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The impact of drug court participation on mortality: 15-year outcomes from a randomized controlled trial
Journal of Substance Abuse Treatment 105 (2019) 12–18
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Journal of Substance Abuse Treatment journal homepage: www.elsevier.com/locate/jsat
The impact of drug court participation on mortality: 15-year outcomes from a randomized controlled trial
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Brook W. Kearleya, , John A. Cosgrovea, Alexandra S. Wimberlya, Denise C. Gottfredsonb a b
University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA University of Maryland, Department of Criminology and Criminal Justice, 2220 Samuel J. LeFrak Hall, 7251 Preinkert Drive, College Park, MD 20742, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Drug courts Mortality Randomized controlled trial
Aim: To test the effects of drug court participation on long-term mortality risk. Methods: During 1997–98, 235 individuals charged with a non-violent offense were randomly assigned to Baltimore City Drug Treatment Court (BCDTC) or traditional adjudication. Heroin was the predominant substance of choice among the sample. Participant mortality was observed for 15 years following randomization. Results: Over 20% of participants died during the study, at an average age of 46.6 years, and 64.4% of deaths were substance-use related. Survival analyses estimated that neither mortality from any cause nor from substance use-related causes significantly differed between BCDTC and traditional adjudication. Conclusions: Frequent and premature death among the sample indicates that this is a high-risk population in need of effective substance use treatment. Roughly half of drug treatment courts are now estimated to offer medication assisted treatment (MAT), which is currently the most effective treatment for opioid use disorders. In this study of BCDTC implemented over 15 years ago, only 7% of participants received MAT, which may explain the lack of program impact on mortality. Historical barriers to providing MAT in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma. Drug treatment courts should implement best practice standards for substance use treatment and overdose prevention, including increased access to MAT and naloxone, and training to reduce stigmatizing language and practice.
1. Introduction In Baltimore City, death by opioid overdose has dramatically increased in the past decade, reflecting national trends. In 2017, 761 Baltimore residents died from unintended drug and alcohol intoxication (91% of which were opioid-related), a figure that is six times the number of opioid-related deaths in 2011 (Maryland Department of Health, 2018). With the highest overdose fatality rate among USA cities in 2017 – estimated at 75 per 100,000 residents during years 2015–17 (Robert Wood Johnson Foundation, 2019) – preliminary 2018 data shows that opioid-related deaths rose another 15% to 798 (Opioid Operational Command Center, 2018; Baltimore City Health Department, n.d.). Yet, these figures do not fully reflect the impact of chronic substance use on mortality. Death has been directly related to complications from substance use, including septicemia, cancer, suicide, hepatitis, injury and HIV/AIDS (Cook et al., 2008; Hingson, Zha, &
Weitzman, 2009; Lopez-Quintero et al., 2015; Rehm & Shield, 2013; Ridolfo & Stevenson, 2001). Unsurprisingly, people with substance use disorders (SUD) are more likely to die prematurely (Neumark, Van Etten, & Anthony, 2000); one study finding that heroin users were 3–4 times more likely to die prematurely, at an average age of 45 (LopezQuintero et al., 2015). For those with criminal justice involvement in addition to a SUD, the statistics are even bleaker. The leading cause of death among returning citizens is drug related, with 18% of deaths across 18 studies attributed to substance use (Zlodre & Fazel, 2012). SUD treatment, therefore, is critical to not only reduce substance use, but also to reduce high mortality rates among people with SUDs (Gossop, Stewart, Treacy, & Marsden, 2002). Various substance use treatment modalities have demonstrated decreased mortality, including psychosocial treatment (Davoli et al., 2007), medication assisted treatment1 (MAT; Davoli et al., 2007; Degenhardt et al., 2011), brief interventions (Cuijpers, Riper, & Lemmers, 2004), and therapeutic
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Corresponding author. E-mail addresses: [email protected] (B.W. Kearley), [email protected] (J.A. Cosgrove), [email protected] (A.S. Wimberly), [email protected] (D.C. Gottfredson). 1 MAT is the provision of buprenorphine, methadone or extended release naltrexone in concert with counseling. Research has demonstrated that medications alone can be as effective as medication with counseling (Schwartz, Kelly, O'Grady, Gandhi, & Jaffe, 2012). https://doi.org/10.1016/j.jsat.2019.07.004 Received 14 January 2019; Received in revised form 14 June 2019; Accepted 10 July 2019 0740-5472/ © 2019 Elsevier Inc. All rights reserved.
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Enrollment Randomized (N = 235)
Allocation Allocated to BCDTC (n = 139) Received allocated intervention (n = 126)
Allocated to traditional adjudication (n = 96) Received allocated intervention (n = 89)
Follow-Up Lost to follow-up (n = 0)
Lost to follow-up (n = 0)
Did not receive allocated intervention (n = 13)
Did not receive allocated intervention (n = 7)
Analysis Analyzed (n = 96) Excluded from analysis (n = 0)
Analyzed (n = 139) Excluded from analysis (n = 0)
Fig. 1. CONSORT flow diagram of Baltimore City Drug Treatment Court randomized controlled trial. Note: This figure represents a modified version of the CONSORT diagram. The research team did not collect data on the number of individuals considered for eligibility and enrollment.
studies have examined whether participants make sustained life changes and few studies have looked at the impact of drug court on outcomes beyond recidivism (Mitchell et al., 2012).
