One of the tendencies people have when combating a problem is the tendency to over-correct. Rather than taking a moderate approach in the first place, they move from one extreme to another. Our drug and alcohol policy sometimes appears to be following that same tendency. Like the boom and bust of capitalism, we put cocaine in our soda and then switched to putting those who use the drug in jail. In the current climate, we have gone from drug companies and doctors promoting opioid painkillers as a life-saving innovation to defeat pain, to restricting the drugs we can use to combat addiction out of fear that it might contribute to the problem even more.

It is of course not an either/or proposition, yet we currently don’t place restrictions on opioid painkillers in the way that we restrict drugs used to treat those who are addicted to opioids. The fear is that if people have unlimited access to drugs like Suboxone they will abuse them rather than use them in recovery. Suboxone is a drug that can mimic some of the effects that opioids have on the brain in order to diminish cravings for and withdrawal from actual opioids. Addicts might also sell drugs like Suboxone to others. We’ve seen this happen with prescriptions for other drugs–in fact, it continues to be a major contributor to the opioid epidemic–so it is not surprising that this fear exists.

Some people will undoubtedly abuse access to Suboxone and drugs like it, the same way that some people abuse cough syrup, which is now restricted in many places. But do the potential abuses of Suboxone and other opioid addiction treatment drugs justify how we restrict them? Or are they such a necessary tool in combatting drug addiction that we should look for alternate means to prevent their abuse so more people can utilize them?

The Devil In the Details

To better understand restrictions on drugs like Suboxone we first need to understand exactly what these drugs do and how they can be dangerous.

When you take an opioid painkiller the drug activates the opioid receptors in the brain, which both blocks pain and creates the high associated with opioids. The more you take the less it becomes about reducing pain and the more it involves achieving that high. Eventually, the brain becomes accustomed to the opioid’s presence and you need more to get high, or even just to maintain normalcy and avoid withdrawal. Because of the way the body processes opioids, once you are chemically addicted to the drug you’ll never get rid of that reaction to it; your brain is permanently wired that way. Many people can and do quit using opioids and avoid addictive behaviors, but the inability to reset your brain chemistry to where it was originally is one of the things that makes opioid addiction particularly difficult to overcome.

Drugs that activate these opiate receptors in the brain are referred to as agonists. A full agonist opioid is a drug like heroin. An antagonist is a drug that attaches to the opiate receptors in the brain but does so without activating them, therefore blocking the opioid from attaching to those receptors. Antagonists, such as Naloxone, are typically used to reverse opioid overdoses and can have no opioid effect at all.

Why People are Uncomfortable With Suboxone

The trouble with Suboxone, in terms of getting skeptics’ approval to use it for addiction treatment, is that while it acts as an antagonist (it blocks opioids) it also acts as a partial agonist. Meaning that it works the same way an opioid does but to a lesser degree. So Suboxone will have some opioid effect–such as suppressing withdrawal symptoms and cravings for an addict–without providing a high.

It is the unique nature of drugs like Suboxone, which are both antagonists and partial agonists, that makes them so effective for the treatment of opioid addiction. They are able to deal with the symptoms of withdrawal and cravings that make addiction recovery so difficult as well as prevent addicts who relapse from getting the chemical rewards for their slip, which keeps that behavior from reinforcing the addiction. But it has led some to argue that giving Suboxone treatment to addicts is simply replacing one addiction with another. This same rationale is what limits maintenance treatment in drug courts, which you can read more about here. It’s an understanding of addiction that focuses on willpower and personal responsibility–which are important elements in combating addiction–but doesn’t give full credit to the best practices determined by the science of how certain drugs affect the body.

This video introduces some of the reasons–from the perspective of an addict and from medical professionals–why treatments with drugs like Suboxone are so effective.

Why Suboxone?

In fact, using partial agonists like Suboxone in treatment isn’t just one effective treatment option, it is the most effective treatment option. Opioid addicts who use the more common rehabilitation model of a 12-step Narcotics Anonymous style program without using opioid replacement medications are twice as likely to have a fatal overdose compared with addicts who use these medications. There have also been numerous studies that show that using these medications leads to other improvements in quality of life and reduces HIV transmission.

This is not to say that psychological treatments and communal supports such as Narcotics Anonymous are not a key component to addiction recovery. But they are often not enough to help most opioid addicts. Most opioid addicts would benefit from access to medications as well. This is like treating a cardiac condition by reducing stress through yoga and getting a pet. Both of those things are treatments that can help in your recovery but are part of a more complex treatment plan that includes other lifestyle changes and medication. A drug addiction recovery plan that dismisses medication as a potential tool is, according to many medical professionals, as unethical as a treatment plan for heart disease that ignores medication.

