Drug Enforcement Versus Drug Treatment: A Public Health Issue

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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

Jac A. Charlier, MPA: Let me actually answer that from a real big picture frame because, at TASC, we talk a lot about systems, such as the public health system, and the criminal justice system. So, there are two things in the United States that really make this clear from a systems level. One is policy, and then there’s money. You always have to talk money, right? Policy in the United States has been about drug enforcement versus drug treatment. There is a massive amount of resources that have gone into treating addiction from an enforcement standpoint, which doesn’t work. We’ve got Josh here, we’ve got all the researchers, all the medical people saying, “Well, you cannot lock your way up out of addiction, it’s just not going to happen.” So, that’s a huge thing. That’s beyond stigma. That’s beyond criminalization. It’s saying that drug use is a problem for the police to solve, or for the drug enforcement agencies, the DA, to solve, for example. When it’s not, it’s a public health issue.

I’m talking about drug use. I want to make it clear, it’s not drug manufacturing, it’s not drug delivery. Those are criminal elements and criminal act, and I want to distinguish that just for the sake of saying that versus drug use. From a policy standpoint, we’ve done enforcement versus treatment. From a funding standpoint, we have so underfunded, in the United States, substance use disorder treatment—and I’ll throw in mental health—to the point that the system is virtually nonexistent in many communities. And, a quick shout out to our citizens who live in rural areas. They’re really out of luck. When Josh described the modalities of treatment that exist in a community—you are lucky, at best, if you have that in the rural communities, and then your ability to get there. How do I actually get there?

So, we want to talk about funding. I want to just bring up here that the Affordable Care Act is a game changer in this community by providing, especially for the justice population, access through Medicaid to a funding stream, so that your medical community will now be able to get paid when the person who’s coming out of a jail or prison says, “Yes, I have insurance, I’m on managed care, Medicaid (or whatever the state system looks like), and I’d like treatment.”

Peter L. Salgo, MD: That being said, whether in the criminal justice system or not, there are physicians out there who see patients who have drug dependency issues. And I would suspect that a lot of doctors would like to treat them. Can a primary care doctor take somebody who has one of these issues and successfully guide this person through it, or is that something best left to you guys?

Jonathan Grand: I think they can, but they have to have a mindset. And one of the mindsets that they have to have is that relapse is just one step on the road to recovery. If a doctor thinks that the first time he or she sees an addict that they’re going to get clean for the rest of their lives, they’re going to be very disappointed. Because this is a tough disease. And, when you think of the physiological and psychological craving that is involved in addiction, it’s a tough nut to crack. It takes a lot to beat it. And, sometimes, it’s not the first or the fifth or the tenth time that someone finally gets the message and gets it right. So, if you’re a physician, don’t expect that to succeed the first time. And to some degree, I think it’s really important that you’re a cheerleader, that you encourage that person, and empathize with that person, and you say, “Okay, you didn’t make it this time, but there’s going to be another time. Now, you’ve learned from what happened this time and you’ll do it differently next time.”

Peter L. Salgo, MD: I want to give you your shot.

Joshua D. Lee, MD PhD: Yes. That’s one of our paradigms. The primary care doctors, family doctors, particularly, if it’s a rural county and you’re one of the only providers, mental health or otherwise, can successfully, and arguably as effectively as any other package of services, use medications for alcohol, nicotine, and opiates, and get rates of success, treatment effectiveness, and recovery comparable to any other kind of setup. And they can do it reasonably lean and mean in terms of the resources. Because for opiates, the medications are great. They’re awesome, they’re quite effective if a patient can have access to them, get on them successfully, and take them every day. You really can extinguish heroin use almost overnight by getting somebody on to the right dose of methadone, buprenorphine, or say a monthly shot of extended release naltrexone.

With alcohol, we have a bunch of different medications we can use, and that’s a very common condition for a family doctor to be seeing anyway; hazardous drinking, risky drinking, or criteria for an alcohol use disorder. So, criminal justice involved or not, that’s just a big problem in our population. Limitations to this are that we’ve had medications to put in the hands of general practitioners for, in the case of alcohol and nicotine, decades now. With the opiates, we’ve had them for a little less time, but long enough. And we haven’t gotten enough doctors to become that interested provider who’s, for example, part of my family practice here in rural Tennessee where I’m from—and is treating opiate addicts. And I’m just going to do it, and I’m going to have 50 people in my practice that I’m actively prescribing medications for. We have not gotten enough people to do that, and we argue in the field about why not. There’s a lot of federal effort now, and legislation we’ll see this summer heavily promoted by the current administration to get more doctors and do it, to put funding into it. But, we haven’t gotten there yet.

And then you look at the smoking model. You know how we treat smoking now? It’s called 1-800-quit-smoking, and there’s nicotine at CVS over the counter. You can even consider taking the formal billable healthcare visit out of the whole equation and just try and get this stuff out there on a mass scale. You probably, overall, in terms of the population, get better rates of success doing it that way. We don’t quite do that with controlled substances and medications that have side effects. But, smoking cessation is a great example of where we don’t even need a system to implement it, let’s just like try and get at the people by any means possible.