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 1. Using the latest evidence-based treatment for Methamphetamine 2. Using Medication Assisted Treatment with Methadone or Buprenorphine 2. Using Medication Assisted Treatment with Methadone or Buprenorphine

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

4. 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

5. 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

6. 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

7. 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

8. Matrix Treatment Model Information 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 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

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

11. History and Setting Alameda County Drug Court, 1999-present Alameda County Drug Court, 1999-present Matrix Methamphetamine Treatment Trial, 1999-2001 Matrix Methamphetamine Treatment Trial, 1999-2001 Programs are located in Hayward, CA: 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 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 Court Program structure SanctionsRewards Assistance with referrals Treatment Programs Assessment Substance abuse treatment Case management Referrals

15. Goals of Each Collaborating Program Court Stop criminal behavior Achieve abstinence Mandate ancillary services Treatment Programs Retain in treatment Move towards abstinence Improve life skills

16. Implementation: Key Roles of Structure and Communication

17. Research Outcomes: Ways to Describe Success 1. Client retention in treatment 2. Client abstinence 3. Client program completion Plus Court Outcomes- 4. Client changes towards NORP behavior 5. Court program completion 6. No further CJ system involvement

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

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

20. Client Retention in Treatment with Drug Court 05101520 Weeks retained (to 2-week drop) 0 10 20 30 40 50 60 70 Frequency

21. Client Retention in MTP Study Treatment Site Length (weeks) Billings8 Concord12 Costa Mesa 12 Hayward16 Honolulu12 San Diego 12 San Mateo-ODASA 16 San Mateo-Pyramid 12

22. Client Abstinence

23. Client Changes Towards NORP Behaviors

24. Percent Reporting Abstinent

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

26. Percent of People Reporting Who They Spend Their Free Time With

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

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

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

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

31. A Strong Drug Court + Treatment Program Collaboration Can: Reduce or eliminate substance abuse Reduce or eliminate substance abuse Help rebuild lives ruined by substance abuse Help rebuild lives ruined by substance abuse Reduce prison and jail costs Reduce prison and jail costs Reduce the social, psychological, and health costs to families and society. 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 Barriers and beliefs about Methadone or Buprenorphine don’t comply with scientific evidence Lack of knowledge by judges, probation, tx providers Lack of knowledge by judges, probation, tx providers New opportunity for collaboration and expansion of these tx modalities 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? Taking Methadone is trading one drug for another. T or F? NADCP Conference in 2002 answered “True” by over 50%! 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.” 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 FACT: Methadone is a medication, not a belief system

36. 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 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 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 Studied for 35 years, more than ANY other medication Costs $13/day and returns 4:1 in savings Costs $13/day and returns 4:1 in savings Reduces heroin use by 69% Reduces heroin use by 69% Criminal activity reduces 52% Criminal activity reduces 52% Employment increases 24% Employment increases 24% 87:100 heroin addicts go back to heroin if withdrawn from Methadone 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 DTCs are abstinence-based programs Most courts include a prohibition on alcohol Most courts include a prohibition on alcohol Some prohibit tobacco Some prohibit tobacco Many judges do not allow graduation if the defendant is on Medication Assisted Therapy (MAT) 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 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 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 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.” 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 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.” 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. 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.” 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 Judges shouldn’t practice medicine Find references to community resources Find references to community resources Find local experts & engage Find local experts & engage Cease & desist letter Cease & desist letter

44. “VA woman jailed for following doctor’s advice” Aug. 23, 2004 D addicted to OxyContin® D addicted to OxyContin® D’s doctor placed her on Methadone 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 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 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 NADCP supported the “no methadone” position for years In April 2002 new position supporting MAT 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 “…[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 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 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 MYTH: Methadone is just another drug like heroin FACT: Patients on Methadone don’t get high; tolerance is stable; rarely overdose; very safe FACT: Patients on Methadone don’t get high; tolerance is stable; rarely overdose; very safe MYTH: A pregnant woman must get off heroin immediately 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 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 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 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 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 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

51. 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) 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)) “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))

52. Judicial Education NADCP training includes MAT NADCP training includes MAT NJC’s courses endorse MAT NJC’s courses endorse MAT State judicial education includes courses on addition and treatment including MAT State judicial education includes courses on addition and treatment including MAT

53. For more information Addiction Treatment Forum Addiction Treatment Forum www.atforum.com www.atforum.com www.atforum.com SAMHSA Medication Assisted Tx SAMHSA Medication Assisted Tx http://dpt.samhsa.gov/treatment.htm http://dpt.samhsa.gov/treatment.htm http://dpt.samhsa.gov/treatment.htm

54. 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…

55. Methadone Will be a sacrament