Drug courts are promoted as a more humane alternative to incarceration for people who use drugs in the United States. But in our recent study, we found judges in New York were ordering patients to stop treatment with methadone or buprenorphine as a condition of participation in, or graduation from the drug court. This practice is unjust, ungrounded in medical evidence, and bad for patients and the public.
Methadone and buprenorphine are medicines prescribed to reduce cravings for and injection of heroin and other opioids. Medical evidence on opioid dependency shows that relapse to opioid use is generally the rule, rather than the exception, when people who are dependent on opioids stop taking them. This is especially true when they stop abruptly.
Drug courts are special non-adversarial courts that handle cases of people charged with offenses related to substance use. They have become a central part of drug policy in the United States. In 1989, there was a single drug court. As of June 2013, there are more than 2,700. The model is heavily promoted by the U.S. Office of National Drug Control Policy, and at least 15 countries now have drug courts along the lines of the U.S.
While, in theory, drug courts offer treatment as a pragmatic alternative to incarceration, few studies look at the workings of drug courts from the perspective of providers or patients. So, in 2011, we began interviewing opioid substitution treatment (OST) providers and patients in New York—one of the states most heavily committed to drug courts, with at least one in every county—to hear how they see the drug court experience with OST.
The results were varied, and showed that many courts do not respect medical consensus on scientifically sound treatment standards. Some courts included OST as part of court-mandated treatment options, while others allowed OST for a court-defined period of time as a bridge to abstinence. Still others showed intolerance and even disdain for anything having to do with methadone and buprenorphine, or—as with the drug court in Albany County—refused outright to admit people on methadone or buprenorphine treatment.
Ordering people who are dependent on opioids to get off their prescribed methadone or buprenorphine medicines can force patients to seek out and become dependent on other opioids like prescription analgesics. Addiction to prescription opioids has been recognized as a priority problem by U.S. policy-makers, but drug courts may be exacerbating it.
Extensive research since the 1960s has shown that maintenance treatment with methadone and buprenorphine is the most effective approach for reducing death, morbidity, criminal involvement, and other harms associated with opioid addiction. Both methadone and buprenorphine are included in the World Health Organization’s Model List of Essential Medicines, and are supported as the most effective treatment for opioid dependence by major U.S. health institutions including the National Institutes of Health, and National Institutes on Drug Abuse.
Forced “tapering” from methadone and buprenorphine, or blanket exclusion from these treatments, shows the danger of what happens when judges play doctor.
These are not just problems in the jurisdictions where we did interviews. In spite of the National Association of Drug Court Professionals’ strong policy statement on the benefits of methadone and buprenorphine maintenance treatment, a 2013 study by Matusow, et al. found a lack of uniformity of policies and arbitrary practices regarding OST within the U.S., and even within individual court districts.
Drug courts can be, as the Obama administration contends, a tool to improve national response to those with drug dependence. But, as our small study suggests, there is big gap between the theory and practice of referrals to drug treatment by these courts.
Judges often don’t know enough about addiction treatment to escape the same prejudices that affect other people, and they demand abstinence-only approaches even when better alternatives exist. Our research speaks not only to the need for greater education of judges and other decision-makers in the justice system about the long-proven efficacy of methadone and buprenorphine in the treatment of dependency on opioids, but also for greater commitment by policymakers to improve the availability of OST to all who need and want it.
We hope that this small study in New York will encourage further investigation of drug courts' practices regarding OST, and help to promote drug policies and practices centered on health and human rights, not on stigmatizing and ill-informed judgments.
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