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Medication-Assisted Treatment in Problem-solving Courts: A National Survey of State and Local Court Coordinators
Abstract
Problem-solving courts (PSCs) are a critical part of a societal effort to mitigate the opioid epidemic's devastating consequences. This paper reports on a national survey of PSCs (N = 42 state-wide court coordinators; N = 849 local court coordinators) and examines the structural factors that could explain the likelihood of a local PSC authorizing medication-assisted treatment (MAT) and MAT utilization. Results of the analyses indicate that MAT availability at the county level was a significant predictor of the likelihood of local courts authorizing MAT. The court's location in a Medicaid expansion state was also a significant predictor of local courts allowing buprenorphine and methadone, but not naltrexone. Problem-solving courts are in the early stages of supporting the use of medications, even when funding is available through Medicaid expansion policies. Adoption and use of treatment innovations like MAT are affected by coordinators' perceptions of MAT as well as structural factors such as the availability of the medications in the community and funding resources. The study has important implications for researchers, policymakers, and practitioners.
... Similar to other legal system efforts, drug courts tend to underutilize medications for opioid use disorders (Matusow et al., 2013). A recent study found that 86% of drug courts allowed participants to use medications but an average of only 14% of eligible drug court clients received medications (Farago' et al., 2023); this is consistent with findings by Smith et al. ...
... Another provider-related issue is the accessibility of providers to the clients. In a national survey of drug courts, it was noted that courts were more likely to have clients that use medications when a provider is local and accessible (Farago' et al., 2023). The lack of availability of providers in the local community impacted the court's willingness to recommend that clients take medications. ...
Background
Implementation science (IS) is an emerging discipline that offers frameworks, theories, measures, and interventions to understand both the effective organizational change processes and the contextual factors that affect how well an innovation operates in real-world settings.
Results
In this article, we present an overview of the basic concepts and methods of IS. We then present six studies where IS was used as a means to understand implementation of a new innovations designed to improve the health and well-being of individuals under criminal legal system supervision.
Conclusion
We discuss how IS has developed new knowledge on how to implement efficacious innovations and suggesting future research needed to further our understanding of implementation and sustainability of innovations in the legal context.
... The disconnect between the strong evidence in support of MOUDs and the underutilization of MOUDs is a perplexing issue, particularly within PSCs. As an example, from a prior article from this study, only 14% of court clients are actually receiving MOUDs (Faragó et al., 2023). This indicates a significant gap between best practice standards and current court practices. ...
Background. Overdose deaths in the United States (U.S.) surpassed 100,000 in 2021. Problem-solving courts (PSCs), which originally began as drug courts, divert people with nonviolent felonies and underlying social issues (e.g. opioid use disorders (OUDs)) from the carceral system to a community-based treatment court program. PSCs are operated by a collaborative court staff team including a judge that supervises PSC clients, local court coordinators that manage PSC operations, among other staff. Based on staff recommendations, medications for opioid use disorders (MOUDs) can be integrated into court clients’ treatment plans. MOUDs are an evidence-based treatment option. However, MOUDs remain widely underutilized within criminal justice settings partially due to negative perceptions of MOUDs held by staff. Objective. PSCs are an understudied justice setting where MOUD usage would be beneficial. This study sought to understand how court coordinators’ perceptions and attitudes about MOUDs influenced their uptake and utilization in PSCs. Methods. A nationally representative survey of 849 local and 42 state PSC coordinators in the U.S. was conducted to understand how coordinators’ perceptions influenced MOUD utilization. Results. Generally, court coordinators hold positive views of MOUDs, especially naltrexone. While state and local coordinators’ views do not differ greatly, their stronger attitudes align with different aspects of and issues in PSCs such as medication diversion (i.e. misuse). Conclusions. This study has implications for PSCs and their staff, treatment providers, and other community supervision staff (e.g. probation/parole officers, court staff) who can promote and encourage the use of MOUDs by clients.
... For example, a recent study surveyed state prisons in states with disproportionate opioid overdose mortality and found that while all prison systems within the states surveyed reported offering at least one medication to treat OUD, only 7% of the 538 individual prisons within the states offered all three medication types (methadone, buprenorphine and naltrexone); 61% of the 538 prisons did not offer any type of MOUD [72]. A recent study on medications used in a nationally representative same of 832 problem solving courts reported that while 86% of the courts would authorize the use of medications, only 14% of those with an opioid use disorder were on MOUD [20]. Other models employing evidence-based cognitivebehavioral treatment (CBT are in place, including in the Federal Bureau of Prisons' non-residential treatment program (a 12-week course for those serving short sentences and/or who are transitioning back to the community as part of their SUD treatment, Federal Bureau of Prisons, n.d.). ...
This manuscript is the product of the authors’ discussions, literature overview, and consultation with experts in the field, and identifies important gaps in the evidence base for substance use disorder (SUD) treatment effectiveness within criminal justice (CJ) settings. Lacking from the extant literature are longitudinal investigations of treatment related outcomes during and after incarceration. Such studies could provide rich contextual data about treatment delivery and effectiveness across the CJ continuum, and would provide important insight into individual characteristics (e.g., motivation, treatment modality preferences, treatment completion rates, etc.) as well as institutional and environmental factors (e.g., appropriate staffing, space limitations for individual treatment sessions, distribution of medications, etc.). We also identified the importance of reproducibility within CJ research, and the unfortunate reality of too many single studies conducted in single (or relatively few) correctional facilities. Some of this has been because the studies designed to produce that evidence are not prioritized for funding, which has continually placed researchers in a position where we cannot make firm conclusions or recommendations based on available evidence. The importance of replicating the foundational studies in this field cannot be overstated. We hope this article spurs other researchers to join in the healthy process of questioning the existing state of the CJ-based SUD treatment research, what should be re-examined, and how we can lay a stronger foundation for the future.
Importance
Many of the approximately 2 million people being held in US correctional facilities are experiencing an opioid use disorder (OUD). Providing medications for OUD (MOUD) to this population is, therefore, essential to curb the opioid crisis.
Objective
To examine the types of MOUD jails are making available, factors associated with availability, and additional supports needed for jails to address implementation challenges.
Design, Setting, and Participants
This survey study used a cross-sectional survey of jails conducted between February 2 and July 1, 2023, to explore how they administer MOUD. Publicly available county-level data were connected with the survey responses to assess how variables in the surrounding community were associated with MOUD availability. The survey was administered to jails via mail, telephone, and online survey link. Participants included jails with MOUD available that completed the survey.
Exposures
Urbanization, average daily population, availability of a health care professional to administer MOUD, whether the state expanded Medicaid, average drive time to MOUD in the county, county overdose rate, and county social vulnerability were assessed.
Main Outcomes and Measures
The primary outcome was the type of MOUD available in the jail, including buprenorphine, methadone, or naltrexone, or all 3 medications. Binary logistic regressions were conducted to identify the characteristics of jails and county-level factors associated with offering the medications.
Results
A total of 462 jails were invited to complete the survey based on responses to a previous nationally representative survey of jails, in which they indicated that MOUD was available to individuals in their facility. A total of 265 US jails with MOUD available were included in the analysis, representative of 1243 jails nationwide with MOUD available after weighting (812 jails [65.3%] provided buprenorphine, 646 jails [52.0%] provided naltrexone, 560 jails [45.0%] provided methadone, and 343 jails [27.6%] provided all 3 medications). Availability was associated with urbanicity, location in a Medicaid expansion state, county opioid overdose rate, and county social vulnerability. Common challenges included jail policies and procedures and the logistical accessibility of the medication.
Conclusions and Relevance
The findings of this survey study of US jails demonstrate that jails with MOUD available still experience challenges with making all 3 types of medication available to anyone held within their facility. Policy, regulatory, financing, staffing, and educational solutions are needed to ensure that all detainees with OUD have access to treatment while incarcerated.
Objectives
Programs to increase linkage to medications for opioid use disorder (MOUD) through peer recovery coaches may hold promise in increasing MOUD initiation. However, the impact of linkage programs may vary based on contextual factors, such as the implementation setting. This study examines whether implementation setting is associated with MOUD initiation following participation in peer-based linkage programs.
