Drug Courts and Drug Treatment: Dismissing Science and Patients’ Rights

Ordering people to stop treatment is bad for patients and the public.

Drug courts are promoted as a more humane alternative to incarceration for people who use drugs in the United States. But in our recent study, we found judges in New York were ordering patients to stop treatment with methadone or buprenorphine as a condition of participation in, or graduation from the drug court. This practice is unjust, ungrounded in medical evidence, and bad for patients and the public.

Methadone and buprenorphine are medicines prescribed to reduce cravings for and injection of heroin and other opioids. Medical evidence on opioid dependency shows that relapse to opioid use is generally the rule, rather than the exception, when people who are dependent on opioids stop taking them. This is especially true when they stop abruptly.

Drug courts are special non-adversarial courts that handle cases of people charged with offenses related to substance use. They have become a central part of drug policy in the United States. In 1989, there was a single drug court. As of June 2013, there are more than 2,700. The model is heavily promoted by the U.S. Office of National Drug Control Policy, and at least 15 countries now have drug courts along the lines of the U.S.

While, in theory, drug courts offer treatment as a pragmatic alternative to incarceration, few studies look at the workings of drug courts from the perspective of providers or patients. So, in 2011, we began interviewing opioid substitution treatment (OST) providers and patients in New York—one of the states most heavily committed to drug courts, with at least one in every county—to hear how they see the drug court experience with OST.

The results were varied, and showed that many courts do not respect medical consensus on scientifically sound treatment standards. Some courts included OST as part of court-mandated treatment options, while others allowed OST for a court-defined period of time as a bridge to abstinence. Still others showed intolerance and even disdain for anything having to do with methadone and buprenorphine, or—as with the drug court in Albany County—refused outright to admit people on methadone or buprenorphine treatment.

Ordering people who are dependent on opioids to get off their prescribed methadone or buprenorphine medicines can force patients to seek out and become dependent on other opioids like prescription analgesics. Addiction to prescription opioids has been recognized as a priority problem by U.S. policy-makers, but drug courts may be exacerbating it.

Extensive research since the 1960s has shown that maintenance treatment with methadone and buprenorphine is the most effective approach for reducing death, morbidity, criminal involvement, and other harms associated with opioid addiction. Both methadone and buprenorphine are included in the World Health Organization’s Model List of Essential Medicines, and are supported as the most effective treatment for opioid dependence by major U.S. health institutions including the National Institutes of Health, and National Institutes on Drug Abuse.

Forced “tapering” from methadone and buprenorphine, or blanket exclusion from these treatments, shows the danger of what happens when judges play doctor.

These are not just problems in the jurisdictions where we did interviews. In spite of the National Association of Drug Court Professionals’ strong policy statement on the benefits of methadone and buprenorphine maintenance treatment, a 2013 study by Matusow, et al. found a lack of uniformity of policies and arbitrary practices regarding OST within the U.S., and even within individual court districts.

Drug courts can be, as the Obama administration contends, a tool to improve national response to those with drug dependence. But, as our small study suggests, there is big gap between the theory and practice of referrals to drug treatment by these courts.

Judges often don’t know enough about addiction treatment to escape the same prejudices that affect other people, and they demand abstinence-only approaches even when better alternatives exist. Our research speaks not only to the need for greater education of judges and other decision-makers in the justice system about the long-proven efficacy of methadone and buprenorphine in the treatment of dependency on opioids, but also for greater commitment by policymakers to improve the availability of OST to all who need and want it.

We hope that this small study in New York will encourage further investigation of drug courts' practices regarding OST, and help to promote drug policies and practices centered on health and human rights, not on stigmatizing and ill-informed judgments

For more detail on our study, read the full version: Methadone Treatment Providers’ Views of Drug Court Policy and Practice: A Case Study of New York State.

