Addiction and mental health treatment has fallen increasingly into the justice system for underserved and indigent patients. How do we bring state-of-the art treatment to this population in desperate need?
[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
Buprenorphine and methadone have a stable if somewhat controversial place in the general anti-addiction pharmacopeia. Drug court data show that the 2 agents are no less effective in the court system compared with outside the court system, because of the particular characteristics of the drug court treatment, ie, behavioral accountability. One survey of family drug courts specifically designed for child abuse/neglect/endangerment cases found that addicts in the program were more than 20% more likely to complete treatment, and 40% more likely to have a reunited family.16 In addition, there were huge cost savings because of less reliance on out-of-home child placements. Other MATs for addiction are used in drug court situations, including extended-release injectable naltrexone and others, all of which benefit from the court’s ability to mandate clinically appropriate care.17
Drug court constraints
Although drug courts are designed to reduce the incarcerated population, the courts are limited by “tight eligibility requirements, specific sentencing requirements, the legal consequences of program noncompliance, and the constraints in drug court capacity and funding.”18 These eligibility requirements usually consist of rules about the nature of the criminal act, and the number of previous convictions. By allowing more access to drug courts for defendant/patients who require MAT, at least the most obvious bottleneck in bringing addicts to treatment will be diminished.
The relative paucity of opioid treatment programs that drug courts can utilize is also a problem. A study of 23,141 methadone patients in 84 opioid treatment programs found that 40% of patients traveled more than 10 miles to their clinician, and 6% traveled from 50 to 200 miles to obtain prescribed medication.19
Drug court leaders promote the idea that MAT should be one of the modalities available to participants, and that not having MAT available is a breach of best practices. In the official publication of the Adult Drug Court Best Practice Standards Committee, the authors note that:
Best practices include psychotropic or addiction medications based on medical necessity as determined by a treating physician with expertise in addiction psychiatry, addiction medicine or a closely related field. . . . Medically assisted treatment can significantly improve outcomes for addicted offenders. . . . Buprenorphine or methadone maintenance [author’s italics] administered prior to or immediately after release from jail or prison has been shown to significantly increase opiate-addicted inmates’ engagement in treatment and reduce illicit opiate use, re-arrests, technical parole violations, and recidivism as well as mortality and hepatitis C infections.20
The leaders of the drug court movement have concurred with the addiction field’s assessment that MAT, including maintenance opiate treatment, can be a valuable component of addiction treatment; sophisticated treatment facilities outside the drug courts also promote diverse evidence-based treatment that includes buprenorphine or methadone. A study of drug court policy in New York State found that patients were required to taper off methadone after an arbitrary period, and that there was profound stigma against opioid maintenance. The authors opined that the “forced ‘tapering’ from methadone, and buprenorphine, or blanket exclusion from thirst treatment, show the danger of what happens when judges play doctor.”21 (This is a frequent jeremiad against drug court judges, although the judges are usually following the abstinence-only recommendations of clinical personnel within the court system, who may themselves need further education about MAT.)
One advocacy group went further and suggested that a failure to allow MAT, whether as a court’s blanket policy or in an individual case in which MAT is clinically indicated, violates the Americans With Disabilities Act and the Eighth Amendment’s prohibition of cruel and unusual punishment, although there is no legal precedent for this perspective.22 From the funding angle, the Office of National Drug Policy implied that MAT will be a required modality to ensure continued public funding of the drug court system. Its director, Michael Botticelli, said, “If you are getting federal dollars . . . you need to make sure that people have access to these medications and that we’re not basically making people go off these medications, particularly as participants of drug court.”23
Despite the official and growing acceptance of MAT among drug court professionals, there is not enough access to MAT owing, at least in part, to a dearth of licensed practitioners who are willing and able to treat drug court participants. Judges complain that this scarcity of licensed providers limits their ability to integrate MAT into their decisions. The lack of buprenorphine prescribers, especially in non-urban areas, is a problem nationwide and has led to calls for lifting the 30-patient limit for buprenorphine.
Advocates claim that the 30-patient limit disproportionately affects the poor, has the potential for causing premature discontinuation of treatment, and is a disincentive for physicians to devote their entire practice to using buprenorphine to treat addiction. Interestingly, the reason prescribers cite for not making buprenorphine their main clinical focus is the exact reason given by those who oppose lifting the cap, the rationale being that physicians who only prescribe buprenorphine will be incapable of, or unwilling to, provide comprehensive care.
Further acceptance of MAT in the drug courts will depend on the continuing education of personnel including judges, prosecutors, and clinicians, as well outside consulting clinicians who provide needed evaluation, treatment, and support. The education must include the science of addiction and MAT, the spectrum of treatment approaches available, and case studies that demonstrate the realities of using MAT and other treatments for addiction. Those who do training and education within the court system must acknowledge the reality that MAT is not a panacea but rather one of many useful and evidence-based weapons in the struggle against addiction.
In addition to education, clinicians who interact with the drug court system need to know more about the obligations of courts that are entrusted with the task of protecting society and have the power to bring lawbreakers to account for their actions. Only with this ideal of therapeutic jurisprudence-collaboration between the clinical and legal worlds for the benefit of both defendants and the larger society-can drug courts live up to their vast potential for delivering good care to persons with addiction disorders.
Dr Westreich is Associate Professor of Clinical Psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine in New York and serves as the consultant on drugs of abuse to Major League Baseball. He is President of the American Academy of Addiction Psychiatry. He reports no conflicts of interest concerning the subject matter of this article.
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