The research newsletter of the National Association of Drug Court Professionals (NADCP) boasts: “From their inception, Drug Courts embraced science like no other criminal justice program. They endorsed best practices and evidence-based practices…” . The MMT policies and practices of drug courts in several New York counties embody just the opposite: a rejection of science and scientifically sound best practices and raise serious questions about medical ethics. Court-ordered forced withdrawal from MMT and allowing methadone and buprenorphine therapy only as a “bridge to abstinence” are contrary to agreed national and international best practices and are a disservice to people who may benefit from the courts but who also benefit clinically from MMT. As noted by the World Health Organization, a strong body of research supports the conclusion that arbitrary limitation of the period of MMT is clinically counter-indicated . The experience of treatment providers in the state indicates that these policies undermine the ability of the courts to serve many of the very persons they were designed to serve.
The practices documented here run contrary to those of bodies with the mandate of guiding and supporting drug courts in the US. In 2011, NADCP, a professional association supported heavily by federal agencies, published a resolution noting that drug courts should not “impose blanket prohibitions against the use of [MMT] for their participants” and that court decisions in this regard should be based on “particularized assessment in each case” . An earlier position paper by the National Drug Court Institute, the “professional services” arm of NADCP, adopted a position statement that methadone patients “should not be required to withdraw from a medication that improves their lives” any more than people who need them should be forced to withdraw from treatment for cardiovascular conditions (This statement no longer appears on the NDCI web site but is reproduced by Parrino in 2003) . Allowing methadone therapy only for arbitrarily specified periods defies the accepted evidence that continuity of MMT over a long period and even indefinitely is well indicated for some patients . A more recent “best practices” document of NADCP notes that in view of “numerous controlled studies” showing “significantly better outcomes” associated with methadone and buprenorphine therapy, “a valid prescription for such medications should not serve as the basis for a blanket exclusion from the Drug Court” .
In 1997, the National Institutes of Health convened a consensus panel that strongly recommended greater access to MMT for people who need it. The panel stressed that “[a]ll opiate-dependent persons under legal supervision should have access to methadone maintenance therapy, and the U.S. Office of National Drug Control Policy and the U.S. Department of Justice should take the necessary steps to implement this recommendation” . This recommendation has never been implemented on a national or local level and is plainly not being followed by some drug courts. Practices of the courts also fly in the face of the recommendations of United Nations expert bodies on health and drugs as well as highly regarded expert reviews of the Cochrane Collaboration that have investigated both methadone and buprenorphine maintenance with respect to effectiveness and safety [4, 36, 37]. Numerous studies have shown that MMT keeps people with opioid dependence in treatment longer than the abstinence-based therapies apparently favored by some drug courts, and dropping out of treatment is a major risk factor for overdose [38, 39].
The State of New York has addressed MMT in guidelines on recommended drug court practices, as follows:
Methadone maintenance therapy can be a controversial topic when utilized in the criminal justice context…. Criminal justice professionals tend to view methadone as another drug that is addictive and subject to misuse…. Drug court programs should make their decisions about [MMT] in the same manner that they make other treatment-related decisions, in close consultation with the treatment professionals on their team .
The experience of the treatment providers we interviewed indicates that this guideline is being routinely violated in some New York counties as treatment providers are not only not consulted in clinical decision-making of the courts but are sometimes compelled to make special appeals to the courts to respect clinical norms and ethics. Decision-making about treatment for drug dependence should always be made by health professionals with specialized knowledge of treatment efficacy and safety.
The perception of treatment providers in this study that the criminal justice system was biased against MMT was corroborated by findings of an unpublished 2011 analysis by the New York State Office of Alcoholism and Substance Abuse Services (OASAS), which found that while “40% of admissions to all drug treatment services were referrals from criminal justice agencies, only 5% were in opioid treatment programs (OTPs)”. This data was presented by OASAS director Arlene Gonzales-Sanchez at a meeting of the Committee of Methadone Program Administrators of New York State on May 15, 2011 in New York City in which one of the authors, HC, was present. Treatment providers’ conclusion that methadone and other medication-assisted treatment for opiate dependence are stigmatized in the drug courts also corresponds to the finding of Matusow and colleagues that MMT was sometimes seen as just a “new addiction” to replace an old one .
In view of the stigmatization of methadone as a treatment option and of methadone patients, the state has a responsibility to protect access to this treatment as a matter of legal protection of the rights of patients. The Americans with Disabilities Act (ADA) of 1990 has been used to defend the placement of methadone clinics in locations where residents have objected to them  and to prohibit discriminatory dismissal of workers who are methadone patients . Similarly, there may be grounds under ADA to assert that the rejection of MMT as a treatment option for drug courts is discriminatory. Apart from legal responsibility, the state should see as costly and problematic the loss of persons with opiate dependence to scientifically sound and supervised care or their diversion to illicit use of prescription opiates. The human cost of denial of this treatment for the individuals kept from medicines that can stabilize their lives and keep them from having to seek drugs in illicit markets is enormous. As the World Health Organization  and an important body of research  has shown, beyond its direct effect in stabilizing opioid cravings, MMT helps people have stable family lives, maintain employment, and be functioning members of their communities.
D’Aunno asserts that a range of barriers to the use of “empirically established treatment” of opioid dependence in the US includes (1) limited resources; (2) poorly designed policies, organizations structures and incentives; (3) organizational and individual values, beliefs and norms; and (4) individual deficits in training, skills and motivation . All of these factors may be relevant to drug courts as a barrier to access to MMT. If limited resources result in waiting lists for MMT slots, it is that much harder to advocate for inclusion of methadone as an option for court-mandated therapy. Policies that incentivize exclusion of needy patients should be corrected. Individual values of judges and drug court personnel that reinforce practices that deviate from clinical and scientific norms should be addressed. Where these values are a result of inadequate technical capacity, training should be brought to bear and measures should be taken to ensure that qualified treatment providers have a meaningful role in treatment-related decisions of the courts.
Until court practices improve, it would be useful for the state to establish a monitoring system to follow cases of people rejected from drug court participation because MMT is their clinically indicated or preferred treatment, especially to ensure that these persons are able to have access to the care they need. The federally supported National Drug Court Institute or another body should investigate the degree to which drug treatment courts in the US are defying best clinical practice on MMT and the reasons why, so as to inform appropriate policy responses.
This study has several limitations. The inclusion of more counties may have elicited more varied case examples. The experiences of MMT patients in the few drug courts in which they could participate or of those receiving MMT who may have been required by the courts to “taper off” methadone would have been a useful complement to that of treatment providers, but we did not have the means to track down the persons whose stories were referred to by treatment providers. The experiences of persons for whom MMT is clinically recommended but who wish to participate in drug courts that do not allow MMT as a treatment option would be a fruitful topic for further research.