Challenges and Solutions for MAT in Drug Courts

Medication-assisted Treatment (MAT) in Drug Courts: Addressing Barriers to Effective Implementation

Estimated read time: 1:20

Summary

This webinar hosted by the SAMHSA GAINS Center delved into the complexities of implementing Medication-Assisted Treatment (MAT) in drug courts, focusing on overcoming the barriers to effective implementation. Spearheaded by notable experts including Dr. Lisa Callahan, Steve Hanson, and Judge Shaun Floerke, the discussion covered a broad spectrum of challenges faced by drug courts, such as stigma, logistical issues, and legal considerations, while also spotlighting potential solutions to these hurdles.

Highlights

Dr. Callahan highlighted the necessity of collaboration and open dialogue in drug courts for successful MAT implementation. 🤝
Steve Hanson discussed the importance of addressing historical biases and stigma associated with MAT among treatment professionals. 🕵️‍♂️
The potential for medication diversion presents challenges; however, structured observation strategies can mitigate risks. 👀
There's an emphasis on using data and scientific research to inform legal practices and overcome barriers in implementing MAT. 📊
Judge Floerke emphasized the importance of champions in driving the case for MAT in drug courts, bringing hearts and minds together. 💪

Key Takeaways

Understanding and addressing stigma is crucial for MAT acceptance and effectiveness in drug courts. 🤔
Legal and logistical frameworks can often pose hurdles, but overcoming them is essential for successful MAT implementation. ⚖️
Active and informed judicial leadership can drive collaboration and success in drug courts. 👩‍⚖️
Knowledge sharing and training among stakeholders help mitigate common misconceptions about MAT. 🧠
Engaging community resources, including healthcare providers and peer support, is key to sustainability. 🌐

Overview

The webinar kicked off with Dr. Lisa Callahan welcoming participants and setting the stage for a deep dive into MAT and its challenges within drug courts. She underscored the critical importance of understanding the scope of the problem, including logistical issues, stigma, and legal barriers that hinder effective MAT implementation.

Key speakers like Steve Hanson presented a detailed account of the historical and ongoing biases against MAT, emphasizing the need for education and reevaluation of old mentalities. This educational push is vital to counteracting the erroneous beliefs surrounding MAT and encouraging a more accepting and informed response from treatment professionals.

Judge Shaun Floerke's sessions were particularly illuminating, underlining the judicial role as a critical driver of success in MAT implementation. By fostering community engagement and educating stakeholders, judges can lead the charge in integrating MAT into drug court systems, ensuring sustainable collaboration and coordination across the board.

Chapters

00:00 - 02:30: Introduction The introduction begins with Dr. Lisa Callahan welcoming participants to a SAMHSA GAINS Center webinar focused on Medication-Assisted Treatment (MAT) in drug courts and the barriers to its effective implementation. She notes that there is an excellent lineup of presenters and proceeds with some housekeeping announcements. Lisa Callahan is identified as working at Policy Research Associates.
02:30 - 05:00: Housekeeping and Agenda The chapter titled "Housekeeping and Agenda" begins with a moderator from the SAMHSA GAINS Center introducing the session. The moderator reads a disclaimer emphasizing that the views expressed in the presentation and discussion do not reflect the official positions of various health services and government bodies, including the Center for Mental Health Services, the Center for Substance Abuse Treatment, SAMHSA, and the US Department of Health and Human Services. Reminders for the participants are mentioned following the disclaimer.
05:00 - 07:30: Welcome and Overview of MAT in Drug Courts In this chapter, participants are introduced to the webinar platform's interactive features, including the Q&A section and polling. The attendees are encouraged to submit questions and take part in polls to gauge the webinar's audience reach and effectiveness.
07:30 - 12:30: Barriers and Practical Solutions for Implementing MAT The chapter discusses the barriers and practical solutions for implementing Medication-Assisted Treatment (MAT). It begins with logistical details of a webinar related to the topic, which includes information on how to participate, the availability of a recording and slides, and the issuance of a certificate of attendance. However, the chapter also notes that this certificate will not confer Continuing Education Units (CEU) credits, suggesting the focus is more on informational and personal portfolio use rather than professional accreditation.
12:30 - 15:00: Training and Education for Staff The chapter, titled 'Training and Education for Staff', discusses the agenda for a webinar that includes presentations by Jon Berg, Doug Marlowe, Steve Hanson, and Shaun Floerke. Jon Berg, who will be introduced in detail later, is a Senior Public Health Advisor. The chapter sets the stage for what to expect from the webinar and outlines the plan for introducing the presenters.
15:00 - 17:30: Questions and Answers This chapter discusses a webinar focused on Medication-Assisted Treatment (MAT) in drug courts, highlighting efforts by the Center for Substance Abuse Treatment at SAMHSA to address barriers to effective implementation. Dr. Callahan and Jon provide opening remarks, emphasizing the importance of policies and practices aimed at lowering overdose risks for individuals with opioid use disorder, particularly those who interact with the criminal justice system.
17:30 - 20:00: Closing Remarks and Resources The chapter discusses the significant impact of medication-assisted treatment (MAT) on opioid use disorders, especially within the criminal justice system. It emphasizes the effectiveness of MAT as an intervention and addresses the high prevalence of opioid use disorders among drug court participants. The chapter highlights gaps in the availability of MAT in drug court programs and mentions SAMHSA's requirement for drug courts to implement such treatments as part of their funding opportunities.

Medication-assisted Treatment (MAT) in Drug Courts: Addressing Barriers to Effective Implementation Transcription

