Drug Courts and Drug Treatment

There is much discussion of the recent “opioid epidemic” and the possible policy responses to it. I often hear suggestions that we expand drug courts and treatment programs for addicts. My take on this is: Sure, those things would be better than what we’re doing now, but don’t assume they will help much.

Regarding drug courts, read The War on Drugs: and Old Wives Tale by Christine Shuck.  The author’s husband was forced to endure the infantilizing hell that is drug court. He probably got off lucky, actually. He got caught growing marijuana, and production/trafficking charges aren’t usually eligible for drug court. So the life-disrupting hell he endured was a lucky break compared to what most marijuana growers might have expected. Under drug court you don’t go to prison, but you are regularly urine tested. You have to call a number every morning and if your number comes up (actually I think they assigned him a color) you have to report to a location and drop urine. If you fail a drug test or if you fail to make the appointment, you go to jail for a day or two. This happened to him once early in his “sentence” because he failed to call the number that morning when his color came up. The case workers have enormous, arbitrary power over drug court defendants (prisoners?), and they often have limited or no clinical experience or psychiatric expertise. One case worker decided she didn’t like Christine (the author), so she considered making David (her husband, the drug court defendant) live elsewhere. This didn’t end up happening, but I was scratching my head thinking, “On what basis are you making this decision? From what psychiatric literature are you drawing this insight?” David’s legal rights were severely abridged for the duration of his drug court sentence. I wasn’t enough that he merely abstain from drug use (and recall that drug use was not even the original charge against him). He also couldn’t have any alcohol. In fact there could be no alcohol in the house, thus abridging Christine’s rights in addition to David’s. There were periodic searches of his house for such contraband. Christine explains that even if he were out at a restaurant and someone at the same table as him ordered alcohol, David could be arrested on the spot. Do read the whole thing. It’s an appeal to reason by someone who lived through that hell.

Many drug courts do not allow any kind of maintenance therapy, in which you replace one drug with another. They insist on strict abstinence. This is actually incredibly dangerous because relapse is very common among opioid addicts. Strictly enforced abstinence forces people to lose their tolerance for a drug, and then perhaps in a moment of weakness they indulge. Well, they may not understand that their tolerance isn’t what it used to be. This is actually a very dangerous time and (prior to the recent spate of fentanyl overdoses) was a or even the leading cause of heroin overdose.

So if people are saying, "Yay! drug courts, because it's better than what we have now. We can improve things from there in a few years," I can probably get on board. If people are saying, "Yay! drug courts, because they are the optimal drug policy and they really help the people who go through them," then I am extremely skeptical and I want to push back hard against this as some kind of permanent solution.

I should also recommend Unbroken Brain by Maia Szalavitz. It’s another part-autobiography, part-policy-analysis kind of book. Szalavitz has a long discussion of the various kinds of drug treatment programs. She discusses with which ones work and which ones don’t. Szalavitz was herself an addict and describes her experience with a 12-step program. She claims that it worked for her, but cautions the reader not to believe her anecdote in isolation. The literature just doesn’t seem to validate 12-step programs as an effective “cure” for addiction. (I always admire this kind of intellectual honesty. She’s obviously favorably disposed to a treatment that worked for her, but her review of the literature made her skeptical enough that she didn’t mislead her readers.) There are also “tough-love” type programs. The “patient” in such programs is usually confined to severely restricted living quarters. They are often subjected to incredibly cruel punishment, taunted, physically abused, emotionally broken down, or neglected. There are countless horror stories and several successful lawsuits against organizations that hosted such programs. For all the horrors, there doesn’t seem to be any compelling evidence that these programs work. Relapse rates for “graduates” of tough love are similar to relapse rates for alternative treatments or no treatment. Examples include Straight Inc. and Synanon. 

I mention this because often drug offenders will be forced into “treatment,” and two broad categories of treatment programs don’t work. So don’t expect that some big federal grant for “drug treatment” is going to suddenly cure all the hopeless addicts. It might help a few struggling addicts find a bed at a treatment facility, assuming they are ready and willing to get clean. But this isn’t going to scale up, such that spending ten times as much on treatment will cure ten times as many addicts. I see “expansion of drug treatment” as something that’s likely to quickly bump into diminishing returns.

Unbroken Brain discusses two kinds of "treatment" that actually work: maintenance and harm reduction. Under maintenance you basically give the addict a measured dose of whatever drug they are addicted to, or perhaps a similar drug. Methadone maintenance for heroin addiction, for example. Harm reduction means you reduce the risks associated with drug use. Clean needle exchanges, test kits that confirm the drug is what you think it is, "buddy" systems or safe injection facilities in the event of an overdose, overdose-reversing drugs like naloxone, etc. Most people "age out" of their addiction and clean up by their early-to-mid thirties or so. Under harm reduction, the idea is that you keep the addict alive until they mature out of their addiction. Opioids like heroin and prescription painkillers are basically only dangerous if you overdose. They don't do the kind of cumulative organ damage that sustained heavy drinking or cocaine use cause. So as long as you can keep the addict from overdosing or getting a blood-borne disease like HIV or hepatitis, you can basically sanitize their drug habit. The beauty of harm reduction is that you don't really need some government program with lots of federal funding and coercive control over the addict. Full drug legalization gets you most of the way there, even without government guardrails.

I see the calls for expanding drug courts and drug treatments as a kind of unserious "do-something-ism" by people who are squeamish about actually legalizing the drug market. Really, there is no way to mitigate the most serious overdose hazards in a regime of drug prohibition. If expanding drug courts is one step in a gradual migration toward legalization, I'll get on board out of realpolitik considerations. But it is not the best possible drug policy. I might as well say so clearly.