MAT in Drug Courts: Recommended Strategies

1. MAT in Drug Courts: Recommended Strategies March 9, 2017 NYS Association of Drug Treatment Court Professionals

2. Presented by: Sally Friedman, Esq. Legal Director and Kim Kozlowski, Regional Project Manager Office of Policy and Planning 2 2

3. 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. • Aim to expanding access to substance use disorder treatment in the criminal justice system and elsewhere. 3 3

4. This presentation is about . . . Recommended strategies for use of Medication-Assisted Treatment (MAT) in drug courts. Based on report produced with NYS Office of Court Administration & Center for Court Innovation (“the report”): 4 4

5. Hand-out & Resources Hand-out • Medication-Assisted Treatment in Drug Courts: Recommended Strategies. Available at: lac.org/MAT-advocacy/ and http://www.courtinnovation.org/. Further resources • See Appendices in the Report for background about MAT, including “Appendix E –Further Resources” Cont…. 5 5

6. Hand-out & Resources • Legal Action Center MAT Advocacy Toolkit lac.org/MAT-advocacy • For patients: • Advocating for Your Recovery When Ordered Off MAT. • Sample Treatment Provider Letter Supporting MAT • For defenseattorneys: Attorneys’ Guide: Addiction Medication & Your Client. 6 6

7. What we’ll Cover today • 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 Anti-Discrimination Laws • Discussion

8. Part 1: Introduction Context & Methodology for the Report

9. 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).

10. Why this report? • 2014 NY drug court trainings–some courts were open to MAT, but had major questions about logistics & practicalities: • “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?

11. Methodology • 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.

12. Part 2: Essential Facts about MAT

13. What is MAT? • Use of medication in combination with counseling & behavioral therapies to treat substance use disorders. • Normalizes brain chemistry, blocks euphoric effects of opioids, relieves cravings so people can focus on recovery and not seek drugs all day. • 3 FDA-approved meds: methadone, buprenorphine/naloxone (Suboxone), injectable naltrexone (Vivitrol). See chart in App. A, p. 55.

14. 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. • Methadone – agonist, dispensed in Opioid Treatment Program (OTP), usually liquid dose, daily, supervised. Many services required.

15. What is MAT? • 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.

16. What is MAT? • 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.

17. 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 Justice System, JAMA Jan. 14, 2009, Vol 301, No.2 at p. 184.) Cont…. 17 17

18. 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.

19. MAT is effective No comparable scientific studies for treatment of opioid addiction without medication. 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. 19 19

20. 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….

21. MAT is effective • 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.

22. MAT is effective • 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.

23. MAT is effective 3. Should MAT be short-term? No. SAMHSA recommends 3 phases: • Stabilization – withdrawal management, assessment, medication induction, counseling • Middle phase – medication maintenance and deeper counseling • 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. 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-addiction-treatment_final.

24. 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.”

25. Part 3: Nine Components of Successful MAT Programs

26. Key findings: Nine components of successful MAT programs Counseling and other services – plus medication – are essential. All 10 programs required counseling and all wrap-around 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. 26 26

27. Nine components of successful MAT programs Courts are selective about treatment programs & prescribing doctors. Assessment for all court participants is performed by designated licensed treatment program. MAT – provided by licensed program, usually on court-provided 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. Cont…. 27 27

28. Nine components of successful MAT programs 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? Reliable communication, Monitoring & follow-through, Quality therapeutic relationship. For office-based physicians, appropriate clinical standards (examine patient; urine testing). No “cash only” doctors. 28 28

29. Nine components of successful MAT programs 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) 29 29

30. Nine components of successful MAT programs 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. 30 30

31. Nine components of successful MAT programs 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. 31 31

32. Nine components of successful MAT programs 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…. 32 32

33. Nine components of successful MAT programs 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. Cont…. 33 33

34. Nine components of successful MAT programs Monitoring strategies: 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. Pill & strip counting (buprenorphine only). Behavioral observation – by program and court team. Consider appearance, behavior, truthfulness, info from other participants. As essential as other methods. Cont…. 34 34

35. Nine components of successful MAT programs Communication with treatment programs. 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. 35 35

36. Nine components of successful MAT programs MAT medications are covered through government and/or private insurance. 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. 36 36

37. Nine components of successful MAT programs 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). 37 37

38. Part 4: Special Issues for Rural Programs

39. 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….

40. Challenges for Rural Courts • 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.

41. Part 5: Why Denial of Access to MAT Can Violate Anti-Discrimination Laws

42. 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 evaluation; and • objective evidence; prohibit decision making based on myths, generalizations, & outdated stereotypes.

43. What is discrimination? • “Discrimination” includes: • 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.

44. 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: • 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; • Screen out people with opioid addiction who need MAT without required justification.

45. 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 Medication-Assisted Treatment in the Criminal Justice System, available at www.lac.org/MAT-advocacy.

46. Part 6: Discussion What do you think?

47. 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?

48. THANK YOU! Prepared by the Legal Action Center 48 48