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What to Know About Mandated Treatment Programs

By: Sarah A. White

 As states and local governments develop plans to invest opioid settlement dollars, policymakers and advocates should consider what the evidence says about mandated drug treatment through the criminal legal system, also known as drug courts, before investing more funds in these programs. 

Evidence from an academic review on the effectiveness of mandated treatment has shown that drug courts often lead to similar rates of re-arrest and future drug use as other interventions. However, local data from the Massachusetts Public Health Department has shown that patients were twice as likely to die of an overdose following mandated treatment compared to those who voluntarily entered treatment.

But why are they not as effective as they may seem? Evidence points to several reasons:

  1. Drug courts often mandate treatment to people who may not have substance use disorders – just drug-related crimes – making this inefficient at connecting patients in need to high-quality treatment. In 2021, a quarter of people entering drug treatment were referred by criminal legal systems. Further, patients going through drug courts often report that court officials prefer intensive residential inpatient services, despite potentially less intensive treatment alternatives being more clinically appropriate for any particular patient.
  2. Mismatches between prescribed treatment and patients’ need may happen because mandated treatment decisions are often overseen by court officials who haven’t received medical training. These officials often show a preference to sobriety focus programs and may not promote evidence-based care, like medication treatment including buprenorphine or methadone. Evidence shows that patients referred to treatment programs by drug courts are nearly ten times less likely to receive medication treatment than patients referred by other sources. This is particularly concerning as a recent Connecticut study demonstrated that patients who were connected to opioid treatment that didn’t include medication were twice as likely to die of an overdose than those who were not connected to treatment at all.
    3. Lastly, studies have shown that Black and Hispanic drug courts participants are less likely to graduate from the program and more likely to be reincarcerated than their White counterparts. A recent review of over 140 drug courts in the U.S. found that nearly two-thirds of program evaluations reported lower graduation rates for Black and Hispanic participants compared to White participants. And further evidence across 8 counties in two U.S. states demonstrated that racial and ethnic disparities persisted in referral and admission rates into drug court programs for the entire decade-long study. This suggests that programs may not be culturally appropriate or that the subjectivity of program success may be influenced by racial biases. 

 Despite this, there are people who have experienced mandated treatment and reported positively about this experience in hindsight. There is evidence that shows these programs are more cost effective than incarcerating individuals for the drug offense, but not more cost effective than less resource-intensive interventions for a patients’ treatment, like outpatient treatment. Further, when drug courts are implemented effectively – by using individualized treatment plans for each patient and a transparent, consistent approach to applying sanctions with sufficient leverage to provide rewards to participants – there is evidence that shows drug courts can reduce recidivism; and, there is qualitative evidence of individuals benefiting from the more rigidly defined program parameters of mandated treatment, highlighting the need to maintain this alternative to incarceration for some patients. However, there are many individuals that are not effectively treated under this system and we lack robust alternative treatment pathways for them.

 Potential solutions

More states are adopting approaches to deliver low-threshold drug treatment services to patients in need of treatment. The four parameters of a medication-first, low-barrier approach include: 

1)    Providing same-day treatment entry and medication access.

2)    Adopting a harm reduction approach that does not punish patients for relapsing.

3)    Removing rigid protocols for in-person appointments, psychosocial counseling, meeting attendance or drug testing.

4)    Providing treatment in non-traditional settings, such as emergency departments and mobile treatment sites. 

These parameters are supported by a report from the National Academies of Sciences that concludes that using behavioral interventions should not be made a condition of accessing medication treatment. 

A recent study of Missouri’s implementation of medication-first treatment in their publicly-funded drug treatment system – which in part included no counseling requirements and same-day medication access – showed that this doubled patients’ utilization of medication treatment, doubled treatment retention rates at six months (the furthest time measured), and reduced treatment costs by 21% compared to the previous year. A 7-year study of buprenorphine treatment in a NYC hospital-based primary care clinic (that did not have counseling requirements) reported retention rates comparable to other centers and no serious adverse events among patients.

Another low-threshold strategy states have adopted is buprenorphine initiation in the emergency department. Patients who were initiated on buprenorphine in an emergency department, compared to a brief intervention and referral, were twice as likely to remain engaged in treatment at follow-up and three times less likely to self-report continued illicit opioid use. Further, buprenorphine initiation in the emergency department has been found to be more cost-effective than referral-based alternatives.

Other recent changes have occurred because of recent DEA regulation changes that allow opioid-treatment programs to dispense methadone through mobile units. Mobile clinics have already been delivering buprenorphine to patients that lack access in rural communities, leaving city jails, and experiencing homelessness, with these programs achieving outcomes similar to those of office-based programs. 

Initiating buprenorphine treatment in the emergency department and delivering medication through mobile clinics are core components of SAMHSA’s “no-wrong door” approach, which focuses on making referrals to treatment wherever patients enter systems of care. Other areas to expand a no-wrong door approach to are primary care clinics, jails, and harm reduction programs. These approaches can be supported by expanded telehealth allowances, which help meet patients where they are without increasing rates of overdose. 

Finally, states that have, or are still planning to adopt, drug courts should adopt harm reduction-centered principles to guide future implementation. This includes not requiring abstinence for successful program engagement, training drug court professionals to connect patients to evidence-based medication treatment, and including alternatives to arrest for people with drug offenses who do not have substance use disorders so treatment resources aren’t strained on those not in need of services. 

About the Author:

Sarah White is a Research Associate in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. Her work has focused on the implementation of state policies on substance use disorder treatment, understanding the impact of policies on patients with chronic pain or substance use disorders, and developing an evidence-base for communication strategies on harm reduction and medications for opioid use disorder.