Incorporating Medication in Opioid Courts - Reducing Overdose Through Triage in Treatment Court Settings
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Incorporating Medication in Opioid Courts Reducing Overdose Through Triage in Treatment Court Settings
Author
Michael Friedrich
Center for Court Innovation
Working Group
Becky Berkebile, MA Sheila McCarthy, LMSW
Senior Program Associate Senior Program Manager, Technical Assistance
Advocates for Human Potential, Inc. Center for Court Innovation
Michael Chaple, PhD Charles Morgan, MD, DFASAM, FAAFP
Assistant Professor of Clinical Medical Psychology Technical Assistance Provider
(in Psychiatry) Opioid Response Network
Division on Substance Use Disorders, New York State
Psychiatric Institute
Department of Psychiatry, Columbia University Dennis Reilly, Esq.
Irving Medical Center Statewide Drug Court Coordinator
Office for Justice Initiatives, Division of Policy
and Planning
Judge Jo Ann Ferdinand (retired)
President
The Joseph LeRoy and Ann C. Warner Fund Kimberly Schwarz, MS
Regional Project Manager
Office for Justice Initiatives, Division of Policy
Steve Hanson and Planning
Associate Commissioner
Courts and Criminal Justice
New York State Office of Addiction Services Susan Sturges, MA, MPA
and Supports Opioid Court Project Director
Office for Justice Initiatives, Division of Policy
and Planning
Ariel Hurley, LMSW/MPH
New York and New Jersey Technology Transfer
Specialist, Opioid Response Network Kathleen West, DrPH
Division on Substance Use Disorders, New York State Senior Program Manager
Psychiatric Institute Advocates for Human Potential, Inc.
David Lucas
Clinical Advisor, Technical Assistance
Center for Court Innovation
Center for Court Innovation bAcknowledgements This project was supported by Grant No. 2018-AR- The authors would like to acknowledge the work BX-K002 awarded by the Bureau of Justice Assistance of the Buffalo City Court in pioneering the opioid (BJA) under the Comprehensive Opioid, Stimulant court model, in 2017, to provide immediate inter- and Substance Abuse Program (COSSAP). BJA is a vention, treatment, and medication for defendants component of the Department of Justice’s Office of at risk of opioid overdose. That work was captured, Justice Programs, which also includes the Bureau in 2019, by the UCS Division of Policy and Planning, of Justice Statistics, the National Institute of Justice, in cooperation with the Center, in The 10 Essential the Office of Juvenile Justice and Delinquency Elements of Opioid Intervention Courts. Opioid courts Prevention, the Office for Victims of Crime, and have been supported by BJA, the National Institute the SMART Office. Points of view or opinions in on Drug Abuse, and the Center for Substance Abuse this document are those of the author and do not Treatment at SAMHSA; prioritized in New York State necessarily represent the official position or policies by Chief Judge Janet DiFiore; and expanded over time of the U.S. Department of Justice. by OASAS. The authors wish to thank the Center, Funding for this initiative was also made AHP, and ORN for making this project possible. possible in part by grant nos. 6H79TI080816 and 1H79TI083343 from Substance Abuse and Mental July 2021 Health Services Administration (SAMHSA). The views expressed in written conference materials or publica- tions and by speakers and moderators do not neces- sarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. The New York State Unified Court System (UCS), Office for Justice Initiatives, Division of Policy and Planning, in partnership with the Center for Court Innovation (Center) and the Office of Addiction Services and Supports (OASAS), carried out this project to develop and expand drug and opioid intervention courts in New York State. Advocates for Human Potential (AHP) and the Opioid Response Network (ORN), funded by SAMHSA, provided techni- cal assistance to support this initiative. The authors consulted two experts in the production of this document. Dr. Charles Morgan, technical assistance provider for ORN and former medical director of OASAS, is a long-time medical expert with a specialty in addiction. Retired Justice Jo Ann Ferdinand of the Kings County Supreme Court developed the Brooklyn Treatment Court, the first drug court in New York City, in 1996, and is a judicial expert known for her court’s innovative practices in the use of medication for opioid use disorder (MOUD). Incorporating Medication in Opioid Courts 1
Interviews
The authors would like to acknowledge the following Denise Dizzine
people, who offered their time to be interviewed for District Liaison, 9th Judicial District Problem Solving
this report. Courts Office, New York
Naima Aiken Aaron Fox, MD
Project Director, Misdemeanor Treatment Courts, Associate Professor of Medicine, Albert Einstein
Queens Criminal Court College of Medicine
Carmen Alcantara Jo Ann Friia
Treatment Alternatives Program Manager, Judge, White Plains City Court, New York
Bronx Community Solutions, Center for
Court Innovation
Edward Gialella
District Liaison, 10th Judicial District,
Maria Almonte Problem Solving Courts Office, New York
Project Director, Bronx Community Solutions,
Center for Court Innovation
Brandon George
Vice President of Recovery, Programs, Advocacy
Elie Aoun, MD, MRO at Mental Health America of Indiana
Psychiatrist Director, Indiana Addiction Issues Coalition
Assistant professor of clinical psychiatry
Columbia University—Division of Law, Medicine
and Psychiatry George Grasso
Supervising Judge, Criminal Court of the City of New
York, Bronx County
Lawrence S. Brown, Jr., MD
Chief Executive Officer, START Treatment &
Recovery Centers Frances Grimaldi
City Court Attorney, Syracuse City Court
Steven W. Brockett
Judge, City Court of Middletown, New York Joseph E. Gubbay
Judge, Brooklyn Treatment Court, Kings County
Supreme Court, New York
Brian D. Burns
Supreme Court Justice, Otsego County, New York
Kristy Holland
Opioid Court Coordinator, Dunkirk Opioid Court,
New York
Center for Court Innovation 2Polly A. Hoye Linda Sacco, PhD
Judge, Fulton County Court, New York Head of Clinical Services, Kaden Health
Sara Luck Daniel Schick
Resource Coordinator, Fulton County Drug Court, Resource Coordinator, Opioid Intervention Court,
New York Syracuse City Court, New York
King McElvy Allegra Schorr
Peer Advocate and Recovery Coach, Camino Nuevo President, Coalition of Medication Assisted
Treatment Providers and Advocates
Rory McMahon
Judge, Opioid Intervention Court, Syracuse City Patrick Seche
Court, New York Senior Associate, Department of Psychiatry,
University of Rochester Medical Center
Mark W. Parrino
President, American Association for the Treatment Matisyahu Shulman, MD
of Opioid Dependence Psychiatrist, Columbia University Department
of Psychiatry
Steven Rabinowitz
Addiction Services Consultant Jeff Smith
Special Projects Coordinator, Argus Community, Inc District Liaison, 8th Judicial District, Problem
Solving Courts Office, New York
Mark Raymond
Opioid Treatment Program Director, Farnham Angelia Smith-Wilson, PhD
