Drug courts are increasingly positioned as pathways to treatment for people with addiction who are in trouble with the criminal justice system, but medication-assisted treatment (MAT) is proving to be a sticking point. At a time when the opioid addiction epidemic is at a crisis point, the importance of MAT is increasingly pointing toward expanding methadone, buprenorphine and Vivitrol treatment. But traditionally, the criminal justice system has been opposed to methadone and, more recently, buprenorphine; the same is true for many drug courts. And, in general, courts prefer the non-agonist medication Vivitrol over methadone and buprenorphine, both opioids (see ADAW, May 12).

West Huddleston, CEO of the National Association of Drug Court Professionals (NADCP), is particularly concerned about the MAT because, he told ADAW, too little is known about what medications work for what patients, and for how long treatment should last. NADCP is a “strong proponent of the proper use of MAT in drug courts,” he said, citing a 2011 position paper supporting it.

According to a survey conducted by National Development and Research Institutes about two years ago, half of adult drug courts utilize MAT, the highest use among corrections, said Huddleston. In jails, when MAT is offered, it is for detoxification, and only 7.5 percent of prisons and 5 percent of parole and probation agencies offer MAT.

But Huddleston made a distinction between “medication assisted treatment” and “medicine as treatment,” blaming buprenorphine for the confusion. (See the article on p. 3 for the controversy about raising the buprenorphine cap, something NADCP strongly opposes.)

Draft guidance forthcoming from NADCP

Huddleston calls the “do you or do you not support MAT?” discussion “tired,” saying that DATA 2000, the law that allowed buprenorphine to be used as treatment for opioid addiction by a physician, has changed the landscape. The following passage from the draft guide most adequately describes, said Huddleston, what the gap is pertaining to medical and legal decisions regarding MAT:

“Most publications describe the pharmacological properties of the medications, report controlled studies demonstrating their efficacy or advise physicians how to manage cases medically. No reliable resource was identified that addresses the important concerns about MAT expressed by drug court professionals. Drug courts need to know, for example, how competent medical practitioners decide which medication to prescribe in a given case, when it is appropriate to taper the medication regimen and how to prevent illegal diversion of the medications.”

Saying that there is only “imperfect knowledge,” the draft guide says “drug courts cannot be faulted for cautious hesitancy.”

Included in the 2011 position paper from NADCP supporting MAT is the requirement that drug courts “not impose blanket prohibitions against the use of MAT for their participants” and that the “decision whether or not to allow the use of MAT is based on a particularized assessment in each case of the needs of the participant and the interests of the public and the administration of justice.” However, the NADCP position paper and forthcoming guidelines are not binding upon drug courts, which report to the Administrative Office of the United States Courts, noted Huddleston.

The guidelines will be released by the end of the year, said Huddleston, who added that the identities of the peer reviewers are not being disclosed. “They are psychiatrists, physicians, and experts” from academe, he said.

Side-by-side comparison

Huddleston faulted the field for not creating a document drug courts — or treatment providers, for that matter — can use “to help them understand the medical rationale for which medication to use for which patient and for how long,” he told ADAW.

There are 2,800 drug courts across the United States, but NADCP doesn’t know how many are using MAT, or what kind of medication they are using, said Huddleston. “I can’t tell you what’s happening in all 2,800 drug courts,” he said. “That’s not our role. We don’t track drug court operations to that level.”

The draft guidance does state that methadone is the treatment modality for opioid dependence that is associated with the least morbidity and mortality. We asked Huddleston if drug courts take health outcomes into consideration, or if they also consider recidivism. “Drug court’s main goal is to save someone’s life, to get them clean and sober,” said Huddleston. “That’s our job. We’re dealing with drug-addicted people, 144,000 drug-addicted people. Our job is to get them the treatment they need.”

Huddleston added that people can be diverted out of the criminal justice system into treatment without a drug court. “That’s our goal as well,” he said. “We just don’t think that jail or prison is the place for addicts.”