Methods
The University of Kentucky and Voices of Hope Lexington, a recovery community organization, trained recovery coaches to implement a MOUD linkage program. Coaches were deployed in 9 criminal-legal organizations (ie, jails, specialty court, and pretrial services) and 20 community organizations in 4 rural and 4 urban counties. Coaches worked with participants (n = 754) to set person-centered goals, provided MOUD education, addressed MOUD initiation barriers, and assisted with scheduling appointments. A typology of implementation setting categorized participants by where they enrolled in the linkage program: (1) urban community organizations (reference group), (2) urban criminal-legal organizations, (3) rural community organizations, or (4) rural criminal-legal organizations. The odds of MOUD initiation were estimated using multivariate logistic regression.
Results
Of 754 participants, 23.1% (n = 174) reported initiating MOUD. Relative to urban community organizations, individuals enrolled in rural community organizations were more likely to initiate MOUD (odds ratio = 1.85, P = 0.04), whereas individuals enrolled in rural criminal-legal organizations were less likely to initiate MOUD (odds ratio = 0.34, P = 0.005).
Conclusions
Implementation setting may impact the likelihood of MOUD initiation through peer-based linkage programs. Future research should examine how implementation strategies might overcome setting-specific barriers to MOUD initiation, particularly in rural criminal-legal settings.
Research summary
Implementation science (IS) is an emerging field that is infrequently used in criminology and criminal justice. IS offers criminology and criminal justice new methods to describe and measure innovations, and new and rigorous research designs that include measuring the implementation of innovations, examining implementation or change strategies, and pursuing a myriad of implementation outcomes. Most important is that the emphasis is on the organizations and/or systems themselves, instead of a focus on individuals. A science of implementation will help to advance reform efforts in justice/legal organizations, whether the reforms are at the policy or practice level. Criminologists’ use of IS methods and techniques should enlarge our knowledge about “what works” to include answers to contextual questions regarding “what works under what circumstances” or “how does it works.” Further, IS can help identify the processes needed to ensure reform efforts are successful and to build capacity for long‐term change.
Policy implications
IS is a field that is growing in importance in medicine and health‐related disciplines and is relevant to criminology/criminal justice. Receptivity to reforming police, judicial, prosecutorial, institutional corrections, and community corrections organizations is typically met with a bit of a cold shoulder, often because researchers do not understand or address the operational issues that affect reform. Of particular importance is understanding which change procedures are useful for what types of reforms—an understudied and underappreciated feature of the implementation conundrum. Policy makers and practitioners will benefit from more information on effective change procedures. IS can be used to understand strategies to define innovations, to master change processes, to study implementation, and to expand outcomes to include organizational and system measures to benefit all stakeholders.
Importance
In 2023, more than 80 000 individuals died from an overdose involving opioids. With almost two-thirds of the US jail population experiencing a substance use disorder, jails present a key opportunity for providing lifesaving treatments, such as medications for opioid use disorder (MOUD).
Objectives
To examine the prevalence of MOUD in US jails and the association of jail- and county-level factors with MOUD prevalence using a national sample.
Design, Setting, and Participants
This survey study used a nationally representative cross-sectional survey querying 1028 jails from June 2022 to April 2023 on their provision of substance use disorder treatment services. The survey was conducted via mail, phone, and the internet. County-level data were linked to survey data, and binary logistic regressions were conducted to assess the probability that a jail offered any treatment and MOUD. A stratified random sample of 2791 jails identified by federal lists of all jails in the US was invited to participate. Staff members knowledgeable about substance use disorder services available in the jail completed the survey.
Exposures
US Census region, urbanicity, jail size, jail health care model (direct employees or contracted), county opioid overdose rate, county social vulnerability (measured using the Centers for Disease Control and Prevention 2020 Social Vulnerability Index summary ranking, which ranks counties based on 16 social factors), and access to treatment in the county were assessed.
Main Outcomes and Measures
Availability of any type of substance use disorder treatment (eg, self-help meetings), availability of MOUD (ie, buprenorphine, methadone, and naltrexone) to at least some individuals, and availability of MOUD to any individual with an OUD were assessed.
Results
Of 2791 invited jails, 1028 jails participated (36.8% response rate). After merging the sample with county data, 927 jails were included in analysis, representative of 3157 jails nationally after weighting; most were from nonmetropolitan counties (1756 jails [55.6%; 95% CI, 52.3%-59.0%]) and had contracted health care services (1886 jails [59.7%; 95% CI, 56.5%-63.0%]); fewer than half of these jails (1383 jails [43.8%; 95% CI, 40.5%-47.1%]) offered MOUD to at least some individuals, and 405 jails (12.8%; 95% CI, 10.7% to 14.9%) offered MOUD to anyone with an OUD. Jails located in counties with lower social vulnerability (adjusted odds ratio per 1-percentile increase = 0.28; 95% CI, 0.19-0.40) and shorter mean distances to the nearest facility providing MOUD (adjusted odds ratio per 1-SD increase, 0.80; 95% CI, 0.72-0.88) were more likely to offer MOUD.
Conclusions and relevance
In this study, few jails indicated offering frontline treatments despite being well positioned to reach individuals with an OUD. These findings suggest that efforts and policies to increase MOUD availability in jails and the surrounding community may be associated with helping more individuals receive treatment.
Objective. Describe how navigator programs from three New England states (Connecticut, Maine, and Massachusetts) function to connect individuals using court services to community-based treatment and services. Hypothesis. Implementation science frameworks can be used to analyze how multiple court programs function to inform replication and address gaps in the use of overdose prevention strategies. Method. The Template for Intervention Description and Replication (TIDieR) Implementation informed semi-structured interviews as part of an exploratory mixed-methods analysis of court navigator programs. Analysis of interviews based on the TIDieR and administrative data on client contacts ( n = 436) were analyzed. A subsample of clients with additional background information ( n = 249) was used to examine court navigator recommendations. Results. The TIDieR revealed court navigator programs shared basic intervention characteristics but varied dramatically by resources and organization contexts. Nearly half (46.5%) of clients were self-referred and more than two-thirds (69.1%) approved follow-up but varied by program. Of those allowing follow-up, more than one-third (35.7%) had previously experienced an overdose. Court navigators were significantly more likely to refer clients with a history of overdose to locations where they can receive naloxone (the opioid overdose antidote) though only one program had naloxone on hand. Conclusion. Navigators are employed by community organizations with access to courthouses to provide resources to those passing through. These efforts can be implemented to support linkages to treatment and services but there is a significant gap in the allocation of overdose prevention strategies in court settings and court navigator programs have the potential to address this unmet need.
Problem-solving courts (PSCs) are specialized courts offering evidence-based interventions for rehabilitating and diverting individuals from carceral institutions. PSCs allow participants to address problems influencing their behavior, such as mental health and/or substance use disorders, while remaining in the community under court supervision. PSCs are designed to serve as linkage sites to support services and research supports PSCs’ efficacy in doing so. Less is known about how PSC operations align with national best practices specified by All Rise (professional association of PSCs) in serving court participants. This study explores whether American PSCs adopt All Rise’s 10 best practice principles based on surveys from a larger study of PSC operations reported by local (n = 849) and state (n = 42) PSC coordinators. Of the All Rise principles captured in our study, only 4% of courts adopted eight EBPs whereas 56% of the courts adopted four to six EBPs. PSCs using EBPs employed diversified staff positions, collaborated with multiple treatment providers, participated in treatment trainings, offered peer navigators, used validated screening tools, used varied treatment modals, and had eligibility criteria for participants to enter PSC programs. PSCs’ operations were generally backed by some of All Rise’s best practices.
During the COVID-19 pandemic, problem-solving courts adopted virtual hearings. We conducted an online nationwide survey with a convenience sample of court staff to elicit their perceptions of court participants' attendance, engagement, willingness to talk, and ability to form connection with judges during in-person versus virtual hearings. Sign tests compared ordinal ratings for perceptions of court participant outcomes during in-person versus virtual hearing modalities, and for audiovisual technology versus audio-only technology. The final analysis included 146 staff. Staff felt that during in-person hearings judges could form closer relationships with participants, quality of information exchanged was higher, and participants were more willing to talk. Staff rated attendance as high regardless of the modality. Staff felt participant engagement was higher with audiovisual technology than audio-only technology. Our results suggest that staff have concerns about effects of virtual hearings on court participant engagement and ability to form relationships with judges. Courts should address these potential negative effects of virtual hearings. We are concerned that staff perceived participants more negatively when participants used audio-only versus audiovisual technology, because technology access could be associated with participant demographic characteristics. Further research is needed to examine court participant perceptions and outcomes.
