Report: Medications can be comfortably integrated into drug court programs

Drug court programs that have traditionally resisted medication-assisted treatment as an option for opioid-dependent participants can successfully integrate medication treatments, even if some of those overseeing the program remain philosophically opposed to this approach. That is among the conclusions of a new report prepared by the Legal Action Center, which emphasizes that drug court practitioners ultimately need to acknowledge that treatment decisions for participants belong in the hands of clinicians.

The report, Medication-Assisted Treatment in Drug Courts: Recommended Strategies, seeks to offer practical guidance at a time when the federal government has now required that its drug court grantees include medication-assisted treatment in the treatment arsenal for their programs. “This was a perfect time to introduce 'how it's done,'” says Legal Action Center legal director Sally Friedman. Prior to this, “There was no guidance anywhere,” she says.

An ideal laboratory for observing any implementation issues surrounding methadone, buprenorphine and injectable naltrexone treatment in drug court programs is New York, since a 2015 law calls for the state's Article 216 judicial diversion program for certain felonies to allow medically prescribed treatments (and not to consider participation in such treatment a basis for a finding that an individual has violated his/her release conditions). The Legal Action Center report therefore based much of its conclusions on information gathered in interviews with 10 drug courts in New York, as well as site visits to three of the courts.

Key components

The interviews led the Legal Action Center to conclude that these are the nine components needed for successful medication-assisted treatment programs in drug court settings:

• Counseling and other services—plus medication—are essential. Counseling from licensed treatment providers must be part of overall treatment, the report states.

• Courts are selective about treatment programs and private prescribing physicians. While New York officials prefer that medication be administered by a licensed substance use treatment facility, some drug court participants in the state do receive medication from private physicians.

• Courts develop strong relationships with treatment programs and require regular communication regarding participant progress. Friedman says concerns about receiving the proper updates from care providers are the second most frequently stated concern from drug court leaders. The report adds, “The consensus among the 10 courts interviewed is that licensed treatment programs generally are more reliable communicators than private physicians.”

• Screening and assessment must consider all clinically appropriate forms of treatment. Clinical staff within the court system must be open to all modalities.

• Judges rely heavily on the clinical judgment of treatment providers as well as the court's own clinical staff. Judges in successful programs generally agree that the courts should not withhold proper medical treatment as a sanction against a participant.

• Endorsement of medication-assisted treatment by all members of the drug court team is the goal, but not a prerequisite. The report states that “even in courts where key players (e.g., a judge or district attorney) have reservations about addiction medication, [medication-assisted treatment] programs can succeed as long as the team views clinical decisions as the province of clinicians.”

• Monitoring for illicit use of medication-assisted treatment medication is a key component of the program and can be accomplished in different ways. Friedman says drug court leaders' most frequently stated concern is, “How do I monitor these medications and make sure they are not abused?” Leaders in the interviewed New York courts acknowledged that while some diversion of medication, particularly buprenorphine, does take place, it can be reasonably managed.

• Medications for medication-assisted treatment are covered through government and/or private insurance programs. Insurance coverage in New York is generally not a problem during the early stages of drug court participation, but can become extremely challenging when participants begin a job.

• Medication-assisted treatment operates very similarly to other kinds of treatment. “These courts run their medication-assisted treatment program mostly like everything else,” Friedman says of the New York programs that the Legal Action Center interviewed.

She adds, “We're hoping the report will help courts that are willing to consider medication-assisted treatment understand that this can be done without resorting to heroic or extraordinary measures.”

The Legal Action Center produced the report in conjunction with the Center for Court Innovation and the New York State Unified Court System.