Family Services Executive Director, Friends of Recovery New York
Ruth Riddick Sharon Stancliff, MD
Community Outreach and Communications, Medical Director for Harm Reduction in Health Care,
Alcoholism and Substance Abuse Providers of New AIDS Institute, New York State Department
York State of Health
Staff Physician, Project Renewal
Robert Ross
President and Chief Executive Officer, St. Joseph’s
Addiction Treatment and Recovery Centers
Incorporating Medication in Opioid Courts 3Ross Sullivan, MD Director-Medical Toxicology Fellowship Medical Director, SUNY Upstate Opioid Emergency Bridge Clinic Zachary Talbott, MSW, CAADC, MATS, CCS Director of Clinical Services, ReVIDA Recovery Centers President of NAMA Recovery Andrew Tartasky, PhD Founder and Executive Director, Center for Optimal Living Timothy Wiegand, MD Associate Professor, Department of Emergency Medicine, University of Rochester Medical Center E. Loren Williams Judge, Newburgh City Court, New York Sarah Wurzburg Program Director, Substance Addiction, Council of State Governments Justice Center Timothy Zacholl Substance Services Coordinator, ACR Health Center for Court Innovation 4
Working Group
Acknowledgements 1
Interviews 2
Table of Contents 5
Abstract 6
I. Introduction 7
II. Findings 10
Provide immediate screening and treatment 10
Offer multiple options and access points to treatment 11
Improve coordination of services 14
Integrate support from peer advocates 16
Use innovative business models to secure sufficient reimbursement 17
Track outcomes 19
III. Conclusion 21
Incorporating Medication in Opioid Courts 5Abstract To manage the opioid crisis in the United States, the justice system has adapted to develop approaches that address opioid use disorder (OUD) while reducing incarceration. One important effort is opioid intervention courts, specialized programs that draw on the experience of other evidence-based treatment courts to offer immediate connections to medication for opioid use disorder (MOUD) and intensive supervision and support. Opioid courts have succeeded in saving lives, but they also face barriers to enrolling participants and delivering MOUD to all who would benefit from it. This report is motivated by a desire to improve access to MOUD, specialty care, community support services, and peer advocates through opioid courts and other drug treatment courts. It shares lessons from opioid court practitioners and their partners about what quality MOUD care, treatment, and use look like; how to promptly identify potential court participants and provide access to MOUD and specialty care; and how to identify and engage MOUD providers. It also in- cludes descriptions of recent innovations developed during the COVID-19 pandemic that could make it easier to connect patients to MOUD in the future. The goal is to assist practitioners in treatment courts and other settings as they seek to improve access to MOUD and specialty treatment services as part of the criminal legal process. Center for Court Innovation 6
I. Introduction and intensive supervision and support.
MOUD has long been an effective approach
to treating OUD. The medications methadone,
The United States faces an urgent crisis of opioid
buprenorphine, and long-acting, injectable
use and overdose deaths. Heroin, prescription pain
naltrexone,5 in combination with counseling and
relievers, and synthetic opioids like fentanyl stand
behavioral therapies, help to stabilize the immediate
at the center of a deadly national epidemic that
withdrawal symptoms associated with opioid use
has surged during the COVID-19 crisis. More than
cessation and begin a process of long-term recovery.
87,000 people died from drug overdoses in the
Research shows that MOUD reduces drug use,
year leading up to September 2020, and overdose
disease rates, overdose deaths, and criminal activity
deaths involving synthetic opioids rose 38.4 percent
while also increasing treatment engagement among
during that period.1 Increasingly, fentanyl appears
patients with OUD.6 According to the National
in other drugs, including stimulants like cocaine
Institute of Drug Abuse, the longer patients remain
and methamphetamine, contributing to a dramatic
in MOUD treatment the better their outcomes.7 More
increase in stimulant overdose in recent years.
importantly, research has shown repeatedly that it
Fentanyl was detected in 80.4 percent of opioid
is safer and more effective to use MOUD than not
overdose deaths involving stimulants between
to use it. Studies demonstrate that the incidence of
January and June of 2019.2
fatal overdose for people who do not receive MOUD
Underlying opioid use disorder (OUD) and the
is as high as 20 percent while it is 0 percent for those
overdose crisis is the disease of addiction. “Addiction
who continue MOUD treatment.8 For people with
is a treatable, chronic medical disease involving
OUD, MOUD is now the recognized standard of care,
complex interactions among brain circuits,
and connecting them to MOUD treatment should be
genetics, the environment, and an individual’s life
the first line of intervention.
experiences,” according to the American Society
Drug treatment courts are an evidence-based
of Addiction Medicine (ASAM). Influences from the
justice system intervention for connecting people to
environment and a person’s life experiences may
treatment for substance use disorder and reducing
include social determinants of health such as a
criminal recidivism.9 Drug courts have been
history of trauma, housing and income instability,
effective in reducing drug use among people who,
and a structural lack of access to care, which
at baseline, used drugs more often and had a more
can contribute to and compound the underlying
serious primary drug of choice than marijuana,
disease. “People with addiction use substances or
such as cocaine, heroin, or methamphetamine.10
engage in behaviors that become compulsive and
However, people with OUD may be disqualified from
often continue despite harmful consequences,”
participation in traditional drug courts because
ASAM continues. “Prevention efforts and treatment
they do not meet the courts’ strict eligibility
approaches for addiction are generally as successful
requirements; often, they face less serious charges,
as those for other chronic diseases.”3
like simple possession, and present a low risk of
The harmful consequences of OUD pose special
recidivism.11 Even when they are accepted into a
challenges for the justice system. Opioid-related
drug court, the treatment they receive may not be
arrests have increased, and police, probation officers,
immediate enough to address their overdose risk.12
corrections officers, and court staff are frequently
In the past, a variety of barriers—including a lack
called upon to respond to people suffering overdoses
of understanding about the science of OUD and
and severe withdrawal symptoms.4 To manage these
the effectiveness of MOUD, the belief that using
challenges, they have worked to develop approaches
MOUD is “substituting one drug for another,” and
that address OUD while reducing incarceration.