00:00 - 00:30 - [Dr. Callahan] Good afternoon, everybody. Welcome to the SAMHSA GAINS Center webinar on Medication-Assisted Treatment in Drug Courts: Addressing Barriers to Effective Implementation. We have an excellent lineup today, and I have a few housekeeping things to take care of before we start with our presentations. My name is Lisa Callahan. I work at Policy Research Associates
00:30 - 01:00 in the SAMHSA GAINS Center, and I'll be moderating the panel today. I'm going to read this disclaimer. "The views, opinions, and content expressed "in this presentation and discussion "do not necessarily reflect the views, opinions, "or policies of the Center for Mental Health Services, "the Center for Substance Abuse Treatment, "the Substance Abuse "and Mental Health Services Administration, "or the US Department of Health and Human Services." Just a couple of reminders, you'll have the opportunity
01:00 - 01:30 to submit questions and answers. You'll see on the right-hand side of this slide the place to do that, the Q and A, and we will also be doing polling. So when you're prompted, if you would please respond to the polls when they are opened, and we'll be sharing those once the poll closes. It gives us an idea of who is on the webinar so we have a sense of the breadth of the reach for these webinars, so please respond to the polls.
01:30 - 02:00 I think they're open now. You'll see them in the lower right-hand corner of your computer screen. The webinar will be recorded, and the slides will be disseminated in the days following the webinar. At the end of the webinar, there will be a certificate of attendance that's available for download, but this does not provide CEU credits, but instead is for your own personal portfolio.
02:00 - 02:30 This is the agenda for today's webinar. As soon as I'm done with introducing this agenda, I'll turn it over to Jon Berg. I just wanted to give you a sense of the overview. The three presenters are Doug Marlowe, Steve Hanson, and Shaun Floerke. I'll introduce them more formally after we hear from Jon Berg. Jon Berg is Senior Public Health Advisor
02:30 - 03:00 with the Center for Substance Abuse Treatment at SAMHSA, and he's going to give some opening remarks. - [Jon] Thank you so much Dr. Callahan. Welcome to today's webinar Medication-Assisted Treatment in Drug Courts: Addressing Barriers to Effective Implementation. We appreciate you taking the time to participate in today's informative webinar. SAMHSA is interested in promoting policies and practices to lower the risk of overdose for person's with opioid use disorder, who are or have been in contact
03:00 - 03:30 with the criminal justice system. There is overwhelming evidence that medication-assisted treatment is an effective intervention for addressing opioid use disorders in criminal justice populations. Research indicates current high rates of opioid use disorder among drug court participants nationally, but there are gaps in the availability of medication-assisted treatment in many drug court programs. In this years adult treatment drug court funding opportunity announcement, SAMHSA is requiring drug courts to implement medication-assisted treatment
03:30 - 04:00 with access to FDA approved medications. Therefore, if drug courts are interested in future SAMHSA funding, this webinar will be very helpful with effective implementation of MAT. Today you will hear three perspectives on common implementation barriers experienced by drug courts transitioning to offer MAT, and how these barriers can be addressed. Themes of funding, stigma, education, training, and partnerships will be discussed. SAMHSA released an evidence-based research guide
04:00 - 04:30 in 2019 titled "Use of Medication-Assisted Treatment "for Opioid Use Disorder in Criminal Justice Settings." This guide focuses on using medication-assisted treatment for opioid use disorder in jails, and prisons, and during the reentry process when justice involved persons return to the community. It provides an overview of policies and evidence-based practices that reduce the risk of overdose and relapse. This document is provided today as a resource and can be found on the SAMHSA website.
04:30 - 05:00 We are excited to host today's webinar, as we have three experts in the criminal justice field present. Dr. Douglas Marlowe, who was a lead writer and contributor on the expert panel for the recently released SAMHSA document noted earlier, Steve Hanson, and Shaun Floerke. I would like to the GAINS Center and their staff for their work in developing and facilitating today's webinar. At this time, I will turn it back to Dr. Callahan. - [Dr. Callahan] Thank you, Jon. The first presenter...
05:00 - 05:30 I wanted to just give a brief overview as you see his just a few bullets about his professional world here. So Dr. Doug Marlowe will be the first presenter. Many of you are probably familiar with Dr. Marlowe's work through the National Association of Drug Court Professionals at NDCI. He is formerly the Chief of Science, Law, and Policy for NADCP, the Director of Law and Ethics and Research at the Treatment Research Institute, and he's also an Adjunct Associate Professor of Psychiatry
05:30 - 06:00 at the University of Pennsylvania's School of Medicine. The second speaker is Mr. Steve Hanson. Mr. Hanson is the Associate Commissioner for Courts and Criminal Justice for the New York State Office of Alcoholism and Substance Abuse Services. He was previously the Associate Commissioner for Treatment in New York state, and he overseeing treatment services including oversight of the 12 state-operated inpatient treatment programs. The third speaker is Judge Shaun Floerke.
06:00 - 06:30 He is a district court judge in the 6th Judicial District of Minnesota. He also founded and presides over the DWI Court in his area, which is also one of the four National Center for DWI Courts Academy Courts in the nation. So we'll begin with our first speaker, and I'm supposed to give you the poll results. In response to the polling that you all responded to.
06:30 - 07:00 Thank you very much for participating. We have a very, very good distribution of participants. The largest percentage is from individuals from rural areas, followed closely by urban areas. It's about a third and a third. We also have, in looking at the professional affiliations of the participants on the webinar today, there are about 20% from the judiciary,
07:00 - 07:30 and 20% from probation and parole. And also a number of people who registered as being from government or community-based service providers. Thank you very much for providing that information, and I'll turn it over to Dr. Doug Marlowe now for his presentation. - [Dr. Marlowe] Thank you very much. Thank you all for attending this webinar. We've been asked to focus on resolving barriers to the use of medication-assisted treatment in drug courts.
07:30 - 08:00 I just wanna start by saying that medication-assisted treatment really is the officially recognized standard of care. Medications in collaboration with psycho-social counseling, social services, is the standard of care according to the organizations you see on your screen. Department of Health and Human Services, NIDA, Surgeon General, and the like, up to and including the National Association of Drug Court Professionals. These are not the only organizations that are in favor of it,
08:00 - 08:30 but basically I think the point's been made, and we pretty much ran out of room on our screen. Research establishes that medication-assisted treatment improves outcomes in the justice system. Green checks indicate that it has been proven to work in the criminal justice system in randomized control trials. Yellow or orange checks mean that it is very promising in justice settings. And as you can see, the main purpose of medication-assisted treatment
08:30 - 09:00 is to enhance treatment entry, and reduce opioid use, and these medications are pretty much all demonstrably effective. Less clear, what effects it has in criminal recidivism, but the purpose of the medications is not to reduce crime, it's to rehabilitate people with the longer term effects of reducing crime. NADCP's Best Practice Standards place an affirmative obligation on drug courts to learn the facts about MAT. Ignorance about MAT is not acceptable,
09:00 - 09:30 and itself violates best practice standards. Drug courts are expected to seek, and if possible, obtain medical consultation. Blanket prohibitions against medication-assisted treatment as a condition of entering a program, or if your graduating from the program are prohibited, by best practice standards, drug courts are expected to make a particularized factual inquiry in each case, not just saying our policy is yes or no, but based on the particular facts
09:30 - 10:00 of this individual participant, the appropriateness of medication-assisted treatment for that case. And drug courts are expected to create a reviewable record and a rationale. Saying just saying no is not enough. It is necessary to say why not. This is a court of law, and so if somebody wished to challenge that decision, it must be reviewable on appeal. And that is the requirement of appellate cases being handed down regarding drug courts.
10:00 - 10:30 This is not to suggest that drug courts don't have very legitimate concerns and barriers to the implementation of medication-assisted treatment. The purpose here is to discuss practical ways to resolve them. One of those concerns is the possibility for misuse, or diversion of these medications on the street, or to other individuals using these drugs, either in the program, or on the community. The most effective way to avoid misuse,
10:30 - 11:00 or diversion of medication, quite frankly, is observed administration. A probation officer, a clinical case manager, a trusted pro social, a non-drug involved family member or friend, can observe the person taking that medication, and this in and of itself can basically reduce, or even eliminate inappropriate use or diversion. Because the legal standards of care require drug courts to look for the least restrictive alternatives
11:00 - 11:30 before they deny people access to medication, the fact that observed administration resolves many of these problems means that a blanket prohibition is itself not the least restrictive alternative. Drug courts in the course of medication monitoring can look to see whether a medication like buprenorphine or methadone is being tested positively so that the person is or is not taking the medication. Looking at actual medication levels is more complicated. Requires usually blood testing
11:30 - 12:00 and more expensive procedures. So generally speaking, many drug courts are not gonna have the resources for that, but they can check to confirm that participants are taking the medications they're supposed to be taking. Calling people back on a random basis for pill counts to see how many pills they have left. Now, of course, just because somebody takes a pill out of their dispenser, doesn't mean that they have in fact taken it, but if people are selling the medications, or using too much, they will not have enough pills and that would be an indication
