A Well-Intentioned, Deeply Flawed Approach to Drug Treatment

Drug court judges are often swayed more by their own sometimes uninformed prejudices about treatment than by the views of clinicians.

It seems like a great idea on paper: stop filling prisons with people convicted of minor, nonviolent drug offenses, and instead, put those people into treatment for drug dependence that is overseen by special courts.

In these courts, defense attorneys and prosecutors would drop their usual adversarial roles and work together with judges and other court staff to be a “support team.” By dealing with the addiction, the courts would get at the “root cause” of crime and prevent recidivism, thereby avoiding the high cost of incarceration.

The United States has made drug courts a high priority, both domestically and as a central element of its foreign policy, encouraging other countries to adopt them. But when it comes to how useful or effective drug courts are, the devil truly is in the details. A recent report by the Open Society Foundations, Drug Courts: Equivocal Evidence on a Popular Intervention highlights the points to watch out for.

After 25 years of drug court experience in the United States, a substantial body of evidence suggests that these courts can do more harm than good. First, drug courts should ideally be working very closely with health professionals, who would make medical decisions about the nature and duration of treatment. But many accounts from across the country indicate that drug court judges are often swayed more by their own sometimes uninformed prejudices about treatment than by the views of clinicians.

For instance, although the World Health Organization and every reputable health policy body endorse the benefits of medication-assisted treatment (MAT) for opiate dependence—which uses stabilizing medicines such as methadone and buprenorphine—many judges and drug courts reject this treatment, sometimes calling it, incorrectly, another form of addiction.

Recent years have seen dramatic increases in opiate dependence and opiate overdose-related death and illness in the United States. But rather than encouraging use of the full range of treatment options available to deal with this difficult problem, many drug courts require MAT patients to be “tapered” off treatment, require them to use medications that may not be the most effective for an individual’s medical condition, or simply refuse to include MAT as an option among court-supervised therapies.

Unfortunately, but predictably, this has only resulted in even more overdose deaths as people pushed into the wrong kind of treatment find themselves turning to street opiates.

Another example of clinically misguided decision making by the courts is punishing people for “failing” treatment, often by putting them in prison. Medical authorities refer to drug dependence as a chronic, relapsing condition—most people need to undergo treatment more than once or try several forms of treatment. But, as shown by the research of Prof. Eric Sevigny of the University of South Carolina, drug court judges often impose incarceration as a sanction for “failing” treatment, negating any benefit of diversion from prison for the original offense.

If a health care facility made decisions like these—denied people the correct treatment for their condition or punished them in cruel ways for treatment failure—it could face a medical malpractice claim. But when a judge makes these decisions, there is no such recourse.

In the United States, most courts also require participants to enter a guilty plea as a condition of accessing court-supervised treatment, raising a host of due-process issues. Again, if a judge determines that there has been treatment failure, people might be tossed back into the adversarial system. But with a guilty plea on the record, they can face a longer sentence than if they had rejected drug court and argued a defense.

Most evaluations of U.S. drug courts, many of which are paid for by the same government money that established the courts, suggest that the courts prevent recidivism. But evaluations have been criticized by scholars and independent research agencies as being skewed by the drug courts’ habit of only admitting those most likely to succeed in treatment.

In Latin America, the U.S. is promoting drug courts heavily, including in countries that have already decriminalized personal use of drugs, a move that undermines both efforts to depopulate overcrowded prisons and decriminalization as a more sustainable and human rights–friendly approach to drugs.

The city of Seattle and a few other U.S. cities are embarking on a different approach to minor drug offenses in a program called Law Enforcement Assisted Diversion (LEAD). In LEAD, people charged with minor offenses are diverted to health and social services not requiring a guilty plea and not overseen by courts but by health and social professionals. This program, which has shown early promise, may avert some of the more fiendish pitfalls of drug courts.

Drug courts are likely to be a subject of discussion in the UN General Assembly Special Session on Drugs in April 2016. Delegates to this important meeting should look carefully at the evidence on drug courts to determine whether they are really a step forward or a new variant of the same drug war policies in dire need of reform. 

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I am a Licensed Clinical Social Worker and Addiction Specialist and have served person's (adolescent) who are enrolled in DJJ drug court. My program was developed to decrease recidivism in the court system for minority males. I have served at risk youth for 15 years and have seen the results of placing kids, whether it is their 1st offense or 5th, placed in groups of their peers who do not belong together, they sometimes get worst. This is one of the reason's I went out on my own. My program has been in operations since 2011 I have received high compliments on the outcome of the few young people that I have served. The ones that were in other programs that were enrolled in programs who were contracted by the courts would come and engage in Beyond today as well and attended consistently and most by public transportation. For some reason the referrals stopped. One reason I believe. is that I do not run a traditional program and my proposals have been rejected. My program operates on what I make as a therapist, fundraiser and sales from what we make. With this money I am able to treat each child as an individual not a part of a system. I have no more that 10 kids at a time, some are lucky enough to be connected with male mentors, engage in culturally sensitive group sessions.
Just recently a young person was encouraged to take a plea of guilty for her first offense, the thing that was appalling to me is that her attorney did not allow her parents in the room with her, and did not give her the opportunity to speak with anyone to help her make a decision, she was only 14 years old.

