Download Medication Assisted Treatment in Drug Courts

MAT IN DRUG COURTS:
RECOMMENDED STRATEGIES
March 9, 2017
NYS Association of Drug Treatment Court Professionals
Presented by:
Sally Friedman, Esq.
Legal Director
and
Kim Kozlowski, Regional Project Manager
Office of Policy and Planning
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WHO IS THE LEGAL ACTION CENTER?


National non-profit law firm.
Policy and legal work to end discrimination
against people with:
Substance use disorders,
 Criminal justice histories, or
 HIV/AIDS.


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Aim to expanding access to substance use
disorder treatment in the criminal justice
system and elsewhere.
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THIS PRESENTATION IS ABOUT . . .
Recommended strategies for use of MedicationAssisted Treatment (MAT) in drug courts.
Based on report produced with NYS Office of
Court Administration & Center for Court
Innovation (“the report”):
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HAND-OUT & RESOURCES
Hand-out
1. Medication-Assisted Treatment in Drug Courts:
Recommended Strategies. Available at:
lac.org/MAT-advocacy/ and
http://www.courtinnovation.org/.
Further resources
1. See Appendices in the Report for background
about MAT, including “Appendix E –Further
Resources”
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Cont…
.
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HAND-OUT & RESOURCES
2.
Legal Action Center MAT Advocacy
Toolkit lac.org/MAT-advocacy
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
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For patients:
 Advocating for Your Recovery When
Ordered Off MAT.
 Sample Treatment Provider Letter
Supporting MAT
For defense attorneys: Attorneys’ Guide:
Addiction Medication & Your Client.
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What we’ll Cover today
1.
2.
3.
4.
5.
6.
Context & Methodology for Report
Basic Facts About MAT
Nine Components of Successful MAT Programs
Special Issues for Rural Courts
Why Denial of MAT Can Violate AntiDiscrimination Laws
Discussion
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Part 1: Introduction
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Context & Methodology for the Report
WHY THIS REPORT?
Opioid epidemic. President, ONDCP & public
health officials calling for increased use of MAT.
 SAMHSA/DOJ mandates: drug courts must
allow MAT if get federal funds.
 More states passing laws (NY, NJ, IL).
 2014 US survey: about 50% courts prohibit MAT
 Similar issues with probation, parole, and child
welfare system. People who don’t/can’t taper off
are imprisoned and lose custody and visitation of
children (even permanent parental rights).

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WHY THIS REPORT?

2014 NY drug court trainings–some courts
were open to MAT, but had major questions
about logistics & practicalities:
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“Don’t have enough resources.”
“How to monitor?”
“How does court know when MAT is
appropriate?”
“How to overcome opposition of DA? Judge?”
“How will participant pay for MAT later?”
No resource existed – how do courts actually
do this effectively?
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METHODOLOGY

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Identified 10 NY courts that permitted all MAT
(no taper requirement, deferred to clinician) &
represented varied geography, demographics,
size, availability of MAT.
Interviewed all 10.
Chose 3 for in-depth profile – varied regions,
different types of MAT, demographics, size. Site
visits. Spoke to all stakeholders. Probed
challenges & strategies to overcome them.
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PART 2:
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Essential Facts
about MAT
WHAT IS MAT?
1.
Use of medication in combination with
counseling & behavioral therapies to treat
substance use disorders.
2.
Normalizes brain chemistry, blocks euphoric
effects of opioids, relieves cravings so people can
focus on recovery and not seek drugs all day.
3.
3 FDA-approved meds: methadone,
buprenorphine/naloxone (Suboxone), injectable
naltrexone (Vivitrol). See chart in App. A, p. 55.
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WHAT IS MAT?
Each MAT medication is different – not
interchangeable; all 3 aren’t right for everyone.
Choice of medication is a clinical decision.
Methadone & buprenorphine – opioid based;
withdrawal if stopped, but when properly dosed
and supervised, no high, no impaired function.
1.
Methadone – agonist, dispensed in Opioid
Treatment Program (OTP), usually liquid dose,
daily, supervised. Many services required.
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WHAT IS MAT?
2.
Buprenorphine –

partial agonist.

can be dispensed in OTP or provided by
physician who undergoes 8-hour training.

