Medication-Assisted Treatment and Drug Courts
Medication-Assisted Treatment and Drug Courts
[Acknowledgment—the author acknowledges The American Academy of Addiction Psychiatry (AAAP) for helping to bring this article to fruition. The AAAP is a professional membership organization for learning and sharing about the science of Addiction Psychiatry translating the research into clinical practice. As relentless advocates for those suffering from the devastation of substance use disorders and mental health disorders, AAAP is driven to transform lives through a commitment to using evidenced-based research to continually improve clinical approaches and outcomes for patients.]
Medication-assisted treatment (MAT) for addiction in the drug court system represents an outstanding, although as yet incompletely realized, opportunity for bringing state-of-the-art treatment to a population in desperate need. Because addiction and mental health treatment falls increasingly into the justice system for underserved and indigent patients, the drug courts can serve as an example for thoughtful, evidence-based care focused on the individual’s needs rather than on preconceived notions about the appropriateness of any particular treatment strategy.
Drug court professionals raise legitimate concerns about MAT such as diversion, adverse effects, ineffectiveness, and the potential for using MAT to decrease rather than entirely stop drug use. Unfortunately, drug courts do not utilize MAT (in particular methadone and buprenorphine) as much as they probably should. A 2010 representative sample of US drug courts found that although fully 98% of cases consisted of opioid-addicted individuals, only 48% were offered the opioid agonists buprenorphine and methadone.1
The major barriers may be the cost of the treatment and court policy. Although there is usually little objection to non–dependence-forming medications such as naltrexone, naloxone, and acamprosate, maintenance medications such as methadone and buprenorphine more commonly provoke unease among drug court professionals. Only by addressing these concerns with available clinical research data, modified to the drug court system, can MAT be a potential life-saving treatment.
The functions of a drug court
Drug courts are designed to divert non-violent offenders away from incarceration and into highly structured addiction treatment programs. By combining good addiction treatment with the threat of sanctions for non-adherence, the drug courts can use public resources to provide more effective and humane treatment than a simple “lock-em up” strategy. Drug courts improve the treatment outcomes of drug-abusing offenders by combining evidence-based treatment with strict behavioral accountability. By using both encouragement for improvement and sanctions for failures, drug courts have been able to address addiction problems in an enlightened manner that is demonstrably more effective than simply incarcerating the addict. About half of the 3400 US drug courts serve criminally involved adults in need of drug treatment, and they share a set of 10 principles, originally operationalized in 1997.2 These principles require, among other things, “Access to a continuum of alcohol, drug, and other related treatment and rehabilitation services.”3 The requirement of “a continuum of . . . treatment and rehabilitations services” imposes a condition that MAT be a part of the full range of services available to the defendant.
Opiate use among non–legally involved Americans remains at disturbingly high levels and has risen over the past 11 years: 681,000 adults acknowledged using heroin in 2013, and 1.9 million Americans met criteria for an opioid use disorder based on their use of prescription painkillers.4,5 In an unintended consequence of the government’s successful crackdown on inappropriate opiate prescribing, many addicts switched to heroin, with a subsequent increase in heroin-related overdose deaths. According to the Centers for Disease Control and Prevention, drug overdose deaths quadrupled between 2000 and 2013, with 43,982 such deaths occurring in 2013.6 Over the past 50 years there has been a shift in heroin use from low-income urban areas with large minority populations to predominantly white, affluent suburban and rural areas.7
For those drug users who are legally involved, drug court settings are ideal for implementing MAT for opioid dependence—the individuals who appear in drug court need treatment rather than incarceration. The drug courts strive to combine the best evidence-based therapies with strict behavioral accountability and long-term mandatory follow-up.8 Throughout the US, drug courts have worked with large numbers of opioid-dependent persons: one survey of 2459 courts nationwide found that 7% of participants listed illicit opioids as their primary drug of abuse, compared with 10% in suburban courts and 12% in rural drug courts, tracking the national trend toward non-urban use of opioids.9 The national numbers indicate that more opioid-dependent drug court participants were dependent on prescription opioids (66%) than on heroin (26%).10
Buprenorphine and methadone
MAT is one of many standard-of-care treatments for addiction: the DATA 2000 Act allows qualified physicians to prescribe or dispense buprenorphine, for the first time allowing use of a narcotic for addiction treatment outside of the traditional methadone clinic system.11 The Act allows for more effective treatment of opiate addiction; however, (unintentionally) it has also resulted in increased illicit use, diversion, and overdose with buprenorphine. Official government publications detail best practice guidelines for the use of buprenorphine, and newer studies have defined, among other things, the efficacy of buprenorphine in staving off relapse as well as the patient characteristics that predict best treatment outcomes.12-15