concerns that MOUD is not a practical fit within
One important effort is opioid intervention courts
the drug court model—also prevented many drug
and other specialized programs designed to offer
courts from permitting patients to enroll in and be
immediate connections to evidence-based treatment
maintained on MOUD.13 Through a combination
including medication for opioid use disorder (MOUD)
of state and federal guidance, research outcomes,
Incorporating Medication in Opioid Courts 7and practical use, drug courts came to recognize to enrolling participants and delivering MOUD to
the need for an additional mechanism to enroll the all who would benefit from it. New York State’s
broad population of people with low-level opioid recently implemented Criminal Justice Reform Act
offenses who were unlikely to take a plea, yet needed (CJRA),16 despite its many positive impacts, makes
immediate access to MOUD and other treatment it more difficult to attract people to opioid court
services for OUD. programs. Traditionally, treatment courts used the
In 2017, the Buffalo City Court designed an crisis of an arrest and the coercive power of the
opioid court, an expansion of its many innovative legal process to motivate people to accept treatment
treatment courts. It has become a national example as an alternative to incarceration. But the CJRA
by innovating ways to rapidly link participants removes that lever by eliminating bail for nonviolent
with evidence-based treatment, and other drug felonies and mandating desk appearance tickets for
courts have established opioid courts based on their most misdemeanors that are eligible for treatment
recognition of this need. In most cases, opioid courts court. This reduces the appeal of diversion programs
sit within drug courts and take advantage of existing because many people are less incentivized to enroll
staff, relationships, and resources to more effectively in a court-supervised treatment program without
triage participants’ immediate needs, serve the large the benefit of avoiding jail. It also delays court
population that may not take a plea, and create contact with potential court participants, reducing
a pathway for longer-term care including MOUD. opportunities for early intervention.
Preliminary findings from a recent study by NPC Other barriers prevent opioid courts from
Research, funded by BJA, show that the opioid court offering MOUD access. In many remote and rural
at Buffalo City Court is succeeding in its primary jurisdictions, courts lack access locally to a federally-
goal of saving lives: participants are half as likely to licensed opioid treatment program, the only
die of a drug overdose within one year of enrollment locations at which methadone can be prescribed.17
when compared to people using opioids who were Buprenorphine access is also subject to limitations.
arrested and experienced typical case processing.14 To prescribe the medication, practitioners must
New York has expanded the model to other regions hold a buprenorphine waiver, and while many
of the state, establishing a total of 25 new opioid practitioners do, a significant proportion do not
courts through its Unified Court System (UCS). currently use it or prescribe to the capacity that
Opioid courts use a person’s initial contact with it allows—often because they lack the training or
police or the justice system as an opportunity to staff to support patients with OUD.18 (In late April
identify OUD and engage potential participants of 2021, during final preparations of this document,
using non-traditional and non-coercive measures. federal requirements for prescribing buprenorphine
This includes immediate screening, treatment were broadened to include the ability for some
engagement, intensive judicial monitoring, and types of prescribers to obtain a waiver from SAMHSA
recovery support to prevent opioid overdose and to treat up to 30 patients without having to meet
set participants on a path to long-term recovery. certain certification requirements.19) Similarly, the
Opioid courts suspend the prosecution of cases while long-acting, injectable forms of naltrexone and
patients are in treatment and do not punish people buprenorphine are complicated and time-consuming
who honestly admit to using again. Importantly, for prescribers to locate, obtain, and store, as well
all opioid courts in New York State also offer access as being cost-prohibitive for many patients who
to MOUD prescription as part of their practices, in are uninsured. Some opioid court participants face
acknowledgment of the research demonstrating its challenges to appearing at in-person appointments
efficacy both as an immediate life-saving measure for MOUD prescriptions and maintenance. Even in
and for maintenance. As one project director of locations where telehealth services are available
a New York City opioid court said, “If there’s a for remote appointments, underserved patients
medication that will help participants to not use and may lack computers, smartphones, or WiFi and
to not die, who are we to prohibit it?”15 data coverage. Meanwhile, as mixing fentanyl into
However, opioid courts face their own barriers stimulants becomes more frequent, there is also
Center for Court Innovation 8a possibility that people at high risk of overdose Many courts have expanded telehealth services to due to stimulant use may be excluded from opioid reach more patients. Finally, courts have benefited courts because courts perceive them to be low-risk from an evolving concept of recovery that recognizes and not to need triage. Finally, opioid courts also more pathways and includes a greater acceptance of struggle with stigma from court, medical, and MOUD. Yet much work still remains to be done. mutual support communities against OUD, MOUD The goal of this report is to identify ways for prescription, and criminal justice involvement. opioid courts and other drug treatment courts to Beyond these issues, research has shown that improve access to MOUD. It shares lessons from race, ethnicity, and income play a significant role opioid court practitioners and their partners in access to certain forms of MOUD, in New York about what quality MOUD care, treatment, and State and elsewhere. Non-Black and non-Latinx use look like; how to promptly identify potential patients with higher incomes are more likely to court participants and provide access to MOUD receive buprenorphine treatment, while Black and specialty care; and how to identify and engage and Latinx patients with lower incomes are more MOUD providers. The goal is to assist an audience of likely to receive methadone treatment, a fact that practitioners in treatment courts and all criminal can increase stigma toward low-income patients of courts where people at risk of overdose have cases, color.20 These factors have contributed to bifurcated as well as partners and potential partners of models of care in which low-income patients of color treatment courts (including treatment providers, often receive methadone