communities (Bale et al., 1983). One systematic review found that people not receiving MAT had mortality rates that were over two times higher than those receiving MAT (Degenhardt et al., 2011). Among individuals with criminal justice involvement, MAT has also proven effective in reducing mortality. MAT provided in prison and post-release has been associated with reduced mortality during community return (Degenhardt et al., 2014; Dolan et al., 2005). Although SUD treatment has largely demonstrated reduced mortality, there are various treatment modalities provided to people with criminal justice involvement that have yet to be assessed for mortality impact, including drug courts. There are over 3500 drug courts nationwide (National Drug Court Resource Center, n.d.), providing an alternative to incarceration for people with SUDs who agree to engage in treatment. Given that nearly two thirds of people in jails and over half of people in prisons have a SUD, yet < 30% of them participate in a drug treatment program (Bronson, Stroop, Zimmer, & Berzofsky, 2017), drug courts provide crucial access to substance use treatment for people who would otherwise be incarcerated with limited access to treatment. Several recent meta-analyses of drug court evaluations conclude that drug courts are a better criminal justice response for defendants with a SUD than traditional case processing (Lowenkamp, Holsinger, & Latessa, 2005; Mitchell, Wilson, Eggers, & MacKenzie, 2012; Wilson, Mitchell, & MacKenzie, 2006). In an analysis of 154 independent evaluations, Mitchell et al. (2012) found that drug courts significantly reduced general and drug-related recidivism, with effects lasting up to three years. While research suggests that drug courts support reduced substance use among participants, much of the existing research is methodologically weak with short follow-up periods (Harvey, Shakeshaft, Hetherington, Sannibale, & Mattick, 2007). Very few
1.1. Current study The current study addresses previous methodological limitations of drug court research by utilizing a randomized design to examine the impact of the Baltimore City Drug Treatment Court (BCDTC) on mortality rates in the 15 years following randomization to either the BCDTC or traditional adjudication. This study is therefore foundational in understanding the impact of drug courts on mortality. We hypothesized that individuals randomized to BCDTC would have lower overall and substance use-related mortality rates than individuals randomized to traditional adjudication during the 15 years following study enrollment. 2. Methods This non-blinded, parallel randomized controlled trial with unequal allocation was conducted in Baltimore City, Maryland. Participants were recruited on a rolling basis from February 1997 to August 1998. Participation in the BCDTC was voluntary and participants were randomized to either the intervention (BCDTC) or to the control group (traditional adjudication). Mortality outcomes were evaluated at 15years post-randomization. 2.1. Participants Defendants with open cases in either the District or Circuit Court 13
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2.3.3. Services received During the first three years after randomization, BCDTC participants received drug testing (86.9%) and attended status hearings (84.2%) at significantly higher rates than those in traditional adjudication (40.2% and 7.3%, respectively; ps < .01). The majority of those in BCDTC received some form of SUD treatment (71.2%)2 – most frequently outpatient treatment, intensive outpatient treatment, and jail-based acupuncture, all of which the BCDTC participants received at significantly higher rates than those in traditional adjudication (ps < .01). The treatment conditions did not differ in the use of MAT, which was received by < 10% of either group. Gottfredson et al., (2006) provide additional detail about the types and doses of supervision and SUD services received by study participants.
were eligible if they resided in Baltimore City, were at least 18 years of age, and were in need of SUD treatment, as assessed by the Addiction Severity Index (McLellan et al., 1992). Previous conviction(s) of a violent offense was the only exclusion criteria.
2.2. Study procedures Baltimore Court personnel identified and referred eligible defendants to the research team. Potential participants were then informed of the study's purpose and procedures (including its voluntary and confidential nature), and gave written informed consent. Once consented, participants were randomly assigned by the research team at a ratio of one BCDTC to one traditional adjudication for Circuit Court cases; and a ratio of two BCDTC to one traditional adjudication for District Court cases. Because fewer defendants who went through the District Court were eligible for drug court (as compared with the Circuit Court), this study's unequal randomization protocol was established to ensure that all BCDTC slots were filled. Randomization results were communicated to court personnel just prior to the participant's appearance before the judge. The judges agreed to abide by the randomization results because the BCDTC did not have the capacity to serve all eligible and interested defendants. As such, randomization represented a fair and ethically defensible method of allocating services. Two hundred thirty-five participants were randomly assigned to the BCDTC (treatment) or to traditional adjudication (control). The CONSORT Flow Diagram outlines the phases of the study through enrollment, intervention allocation, follow-up, and analysis (see Fig. 1).
2.4. Data sources Mortality data from the Maryland Vital Statistics Administration were obtained for the 15-year follow-up period and included date of death and cause of death. Date of death was also obtained from the U.S. Social Security Death Index in order to validate Maryland records and capture mortality data for study participants who had moved out of state. Demographic data along with official records of substance use treatment and criminal justice involvement were collected from the Maryland Department of Public Safety and Correctional Services, and the Baltimore Substance Abuse Systems, Inc., an organization that coordinated SUD treatment services in Baltimore. 2.5. Outcomes 2.5.1. Mortality Mortality was operationalized as whether a participant died during the study period, and the number of years between the date of randomization and the date of death. Years-to-death was right-censored at 15 years post-randomization.
2.3. Treatment condition 2.3.1. Intervention description At the time of the trial's initiation in 1997, the BCDTC comprised four main elements: intensive probation supervision, drug testing, SUD treatment, and judicial monitoring. The average length of stay in the program was 12 months. Intensive probation supervision included three face-to-face probation contacts per month, two home visits, and verification of employment status. After a sustained period of compliance, participants' level of supervision was downgraded from “intensive” to “standard high.” Drug testing via urinalysis was performed at local probation offices in a series of phases of decreasing frequency similar to probation supervision. SUD treatment was provided by one of eight providers located throughout Baltimore City, and varied in services and intensity based on the needs of the participant. Services included methadone maintenance, detoxification, outpatient, intensive outpatient, residential and correctional-based services. Judicial monitoring took place in the form of frequent status hearings. At these hearings, the judge reviewed reports from treatment and probation personnel to assess a participant's program compliance. Failure to comply with program requirements resulted in a variety of sanctions including increased status hearings, increased probation supervision, increased drug testing, and curfews. The sanctions graduated to more severe measures such as home detention, temporary incarceration, and community service. In response to extreme noncompliance, the judge might re-impose the original sentence, which could be more severe than what might have been imposed via traditional adjudication. For a detailed description of BCDTC program components, please see Gottfredson, Najaka, Kearley, and Rocha (2006).
2.5.2. Substance use-related mortality Participants' causes of death were categorized as substance use-related or non-substance use-related. Substance use-related mortality included deaths from explicit drug poisoning or overdose (36.0%) and conditions for which the scientific literature suggests substance use plays a significant role in infection and disease progression (64.0%). These conditions included HIV, hepatitis, bronchopneumonia, septicemia, and necrotizing fasciitis. 2.6. Statistical analyses An intent-to-treat approach was used in all analyses; all randomized study participants were included in analyses to preserve the baseline comparability of the groups. Descriptive analyses explored sample characteristics and mortality rates. Bivariate analyses tested for equivalence between BCDTC and traditional adjudication on observed characteristics. Multivariate proportional hazards models tested the effects of BCDTC on mortality over time: A Cox regression model estimated the risk of (any) death over the 15-year study period. A competing-risks regression model estimated the risk of death from substance use-related causes, while adjusting for death from non-substance use related causes as a competing event. Each model tested the effects of the treatment condition (BCDTC vs. traditional adjudication) as well as baseline characteristics on which participants who died (i.e., age) 2
All BCDTC participants were required to receive SUD treatment, but due to waiting lists for treatment not all participants began treatment immediately following random assignment. In some instances, participants were re-arrested or deemed noncompliant before they began treatment (see Banks & Gottfredson, 2004, for additional detail).
2.3.2. Control condition Individuals in the control condition received traditional adjudication in the District and Circuit courts. Participants may have pursued substance use treatment independently or as a condition of probation. 14
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Table 1 Characteristics of the study sample and deceased subsamples.