12:00 - 12:30 of a potential for misuse. Medication event monitoring systems, the short term for that is MEMS, are medication vials, or containers, where the cap has a microprocessor in it. And every time the individual takes a pill out of the medication vial, it records the date, the time, and the number of pills that were removed. And this provides a pretty good indicator of medication compliance. It's mostly been used in severe mental health populations,
12:30 - 13:00 but shows a lot of promise for the criminal justice system. Smart phone applications are now available where you can send a reminder, or they can be sent automatically to participants reminding them to take their medication. And then you can be using actual observed administration through having the person taking a film of themselves taking the medication to observe ingestion in real time. Again, these things are becoming more and more available and less expensive, and it is possible to monitor medication use,
13:00 - 13:30 and many studies have shown that this has reduced under-utilization and over-utilization of medications. Just about all the medications have misuse deterrents formulations. Methadone, for example, is taken in liquid form, which cannot be cheeked or tongued. Buprenorphine is available in a sublingual tape, which can be placed under tongue, or in the cheek, and dissolved. So again, makes it far more difficult to misuse the medication.
13:30 - 14:00 Both buprenorphine and naltrexone are available in monthly injections. And buprenorphine in six month implants, which can prevent misuse of the medications when people often take their pills on a daily basis. All participants in drug court should be required to get pre-approval from the program for medications that are intoxicating and or addictive, required to disclose their enrollment in a drug court
14:00 - 14:30 to the prescribing physician, and provide a release of information so that the physician in the drug court can communicate freely about participant's compliance and use of the medications. Because many of the participants, even when told they must do this, don't always do that, drug courts are being strongly encouraged to make a use of what are called prescription drug monitoring programs, PDMPs. These are state, or territorial, maintained data bases
14:30 - 15:00 that have information on controlled medication prescriptions that are filled for an individual usually in the previous 12-month reporting period. Most states have mandatory participation in PDMPs. In fact, I believe the most recent analysis I looked at was something like 85% of drug courts have... I'm sorry. 80% of jurisdictions have mandatory reporting to PDMPs.
15:00 - 15:30 What research shows is that states that have mandatory reporting have fewer dangerous medication interactions 'cause physicians are aware of other medications their clients are taking that they may not tell them about. There are fewer overlapping prescriptions for the same medication. Fewer patients obtaining prescriptions from five or more doctors or pharmacies. So in other words, what we sometimes call doctor shopping is substantially reduced. Fewer refill authorizations of seven or more months, so participants are required to come back
15:30 - 16:00 and get these authorizations in real time basis. They are associated with a three to four percent decrease in overall crime rates. A five to seven percent decrease in violent crime rates. Now, there is some question about whether this reduces opioid overdose and mortality because individuals who already have an opioid use disorder, when you reduce the availability of pharmaceutical opioids, will very often switch to illicit opioids.
16:00 - 16:30 For example, heroin, which now days are tainted with fentanyl in many cases. So what these PDMPs usually do is they prevent new initiates into opioid addiction, but it's unclear what effect they have on overdose rates. Although they do, as I said earlier, reduce doctor shopping and crime rates. Mandatory inquiries, although most states require physicians
16:30 - 17:00 to register with the PDMP, and to submit information to the PDMP, not all physicians are required to inquire about a patient before prescribing it for their patient. So regardless of whether or not your state has a mandatory inquiry policy, drug courts should require all physicians working in their programs through an MOU with a drug court, to do inquiries on all drug court participants, and not only when they first prescribe, but when they are refilling prescriptions,
17:00 - 17:30 or at regular time periods afterwards, to make sure that their patients are not obtaining controlled medications, especially for opioids or benzodiazepines, from other providers. In this this slide, and you guys will all be receiving this slide, so you actually have links here that will take you to websites. What I've put in here is you can find out whether physician drug monitoring programs in your state are mandatory or permissive for enrollment.
17:30 - 18:00 As I said earlier, about 83% are mandatory as of January of 2019. You can also find out whether providers, physicians, pharmacies are required to query the PDMP before writing a new prescription. And again, 85% are required. Regardless of whether they're required, you are encouraged to require them to do so as part of your MOU. Big question is whether your PDMPs include information
18:00 - 18:30 from other jurisdictions. Can they go to another state, get a controlled medication elsewhere, and would you know about it? So you can find out. By clicking on that web link, you can find out what states share, have reciprocity with your state. And then another question I get frequently is well, can they share this information with law enforcement, with community corrections, with the courts? The answer is that just about all states permit solicited, which means requests of reports, to law enforcement.
18:30 - 19:00 However, they do not necessarily explicitly authorize reports to drug courts or community corrections. About a third of states do explicitly authorize them. You'd want to check to make sure whether or not there's an explicit authorization in your state. And if not, whether there's any reason why it would be prohibited. And if for any reason it is, then of course you simply ensure that that information is shared with physicians working with your program, even though the criminal justice system itself
19:00 - 19:30 is not soliciting reports. Here's another link where you can get additional information about your state or territorial's prescription drug monitoring programs. Now, the big issue that drug courts face is being able to identify authorized MAT providers. As many of you I'm sure know, methadone, if it's being used for the treatment of a substance use disorder, may only be prescribed and dispensed from an opioid treatment program, a licensed program.
19:30 - 20:00 Take home doses may be permitted, but statutorily only after individuals meet specified requirements for treatment attendance, stability, and abstinence. So unless there's an OTP program in your community, it would be difficult in many ways to access methadone prescribers. The purpose of buprenorphine, which many of you may be familiar with it as suboxone, or subutex. It's also called probuphine,
20:00 - 20:30 what's a monthly injection, or sublocade. I think I've got that backwards. Sublocade I think may be the... One of those is the monthly injection and the other's a six month implant. They can only be prescribed by physicians who have been specifically waivered through what's called the Drug Abuse Treatment Act 2000 Waiver. Physicians are required to complete an eight hour training, and can treat up to 100 patients in the first year, 275 patients after that.
20:30 - 21:00 Some people have criticized that and say is eight hour of training really enough to treat our population? Well, the fact of the matter is, eight hour training for buprenorphine is far higher than training for virtually all other medications that are used routinely in medical practice. So in fact, a specific training on a specific medication is not often required, and this is actually pretty intense for many physicians. Nurse practitioners and physician's assistants are required to complete a 24 hour training,
21:00 - 21:30 and they can treat up to 100 patients. A big problem here is that about only about 5% of physicians have obtained DATA-2000 Waivers. Drug courts may have trouble locating buprenorphine waivered physicians in their communities. And so this is really something for the drug court team. Judges may really have to beat the bushes, going to speak to local medical societies, local physician's practices,
21:30 - 22:00 getting the word out that they need providers to help them to help treat their clients, and offering their assistance in helping those physicians to achieve waivers, which I'll discuss in a moment. Naltrexone, which is a blockade medication, including Vivitrol, which is a long acting blockade. It is not itself an opioid, can be prescribed and dispensed by virtually any licensed medical provider, competent to do so, including physicians, physician's assistants, and nurse practitioners.
22:00 - 22:30 So getting naltrexone providers is generally substantially less complicated. If you or your program is looking to find providers in your community... Many programs will tell me that there are no providers, we can't anybody to do this in our community, and then if I go on one of these locator services I can find several within a 10 or 15 mile radius of those programs they just were not aware of. These are websites. If you click on them, you can query these sites
22:30 - 23:00 by state, by county, by zip code, to find providers near you. Behavioral health service providers, specifically those DATA-2000 Waivered buprenorphine providers, finding opioid treatment programs and the like. You can also locate providers by contacting the single-state agency for substance use in your jurisdiction. Your state would normally be Department of Human Services, or whatever single-state agency for substance use treatment. Local colleges and medical schools will often
23:00 - 23:30 have faculty who are waivered and trained in this area, or your county or state board of health. The courses I had mentioned earlier, many physicians who could be doing this are not DATA-2000 Waivered. Here are some websites that you can click on to help physicians complete the application forms, take the online eight, or 24 hour training for nurse practitioners, and become DATA-2000 Waivered.
23:30 - 24:00 It gives information on what it takes to maintain the credentials, and also to provide even additional information, study materials, and the like, to pass the certification requirements. So this is the kind of thing I think if judges send letters out, and go have brown bag lunches, invite physicians, go to local medical groups and speak about the need for these services, and make people aware that these trainings do exist,
24:00 - 24:30 that it's not as complicated as some people may think, that they can become DATA-2000 Waivered, we can increase the number of people out there who are capable of serving our clients. What is not happening, and what absolutely need to happen, is that any participant in a drug court program, any participant with a substance use disorder, especially in the midst of an opioid crisis, an opioid epidemic, should be screened routinely. All participants, for symptoms of an opioid use disorder.