treatment requiring daily health care practitioners, law enforcement officials, clinic visits and close scrutiny, while middle-class probation departments, and social service agencies), White patients often receive more discrete, less as they seek to improve access to MOUD and intrusive buprenorphine treatment administered specialty treatment services as part of the criminal outside of clinics.21 Moreover, implicit racial bias legal process. among physicians is common in the medical While this report was in progress, the country profession, and Black patients who perceive their began to experience the effects of COVID-19. provider as discriminatory are more likely to The pandemic drove an increase in drug use cease treatment for substance use disorder.22 In and overdoses and disrupted court operations, general, Black patients are less likely to accept treatment programs, and health services.25 It also MOUD treatment due to mistrust of the American led to policy changes by the government—such as health care, social services, and criminal justice waiving requirements for in-person visits before systems, which have historically contributed to beginning MOUD, relaxing prescribing regulations their oppression.23 These facts present a particular to allow clinicians to write prescriptions for longer challenge, since Black Americans now face the periods, and increasing opportunities for telehealth highest rate of increase in opioid deaths.24 counseling—that improved access to life-saving Opioid courts have worked to address these services. Accordingly, this report also includes barriers. They have responded to the lack of perspectives from practitioners considering very legal leverage by developing new incentives recent innovations that could make it easier to to encourage voluntary participation, such as connect patients to MOUD in the future. allowing participants to defer the prosecution of a criminal case, enrolling them in the program on a pre-plea basis, using fewer sanctions for non- compliance, emphasizing positive reinforcement for attendance, and not requiring a commitment to long-term abstinence from all substances in order to participate. They have also supported participant engagement by providing more immediate access to MOUD, health, mental health, peer advocate, and recovery support services on a voluntary basis. Incorporating Medication in Opioid Courts 9
II. Findings that they typically screen patients before,
during, or immediately after arraignment.
They use validated risk assessment tools, and
To produce the findings in this report, the authors
employ broad eligibility requirements for
conducted in-depth interviews with 40 practitioners
participation.27 During screening, court staff
from across disciplines, including treatment pro-
determines patients’ eligibility for treatment
viders; prescribers; office-based addiction treatment
court programs, allows them to opt into MOUD
programs; opioid court case managers, coordinators,
and treatment immediately, and connects them
and project directors; harm reduction specialists;
to an opioid treatment program or provider that
judges; researchers; justice-involved people; and
prescribes the MOUD option they need.
people with lived experience of recovery. The authors
asked these interviewees questions about their
At Syracuse Opioid Court, a community resource
experience with partnerships between opioid courts
provider meets patients in jail to assess them as
and prescribers, settings for prescribing and induc-
candidates for opioid court, begin the process
tion, added responsibilities for prescribers, business
of referral to services, and connect them with
models and reimbursement, ways to address stigma,
MOUD prescribers as soon as possible.28 At the
roles for peer advocates, coordination of care, and
Bronx Overdose Avoidance and Recovery Court,
telehealth services. Practitioners offered a range of
staff conducts identification and assessment
perspectives, made recommendations, and offered
of candidates for opioid court and MOUD
resources based on their work under the current
while defendants are awaiting arraignment or
system New York State’s opioid courts use to connect
immediately thereafter. That jurisdiction has
participants with MOUD. The authors reviewed these
also worked with its police precinct to identify
practitioner perspectives and several important
candidates immediately after arrest, a measure
themes emerged in the findings, which are present-
that assists patients who would otherwise
ed here in the form of distinct recommendations.
face a delay in assessment while they awaited
arraignment under the recent CJRA bail reform.29
Researchers and clinicians said that it is a best
Provide immediate screening practice for courts to offer patients a telehealth
and treatment services link for MOUD assessment before
connecting them with other psychosocial and
Practitioners reported that it is extremely important community-based treatments.30 (For more on
that courts offer patients MOUD access as soon telehealth services, see the recommendation
as possible, because they suffer potentially grave “Provide telehealth access to treatment” on p. 13.)
consequences if forced to wait for treatment while
they move through the legal process. “From a clinical 2. Screen for co-occurring disorders: Clinicians
standpoint, as soon as you’ve got them, treat them,” stressed that courts should screen patients
said Linda Sacco, head of clinical services at Kaden not only for opioid and other substance use
Health, a company that provides MOUD prescrip- disorders but for co-occurring mental health
tions along with individual and group therapy disorders and social determinants of health. They
through its online platform.26 This approach offers should also learn about patients’ histories with
patients the best chance of recovery and favorable psychiatric and other medications. Devoting
criminal justice outcomes. Practitioners recommend- equal attention to each of these factors can help
ed the following. avoid complications and side effects for patients
during treatment.
1. Screen and treat patients on a pre-plea basis:
Providing patients with treatment on a pre-plea Resources: The Brief Jail Mental Health Screen,
basis distinguishes opioid courts from many developed by Policy Research Associates with
traditional drug courts. Court staff reported funding from the National Institute of Justice, is
Center for Court Innovation 10a booking tool for screening people in jails and and the U.S. Department of Agriculture
detention centers to determine their needs for provide community assessment tools:
further mental health assessment. https://www. ruralcommunitytoolbox.org.
prainc.com/?product=brief-jail-mental-health-
screen Shatterproof recently launched an online tool:
Addiction Treatment Locator Assessment and
3. Use a validated risk assessment tool: Court staff Standards Platform in nine states, including New
and practitioners recommended that all courts York: treatmentatlas.org.