Huddleston is not the only person to have suggested “side-by-side comparisons” with regard to the three federally approved medications, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD). Many NADCP members would probably like “some kind of clinical decision-making outline, indicating what medications should be used for specific populations,” he said. However, this is “a much more complicated issue than first meets the eye,” he said. “It would appear that many addiction professionals are of the judgment that buprenorphine should be the first medication used to treat opioid addiction in a younger patient population with less complicated addiction histories.” Some experts believe that buprenorphine should be the first medication for opioid addiction for adults as well, he said. “Such clinicians indicate that if buprenorphine should not prove effective in treating the symptoms of withdrawal or otherwise stabilizing the patient, then methadone should be the second-line medication,” he said.

Courts as barrier to treatment

But treatment providers have said that courts repeatedly refuse to allow clients to remain on MAT, if they are on it, or to recommend them for it. “The courts have been an impediment to the progress of MAT treatment,” Jerry Rhodes, CEO of CRC Health Group, the Cupertino, Calif.–based treatment chain that has the largest number of OTPs in the country, told ADAW. “Courts have, unfortunately, been a font of discrimination against the use of MAT, and it is an imposition of less than a best practice for many potential clients,” he said. “Until the drug courts adopt a greater perspective on the use of MAT, they will risk enforcing politics and prejudice against what is widely acknowledged as an important alternative for treatment.”

Huddleston cited the Brooklyn Treatment Court in New York City as an example of a drug court with cooperative agreements with treatment providers, including with opioid treatment programs (OTPs), clinics that provide methadone maintenance. “The number-one job of a drug court is to understand addiction, to understand that it is a long-term process, and not to throw people away in prison,” said Huddleston.

Other responses

Alkermes, the Ireland-based pharmaceutical company that makes Vivitrol, “is in full support of the organizations whose mission it is to determine a way to solve the addiction problem,” said corporate spokeswoman Jennifer Snyder in an email to ADAW. “To that end, we fully endorse the position that ONDCP recently relayed in their 2014 strategy regarding NADCP’s focus on criminal justice reform and the importance of alternatives to incarceration for nonviolent drug offenders.” Snyder went farther, extolling NADCP for taking “an evidence-based, highly rigorous research approach to develop and outline strategies for drug courts and related judicial models to incorporate addiction medicine as part of a comprehensive treatment program for the patient populations in which they serve.” Alkermes is a sponsor of NADCP.

There are experts who prefer naltrexone or Vivitrol (depot naltrexone) over methadone or buprenorphine for younger users or opioid-naïve users, Parrino said.

“This varies depending on who you speak with,” he said. It also varies depending on who is sponsoring the research.

“The distrust of methadone maintenance treatment is rooted in the past, even when I wrote an article for American Jail Magazine in 2000,” said Parrino. “The editor asked me to write the article, focusing on Rikers Island as a method of responding to jail administrators and their medical personnel, who refused to recognize methadone maintenance as a legitimate treatment for opioid addiction.”

If drug courts once thought buprenorphine was a valid option, their perspective may have “darkened” because of diversion, and because of the policy of encouraging the use of buprenorphine without any other treatment interventions, such as counseling, said Parrino. “Obviously, this is not a written policy but it is a frequent practice,” he said.

Stuart Gitlow, M.D., president of the American Society of Addiction Medicine, had no comment on the NADCP criticism of MAT. ASAM is supporting lifting the cap on the number of patients a physician can treat with buprenorphine, which has aroused opposition from NADCP and AATOD alike (see article, p. tk).

Meanwhile, Michael Botticelli, acting director of the Office of National Drug Control Policy, is a stalwart supporter of MAT, based on his past statements, his history as SSA in Massachusetts, and his leadership at the recent heroin summit (see ADAW, June 30). However, the recently released national drug strategy seemed to pull back from full support of MAT, with Botticelli citing “hesitancy” in supporting it (see ADAW, July 14). No one from ONDCP would comment on the record for this story, but Botticelli has shown leadership by having the MAT conversation with treatment groups in the past. As for prosecutors and judges in drug courts, ONDCP has decided that convincing them of the science behind MAT will require a long-term strategy, something that won’t happen overnight. Stay tuned.

Bottom Line…

Drug courts want nonviolent offenders to get treatment if they need it, but they aren’t ready to line up in support of methadone and buprenorphine.