24:30 - 25:00 This should include whether or not they in the past, or currently are using opioids. Whether they've experienced withdrawal symptoms, cravings. Whether they have an overdose history. Whether they've been in opioid treatment before. Whether they've received medication assisted treatment in the past. Many assessment procedures for drug courts do not ask about cravings, withdrawal, or overdose history, which is absolutely unacceptable. Inexcusable in the midst of an opioid crisis.
25:00 - 25:30 Any person who screens positive should be referred to a licensed and trained medical provider. A physician, nurse practitioner, or a physician's assistant, assuming that one is available. And hopefully, you should be able to locate such people for a follow up diagnostic evaluation and determination of whether they're suitable for MAT. Even if they say they don't want medication-assisted treatment, they should still be referred for follow up assessment. This does not mean you're forcing a medication on them,
25:30 - 26:00 but you are requiring a thorough diagnostic evaluation for purposes of entering your program. The reason to get this taken care of early on is because motivation changes, situations change, participants change their mind very often after multiple relapses, and they're facing a potential revocation, a potential jail sanction. They may very often change their mind about MAT, and you don't want to then first have to refer them for assessment, which could take several days, or a week or two and slow down the process.
26:00 - 26:30 You want to have the case ready, willing, and able to go for medication when needed. Another issue is many participants will say that they're willing to take medication, but they're not interested in the other services in the program. The fact that people are motivated for medications, but not motivated for counseling is not a contraindication for medication-assisted treatment. What research has shown is that when people first enter programs,
26:30 - 27:00 when they are clinically unstable, they're experiencing withdrawal symptoms, drug cravings, anhedonia, or the ability to experience pleasure, basically clinical stabilization is very often the first order of business. And until the case is clinically stabilized, many people are not able to, have a very difficult time taking advantage of moral reconation counseling, and relapse prevention counseling, and the like. And so motivation is really, for psycho-social counseling,
27:00 - 27:30 is not a contraindication. Those are the citations to those studies are in the resource guide that Jon had mentioned earlier, and it will be available in your resources if you wanna know where that evidence comes from. Now, of course in a drug court, we do require people to go to counseling, and you should continue to do so. I'm not suggesting it's not necessary. I'm simply saying that motivation for it is not a contraindication for these medications. We've put in your materials examples of screening instruments that your clinical experts
27:30 - 28:00 should be using, and many are not in drug courts. There's some of these examples that focus specifically on opioid dependence. There are instruments that focus specifically on withdrawal symptoms, drug cravings, and overdose risk potential. These are short tools. They can be delivered within a matter of minutes by trained providers in your programs, and we should be looking at these symptoms routinely for all of our participants instead of overlooking
28:00 - 28:30 what could be a life-threatening disorder. Many programs send participants to self-help recovery groups in the community, as they should. The most commonly available are those that follow the 12-step model. Narcotics Anonymous, Alcoholics Anonymous, and the like. The official policy of NA is to accept medication-assisted treatment, despite what many people say. And they are on the record in writing saying that that includes agonists, methadone and buprenorphine are not contraindications
28:30 - 29:00 for Narcotics Anonymous. However, despite their official policy, many groups do in fact disapprove of MAT, or actively even discourage participants from entering the groups while they're still on the medication. A study that my colleagues and I recently did in drug courts found that 58% of participants in drug courts said that they themselves either experience, or they witness other people in the program experiencing disapproval of MAT from peer support group members.
29:00 - 29:30 So there is undoubtedly a stigma associated with this. There are two ways to handle this. The first is to explicitly prepare participants in your program for this possibility. Telling them this can happen, arming them with the facts that NA supports MAT so that they can bring that up, helping them to discuss how, and whether, and when to share their use of MAT in the group increases their group satisfaction
29:30 - 30:00 and tenure in the program. So it's a preparatory issue. There is also a website called MARA, Medication Assisted Recovery Anonymous, and this lists places where you can locate peer support groups that are explicitly accepting of medication-assisted treatment. And if there are none in your jurisdiction, information on how you can get your participants to set up, to seed, and to maintain their own Medication-Assisted Recovery Anonymous groups. So this is not something that we should just simply accept,
30:00 - 30:30 stigma and disapproval as a normal course of business. Many programs are concerned about how to pay for MAT. Most rural or urban jurisdictions have federally qualified health centers somewhere available to them, and these all offer buprenorphine at highly discounted rates. Many drug courts have been quite successful at negotiating reduced rates from pharmaceutical companies, those especially that make Vivitrol,
30:30 - 31:00 and that make suboxone. You may or may not be aware of the 340B drug discount program. These are programs that require any pharmacy, any drug manufacturer that participates in Medicaid, and they basically all do, that they must provide medications at significantly reduced prices to covered entities. What's a covered entity? Rural health centers, community hospitals that treat a disproportionate share of poor
31:00 - 31:30 and uninsured patients. These are a number of different facilities that basically treat our patients, and manufactures are required to offer discounted rates for these medications. Now, it does not matter if your individual patient is on Medicaid or not. They can have no coverage whatsoever. They could be covered by private insurance. They could be covered by other types of third party reimbursement, and it doesn't matter. If the drug manufacturer participates in Medicaid,
31:30 - 32:00 and they serve a covered entity, they must provide these medications at discounted rates. Medicaid is, many states are Medicaid expansion states, so they're more fully available to a larger proportion of people. Not all states, obviously, is that true. As of February of 2018, 36 states and territories covered methadone explicitly through Medicaid, 51 covered buprenorphine, 49 covered naltrexone,
32:00 - 32:30 and more than half had substantially increased coverage for naloxone, which you may know as Narcan, which is to reverse opioid overdose. So very often people tell me that these medications aren't covered, and that's in many cases not true. There is discretion in Medicaid to cover rehabilitative services, broadly defined to include substance use counseling, peer support specialists, supportive housing, and vocational services. And most importantly, in many respects,
32:30 - 33:00 there is discretion to cover benefits assistance. These are people working with your participants to help them get the coverage they're legally entitled to. Many jurisdictions, many states, many third-party managers will erect barriers, and make it practically difficult for people to access benefits to which they are entitled, and benefits assistants can help people manage those barriers and those hurtles.
33:00 - 33:30 I'm trying to get this to go down. There we go. As for staff training, it is particularly important to train your staff on medication-assisted treatment common misconceptions about these medications. However, what we have learned is that knowledge acquisition generally declines within a month. So it is critically important for you to get your MAT treatment providers, and your drug court staff meeting together on a regular basis, preferably once a month
33:30 - 34:00 for the first few months, then at least quarterly to discuss issues that are coming up, barriers to implementation, common concerns, to designate peer mentors, or supervisors in your program. We tend to call them champions. Who's gonna be the person who's constantly advocating and pushing for continued organizational support for medications? A list here of two studies you might be interested in that describe in great detail staff training exercises
34:00 - 34:30 that have been proven to increase actual use of medication-assisted treatment. Bringing MAT providers and criminal justice professionals together to discuss mutual concerns, resolve barriers, teaching staff how to use naloxone overdose reversal kits. Showing them how to do it. Providing them with videotape boosters has been shown to substantially increase not just knowledge, we're not here to just increase knowledge, we're here to increase actual utilization. Stigma is a big issue in these programs.
34:30 - 35:00 It's very important for us to work on changing the language we use. Instead of using terms like addicts and drug abuse, switch that to people who are in recovery. Relapse is a more negative term than recurrence of use, people suffering from substance use disorders. We need to be able to describe how hard people try to stop using without these medications, and how often they're devastated when they're unsuccessful. People need to get a sense of that.
35:00 - 35:30 Using vignettes and examples describing successful efforts at recovery. Describing all the misuse-prevention strategies I mentioned earlier, observed administration. Helping people to understand that there are ways to stop misuse and diversion. We don't have to just say "No, you can't have these medications." There are other things we can do. Educating on the disease model of addiction, including showing pictures of brain injury imaging studies, describing the kinds of things that precipitate drug use like trauma, poor prescription practices,
35:30 - 36:00 exposure to advertising, negative peer influences. Describing medical and psychiatric disorders that frequently co-occur with substance use disorders helps build empathy, and reduces stigma. Now, finally, I just want to end with a lot of programs will say to me that what very often happens is they will, when they use medications, as soon as they put somebody in jail in a jail sanction, the jail immediately takes people off these medications as a matter of course. While I'm not encouraging you to get