employ one or more validated risk assessment
tools as part of their screening process to 5. Use the Sequential Intercept Model: Because
determine which patients are candidates for opioid courts operate on a pre-plea basis, the
MOUD. These could include the Clinical Opiate opportunity for intervention often occurs at
Withdrawal Scale,31 the Overdose Risk Tool,32 and the point of initial detention, before the first
others.33 court appearance. Therefore, opioid courts
must engage with community partners and
Resources: The National Institutes of Health patients earlier in the process. The Sequential
provides risk assessment resources: Intercept Model (SIM) is a framework detailing
drugabuse.gov. how those with mental health and substance
use disorders come into contact with and move
The BJA Public Safety Risk Assessment through the criminal justice system. The SIM
Clearinghouse provides information on the basics helps communities identify resources and gaps
of risk assessments: https://bja.ojp.gov/program/ in services at specific intercepts, develop local
psrac/basics. It also provides selection resources: strategies to divert people away from the justice
https://bja.ojp.gov/program/psrac/selection. system and into treatment, introduce community
providers to evidence-based practices, and
4. Prescribe within 24 hours of arrest: Practitioners enhance relationships across agencies in order to
agreed that when courts prioritize making MOUD facilitate earlier intervention.36 Using the SIM can
available to patients within 24 hours of arrest, it help jurisdictions plan to provide screening for
is possible to do. Staff at Syracuse Opioid Court MOUD needs at early intercepts—for example, in
estimated that in 90 percent of cases, patients hospitals after overdoses and in police precincts
receive MOUD the same day as their screening.34 after arrests—before a desk appearance ticket is
The opioid court in Rochester’s Hall of Justice issued. Practitioners recommended that justice
makes a policy of prescribing MOUD to patients agencies, working within federal confidentiality
within 24 hours of screening.35 Both courts rely restrictions, seek to enhance communication
on close partnerships with prescribers to provide and establish a continuum of care, supervision,
rapid access to all three MOUD options. and recovery supports with warm hand-offs
when necessary. In Indiana, for example, training
Resources: OASAS makes an online tool available judges on the SIM has encouraged them to
to help case managers find local treatment send peer advocates on police dispatch calls for
providers: findaddictiontreatment.ny.gov. patients who fail to appear in court and triage
them into treatment rather than arrest them.37
SAMHSA provides a treatment locator with
numerous filtering capabilities (e.g., for age
group, insurance accepted, and special programs Offer multiple options and access
or groups offered for certain populations):
findtreatment.gov.
points to treatment
Practitioners said that it is crucial that opioid courts
The Office of National Drug Control Policy
offer patients access to all MOUD options that are
Incorporating Medication in Opioid Courts 11reasonably available in their jurisdiction. Different and rural areas, requires forming partnerships
court participants will require different MOUD with a greater number of practitioners who
options, depending on their needs and preferences. have received a waiver to dispense and prescribe
Court staff can begin to understand the best MOUD buprenorphine through the SAMHSA Center
fit by speaking with patients during the screening for Substance Abuse Treatment.39 Many
process. Ultimately, patients should be referred for a waivered medical practitioners face barriers to
clinical assessment, because the choice and duration prescribing.40 Private physicians’ offices may have
of MOUD is a decision to be made by prescriber time constraints that prohibit the prescriber
and patient together. Prescribers must take into from providing the services that staff would
account a variety of factors when determining which provide in a treatment program, and they may
option is best, including length of opioid use, prior lack the expertise to address patient issues that
treatment experience, past trials of MOUD, patient an addiction specialist could easily address.
preference and characteristics, and other health Practitioners recommended that opioid court
issues. The decision to discontinue MOUD is based staff and treatment providers offer additional
on current functioning, stabilization of withdrawal outreach, education, and links to services to
symptoms, and health issues, as well as risk of support buprenorphine-waivered practitioners.
relapse and overdose. The course of MOUD may be They also recommended documenting
indefinite, and full recovery can occur while patients agreements between courts and practitioners so
are maintained on medication; in fact, some people that expectations are clear.
do well when maintained over a lifetime.
To meet these needs, courts must consider Resources: The American Academy of Addiction
how to form partnerships with community-based Psychiatry’s Providers Clinical Support System
providers that are willing to prescribe each MOUD offers free waiver trainings, clinical mentorship,
option and educate them on what justice-involved and educational opportunities: https://pcssnow.
patients require. Courts should also work with a org/.
range of providers to help ensure that MOUD is
prescribed equitably across patients of different 2. Establish partnerships with local hospitals:
racial, ethnic, and income backgrounds, which Working with local hospitals is a promising
currently is not the case.38 In New York State, means for opioid courts to connect patients with
jurisdictions provide office-based addiction MOUD more quickly. Practitioners reported that
treatment through a range of providers that operate hospitals can rapidly provide buprenorphine
in partnership with opioid courts, including prescription and induction to patients,
federally-qualified health centers, substance use directing them to further treatment resources
disorder programs, and other buprenorphine- and services from there. This can increase the
waivered practitioners, like independent number of MOUD prescribers in a jurisdiction
psychiatrists in private practice and primary and decrease wait times between a patient’s risk
care physicians. OASAS makes treatment services assessment and referral to MOUD treatment.
available by licensing opioid treatment programs Syracuse Opioid Court maintains partnerships
to prescribe methadone and supporting outpatient with several local hospitals that provide same-
programs that treat substance use disorder with day buprenorphine access, alongside other
buprenorphine and naltrexone. These providers, treatment providers.
however, vary greatly in the services they provide
and may not be available in every jurisdiction. The opioid court in Saratoga is currently
Practitioners recommended the following: developing a new program to identify candidates
for MOUD and treatment in the hospital after
1. Support buprenorphine-waivered an overdose.41 Another opioid court works
practitioners: Court staff reported that with local law enforcement to bring patients
expanding access to MOUD, especially in remote to the hospital where they can stabilize and
Center for Court Innovation 12potentially receive MOUD before arrest, 4. Form partnerships with correctional
arraignment, and identification for referral institutions: Many opioid court participants
to the court program.42 receive MOUD to stabilize and later must serve
sentences in jail or prison. Practitioners stressed
Practitioners noted that these measures often that it is essential to patients’ long-term success
require finding a champion for MOUD within that they be offered the ability to continue
the hospital, since prescribing entails challenges: MOUD treatment while incarcerated. State and
hospitals must allocate staff, clinic space, and local representatives who support opioid courts
scheduling for patients with OUD. Some hospital- can work with law enforcement and correctional
based physicians acknowledged that prescribers institutions to ensure that incarcerated people
in emergency and other hospital departments with OUD have access to MOUD. In New York
express stigma against MOUD, which must State, OASAS, the Department of Health, and
be overcome with training. To meet these the Department of Corrections and Community
challenges, practitioners recommended forming Supervision (DOCCS), alongside local sheriffs
a strategic partnership with a knowledgeable and district attorneys, have worked with local
clinician inside the hospital who can monitor jails to implement MOUD programs that offer
patients, identify their needs, and advocate for short-acting naloxone, long-acting naltrexone,
MOUD prescription. buprenorphine, and methadone when locally
available. Additionally, DOCCS has initiated both
3. Employ mobile prescription units: Practitioners methadone and buprenorphine programs for
noted that mobile prescription units, vehicles people who are incarcerated who were actively
like trailers or vans that can travel to provide receiving those medications when the state took
resources in places where people with substance them into custody.