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"The National Association of Drug Court Professionals and the National Drug Court Institute claim that drug treatment courts are the answer to reducing recidivism within the prison system. Although supporters praise the drug treatment court movement, it has yet to demonstrate a reduction in incarceration numbers, alcohol and drug use, or cost savings..." Read more: http://www.huffingtonpost.com/elaine-pawlowski/drug-treatment-court_b_43...

I generally enjoy the content provided by open society but I am sorry to say that after reading the mini findings of this study I am skeptical of other things I have read now. I worked with alternative sentencing programs for 8 years. The last year or so I worked with drug court. I kept in mind that things in my state may be different from New York however, given the issues I faced with Judges were not addressed in this article I cannot assume that it is different. My experience was that, yes there were some Judges that would order people not to participate in opiate replacement therapy. Their reasons were not all the same though. Some Judges were just against taking something to quit using drugs. These Judges often were not familiar with addiction. There were other Judges however that would only make such a decision after the client was found not to be appropriate for opiate replacement therapy. The fact is there are people that are addicted to drugs and afraid to do the work required for treatment. They fear the struggle to overcome the physical and mental impact of drug use. Often times clients would start a methadone or suboxone therapy and would use other drugs that are not opiates. They believed the problem with opiates was fixed and the other drugs were not a problem for them for legal reasons or just because they did not understand that often times addicts quit using one drug and replace it with another. Often times they just did not want to quit the lifestyle either. Because they were involved in opiate replacement therapy they could not participate in drug treatment (in the past 2 years treatment centers have had to start allowing opiate therapy patients permission to attend their centers as well ). So essentially they continued to use drugs but not opiates. Most of the time the expense was a major factor for those people to just decide to stop opiate replacement treatment and not the way they medically should. They would just no longer go. They would also tell themselves that the opiate replacement therapy had cured them and had this delusional self confidence that they could just quit the medicine. Well of course that means relapse, not always but more times than not. So they would use again, test positive again, and have to see the Judge again. When they knew they were going to court again they would start on opiate replacement therapy...again. With my agency we recommended that clients try drug treatment a few times before we would recommend opiate replacement therapy. It was recommended however and when it was most of the Judges I worked with were more than accepting of that recommendation. This response is not meant to be critical of my former clients but merely pointing out the nature of the disease.

Thank you for shining a light on this issue.... Judges and probation/parole officers practicing medicine without a license is becoming an epidemic and making up an ever growing portion of the advocacy cases we are dealing with at NAMA Recovery. Keep up the good work, and thank you!

Yes it is very important that one can concentrate or make focus on this kind of things because these are the issues are not related with individual but it is actually it is related with society.

My girlfriend is in drug court and the judge told her to get off it. The judge told her " You have till the next time I see you" which was 4 day. She has been on it for a year now. I guess what I'm trying to say is that people that have been on it can't just quit in 4 days. So I'm agreeing with some judges have no clue about addiction. So what I would like to propose is if you want to be a judge for drug court maybe you should study addiction before you become one.

I agree that judges and others involved in the criminal justice system should not "play doctor." However, isn't it just as important that the doctors who are prescribing these medications be knowledgeable about addiction and addiction treatment? The majority of physicians who prescribe the medications aren't addictionoligists. The experience in our area is not only that they aren't, but they have never taken a class or participated in any training programs related to addiction. Some would speculate that over prescribing of opiates could have contributed to the probelm that the continued prescribing of opiate like medications is attempting to address. I've worked with addicts for many years, long enough to know that many report being just as addicted to and will go to the same lengths to obtain suboxone and methadone as they did to obtain the opiates. Judges and others in the criminal justice system are not doctors, but they have more experience with and see more of the devastating effects of addiction and the use of the opioid replacement medications in a year than most doctors will see throughout their entire practice. They face it and try desperately to find ways to address it on a daily basis. The answer to drug addiction can't be found by using more drugs. It can only be found in lifestyle changes, education about the disease and how to manage and overcome the symptoms, support and encouragement from others, employment opportunites and accountability...imagine that, all the things that drug courts provide.