36:00 - 36:30 into conflicts with jails, or to get into litigation with jails by any means, the emerging appellate evidence is quite clear that that is unconstitutional. Or certainly a violation of the Americans with Disabilities Act. Blanket prohibitions, or routine denials of medication-assisted treatment for pretrial detainees, and even individuals who are being held as a sentence, violates the Americans with Disabilities Act according to three federal cases decided just in the past year and a half, the Rehabilitation Act,
36:30 - 37:00 if you're working with Federal Bureau of Prisons, and may even violate the 8th Amendment's prohibition against deliberate indifference. I'm not suggesting you sue jails so much as bring their attention to these cases so that they begin to understand that they cannot continue taking people off these medications. At least one Department of Justice warning letter has gone out to a treatment court saying that a treatment court that treats participants differently because they're receiving medications violates the ADA as well.
37:00 - 37:30 Those of you who want to get examples of sample letters that you can use to educate jail officials and others about the importance of medications, you can get at the Legal Action Center website, and the link is there for you. So that concludes my presentation. I'm gonna move it along to Steve Hanson, but we should have plenty of time later for a Q and A. Thank you very much. - [Steve] Thanks, Doug.
37:30 - 38:00 What we're gonna go over and sort of overlap with some of the things that Doug talked about were the obstacles to implementing MAT. And these include stigma, some of the logistics, and access, particularly to medications like methadone where you need a methadone clinic, the cost involved, and go over again the diversion concerns. And stigma's probably the largest obstacle to MAT. And it's frequently based on philosophical bias
38:00 - 38:30 and erroneous beliefs about the medication. And the beliefs are like many people have achieved recovery without medication. Well, that's true. If you have to take a medication, it's not real recovery. False. About 12 years ago the National Drug Court Conference, we met in Boston, and there was actually almost hostility towards the notion of using MAT, as this didn't afford people a real chance at recovery.
38:30 - 39:00 We were basically just condemning them to be addicted to another substance, et cetera, despite that there's a lot of evidence saying that that's not true. They thought we're just replacing on drug with another. No, it's a medication. At proper dosage levels it's not gonna produce a level of intoxication. The people will be able to act normally, look normal, et cetera. They thought people on methadone are just zombies.
39:00 - 39:30 This was false. You will frequently see people who are early on in the stabilization who will be at the methadone clinic, and they're working through getting their dose to the proper level, still dealing with some residual withdrawal effects from the heroin, and other things that are going on. But people who are on MAT can function very normally. They can take care of their children. We've had a couple of cases where patients
39:30 - 40:00 who have been doing well on methadone, not using other substances, not committing crimes, paying their bills, going to work, where family courts have decided that because they're on methadone that they're unfit parents, and taking the children away. And that completely goes against issues like the ADA, and really understanding what the dynamic is that when somebody's on this medication, you wouldn't be able to tell one from another.
40:00 - 40:30 Now, when you look at what happens with driving by a methadone clinic, the folks are standing in line, look like they're still using drugs. Well, generally these are the people who just started. They haven't reached full stabilization yet. As they continue in treatment, they look and feel better, and they also don't have to stand in a line every day. And we really don't get to see the people who are doing well. So somebody who's been on it for a period of time is very successful, stabilized. They're gonna come in quickly.
40:30 - 41:00 They might be getting a weeks worth of dose at a time, and they're off doing all the normal things that they would have to be. Now, some of the things that we have to do is look at some of the historical perspectives. And many of the people that have been in this field for a long time are in their own recovery, and what they were told and came to believe about MAT influenced their treatment recommendations.
41:00 - 41:30 And many counselors would not recommend MAT, as it conflicted with their beliefs. We had to deal with that in New York where courts were not using MAT, and when I asked the judge why not, he says well, my treatment person says it's not really good for people. So were trying to follow what the treatment person says. So we had to do a lot of education to our treatment programs and point out many of the things that the court also hears around the effectiveness and importance of using MAT,
41:30 - 42:00 particularly as related to opioids, and the current crisis we're in with analogs like fentanyl and carfentanil on the street, making it very dangerous, high-risk for overdose. And so we're trying to make sure that MAT has become recognized as a pathway for recovery. The variety of studies have shown the best way you address those mistaken beliefs, as Doug mentioned, is education.
42:00 - 42:30 Teaching people what's going on. And if you're looking to work with an OTP, go visit the OTP program. Go see what they're doing. Talk with the patients. Find out what it's like for them to be on it. What the experience of not having the medication is like. And then there's a number of evidence-based practices, and there's that SAMHSA guide that Jon and Doug have been mentioning before. Now, some of the logistics is really complicated. Methadone for opioid use disorder is highly regulated.
42:30 - 43:00 There's no other medication for anything else that's regulated as much as methadone is. Clinics are not available everywhere. Some places have caps on the number of patients, so if you're at your cap, say it's 150 patients, and there's 20 people waiting to get in, there gonna have to wait to get in, and they're at high-risk for potential overdose. Buprenorphine, as Doug mentioned, is the only medication that we know of
43:00 - 43:30 that requires special certification from the federal government to prescribe it. No other medication does that. And this might be deterring from offering because doctors would have to give up time and not get revenue in order to take the course in order to be able to prescribe buprenorphine. There are also the caps that are on the number of patients, and that can be challenging as you're trying
43:30 - 44:00 to find folks to refer to. Does the doctor have enough room in their cap in order to handle new patients? Now without insurance the cost of medications can be fairly great. Vivitrol's estimated about $1176 a month for that shot. Buprenorphine, 460 a month, and then methadone, 500 a month. And the methadone is not just the cost of the medication. That includes other services.
44:00 - 44:30 The counseling and other things that go along with it. Addressing the diversion concerns. Buprenorphine is commonly diverted. In some settings people try and divert methadone. It's really complicated. Involves cotton balls in your mouth, et cetera, et cetera, regurgitation. We won't have to go there. But some patients with low tolerance to buprenorphine may experience some effects from it. But most patients who receive buprenorphine remain
44:30 - 45:00 on the medication to avoid withdrawal symptoms. This is what it's prescribed for. So to think of it sort of as what happens if I can't get my other opioid, and I'm experiencing a very, very uncomfortable withdrawal symptoms. What can I do? So that increases the value of the buprenorphine diversion. And preventing diversion is very difficult. There's a lot of things. Particularly, the strips are easy to hide.
45:00 - 45:30 Patients will take half their strip to deal with their issues, while being able to sell the other half of the strip. And while diversion's a real issue, it should not deter us from prescribing it for people who actually need it. And why it's really important is because MAT saves lives. Studies have compared MAT versus non-MAT treatment for opioid use disorders, and non-MAT methods have been shown
45:30 - 46:00 to have fatality rates as high as 20%. That is one in five. And you know what has better odds than one in five? Is Russian roulette. There you're one in six, and no sane individual is going to play Russian roulette because that risk is so high. We shouldn't be putting people at risk of one in five by saying no, you can't have MAT. And in the comparison groups in those studies, the MAT methods have zero percent fatalities.
46:00 - 46:30 So again, this is a real important issue about keeping people alive. And helping people stay alive is our first and primary objective. Back when drug courts started, our primary role was sort of keeping people out of jail who didn't need to be in jail, and getting them treatment that would prevent them from getting entangled in the criminal justice system down the road. Now, we see drug courts as acting
46:30 - 47:00 as a primary player in helping to keep these participants alive, and it's critical that we give them the best tools, the most effective evidence-based treatment approaches that there are out there. And now I'll turn it over to Judge Floreke. - [Judge Floerke] Thanks, Steve. Hi everyone. Appreciate the time. Shaun Floerke here. These guys have covered kind of
47:00 - 47:30 the best practices, the standard. One of the things that always strikes me in thinking about the criminal justice system, and it probably gives Doug some gray hair, is when you look around the room, most of us are liberal arts majors. There's not a lot of hard science people. I talked to the Reno Judicial College a couple of months ago. There were 50 judges, opioid lead judges from around the nation there to receive training on best practices on these issues,
47:30 - 48:00 and I asked how many of you are hard science people, and one raised her hand. Data can be tricky to uptake, but we keep bringing it, we keep talking about it, and you gotta have it land. Here are some resources that I think are helpful. The first one on the left is the "SAMHSA Opioid Overdose Prevention Tool Kit." I find that really helpful to give to other system professionals
48:00 - 48:30 to try to help them understand what's at play, what's at stake, kind of the mass of issues that we're facing. I'm in Duluth. It's a town of 86,000 people. I was on search warrants two weeks ago. I signed search warrants for three opioid deaths in five days. My community's aware, but it can be a good tool kit to give to folks who maybe aren't.
48:30 - 49:00 We've all mentioned the SAMHSA publication on medically assisted treatment in criminal justice systems settings. It's fantastic. Doug mentioned trauma. I think Steve mentioned trauma. SAMHSA has the "Trauma Informed Approach Guidance." It's the middle document I have for you. You can't do this work if you don't have an understanding, and building understanding of trauma. A couple of other resources
