Moving Evidence Based Treatment into the Drug Court Setting

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"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

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2 New Agendas for Drug Courts

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

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MATRIX Project

• Best practices for stimulant addiction
• TIP 33 congruent with DTC

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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

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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

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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

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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

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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
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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

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Collaborating Entities

• The Court
• The District Attorneys Office
• The Office of the Public Defender
• East Bay Community Recovery Project
• Second Chance
• Other service providers

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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

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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

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MTP Study Enrollment by Criminal Justice Group
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The Partners What Each Brings to the
Collaboration
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Goals of Each Collaborating Program
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Implementation Key Roles of Structure and
Communication
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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

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Judges should coerce treatment until sobriety
becomes tolerable   John Chappel, M.D., Prof. of
Med., UNR    
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Judicial Supervision

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

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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)
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Client Retention in MTP Study Treatment
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Client Abstinence
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Client Changes Towards NORP Behaviors
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Percent Reporting Abstinent
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Client Barriers

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

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Percent of People Reporting WhoThey Spend Their
Free Time With
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Process Outcomes What Worked?

• Mutual support of court and treatment programs
• Open communication about expectations and
  sanctions
• Rewards and recognition

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Process Outcomes What Barriers Hindered Success?

• Types Of Barriers
• Program-related
• Client-related

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Program Barriers

• Limited resources
• Resistance from some players
• Communication problems
• Conflicting goals

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Client Barriers

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

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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.

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For More Information

• Copies of Slide Presentation
• www.ebcrp.org
• Methamphetamine Treatment Project
• www.matrixinstitute.org

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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

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Medically Assisted Tx

• Barriers and beliefs about Methadone or
  Buprenorphine dont comply with scientific
  evidence
• Lack of knowledge by judges, probation, tx
  providers
• New opportunity for collaboration and expansion
  of these tx modalities

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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, Im a judge
  and I dont believe in Methadone.
• FACT Methadone is a medication, not a belief
  system

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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

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Methadone

• Studied for 35 years, more than ANY other
  medication
• Costs 13/day and returns 41 in savings
• Reduces heroin use by 69
• Criminal activity reduces 52
• Employment increases 24
• 87100 heroin addicts go back to heroin if
  withdrawn from Methadone

Methadone, ONDCP Fact Sheet, Executive Office
of the President, (April 2000)
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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 wont allow admission to DTC if defendant on
  MAT

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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

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• 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, Id
  rather be a junkie.
• He died of an overdose one week later

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• His judge said, If 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.

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• His health care professionals said, Mr. Moores
  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.

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Be a Professional Ask a Professional

• Judges shouldnt practice medicine
• Find references to community resources
• Find local experts engage
• Cease desist letter

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VA woman jailed for following doctors advice
Aug. 23, 2004

• D addicted to OxyContin
• Ds doctor placed her on Methadone
• Judge ordered her off Methadone as a condition of
  probation but she resumed tx with her doctors
  advice to combat craving
• Found in violation, she was sentenced to 3 years
  in state prison

http//www.jointogether.org/sa/news/summaries/read
er/0,1854,574254,00.html
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NADCP

• NADCP supported the no methadone position for
  years
• In April 2002 new position supporting MAT
• Methadone 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

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• 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

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Myths Misconceptions

• MYTH Methadone is just another drug like heroin
• FACT Patients on Methadone dont 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

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• 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

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• 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 lt10
  if Methadone patients

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State Statutes

• California law, in response to Mr. Moores 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))

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Judicial Education

• NADCP training includes MAT
• NJCs courses endorse MAT
• State judicial education includes courses on
  addition and treatment including MAT

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For more information

• Addiction Treatment Forum
• www.atforum.com
• SAMHSA Medication Assisted Tx
• http//dpt.samhsa.gov/treatment.htm

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What will it take?

• Just as the 60s brought drugs to the middle
  class followed by a treatment explosion, when
  judges kids get hooked on OxyContin, or snort
  heroin because you cant get hooked, then

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Methadone
Will be a sacrament
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(No Transcript)