Fewer than 1% of United States’ largest corrections facilities allow access to MOUD. The cascade of care is an organizing framework that quantifies treatment processes within and across systems of care ranging from screening to treatment discharge. This study highlights best practices for the implementation of MOUD across the cascade of care, addressing unique characteristics of legal settings and individuals within them. After reviewing best-practices for MOUD implementation in legal settings and examining jail and community provider’s use of and goals toward improving these practices, this study concludes that despite interest from agencies to improve care considerable variation remains in treatment availability between agencies and within agencies at different stages of incarceration. Seamless systems of care require multiagency collaboration, staff and provider competency, and patient awareness of MOUD. These strategies will decrease punishment-oriented ideologies surrounding MOUD application in justice settings and improve access to resources that remove barriers to care.
Introduction:
Access to medications for opioid use disorder (MOUD) is limited for individuals in drug courts - programs that leverage sanctions for mandatory substance use treatment. Drug courts rely on community agencies to provide MOUD. However, relationships with MOUD agencies, which impact access to treatment, are understudied. We examined barriers and facilitators from drug court staffs' perspectives to understand how to enhance collaborations with MOUD providers.
Methods:
Drug court staff (n = 21) from seven courts participated in semi-structured interviews about their experience in collaborating with MOUD providers. Interviews were informed by the Consolidated Framework for Implementation Research. Inductive (theory-based) and deductive (ground-up) approaches were used for analyses.
Results:
Facilitator and barrier themes centered around the needs and resources of drug court participants, external policies such MOUD access in jails, networking with external agencies, and beliefs about MOUD providers. Drug court staff preferred working with agencies that offered MOUD alongside comprehensive services. Drug courts benefited when jails offered MOUD in-house and facilitated community referrals. Existing relationships with providers and responsive communication eased referrals and served to educate the courts about MOUD. Barriers included logistical limitations (limited hours, few methadone providers) and inadequate communication patterns between providers and drug court staff. A lack of confidence in providers' prescribing practices and concerns around perceived overmedication of participants impacted referrals, interagency collaboration, and further burdened the participants.
Conclusions:
Collaboration between drug courts and MOUD providers was driven by patient needs, external policies, communication patterns, and perceptions. Interventions to increase access MOUD for drug court participants will need to incorporate collaboration strategies while considering the unique features of drug courts.
With an ongoing pandemic claiming hundreds of lives a day, it is unclear how COVID-19 has affected court operations, particularly problem-solving courts (PSCs) which have goals rooted in rehabilitation for participants in their programs. Even with practical recommendations from national organizations directing courts on how to manage COVID-19, whether and how PSCs met the needs of PSC participants during this time is underexplored. This study, drawn from a larger national study using a survey of PSC coordinators, examines the COVID-19 responses of PSCs to remain safely operational for participants. A sub-sample of survey respondents (n = 82 PSC coordinators) detailed how the COVID-19 pandemic led to changes to their court and treatment operations amidst the constraints of the pandemic. The courts’ shifts in policy and practice have important impacts for court participants’ treatment retention and success in the PSC program, and these shifts need more in-depth research in the future.
Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.
Objectives
This study compares 15-year recidivism and incarceration outcomes for individuals randomly assigned to Baltimore City’s Drug Treatment Court (BCDTC) or traditional adjudication. Additionally, the study examines the moderating effect of court of assignment.
Methods
This study is based on a randomized controlled trial. Participants include 235 drug-involved offenders with substantial criminal and substance use disorder histories who were adjudicated within Baltimore City’s District and Circuit Courts. Key measures include number of arrests; convictions; person, property, drug, and violation of probation (VOP) charges; and days of incarceration. A measure of exposure time is included to account for time spent free in the community. Negative binomial regression and growth curve models test for group differences on each dependent variable over the 15-year follow-up. Additional models assess whether or not originating court moderates the treatment effect.
Results
Participation in BCDTC resulted in significantly fewer arrests, charges, and convictions across the 15-year follow-up period, including several crime-specific differences. Originating court moderated the effect of participation for convictions, such that treatment participants in the Circuit drug court had significantly better outcomes than those in the District drug court relative to their controls. Participation in BCDTC did not have a significant effect on total days of sentenced incarceration.
Conclusions
Results suggest that drug courts have the potential to lead to sustained, long term effects on criminal offending for individuals with significant criminal history records and chronic substance use histories.
Objectives
Whereas the USA has numerous problem solving courts (e.g., drug courts, mental health courts), other countries do not have such courts, have altered versions of these courts, or have problem solving courts for other social issues. This qualitative research develops hypotheses regarding the reasons for such diversity.
Methods
After a description of the history and types of courts in various countries, the article situates interviews, observations, and document reviews in the existing literature in order to create a qualitative typology of factors that hypothesize why a society has (or has not) developed problem solving courts. Examples from over a dozen countries support the typology.
Results
Hypothesized factors that seem to encourage development of problem solving courts include practical reasons (e.g., community demand); changes in legal or social structure; advances in medicine, social science, and technology; and recognition of a social issue (with or without a specific event or movement) as a problem worthy of legal attention. Factors that seem to discourage development include lack of resources or demand; fear of negative outcomes; prohibitions on providing special courts for only some offenders; legal requirement for all courts to provide rehabilitation; perceptions that it is not the courts’ role to help; and the presence of broader social issues demanding the country’s attention.
Conclusion
Some of these hypothesized factors are practical (e.g., money, public demand), while others are social (e.g., social movements) or psychological (e.g., community attitudes). Future research should investigate a broader variety of countries and quantitatively test the hypotheses contained in the typology developed here.
We sought to understand the implementation of medication-assisted treatment (MAT) access for opioid-involved participants in an urban Midwestern drug treatment court (DTC) over a time period beginning in October 2012 and ending in June 2016. Among those whose primary substance problem on the Addiction Severity Index (ASI) was identified as heroin or other opioids, less than half accessed MAT while they participated in the DTC. Those who accessed MAT were more likely to be White, non-Hispanic, more highly educated, with more in-program violations, and less likely to have a history of inpatient psychiatric treatment. Of the three types of medication (buprenorphine, naltrexone, and methadone) accessed, extended release, injectable naltrexone was the most common treatment. There was no association between accessing MAT and program completion. Nevertheless, there was a trend suggesting that those accessing specifically methadone in Opioid Treatment Programs (OPTs) had more success in completing DTC. Our analyses, which are informed by qualitative observations of staff from meetings and interviews and from focus groups with participants, suggest the importance of strategies for enhancing DTC court staff training on opioid disorders and related treatments.
Beginning with the original drug court model, specialized court programs (SCPs) have expanded to address a variety of offense-related problems, such as domestic violence courts, mental health courts, veteran courts, and homeless courts. To date, there has been no empirical assessment as to whether these types of court programs share similar program characteristics with the drug court model. To address this gap, we used data from the 2012 Census of Problem-Solving Courts of 2,793 problem-solving court programs in the United States to examine differences between drug courts and other court types. We used multinomial logistic regression to analyze program-level characteristics between SCPs and drug courts. SCPs were similar on several key characteristics to drug courts, such as specialization and services, staff training, and procedures. Where SCPs tend to differ were whether felony offenders were allowed, charges dismissed after program completion, and participants entering the program post-adjudication. Though they may go by different names, many SCPs continue to rely on the original drug court model. Future research within the drug court paradigm should consider expanding to other types of SCPs to provide more comprehensive knowledge on the “black box” of problem-solving courts and how courts can more effectively implement court programs.
Importance
Expanding Medicaid eligibility could affect prescriptions of buprenorphine with naloxone, an established treatment for opioid use disorder, and opioid pain relievers (OPRs).
Objective
To examine changes in prescriptions of buprenorphine with naloxone and OPRs after the US Affordable Care Act Medicaid expansion.
Design, Setting, and Participants
In this cohort study, longitudinal, patient-level, retail pharmacy claims were extracted from IQVIA real-world data from an anonymized, longitudinal, prescription database. The sample included 11.9 million individuals who filled 2 or more prescriptions for a prescription opioid during at least 1 year between January 1, 2010, and December 31, 2015, from California, Maryland, and Washington (expansion states) and Florida and Georgia (nonexpansion states). Data analysis was conducted from August 1, 2017, to May 31, 2018. Data were aggregated to county-year observations (N = 2082) and linked to county-level covariates. For each outcome, a difference-in-differences regression model was estimated comparing changes before and after expansion in expansion vs nonexpansion counties. Models were adjusted for county demographics, uninsured rate, and overdose mortality in the baseline year (2010).