49:00 - 49:30 are anything Bessel van der Kolk does, or anything Gabor Mate does. I wrote the fourth item that we list here for the National Judicial Opioid Task Force. It's a short monograph on how judges can build teams. So if you're looking to build a court, or maybe more importantly, looking to build a team out into the community to try and tackle this, it can have some good insights for you.
49:30 - 50:00 And then I included the "Drug Court Petitioner Fact Sheet." All good, all good resources. Others have said it. It's in the SAMHSA Judicial Settings document. This needs a champion. This doesn't happen, this change in our communities doesn't happen without a champion. My argument is always the judge is the champion.
50:00 - 50:30 A judge needs to become informed, make connections into the community, and champion this process. Our jail, sadly, was one of the places that did not offer any MAT until we started a community kind of collaboration, and applied for some grants, and now we're offering Suboxone at our jail. That started through emails and phone calls. Me inviting people to the table, and not stopping til we got it there.
50:30 - 51:00 I didn't have to sue anybody. I don't think I have authority to sue anybody, but a judge can be the champion, and none of this will start without a champion. I'd suggest folks think about Narcan as a really good start on some of this. We had law enforcement several years ago, we were pushing to equip all of our law enforcement throughout the entire area with Narcan, naloxone. Had some press back.
51:00 - 51:30 Kind of dealt with that. Did some training, got Narcan into people's hands. Our sheriff's office, the first person a deputy saved way out in the sticks with Narcan was a mom that he found lying on her gravel driveway with her little children watching her die. He administered Narcan. By the time the paramedics got there, she climbed into the ambulance on her own two feet.
51:30 - 52:00 That story spread like wildfire, and people's hearts and minds were changed. And I think some of this really is hearts and minds. Steve talked about maybe some kind of old school thinkin' about that's not how it was done back in the day, or this isn't how I achieved recovery, or this isn't the path that I followed. Some of this is honestly changing hearts and minds. Especially when you looking at folks who may not be real responsive to data.
52:00 - 52:30 I will find on my teams every now and then I'll be assigned somebody who doesn't believe in MAT, or who doesn't believe in a best practice. I'm a history major, but I've come to embrace the research and I won't do anything unless I know it's research supported. I've had side conversations with folks and encouraged them that we're going to follow the data in my court room and on my teams.
52:30 - 53:00 The analogy I use is the research around washing your hands before a surgeon cuts into you. The surgeons always scrub, and scrub, and scrub. If I had a surgeon who said I don't believe in that, I would look for a different surgeon. So I think as judges, we need to lead on that issue too. We need to insist on best practice. Doug mentioned it can be hard to find prescribers. It can be hard to find folks who are interested.
53:00 - 53:30 In Duluth we've done a lot of outreach to providers. We have methadone and suboxone treatment facility, but we also needed prescribers. I have a client in my court who has been receiving suboxone for over a year. His sister happens to be a waivered provider. She's a chief resident at one
53:30 - 54:00 of our local medical practices. The two of them, and sometimes me, go around to different medical groups. We will go wherever, whenever, I don't care how big, or how small the crowd is, and talk about the life-saving capacity of these medications. And I think we can't underestimate the power of people's stories, and the power of kind of shared experience.
54:00 - 54:30 You have to reach out. You just have to reach out, and as a judge, I think that i rarely have people that don't respond to an invitation to a cup of coffee, or don't respond to coming to a meeting. You can convene, and convene, and convene, and reach out. And I think that's part of the job. I had a sad conversation with a person
54:30 - 55:00 who's a national representative for a certain element of our work, and she said that well, in her groups, in her circles, people tended to not change their minds until somebody they knew, like their nephew, or niece, or someone in their direct circle went down with an overdose.
55:00 - 55:30 And I think I was just mortified at that. I can't believe that we are at a point where I have to know somebody in my own immediate circle before I would get on board. The problems with finding prescribers are significant and real, but if I need to change my thinking, then I'm gonna do that, and I'm gonna reach out. I know some of you are having a hard time hearing me. I'm gonna talk louder.
55:30 - 56:00 I think sharing stories, I think champions, I think judges can do so much to reach out into their community and start talking with folks. Here's my theme, embrace the research. I offer this video for you guys. It's Dr. Corey Waller. It's an addiction overview. It isn't specifically geared toward MAT, but it's a real, real, real concise, and fascinating description of the addictive process,
56:00 - 56:30 and how someone can find themselves struggling with substance use disorder. I use it for every new team member. I give it to family members. I give it to anybody interested. It can go a long ways towards opening people's view of what the struggle is with addictive behavior with substance use disorder. It does a deeper dive than I can even understand in the kind of brain chemistry and the impacts.
56:30 - 57:00 I think it's 24 minutes long, and it's well worth it. Nobody comes to this work understanding everything. When I started as a judge, I knew nothing about recovery. I knew nothing about treatment. Everything I knew was wrong, so I had to learn, and learn, and learn, and read, and try to strive to understanding. So bringing someone onboard, I thinks it's really important to get them grounded in an understanding
57:00 - 57:30 of substance use disorder, recovery, and then the available tools that we have. I also listed several different organizations that are there to help you. You guys know NADCP. NDCI is the National Drug Court Institute. NPC Research. Shout out to Shannon Kerry and the work they're doing out in Portland. Fantastic resources about best practices,
57:30 - 58:00 and getting people up to speed. I think Steve said a lot of the problem that we're facing are just folks who don't understand and haven't been educated. So I'm gonna work to educate, educate, educate as I advocate out in my community. There's a ton of online resources that you can find as well. I don't think our problem is a lack of information. I think it's hearts and minds, and then a good education. A good solid education for people who are interested.
58:00 - 58:30 I offer this quote. I clicked twice, sorry. It's a Margaret Mead quote that I love. "Never doubt that a small group of thoughtful, "committed citizens can change the world; "indeed, it's the only thing that ever has." I've been doing this work for 15 years in a couple of months as a judge. Our drug courts, our treatment courts, our mental health courts, our veteran's courts have truly changed people's lives, and truly changed the lay of the land
58:30 - 59:00 in the criminal justice system. And it's just a small group of thoughtful people doing this work, and it spreads, and spreads, and spreads. So I will hand this back, but thank you so much. I sure appreciate the work everybody's doing, and your willingness to be here on a Monday. - [Dr. Callahan] Okay, thank you very much, all three of the presenters for very interesting and very thought-provoking presentations.
59:00 - 59:30 We will open the field now for, the floor for question and answer. Some did come in during the presentations, so we'll start with those. And the first question, I think any of the presenters can jump to answer, but think Dr. Marlowe, you might be the best person to answer the first question from Dawn Schwartz. Whether or not drug courts... They're requiring MAT. Does that mean that you have to offer MAT for those who interested, or drug court participants
59:30 - 60:00 to be mandated to be active in MAT? - [Dr. Marlowe] So no. The mandate means that you cannot exclude somebody from your program, or prevent them from graduating because they're taking the medication. Forcing somebody to take medication against their will can only occur legally in a few contexts. If it's a medical emergency, the person's unconscious, or their life is immediately in danger,
60:00 - 60:30 you can give them medication without consent. You can also give medication without consent if somebody has been declared sort of incompetent to make that decision, and they have a-- - [Dr. Callahan] Does that answer the first two? Okay. - [Dr. Marlowe] I'm sorry? - [Dr. Callahan] Thank you very much. The next question, and perhaps Mr. Hanson, you might want to address it is whether or not there are any steps being taken to collaborate between bordering states with PDMPs?
60:30 - 61:00 - [Steve] There are some states who are talking about it, but it does have some relatively complex legality issues, as well as IT, in terms of getting that cross pollination on things. And it's complicated. - [Dr. Marlowe] This is Doug. Can I comment? - [Dr. Callahan] Yep, absolutely. - [Dr. Marlowe] There should be a link on one of my slides where you can find out what states
61:00 - 61:30 do have reporting reciprocity with your own state. So Steve's right. It's a very early burgeoning kind of issue, but there is a place to find out what's covered for your state's reporting. - [Dr. Callahan] Okay, thank you. The next question, and maybe all three of you want to weigh in on this, is from a director of nursing of inmate health who wants to know about diversion problems in the jail, and how to get the correctional staff on board with MAT because of that.
61:30 - 62:00 - [Steve] Well, we've been doing a lot of work with getting MAT into both our county jails and state correctional system. And SAMHSA just put on a conference last month in Rhode Island, which was one of the first state corrections systems to incorporate MAT into their practice. And diversion's a real concern. And again, you're weighing the risk of what happens to people when they leave corrections
62:00 - 62:30 if they haven't been on their medication. And we know that there's a very high risk of mortality in the first few weeks after release from custody, and a lot of that is due to while in custody they're tolerance has gone away. They haven't received the medication. And very few people are thinking yeah, somebody who came in and spent a couple months here because of shoplifting, their life isn't worth saving,
62:30 - 63:00 so we don't really care about that. We really want people to be able to survive. A life is good. And so the same things that we've been talking about. Education to the corrections staff, getting the buy in from either the sheriff, or the superintendent, whoever's running the facility, and it can be incorporated, and there's a number of different processes that corrections officers and medical staff use to limit the amount of diversion.