Available in private doctors offices OR
licensed treatment programs.

Usually taken as “strip.”

Cap of 275 patients (formerly, 100).

Implant (Probuphine) approved by FDA in
2016.
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WHAT IS MAT?
3.
Injectable naltrexone –
 not an opioid or controlled substance;
 does not produce physical dependence or
result in withdrawal;
 Injected monthly in physician’s office, OTP,
or other licensed treatment programs;
 Blocks effects of opioid/won’t get high.
 Must be off all opioids for 7-14 days first.
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MAT IS EFFECTIVE

Dozens of studies show MAT reduces drug use,
disease, overdose deaths and criminal behavior.
 National Institute on Drug Abuse (NIDA):
“All [MAT] medications help patients disengage
from drug seeking and related criminal
behavior and become more receptive to
behavioral treatments.” (See Myth & Fact sheet)
 Baltimore study: incarcerated people who
received medication plus counseling before
release were significantly less likely to use
heroin or engage in criminal activity than
those who received just counseling.
(Chandler, Fletcher & Volkow, Treating Drug Abuse and Addiction in the Criminal 17
Justice System, JAMA Jan. 14, 2009, Vol 301, No.2 at p. 184.)
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Cont…
MAT IS EFFECTIVE

Research shows that MAT patients experience
dramatic improvements while in treatment and for
several years following, including decreases in
narcotic use, drug dealing, and other criminal
behavior as well as increases in marriage and
employment.
(NIDA Int’l Program, Methadone Research Web Guide, Part B-20 Questions
and Answers regarding Methadone Maintenance Treatment research, Part B,
B-1 (2018), available at www.drugabuse.gov/sites/default/files/pdf/partb.pdf.
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MAT IS EFFECTIVE
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No comparable scientific studies for treatment of
opioid addiction without medication.
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MAT is not appropriate for all. Treatment mode
should be individualized, clinical decision.

No medical/scientific basis for requiring people
to stop MAT or change dose against physician’s
recommendation.

See pages 9-10 of report for citations.
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MAT IS EFFECTIVE

Common misperceptions –
 Substituting one addiction for another; crutch;
not true recovery;
 Lower dose is better;
 Short-term MAT is better than long term.
See pages 9-11 of report and Myths & Facts
Sheet (App. C).
 Will discuss each of these misperceptions….

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MAT IS EFFECTIVE
1.
Substitutes one addiction for another? No.
 Physical dependence created by methadone and
buprenorphine (not naltrexone) is not addiction.
 When properly prescribed and taken, MAT
medications address cravings and physical
responses so people can focus on counseling and
work necessary for recovery. MAT helps patients
disengage from drug-seeking behavior and crime
and become more receptive to behavioral
treatment. Similar to medications taken daily
to treat other chronic conditions.
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MAT IS EFFECTIVE
2.
Is a lower dose preferable?
 No. Choice of medication and dosage are
individualized, clinical determinations.
No one-size-fits-all approach.
 Dose of methadone/buprenorphine
determined during stabilization period and
are calibrated to individual’s medical and
physiological needs. For injectable
naltrexone, standard dose.
 Judges are not qualified to make medical
decisions.
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MAT IS EFFECTIVE
3. Should MAT be short-term? No. SAMHSA
recommends 3 phases:
1. Stabilization – withdrawal management, assessment,
medication induction, counseling
2. Middle phase – medication maintenance and deeper
counseling
3. Ongoing rehabilitation – provider and patient can
choose to taper off medication or pursue long-term
maintenance, depending on patient’s need.
Studies: longer term MAT  less illicit drug use.
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Mady Chalk, et. al., Treatment Research Institute, FDA Approved Medications for the Treatment of Opiate Dependence: Literature Reviews on Effectiveness
and Cost-Effectiveness, 2013, at pp. 8, 11, 24-25available at http://www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addictiontreatment_final.
HARM OF FORCED TAPER