use disorder need treatment, dramatically
expedite MOUD prescription and other treatment 5. Make injectable MOUD options available:
interventions. Several New York State Centers Injectable forms of MOUD are simpler to
of Treatment Innovation are leading the way in administer and can therefore promote better
this area.43 Buffalo City Court, where a treatment adherence. Whereas patients must take
van parks outside each morning to offer on-site methadone doses daily, they can receive the long-
prescriptions, is a standard-bearer for providing acting, injectable form of naltrexone marketed
rapid prescription and recovery support services under the brand name Vivitrol, or the injectable
within 24 hours of arrest.44 Syracuse Opioid Court form of buprenorphine marketed under the
works with Helio Health, a treatment provider name Sublocade, in monthly shots. Opioid
that uses mobile vans to assist patients in rural courts may be reluctant to connect patients
areas, conduct on-site assessments, and transport with injectable forms of MOUD because they
patients to treatment if needed. OASAS funds 96 are more expensive than other options, because
mobile prescription units across New York State, there are challenges with pharmacy access, or
contributing to the infrastructure available to simply because they are newer to the market and
serve opioid court participants wherever they less well-known. However, some clinicians noted
are. Practitioners recommended expanding that Vivitrol and Sublocade can be as effective as
mobile prescription units to bring MOUD and other forms of MOUD.46 They recommended that
other resources to underserved patients. Some these forms of the medications be considered
practitioners noted that new rules for mobile for patients, so long as courts work closely with
units will allow them to function without a counselors and case managers to administer
separate Drug Enforcement Agency registration,45 treatment.47
streamlining the process and making them
easier to establish. 6. Provide telehealth access to treatment:
Practitioners reported that providing telehealth
Incorporating Medication in Opioid Courts 13services by phone or using videoconferencing practitioners agreed that in-person care is helpful
technology is a promising way to offer greater in assessing patients and connecting them to
access to MOUD prescriptions and clinical check- services, they identified a group of patients who
ins for patients who have transportation or have stabilized on a longer-term basis and need
mobility limitations, child care responsibilities, only monthly telehealth check-in appointments.
full-time work, or other challenges to appearing For patients struggling to meet treatment goals,
in-person. Many treatment courts offer extensive providers simply called them more regularly. Even
telehealth models,48 and these can provide as social-distancing requirements relaxed, many
remote care of the same quality as, or even better practitioners reported an intention to continue
quality than, in-person appointments. Several offering broad MOUD access through telehealth.
New York jurisdictions have been operating Practitioners recommended that relaxed
as pilot sites for BJA’s Comprehensive Opioid, restrictions on prescribing MOUD through
Stimulant, and Substance Abuse Program telehealth services be allowed to continue after
(COSSAP). That initiative encourages drug court the pandemic is under control.
coordinators to use the videoconferencing
platform Microsoft Teams to schedule check- Resources: The National Consortium
ins with clients, which allows “face-to-face” of Telehealth Resource Centers provides
interventions when a client is struggling in consultation, resources, news, and updates on
treatment.49 Courts from this pilot have also telehealth at no cost: telehealthresourcecenter.org.
been holding virtual court appearances, case
management sessions, and staffings since The Center’s document Taking Action: Treatment
September 2019. One site, the Dunkirk Drug Courts and COVID-19 highlights some of the unique
Court, has been planning to add virtual links solutions treatment courts used to stay engaged
to substance use disorder services, counseling, with participants throughout the pandemic:
and MOUD prescription, in addition to remote https://www.courtinnovation.org/publications/
court appearances.50 Practitioners said that taking-action-treatment-courts-and-COVID-19
videoconferencing is also an important way
for better-resourced jurisdictions to provide The National Association of Drug Court
knowledge and resources to underserved areas Professionals provides COVID-19 resources for
as they aim to build systems that provide rapid treatment courts: https://www.nadcp.org/COVID-
MOUD prescription. 19-resources/.
The COVID-19 pandemic led the federal
government and New York State to temporarily Improve coordination of services
relax telehealth regulations, making remote
access to MOUD prescription even more widely In order to effectively provide screening and access to
available.51 As the pandemic spread, many MOUD, practitioners agreed that close coordination
prescribers were forced to hold all appointments between opioid courts, community-based providers,
using videoconferencing platforms, a and opioid court participants is of paramount
circumstance that offered important lessons. importance. In New York State, the goal of opioid
Clinicians reported that by being “creative,” courts is to develop a model of collaborative care
they could offer patients a high level of care.52 that integrates and prioritizes medical and mental
Prescribing medical practitioners found that health interventions for patients at high risk of
they could admit new patients safely through overdose. Once a participant is engaged in the court,
telehealth appointments, without initial in- clinicians, medical practitioners, peer advocates, and
person contact.53 To perform remote drug testing, judicial staff work together to stabilize them before
some clinicians used saliva testing on camera or their legal case is addressed.