Exposures
Presence of Medicaid expansion in the year.
Main Outcomes and Measures
For buprenorphine with naloxone and OPRs, rates per 100 000 county residents were calculated separately for any prescriptions overall and by different payment sources. Mean days of medication per county among people filling prescriptions for these agents were also determined.
Results
The study sample included 11.9 million individuals (expansion states: 40.9% men; mean [SD] age, 44.1 [13.8] years; nonexpansion states: 41.0% men; mean [SD] age, 43.7 [13.7] years). In expansion counties, 68.8 individuals per 100 000 county residents filled buprenorphine with naloxone and 5298.3 filled OPR prescriptions in 2010. After expansion, buprenorphine with naloxone fills per 100 000 county residents increased significantly in expansion relative to nonexpansion counties (8.7; 95% CI, 1.7 to 15.7). Opioid pain reliever fills per 100 000 county residents did not significantly change in expansion counties relative to nonexpansion counties (327.4; 95% CI −202.5 to 857.4). The rate of OPRs per 100 000 county residents paid for by Medicaid significantly increased (374.0; 95% CI, 258.3 to 489.7). There were no significant changes in days per 100 000 county residents of either medication after expansion.
Conclusions and Relevance
Medicaid expansion significantly increased buprenorphine with naloxone prescriptions per 100 000 county residents in expansion counties, suggesting that expansion improved access to opioid use disorder treatment. Expansion did not significantly increase the overall rate per 100 000 county residents of OPR prescriptions, but increased the population with OPRs paid for by Medicaid. This finding therefore suggests the growing importance of Medicaid in pain management and addiction prevention.
The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013-14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations. © 2016 Project HOPE-The People-to-People Health Foundation, Inc.
Background:
The purpose of this paper is to describe the Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) study, a cooperative implementation science initiative involving the National Institute on Drug Abuse, six research centers, a coordinating center, and Juvenile Justice Partners representing seven US states. While the pooling of resources across centers enables a robust implementation study design involving 36 juvenile justice agencies and their behavioral health partner agencies, co-producing a study protocol that has potential to advance implementation science, meets the needs of all constituencies (funding agency, researchers, partners, study sites), and can be implemented with fidelity across the cooperative can be challenging. This paper describes (a) the study background and rationale, including the juvenile justice context and best practices for substance use disorders, (b) the selection and use of an implementation science framework to guide study design and inform selection of implementation components, and (c) the specific study design elements, including research questions, implementation interventions, measurement, and analytic plan.
Methods/design:
The JJ-TRIALS primary study uses a head-to-head cluster randomized trial with a phased rollout to evaluate the differential effectiveness of two conditions (Core and Enhanced) in 36 sites located in seven states. A Core strategy for promoting change is compared to an Enhanced strategy that incorporates all core strategies plus active facilitation. Target outcomes include improvements in evidence-based screening, assessment, and linkage to substance use treatment.
Discussion:
Contributions to implementation science are discussed as well as challenges associated with designing and deploying a complex, collaborative project.
Trial registration:
NCT02672150 .
Background
Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited.
Methods
In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78.
Results
A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures — self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration — were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02).
Conclusions
In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.)
Background
The Heath & Justice journal is devoted to addressing the unmet needs of those involved in or working in the justice system. With attention to both health and justice processes and outcomes, this journal is designed to provide a forum for scholarship and research that is usually dispersed across many different disciplines.
Findings
In this article, we focus on the need for more service related research to broaden our understanding of how to improve system, program, and client level outcomes. A review of pertinent research in each area is provided to illustrate contemporary findings.
Conclusions
Current research also makes the case for a focused discussion about processes, policies, and procedures that need further exploration. To better understand how to improve health and justice outcomes, research is needed in program fidelity, services, geographical and activity spaces, and other arenas that affect individual, program, and system level outcomes.
Electronic supplementary material
The online version of this article (doi:10.1186/2194-7899-2-2) contains supplementary material, which is available to authorized users.
Objectives
We report the results of a multilevel structural equation model of the Multisite Adult Drug Court Evaluation that empirically tests theoretical pathways to desistance from drug use and criminal behavior.Methods
First, we consider how to operationalize the theoretical mechanisms through which drug court practices are meant to impact outcomes. A path model is proposed that delineates how drug-court practices change perceptions and attitudes, and how these changes subsequently affect drug use and crime. Proposed mediators include changes in court practices (e.g., court appearances, drug testing, and treatment) and psychological mediators, including perceived risk and reward (deterrence), perceived legitimacy (procedural justice), and motivation to change one’s behavior through substance abuse treatment.ResultsResults suggest that one element of procedural justice, the clients’ attitude toward the judge, is the most crucial theoretical mediator on the pathway to desistance from drug use and crime.Conclusions
Study limitations and directions for future research are discussed.
Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n = 172), 1990 (n = 140), 1995 (n = 116), 2000 (n = 150), 2005 (n = 146), and 2011 (n = 140). Results show that the proportion of patients who received doses below 60 mg/day--the minimum recommended—declined from 79.5 to 22.8 percent in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were program that serve a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.
There has been a rapid proliferation of drug courts over the past two decades. Empirical research examining the effectiveness of the model has generally demonstrated reduced rates of recidivism among program participants. However, relatively little is known about the structure and processes associated with effective drug courts. The current study seeks to address the issues by exploring the moderating influence of programmatic and non-programmatic characteristics on effectiveness. The methodology goes beyond previous meta-analyses by supplementing published (and unpublished) findings with a survey of drug court administrators. Consistent with previous research, the results revealed drug courts reduce recidivism by 9% on average. Further analyses indicated target population, program leverage and intensity, and staff characteristics explain the most variability in drug court effectiveness. These findings are discussed within the context of therapeutic jurisprudence and effective interventions.
The federal government has a fundamental as well as critical role in the successful development, implementation and utilization of controlled medications for the treatment of opioid abuse and dependence. The development and implementation of a federal regulatory structure establishes minimum standards which provide the basis for the development of treatment policies and medical best practices for the treatment of drug abuse and dependence. In the United States, the use of pharmacotherapies in combination with counseling, behavior therapies and other core services including primary medical care provide a comprehensive therapeutic approach termed as an evidence-based best practice termed "Medication Assisted Treatment" (MAT). Federally supported research studies have shown that the most efficacious treatment for opioid abuse and dependence comprises treatment programs that utilize pharmacotherapies and include psychosocial counseling, financial, legal, educational services as well as wrap around social services (NIDA, 2000). Federal programs catalogue such evidence-based best medical practices and promote their implementation in the care and treatment of patients to optimize good medical outcomes. In a non regulatory role, federal programs can also mandate medical education and training as well as support the piloting of treatment improvement projects to develop national implementation strategies. Drug treatment programs that utilize MAT are regulated by the federal government in their adherence to treatment standards through accreditation and in their record keeping requirements for use of controlled pharmaceuticals. Thus, multiple federal agencies combine to support MAT in the treatment of opioid dependence throughout the treatment continuum from drug discovery to patient care and treatment outcome. Salient policy issues that involve MAT as a direct result of the federal regulatory structure(s) include the provision and integration of medical services into Opioid Treatment Programs (OTPs), infectious diseases prevention counseling, the availability of opioid treatment using either buprenorphine or methadone, the limited use of Suboxone/Subutex in OTPs and which health care providers can prescribe as well as the number of patients prescribed Suboxone/Subutex in an office based setting.
Mental health courts have recently emerged as one means to reduce the number of persons with mental illness in the criminal
justice system. Using a post-test only comparison group design, this study examined rearrest rates for 1year post discharge
among three groups meeting admission criteria for a municipal mental health court. The rearrest rate of defendants who successfully
completed the program (N = 351) was 14.5%, compared to 38% among defendants negatively terminated from the program (N = 137), and 25.8% among defendants who chose not to participate (N = 89). This positive result held even when controlling for a range of variables in a Cox regression survival analysis. Factors
associated with rearrest are identified for each of the three groups.
