The Political and Personal Side of Drug Addiction

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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

Jonathan Grand: The Medicaid expansion states really have an advantage right now, because what they can do is they can register inmates, while they’re still in jail and prison, for Medicaid. And then, in many cases, they get their injection of Vivitrol before they leave. They’re good for 28 days. When they’ve done that, they now make arrangements through, we’ve talked about those navigators, those people who are working with the inmates. Now, they move them out into the community, they’re already on Medicaid, and so now they can get their next medication for free.

So, not only is that good for those Medicaid expansion states, what’s happening now, because of the opioid epidemic, is you’re having non-Medicaid expansion states starting to fund these medications. Missouri is a great example. It is a non-Medicaid expansion state, but the legislature has put together hundreds and hundreds of thousands of dollars specifically for MAT. And they’re one of the model programs in the country.

Peter L. Salgo, MD: I can hear this, because I listen to political radio all the time, and I can tell you how the spin is going to be, or is, which is, “Darn it, they’re taking our tax dollars that we worked hard for, and they’re giving it to these criminals.”

Phillip Barbour: But, it’s actually going to save them money, because it costs more.

Peter L. Salgo, MD: I was going to ask you, what’s the counter answer here?

Phillip Barbour: It’s been the same story for the last 25 years; treatment is cheaper than incarceration.

Jonathan Grand: That’s right.

Jac A. Charlier, MPA: It’s cheaper and for the right population when you use screening and assessment right, which is well known to the medical field. When you do screening and assessment, and you apply the behavioral intervention to the right population, not only is it cheaper—this is more important—it is more effective at reducing recidivism. Then, when done, we can talk about recidivism within the full totality of interventions that are needed. And reduce recidivism, Peter, in the world of criminal justice, means someone who might not be murdered, sexual assault that might be prevented, and a burglary that might not happen. The criminal justice system, like the medical community, deals with situations that are life and death; very serious, very critical.

Peter L. Salgo, MD: If you take a look at the demographics now of opioid use in the United States, it’s changing.

Phillip Barbour: Big time.

Peter L. Salgo. MD: Either that or we’re recognizing it more than we used to recognize it. But, the sense of it is when you look at the literature, you look at the press, and you look at the numbers, this epidemic of opioid use is moving out of the inner city. It’s into the suburbs. You were talking about rural communities, right? So, these are users that are now constituents and voters of the very people who used to oppose funding. Is that going to make a change?

Joshua D. Lee, MD, PhD: Yes, it already has. You saw the New Hampshire Republican Primary, right? Every candidate had to go up there with a story about addiction and how they were going to humanely approach the opiate problem. New Hampshire is essentially an all-white, mostly rural state, that is largely conservative, and kids are dying in basements every night there. It’s a disaster in terms of how heroin and other opiates have penetrated that state, and particularly affected young people. So, grandmas don’t have their daughters any more, they’re raising their grandkid, and now the grandkid is addicted. That kind of stuff is typical, and we heard it throughout that campaign. And so, it just wasn’t going to be a sale politically; to be tough on crime there, drugs are illegal, and they should all be locked up. That just is a nonstarter at that point.

Jac A. Charlier, MPA: I’ll add to what Josh said. So, you mentioned New Hampshire. Ohio has been a leader on this under Governor Kasich’s administration in putting resources at all levels—educational awareness, actual resources in the justice system, the public health system—into fighting the opiate epidemic. And that is, again, a republican governor, but because the impact is so widespread, it has political lift. We should not be that cynical. These are people, family members and neighbors, who are dying. We can’t have achieved that level of cynicism yet. If you know someone who died from this, my gosh, of course, that would have some impact on you no matter who you are.

Peter L. Salgo, MD: So, you talked about Ohio, you talked about Missouri, New Hampshire. Give me some examples, just anecdotally, of how this works successfully.

Phillip Barbour: Well, I’ll give you one. In Illinois, we have a small police department in the fairly small Will County, where you’re seeing law enforcement actually taking a different approach to the opiate problem in their communities. They have a program called ‘Safe Passage’ in Dixon, Illinois, where an addict can come in, surrender their drugs and their paraphernalia, and say, “I want to get some help.” They do not go through the prosecutorial process. They’re not even charged with anything. Now it doesn’t protect them if they have warrants out or something like that, which if they did, they probably wouldn’t even know that. But, the idea that law enforcement is taking a different approach to this war on drugs, if you will, it’s like the tail wagging the dog.

What it’s doing is forcing legislators to start paying attention to the problem in a different way, as well. If law enforcement is about, just like you say, “you’re taking my tax dollars and giving these to these criminals,” well, even the jails realize that just locking them up is not going to solve the problem, that we have to take a different approach to this problem and give them an opportunity to get some help.

Now, what if they don’t comply? Sure, there’s going to be consequences. That’s part of an effective evidence-based model that we talk about a lot called RNR, which is Risk-Needs-and-Responsivity. If somebody’s in noncompliance, there needs to be a sanction imposed. Whatever that is will depend on the program. But, I do think, again, there’s a different shift in how everybody’s approaching this problem. This is not about crime anymore. It’s a public health issue.