In 1989, Miami-Dade County realized that judges were seeing far too many familiar faces in their chambers, especially offenders with substance use disorders. Thus, drug courts were born.
Drug courts place eligible defendants in a treatment program, monitor their progress, and decide whether they have recovered sufficiently to have their cases dismissed. A typical drug court runs for 12 to 18 months and is designed for high risk, high need individuals. Many programs revolve around the development of a recovery plan, individual and group counseling, random drug/breathalyzer testing, 12-step meetings, and drug and alcohol education.
Drug courts are widespread. Since 1989, over 3,000 programs have sprung up around the country. This year, approximately 136,000 people will participate in a U.S. drug court program. Unfortunately, many drug court participants will not receive evidence-based treatment for their opioid use disorders. Medication-assisted treatment (MAT) has permeated only half of drug courts operating around the country.
The three medications approved by the FDA for the treatment of opioid use disorder are methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are opioid agonists, which means they occupy the brain’s opioid receptors to eliminate symptoms of opioid withdrawal and reduce cravings. An opioid antagonist, naltrexone blocks the euphoric effects of opioids. Given the strong scientific support for use of these medications to treat opioid addiction—and the growing opioid epidemic—the National Institute on Drug Abuse and other public health authorities urge providers to offer MAT as a standard of care for people with opioid addictions.
Efforts have been made to address the limited use of MAT in drug courts. In 2015, the Bureau of Justice Assistance (BJA) began requiring drug courts receiving federal funding to attest in writing that they would not deny eligible candidates access to the program because of their use of an FDA-approved medication for addiction treatment, nor would participants be required to taper off such medications as a condition of graduating from the program. In 2016, the National Drug Court Institute endorsed MAT as a best practice for treatment of opioid use disorder and made free training available online.
Still, adoption has been slow. Below are three well-known barriers to broader availability of MAT for drug court participants, and ways they can be overcome.
Barrier #1: Access to MAT for Drug Court Participants
Access to MAT is a legitimate problem due to utilization management, financing, reimbursement, and regulatory issues, according to the American Society of Addiction Medicine. Some drugs courts, especially those in rural areas, may have difficulty connecting participants with MAT providers. Moreover, many commercial and public insurers impose “fail first” policies, where coverage of MAT only applies after a patient has “failed” with other treatment modalities.
However, changes at the federal level should help chip away at obstacles to MAT access.
The Affordable Care Act has addressed some of the barriers in access to MAT in a number of ways. It has expanded health insurance coverage to 20 million previously uninsured Americans, has included addiction treatment as an essential health benefit, and required that addiction treatment benefits be provided at the same level as physical health benefits (known as “parity”).
Last year saw a significant federal push to improve access to MAT. In 2016, Congress passed the Comprehensive Addiction and Recovery Act (CARA), which expanded buprenorphine prescribing privileges to include nurse practitioners and physician’s assistants. Also in 2016, the Department of Health and Human Services lifted the buprenorphine patient cap for physicians from 100 to 275. Following this policy change, over 11,000 prescribers have become certified to prescribe buprenorphine. The expected result of these policy changes combined is that MAT will become more accessible for all populations, but particularly for those in rural communities.
Barrier #2: Concerns About Diversion
Drug diversion is the redirection of prescription drugs for illegitimate purposes. The potential for diversion of buprenorphine is a concern that some drug courts may raise and use to justify the prohibition of MAT.
However, diversion can be managed in a number of ways, including better coordination between MAT prescribers and drug court program staff.
For example, the state of Kentucky has introduced a proactive approach to engaging participants’ MAT prescribers. Through a Clinician Letter, the drug court seeks to inform prescribers of the expectations and coordination needed to help a patient successfully complete the court’s program.
Barrier #3: Negative Attitudes and Strict Rules
It is clear that logistical concerns are not the only barriers to MAT for drug court participants. Negative attitudes, misinformation, and rigid policies all play a role in stalemating MAT expansion among courts.
The solution is to change rules and address the misinformation that leads to negative attitudes in drug court programs.
Many drug courts maintain blanket prohibitions of the inclusion of MAT patients. Some require participants to have detoxed before entering the program. Among drug courts supervising pregnant participants, only one in four courts permit the use of MAT. These policies are contrary to best practices in treating addiction.
Misinformation among drug court program staff is common. One survey showed that in courts where these medications are not available, only 5% of drug court professionals agreed that the use of buprenorphine is more effective than non-pharmacological treatments for opioid addiction, which is not consistent with scientific research.
Survey respondents also suggested that MAT is essentially replacing one addiction with another (untrue) and that participants should only be on these medications temporarily, until drug-free recovery is established (also not consistent with research on addiction treatment).
MAT Should Be An Option for Participants with Opioid Addiction
MAT may not ultimately be appropriate for all persons with opioid use disorder; each drug court participant needs individualized and tailored care when it comes to creating a recovery program. What’s important is that participants with opioid use disorder are given the option to use life-saving medications to help treat their addictions. It has been argued that the denial of MAT to a participant may violate the Americans with Disabilities Act, although a legal precedent has not been set on MAT specifically.
The message is simple: substance use disorder treatment should always be applied according to the best available scientific evidence, drug courts not excluded.
Miranda Gottlieb works for the State of Florida to reduce opioid-related overdose. Miranda is a scholar of drug policy and a weekend scuba diver. She is a native New Mexican and a graduate of the University of Tennessee. In the fall, Miranda will begin graduate work at Tsinghua University in Beijing, China to study international drug law.