Increasing Access to Medication-assisted Treatment for Opioid Addiction in Drug Courts and Correctional Facilities and Working Effectively With Family Courts and Child Protective Services – pdf
July 26, 2016
Douglas B. Marlowe, J.D., Ph.D.
Chief of Science, Policy & Law
National Association of Drug Court Professionals
Sarah Wakeman, M.D.
Substance Use Disorder Initiative
Massachusetts General Hospital
Josiah D. Rich, M.D., M.P.H.
Professor of Medicine and Epidemiology
Director of the Center for Prisoner Health and Human Rights
Pamela Peterson Baston, M.P.A., C.A.P., C.P.P
Solutions of Substance, Inc.
This is the third of three policy papers that the American Association for the Treatment of Opioid Dependence (AATOD) has developed for the Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. Department of Health and Human Services. The aim of these three policy papers is to provide a blueprint for more innovative and integrated service delivery for opioid treatment programs (OTPs) and authorized prescribers under the Drug Addiction Treatment Act of 2000 (DATA 2000), which primarily use buprenorphine to treat opioid addiction.
This paper describes opportunities for OTPs and authorized prescribers under DATA 2000 to work with drug courts, correctional facilities, probation and parole offices, and family courts and Child Protective Services (CPS). It provides effective strategies to achieve challenging goals at a time when opioid abuse and addiction has increased sharply throughout the United States.
Each of the three sections of this paper has an important focus. The first describes how OTPs and authorized prescribers under DATA 2000 can best engage drug courts. Doug Marlowe provides excellent examples of how to achieve this end result. He indicates in this section of the paper that the most effective way to garner support for medication-assisted treatment (MAT) is “to educate drug court team members about its use when a contentious case is not presently at issue.” Mr. Marlowe goes on to say that “OTPs and other MAT providers may find it necessary to engage in proactive outreach strategies to educate drug courts in their communities.” Harlan Matusow et al. (2013), who conducted a survey among drug court professionals, found that 56 percent of drug courts referred their participants to OTPs for MAT and 44 percent did not. The survey also found that only about half of the drug courts that did not offer MAT reported having a blanket policy against MAT (Matusow et al., 2013).
To quote the Adult Drug Court Best Practice Standards, from the National Association of Drug Court Professionals (2013):
“Numerous controlled studies have reported significantly better outcomes when addicted offenders receive medically assisted treatments including opioid agonist medications such as Naltrexone, opioid antagonists such as methadone, and partial agonist medications such as buprenorphine. Therefore, a valid prescription for such medications should not serve as the basis for a blanket exclusion from a drug court.”
The point of including Doug Marlowe’s section, with recommendations on how OTPs and DATA 2000 practices can better engage and educate drug courts in the United States, is to break through the existing isolation which prevents drug court participants from gaining better access to the three federally approved medications to treat opioid addiction (methadone, buprenorphine, and combination naltrexone products). This is especially critical in an era of increasing opioid addiction, which has been repeatedly reported by federal agencies and professional journals for many years. The National Institute on Drug Abuse (2012) has established that MAT “increases patient retention and decreases drug use, infectious disease transmission, and criminal activity.”
The second section of this paper provides recommendations to OTPs and authorized prescribers under DATA 2000 about methods of improving access to pharmacotherapy for opioid use disorders within the criminal justice system. Many studies have pointed to the need to increase access to MAT for opioid addiction when people are under legal supervision. In fact, a key recommendation from the National Institutes of Health (1997) indicated that “all opioid dependant persons under legal supervision should have access to methadone maintenance therapy.” Though this recommendation was made in 1997, few correctional facilities in the United States have provided access to such care. In this section of the paper, Drs. Sarah Wakeman and Jody Rich describe ways to work with U.S. correctional facilities to improve access to MAT. They focus on several models that exist at the present time, including having OTPs delivering medication to correctional settings and, alternatively, locating the OTP within the correctional setting.
In its groundbreaking paper, Legality of Denying Access to Medication Assisted Treatment in the Criminal Justice System, the Legal Action Center (2011) makes the case very well:
An estimated 65% of individuals in United States’ prisons or jails have a substance abuse disorder, and a substantial number of these individuals are addicted to opioids. Rates are at least as high in all other phases of the criminal justice system. This enormous amount of substance use among individuals with criminal justice involvement has far reaching consequences, including higher recidivism rates, harm to families and children of criminal justice involved individuals, and negative public health effects, including the transmission of infectious diseases and overdose deaths…. Denial of access to MAT at any level of the criminal justice system violates the ADA [Americans with Disabilities Act] and the Rehabilitation Act where the denial is pursuant to a blanket policy prohibiting MAT or is carried out on a case by case basis without the required objective, individualized evaluation.
Federal agencies and state correctional entities need to develop arrangements so that people under legal supervision who are opioid addicted can get access to the three federally approved medications to treat opioid addiction in the United States. Drs. Wakeman and Rich make the point succinctly:
Among state prisoners with a drug use disorder in 2004, only 0.8 percent received detoxification services, 0.3 percent received maintenance pharmacotherapy, and 6.5 percent received counseling by a professional. According to the World Health Organization, incarcerated individuals should have access to the same treatments offered in the community, including opioid agonist therapy.
The third and final section of this paper focuses on how OTPs and DATA 2000 practices can work with Child Protective Services (CPS) and family courts. Pamela Peterson Baston makes a critical point: “Failure of the child welfare and SUD treatment system to work together to identify, assess, connect to, and stabilize in treatment, parents with children in out of home placement, results in fiscally and emotionally costly consequences including termination of parental rights.” The author provides excellent recommendations on how substance abuse treatment programs can work to educate representatives in CPS and family courts.
Ms. Peterson Baston makes another observation as well:
Cross-training is needed for all relevant parties in the opioid treatment and CPS sectors on how to timely identify and respond to parents with opioid use and other SUDs including the importance of MAT. New Jersey and Pennsylvania are in various stages of expanding and improving SUD training.
One final point, to preface the sections that follow, is provided by SAMHSA (2005) in its Treatment Improvement Protocol (TIP) 43, Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs:
Discussions about whether addiction or a medical disorder is a moral problem have a long history. For decades, studies have supported the view that opioid addiction is a medical disorder that can be treated effectively with medications administered under conditions consistent with their pharmacological efficacy, when treatment includes comprehensive services, such as psychosocial counseling, treatment for co-occurring disorders, medical services, vocational rehabilitative services, and case management services.