"Moving Evidence Based Treatment into the Drug Court Setting"

1. "Moving Evidence Based Treatment into the Drug Court Setting" Hon. Peggy Fulton Hora Alameda County Superior Court California Dept. of Alcohol/Drug Programs "Designing the Road Map: Research to Policy - Shaping the Future of Alcohol and Other Drug Treatment Services” May 4-6, 2005 Sacramento CA

2. 2 New Agendas for Drug Courts • 1. Using the latest evidence-based treatment for Methamphetamine • 2. Using Medication Assisted Treatment with Methadone or Buprenorphine

3. MATRIX Project • Best practices for stimulant addiction • TIP 33 congruent with DTC

4. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Create explicit structure and expectations • Establish positive, collaborative relationship with patient • Teach information and cognitive-behavioral concepts • Positively reinforce positive behavior change

5. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment (cont.) • Provide corrective feedback when necessary • Educate family regarding stimulant abuse recovery • Introduce and encourage self-help participation • Use urinalysis to monitor drug use

6. Matrix Treatment ModelImportance of Structure • Counterpoint to addict lifestyle • Requires proactive behavior planning • Reduces “accidental” relapses • Cortical control of behavior vs. limbic control of behavior • Reduces anxiety/encourages self-reliance • Operationalizes one day at a time

7. Matrix Treatment ModelWays to Create Structure • Time scheduling • Attending 12-step meetings • Going to treatment • Exercising • Attending school • Going to work • Performing athletic activities • Attending church

8. Matrix Treatment ModelInformation in Initial Sessions - Substance abuse - Sex and recovery and the brain - Relapse prevention issues - Triggers and cravings - Emotional readjustment - Stages of recovery - Medical effects - Relationships and recovery - Alcohol/marijuana

9. Matrix Treatment ModelInformation Helps: • Reduce confusion and guilt • Explain addict behavior • Give a roadmap for recovery • Clarify alcohol/marijuana issue • Aid acceptance of addiction • Give hope/realistic perspective for family

10. Collaborating Entities • The Court • The District Attorney’s Office • The Office of the Public Defender • East Bay Community Recovery Project • Second Chance • Other service providers

11. History and Setting • Alameda County Drug Court, 1999-present • Matrix Methamphetamine Treatment Trial, 1999-2001 • Programs are located in Hayward, CA: • Small city and suburban area • Primarily working class population • Diverse population

12. The CSAT Methamphetamine Treatment Project • Randomized Treatment Trial • Seven sites with outpatient treatment programs • Matrix Treatment vs. Treatment As Usual • Standardized Assessment: • Intake • Weekly during treatment • End of treatment • Six months • Twelve months

13. MTP Study Enrollment by Criminal Justice Group

14. The Partners: What Each Brings to the Collaboration

15. Goals of Each Collaborating Program

16. Implementation: Key Roles of Structure and Communication

17. Research Outcomes: Ways to Describe Success • Client retention in treatment • Client abstinence • Client program completion Plus Court Outcomes- • Client changes towards NORP behavior • Court program completion • No further CJ system involvement

18. “Judges should coerce treatment until sobriety becomes tolerable” John Chappel, M.D., Prof. of Med., UNR

19. Judicial Supervision • Ongoing judicial supervision increases the likelihood that the participant will remain in treatment • Regular status hearings are used to monitor participant performance

20. Client Retention in Treatment with Drug Court 70 60 50 40 Frequency 30 20 10 0 0 5 10 15 20 Weeks retained (to 2-week drop)

21. Client Retention in MTP Study Treatment

22. Client Abstinence

23. Client Changes Towards NORP Behaviors

24. Percent Reporting Abstinent

25. Client Barriers • Mental disorders • History of abuse and violence • Parenting (child care conflicts) • Conflicting requirements

26. Percent of People Reporting WhoThey Spend Their Free Time With

27. Process Outcomes: What Worked? • Mutual support of court and treatment programs • Open communication about expectations and sanctions • Rewards and recognition

28. Process Outcomes: What Barriers Hindered Success? • Types Of Barriers: • Program-related • Client-related

29. Program Barriers • Limited resources • Resistance from some players • Communication problems • Conflicting goals

30. Client Barriers • Mental disorders • History of abuse and violence • Parenting (child care conflicts) • Conflicting requirements

31. A Strong Drug Court + Treatment Program Collaboration Can: • Reduce or eliminate substance abuse • Help rebuild lives ruined by substance abuse • Reduce prison and jail costs • Reduce the social, psychological, and health costs to families and society.