Age (years) at randomization (M, SD) Male (n, %) Black (n, %) Count of prior arrests (Mdn, range) Count of prior convictions (Mdn, range) Years to death 25th percentile 50th percentile 75th percentile Age (years) at death (M, SD)
Full samplea
Deceased, any causeb
Deceased, substance use-related causec
35.37 (7.63) 174 (74.0) 210 (89.4) 10.0 (0–55) 4.0 (0–24)
39.88 (8.67) 38 (77.6) 45 (91.8) 10.0 (0–55) 4.0 (0–24)
39.51 (7.26) 23 (92.0) 23 (92.0) 14.0 (4–55) 5.0 (0–24)
2.27 5.19 12.13 46.55 (10.66)
2.01 4.87 13.79 46.40 (9.12)
Note. a N = 235. b n = 49. c n= 25.
Fig. 2. Cumulative hazard curves of mortality, by treatment condition. Note. Cox regression estimates, controlling for age (Wald x2[2] = 20.95, p < .01). N = 235 (49 deceased; 186 censored).
(89.4%) and male (74.0%). The sample had a median of 10 prior arrests and 4 prior convictions, although these counts varied widely, with as many as 55 arrests and 24 convictions for a single participant. Compared to the full sample, the subsamples that died and died from substance use-related causes were, on average, more than four years older at randomization. Further, the subsample that died from substance userelated causes had a larger proportion of male participants (92.0%), and more prior arrests (Mdn = 14) and prior convictions (Mdn = 5). Among those for whom substance use data were available (66.2% of BCDTC and 31.3% of traditional adjudication), 77.9% self-reported heroin as their primary substance of choice and 88.5% self-reported heroin as either their primary or secondary substance of choice. The proportions of BCDTC (89.1%) and traditional adjudication (86.7%) reporting heroin as the primary or secondary substance of choice did not significantly differ (x2[1] = 0.14, p = .71). Missing substance use data was not associated with mortality or any observed baseline characteristics (x2[5] = 2.05, p = .84), suggesting that the available substance use data were representative of the full sample.
and died from substance use-related causes (i.e., age, prior convictions) differed from the rest of the sample, respectively (see Table 1). Although a larger proportion of men died from substance use-related causes, gender was excluded from analysis due to small cell counts. To test for proportional hazards, the Schoenfeld residuals test was conducted on each model. The residuals of mortality and substance userelated mortality did not significantly vary over time for any model covariates (ps > .05), indicating proportionality. 3. Results 3.1. Baseline characteristics Bivariate comparisons indicate that random assignment yielded equivalence between BCDTC and traditional adjudication on observed baseline characteristics, including age (t[233] = 0.18, p = .86), gender (x2[1] < 0.01, p = .98), race (x2[1] = 0.01, p = .93), prior arrests (U = 6710.00, p = .83), and prior convictions (U = 6907.50, p = .43). Table 1 reports descriptive characteristics of the full sample (N = 235), the subsample that died (n = 49), and the subsample that died from substance use-related causes (n = 25). On average, participants were about 35 years old at randomization, and a majority were Black
3.2. Mortality Over the 15 years following randomization, 20.9% of the sample 15
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use-related mortality risk. This was surprising given that substance use treatment has been associated with reduced mortality (Gossop et al., 2002). The large percentage of premature deaths in this sample may be related to insufficient access to appropriate substance use treatment, whether in BCDTC or traditional adjudication. Despite that a large proportion of the sample for whom data were available self-reported heroin as their primary substance at intake, < 10% of participants in either group received MAT, which is considered the most effective treatment for opioid used disorder (American Society of Addiction Medicine, 2015) and is estimated to reduce long-term opioid-related mortality (Pitt, Humphreys, & Brandeau, 2018). In addition, drug court participants with opioid use disorders have reported MAT delivered in combination with [cognitive-behavioral] psychosocial treatment to be particularly effective for sustained harm reduction, as well as averting relapse, incarceration, and even death for some participants (Gallagher, Wahler, Minasian, & Edwards, 2019). Regardless, recent national estimates indicate that while 98% of drug courts served participants with opioid use disorders, only 47% offered MAT, i.e., methadone and buprenorphine products (56% when including naltrexone; Matusow et al., 2013). The extremely low provision of MAT in this study may be due to its implementation in 1997–98 when MAT was less widespread and limited to methadone. Buprenorphine products were not approved by the FDA until 2002 (Welsh & Valadez-Meltzer, 2005), and extendedrelease naltrexone was first approved by the FDA in 2010 to treat opioid dependence (Substance Abuse and Mental Health Services Administration, 2015). Historical barriers to MAT inclusion in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma (Matusow et al., 2013). In this study we also found that among participants who died of a substance use-related cause, more prior convictions was associated with a higher risk of mortality. This finding highlights the need to take into account criminal justice history in determining appropriate substance use treatment. Number of convictions may serve as a proxy for criminal and/or substance use related activity that puts one at risk for negative health consequences, as extensive criminal justice involvement has been associated with limited supports and higher levels of stress that negatively impact health (Massoglia & Pridemore, 2015).
died, including 23.0% of those assigned to BCDTC (1.7 per person-year) and 17.7% of those assigned to traditional adjudication (1.3 per personyear). Of the 49 deceased participants, the median time-to-death was 5.19 years after randomization, and the average age at death was about 47 years old (see Table 1). Cox regression estimates found that mortality rates over time did not significantly differ between BCDTC and traditional adjudication (HR = 1.26, 95% CI [0.70, 2.27], p = .44). Cumulative hazard curves of mortality over time are shown in Fig. 2. Participants who were older at randomization had increased risk of mortality (HR = 1.08, 95% CI [1.05, 1.12], p < .01). 3.3. Substance use-related mortality Cause of death was available for 39 (79.6%) of the deceased participants. The majority (64.1%, n = 25) of those deaths were identified as substance use-related, comprising 10.8% of BCDTC (0.8 per personyear) and 11.6% of traditional adjudication (0.9 per person-year). Nearly 25% of substance use-related deaths occurred within two years and half occurred within five years of randomization (Mdn = 4.87; see Table 1). The average age at death was approximately 46 years old. Competing-risks regression estimates found that substance use-related mortality rates over time did not significantly differ between BCDTC and traditional adjudication (SHR = 0.85, 95% CI [0.40, 1.83], p = .68). Fig. 3 presents the cumulative subhazard curves of substance use-related mortality over time. Increases in age (SHR = 1.06, 95% CI [1.01, 1.12], p = .01) and number of prior convictions (SHR = 1.13, 95% CI [1.04, 1.23], p < .01) were associated with increased risk of substance use-related mortality. 4. Discussion In this study, we found that nearly 21% of the total sample died over the 15-year follow-up period. The average age at time of death was 46.6 years old, approximately 26 years younger than the projected life expectancies of both the general population in Baltimore City and Black men in the US (Bond & Herman, 2016; Maryland Department of Health and Mental Hygiene Vital Statistics Administration, 2015). The majority of individuals for whom data were available died from overdose or a substance use-related disease or infection, deaths that could otherwise be prevented through reduced substance use and treatment that meets the needs of the individual. This study also found that participation in BCDTC did not result in a reduction of total or substance
4.1. Implications for drug court implementation This study underscores several implications for implementing drug Fig. 3. Cumulative subhazard curves of substance use-related mortality, by treatment condition. Note. Competing-risks regression estimates, controlling for age and count of prior convictions (Wald x2[3] = 20.72, p < .01). N = 223 (25 deceased, substance use-related; 12 deceased, non-substance use related; 186 censored); 12 cases dropped listwise due to missing cause of death or count of prior convictions.