Studies show: forced taper increases risk of
relapse & death. Because opioid tolerance fades
rapidly, one episode of opioid misuse after
withdrawal can result in life-threatening or
deadly overdose. (See ONDCP, Medication-Assisted
Treatment for Opioid Addiction, Sept. 2012).
SAMHSA recommends: never coerce taper.
 Tapering off MAT is not a question of “will” or
“moral courage.”
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PART 3:
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Nine Components of
Successful MAT
Programs
KEY FINDINGS: NINE COMPONENTS OF
SUCCESSFUL MAT PROGRAMS
1.
Counseling and other services – plus
medication – are essential.
All 10 programs required counseling and all wraparound services required of other participants (e.g.
employment, medical housing, child care).
Counseling decreases as patient progresses &
eventually completes it.
 Addresses common concern about MAT – no
counseling; substituting addiction.
 Medications often continue when graduate from
counseling.
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NINE COMPONENTS
MAT PROGRAMS
OF SUCCESSFUL
Courts are selective about treatment
programs & prescribing doctors.
2.
Assessment for all court participants is performed by
designated licensed treatment program.
 MAT – provided by licensed program, usually on courtprovided list (more later about courts’ criteria)
 Exception – when licensed program reaches
buprenorphine cap, some permit participants to receive
buprenorphine from private doctor (approved by court)
but also must get counseling from licensed program.
This may be less of an issue with increased cap.
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Cont…
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NINE COMPONENTS
MAT PROGRAMS
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OF SUCCESSFUL
The court, not participant, chooses MAT
provider – as they do for all types of treatment.
Courts discontinue use of programs and doctors
who do not meet court’s requirements.
Requirements?
1.
Reliable communication,
2.
Monitoring & follow-through,
3.
Quality therapeutic relationship.
4.
For office-based physicians, appropriate
clinical standards (examine patient; urine
testing). No “cash only” doctors.
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NINE COMPONENTS
MAT PROGRAMS
3.
OF SUCCESSFUL
Courts develop strong relationships with
treatment programs & require regular
communication.
 Trust and communication = fundamental
baseline. If programs don’t communicate
sufficiently, courts discontinue using them.
 Licensed programs are seen as more reliable
communicators than private doctors.
 More about this in #7 (monitoring)
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NINE COMPONENTS
MAT PROGRAMS
4.
OF SUCCESSFUL
Screening and assessment must consider all
clinically appropriate forms of treatment.
Court staff do initial screening, but
 Refer to programs (on chosen list) for complete
assessment. Assessor must be open to all clinically
appropriate modalities, including MAT.

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NINE COMPONENTS
MAT PROGRAMS
5.
OF SUCCESSFUL
Judges rely heavily on clinical judgment of
treatment providers and court’s clinical
staff.
 Judges believe decision-making should be
evidence-based, made by clinicians.
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NINE COMPONENTS
MAT PROGRAMS
7.
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OF SUCCESSFUL
Monitoring for illicit use of MAT medication
is critical. There are different ways to do it.
 Concerns about how to monitor for illicit use of
MAT meds is often cited as great obstacle.
 Common theme of 10 courts interviewed: do it
the same way it’s done for other illicit drugs,
with few modifications. Must do it well.
Cont…
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NINE COMPONENTS
MAT PROGRAMS
OF SUCCESSFUL
Common themes:
 Injectable naltrexone – easiest to monitor because
doctor gives shot and no street value/use. But rarely
used yet.
 Methadone also easy to monitor –don’t take it home;
observed at clinic. Most methadone sold on street
was prescribed for pain, not addiction.
 Buprenorphine – greatest diversion potential, but
can keep it under control. Participants often report
illicit use of buprenorphine before entered drug
court. Illicit use decreased once enrolled in MAT.
Lack of access to MAT drives diversion.
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Cont…
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NINE COMPONENTS
MAT PROGRAMS
OF SUCCESSFUL
Monitoring strategies:
A. Urine testing – by court/probation and
program – Unpredictable timing preferred.
Courts that think programs do not do it well
enough do more of it themselves.
B. Pill & strip counting (buprenorphine only).
C. Behavioral observation – by program and
court team. Consider appearance, behavior,
truthfulness, info from other participants. As
essential as other methods.
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Cont…
NINE COMPONENTS
MAT PROGRAMS
D.
Communication with treatment programs.
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OF SUCCESSFUL
Regular and honest communication is essential.
Multiple forms of communication – email, phone, court
appearances, meetings, written reports.
Need early, problem-solving approach.
Quantity of communication depends on participant
progress and stage (more communication early & when
struggling)
Swiftly address communication lapse, e.g., “cc’ing” clinical
director, urging participant to talk to program.
Discontinue referrals if inadequate communication.
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NINE COMPONENTS
MAT PROGRAMS
8.
MAT medications are covered through
government and/or private insurance.
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OF SUCCESSFUL
MAT coverage is essential. Varies from state to state.
ACA and federal parity law are changing the landscape –
more MAT is being covered.
Can be challenge when participants start working, if lose
Medicaid. Courts assisted in finding other payment
options.
Cost of MAT varies from type to type and location to
location.
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NINE COMPONENTS
MAT PROGRAMS
9.
OF SUCCESSFUL
MAT operates very similarly to other kinds
of treatment.