through the DynamicCare app.54 While medical Opioid courts typically designate a leader
Center for Court Innovation 14responsible for coordination from the beginning. share standards about opioid court program
Often, this is the court coordinator, who supports participation and MOUD access. New York State
communication with and assigns roles among provides training for all judges emphasizing that
judges, court staff, court-based case managers, providing MOUD access is a clinical decision,
probation officers, treatment providers, prescribers, not a legal one. One practitioner suggested
and patients. Court-based case managers also play that a training like Our Stories Have Power,57
a special role in representing patients by working through which people who have recovered from
with each partner to meet the patient’s needs. substance use disorder share their firsthand
Practitioners recommended the following: experiences with peers, could be adapted for
treatment providers and prescribers.58 In general,
1. Set clear expectations for providers and practitioners emphasized that regular cross
prescribers: Clinicians said that opioid courts education between roles has been crucial to
should make expectations clear to treatment building the mutual understanding and orderly
providers, including the details of patients’ functioning of the state’s opioid courts.
treatment plans, the toxicology reports that
will be required, and the support services Resources: The Center for Court Innovation
that the patient will receive.55 Many opioid and the National Drug Court Institute offer
treatment programs have established systems training programs that can help opioid courts to
for staff to share information with opioid courts. implement programs, coordinate partnerships,
In some cases, these are existing systems of and deliver MOUD effectively.59
communication created by a drug court; in other
instances, the partnerships are new or evolving. The Opioid Response Network (ORN) is a coalition
This allows judges and court staff to learn, in a of national organizations working to address
timely and systematic way, what successes and opioid and stimulant use disorders by providing
challenges participants are facing. Practitioners education and training on prevention, treatment,
reported that office-based addiction treatment and recovery. Providers can receive these
providers and other prescribers do not partake services at no cost after submitting a request
in these systems of communication as readily as at opioidresponsenetwork.org. Many of the
treatment programs.56 Many of those providers act recommendations in this document fall within
as prescribers only and are not prepared to offer the scope of ORN. In addition, ORN’s Law and
specialty treatment. Court staff reported that Medicine Guide supports judges and other justice-
they should be expected to connect patients with system stakeholders as they further integrate
trusted local substance use specialists who can evidence-based substance use disorder treatment
make referrals for counseling and other services. practices into their work. The guide focuses in part
Placing these expectations in writing in the form on the development of partnerships between the
of a memorandum of understanding or other justice system and medical community: https://
agreement helps to hold all parties accountable. www.aaap.org/education/law-and-medicine-guide/
2. Provide education and resource sharing: To get Faces and Voices of Recovery makes the Our
partners on the same page and reduce stigma, Stories Have Power training publicly available:
practitioners recommended providing education https://for-ny.org/stories-power-train-trainer/.
on the effectiveness of MOUD treatment and
specific barriers. This could include training 3. Form a therapeutic alliance with patients:
on the neurobiology of addiction, the evidence Clinicians stressed that after rapid MOUD
base for MOUD, the importance of coordinating induction, maintenance should occur as part of
care, and the implications of working with a sustainable recovery plan that gives patients
justice-involved people. Practitioners stressed the psychosocial support they need to continue
the importance of training judges so that they treatment. This should include a therapeutic
Incorporating Medication in Opioid Courts 15alliance between counselors and patients.
In supporting patients to accept beneficial 5. Integrate community support services: A variety
counseling while they are receiving detox of community support structures help patients to
services, it is most helpful to approach clients stabilize within their treatment plan, reintegrate
before the physical symptoms of withdrawal have into the community, and recover from opioid
subsided. If patients believe that substance use is use disorder on a long-term basis. These include
the root of their problems and do not understand traditional social services, like mental health
holistically how it has affected their lives, they treatment, housing assistance, employment
may think they need no further treatment. “What placement, education, and family reunification.
works best is having someone intervene with They also include services specific to substance
counseling services before clients start to feel use disorder, like recovery community
better,” said Bob Ross, chief executive officer of organizations, peer advocates, twelve-step
St. Joseph’s Addiction Treatment and Recovery recovery programs, and other mutual support
Centers in Saranac Lake, New York. groups that link patients to resources and social
connections with people in long-term recovery.
Following detox, a court-based case manager, This helps treat the isolation that is endemic
physician, therapist, or psychiatrist can assist to substance use disorder. Harm reduction
patients as they make choices about engaging in experts agreed that communities and providers
an MOUD treatment and a specialty care regimen should employ a range of measures to keep
tailored to their needs. Some practitioners patients engaged over time along a continuum
reported having strong support from these of care.60 Practitioners recommended persistent
partners for patients receiving buprenorphine outreach to patients from professionals, peer
and naltrexone treatment, while others lacked advocates, and family to keep them connected to
adequate support in the form of case managers their MOUD regimen, treatment program, and
and connections to services, especially for community.
patients who are justice-involved. Practitioners
said that treatment conferences—regularly
scheduled meetings between the various agencies Integrate support from
supporting a patient—are an important way for
agencies to collaborate regarding a patient’s
peer advocates
treatment and goals and thereby effectively
Peer advocates are frontline practitioners, sometimes
support their recovery.
with lived experience of justice involvement and
long-term recovery from substance use disorder,
4. Offer specialty care: Patients often need an
who are trained and certified to serve as liaisons
array of therapeutic and social services in
between opioid courts, clinicians, and participants.
addition to MOUD. Practitioners noted that
Practitioners recommended integrating peers into
while private physicians are a good resource for
opioid courts. A significant body of research shows
writing prescriptions, they lack the structure
that including peer advocates’ services in treatment
that OASAS outpatient programs can offer.
courts and other programs improves program
Many recommended that patients be directed to
completion rates and reduces recidivism among
these programs and treatment facilities. While
participants.61
outpatient programs vary greatly in the services
Often, peers can help prepare a person for court,
they provide, they typically have a core structure
set realistic expectations, explain the process in
that offers individual and group therapy, and
straightforward terms, and discuss the challenges
they may also include services like physical
of opioid court and MOUD treatment. Peers who
examinations, one-on-one counseling, housing
have recovered from substance use disorder can put
referrals, and employment assistance.