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4.2. Strengths and limitations
court programs. First, drug courts should provide best practices in substance use treatment, including MAT. The National Association of Drug Court Professionals (NADCP) has endorsed MAT as a best practice standard (National Association of Drug Court Professionals, 2013). Additionally, the Bureau of Justice Assistance and the Substance Abuse and Mental Health Services Administration now require drug court award recipients to: 1) provide eligible participants access to MAT; and 2) not require discontinuation of said medications as a condition of graduation (Bureau of Justice Assistance, Office of Justice Programs, 2015). Drug court professionals can ensure that MAT options are available to participants and, when not, advocate for the expansion of MAT services in their community. Additionally, support should be provided to drug court professionals to educate themselves, their peers, and participants on the positive outcomes associated with MAT use, thereby dispelling common myths and inaccuracies. A related implication is that substance use treatment in drug courts should be individualized to meet participant needs, as SUD is a chronic, complex condition that differs from person to person. Participants with more criminal justice involvement (such as more prior convictions) may need additional and ongoing services. Evidence suggests that MAT is often denied to those in the criminal justice system who have an opioid use disorder – particularly in jails and prisons – even when it is prescribed by a medical professional (Legal Action Center, 2011). Therefore, participants with extensive criminal justice system involvement may experience more treatment disruptions, destabilizing their recovery. Additionally, because SUD is a chronic condition, it is important that drug courts (which have a finite period) consider participants' transition to substance use treatment in the community. Lastly, with the majority of this study sample being Black, the importance of providing culturally proficient treatment should be considered. Several studies have found that Black and Latinx individuals have poorer SUD treatment retention and outcomes than non-Latinx Whites, but these differences can be significantly diminished when programs use culturally proficient practices (Guerrero, 2013; Mennis & Stahler, 2015). Promising findings from a few drug court studies suggest that drug court outcomes may be similarly improved when services are developed and implemented in a culturally competent manner (Marlowe et al., 2018; Vito & Tewksbury, 1998). A third implication is that drug court professionals can play an important role in training clients in overdose prevention and response and, when possible, provide them with naloxone.3 Take-home naloxone, administered intranasally or via injection, has been found to reduce overdose mortality with few adverse events (McDonald & Strang, 2016). In 2015, the NADCP passed a resolution supporting naloxone provision and the National Drug Court Institute has since created a fact sheet for drug courts considering implementing overdose education and take-home naloxone (Nordstrom & Marlowe, 2016). Finally, stigma is a central barrier to both seeking and receiving help for a SUD, particularly in criminal justice settings (Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013). Among pressing public health concerns, it could be argued that no other health condition is as stigmatized. A number of empirical studies have found that commonly used words or phrases (e.g., “drug abuser,” “addict,” “dirty urine”) induce implicit cognitive biases against those living with a SUD and may influence judgments regarding blameworthiness and decrease a person's own sense of hope and self-efficacy for change (Kelly & Westerhoff, 2010). Drug court professionals should have a clear understanding of the behavioral and neurological changes that occur as a result of problematic substance use and should use language that is clinically appropriate.
To our knowledge, this study represents the first randomized controlled trial to assess the effect of the drug court model on mortality risk, and does so with an extended follow-up period of 15 years. Further, we used robust sources of administrative data that ensured low loss-to-follow-up rates. Finally, this study's setting in Baltimore represents a city where substance use disorder in general, and opioid use disorder in particular has long been a public health issue, particularly for the city's poor and Black residents. The current national opioid epidemic continues to underscore economic and racial disparities in treatment and access to effective services (James & Jordan, 2018; Lagisetty, Ross, Bohnert, Clay, & Maust, 2019). This study therefore addresses an underserved and under-resourced population that faces many challenges, including SUD, criminal justice involvement, and intersecting sources of stigma and discrimination. This study faces several limitations. First, the study results may not be generalizable to drug court participants outside of urban settings with chronic criminal and SUD histories. However, in terms of prognostic risk and need, this population represents current recommendations regarding those best suited to the intensive requirements and resource expenditure of the drug court model (Marlowe, 1997). Additionally, the BCDTC contains all of the key components of the model (e.g., judicial monitoring, drug treatment, intensive supervision) and, as such, does not vary significantly from the “typical” drug court. A related limitation is that the implementation and features of the BCDTC have changed over the past 15+ years. Discussions with a drug court coordinator revealed the following changes in the program's implementation: increased average length of stay; increased community service requirements; expanded aftercare resources that focus on stepped down treatment supports; increased health care access; increased acceptance and expansion of MAT, mandatory naloxone training and prescriptions; and more tailored case management for special populations such as young adults and women with children. Therefore, it may be that the current model of BCDTC has different effects on mortality rates than it did in 1997–98. 5. Conclusions Despite the existence of effective treatment for substance use disorder, substance use-related morbidity and mortality continue to rise. Criminal justice populations are among the most vulnerable to negative outcomes given their multiple and intersecting risk factors. In this longterm follow-up study, drug court participants did not have significantly different mortality outcomes than participants who received traditional adjudication. Drug court programs looking to improve outcomes in this area should consider: 1) increasing access to MAT and individualized, culturally proficient SUD treatment; 2) increasing access and training in the administration of naloxone; and 3) offering training opportunities to drug court professionals with the goal of reducing stigmatizing language and practice and increasing the use of SUD treatment best practices. Funding Funding for the long-term follow-up study was provided by the National Institute of Justice, NIJ GRF Award 2014-IJ-CX-009. Declaration of Competing Interest None. References
3
Naloxone is a medication that can block and reverse the effects of opioids and is available at pharmacies in many states, including Maryland, without a prescription.