Regulations and Restrictions

Because of the fear that addicts will personally abuse or sell Suboxone and other partial agonists, federal regulations restrict the amounts that doctors can prescribe. In their first year practicing, doctors can treat 30 patients, and in subsequent years, they can treat 100 patients. This may seem like a lot, but in communities with thousands of addicts needing treatment and few doctors, these restrictions can prevent many people from getting these medications. Senators Ed Markey and Rand Paul introduced a bipartisan bill last year, known as The Recovery Enhancement for Addiction Treatment Act, which would allow nurse practitioners and assistants to administer these drugs, raise the first year cap from 30 patients to 100, and create a pathway for certain doctors to eliminate the patient cap altogether after their first year.

Recently the TREAT Act passed through the HELP Committee (Health, Education, Labor and Pensions). In the video below, Senator Rand Paul gives a brief explanation of why he is promoting this policy change:

Restrictions on Suboxone reduce its supply, and therefore, curtail its potential for abuse. But since there is no similar restriction on the amount of painkillers that doctors can prescribe–which is a huge contributing factor to the massive increase in opioid addiction and the sale of opioids–it makes little sense to restrict Suboxone. The use of Suboxone and other partial agonists won’t actually produce a high for an addict so there is less incentive for an addict to try to obtain Suboxone illegally when he or she could try to get full agonists and get high.

There are some drugs that can be used to replace opioids that produce similar euphoric effects, in a lesser quantity, but not all of them do. At best, the use of Suboxone will prevent withdrawal symptoms and block a full opioid from taking effect, which is exactly why they are helpful to addicts trying to quit their addiction. So while they could be misused and sold, their misuse isn’t damaging in the same way that misusing a prescription for Vicodin would be.

A better strategy for curtailing drug abuse would be to regulate the amount of full agonists that can be prescribed; if we are going to regulate anything. But this regulation would run into some of the same concerns that the current regulations for Suboxone do. Rather than encouraging or requiring proper training for those who are allowed to prescribe these drugs, regulations place a one-size-fits-all rule in every community. There may be some doctors in areas that have more patients in real need of opiates, just as there are communities where the demand for Suboxone has far outstripped doctors’ ability to provide treatment. Like the current regulation of Suboxone, regulations for painkillers would also reduce the supply of the drugs–but placing restrictions that are too harsh on painkillers reduces everyone’s ability to get them–even those who legitimately need them.

Conclusion 

Regulations on drugs like Suboxone are an understandable reaction to a situation that has many lawmakers panicked. If the supply of drugs is causing a problem, then cracking down on the supply of drugs seems like the solution. The idea that the answer to bad drugs may be MORE drugs seems counterintuitive. And it is a tough sell in a culture that has been trained to treat addiction more like a psychological or spiritual dilemma than a medical one.

But drug addiction is a complex problem with psychological and medical components. Ignoring either of those elements makes combating addiction much more difficult and places more barriers in front of those in recovery. Changes in policy that allow patients to get individualized treatment for their illness, versus hoping you win the Suboxone lottery, will ultimately lead to better outcomes. Doctors do need appropriate training to deal with the specific issues involving opioid addiction. The medical profession has much to answer for when it comes to the promotion and prescription of unnecessary painkillers. But throwing the baby out with the bathwater and restricting their ability to prescribe effective treatment just because they had a hand in causing the disease is not effective.

Resources

The Washington Post: Getting Pain Killers Is Easy. Getting Help For Pain Killer Addiction Is Hard

The Huffington Post: Senate Bill Would Dramatically Alter Treatment For Heroin Addiction

Senator Edward Markey: TREAT Act One-Pager

The Daily Beast: Why Drug Rehab Is Outdated, Expensive and Deadly

Serenity Recovery: Kentucky Just Passed A New Law To Help Addicts

WJHL: New Tennessee Law Puts Restrictions on Suboxone, Subutex Prescribing

NAABT: What’s This Agonist/Antagonist Stuff?

PEWCharitableTrusts: States, CDC Seek Limits On Painkiller Prescribing

Mary Kate Leahy

Mary Kate Leahy (@marykate_leahy) has a J.D. from William and Mary and a Bachelor’s in Political Science from Manhattanville College. She is also a proud graduate of Woodlands Academy of the Sacred Heart. She enjoys spending her time with her kuvasz, Finn, and tackling a never-ending list of projects. Contact Mary Kate at staff@LawStreetMedia.com

The post Suboxone Restrictions: Is it Possible to Fight Fire with Fire? appeared first on Law Street.