their story and experience at the forefront of their
connection with the people they work with in a way
Center for Court Innovation 16that clinicians often cannot because of their clinical courts, including planning a menu of services;
role. Peers also serve as a crucial conduit to mutual setting policies and procedures; scheduling
support groups like 12-step programs and social check-ins between courts, providers, and peers;
services like resume development and employment and promoting recovery orientation among
assistance. Perhaps most importantly, peers can stakeholders.63 Practitioners noted that court staff
provide people with an example of another person could benefit from special training and protocols
who has recovered from substance use disorder. to clarify the relationship between courts and
In New York State, many peers are linked to peers. These could include using a group tracking
OASAS-funded recovery community organizations, model to supervise the work of peers, creating an
through which they can provide in-house services. onboarding process specific to courts, developing
Others are connected to grassroots community- an overview of peer training to help other
based organizations. Practitioners reported several partners understand the ethics of the profession,
challenges in working effectively with peers, and inviting peers to community meetings with
including poor understanding of what they do, bias recovery community organizations.64
against them, and employment arrangements and
funding streams that present barriers. As a result Resources: Altarum, a technical assistance
of COVID-19, the field faces additional challenges, provider for opioid courts under COSSAP, has
with peers and their employers “scrambling” to developed Peer Recovery Support Services in New York
develop protocols for reaching people with substance Opioid Intervention Courts: Essential Elements and
use disorder, to use one practitioner’s word.62 Processes for Effective Integration, a forthcoming
Practitioners recommended the following: publication and curriculum on integrating peers
into opioid courts: https://altarum.org/.
1. Provide training for peer advocates: The
certification board at the Alcoholism and
Substance Abuse Providers of New York State Use innovative business models to
(ASAP) certifies peers as Certified Recovery Peer
Advocates. Certification establishes that a peer
secure sufficient reimbursement
advocate has been trained on and possesses
In New York State, all health insurers are required to
a standard set of competencies delineated
cover all three MOUD options.65 Medicare offers ad-
by subject matter experts. Some recovery
equate coverage, fully reimbursing take-home doses
community organizations offer training for this
of buprenorphine and methadone as well as opioid
certification. ASAP has developed specialized
treatment programs through bundled payments
certifications for peer roles to work with
for OUD treatment services.66 Rules under Medicaid
veterans, families, and youth, each of which
have also changed in recent years to make it more
requires specialized training. Practitioners
feasible for providers to offer all federally approved
recommended creating a specialized role for
medications for treating substance use disorder.
peers on working within the opioid court
Practitioners agreed that marketplace insurers are
context and with patients who have co-occurring
still on a learning curve for reimbursing treatment
disorders.
programs, and it can at times require more staff
effort to receive reimbursement. Practitioners
Resources: ASAP provides listings of approved
recommended the following.
roles, trainings, and trainers: http://www.asapnys.
org/ny-certification-board/nycb-approved-training/
1. Extend prescribing to new sites: New York
State has recently put measures in place
2. Create systems for integrating peer advocates
to assist MOUD-prescribing providers with
into opioid courts: Technical assistance
reimbursement. A 2018 statewide plan mandates
providers have recommended several measures
insurance reimbursement for in-community
to take when integrating peers into opioid
addiction services rendered by outpatient
Incorporating Medication in Opioid Courts 17providers. OASAS authorized community-based managers address their needs related to OUD,
outpatient providers to deliver these services much as they would for patients with other
on site—that is, outside of the providers’ offices. chronic medical conditions. The model allows
Practitioners recommended that treatment office-based addiction treatment providers to see
counselors and other providers consider more patients, assists with reimbursement, and
extending MOUD prescribing and treatment maintains cost-effectiveness at larger scales,72
services for OUD into more primary care which expands access to MOUD and ongoing care
physician sites and other, less commonly used in the context of opioid courts.
community spaces where they will receive full
reimbursement. Resources: The Boston Medical Center hosts
an office-based addiction treatment training
Resources: OASAS has committed to help and technical assistance program through
manage the challenges of this expansion and which providers can receive assistance with
makes information publicly available67: https:// implementing the Massachusetts Model: https://
oasas.ny.gov/system/files/documents/2019/05/ www.bmcobat.org/
CoverageforCommunityServices5.18.18.pdf.
4. Consider using the “hub-and-spoke” model:
2. Form agreements with opioid treatment Practitioners recommended that states consider
programs and providers: Practitioners noted adapting the “hub-and-spoke” business model
that opioid courts have an advantage when to streamline the workflow and funding
seeking to attract opioid treatment programs arrangements between treatment programs and
and providers. Despite the varying rates they may prescribers.73 Developed in Vermont, it aims to
collect from Medicaid and private insurance, increase MOUD access through opioid treatment
opioid courts help them gain regular referrals, programs by linking patients to community-
fill spots, and get reimbursed for services. Drug based health care providers in remote areas,
courts also have a higher retention rate over time often through telehealth platforms, once they
than community-based treatment programs are stabilized and meet certain criteria. Under
alone,68 which means that providers see patients the model, patients see a specialist at a treatment
more consistently. This can require that providers program, a “hub,” for MOUD induction; when
add staff and clinical support to manage patients patients meet certain criteria, they are then
using MOUD. In some jurisdictions providers referred to a community-based provider, a
work with local treatment programs to share “spoke,” for further services.74 The model, which
resources and responsibilities.69 In New York allows people with OUD to be linked to care
City, practitioners noted that NYC Health and expediently while Medicaid pays for the benefits,
Hospitals along with other providers offer could help connect underserved opioid court
great capacity for office-based buprenorphine participants to treatment.
delivery. Some suggested that this system could
be streamlined to make MOUD available to more Resources: The State of Vermont’s Blueprint
patients.70 for Health website contains implementation
materials for the hub-and-spoke model: https://
3. Pilot the Massachusetts Model: Practitioners blueprintforhealth.vermont.gov/about-blueprint/
suggested that opioid treatment programs hub-and-spoke.
consider piloting the Massachusetts Model,
currently under trial in Boston, which has aimed 5. Reimburse the services of peer advocates:
to help scale up MOUD access for people with Practitioners stressed the importance of building
OUD.71 Using this approach, nurse care managers a business model and reimbursement structure
form partnerships with physicians who assess for peer advocates, not just clinicians. When
patients and prescribe MOUD. The nurse care peers are employed by an opioid treatment
Center for Court Innovation 18You can also read