63:00 - 63:30 They're trying to overcome sort of the correction perspective, we're doing everything we can to keep this out of the building, and now you're just gonna walk it in the front door. But when you start to explain to them why you're doing it, what the risks are, and as the Judge mentioned before, a lot of people are getting impacted by this directly where they have family members, or people that they know who have died of an overdose. And there's a lot less resistance
63:30 - 64:00 than there was a while ago to this notion. - [Dr. Marlowe] Can I weigh in on that too? - [Judge Floerke] Go ahead, Doug. - [Dr. Marlowe] No, you go ahead Judge. - [Judge Floerke] Agreed. We've spent a lot of time working with folks on the monitoring piece to make sure that diversion is not happening. I think that's essential. Second, the best way I've seen jail corrections officers
64:00 - 64:30 grab this quickly is one, policy and procedure, but two, I've known jails where folks are actually one suboxone and working there, and they've been really good about understanding the need and the impetus behind the medication. Educate, educate, educate, educate, and then finally policy procedure. This is not a personal choice. This is what we're going to do.
64:30 - 65:00 - [Dr. Marlowe] I'd also like to just comment that those cases that I had mentioned towards the end of my talk, I'll address this issue because the many jails and prisons were not letting inmates receive buprenorphine or methadone as a matter of policy because of fears of diversion. And what all three of the appellate courts said was that kind of across the board mandate is simply no longer acceptable.
65:00 - 65:30 That you can only deny these medications if there's no less restrictive alternative, and the courts talked about all the things you can do that Steve and Judge Floerke just mentioned. You can do observed administration, you could have separate units for individuals receiving medication-assisted treatment. You could have individual cell-to-cell administration, dispersal windows. There are many things that can be done, and until and unless a jail has exhausted
65:30 - 66:00 those efforts, it can't be an across the board reason for a blanket policy. So it gets down to this least restrictive alternative. If there are other things you can do to deal with this problem, then you need to do them. It's what the courts are saying. - [Dr. Callahan] Thank you very much, all of you, for weighing in on that question. The next question comes from Chris Brown, and wants to know about a participant that's indicated that he does not wanna be
66:00 - 66:30 on MAT if he's accepted back into the drug court program. Can we hold this person to this agreement if they're accepted back into the program under the current federal laws? - [Dr. Marlowe] I'm not sure I understand the question. This somebody who's refusing medication? - [Dr. Callahan] The question as it's written is the participant has indicated they do not want MAT if accepted back into the program. I think by implication perhaps he had been dismissed,
66:30 - 67:00 or had terminated in the program, and now is coming back, but doesn't want MAT. I guess the question is can they require it? - [Dr. Marlowe] So the way it generally goes is somebody has been discharged from a drug court, and they're sort of applying to return. Usually you're gonna have what's called a show cause hearing where the person's basically making an application to come back to the program and needs to establish what's gonna be different this time. You know, what I'm gonna do to do better in the program,
67:00 - 67:30 and what I need from the program. And so if the person can offer up a reasonable treatment plan that they will agree to, that seems like it has a reasonable chance of succeeding, then you can do it. But if the clinical assessment is we've exhausted non-MAT, and the person's not getting better, and they're still saying they won't accept it, at some point you can discharge the person from the program because they're unamenable, or unwilling to take the treatment that they need to get better.
67:30 - 68:00 But there needs to be some finding of that by the court. - [Dr. Callahan] Okay, thank you. - [Judge] Can I weigh in a bit? And Doug, I wanna bounce this off of you. - [Dr. Callahan] Go right ahead. - [ Judge Floerke] Maybe I'm misunderstanding the thrust of question too, but I think if the question were posed differently, can we require that person to continue to not engage in medically-assisted therapy? Even if clinicians recommend it, they change their mind.
68:00 - 68:30 It seems like a good practice for that person. I would be reluctant to say that you could hold the person to not engaging in MAT if clinical providers, they made the decision they wanted to engage in MAT down the road. Think I'm right there? That it would have to be reassessed as you went. You could not make that a condition that lasted forever just as a blanket prohibition for that person.
68:30 - 69:00 - [Dr. Marlowe] Right. I think there's, yes, that's right. - [Steve] I think that one of the issues that you pointed out earlier, Doug, about there's only a few circumstances where you can require somebody to take a medication against their will, and the part of the thing that the drug court offers for people is the ability to stay engaged in treatment, and to work through with both clinicians, and the court staff, and the other support, on helping the person get through to the best pathway for recovery that will work for them.
69:00 - 69:30 And if somebody's reluctant to take a medication at a certain point, I wouldn't say no, you can't come into the court. I'd say okay, come on into the court, and let's keep working and see how you're doing, and here's some alternatives if you seem to be experiencing a struggle. The engagement with the treatment process is really important in getting through some ambivalence. Somebody might be being told by their sponsor no, that's not the way to do it. So it's a complex position to be in,
69:30 - 70:00 but we wouldn't want to mandate people to take a medication against their will. And we wouldn't want judges to be in the role of determining what medications people should take. - [Judge] Right, exactly. Exactly. We have commitment hearings where we commit people as mentally ill, and we have proceedings where we force medication.
70:00 - 70:30 The judge's question is never which medication risperidone or Haldol? The question is whether the person, whether they should be forced, and then the doctors are making decisions around which medication. - [Dr. Callahan] Okay, speaking of medications, we have a couple of specific questions, and if any of the panelists would like to answer them. The first one is how long does Sublocade stay in someone's system after their last injection? Is it possible for them to test negative
70:30 - 71:00 and then test positive? - [Steve] I'm gonna say there's probably a chance that can happen. - [Dr. Callahan] Okay. - [Dr. Marlowe] Yeah, I think there's probably more of a toxicologist question, and you don't have a toxicologist on the line right now. But they generally last, the injections lasts about a month, as I understand. It's only like 28 to 30 days, my understanding. And whether or not you could have increases
71:00 - 71:30 and decreases in serum levels, that is a question that we would need to pose to some of our toxicology experts. So if somebody wants to email me, I'll find out the answer for you. - [Dr. Callahan] Okay, thank you. We also had a question in terms of interpreting the levels on drug tests to determine whether or not it's being misused. Whether or not the levels are a good tool to use, or should it considered only positive, negative basis.
71:30 - 72:00 - [Steve] The best way to approach those tests is it's positive or negative. Any types of levels interpretation, which was driven primarily by looking at marijuana levels, which could be very misleading. Depending on what kind of test you were using, and how you were trying to interpret, yes, no is the best answer 'cause most of those tests are qualitative, not quantitative.
72:00 - 72:30 - [Dr. Marlowe] Yeah, if you wanna do an investigation... Sorry. - [Dr. Callahan] Okay, another question about MAT is how long is a patient typically, or on average, expected to remain on MAT? She says that she's had several participants who want to get off suboxone, but are medically advised to stay on.
72:30 - 73:00 - [Dr. Marlowe] So this is Doug. I'll take a crack at this one. So the first thing to understand is that these are really maintenance medications. So they are going to achieve the desired effects, and those effects are likely to last if people are maintained on them for a substantial period of time. According to the Surgeon General, most successful tapers from methadone, and or suboxone will occur after somebody
73:00 - 73:30 has been on a maintenance regiment for an average of three years. Now, that does not mean everybody needs to be on it for three years. It means that that's an average. So some people are maybe on it for substantially shorter, and others longer. The person should be clinically stable for at least a year. Preferably 18 to 24 months, which means not just that they're not using, but that they are not experiencing withdrawal, cravings, a lack of interest in life, that they're able to maintain employment.
73:30 - 74:00 So they're really stable for at least a year and a half to two years before you would be doing a medication taper. Most failures occur because the taper was done too soon, and when the participant wasn't ready. So for a drug court program, I think the assumption should be that relatively few people would be tapering off the medication before they graduated from a drug court, given the typical length of a drug court.
74:00 - 74:30 - [Dr. Callahan] Okay, speaking of graduating from drug court, we had a question of whether or not there's any follow up regarding MAT once someone graduates from the drug court program? - [Steve] Well, if the continuing on with their MAT, they either continuing to work with their OTP program for methadone, or an outpatient or other provider for their buprenorphine, or Vivitrol if they're using those two. So again, the notion is to try and stay on these
74:30 - 75:00 as long as it takes for somebody to be stabilized, and to reach a point where they may decide with the doctor's advice to taper off. Being on this for a long, long time should not have the stigma, and people automatically thinking oh, I have to get off it in a certain time period. We've been looking at some data in New York where people who have just dropped out of methadone, or buprenorphine programs,
75:00 - 75:30 and the mortality rate in the first three days is astronomical for folks who are doing that. So the risk of stopping abruptly, and not working through a variety of issues, including a long appropriate tapering, is really risky. - [Dr. Callahan] At the very beginning during the polling, we mentioned that we have a lot of people from rural areas that we're on the webinar, and I wondered if perhaps Mr. Hanson,