This is so, so very incorrect. Replacement therapy may not work for everyone but I can tell you it saved my life. Quite literally, if I hadn't gotten on ORT I'd be in jail, or dead.

I think they need to stop frowning on stuff like that, and the old, "take a drug to get off another drug" is trite and has no place in this argument. No, I take methadone because I need it, not to get off heroin, but to find a cheap, LEGAL, and available way to get through this world. Before methadone I was a homeless street junkie in and out of jail bc I couldn't live totally sober. Every time I've tried to be totally sober, it EVENTUALLY falls apart in a flaming ball of wreckage.

However, when I got on methadone, that side of me that never felt right even before drug use, that side that was only quelled by using drugs or drinking, that side was satisfied, and I have been able to buy a house, get engaged, finsh school, and excel in my career with the help of methadone. So, do you think I don't want to do that "hard work", or have some excuse to just want to "use" methadone? Or do you think that maybe, just maybe, it makes me RIGHT? I don't get "high" off it, or do ridiculous things to get it, and there's nothing wrong with it.

The abstinence model has been useless for some time now, let's cut the Dr. Phil "you have to be 100% totally clean to ever succeed in life" bullshit and quit with the labeling. Find what works for each individual and encourage that. You preachers of abstinence are living a fantasy, and quite frankly, more often than not, that fantasy ends with a needle in an arm and quite often an overdose since forced abstinence sets up people for OD's.

"The abstinence model has been useless for some time now." is a completely incorrect statement. As a researcher in the field of addiction studies, I can tell you that simply measuring a persons by how less likely they are to commit crime, or how less likely they are to OD, is a terrible way to measure quality of life. In fact, those who are abstinent, far exceed MAT clients in all areas of life. They are not merely subsisting, they are flourishing. Still, I believe there is a need for time-limited opioid detox through medical assistance. The other thing that gets lost in all of this is that opioid withdrawal is not fatal, like withdrawal from benzo's or alcohol. The idea that this population os somehow special, and needs lifelong MAT support, is ridiculous. From a public health perspective, it is important to help people, but that should be part of a larger transitory system that goes from MAT, to transitional environments, 12-Step Supports, Legal and Financial Supports, Peer driven communities, and Educational or Vocational supports.

Austin Brown MSW, perhaps we could measure quality of life by whether or not a person is actually alive? MAT saves lives and that is why it is endorsed by the WHO, CDC and other organizations as the medical standard of care to treat/manage opiate addiction. As to your comment "those who are abstinent, far exceed MAT clients in all areas of life. They are not merely subsisting, they are flourishing", there is simply no evidence to support this. For every person who is abstinent and flourishing, there is likely at least one person on MAT who is flourishing also. Of course, there are no studies to prove this, either way, but assuming you're basing your conclusions on a self-selected sample, I'll do the same. MAT has literally transformed the lives of several people I know personally, and I've read countless stories in online support groups attesting the same. MAT is imperfect and may not work for everyone all the time, but there are many people for whom it works very well, allowing them to live lives that are every bit as fulfilling and meaningful as anyone who is "abstinent." When death rates from overdose are skyrocketing (typically following short-term stints of abstinence in rehab or jail), it's inexcusable to not include this in the arsenal of treatment modalities available. Abstinence is certainly a laudable and worthwhile goal to be encouraged, but not everyone is ready for it, especially early on, and some may never be. Why not give them the opportunity to live (more) functional lives in the meantime? By the way, opiod addiction is unique among addictions precisely because of the biology surrounding tolerance, which makes the likelihood of death following periods of abstinence many times higher than for any other commonly abused substances. Opiate withdrawal may not be fatal (though symptoms of opiate withdrawal, like dehydration, can be), but getting through withdrawal symptoms isn't all there is to overcoming addiction. If that were the case, once all addicts "withdrew" from their drug of choice, there would be very little relapse. There is a huge difference between physical dependence on a substance and addiction.

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