Decision Making in Substance Abuse Treatment

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: We just unpacked this drug. Went through it. Now it’s a tool. The question next is, who gets the tool? Who’s the right candidate for a long-acting drug like this?

Jac A. Charlier, MPA: Well, I’ll speak from the justice perspective. The medical community should be making that decision. It’s an important consideration before we jump back in.

Peter L. Salgo, MD: Is it the medical community or is it somebody involved in the entire addiction community—the psychosocial, the medical, everything? Who’s the right candidate?

Jac A. Charlier, MPA: I threw that in because the intersection of medication-assisted treatment, or any medical or public health issue, into the justice side of it means you’re going to have probation officers, parole officers, and judges making or wanting to make medical or clinical decisions. That is problematic.

But, it’s important to understand that for the medical community, as it gets involved with the justice system, or wants to get involved and broker those relationships, so it plays its proper role, this is a medical opinion. A judge, a parole officer, and a probation officer should not be practicing medicine and making medical decisions. So, yes, the decision rests between the patient and their doctor, like any other disease. But, the challenge is the justice system wants to put its hands in it. Let me give you a very practical example of what I mean by this. We have courts, including drug courts, that are designed around making sure you have reduced drug use to reduce crime, right? That’s all criminal justice is about, crime reduction, that’s our profession—saving lives, protecting communities. But, we have drug courts that say in order to graduate, you must be abstain from it. And, by the way, medicines are drugs to the court. So, they look and say, “You have to get off of buprenorphine, methadone, or Vivitrol to successfully graduate.”

Peter L. Salgo, MD: Can I just interrupt and say, from the totally uninitiate that I am, that sounds stark scaring bonkers.

Phillip Barbour: Ideally, Peter, we want to have somebody like Josh on that reentry team that we talked about earlier, so he could advise us, the clinical team, as to whether or not this is an appropriate client.

Jac A. Charlier, MPA: Well, even more than advise. This is why I wanted to intercede this, because you’ll hear the medical and the pharmacology side of it. I totally get that for the “TV audience”, but I want to be very clear about how the intersection of that to justice is problematic in implementation, and we have to ensure that the justice system steps out of that. And, part of that will fall to the medical community. One thing I always ask doctors to do, and medical researchers used to say, is please come as well-respected people, not just in your profession but in our society, and literally speak to us on the criminal justice side, who will listen to you and say, “Oh, that’s really how this should operate. It should be a medical decision.”

Peter L. Salgo, MD: Okay. So, expert in the criminal justice system, with all due respect, speak to me, all right? You know the system. And I ask you, “Okay, I’ve got this guy. He’s going to be coming out, he’s clean in prison, he’s been through the system. He may or may not be on methadone in jail, or prison. Should he come out on methadone? Should he come out on Vivitrol?” Who’s the right candidate for Vivitrol? How do you describe this?

Jac A. Charlier, MPA: I think I’ll let Josh answer about the right candidate. Probably what I would say, as the criminal justice person here, is this: as that person, I should turn to the doctor and/or to the clinician, and say, “You tell me from the medical side, the behavioral health side, what I should write as a judge on the order to make sure that that goes on and gets to the right person?” Then, I’m out of it, other than the supervision.

Peter L. Salgo, MD: He just went, tag, you’re it.

Jac A. Charlier, MPA: But, that’s exactly the model that should be in play.

Phillip Barbour: Sure, absolutely.

Joshua D. Lee, MD, PhD: Yes, totally. These are generally applicable drugs for pretty much everyone with an opiate use disorder or any significant risk of relapse to heroin or other opioids. They would all be good choices to start and maintain on methadone, buprenorphine, or extended-release naltrexone. We don’t have any data that says, “Oh, the redhead who’s 23-years-old who also uses marijuana, that person needs to be on buprenorphine, but the 46-year-old who’s been in treatment a bunch of times, that one needs to be on Vivitrol.”

We’re doing studies that may help us with the “cookbook”, but really it’s about, what are the drugs available in my system? Most jails and prisons can’t actually deliver methadone because of the regulations. That’s not their fault. It’s a matter of you have to create a methadone clinic program in the thing, paperwork, bureaucracy, etc. It’s not going to happen. So, buprenorphine or Vivitrol might be the easiest to, say, layer into a county jail that currently doesn’t offer any medications, but has a large number of untreated opiate users. And then, what’s realistic for them to follow up with? Is there a model reentry program that’s going to handhold? Maybe there isn’t.

Peter L. Salgo, MD: Tell me about model reentry programs. Are they mostly getting people out of prisons that are drug-free, and so they might be candidates for Vivitrol? Or are they mostly getting people that have been transitioned to a narcotic agonist or partial agonist?

Jonathan Grand: Well, Peter, one thing you have to remember is that it’s not always what’s best for the inmate as to what medication they’re going to get. It may also be that in a lot of prisons and jails, for instance, buprenorphine is not given because it’s something that can be like contraband. It gets snuck in very easily into prisons. It becomes a security issue and it also has a resale value. It has a street value. For security purposes, a lot of jails and prisons will not treat a person with buprenorphine, or Suboxone. So, now you have that out.

Some of them have DEA licenses, so they can do methadone. Connecticut, for instance, is one of the states that has methadone for their inmates. Vivitrol is the new ‘dame on the block’, and that’s the one that is being encouraged a lot in different states and jails around the country. So, it’s not necessarily what’s best for the inmate, it may be what the inmate can get based on what is the preference for the jail and the prison.