KeywordsMental health court–Recidivism–Mentally ill offenders–Diversion
Providing access to and utilization of medication assisted treatment (MAT) for the treatment of opioid abuse and dependence provides an important opportunity to improve public health. Access to health services comprising MAT in the community is fundamental to achieve broad service coverage. The type and placement of the health services comprising MAT and integration with primary medical care including human immunodeficiency virus (HIV) prevention, care and treatment services are optimal for addressing both substance abuse and co-occurring infectious diseases. As an HIV prevention intervention, integrated (same medical record for HIV services and MAT services) MAT with HIV prevention, care and treatment programs provides the best "one stop shopping" approach for health service utilization. Alternatively, MAT, medical and HIV services can be separately managed but co-located to allow convenient utilization of primary care, MAT and HIV services. A third approach is coordinated care and treatment, where primary care, MAT and HIV services are provided at distinct locations and case managers, peer facilitators, or others promote direct service utilization at the various locations. Developing a continuum of care for patients with opioid dependence throughout the stages MAT enhances the public health and Recovery from opioid dependence. As a stigmatized and medical disenfranchised population with multiple medical, psychological and social needs, people who inject drugs and are opioid dependent have difficulty accessing services and navigating medical systems of coordinated care. MAT programs that offer comprehensive services and medical care options can best contribute to improving the health of these individuals thereby enhancing the health of the community.
The following study, conducted in Puerto Rico, examined the feasibility of providing daily buprenorphine-naloxone (bup-nx) in prison and on release to 45 male inmates with histories of heroin addiction. Participants were assessed at study entry and at 1 month after release (N = 42; 93.3% follow-up rate). Treatment completers compared with noncompleters had significantly greater reductions in self-reported heroin use, cocaine use, and crime and were less likely to be opioid-positive according to urine drug testing. Despite study limitations, the short-term outcomes of this study suggest that bup-nx may contribute to reductions in readdiction to heroin and in criminal activities among re-entering male prisoners.
Integration of community parole and addiction treatment holds promise for optimizing the participation of drug-involved parolees in re-entry services, but intensification of services might yield greater rates of technical violations. Collaborative behavioral management (CBM) integrates the roles of parole officers and treatment counselors to provide role induction counseling, contract for pro-social behavior, and to deliver contingent reinforcement of behaviors consistent with contracted objectives. Attendance at both parole and addiction treatment are specifically reinforced. The Step'n Out study of the Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS) randomly allocated 486 drug-involved parolees to either collaborative behavioral management or traditional parole with 3-month and 9-month follow-up. Bivariate and multivariate regression models found that, in the first 3 months, the CBM group had more parole sessions, face-to-face parole sessions, days on which parole and treatment occurred on the same day, treatment utilization and individual counseling, without an increase in parole violations. We conclude that CBM integrated parole and treatment as planned, and intensified parolees' utilization of these services, without increasing violations.
Background
Buprenorphine is an effective medication for opioid use disorder (MOUD) when offered in community-based settings, but evidence is limited for incarcerated populations, particularly in relation to recidivism. In Massachusetts, Franklin County jail (FCSO) was among the first to provide buprenorphine; adjacent Hampshire County jail (HCHC) offered it more recently. These jails present a natural experiment to determine whether outcomes are different between individuals who did and did not have the opportunity to receive buprenorphine in jail.
Methods
We examined outcomes of all incarcerated adults with opioid use disorder (n = 469) who did (FCSO n = 197) and did not (HCHC n = 272) have the opportunity to receive buprenorphine. The primary outcome was post-release recidivism, defined as time from jail exit to a recidivism event (incarceration, probation violation, arraignment). Using Cox proportional hazards models, we investigated site as a predictor, controlling for covariates. We also examined post-release deaths.
Results
Fewer FCSO than HCHC individuals recidivated (48.2% vs. 62.5%; p = 0.001); fewer FCSO individuals were re-arraigned (36.0% vs. 47.1%; p = 0.046) or re-incarcerated (21.3% vs. 39.0%; p < 0.0001). Recidivism risk was lower in the FCSO group (hazard ratio 0.71, 95% confidence interval 0.56, 0.89; p = 0.003), net of covariates (adjusted hazard ratio 0.68, 95% confidence interval 0.53, 0.86; p = 0.001). At each site, 3% of participants died.
Conclusions
Among incarcerated adults with opioid use disorder, risk of recidivism after jail exit is lower among those who were offered buprenorphine during incarceration. Findings support the growing movement in jails nationwide to offer buprenorphine and other agonist medications for opioid use disorder.
Introduction
In response to the COVID-19 pandemic, a federal exemption allowed stable and less stable patients greater take-home doses of methadone. We assessed the adoption of increased take-home medication during COVID-19 and whether increased take-home doses is associated with clients' characteristics.
Methodology
We completed a pre-post study of adults receiving methadone for OUD from an OTP in Spokane, Washington. Our outcome was the change in the number of take-home methadone doses three months before and three months after the March 2020 take-home medication exemption. Clients' characteristics included age, gender, ethnicity, education level, homelessness, spatial access to the clinic, and methamphetamine use.
Results
The study included 194 clients in treatment for a median of three years. All study participants experienced an average increase in take-home medication of 41.4 in the three-month period after the COVID-19 exemption. In the final adjusted models, clients who reported using methamphetamine in the last 30 days experienced a significantly larger increase in take-home dosage (55.6 days) compare to clients who did not use methamphetamine (p ≤0.001). Most of the clients who reported using methamphetamine were also likely to be homeless. All other variables were not associated with a change in take-home doses.
Conclusion
These results suggest that the Spokane OTP quickly expanded take-home medication dosing in response to the COVID-19 exemption and broadly expanded take-home dosing among established clients. Clients with concurrent methamphetamine use were allowed fewer take-home doses prior to COVID-19, but after the exemption the clinic provided them the same number of take-home doses as clients who had not used methamphetamine.
Drug courts are an alternative to incarceration for individuals who have substance use disorders and nonviolent arrests, and these programs can be an avenue to recovery for those who have opioid use disorders. This qualitative study used a focus group methodology to explore drug court team members’ thoughts, opinions, and lived experiences related to how the program treats opioid use disorders and the role of medication-assisted treatment (MAT) in programming. The drug court team had favorable views toward MAT and reported that participants who received MAT experienced many positive outcomes. Additionally, members of the drug court team often had to educate participants on MAT, as some participants had inaccurate information and beliefs about MAT that were based on myths. The drug court team also candidly discussed their paradigm shift from not allowing MAT to incorporating MAT into programming. Implications for drug court practice and future research are discussed.
Background
Criminal problem-solving and dependency courts set treatment standards for opioid use disorder (OUD) but sometimes prohibit or limit utilization of medications for OUD (MOUD). Court staff beliefs about MOUD inform court treatment policies. Court staff MOUD policies may also be influenced by social norms, meaning perceptions of opinions of other individuals/entities about MOUD, including opinions of fellow staff in their court, staff in other courts, the state supreme court, other state agencies, the National Association of Drug Court Professionals (NADCP), federal agencies, and local peer support groups. To date no study has examined social norms among court staff with respect to MOUD.
Methods
We distributed an online cross-sectional survey in 2019 to all criminal problem-solving and dependency court staff in Florida. Respondents were asked to identify the extent to which they cared about different entities’/individuals’ opinions about MOUD and the extent to which they perceived each of those entities/individuals as encouraging MOUD. We hypothesized that court role and court type would be associated with responses. We used descriptive statistics, logistic regressions, and difference of proportions tests to analyze data.
Results
20% of the population ( n = 119) completed the survey. Respondents cared most about the opinions of external treatment providers with whom they collaborate, fellow staff in their court, and the NADCP regarding MOUD. Fewer than half felt that any of these entities/individuals encourage methadone or oral buprenorphine. Additionally, fewer than 11% of respondents felt that local twelve-step peer support groups encourage the use of any form of MOUD.
Conclusions
MOUD education should target all members of court teams, including collaborating treatment providers. Since court staff care relatively little about the MOUD opinions of staff in other courts, changes in opinions in one court may not affect changes in opinions in a neighboring court. The NADCP should more explicitly state its support for MOUD, and specifically oral buprenorphine and methadone treatment.
Objective:
Research has examined the effect of Medicaid expansion on access to physicians with buprenorphine waivers, but less attention has been paid to Medicaid's impact on opioid use disorder medication availability within the specialty substance use disorder treatment system. To address this gap in the literature, this study examined the impact of Medicaid expansion on availability of opioid medications in specialty programs.
Methods:
This study used data from the National Survey of the Substance Abuse Treatment Services (2002-2017), containing all known substance use disorder treatment programs in the United States, to examine the effect of Medicaid expansion on the availability of opioid use disorder medications by treatment program ownership type (publicly owned, private for profit, and private nonprofit) among opioid treatment programs (OTPs) and non-OTPs.
