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June 8, 2017

"Neither Justice Nor Treatment: Drug Courts in the United States"

PhrThe title of this post is the title of this notable new report issued by the group Physicians for Human Rights. Here is an excerpts from the report's executive summary:

U.S. drug courts [are] specialized courts within the criminal justice system set up to provide alternative sentencing options — treatment instead of jail or prison time — for people charged with criminal behavior linked to drug possession, sale, or addiction.  The first courts were opened in 1989 to ease dockets and jails that were overflowing as a result of strict federal and state laws passed in the 1980s in an attempt to reduce drug supply and consumption.

Almost three decades later, there are more than 3,100 drug courts operating in the United States.  But while the courts’ proponents say they reduce recidivism for people with substance use disorders, critics say the system abuses due process, often mandates treatment for people who don’t actually need it — people without drug dependence — and fails to provide quality care to many who do.

Physicians for Human Rights (PHR) assessed the availability and quality of substance use disorder treatment through drug courts in three states — Florida, New Hampshire, and New York, chosen for the diversity of their drug court and health system approaches — and found major obstacles to quality evidence-based treatment for drug court participants in all three states.  Overall, PHR found that drug courts largely failed at providing treatment to those who truly needed it, and filled up limited treatment spaces with courtmandated patients who didn’t always need the care.  In many cases, court officials with no medical background mandated inappropriate treatment not rooted in the evidence base, or mandated treatment for people who didn’t need it.  In all cases, the functioning and mandate of the drug courts posed significant human rights concerns.

At the most basic level, PHR found that access to quality treatment was hampered by the inherent tension between a punitive criminal justice logic and therapeutic concern for drug court participants as patients.  In fact, despite the stated intention of drug courts to treat people who use drugs as ill rather Executive Summary than deviant, drug court participants were often punished for relapsing, missing therapy appointments, or otherwise failing to follow court rules.

One key concern motivating this research was whether drug courts were able to appropriately diagnose and facilitate treatment for people with substance use disorders who are in conflict with the law.  We found that, in many cases, they were not.  Diagnosis and initial treatment plans for drug court participants were often developed by people with no medical training or oversight, at times resulting in mandated treatment that was directly at odds with medical knowledge and recommendations.  The most egregious example of this was the refusal, delay, or curbing of medication-assisted treatment (MAT) (also known as substitution or replacement therapy) to people with opioid use disorders, despite evidence that treatment for such disorders in many cases requires long-term — sometimes permanent — medication.  Some drug courts also prevented participants from accessing or staying on medically prescribed treatment for anxiety, Attention Deficit Hyperactivity Disorder, and other chronic health problems.

Human rights concerns are thus particularly relevant for drug courts, as these courts blur the line between voluntary and coerced treatment, and compel participants to waive the right to confidentiality.  Furthermore, most drug courts operate with regulations that subject medical expertise and advice regarding treatment to prosecutorial oversight and potential veto, raising questions about a person’s ability to access impartial evidencebased care.  Even where courts did not actively violate human rights protections of their participants, the regulatory set-up constantly threatened such violations.

June 8, 2017 at 05:05 PM | Permalink


Given that drug court participation is entirely voluntary (with the carrot of a lower offense or no conviction at all) I really don't see the due process concerns being at all relevant. These folks could always choose the stigma of a true conviction instead.

And given what various groups have put out about medical care in the prison environment I very much doubt that things (such as continuation of treatment would be any better there.

What, exactly, does PHR think states should do with malingerers?

Other concerns raised do strike me as being worth examining (particularly making sure that whatever treatment is applied actually matches the offender's profile).

Posted by: Soronel Haetir | Jun 8, 2017 5:32:53 PM

One problem with this source is that average physicians don't know how to treat many drug use disorders, namely addiction. It's a combination of psychological and medical/psychiatric problems that doesn't lend itself to a "medical" treatment necessarily. While prescription medications may be appropriate for some opioid abusers, it isn't a necessary or mandatory thing: plenty of people recover from heroin usage without Methadone or Suboxone and it's a better quality of life if they do. Medications for alcohol or non-opioid addictions are almost, not quite, useless. And treatments for anxiety (benzodiazepines) and ADD (basically meth) are either lazy treatment (benzos) or simply unnecessary. Many relatively minor mental health problems disappear once abstinence and recovery are achieved, and they cannot be properly disagnosed until an addict is abstinent.

Posted by: Fat Bastard | Jun 8, 2017 11:44:08 PM

I neglected to add a couple of things. Average physicians are, in fact, complicit in the opioid problem sweeping the nation as a result of their ignorance of the mechanisms of addiction.

Further, a heroin addict on Methadone or Suboxone remains at high risk for relapse if the substitute drug happens to become unavailable. It's really just switching one addiction for another, less devastating one. Same problem with treating anxiety with benzos and "ADD" with meth: they'll just become addicted to those instead of their drug of choice. There are smarter options (CBT) for both maladies if they happen to remain after abstinence.

Posted by: Fat Bastard | Jun 8, 2017 11:52:15 PM

Fat. If you want to understand addiction better, try to lose weight. Get Cognitive Behavior Therapy for weight loss.

Stop. I was just pranking you. There is virtually zero chance you will lose weight long term without medical technology and external controls.

Posted by: David Behar | Jun 9, 2017 12:32:23 AM

This is part of a wider malaise in the prison system which is full of poorly paid, poorly trained, and poorly motivated jailers (at all levels) who have little or no understanding or sympathy for the notion of human rights, let alone constitutional rights of inmates in their "care". The punitive regimes that are so common, and which are so contrasting with the best of European regimes for example, need radical reform ....... but it seems we are light years from the political will to turn this around. That is not to say there may not be some few outstanding examples in the US .... if there are, they need to be pushed into the public and political consciousness so that the benefits can be seen.

Posted by: peter | Jun 9, 2017 5:42:02 AM

Europe has higher crime rates, even with their left wing cover up of crime reports. If you compare white areas of the US, their rates are way higher. Once the refugees feel comfortable, they will face massive criminality. The single most powerful factor in criminality is prosecution risk. In Vietnam, the opiate addiction rate of our military was 40%. Upon return, it fell to the average rate in the US, around 1%. Addicts were not prosecuted in Vietnam, they are in the US. The features of the 1% still addicted were similar to those of non-military addicts. So victims pay the price for the coddling of criminals. Stop believing the lying cover ups of left wing government coddling their constituencies, the criminals.

Posted by: David Behar | Jun 10, 2017 8:58:43 AM

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