American Society of Addiction Medicine (2015). The national practice guideline for the use of medications in the treatment of addiction involving opioid use. Retrieved from
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Contents lists available at ScienceDirect
Journal of Substance Abuse Treatment journal homepage: www.elsevier.com/locate/jsat
The impact of drug court participation on mortality: 15-year outcomes from a randomized controlled trial
T
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Brook W. Kearleya, , John A. Cosgrovea, Alexandra S. Wimberlya, Denise C. Gottfredsonb a b
University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA University of Maryland, Department of Criminology and Criminal Justice, 2220 Samuel J. LeFrak Hall, 7251 Preinkert Drive, College Park, MD 20742, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Drug courts Mortality Randomized controlled trial
Aim: To test the effects of drug court participation on long-term mortality risk. Methods: During 1997–98, 235 individuals charged with a non-violent offense were randomly assigned to Baltimore City Drug Treatment Court (BCDTC) or traditional adjudication. Heroin was the predominant substance of choice among the sample. Participant mortality was observed for 15 years following randomization. Results: Over 20% of participants died during the study, at an average age of 46.6 years, and 64.4% of deaths were substance-use related. Survival analyses estimated that neither mortality from any cause nor from substance use-related causes significantly differed between BCDTC and traditional adjudication. Conclusions: Frequent and premature death among the sample indicates that this is a high-risk population in need of effective substance use treatment. Roughly half of drug treatment courts are now estimated to offer medication assisted treatment (MAT), which is currently the most effective treatment for opioid use disorders. In this study of BCDTC implemented over 15 years ago, only 7% of participants received MAT, which may explain the lack of program impact on mortality. Historical barriers to providing MAT in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma. Drug treatment courts should implement best practice standards for substance use treatment and overdose prevention, including increased access to MAT and naloxone, and training to reduce stigmatizing language and practice.
1. Introduction In Baltimore City, death by opioid overdose has dramatically increased in the past decade, reflecting national trends. In 2017, 761 Baltimore residents died from unintended drug and alcohol intoxication (91% of which were opioid-related), a figure that is six times the number of opioid-related deaths in 2011 (Maryland Department of Health, 2018). With the highest overdose fatality rate among USA cities in 2017 – estimated at 75 per 100,000 residents during years 2015–17 (Robert Wood Johnson Foundation, 2019) – preliminary 2018 data shows that opioid-related deaths rose another 15% to 798 (Opioid Operational Command Center, 2018; Baltimore City Health Department, n.d.). Yet, these figures do not fully reflect the impact of chronic substance use on mortality. Death has been directly related to complications from substance use, including septicemia, cancer, suicide, hepatitis, injury and HIV/AIDS (Cook et al., 2008; Hingson, Zha, &
Weitzman, 2009; Lopez-Quintero et al., 2015; Rehm & Shield, 2013; Ridolfo & Stevenson, 2001). Unsurprisingly, people with substance use disorders (SUD) are more likely to die prematurely (Neumark, Van Etten, & Anthony, 2000); one study finding that heroin users were 3–4 times more likely to die prematurely, at an average age of 45 (LopezQuintero et al., 2015). For those with criminal justice involvement in addition to a SUD, the statistics are even bleaker. The leading cause of death among returning citizens is drug related, with 18% of deaths across 18 studies attributed to substance use (Zlodre & Fazel, 2012). SUD treatment, therefore, is critical to not only reduce substance use, but also to reduce high mortality rates among people with SUDs (Gossop, Stewart, Treacy, & Marsden, 2002). Various substance use treatment modalities have demonstrated decreased mortality, including psychosocial treatment (Davoli et al., 2007), medication assisted treatment1 (MAT; Davoli et al., 2007; Degenhardt et al., 2011), brief interventions (Cuijpers, Riper, & Lemmers, 2004), and therapeutic
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Corresponding author. E-mail addresses: [email protected] (B.W. Kearley), [email protected] (J.A. Cosgrove), [email protected] (A.S. Wimberly), [email protected] (D.C. Gottfredson). 1 MAT is the provision of buprenorphine, methadone or extended release naltrexone in concert with counseling. Research has demonstrated that medications alone can be as effective as medication with counseling (Schwartz, Kelly, O'Grady, Gandhi, & Jaffe, 2012). https://doi.org/10.1016/j.jsat.2019.07.004 Received 14 January 2019; Received in revised form 14 June 2019; Accepted 10 July 2019 0740-5472/ © 2019 Elsevier Inc. All rights reserved.
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Enrollment Randomized (N = 235)
Allocation Allocated to BCDTC (n = 139) Received allocated intervention (n = 126)
Allocated to traditional adjudication (n = 96) Received allocated intervention (n = 89)
Follow-Up Lost to follow-up (n = 0)
Lost to follow-up (n = 0)
Did not receive allocated intervention (n = 13)
Did not receive allocated intervention (n = 7)
Analysis Analyzed (n = 96) Excluded from analysis (n = 0)
Analyzed (n = 139) Excluded from analysis (n = 0)
Fig. 1. CONSORT flow diagram of Baltimore City Drug Treatment Court randomized controlled trial. Note: This figure represents a modified version of the CONSORT diagram. The research team did not collect data on the number of individuals considered for eligibility and enrollment.
studies have examined whether participants make sustained life changes and few studies have looked at the impact of drug court on outcomes beyond recidivism (Mitchell et al., 2012).
