner didn’t graduate high school but did manage to get his GED. He was living with his parents in Villa Park — where he’s from — working as a UPS sorter and unloader, when they kicked him out for stealing from them. He said he hasn’t spoken to his parents since April 2022.

Over the past year, he spends his nights scrounging for a place to sleep and his days searching for dope. He said he has made several failed attempts to schedule appointments for treatment. Until Tuesday morning, when he got tired of digging.

Clark, who says he’s able to empathize with his patients because he was an opioid user himself, helped Castner when he checked himself in by immediately suggesting he receive an injection.

“He’s in contemplation right now. He’s got one foot in, one foot out right now,” he said, calmly observing Castner squirm in the lobby waiting room chair. “Over the next couple of hours, it will get progressively worse. He will be prescribed Sublocade today.”

[ New test strip detects opioids laced with veterinary sedative xylazine: ‘They give us the ability to curb that exposure’ ]

Addiction experts say fentanyl has changed the drug landscape in Chicago and nationally over the past decade, as it has trickled into the street supply. In 2022, there were more opioid-related overdose deaths in Chicago than there were homicides and traffic crash fatalities combined, according to the Chicago Department of Public Health.

Earl Spann, 62, who also received an injection Tuesday, said he started using in 1986. Over the past 40 years, he said, he’s seen the drug supply become a lot more dangerous.

“From the ‘80s to now, you can’t even explain the difference,” he said.

Spann helps pass out Narcan — a medicine that can help people who are overdosing on an opioid — at his community church. He said he checked himself into PCC after relapsing.

“You want to always try to continue to comply with a positive environment. Anything negative, you want to push it to the side,” Clark told him as he sat on the edge of his hospital bed before the injection, looking out the window.

Fitzgerald said the program has enrolled over 200 people in a little over a year. They serve patients of all kinds: older adults, postpartum patients, individuals living with HIV and those experiencing homelessness, like Castner.

Most of their clients come from the nearby Austin neighborhood, and some come from miles away.

[ Women with opioid-use disorder face stigma in getting help, seeking treatment ]

Chemical dependency care manager Takara Wallace said Project LIFE puts equitable behavioral health at the forefront of their patient care. And it all begins with the injection.

“Patients come back and say, ‘That shot was a miracle,’” Wallace said. “But having addiction medicine teams in hospitals is not that common. We’re a rare breed. That’s part of it.”

Harvard professor of health policy and management Michael Lawrence Barnett called the injectable “a compelling idea,” but had some concerns about its widespread application in hospitals.

“It’s a little bit daring,” Barnett said. “It’s kind of a big commitment for an (emergency department) provider to give someone a depot injection that lasts a month.”

Barnett said he’d seen research about a seven-day, extended-release injectable buprenorphine, but not a month. He also said Sublocade access right now is minimal because it’s expensive. He pointed out that some opioid clinics use methadone, which lessens the painful symptoms of opioid withdrawal, but said it’s under regulations that make it difficult to access.

He recently published a study in the New England Journal of Medicine which found white patients were far more likely to receive buprenorphine treatment than Black patients following a high-risk event like an overdose. While he is in favor of wider distribution of buprenorphine, he was skeptical the Sublocade injection program would reach the neighborhoods on the South and West sides that might need it the most.

“We need investments in addiction provider presence and options across Chicago, which is not something that happens by itself,” he said.

[ As opioid overdose deaths grow in Chicago area, so does push for harm reduction and ‘safe consumption’ ]

Though Sublocade is approved by the Food and Drug Administration, said Dr. Fitzgerald, it is still fairly restricted in its use and hospitals can’t easily enroll. For now, Fitzgerald is satisfied to provide a “one-stop-shop” pilot program and blueprint for other models across the country.

“What we’ve found is that by offering this medication to these individuals, they’re following up with us at twice the follow-up rate than they have in the past versus when they were hospitalized,” she said.

Castner said he was brought to West Suburban by his friend earlier this summer after he overdosed. Tuesday he received his first injectable.

“There have been times where I’ve gotten sober, gotten clean, and then I’ve fallen off again,” he said. “This is the umpteenth time I’m trying this. Hopefully, I get it this time.”

Before receiving his injection, Dr. Fitzgerald asked Castner to remove the contents of the pockets in his sweatpants and sweatshirt — remains from his last time using at 8 p.m. the previous evening. “Let’s take everything out, all right? We just want to keep you safe in the hospital,” she said, gently.

Castner lay down on the thin paper under the warm hospital light and looked up at the ceiling.

“What I’ll have you do is pull your shirt up, and we’re going to do it in the left side of your abdomen, OK?” said Dr. Daniel Ignell as he administered the injection into his stomach.

His recovery journey had only just begun, but he said the injection had given him a head start. He stumbled back to the chair in the lobby to wait to go to the detox center at the hospital.

He said still had a lot to learn — about himself, the drugs, the severity of the triggers.

nsalzman@chicagotribune.com