Results:
The effects of Medicaid expansion were limited to nonprofit and for-profit OTPs. Medicaid expansion was associated with 135.1% and 57.5% increases in the number of nonprofit and for-profit OTPs offering injectable naltrexone, respectively, and with a 64.4% increase in the number of nonprofit OTPs offering buprenorphine. Nonprofit and for-profit OTPs compose <10% of the treatment system, indicating that improvements in opioid use disorder treatment associated with Medicaid expansion were limited to a small share of the specialty system.
Conclusions:
The limited impact of Medicaid expansion on the specialty treatment system may perpetuate disparities in the accessibility and quality of opioid use disorder treatment for Medicaid enrollees and fail to alleviate high rates of opioid use disorder and opioid overdose deaths in this vulnerable population.
Background:
Criminal problem-solving and dependency (child/dependent) court staff refer clients with opioid use disorder (OUD) to treatment and set treatment policies. Negative beliefs regarding the safety and efficacy of medications for opioid use disorder (MOUD) have previously been reported in court staff. MOUD is superior to other OUD interventions, is severely underutilized, and is highly effective even in the absence of behavioral treatment.
Objective:
We examined Florida court staff MOUD beliefs, exploring associations with court type and staff role. We also explored beliefs about the relationship of MOUD to child reunification, counseling, polysubstance use, and titration requirements.
Methods:
We modified a previously developed cross-sectional survey. We fielded the online survey among all Florida criminal problem-solving and dependency court staff. Likert scale questions were asked about beliefs regarding methadone, buprenorphine, and extended-release naltrexone. We analyzed responses using descriptive statistics and logistic regression.
Results:
154 individuals (26% of the population) responded. Only 1/3 believed MOUD was more effective for OUD than nonpharmacological treatment. 31% believed methadone treatment makes it difficult for parents to regain child custody. Criminal problem-solving court staff were more likely to report certain positive beliefs about naltrexone. Fewer than 10% felt any MOUD should be permitted without counseling. Over 60% felt prescribers should have tapering plans for each MOUD patient. Beliefs were generally more positive for naltrexone than buprenorphine, and more positive for buprenorphine than methadone.
Conclusions:
Court staff need education about MOUD efficacy. Policymakers should prohibit courts from banning MOUD and from preventing child reunification for parents utilizing MOUD.
Background
Medication-assisted treatment (MAT) is an evidence-based strategy to treat opioid use disorder (OUD). However, MAT-related stigma reduces MAT uptake, which is particularly low in rural areas. To date, perceptions and attitudes towards MAT in rural settings have not been described.
Objective
This qualitative study aims to characterize perceptions and attitudes towards MAT and the environmental factors contributing to these views in Appalachian Ohio.
Methods
From February to July 2018, semi-structured interviews were conducted with 34 stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement agents and judicial officials, and 3 members of relevant organizations) in three rural counties in Appalachian Ohio. Interviews were transcribed, coded, and analyzed to characterize the risk environment and participants’ perceptions and attitudes towards MAT.
Results
Participants expressed or described pervasive MAT-related stigma in the region. Participants consistently described three elements of the environment affecting stigma: (1) a “conservative” culture in which abstinence is necessary to be in recovery successfully, (2) fear of medication diversion and abuse, and (3) drug court policies that keep MAT out of the criminal justice system.
Conclusion
MAT-related stigma will need to be addressed to tackle the opioid epidemic through evidence-based treatment effectively.
Background:
Opioid use disorder (OUD) has become an increasingly consequential public health concern, especially in the United States where 47,600 opioid overdose deaths occurred in 2017 (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2019). Medications for OUD (MOUD) are effective for decreasing opioid-related morbidity and mortality, including within the criminal justice system (Hedrich et al., 2012; Medications for Opioid Use Disorder Save Lives, 2019; Moore et al., 2019).While a stronger evidence base exists for agonist MOUD than for antagonist MOUD, a national study of drug courts found that half prohibited agonist MOUD (Matusow et al., 2013).Furthermore, recent media reports suggest that the pharmaceutical manufacturer of an antagonist MOUD has marketed its product towards drug court judges (Goodnough & Zernike, 2017; Harper, 2017). However, no study to date has systematically examined the relationship between MOUD marketing practices and drug courts. This ecological study examines the association at the county level between MOUD manufacturer payments to prescribers and drug court locations.
Method:
We extracted provider-directed payments from Centers for Medicare and Medicaid Services (CMS)'s Sunshine Act Open Payments data 2014-2017, isolating those records mentioning any MOUD. We compared provider-directed payments for two major MOUDs: buprenorphine and extended-release naltrexone, in counties with and without drug courts.
Results:
The presence of any adult drug courts in the county is associated with a 7.86 percentage-point increase in the likelihood of providers in that county receiving any MOUD-related payments (about 22.46% of the sample mean, p<0.001) and with a 10.70% increase in the amount of these payments per 1000 county residents (p<0.001). The association between other forms of drug courts such as juvenile drug courts and Driving-Under-the-Influence courts (DUI) courts are less significant and slightly smaller in magnitude compared to those of adult drug courts. We did not find significant difference between payments by the manufacturer of Vivitrol and manufacturers of Zubsolv, Bunavail, and Suboxone (oral forms of buprenorphine).
Conclusions:
Our results show an ecological association at the county level between MOUD manufacturer payments to prescribers and drug court presence. However, we did not examine a causal association between these variables.
Background:
Despite its efficacy, medication-assisted treatment (MAT) is rarely available in the criminal justice system in the United States, including in problem-solving courts or diversionary settings. Previous studies have demonstrated criminal justice administrators' hostility towards MAT, especially in prisons and jails. Yet, few studies have examined attitudes among court personnel or compared beliefs among different types of personnel. Also, few studies have explored the relationship between MAT education/training and attitudes. Finally, few studies have directly compared attitudes towards methadone, oral buprenorphine, and extended-release naltrexone in the criminal justice system.
Methods:
We modified a survey by Matusow et al. (2013) to explore justice professionals' MAT attitudes, including associations with demographic variables, court role, and previous MAT education/training. After piloting the survey, we distributed it to a convenience sample of justice professionals registered for an educational summit held in Indiana in 2018. Data was analyzed using descriptive and inferential statistical methods.
Results:
231 Indiana court employees who had registered for a state MAT educational summit completed the survey prior to the summit, including judges, probation officers, law enforcement personnel, attorneys, probation officers, program directors, counselors, and case managers. Overall, participants had significantly more positive attitudes towards extended-release naltrexone than towards other medications (p value <0.01). Court employee average attitudes towards methadone were significantly more negative than average attitudes towards oral buprenorphine; and average attitudes towards oral buprenorphine were significantly more negative than average attitudes towards extended-release naltrexone (p value <0.01). Employment as a prosecutor or law enforcement officer was associated with more negative attitudes towards oral buprenorphine and methadone (p value <0.05). Exposure to previous MAT training was associated with more positive attitudes for all medications (p value <0.05). Compared to participants with graduate degrees, participants with less education had significantly more negative attitudes towards extended-release naltrexone (p < 0.05). Gender, age, rurality, and personal/family recovery history were not associated with differences in attitudes.
Conclusion:
As expected, court employees' attitudes significantly differ by medication, with average attitudes towards agonist medications being more negative than attitudes towards extended-release naltrexone. Despite a larger evidence base for the efficacy of methadone and oral buprenorphine, justice personnel may have more positive attitudes towards extended-release naltrexone due to targeted marketing by the pharmaceutical manufacturer, fears about diversion or misuse of agonist medications, and historic criminal justice hostility towards agonist medications. Importantly, previous education/training regarding MAT is associated with more positive attitudes, suggesting that more awareness-raising or capacity building educational interventions are needed, especially for prosecutors and law enforcement personnel.
Drug courts began in 1989 in Miami-Dade County, FL. Due to their success in treating substance use disorders and reducing criminal recidivism, they have expanded globally and are currently operating in countries such as Australia, Canada, and Scotland, to name a few. Drug courts can be a key intervention in addressing the opioid epidemic. This is the first known qualitative study to ask drug court participants (n = 38) who have opioid use disorders questions related to their lived experiences in drug court, as well as direct questions related to the use of medication-assisted treatments (MATs) in drug court. Overall, drug court participants felt that MATs were helpful for treating their opioid use disorders; however, some participants reported using other drugs while on MATs and they viewed their recovery through a harm reduction lens. Additionally, participants emphasized the importance of using MATs in combination with counseling that used cognitive and behavioral therapies. Implications for drug court practice and future research are discussed.