communities (Bale et al., 1983). One systematic review found that people not receiving MAT had mortality rates that were over two times higher than those receiving MAT (Degenhardt et al., 2011). Among individuals with criminal justice involvement, MAT has also proven effective in reducing mortality. MAT provided in prison and post-release has been associated with reduced mortality during community return (Degenhardt et al., 2014; Dolan et al., 2005). Although SUD treatment has largely demonstrated reduced mortality, there are various treatment modalities provided to people with criminal justice involvement that have yet to be assessed for mortality impact, including drug courts. There are over 3500 drug courts nationwide (National Drug Court Resource Center, n.d.), providing an alternative to incarceration for people with SUDs who agree to engage in treatment. Given that nearly two thirds of people in jails and over half of people in prisons have a SUD, yet < 30% of them participate in a drug treatment program (Bronson, Stroop, Zimmer, & Berzofsky, 2017), drug courts provide crucial access to substance use treatment for people who would otherwise be incarcerated with limited access to treatment. Several recent meta-analyses of drug court evaluations conclude that drug courts are a better criminal justice response for defendants with a SUD than traditional case processing (Lowenkamp, Holsinger, & Latessa, 2005; Mitchell, Wilson, Eggers, & MacKenzie, 2012; Wilson, Mitchell, & MacKenzie, 2006). In an analysis of 154 independent evaluations, Mitchell et al. (2012) found that drug courts significantly reduced general and drug-related recidivism, with effects lasting up to three years. While research suggests that drug courts support reduced substance use among participants, much of the existing research is methodologically weak with short follow-up periods (Harvey, Shakeshaft, Hetherington, Sannibale, & Mattick, 2007). Very few
1.1. Current study The current study addresses previous methodological limitations of drug court research by utilizing a randomized design to examine the impact of the Baltimore City Drug Treatment Court (BCDTC) on mortality rates in the 15 years following randomization to either the BCDTC or traditional adjudication. This study is therefore foundational in understanding the impact of drug courts on mortality. We hypothesized that individuals randomized to BCDTC would have lower overall and substance use-related mortality rates than individuals randomized to traditional adjudication during the 15 years following study enrollment. 2. Methods This non-blinded, parallel randomized controlled trial with unequal allocation was conducted in Baltimore City, Maryland. Participants were recruited on a rolling basis from February 1997 to August 1998. Participation in the BCDTC was voluntary and participants were randomized to either the intervention (BCDTC) or to the control group (traditional adjudication). Mortality outcomes were evaluated at 15years post-randomization. 2.1. Participants Defendants with open cases in either the District or Circuit Court 13
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2.3.3. Services received During the first three years after randomization, BCDTC participants received drug testing (86.9%) and attended status hearings (84.2%) at significantly higher rates than those in traditional adjudication (40.2% and 7.3%, respectively; ps < .01). The majority of those in BCDTC received some form of SUD treatment (71.2%)2 – most frequently outpatient treatment, intensive outpatient treatment, and jail-based acupuncture, all of which the BCDTC participants received at significantly higher rates than those in traditional adjudication (ps < .01). The treatment conditions did not differ in the use of MAT, which was received by < 10% of either group. Gottfredson et al., (2006) provide additional detail about the types and doses of supervision and SUD services received by study participants.
were eligible if they resided in Baltimore City, were at least 18 years of age, and were in need of SUD treatment, as assessed by the Addiction Severity Index (McLellan et al., 1992). Previous conviction(s) of a violent offense was the only exclusion criteria.
2.2. Study procedures Baltimore Court personnel identified and referred eligible defendants to the research team. Potential participants were then informed of the study's purpose and procedures (including its voluntary and confidential nature), and gave written informed consent. Once consented, participants were randomly assigned by the research team at a ratio of one BCDTC to one traditional adjudication for Circuit Court cases; and a ratio of two BCDTC to one traditional adjudication for District Court cases. Because fewer defendants who went through the District Court were eligible for drug court (as compared with the Circuit Court), this study's unequal randomization protocol was established to ensure that all BCDTC slots were filled. Randomization results were communicated to court personnel just prior to the participant's appearance before the judge. The judges agreed to abide by the randomization results because the BCDTC did not have the capacity to serve all eligible and interested defendants. As such, randomization represented a fair and ethically defensible method of allocating services. Two hundred thirty-five participants were randomly assigned to the BCDTC (treatment) or to traditional adjudication (control). The CONSORT Flow Diagram outlines the phases of the study through enrollment, intervention allocation, follow-up, and analysis (see Fig. 1).
2.4. Data sources Mortality data from the Maryland Vital Statistics Administration were obtained for the 15-year follow-up period and included date of death and cause of death. Date of death was also obtained from the U.S. Social Security Death Index in order to validate Maryland records and capture mortality data for study participants who had moved out of state. Demographic data along with official records of substance use treatment and criminal justice involvement were collected from the Maryland Department of Public Safety and Correctional Services, and the Baltimore Substance Abuse Systems, Inc., an organization that coordinated SUD treatment services in Baltimore. 2.5. Outcomes 2.5.1. Mortality Mortality was operationalized as whether a participant died during the study period, and the number of years between the date of randomization and the date of death. Years-to-death was right-censored at 15 years post-randomization.
2.3. Treatment condition 2.3.1. Intervention description At the time of the trial's initiation in 1997, the BCDTC comprised four main elements: intensive probation supervision, drug testing, SUD treatment, and judicial monitoring. The average length of stay in the program was 12 months. Intensive probation supervision included three face-to-face probation contacts per month, two home visits, and verification of employment status. After a sustained period of compliance, participants' level of supervision was downgraded from “intensive” to “standard high.” Drug testing via urinalysis was performed at local probation offices in a series of phases of decreasing frequency similar to probation supervision. SUD treatment was provided by one of eight providers located throughout Baltimore City, and varied in services and intensity based on the needs of the participant. Services included methadone maintenance, detoxification, outpatient, intensive outpatient, residential and correctional-based services. Judicial monitoring took place in the form of frequent status hearings. At these hearings, the judge reviewed reports from treatment and probation personnel to assess a participant's program compliance. Failure to comply with program requirements resulted in a variety of sanctions including increased status hearings, increased probation supervision, increased drug testing, and curfews. The sanctions graduated to more severe measures such as home detention, temporary incarceration, and community service. In response to extreme noncompliance, the judge might re-impose the original sentence, which could be more severe than what might have been imposed via traditional adjudication. For a detailed description of BCDTC program components, please see Gottfredson, Najaka, Kearley, and Rocha (2006).
2.5.2. Substance use-related mortality Participants' causes of death were categorized as substance use-related or non-substance use-related. Substance use-related mortality included deaths from explicit drug poisoning or overdose (36.0%) and conditions for which the scientific literature suggests substance use plays a significant role in infection and disease progression (64.0%). These conditions included HIV, hepatitis, bronchopneumonia, septicemia, and necrotizing fasciitis. 2.6. Statistical analyses An intent-to-treat approach was used in all analyses; all randomized study participants were included in analyses to preserve the baseline comparability of the groups. Descriptive analyses explored sample characteristics and mortality rates. Bivariate analyses tested for equivalence between BCDTC and traditional adjudication on observed characteristics. Multivariate proportional hazards models tested the effects of BCDTC on mortality over time: A Cox regression model estimated the risk of (any) death over the 15-year study period. A competing-risks regression model estimated the risk of death from substance use-related causes, while adjusting for death from non-substance use related causes as a competing event. Each model tested the effects of the treatment condition (BCDTC vs. traditional adjudication) as well as baseline characteristics on which participants who died (i.e., age) 2
All BCDTC participants were required to receive SUD treatment, but due to waiting lists for treatment not all participants began treatment immediately following random assignment. In some instances, participants were re-arrested or deemed noncompliant before they began treatment (see Banks & Gottfredson, 2004, for additional detail).
2.3.2. Control condition Individuals in the control condition received traditional adjudication in the District and Circuit courts. Participants may have pursued substance use treatment independently or as a condition of probation. 14
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Table 1 Characteristics of the study sample and deceased subsamples.
