Drug courts and the “wonder drug”

Anyone who reads this blog regularly knows that the evidence for Suboxone has been oversold and that it often does not address the real-world goals of most addicts or families. They want recovery–a restoration to wholeness and full participation in all spheres of life over the rest of their lifespan. The evidence base for maintenance drugs tends to focus on short term outcomes and on reductions in overdose, disease transmission and criminal justice involvement.

That said, I’ve made it plain that I’m not interested in taking options away from patients, especially well-informed patients.

Along comes this news that the new drug czar is going to require drug courts receiving federal funds allow the use of maintenance drugs. (Under the headline. “Wonder Drug” at Slate.)

It’s got maintenance treatment and harm reduction advocates whoop-whoop-ing. It’s got abstinence-based recovery advocates concerned.

The article begs a lot of questions. For example,

• If “doctors and scientists view [these drugs] as the most effective care for opioid addicts”, why aren’t more doctors willing to prescribe it? And, why don’t they use these drugs with their addicted colleagues?
• Why do the authors fail to acknowledge the longer term studies that find poor retention of patients on Suboxone? (Here, here, here, here and here.)
• How did these “medications, when combined with other behavioral supports” become “the standard of care for the treatment of opiate addiction” when studies have found that people on maintenance medications do not benefit from additional behavioral therapy? (Here, here, here and here.)

However, as a policy matter, given the context within the field, this move makes sense.

Drug courts have sought more than reduced criminal activity. They’ve looked for the same kind of transformational recovery that families often seek. Maybe it’s appropriate for the feds to take these steps. I don’t have any strong feelings about it.

However, this is going to be a very good opportunity to learn a lot about the effectiveness of Suboxone over 12 to 24 months.

• What will happen when you prescribe it to patients who are in a system that provides long term and robust recovery monitoring with enforced abstinence from illicit drugs and participation in behavioral treatment/support?
• Will patients want to stay on the drug?
• If not, will courts treat the decision to discontinue maintenance as non-compliance with treatment?
• How will improvements in quality of life measures for these participants compare to other participants?
• Will they experience the same benefits from the behavioral interventions that other participants do?

Drug Courts Are Not the Answer?

The Drug Policy Alliance has a new paper that characterizes drug courts as a failure and advocates abandoning them for all but the most serious cases.

I often disagree with the DPA, but this time I feel a little disappointed.

Basically, they poke holes in the arguments that drug courts are an effective alternative to incarceration and make the argument that drug courts are no better or worse than conventional criminal justice approaches.

They poke holes by pointing to the inconclusive nature of a lot of research frequently cited by drug court supporters. This is fair, but, of course, their challenges are also pretty equivocal. Further, they complain that the outcome measures are abstinence focused. This may be a perfectly legitimate criticism of outcome measures, but it kind of undermines the argument that drug courts are not effective—if we lower the bar to include reduced drug use, the outcomes will look better, no?

What disappointed me that the argument that they are no better or worse than conventional approaches. This is hard to swallow and they didn’t make the case, leaving one to assume that this conclusion is based on their point of view rather than evidence. (That is ok with me. I can respectfully discuss a point of view if the person acknowledges and is prepared to discuss the values that inform their point of view. The problem is that they frequently present themselves as being guided only by evidence.) My perspective of drug courts is limited to what I’ve seen in my region and clearly, some are better than others and, maybe in some communities, they’ve made the situation worse.  However, the drug/sobriety court in Ann Arbor works. I have no doubt that it results in far fewer days of incarceration overall and significant improvements in quality of life for most participants.

There were some recommendations for improvement and an acknowledgement that Prop 36 in California was an improvement, but, unless you want to talk about legalization, it’s sweeping “findings” didn’t exactly feel like a conversation starter.