As of 2015, there were 2,800 drug courts in the United States and they were working with 120,000 defendants per year. The idea behind these courts is to use the criminal justice system to compel addicts to rehabilitate themselves. The ultimate goal is to reduce recidivism for drug use and the other crimes that often accompany drug addiction. In order to do this, drug courts use both a carrot and a stick approach with addicts. Courts promise to reduce or eliminate jail time in exchange for the successful completion of a drug treatment program–hopefully saving money for taxpayers along the way.

The first drug court program was started in 1989 and represented a very different approach to dealing with drug crimes. A traditional criminal justice approach is for the court to only analyze if the state has proved that the defendant committed the crime and then to sentence him or her. Drug courts are an attempt to cure the underlying cause of these crimes in the first place, based on a better understanding of the nature of addiction. Drugs were increasingly being viewed as a public health crisis and not an individual moral failing. Traditional criminal justice approaches can do nothing to combat that kind of problem and are not designed to take those factors into consideration.

Drug courts were therefore built on the idea that the court is part of a team–including law enforcement, prosecutors, social workers, and the defendant–that is engaged in helping the defendant to stop using drugs and not commit future crimes. The judge in a drug court also takes on an active role in the defendant’s treatment. This engagement by the court is actually a key factor in the lives of defendants where drug courts have proven successful. At the very least, drug courts represent a judicial system that is trying to adapt to our evolving knowledge about drug addiction and the best ways to combat it.

But drug courts may not be as enlightened a solution to the problem of drug addiction as they seem at first blush. There are serious concerns about the scope of drug courts in terms of who can participate, the role of judges, and the rights that defendants give up in order to be a part of this process. There are also questions about the efficacy of these programs and whether the same goals could be accomplished through different means.

How Do Drug Courts Work?

Drug courts actually come in two main varieties, which is a nuance that is sometimes lost in the debate–deferred prosecution, and post-adjudication. In the deferred prosecution model (sometimes referred to as a “diversion” model), defendants are sent to a rehabilitative program or are given a set of guidelines before they are prosecuted. If they successfully complete their program the charges are dropped. In contrast, the post-adjudication model requires that the defendants plead guilty to the charges they face and are then sent to a drug program. If they complete the program successfully the sentence will be waived and the record potentially expunged.

This may not seem like an important difference if, after a drug program is completed, the defendant avoids jail time in both cases. But it is a very important difference for defendants who don’t successfully complete their programs. This is because in a deferred prosecution model the defendant goes back to the beginning of the process and still retains their right to plea bargain or plead not guilty and receive a jury trial. For defendants with a weak case against them or sympathetic facts, that can be significant. The defendant in a post-adjudication model drug court goes right to the sentencing phase of their trial–because in order to participate in the program a defendant must first plead guilty.

In this short video, Mae Quinn, the co-director of the Civil Justice Clinic at Washington University in St. Louis, discusses drug courts and her experience working in one of the earliest ones in the 1990s.

Concerns about Drug Courts

Quinn’s video presents us with several concerns about drug courts that should be unpacked. The first concern is one that could be viewed as both a blessing and a curse. In drug courts, judicial involvement with the defendant is much more intimate than it is in a traditional court setting. Judges are less like the neutral arbitrators of a normal court proceeding. Instead, they are as Quinn suggests, part of a “team” of people–which includes the defendant–who are working on the defendant’s sobriety. This could be of enormous benefit to drug users. And, in fact, the research suggests that one of the main indicators of success for a defendant in a drug court program is the level of involvement that a judge has in the process.

One study found a startling difference between defendants who were required to attend biweekly hearings with the judge in their case and those who only attended hearings on an “as-needed” basis. In the former group, 80 percent of participants graduated (completed the program) and in the latter group, only 20 percent of participants did so. Both groups involved high-risk drug court participants, meaning participants who had previously failed treatment.

One of the criticisms of drug courts is that the people who need them the most often don’t have access to them. Federal grants to establish these courts, which are still managed on the state or local level, make excluding violent offenders a pre-requisite to taking grant money. These courts also tend to restrict access to drug court programs for addicts who have long criminal records or histories of failure. Placement in a treatment program can also be difficult to get, with long wait times before entering into a program. Since placement in a program within 30 days is one of the strongest predictors of a successful outcome, these wait times have a negative impact on the success of drug courts, especially for women who have to wait twice as long for an available spot in a treatment program.

As Professor Quinn discusses in the video, defendants sometimes receive a longer sentence than they otherwise would have if they participate in a drug court program and fail–sometimes two to five times the length of the prison term they would otherwise have received. Since “flash incarcerations,” or short prison stays, are also one of the sanctions available to judges they may also spend more time in jail even if they have the charges dropped after graduating from the program and therefore face no sentence for their initial crime. Drug courts may also encourage law enforcement officials to arrest more low-level drug offenders since they view drug courts as a better means of processing them, which puts additional stress on the system and exacerbates some of these concerns.

