Understanding Medication-Assisted Drug Treatment Programs

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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: I agree with what Jon’s saying. I’ll also throw in, and go back to what I brought up earlier about the systems pitch on this, the issue of medication-assisted treatment (MAT) in criminal justice and the resolution of that on the jail and prison side. Who’s going to pay for it? Until that’s resolved, everything that you hear here is small scale. I want nobody to walk away with a belief that this is going on all over. It is absolutely not going on all over. It is like drug courts. It’s a very small number of people who are accessing that type of treatment as part of their recovery.

Peter L. Salgo, MD: Okay, well give me the 10,000-foot view. If we don’t have a lot of these MAT Programs, describe how a program should work. How is it supposed to work? Talk about adherence. What happens when people don’t adhere? Talk about all of the nuts and bolts that go into a program like this. You want to start us off?

Phillip Barbour: Well, from the reentry perspective, one of the things that needs to occur is you need to have a complete team, which includes medical people, your clinicians, your community supervision folks, even the judge, in some cases, if they have an interest in that type of thing. Parole Board member perhaps could be included, because a lot of times they’re going to make recommendations that might undermine the reentry process. So, you have to have a complete team.

Assuming you have the funding in place, all the systems issues have been resolved, and somehow you have a facility that has the license and the proper certification to administer that stuff, that would be the ideal scenario. And, again, the other thing that I think is very important, at least in our state it is, is the medication or the application of medication. All that is always done by informed consent. Clients have a right to refuse, at least in our state. Even though we may give them the best recommendation possible, they have a right to refuse that. And so, there also needs to be some education of the client. Josh has talked so much about methadone today that I still didn’t know about, and I work in a methadone clinic. So, educating clients properly on what they’re doing and what decisions they need to make in order to best enhance their recovery is important. And, obviously, that’s going to be a chain reaction thing. If they’re staying off of drugs, there’s a good chance that that population or that individual’s not going to recidivate back into the system.

Peter L. Salgo, MD: Okay, let me ask a simple yes-or-no question to get us on track. MAT programs, or pilot programs—I’m going to assume because they’re not widespread.

Jac A. Charlier, MPA: That’s correct.

Peter L. Salgo, MD: In the pilot programs, do these programs work? Do they keep people from recidivism? Do they keep them from going back to jail? Yes, or no?

Jac A. Charlier, MPA: Yes, on the reduced drug use. Recidivism is larger than just reduction and drug use.

Peter L. Salgo, MD: Okay, fair enough.

Jac A. Charlier, MPA: So, yes on the reduced drug use, from the little research that we have about what we know.

Peter L. Salgo, MD: You get a vote. Yes? No?

Joshua D. Lee, MD, PhD: I’ve got to be neutral on that as well. It’s very tricky when you’re saying, “Oh, just take MAT and then you’ll never go back to jail.” It does not work that way.

Peter L. Salgo, MD: Let’s take jail out. How about just recidivism on drugs?

Joshua D. Lee, MD, PhD: Oh, relapsed to drug use? These are the most effective treatments.

Peter L. Salgo, MD: I got a great big yes. Now, if they work, why do they work? Because people have tried everything. There are well-intentioned people in this business who go back decades and decades, and they’ve tried everything. Why now does MAT seem to work in these pilot projects? Is it that we have better drugs, that we understand the problem better? Do we have a different class of client? I’ll use the word client as opposed to patient, I think that’s appropriate. Why?

Phillip Barbour: I think you answered part of the question. There’s a change of perception about medicated-assisted treatment. It’s slow, it’s got to go a lot further, but there seems to be more of acceptance from the system that this is an effective intervention. Because, like you say, they tried everything else. They tried to lock it down, that didn’t work. I do think there’s a change in attitude about medication-assisted treatment. Not to say it’s where it needs to be fully, but we’re getting there slowly. And we’ve tried all these other types of interdictions and nothing has worked. So, you answered your own question, it’s because they’ve tried everything else.

Peter L. Salgo, MD: Well, participants are monitored for adherence, right? They’ve got to adhere. What happens if they don’t? Is there some penalty, other than going back on drugs?

Jac A. Charlier, MPA: You mean the justice system penalty?

Peter L. Salgo, MD: Yes.

Jac A. Charlier, MPA: So, let me go back though. When we trained judges—probation, parole, prosecutor, defense—and we take the neuroscience of addiction, I take it down to one thing: it eliminates or substantially reduces the cravings. And those cravings are then the desire that drives them to go get more drugs, to get high again. That’s how I boil it all down. It’s not clinical, it’s not scientific, but it’s a way that the justice system can understand it.

Jonathan Grand: And, also, security. It gives the addicts a sense of security that they’re not going to do drugs immediately, because they have this thing in their system. It’s an insurance policy for them. And you have to realize that you get up one morning and you think you’re not going to use the drug. Then, something happens and you say, “I’ve had it, I’m going out and I’m going to use.” But, if you had something in your system, you go, “I have to wait a couple of days before I can do it.” And by that time, the crisis might be over, and now they can continue.

Peter L. Salgo, MD: Who’s funding all this? These are pilot projects. Where’s the money?

Jac A. Charlier, MPA: So, the Affordable Care Act represents a new funding stream, but for the community side. Without getting too much into it, there are Medicaid waivers that can be secured so that you can do some pre-jail release, say, of Vivitrol injections very early on. It’s very experimental, not widespread at all. Right now, county government funding or state funding is what’s being used for this. There is some foundation funding, I’m sure, and experimental research funding might be in play.

Joshua D. Lee, MD, PhD: Yes, we’ll see what happens in Washington, DC this summer. There might be more and more federal-to-the-state money. So, it’s a variety of budgets.