Drug courts have been a key part of the criminal justice system since 1989, and this study contributes to the existing body of research by identifying which participants (n = 248) were most likely to graduate from a drug court in Indiana (United States). Three variables emerged as significant predictors of graduation. First, participants who were employed or were students at the time of admission were nearly 2.5 times more likely to graduate than participants who were not. Second, participants who were using opiates as their primary drug of choice were over 80% less likely to graduate than participants who were using non-opiates as their primary drug of choice. Third, participants who had violations in the first 30 days of the program were nearly 50% less likely to graduate than participants who did not violate in the first 30 days. Offering medication-assisted treatment (MAT), such as methadone, Suboxone, or Vivitrol, to participants who have an opiate use disorder may improve graduation rates for this population. Additionally, graduation rates may also improve by offering more resources to assist participants in gaining and maintaining employment or schooling, and this seems to be especially important within the first month of the program.
The evidence-based practices literature has defined a core set of practices and treatments that are effective, at least in empirical studies. Implementing these evidence-based practices and treatments requires a different set of empirical studies to understand the operational issues that affects client-driven outcomes. In this article, we review the following three areas: (a) use of a standardized risk and need assessment tool, (b) use of cognitive-behavioral programs to address criminogenic needs, and (c) use of swift and certain responses to shape behavior. The review focuses on the unanswered questions regarding implementation and organizational change strategies to increase receptivity for the evidence-based practices, lay the foundation for improving effectiveness of “evidence-based practices and treatments,” and provide a work environment that supports evidence-based practices and treatments. This article outlines a research agenda to build implementation knowledge that can further the use of evidence-based practices and treatments.
Background:
This study examined whether starting buprenorphine treatment prior to prison and after release from prison would be associated with better drug treatment outcomes and whether males and females responded differently to the combination of in-prison treatment and post-release service setting.
Methods:
Study design was a 2 (In-Prison Treatment: Condition: Buprenorphine Treatment: vs. Counseling Only)×2 [Post-Release Service Setting Condition: Opioid Treatment: Program (OTP) vs. Community Health Center (CHC)]×2 (Gender) factorial design. The trial was conducted between September 2008 and July 2012. Follow-up assessments were completed in 2014. Participants were recruited from two Baltimore pre-release prisons (one for men and one for women). Adult pre-release prisoners who were heroin-dependent during the year prior to incarceration were eligible. Post-release assessments were conducted at 1, 3, 6, and 12-month following prison release.
Results:
Participants (N=211) in the in-prison treatment condition effect had a higher mean number of days of community buprenorphine treatment compared to the condition in which participants initiated medication after release (P=0.005). However, there were no statistically significant hypothesized effects for the in-prison treatment condition in terms of: days of heroin use and crime, and opioid and cocaine positive urine screening test results (all Ps>0.14) and no statistically significant hypothesized gender effects (all Ps>0.18).
Conclusions:
Although initiating buprenorphine treatment in prison compared to after-release was associated with more days receiving buprenorphine treatment in the designated community treatment program during the 12-months post-release assessment, it was not associated with superior outcomes in terms of heroin and cocaine use and criminal behavior.
Objective:
Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment.
Method:
The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment.
Results:
Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance?
Conclusions:
High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
Specialized court programs have expanded beyond drug treatment to address issues such as mental health, domestic violence, veterans, and reentry through evidenced-based treatment. Although these programs have been successful at reducing recidivism, their lack of an overarching theoretical framework has limited generalizability to other offender populations and contexts. The purpose of this article is to present an integrated model for specialized court programs that incorporates therapeutic jurisprudence and procedural justice concepts. We argue that although therapeutic jurisprudence offers guiding principles, it lacks the ability to explain how these programs work to change offender behavior and perceptions. Procedural justice can provide this missing piece of the puzzle in understanding the effectiveness of specialized courts. We conclude with a discussion of directions for future research and practice that is guided by this integrated perspective. © 2015, 2015 International Association for Correctional and Forensic Psychology.
Background:
Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes.
Methods:
In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964.
Findings:
Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively.
Interpretation:
Although our study had several limitations--eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours.
Funding:
National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.
Background:
Buprenorphine is a promising treatment for heroin addiction. However, little is known regarding its provision to pre-release prisoners with heroin dependence histories who were not opioid-tolerant, the relative effectiveness of the post-release setting in which it is provided, and gender differences in treatment outcome in this population.
Methods:
This is the first randomized clinical trial of prison-initiated buprenorphine provided to male and female inmates in the US who were previously heroin-dependent prior to incarceration. A total of 211 participants with 3-9 months remaining in prison were randomized to one of four conditions formed by crossing In-Prison Treatment Condition (received buprenorphine vs. counseling only) and Post-release Service Setting (at an opioid treatment center vs. a community health center). Outcome measures were: entered prison treatment; completed prison treatment; and entered community treatment 10 days post-release.
Results:
There was a significant main effect (p=.006) for entering prison treatment favoring the In-Prison buprenorphine Treatment Condition (99.0% vs. 80.4%). Regarding completing prison treatment, the only significant effect was Gender, with women significantly (p<.001) more likely to complete than men (85.7% vs. 52.7%). There was a significant main effect (p=.012) for community treatment entry, favoring the In-Prison buprenorphine Treatment Condition (47.5% vs. 33.7%).
Conclusions:
Buprenorphine appears feasible and acceptable to prisoners who were not opioid-tolerant and can facilitate community treatment entry. However, concerns remain with in-prison treatment termination due to attempted diversion of medication.
PurposeThe objective of this research was to systematically review quasi-experimental and experimental evaluations of the effectiveness of drug courts in reducing offending.Methods
Our search identified 154 independent evaluations: 92 evaluations of adult drug courts, 34 of juvenile drug courts, and 28 of DWI drug courts. The findings of these studies were synthesized using meta-analysis.ResultsThe vast majority of adult drug court evaluations, even the most rigorous evaluations, find that participants have lower recidivism than non-participants. The average effect of participation is analogous to a drop in recidivism from 50% to 38%; and, these effects last up to three years. Evaluations of DWI drug courts find effects similar in magnitude to those of adult drug courts, but the most rigorous evaluations do not uniformly find reductions in recidivism. Juvenile drug courts have substantially smaller effects on recidivism. Larger reductions in recidivism were found in adult drug courts that had high graduation rates, and those that accepted only non-violent offenders.Conclusions
These findings support the effectiveness of adult drug courts in reducing recidivism. The evidence assessing DWI courts' effectiveness is very promising but more experimental evaluations are needed. Juvenile drug courts typically produce small reductions in recidivism.
Mental health courts have recently emerged with goals to reduce recidivism and improve clinical outcomes for people with serious mental illness in the criminal justice system. The present study is a review of mental health court literature assessing their effectiveness in reducing recidivism and improving clinical outcomes for participants using meta-analytic techniques. A total of 20 studies that included sufficient information to compute the standardized mean difference effect size, focused on adult populations, and were within the United States were included in the analysis. Only experimental and quasi-experimental research designs were obtained. Using Cohen's d (1988) guidelines, mental health courts were found to have a small effect on reducing recidivism (0.32, p
Drug treatment courts are an increasingly important tool in reducing the census of those incarcerated for non-violent drug offenses; medication assisted treatment (MAT) is proven to be an effective treatment for opioid addiction. However, little is known about the availability of and barriers to MAT provision for opioid-addicted people under drug court jurisdiction. Using an online survey, we assessed availability, barriers, and need for MAT (especially agonist medication) for opioid addiction in drug courts. Ninety-eight percent reported opioid-addicted participants, and 47% offered agonist medication (56% for all MAT including naltrexone). Barriers included cost and court policy. Responses revealed significant uncertainty, especially among non-MAT providing courts. Political, judicial and administrative opposition appear to affect MAT's inconsistent use and availability in drug court settings. These data suggest that a substantial, targeted educational initiative is needed to increase awareness of the treatment and criminal justice benefits of MAT in the drug courts.
This essay traces the history of problem-solving courts (including drug courts, community courts, domestic violence courts and others), outlines problem-solving principles, and answers a basic set of questions about these new judicial experiments: Why now? What forces have sparked judges and attorneys across the country to innovate? What results have problem-solving courts achieved? And what – if any – trade-offs have been made to accomplish these results?