32. For More Information • Copies of Slide Presentation • www.ebcrp.org • Methamphetamine Treatment Project • www.matrixinstitute.org

33. Heroin & MAT • 977,000 heroin dependent people in US • 146,000 used heroin for the first time in 2000 • 15% ER drug visits • OxyContin® accounting for most new Methadone users

34. Medically Assisted Tx • Barriers and beliefs about Methadone or Buprenorphine don’t comply with scientific evidence • Lack of knowledge by judges, probation, tx providers • New opportunity for collaboration and expansion of these tx modalities

35. Beliefs about Methadone • Taking Methadone is trading one drug for another. T or F? • NADCP Conference in 2002 answered “True” by over 50%! • NEADCP Bd. Of Directors member said, “I’m a judge and I don’t believe in Methadone.” • FACT: Methadone is a medication, not a belief system

36. ONDCP & USDOJConsensus Statement 1997 • Opiate dependence is a brain-related medical disorder that can be effectively treated with significant benefits for the patient and society • All opiate-dependent persons under legal supervision should have access to MAT including Methadone

37. Methadone • Studied for 35 years, more than ANY other medication • Costs $13/day and returns 4:1 in savings • Reduces heroin use by 69% • Criminal activity reduces 52% • Employment increases 24% • 87:100 heroin addicts go back to heroin if withdrawn from Methadone “Methadone,” ONDCP Fact Sheet, Executive Office of the President, (April 2000)

38. Abstinence Based • DTCs are abstinence-based programs • Most courts include a prohibition on alcohol • Some prohibit tobacco • Many judges do not allow graduation if the defendant is on Medication Assisted Therapy (MAT) • Some won’t allow admission to DTC if defendant on MAT

39. A True Story • Bradley Douglas Moore, an addict with a 12-year heroin habit, had the “best summer of his life” according to his wife, when he started a Methadone program • He was given 45 days to get off MAT as a condition of participation in the Nevada County (CA) drug treatment court

40. As his dose dropped, he began to get sick so he started using again. He “kicked cold turkey” in jail and though clean when released, he was “angry and on edge” according to his wife. He said, “If this is what sobriety is like, I’d rather be a junkie.” • He died of an overdose one week later

41. His judge said, “…[I]f a person chooses to not be a drug addict, they can also choose to not be addicted to methadone. Our goal is to break the cycle of addiction.” • The judge admitted he never had any input from a medical professional.

42. His health care professionals said, “Mr. Moore’s was an unnecessary death, caused by the ignorance – perhaps arrogance – of a court that overruled the considered medical judgments of a physician-led team of health providers.”

43. Be a Professional; Ask a Professional • Judges shouldn’t practice medicine • Find references to community resources • Find local experts & engage • Cease & desist letter

44. “VA woman jailed for following doctor’s advice” Aug. 23, 2004 • D addicted to OxyContin® • D’s doctor placed her on Methadone • Judge ordered her off Methadone as a condition of probation but she resumed tx with her doctor’s advice to combat craving • Found in violation, she was sentenced to 3 years in state prison http://www.jointogether.org/sa/news/summaries/reader/0,1854,574254,00.html

45. NADCP • NADCP supported the “no methadone” position for years • In April 2002 new position supporting MAT • “…[M]ethadone patients should not be required to withdraw from a medication that improves their quality of life” to participate in or graduate from drug treatment court

46. NADCP primary goal is to train drug courts all over the country on Methadone • CEO Hon. Karen Freeman-Wilson (Ret.) is committed to MAT with Methadone or Buprenorphine in DTCs

48. Myths & Misconceptions • MYTH: Methadone is just another drug like heroin • FACT: Patients on Methadone don’t get high; tolerance is stable; rarely overdose; very safe • MYTH: A pregnant woman must get off heroin immediately • FACT: Cold turkey withdrawal is likely to cause a miscarriage. Methadone is the preferred treatment for pregnant women

49. MYTH: Methadone affects moods and perceptions just like heroin • FACT: Heroin causes constant mood swings; mood is stable on Methadone. Reaction times and intellectual functioning are normal on Methadone but impaired on heroin

50. MYTH: It makes no difference to the community • FACT: Heroin has a destructive impact on the community; crime is rampant. Methadone reduces crime considerably. Death rates decrease as do HIV/HEP C rates with Methadone. In one study 50-60% of heroin uses tested + compares with <10% if Methadone patients