Yet there is evidence that for some individuals these programs can be very effective. Take a look at this Ted Talk by Judge David Ashworth, who is the presiding judge of the Lancaster County Drug Court.

Measuring Results

The courts that Judge Ashworth describes may be different from the “typical” drug court because they are controlled at the state and local level and can vary widely. For example, Judge Ashworth’s court specifically targets “high risk” drug users. Participation is also voluntary and is designed, by his own admission, for people who already want to get clean. It is, however, a post-adjudication style court, meaning that the defendant pleads guilty as the first step in their drug court process.

The statistics he cites suggest that the drug court of Lancaster County has been particularly successful for those who graduate, reducing recidivism rates to below those of the national average. But not all of the participants in drug courts end up graduating from the program. Most of the pro-drug court data out there is written in terms of how much recidivism is reduced among graduates, but may not include the number of initial participants who enter the program in the first place.

Critics claim that this can lead to an overly positive picture of the impact of drug courts, particularly in jurisdictions that cherry-pick data. Jurisdictions are forced to exclude many types of potential defendants, most notably anyone who has committed a violent crime, in order to receive federal funding. One study indicated that, because of the eligibility restrictions, only 7 percent of the 1.5 million arrested for drug offenses were eligible to participate. Only half of the initial participants in most drug court programs end up graduating. A study of New York’s drug courts by the Urban Institute and the Center for Court Innovation found that for those who participated in drug courts, 64 percent of the non-graduates were re-arrested within three years, versus 36 percent of the graduates. But of those who were arrested but did not participate in a drug court, only 44 percent were re-arrested in the same period. So defendants were actually more likely to be re-arrested if they went to drug court and failed to complete the program than if they had gone through the normal court process in the first place.

One of the most significant issues with drug courts that Judge Ashworth did not address is the issue of maintenance treatment. Maintenance treatment, which involves using drugs like methadone to treat opioid addiction, is by far the most effective means of treatment–reducing the risk of death by 66 to 75 percent. But a third of drug courts will not allow it.

Drug courts vary widely in different localities, just as their effectiveness varies widely based on the kinds of judges serving on them. That can be positive in that it allows jurisdictions to experiment with different methods of operation. However in jurisdictions where those experiments are unsuccessful, it can lead to tragic outcomes and the judges involved in drug courts may not be specially trained in the science behind addiction, particularly opioid addiction. The increased flexibility of judges to deal with drug addicts in a drug court setting is only a positive if these judges are both eager to help the addicts in their court and properly educated on how to do so.

Conclusion

As a society, we have acknowledged that drug addiction, and the crimes that accompany it, are somehow different than other crimes; that it is as much a public health crisis as it is an issue of safety. Conservatives and liberals are both willing to seek innovations in how we deal with these individuals. Drug courts actually end up appealing to both sides of the aisle for various reasons.

The truth about drug courts is more complicated than it appears. These programs are not “hug-a-thug” initiatives, as Judge Ashworth points out. And while they may save money, they only do so when they keep people from seeing jail time at all, not when they just delay incarceration until after participants fail the program. The best elements of drug courts–judicial flexibility and interdisciplinary teams working with defendants–should be encouraged. In fact, these characteristics could be beneficial in other parts of the justice system as well, even for violent offenses. But the negative aspects need to be addressed. Defendants should not be coerced into pleading guilty to participate in treatment. Access to rehabilitation should be opened up to more cases, not just the “easy” ones that make drug courts look better, access should be increased for female offenders, and maintenance treatment for opioid addiction needs to be addressed.

Resources

The Sentencing Project: Drug Courts: A Review of the Evidence

Pacific Standard: How America Overdosed On Drug Courts

SADO: Michigan State Appellate Defender Office

WhiteHouse.gov: Drug Courts Fact Sheet

TribLive: Westmoreland District Courts First in PA to Offer Drug Treatment in Lieu of Punishment

National Institute of Justice: Drug Courts

U.S. Department of Justice: Drug Courts

DrugWarFacts.org: Drug Courts

Atlanta Journal-Constitution: Pro & Con: Drug Courts An Effective Alternative For Offenders?

Open Society Foundation: Drug Courts Are Not The Answer

Mary Kate Leahy

Mary Kate Leahy (@marykate_leahy) has a J.D. from William and Mary and a Bachelor’s in Political Science from Manhattanville College. She is also a proud graduate of Woodlands Academy of the Sacred Heart. She enjoys spending her time with her kuvasz, Finn, and tackling a never-ending list of projects. Contact Mary Kate at staff@LawStreetMedia.com

The post Are Drug Courts the Answer For Addicts Who Commit Crimes? appeared first on Law Street.