A grant announcement issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) last month to fund drug courts contains an important new condition: drug courts funded by the grants would no longer be allowed to tell offenders to stop taking medications to treat opioid use disorders. Many drug court judges have opposed methadone or buprenorphine and required participants to stop taking them. Drug courts prefer either abstinence or Vivitrol.

From the SAMHSA Request for Applications (RFA): “Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any other staff connected to the identified drug court deny the use of these medications when made available to the client under the care of a properly authorized physician and pursuant to a valid prescription and under the conditions described above.”

The grant language refers to medication-assisted treatment (MAT) and includes methadone, buprenorphine, oral naltrexone, Vivitrol (injectable 30-day naltrexone) and other medications.

Under the January 26 grant announcement, drug courts would be allowed — but not required — to use 20 percent of SAMHSA grants for MAT.

Grant language

Below is the language from the RFA:

“Recognizing that Medication-Assisted Treatment (MAT) may be an important part of a comprehensive treatment plan, SAMHSA Treatment Drug Court grantees are encouraged to use up to 20 percent of the annual grant award to pay for FDA-approved medications (e.g., methadone, injectable naltrexone, noninjectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) when the client has no other source of funds to do so.

“MAT is an evidence-based substance abuse treatment protocol and SAMHSA supports the right of individuals to have access to FDA-approved medications under the care and prescription of a physician. SAMHSA recognizes that not all communities have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using anti-alcohol and opioid medications. This will not preclude the applicant from applying, but where and when available, SAMHSA supports the client’s right to access MAT. This right extends to participation as a client in a SAMHSA-funded drug court. Applicants must affirm, in Appendix II: Statement of Assurance, that the treatment drug court(s) for which funds are sought will not: 1) deny any appropriate and eligible client for the treatment drug court access to the program because of their use of FDA-approved MAT medications (e.g., methadone, injectable naltrexone, noninjectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) that is in accordance with an appropriately authorized [physician's prescription]; and 2) mandate that a drug court client no longer use MAT as part of the conditions of the drug court if such a mandate is inconsistent with a physician’s recommendation or prescription. If an application does not include the Statement of Assurance affirming these conditions, the application will be screened out and will not be reviewed. In those circumstances where resources such as available physicians to prescribe FDA-approved medications do not exist the applicant must include in the Statement of Assurance justification as to why clients may not be able to access MAT; however, this circumstance does not alleviate the applicant from complying with conditions 1) and 2) stated above.

“Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any other staff connected to the identified drug court deny the use of these medications when made available to the client under the care of a properly authorized physician and pursuant to a valid prescription and under the conditions described above.”

Later in the RFA, there is the following statement, which the applicant for the funds must sign: “…for the treatment drug court(s) for which funds are sought will not: 1) deny any appropriate and eligible client for the treatment drug court access to the program because of their use of FDA-approved MAT medications (e.g., methadone, injectable naltrexone, non-injectable naltrexone, disulfiram, acamprosate calcium, buprenorphine, etc.) that is in accordance with an appropriately authorized prescribed by a physician’s prescription; and 2) mandate that a drug court client no longer use MAT as part of the conditions of the drug court if such a mandate is inconsistent with a physician’s recommendation or prescription.”

ONDCP-NADCP link

Michael Botticelli, director of the Office of National Drug Control Policy (ONDCP), was cited in a Huffington Post article as heralding in a new federal initiative banning drug courts from ordering people on physician-ordered methadone or buprenorphine to stop taking them. However, Sam Schumach, press secretary for ONDCP, told ADAW that this referred to the SAMHSA grant language. Still, Botticelli and the ONDCP are strongly in favor of MAT, including Vivitrol. “We have highly effective medications that, when combined with other behavioral supports, are the standard of care for the treatment of opioid use disorders,” Schumach told ADAW. “However, there continues to be a lot of misunderstanding about these medications. We are working at the federal level to increase education about these medications, as well as to strengthen policies and contractual language to ensure that grantees — including criminal justice and treatment programs — permit the use of medication-assisted treatment.”

West Huddleston, CEO of the National Association of Drug Court Professionals (NADCP), agrees. “No drug court should prohibit the use of MAT for participants deemed appropriate and in need of an addiction medication,” he told ADAW. He added that ONDCP, SAMHSA and NADCP “are not at odds whatsoever on MAT.” The only leverage that can be applied is through federal grants, said Huddleston — the NADCP can’t tell drug courts what to do. However, “we urge all drug courts to consult a physician who has expertise in addiction medicine and/or addiction psychiatry.”

ONDCP is reviewing the NADCP MAT publication on drug courts. It is not ready for release, said Huddleston. “Since it was developed under funding from ONDCP, it is in their possession for formal review and approval,” he told ADAW.

Huddleston added that the issue is more complicated than “Do you or don’t you support MAT?” For the NADCP, it’s not about “liking or not liking” methadone, buprenorphine or Vivitrol. Huddleston said, “The real issues are, who gets MAT? Which medication is appropriate for which person? How long is the appropriate course of MAT?  And what is the medical rationale for making those and other decisions? That is what our publication seeks to answer for drug court professionals.”

Huddleston’s response to the Huffington Post article included a strong critique of “Big Pharma.” Alkermes, which makes Vivitrol, is very involved with behind-the-scenes promotion of the use of the medication in drug courts but did not respond to multiple requests from ADAW for information on the use of the medication.

Over the years, Vivitrol, originally developed for use in alcoholism treatment programs, has had a more important role in the criminal justice system to prevent opioid users from getting high (it blocks the effects of opioids). It can’t be administered until the patient has been free of opioids — including methadone or buprenorphine — for a week. The once-a-month injection is now provided for in the 2015 appropriations bill (see ADAW, Dec. 15, 2014). Stay tuned; ADAW will report on the MAT manual for drug courts as soon as it is available.

For the SAMHSA grant announcement, including links to the RFAs, go to http://www.samhsa.gov/grants/grant-announcements/ti-15-002.