Transcript 'Moving Evidence Based Treatment into the Drug Court Setting'

"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 New Agendas for Drug Courts
1. Using the latest evidence-based
treatment for Methamphetamine
 2. Using Medication Assisted Treatment
with Methadone or Buprenorphine

MATRIX Project
Best practices for stimulant addiction
 TIP 33 congruent with DTC

Matrix Model of
Outpatient 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
Matrix Model of
Outpatient 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
Matrix Treatment Model
Importance 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
Matrix Treatment Model
Ways to Create Structure
•Time scheduling
•Attending 12-step meetings
•Going to treatment
•Exercising
•Attending school
•Going to work
•Performing athletic activities
•Attending church
Matrix Treatment Model
Information in Initial Sessions
- Substance abuse
and the brain
- Sex and recovery
- Relapse prevention issues
- Triggers and cravings
- Emotional readjustment
- Stages of recovery
- Medical effects
- Relationships and recovery
- Alcohol/marijuana
Matrix Treatment Model
Information 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
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

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
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
MTP Study Enrollment by
Criminal Justice Group
38
Pyramid
ODASA
13
72
34
42
San Diego
106
Honolulu
Hayward
Billings
80
60
10
100
Co Mesa
Concord
Non-Crim
Criminal
69
84
105
50
64
88
The Partners: What Each Brings
to the Collaboration
Court
Treatment
Programs
Program structure
Sanctions
Rewards
Assistance with referrals
Assessment
Substance abuse treatment
Case management
Referrals
Goals of Each Collaborating
Program
Court
Treatment
Programs
Stop criminal behavior
Achieve abstinence
Mandate ancillary services
Retain in treatment
Move towards abstinence
Improve life skills
Implementation: Key Roles of
Structure and Communication
Treatment Providers
Counselor
Case Manager
Court
The Judge
The Drug Court Coordinator
Research Outcomes: Ways to
Describe Success
Client retention in treatment
2. Client abstinence
3. Client program completion
Plus Court Outcomes4. Client changes towards NORP behavior
5. Court program completion
6. No further CJ system involvement
1.
“Judges should coerce treatment
until sobriety becomes tolerable”
John Chappel, M.D., Prof. of Med., UNR
Judicial Supervision
Ongoing judicial supervision increases the
likelihood that the participant will remain in
treatment
 Regular status hearings are used to monitor
participant performance

Client Retention in Treatment
with Drug Court
70
60
Frequency
50
40
30
20
10
0
0
5
10
15
20
Weeks retained (to 2-week drop)
Client Retention in MTP Study
Treatment
Site
Length (weeks)
Billings
Concord
Costa Mesa
8
12
12
Hayward
Honolulu
16
12
San Diego
San Mateo-ODASA
12
16
San Mateo-Pyramid
12
Client Abstinence
mean number of MA-free
UA's
Mean Number of UA’s that were
Methamphetamine
-free during treatment
10
8
6
4
2
0
Matrix
TAU
Billings*
Concord*
CostaMesa*
Hayward
Honolulu*
SanDiego
SanMateoODAS
SanMateoPyra*
GROUP
tesAMP
controlled for Site:
Fgroup= 38.67, p=0.000
Client Changes Towards NORP
Behaviors
Mean # Days
Conflict with
Family
Mean # Days
Conflict with
Others
Mean # Days
Worked
4.0
1.3
1.6
Baseline
6 Month
12 Month
2.0
0.6
1.7
9.0
12.2
12.5
Percent Reporting Abstinent
48
86
85
Methamphetamine
74
Marijuana
64
Alcohol
0
20
40
60
85
84
Baseline
6 Month
79 12 Month
82
80
100
Client Barriers
Mental disorders
 History of abuse and violence
 Parenting (child care conflicts)
 Conflicting requirements

Percent of People Reporting Who
They Spend Their Free Time With
70
60
50
40
30
20
10
0
Baseline
6 Month
12 Month
Family
Friends
Alone
Process Outcomes: What
Worked?
Mutual support of court and treatment
programs
 Open communication about expectations and
sanctions
 Rewards and recognition

Process Outcomes: What Barriers
Hindered Success?

Types Of Barriers:
– Program-related
– Client-related
Program Barriers
Limited resources
 Resistance from some players
 Communication problems
 Conflicting goals

Client Barriers
Mental disorders
 History of abuse and violence
 Parenting (child care conflicts)
 Conflicting requirements

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.

For More Information
•Copies of Slide Presentation
www.ebcrp.org
•Methamphetamine Treatment Project
www.matrixinstitute.org
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
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

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

ONDCP & USDOJ
Consensus 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

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)
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

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

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

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.


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.”
Be a Professional;
Ask a Professional




Judges shouldn’t
practice medicine
Find references to
community resources
Find local experts &
engage
Cease & desist letter
“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
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

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

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
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

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

State Statutes
California law, in response to Mr. Moore’s
death, changed to prohibit exclusion or
MAT patients in any drug diversion
program (PC 1000.8)
 “Prop. 36” includes MAT in the definition
of drug treatment and will be paid for by the
state if the defendant cannot afford to pay
(PC 1210(b))

Judicial Education
NADCP training includes MAT
 NJC’s courses endorse MAT
 State judicial education includes courses on
addition and treatment including MAT

For more information
Addiction Treatment Forum
 www.atforum.com
 SAMHSA Medication Assisted Tx
 http://dpt.samhsa.gov/treatment.htm

What will it take?

Just as the ’60’s
brought drugs to the
middle class followed
by a treatment
explosion, when
judges’ kids get
hooked on OxyContin,
or snort heroin
because “you can’t get
hooked,” then…
Methadone
Will be a sacrament