One recent development is the emergence of drug courts in the criminal justice system, which can incorporate treatment components into sentencing. "Therapeutic jurisprudence," Peggy Hora, J.D., a superior court judge from Hayward, Calif., explained, "proposes the exploration of ways in which, consistent with principles of justice, the knowledge, therapies and insights of mental health and related disciplines can help shape the law."
This new facet of criminal justice, according to Hora, requires the court to evolve from an isolated institution for meting out consequences into an interdisciplinary, problem-solving community institution. In this context, judges are increasingly concerned with wielding their sentencing powers to produce better outcomes.
This direction in the courts was codified in 2000 when the Conference of Chief Justices, representing each state, passed a unanimous resolution supporting problem-solving courts. "They are in the process of developing best practices for problem-solving courts," Hora explained, "and they recognize that collaboration and interdisciplinary training [are] appropriate for the successful outcomes of these courts."
She read a similar resolution recently passed by the Conference of State Court Administrators:
The human and political success of therapeutic jurisprudence programs is too great to ignore. ... Courts must be responsive to changing times and changing expectations, but not at the cost of their fundamental roles and responsibilities.
While therapeutic jurisprudence can be implemented only when it coincides with equal protection and due process, Hora noted, addicts receiving sentences without a treatment component are likely to commit repeat offenses. Although this link to recidivism may be apparent to health care professionals, incorporating addiction treatment into sentencing was considered radical thinking among most judges as little as three to four years ago. Progress in this area may not have risen as much from compassion, Hora suggested, as recognition of the futility of standard sentencing and increasing appreciation of data on the effectiveness of treatment.
"Patterns of systematic failures are contrary to the purpose of the courts, undermine the rule of law, and diminish public trust and confidence in the courts," she observed. This pattern can be countered by an effective problem-solving court that, she added, "moves deliberately in response to emergent issues [and] is a stabilizing force in society."Science-Based Treatments
Public agencies can facilitate the dissemination, adoption and implementation of evidenced-based addiction treatments by health care providers, according to Jack Stein, Ph.D., chief of the services research branch of the National Institute on Drug Abuse (NIDA).
"We clearly know that advances in science are giving us a broad range of promising options for treating addictions," he said. "The problem has been that many of these approaches are not really adopted or implemented widely."
Stein referred to studies that indicate that few recommended treatments for alcohol(Drug information on alcohol) dependence are used; few prevention programs have been embraced by schools, despite evidence of their effectiveness for student populations; and few treatment program administrators report employing newer treatment interventions.
"What we're dealing with ... is a real bottleneck--if not actually a true barrier--moving from both the [laboratory] bench to the bedside, and then into the community."
He added that it is not sufficient to develop science-based interventions for addictions if multiple issues affecting their application are not also addressed. Among these he included organizational and financial issues, and the provider's knowledge, skills and training. He attributed the slow adoption of office-based buprenorphine(Drug information on buprenorphine) (Subutex) treatment of narcotic addiction, for example, to such factors as physician reluctance to treat this population, reimbursement issues and lack of avenues for referring patients for concurrent psychosocial treatment.
One means for federal agencies to approach these issues is with greater interagency collaboration. In the "Science to Services Initiative" collaboration of the National Institutes of Health and SAMHSA, Stein explained, each agency examined its activities in the three areas of research, dissemination and monitoring and considered opportunities to complement or reduce overlap.
Stein recounted NIDA efforts to provide technical assistance for SAMHSA program officials and grantees; consult to SAMHSA regarding selection of effective interventions for implementation; and link grant programs for blended funding. The latter could, for example, place a newly proposed outcome measure process into an ongoing, funded services program. One blended-funding stream described encourages integration of addiction services into primary care.
Technology-transfer centers developed by the Center for Substance Abuse Treatment (CSAT) of SAMHSA have also been funded and supported by NIDA. "[They're] a great training resource available all over the country," Stein commented. "We feel very strongly about tapping into that to ensure that NIDA-based findings are incorporated into that training system."
A NIDA collaboration with criminal justice has produced a series of grants for Criminal Justice/Drug Abuse Treatment Studies (CJDATS). "This is the major multisite study that was started in 2002, with the goal being to develop models for integrated approaches to the treatment of substance-abusing offenders," Stein explained.
Mady Chalk, Ph.D., the director of the division of services improvement at CSAT, indicated that her agency was also focused on funding and delivery of services, while noting her office's particular interest in improving treatment practices in the field.
"What we're trying to do is to create a way to accelerate the application of effective treatment interventions across agencies and among stakeholders," Chalk said.
In addition to the technology transfer centers, which train clinical personnel and help organizations adopt best practices, CSAT is co-funding with the Robert Wood Johnson Foundation an initiative to improve access to, and retention in, treatment. While the level of this funding of approximately 40 to 50 grantees is relatively low, Chalk reported that it is yielding highly innovative approaches.
Chalk described other CSAT efforts, including technical-assistance publications and consensus-developed treatment improvement protocols in areas such as brief intervention and motivational enhancement therapy. Chalk's agency is also developing a registry of effective treatment programs that have produced evidence of their success and the applicability of their methods to different treatment settings. Chalk is hopeful that within three to five years there might be block grant funding that imbeds such best practice program procedures.
She acknowledged, however, "We need to get moving on developing guidelines that support implementation of new or improved practices. We don't have very many. Our consensus documents are fine, but they are not as useful, and as usable, as they might be."