Age (years) at randomization (M, SD) Male (n, %) Black (n, %) Count of prior arrests (Mdn, range) Count of prior convictions (Mdn, range) Years to death 25th percentile 50th percentile 75th percentile Age (years) at death (M, SD)
Full samplea
Deceased, any causeb
Deceased, substance use-related causec
35.37 (7.63) 174 (74.0) 210 (89.4) 10.0 (0–55) 4.0 (0–24)
39.88 (8.67) 38 (77.6) 45 (91.8) 10.0 (0–55) 4.0 (0–24)
39.51 (7.26) 23 (92.0) 23 (92.0) 14.0 (4–55) 5.0 (0–24)
2.27 5.19 12.13 46.55 (10.66)
2.01 4.87 13.79 46.40 (9.12)
Note. a N = 235. b n = 49. c n= 25.
Fig. 2. Cumulative hazard curves of mortality, by treatment condition. Note. Cox regression estimates, controlling for age (Wald x2[2] = 20.95, p < .01). N = 235 (49 deceased; 186 censored).
(89.4%) and male (74.0%). The sample had a median of 10 prior arrests and 4 prior convictions, although these counts varied widely, with as many as 55 arrests and 24 convictions for a single participant. Compared to the full sample, the subsamples that died and died from substance use-related causes were, on average, more than four years older at randomization. Further, the subsample that died from substance userelated causes had a larger proportion of male participants (92.0%), and more prior arrests (Mdn = 14) and prior convictions (Mdn = 5). Among those for whom substance use data were available (66.2% of BCDTC and 31.3% of traditional adjudication), 77.9% self-reported heroin as their primary substance of choice and 88.5% self-reported heroin as either their primary or secondary substance of choice. The proportions of BCDTC (89.1%) and traditional adjudication (86.7%) reporting heroin as the primary or secondary substance of choice did not significantly differ (x2[1] = 0.14, p = .71). Missing substance use data was not associated with mortality or any observed baseline characteristics (x2[5] = 2.05, p = .84), suggesting that the available substance use data were representative of the full sample.
and died from substance use-related causes (i.e., age, prior convictions) differed from the rest of the sample, respectively (see Table 1). Although a larger proportion of men died from substance use-related causes, gender was excluded from analysis due to small cell counts. To test for proportional hazards, the Schoenfeld residuals test was conducted on each model. The residuals of mortality and substance userelated mortality did not significantly vary over time for any model covariates (ps > .05), indicating proportionality. 3. Results 3.1. Baseline characteristics Bivariate comparisons indicate that random assignment yielded equivalence between BCDTC and traditional adjudication on observed baseline characteristics, including age (t[233] = 0.18, p = .86), gender (x2[1] < 0.01, p = .98), race (x2[1] = 0.01, p = .93), prior arrests (U = 6710.00, p = .83), and prior convictions (U = 6907.50, p = .43). Table 1 reports descriptive characteristics of the full sample (N = 235), the subsample that died (n = 49), and the subsample that died from substance use-related causes (n = 25). On average, participants were about 35 years old at randomization, and a majority were Black
3.2. Mortality Over the 15 years following randomization, 20.9% of the sample 15
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use-related mortality risk. This was surprising given that substance use treatment has been associated with reduced mortality (Gossop et al., 2002). The large percentage of premature deaths in this sample may be related to insufficient access to appropriate substance use treatment, whether in BCDTC or traditional adjudication. Despite that a large proportion of the sample for whom data were available self-reported heroin as their primary substance at intake, < 10% of participants in either group received MAT, which is considered the most effective treatment for opioid used disorder (American Society of Addiction Medicine, 2015) and is estimated to reduce long-term opioid-related mortality (Pitt, Humphreys, & Brandeau, 2018). In addition, drug court participants with opioid use disorders have reported MAT delivered in combination with [cognitive-behavioral] psychosocial treatment to be particularly effective for sustained harm reduction, as well as averting relapse, incarceration, and even death for some participants (Gallagher, Wahler, Minasian, & Edwards, 2019). Regardless, recent national estimates indicate that while 98% of drug courts served participants with opioid use disorders, only 47% offered MAT, i.e., methadone and buprenorphine products (56% when including naltrexone; Matusow et al., 2013). The extremely low provision of MAT in this study may be due to its implementation in 1997–98 when MAT was less widespread and limited to methadone. Buprenorphine products were not approved by the FDA until 2002 (Welsh & Valadez-Meltzer, 2005), and extendedrelease naltrexone was first approved by the FDA in 2010 to treat opioid dependence (Substance Abuse and Mental Health Services Administration, 2015). Historical barriers to MAT inclusion in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma (Matusow et al., 2013). In this study we also found that among participants who died of a substance use-related cause, more prior convictions was associated with a higher risk of mortality. This finding highlights the need to take into account criminal justice history in determining appropriate substance use treatment. Number of convictions may serve as a proxy for criminal and/or substance use related activity that puts one at risk for negative health consequences, as extensive criminal justice involvement has been associated with limited supports and higher levels of stress that negatively impact health (Massoglia & Pridemore, 2015).
died, including 23.0% of those assigned to BCDTC (1.7 per person-year) and 17.7% of those assigned to traditional adjudication (1.3 per personyear). Of the 49 deceased participants, the median time-to-death was 5.19 years after randomization, and the average age at death was about 47 years old (see Table 1). Cox regression estimates found that mortality rates over time did not significantly differ between BCDTC and traditional adjudication (HR = 1.26, 95% CI [0.70, 2.27], p = .44). Cumulative hazard curves of mortality over time are shown in Fig. 2. Participants who were older at randomization had increased risk of mortality (HR = 1.08, 95% CI [1.05, 1.12], p < .01). 3.3. Substance use-related mortality Cause of death was available for 39 (79.6%) of the deceased participants. The majority (64.1%, n = 25) of those deaths were identified as substance use-related, comprising 10.8% of BCDTC (0.8 per personyear) and 11.6% of traditional adjudication (0.9 per person-year). Nearly 25% of substance use-related deaths occurred within two years and half occurred within five years of randomization (Mdn = 4.87; see Table 1). The average age at death was approximately 46 years old. Competing-risks regression estimates found that substance use-related mortality rates over time did not significantly differ between BCDTC and traditional adjudication (SHR = 0.85, 95% CI [0.40, 1.83], p = .68). Fig. 3 presents the cumulative subhazard curves of substance use-related mortality over time. Increases in age (SHR = 1.06, 95% CI [1.01, 1.12], p = .01) and number of prior convictions (SHR = 1.13, 95% CI [1.04, 1.23], p < .01) were associated with increased risk of substance use-related mortality. 4. Discussion In this study, we found that nearly 21% of the total sample died over the 15-year follow-up period. The average age at time of death was 46.6 years old, approximately 26 years younger than the projected life expectancies of both the general population in Baltimore City and Black men in the US (Bond & Herman, 2016; Maryland Department of Health and Mental Hygiene Vital Statistics Administration, 2015). The majority of individuals for whom data were available died from overdose or a substance use-related disease or infection, deaths that could otherwise be prevented through reduced substance use and treatment that meets the needs of the individual. This study also found that participation in BCDTC did not result in a reduction of total or substance
4.1. Implications for drug court implementation This study underscores several implications for implementing drug Fig. 3. Cumulative subhazard curves of substance use-related mortality, by treatment condition. Note. Competing-risks regression estimates, controlling for age and count of prior convictions (Wald x2[3] = 20.72, p < .01). N = 223 (25 deceased, substance use-related; 12 deceased, non-substance use related; 186 censored); 12 cases dropped listwise due to missing cause of death or count of prior convictions.