This study aimed to determine the relative effectiveness of 12 months of interim methadone (IM; supervised methadone with emergency counseling only for the first 4 months of treatment), standard methadone treatment (SM; with routine counseling) and restored methadone treatment (RM: routine counseling with smaller case-loads).
A randomized controlled trial was conducted comparing IM, SM and RM treatment. IM lasted for 4 months, after which participants were transferred to SM.
The study was conducted in two methadone treatment programs in Baltimore, MD, USA.
The study included 230 adult methadone patients newly admitted through waiting-lists.
We administered the Addiction Severity Index and a supplemental questionnaire at baseline, 4 and 12 months post- baseline. Measurements included retention in treatment, self-reported days of heroin and cocaine use, criminal behavior and arrests and urine tests for heroin and cocaine metabolites.
At 12 months, on an intent-to-treat basis, there were no significant differences in retention in treatment among the IM, SM and RM groups (60.6%, 54.8% and 37.0%, respectively). Positive urine tests for the three groups declined significantly from baseline (Ps < 0.001 and 0.003, for heroin and cocaine metabolites, respectively) but there were no significant group x time interactions for these measures. At least one arrest was reported by 30.6% of the sample during the year, but there were no significant between-group effects.
Limited availability of drug counseling services should not be a barrier to providing supervised methadone to adults dependent on heroin--at least for the first 4 months of treatment.
Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services.
To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence
We searched the Cochrane Drugs and Alcohol Group trials register (June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2011), PUBMED (1996 to 2011); EMBASE (January 1980 to 2011); CINAHL (January 2003 to 2011); PsycINFO (1985 to 2003) and reference list of articles.
Randomised controlled trials and controlled clinical trial comparing any psychosocial plus any agonist with any agonist alone for opiate dependence.
Two authors independently assessed trial quality quality and extracted data.
35 studies, 4319 participants, were included. These studies considered thirteen different psychosocial interventions. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 27 studies, 3124 participants, RR 1.03 (95% CI 0.98 to 1.07), abstinence by opiate during the treatment, 8 studies, 1002 participants, RR 1.12 (95% CI 0.92 to 1.37), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, 3 studies, MD 0.02 (-0.28 to 0.31), depression, 3 studies, MD -1.70 (95% CI -3.91 to 0.51) and results at the end of follow up as number of participants still in treatment, 3 studies, 250 participants, RR 0.90 (95% CI 0.77 to 1.07) and participants abstinent by opioid, 3 studies, 181 participants, RR 1.15 (95% CI 0.98 to 1.36). Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.
For the considered outcomes, it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits. Data do not show differences also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality. It should be noted that the control intervention used in the studies included in the review on maintenance treatments, is a program that routinely offers counselling sessions in addition to methadone; thus the review, actually, did not evaluate the question of whether any ancillary psychosocial intervention is needed when methadone maintenance is provided, but the narrower question of whether a specific more structured intervention provides any additional benefit to a standard psychosocial support. These interventions probably can be measured and evaluated by employing diverse criteria for evaluating treatment outcomes, aimed to rigorously assess changes in emotional, interpersonal, vocational and physical health areas of life functioning.
Different pharmacological approaches aimed at opioid detoxification are effective. Nevertheless a majority of patients relapse to heroin use, and relapses are a substantial problem in the rehabilitation of heroin users. Some studies have suggested that the sorts of symptoms which are most distressing to addicts during detoxification are psychological rather than physiological symptoms associated with the withdrawal syndrome.
To evaluate the effectiveness of any psychosocial plus any pharmacological interventions versus any pharmacological alone for opioid detoxification, in helping patients to complete the treatment, reduce the use of substances and improve health and social status.
We searched the Cochrane Drugs and Alcohol Group trials register (June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 6, 2011), PUBMED (1996 to June 2011); EMBASE (January 1980 to June 2011); CINAHL (January 2003 to June 2008); PsycINFO (1985 to April 2003) and reference list of articles.
Randomised controlled trials and controlled clinical trial which focus on any psychosocial associated with any pharmacological intervention aimed at opioid detoxification. People less than 18 years of age and pregnant women were excluded.
Two authors independently assessed trials quality and extracted data.
Eleven studies, 1592 participants, fulfilled the criteria of inclusion and were included in the review. The studies considered five different psychosocial interventions and two pharmacological treatments (methadone and buprenorphine). Compared to any pharmacological treatment alone, the association of any psychosocial with any pharmacological was shown to significantly reduce dropouts RR 0.71 (95% CI 0.59 to 0.85), use of opiate during the treatment, RR 0.82 (95% CI 0.71 to 0.93), at follow up RR 0.66 (95% IC 0.53 to 0.82) and clinical absences during the treatment RR 0.48 (95%CI 0.38 to 0.59). Moreover, with the evidence currently available, there are no data supporting a single psychosocial approach.
Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, use of opiate, participants abstinent at follow-up and clinical attendance. The evidence produced by this review is limited due to the small number of participants included in the studies, the heterogeneity of the assessment or the lack of detailed outcome information that prevented the possibility of cumulative analysis for several outcomes. Nevertheless it seems desirable to develop adjunct psychosocial approaches that might make detoxification more effective.
This study examined the impact of prison-initiated methadone maintenance at 12 months postrelease. Males with pre-incarceration heroin dependence (N = 204) were randomly assigned to (a) Counseling Only: counseling in prison, with passive referral to treatment upon release; (b) Counseling + Transfer: counseling in prison with transfer to methadone maintenance treatment upon release; and (c) Counseling + Methadone: counseling and methadone maintenance in prison, continued in the community upon release. The mean number of days in community-based drug abuse treatment were, respectively, Counseling Only, 23.1; Counseling + Transfer, 91.3; and Counseling + Methadone, 166.0 (p < .01); all pairwise comparisons were statistically significant (all ps < .01). Counseling + Methadone participants were also significantly less likely than participants in each of the other two groups to be opioid-positive or cocaine-positive according to urine drug testing. These results support the effectiveness of prison-initiated methadone for males in the United States. Further study is required to confirm the findings for women.
This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release.
A three-group randomized controlled trial was conducted between September 2003 and June 2005.
A Baltimore pre-release prison.
Two hundred and eleven adult pre-release inmates who were heroin-dependent during the year prior to incarceration.
Participants were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71).
Addiction Severity Index at study entry and follow-up. Additional assessments at 6 months post-release were treatment record review; urine drug testing for opioids, cocaine and other illicit drugs.
Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants.
Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.
Preclinical studies have exploded our knowledge about the behavioral and biological underpinnings of alcoholism. These studies suggest that certain neurotransmitters, particularly those interacting with the opioid, N-methyl-D-aspartate, and monoamine systems, may play a critical role in the expression of alcohol-drinking and other behaviors associated with its abuse liability. Built upon this foundation, important advances have been made in the development of therapeutic medications for the treatment of alcoholism. Of the medications reviewed, acamprosate's potential appears to be the most widely established. In the USA, naltrexone was approved by the Food and Drug Administration in 1995 for the treatment of alcoholism; however, the results of some studies have been less encouraging. Naltrexone's reliance on high compliance rates for efficacy may, eventually, limit its potential in clinical settings offering generic treatment for alcoholism. The relative paucity of dose-response studies on naltrexone's effects in treating alcoholics is an important gap in the literature. Recent data from a large clinical trial suggests that ondansetron, a serotonin3 antagonist, offers new hope for the treatment of early onset alcoholics; a type of alcoholism most difficult to manage with psychosocial measures alone. Different subtypes of alcoholic may, therefore, have varying treatment responses to serotonergic agents. Matching subtypes of alcoholic to effective treatment medications based upon their different biologies remains an important therapeutic goal. Combinations of effective pharmacological agents need exploration as they may prove to be synergistic, and could shepherd in a new era of treatments aimed at multiple neurotransmitter targets associated with the alcoholism disease. The coming decade promises more powerful tools for characterizing drug effects on alcohol drinking, thereby closing the gap between animal models of addiction and the human condition.
To summarize the major findings of the five Cochrane reviews on substitution maintenance treatments for opioid dependence.
We conducted a narrative and quantitative summary of systematic review findings. There were 52 studies included in the original reviews (12,075 participants, range 577-5894): methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT).
Outcomes considered were retention in treatment, use of heroin and other drugs during treatment, mortality, criminal activity, and quality of life.
Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity.
These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes. Future clinical trials should collect data on a broad range of health outcomes and recruit participants from heterogeneous practice settings and social contexts to increase generalizability of results.