Don’t do things very differently for MAT than other
participants.

Main differences for MAT: getting players on board;
potential tweaks in urine testing (some courts test all
participants for MAT meds; some don’t) and pill/strip
counting (some courts do it; some don’t).
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PART 4:
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Special Issues for Rural
Programs
CHALLENGES FOR RURAL COURTS
Challenge: Scarcity of treatment, great
distances and limited transportation.

Strategy:
• Heavier reliance on buprenorphine, ideally
from same outpatient program other
participants use. Using one program for meds
and other services also helps participants with
medi-cab reimbursement.
• Private doctors permitted where no other
option. One court permits only after program
graduation. Other restrictions (i.e., no “cash
only” doctors).
Cont…
.
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CHALLENGES FOR RURAL COURTS
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Injectable naltrexone will be more logistically
feasible as it becomes more available. Only
once/month.
Use small-town relationships to urge
treatment programs to provide MAT.
Challenge: Smaller court staff.

Strategy:
• Rely more on program and probation for
monitoring.
• Small-town relationship can foster better
communication between court and program.

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PART 5: WHY DENIAL OF
ACCESS TO MAT
CAN VIOLATE ANTIDISCRIMINATION LAWS
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WHAT IS DISCRIMINATION?
•

Americans with Disabilities Act (ADA)
prohibits states & local governments – including
courts – from discriminating based on disability.
Purpose: require –
fair
treatment of individuals with disabilities;
individualized
objective
evaluation; and
evidence; prohibit decision making based
on myths, generalizations, & outdated stereotypes.
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WHAT IS DISCRIMINATION?
•
“Discrimination” includes:
1.
2.
3.
Disparate treatment: Treating people
differently because of disability, not based
objective medical/scientific evidence
Disparate impact: Eligibility criteria that
screen out individuals with disabilities or
disproportionately affect them,
Failure to make reasonable modifications
of policies referenced in #2.
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WHAT IS DISCRIMINATION?
•
•
•
Courts that prohibit MAT or set arbitrary
dose/duration limits can violate ADA. Why?
Opioid addiction is considered a “disability”
under well-established case law.
Such policies/practices:
1. Treat opioid-addicted people differently than
others; only prohibit their prescribed
medication; no legitimate scientific basis,
individualized consideration, or other
purpose essential to the program;
2. Screen out people with opioid addiction who
need MAT without required justification.
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WHAT IS DISCRIMINATION?
•
Many drug court participants lack financial
means to bring these challenges, but courts
that prohibit MAT may face them.
•
Can be raised on appeal in some cases.
•
Read Legality of Denying Access to MedicationAssisted Treatment in the Criminal Justice
System, available at www.lac.org/MATadvocacy.
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PART 6: DISCUSSION
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What do you think?
DISCUSSION – YOUR EXPERIENCE
Challenges implementing MAT in drug courts
 Strategies (i) used and (ii) might try.
 How might you use the new report to facilitate
MAT in your state’s drug courts?

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THANK YOU!
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Prepared by the Legal Action Center