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4.2. Strengths and limitations
court programs. First, drug courts should provide best practices in substance use treatment, including MAT. The National Association of Drug Court Professionals (NADCP) has endorsed MAT as a best practice standard (National Association of Drug Court Professionals, 2013). Additionally, the Bureau of Justice Assistance and the Substance Abuse and Mental Health Services Administration now require drug court award recipients to: 1) provide eligible participants access to MAT; and 2) not require discontinuation of said medications as a condition of graduation (Bureau of Justice Assistance, Office of Justice Programs, 2015). Drug court professionals can ensure that MAT options are available to participants and, when not, advocate for the expansion of MAT services in their community. Additionally, support should be provided to drug court professionals to educate themselves, their peers, and participants on the positive outcomes associated with MAT use, thereby dispelling common myths and inaccuracies. A related implication is that substance use treatment in drug courts should be individualized to meet participant needs, as SUD is a chronic, complex condition that differs from person to person. Participants with more criminal justice involvement (such as more prior convictions) may need additional and ongoing services. Evidence suggests that MAT is often denied to those in the criminal justice system who have an opioid use disorder – particularly in jails and prisons – even when it is prescribed by a medical professional (Legal Action Center, 2011). Therefore, participants with extensive criminal justice system involvement may experience more treatment disruptions, destabilizing their recovery. Additionally, because SUD is a chronic condition, it is important that drug courts (which have a finite period) consider participants' transition to substance use treatment in the community. Lastly, with the majority of this study sample being Black, the importance of providing culturally proficient treatment should be considered. Several studies have found that Black and Latinx individuals have poorer SUD treatment retention and outcomes than non-Latinx Whites, but these differences can be significantly diminished when programs use culturally proficient practices (Guerrero, 2013; Mennis & Stahler, 2015). Promising findings from a few drug court studies suggest that drug court outcomes may be similarly improved when services are developed and implemented in a culturally competent manner (Marlowe et al., 2018; Vito & Tewksbury, 1998). A third implication is that drug court professionals can play an important role in training clients in overdose prevention and response and, when possible, provide them with naloxone.3 Take-home naloxone, administered intranasally or via injection, has been found to reduce overdose mortality with few adverse events (McDonald & Strang, 2016). In 2015, the NADCP passed a resolution supporting naloxone provision and the National Drug Court Institute has since created a fact sheet for drug courts considering implementing overdose education and take-home naloxone (Nordstrom & Marlowe, 2016). Finally, stigma is a central barrier to both seeking and receiving help for a SUD, particularly in criminal justice settings (Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013). Among pressing public health concerns, it could be argued that no other health condition is as stigmatized. A number of empirical studies have found that commonly used words or phrases (e.g., “drug abuser,” “addict,” “dirty urine”) induce implicit cognitive biases against those living with a SUD and may influence judgments regarding blameworthiness and decrease a person's own sense of hope and self-efficacy for change (Kelly & Westerhoff, 2010). Drug court professionals should have a clear understanding of the behavioral and neurological changes that occur as a result of problematic substance use and should use language that is clinically appropriate.
To our knowledge, this study represents the first randomized controlled trial to assess the effect of the drug court model on mortality risk, and does so with an extended follow-up period of 15 years. Further, we used robust sources of administrative data that ensured low loss-to-follow-up rates. Finally, this study's setting in Baltimore represents a city where substance use disorder in general, and opioid use disorder in particular has long been a public health issue, particularly for the city's poor and Black residents. The current national opioid epidemic continues to underscore economic and racial disparities in treatment and access to effective services (James & Jordan, 2018; Lagisetty, Ross, Bohnert, Clay, & Maust, 2019). This study therefore addresses an underserved and under-resourced population that faces many challenges, including SUD, criminal justice involvement, and intersecting sources of stigma and discrimination. This study faces several limitations. First, the study results may not be generalizable to drug court participants outside of urban settings with chronic criminal and SUD histories. However, in terms of prognostic risk and need, this population represents current recommendations regarding those best suited to the intensive requirements and resource expenditure of the drug court model (Marlowe, 1997). Additionally, the BCDTC contains all of the key components of the model (e.g., judicial monitoring, drug treatment, intensive supervision) and, as such, does not vary significantly from the “typical” drug court. A related limitation is that the implementation and features of the BCDTC have changed over the past 15+ years. Discussions with a drug court coordinator revealed the following changes in the program's implementation: increased average length of stay; increased community service requirements; expanded aftercare resources that focus on stepped down treatment supports; increased health care access; increased acceptance and expansion of MAT, mandatory naloxone training and prescriptions; and more tailored case management for special populations such as young adults and women with children. Therefore, it may be that the current model of BCDTC has different effects on mortality rates than it did in 1997–98. 5. Conclusions Despite the existence of effective treatment for substance use disorder, substance use-related morbidity and mortality continue to rise. Criminal justice populations are among the most vulnerable to negative outcomes given their multiple and intersecting risk factors. In this longterm follow-up study, drug court participants did not have significantly different mortality outcomes than participants who received traditional adjudication. Drug court programs looking to improve outcomes in this area should consider: 1) increasing access to MAT and individualized, culturally proficient SUD treatment; 2) increasing access and training in the administration of naloxone; and 3) offering training opportunities to drug court professionals with the goal of reducing stigmatizing language and practice and increasing the use of SUD treatment best practices. Funding Funding for the long-term follow-up study was provided by the National Institute of Justice, NIJ GRF Award 2014-IJ-CX-009. Declaration of Competing Interest None. References
3
Naloxone is a medication that can block and reverse the effects of opioids and is available at pharmacies in many states, including Maryland, without a prescription.
American Society of Addiction Medicine (2015). The national practice guideline for the use of medications in the treatment of addiction involving opioid use. Retrieved from
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