Indeed you point to a basic problem; we're more willing to let governments spend money on enforcement than on services so in many instances the only way to get any assistance is to have them arrested. Yet, voluntary and individualized services work best. Thank you for doing this great work, that's the effort that can truly change the live's of those young people.

Interesting point, but not completely explored! Better rewrite explaining everything, to complete the picture! Sorry, not happy with you incomplete comments

Respectfully submitted
WJJ, Alaskabushman


Hi Carlos, We are hoping to develop a brief that looks at the concerns over Drug Courts as used in the Latin America region. It's better to examine interventions within the legal, cultural and institutional context, therefore we are working on these separate materials that will be available in Spanish.

It is time to let people live their own lives without courts or the medical field to act as parents or preachers. Adult beer standards for most vices shall suffice .

I do not agree with this assessment. I have managed an adult drug court in Seattle, King County, WA for 17 years of the 20 years it has been in existence. In that 20 years, approximately 2,050 people have graduated from the program. King County is a pre adjudication model that allows for dismissal of all cases at graduation. King County Drug Court follows the national adult drug court standards which are based on 25 years of research as noted in this article. We cater to high risk and high needs individuals. We have provided access to methadone to all participants in need since 1998 as well as residential treatment, evidenced-based outpatient treatment and supportive housing. The people referred to our program are not “the most likely to succeed". All are charged with felonies, many facing 5 to 10 years in prison due to extensive criminal histories. They suffer from mental health issues, homelessness and long-term addictions. We venture to address all of these issues as resources permit. From the moment the person walks through the door they are treated with respect and care from a team of professionals committed to assisting them in bettering their lives and overcoming their addiction. The clinicians make the clinical decisions. Every year approximately 125 people graduate from the program, their charges are dismissed, and they have their families, their health, their livelihoods returned to them, sometimes after 30 years. People are young and old and from all races and ethnic backgrounds. Again and again they thank drug court for the care, the services and the structure and accountability they received.
In August, 2011, a local Seattle weekly paper, The Stranger, published an article: The War on Drug Courts: King County’s Drug Courts are Successful, So Why Are DC Progressive Against Them? In that article Eli Sanders spoke with Dan Abramson, director of legal affairs for the Drug Policy Alliance about a 26 page critique of drug courts released in March, 2011 by the Drug Policy Alliance. The report claimed “Drug Courts have not demonstrated cost savings, reduced incarceration, or improved public safety.” Mr. Abrahamson also admitted in the article that his group’s report wasn’t based on new research findings or even a “meta-analysis” of current findings, “We never claimed to undertake any research on drug courts” he said.
This more recent article: “A Well-Intentioned, Deeply Flawed Approach to Drug Treatment” in reference to drug courts feels strangely familiar to me. I agree that drug courts are not the only way to treat addicts who commit crimes and especially minor crimes. Drug Court should be part of a continuum. Drug Court researchers agree with that assessment. What I don’t understand is why people who champion alternatives to drug courts see an attack on them as the only way to prove their worth?

Great that Open Society is critiquing claims on the effectiveness of drug courts but your summary and your literature is overly selective and maybe too well intentioned.

You have to include other meta analyses,such as McKenzie. You also have to deal with HOPE. You have distinguish folk involved with drugs and also violence. You have to look at alcohol.

If governments legalized marijuana that would reduce some of the need for drug courts. If governments followed the evidence on prescription of heroin, that reduce some of the need for drug courts. If governments controlled opioids better, that would reduce need for drug courts.

If governments followed the evidence on prevention, including investing in early childhood and housing first that would reduce both the number of alcToholics and other drug addicts, and that would remove even more of the need for drug courts.

he evidence is clear that the most effective and cost effective to deal with violence is prevention and that all the rest such as courts and incarceration are picking up the pieces.

The US has worst rates of murder, traffic fatalities and drug overdoses and spends the most per capita on incarceration of advanced nations. If you look through a racial lens it is even worse.

But the US has more knowledge than the rest of the world on how to prevent these deaths. Unfortunately it does not use it. It is not just criminal court judges who fly the wrong way by the seat of the pants but politicians.

Hope Open Society will start taking an interest in ways for the US to be smart on crime domestically and work with countries who are becoming smarter on crime than the US.

To get an overview of the evidence and its implications - see my book Smarter Crime Control that reviews all the evidence - not just a couple of authors. http://bit.ly/1av9GHF.

Agree with the article. The majority of drug courts are not effective in my opinion because they are not supporting evidence based treatments for addiction. Have seen most cases referred to 12 step programs, free rehabs where they are not using evidence based treatments, proper medical support, using medications proven to aid with recovery. I feel most of this started with the push to use self help programs like AA and NA and considering it adequate treatment for addiction. And this doesnt even touch other mental health disorders. 12 step programs notoriously supply pressure against the use of medications be it in meetings, the individual beliefs of those running the drug courts through their affiliations, etc. so much change is needed.