75:30 - 76:00 given the fact that a lot of New York state is in fact rural, most people don't realize that, but what are the best practices for MAT expansion, particularly in rural areas? - [Steve] Well, the things that we've been doing in rural areas is trying to really beat the drum of getting buprenorphine and Vivitrol available in all parts of the state. Methadone is pretty much indicated, reduced to where you're, how close you are to a methadone program,
76:00 - 76:30 and it might not be at all practical for you to go there everyday if it's a couple hour drive to get it. So trying to get local communities working through county health departments, working with the law enforcement, the drug courts in the area, et cetera, to sort of talk about okay, how do we build up the capacity? And sometimes it's a little difficult, but if you can particularly get the local health department engaged and focus on how this is a method
76:30 - 77:00 to help save lives, and will reduce other problems including crime related to opioid use, you can get folks on board. It's a challenge. Working with the local medical society can be helpful. Getting them to have somebody come in and talk about what's going on. We've also had in New York where we've sent groups out who are providing the necessary training for free, and just okay, we're gonna be
77:00 - 77:30 at the county health department next Wednesday. If you wanna get the training, please stop by. - [Judge Floerke] That's what we're doing here too. We're looking for medical champions, and then having them do like a one day training. Advertise that I'll get free food, and go to rural areas, and try to get waivered physicians. A medical champion can help you a ton. - [Steve] One of the other things that we've been working on is getting people to start inductions in emergency rooms.
77:30 - 78:00 Emergency rooms are frequently, they'll bring somebody in who is in an overdose, or just was reversed from an overdose, and they're no longer in immediate need of healthcare 'cause of a risk of dying they're doing okay. So they say okay, fine. You can go. But instead, some of our hospitals are starting to say okay, now we're gonna put you on a buprenorphine. We're gonna give a three day dose,
78:00 - 78:30 and get you connected to a prescriber out in the community who can continue on. Thinking that people at that point are kind of vulnerable, and would be open to the suggestion of getting into the medication program. - [Dr. Callahan] Speaking of reversing overdose, we have a question. Whether or not if any of the panelists have any experience with, or concerns about liability with the use of Narcan?
78:30 - 79:00 The person asking the question said that they've had some concerns about liability in her communities. - [Steve] Most states have Good Samaritan Laws that will protect folks from this. The liability concerns are often, don't have good things to support why... If you can give Narcan to somebody who isn't in an overdose,
79:00 - 79:30 it'll have no effect on 'em. So the only thing that you can really do is it will help somebody who is experiencing and overdose of an opioid, and reverse the respiratory arrest that would cause a death. And so your state should have some Good Samaritan Laws where that's covered. There are certain nursing practices that might be where nurses practice rules forbid them from giving a prescription medication
79:30 - 80:00 to a patient who's name's not on the prescription. And many states have sort of given waivers to nurses to be able to do that. But that was the only obstacle that we've found for anybody in the state of New York, particularly with school nurses being able to have naltrexone on hand, Narcan on hand to give to somebody who overdosed. - [Dr. Callahan] Okay, we have a question also
80:00 - 80:30 about paying for MAT. If a drug court participant cannot afford to pay for MAT, is the drug court responsible for covering the cost? The person asking the question said the issue has come up in the public defender's office, and not all drug courts have access to that kind of funding. - [Dr. Marlowe] So I don't know that anybody would say that drug court is required to come up with the payment. If they don't have the money, they don't have the money,
80:30 - 81:00 and any appellate cases that have looked at this have basically said that cost is legitimate in terms of not being able to provide services. But the real key here is that drug courts really need to do everything they can to figure out ways of finding coverage because as was mentioned earlier, many drug courts have been able to negotiate low payments, or even in some respects, no payments for some of these medications through the pharmaceutical companies. They've been able to work with federally qualified health centers,
81:00 - 81:30 with centers that are covered by the 340B Program. So just because the person themselves doesn't have insurance coverage, doesn't mean that you can't get the medications covered. But no, were not gonna require drug court to pay for something that they can't pay for. - [Judge Floerke] Right. And that could include having insurance navigators. If you have insurance availability in your state that would cover this, insurance navigators can help folks get hooked up,
81:30 - 82:00 and then they're available to get insurance coverage for the MAT. - [Dr. Callahan] Okay, we had a question also about how to incorporate peer mentors and coaches into drug court. I wondered if one, or all of you would want to take that question? - [Judge Floerke] I could start. I have them on my team. So they're in staffing, in court, available. I consider it one of the essential pieces of what I do.
82:00 - 82:30 In Minnesota, and I think maybe Steve mentioned it, there's more availability for billing and reimbursement for peer recovery, peer support services. So we're doing that to the extent we can. And we are also providing, we're getting funding to do free training to get people through what in Minnesota is a 40 hour certification program to become peer recovery specialists.
82:30 - 83:00 I think they're critical, critical support for what we're doing. But you've gotta invite 'em in. You gotta build a relationship. You gotta get 'em comin'. Get 'em connected. - [Steve] And usually they're very willing to come in. - [Dr. Callahan] So we have a question. Could treatment court case managers have any involvement in implementing the MAT, or is this solely up to the judges, clinicians,
83:00 - 83:30 and probation and parole officers? - [Steve] I think the question would be what do they mean by implementation? The choice of a medication, through state law, is between the physician, or the physician extender, and the patient. So making a determination of which medication to use, what the dosage is, et cetera,
83:30 - 84:00 is all within the medical field, and the role of the court, including the judge, the case manager, both the prosecutor, and defense is to be supportive of the person's effort to get into the medication program. And just as Doug mentioned before, the risk of, unless your jail can continue medication while somebody's getting sanctioned, you basically want to slap their wrist for something,
84:00 - 84:30 but you don't wanna put them at a risk for a big overdose. So the notion of being able to use jail sanctions carefully, particularly if they don't have access to their medication while their incarcerated. - [Dr. Callahan] Okay, we have, I'm gonna read one more question, and then we will make just for everyone who's still on the call, and if your question wasn't answered, or you had some additional follow up information, we'll make every effort of doing a Q and A document
84:30 - 85:00 to respond to the questions that were left unanswered, which we'll include with the slides and other information to everyone who's registered. So the last question I'd like to put out there is what is an example of a higher magnitude sanction if someone is not complying with MAT requirements? - [Judge Floerke] I'm just trying to understand what not complying would mean.
85:00 - 85:30 - [Dr. Marlowe] I think as we said earlier, you can't force... I mean if a person is misusing the medication, if that's what's meant, that the person has gotten a prescription they weren't supposed to get, or they were not taking their medication, they're not testing positive for the medication they're supposed to be taking, or their pill count is short, then those are considered what we call proximal infractions. Those are wilful infractions.
85:30 - 86:00 They're not a manifestation of their disorder. Then higher magnitude sanctions could include day reporting requirements. They could include home monitored curfew requirements. They could include community service. They could include brief jail detention. You know, 24, 48 hour sanction if the person is engaged in fraudulent activities, especially diversion of the medications. So there's a whole list of sanctions
86:00 - 86:30 of varying magnitudes that are listed. You can download them from NDCI's website. So they list them as sort of low, moderate, high, for both rewards and sanctions. They give sort of examples of consequences that are frequently used. (presenters drown each other out) Go ahead - [Judge] Go ahead, Doug. - [Dr. Marlowe] No, no, go ahead. - [Judge Floerke] I like all those points. My first questions would be more what is our treatment response? What's going on with this medication?
86:30 - 87:00 What's happening? Are there issues that we can take up in treatment around the medication usage, and the adherence to the treatment? That might answer your question too. I don't know that it... I'd be considering sanctions as well, but I'd firstly be asking what's going on here, and what can we do in treatment milieu? - [Dr. Callahan] Okay, thank you very much.
87:00 - 87:30 Before we sign off from this webinar, I wanna again thank all of our speakers for both their presentations, and their responses to the questions. We have opened another poll with two questions about any kind of follow up information that you believe would be helpful, and if you would respond, we would be grateful. Right now you'll see on your screen that there are three documents that we have provided for you that you can download that's specifically speak to the issues about medication-assisted treatment.
87:30 - 88:00 The certificate of attendance can be downloaded at this time for your own portfolio. Again, if you signed on a few minutes into the webinar, this does not equate with CEU credits, but it's for your own personal portfolio. We also have one of the questions had to do with mentors in court, and we have an upcoming webinar from the GAINS Center specifically with mentors in veterans treatment courts.
88:00 - 88:30 But many of the strategies to engage mentors in veterans treatment courts would be the same as in drug treatment courts, and other kinds of treatment courts. And we also have a listserv. If you want to be given notice of webinars and other kinds of materials that are released from the GAINS Center. You can sign up to the listserv here. And finally, here is the information from SAMHSA. Contact information and their website,
88:30 - 89:00 as well as from the GAINS Center, which is co-hosting this webinar with SAMHSA today. So we wanna thank everyone very much. If you could respond to the poll before you sign off, we'd be very appreciative, and I wanna thank you very much for your participation.