Could not agree more. My son, a stage 5 chronic heroin addict, plead guilty in charleston sc drug court and his "treatment" for his seven year heroin addiction was two group meetings a week with counselor with assoc degree despite medical doctor sending letter stating that he must be allowed to be on MAT. Drug Courts don't follow evidence based treatments, don't follow best practice standards, and serve only prosecutors, not defendants, and certainly not public safety. They are not accountable to produce outcomes to the public and have robbed many of both their constitutional rights and the treatment they deserve. Addiction is a public health problem not a legal problem.

I have a great deal of sympathy with the criticism of drug courts, in fact I was part of team that evaluated criminal justice responses to addiction. But I am also critical of the 'over-medicalisation' of addiction. By that I mean the diagnosis of addiction based on the 'disease' perception. That does not mean dismissing individuals with acute psychiatric conditions that help to explain the difficulty they face with addiction. But it does mean seeing addiction as a choice. The good thing about criminal justice responses is that they help people to make good choices. The problem with the health perspective is that it socialises people into believing that they can do little about their 'condition'. MAT may not be another addiction but it is a crutch that most of the people that experience drug addiction can do without - most of the people that experience addiction move to abstinence, many without MAT, some without treatment (a greater proportion did so in previous generations).
Simply sending people to prison for addiction is clearly not a solution. But nor is loading people up with MAT. Neither do anything to tackle underlying problems that exasperate the effects of addiction, nothing to restore hope to poorer neighbourhoods. Getting the balance right is tough, the fact the debate is polluted by strong sets of ideological belief on both (a simplification) sides does not help.

I go to NA and see Drug Court destroying the NA program. We are not supposed to be affiliated but every meetings signs slips. Removing the bottom of prison kills a lot of addicts. Yes, Drug Court sounds good on paper, if only it worked.

I am currently in a Drug Court program in NY. I have to say that it has done more harm than good. They have been helpful in linking me to receive help, but that is all negated the moment I am not "compliant" to their every whim. I don't want to complain because they did help link me to MAT, which has changed my life and allowed me to live again and be more than a functioning part of society. However, the moment I miss a treatment date, or tell them that what they expect is impossible, that's it! I am sanctioned and during that period of time I am not able to receive my MAT. Therefore, after receiving a 1-2 week sanction, which is pretty much a mandate to detox in jail, I leave and look for the fastest relief from the pain, my drug of choice, heroin. And it starts the cycle all over again. If drug addicts could be threatened into sobriety, we wouldn't be in drug court. The threat of losing everything else in our lives would be enough. Unfortunately, threats do not help, not even the threat of jail. I appreciate everything that the courts have done to help me, however, it took me being pregnant to receive help in jail. I turned myself in and I was pregnant, and that is where they put me on MAT. I have since been on it and am doing very well. However, it's been 15 months and drug court still hasn't let me move on with my life. I have jumped through all of their hoops and finally the responsibilities that I have picked up in sobriety added with the responsibilities of drug court have become overwhelming. I find myself 15 months sober and running from drug court because i missed an appt. with my outpatient. In fear of a sanction where I will be thrown back into the throes of addiction, I have not returned to drug court on my last set date. I feel as if they are eradicating all of the help they've given me. I don't have a problem sitting down for a week or two and taking responsibility for my actions, but I do have a problem with being thrown back into active addiction for something as silly as missing an appt. I cannot speak up in drug court as I am nothing but an addict making excuses for myself and no matter what, my respectful voice means nothing and will never be taken seriously. I am a human being. Addiction in itself is a hard enough stigma to carry around without being made to feel less than human by the courts. Trust me, I hate myself enough for everyone in the world for my past. I wish there were a program like LEAD where I am. I was arrested for possessing an empty bag of heroin, my first offense, and was thrown into drug court. I have been in drug court for 4 years and have served about 4-5 months in sanctions already and spent countless time in rehabs. It wasn't until MAT that I was actually able to gather some clean time under my belt and begin to heal. I wish rather than jail for my mistake, I could continue my treatment without the risk of relapse and death. If it is truly the want of the court to help people get and STAY clean, why would they impose a sanction that would put me at high risk for a relapse? The courts would say that this is just an excuse, but it isn't an excuse, it's my reality and I know this from past experience. I suffer and suffer more and I just want out of the legal system so that I can move on and not live with this fear hanging over me everyday of my life. It is such that it is crippling now. I wish they would let me go now. I've given them so much time and cooperation and hoped they would have graduated me by now. At this point I feel like the harm outweighs the help. I want out of this cycle, I just can't take it anymore. Why tease me and help me get clean and get my life back just to rip it away again? I feel like a cat chasing a laser pointer non stop, trying to do everything that they want me to do, missing opportunity after opportunity to continue jumping through the hoops that they continually supply. So very frustrated and in need of some advice. I want to clear up my warrant but not at the risk of relapsing back into my shitty life I once lived on heroin. I love my life now and I don't want to die anymore.

Drug Court continues to destroy NA. In my town we have gone from 97 meetings to 14 over the last ten years. The chaos of Drug Court drives those really wanting recovery away. Now every newcomer is forced to attend by Drug Court. Soon, there will be no NA in town. Then what?

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