State of the Field: Adult Drug Courts

Dr. Christina Lanier:
Welcome back to the Justice to Healing podcast. I'm Dr. Dr. Christina Lanier, one of the co-directors of the National Drug Court Resource Center alongside the other co-director Dr. Dr. Kristen DeVall.

Dr. Kristen DeVall:
Hello.

Dr. Christina Lanier:
We want to welcome you to the first of a series examining specific treatment court types. Today's episode will focus on the state of the field in adult treatment courts. We have two very special guests with us today. Carson Fox, the CEO of the National Association of Drug Court Professionals and Terrence Walton, the COO of the National Association of Drug Court Professionals. Welcome, to both of you.

Terrence Walton:
Thank you. 

Carson Fox:
Thank you. It's an honor to be here.

Dr. Christina Lanier:
If you could take a few minutes just to tell us a little bit about yourselves, that would be great. Carson, can we start with you?

Carson Fox:
Thanks again. It's great to be part of the podcast today. As you said, my name is Carson Fox. I'm the chief executive officer of the National Association of Drug Court Professionals. I started NADCP full-time in 2001. And before that I was a prosecutor in the 11th Judicial Circuit of South Carolina, where I helped start the first adult drug court in that circuit.

Dr. Christina Lanier:
Terrence. 

Terrence Walton:
Yes. Hello everyone. I'm again, Terrence Walton, I'm NADCP's chief operating officer. I work with Carson to help run this organization day by day. I also have the pleasure of spend lots of time in the country, working with treatment courts all across the country, helping them to implement best practices. I think Carson... I guess it was 2014 when I joined the team here, before that I was a consultant for a long time with NADCP but came on board and I guess it was 2014. Prior to that, I spent 15 years as director of treatment for the Treatment Court here in Washington, DC. And frankly, I have spent all of my career, which now spans more than three decades, helping men and women and young people get free from addiction. And for most of that time, it is involved helping people who help people get free. So I'm always happy to talk about anything that works to help people be able to get control of their lives like treatment courts.

Dr. Christina Lanier:
Great. Thank you so much for being here. We'd like to start this episode with a brief history of treatment courts. We know that this movement began Miami-Dade county, 1989. So we're now more than 30 years beyond the implementation of that first treatment court. So can you talk a little bit about how this model has evolved over time?

Carson Fox:
Absolutely. So, as you said back in the late 1980s, the first treatment course started in Miami-Dade county, Florida. What happened there, if you talk to the professionals... And I had the opportunity back in the 1990s to speak to some of the folks who actually had a role in starting that very first treatment court, and they talked about a frustration that they had among folks working in the court system where they didn't feel like that they had the opportunity to really help folks coming into the system who had serious substance use problems. And they wanted a new model for working with folks with substance use disorders. 

And so they created this model that that's now called drug court or treatment court. And I think that it's been around now for, as you said longer than 30 years. And so many folks think of it as being just an intuitive thing, but at the time it was really counterintuitive. The idea that they brought treatment providers into a team with judges and defense attorneys and prosecutors and other folks to help folks with substance use disorders from coming back into the system was a really novel approach at the time. And what we see then is that the same problems they were having in South Florida, the same problems they were having in Miami with the cocaine epidemic as it's often referred to at that point in time, was mirrored in other parts of the country. And news started to get out about this new model, this experiment that was working in Miami-Dade county. And so the model started to gain popularity and to fairly rapidly spread. And so in 1989, that first court started, but by 1994, there were 44 or so these treatment courts around the nation. And what we saw at that point in time was there was a gathering of professionals recognizing that this was indeed working. 

It seemed to be working in their jurisdictions, and some of those folks got together at that point in time. In 1994, they created the National Association of Drug Court Professionals. The model continued to grow, by a couple years later, we saw the creation of the first DWI court, the first family treatment court, the first Tribal Healing wellness Court, the first Juvenile Drug Court. And we saw the ADP's first conference. We saw the creation of the National Drug Court Institute within NADCP with help and support from the office of National Drug Control Policy at the White House. And it was just really an amazing and expansive growth of these programs based on the success that folks were seeing within their own jurisdictions, within these programs. 

And then we started to see the research come out and the research underscored that. The research showed that they were indeed having success and they were helping folks turn their lives around and helping reduce recidivism. And that the model was really something, again, to be replicated.

Terrence Walton:
Carson, I was just thinking the other day that I got my first job in the addiction field in 1987. It was an adolescent program in Dayton, Ohio. And then I got my first job as a counselor in 1989 just as treatment courts were being birthed. I didn't know about it. It was another decade before I discovered treatment courts, but I had to benefit of really working with men and women and young people in the throes of addiction. Those of us who are old enough to remember what it was like with the sort of twin epidemics of the crack cocaine epidemic and the HIV aids epidemic at the same time and the impact that had on communities. And, I grew to love my clients and so many of them were super well intentioned and they wanted to do the right thing. It was just hard for them to resist the chaos of their lives and keep showing up in treatment long enough for it to work. 

And we had some success stories, but we lost so many people often to the justice system getting locked up. We couldn't treat them and then we see them again, once they got out for a while. I wish I had known the treatment courts, I wish they had existed where I was at that moment. And I wish I had known about them if they did, because we probably could have helped a lot more people.

Carson Fox:
And it's fascinating to hear Terence talk about that because when... And I think about that growth in the first decade of treatment courts and while a lot of folks know that in the field that treatment court started in 1989 and in Miami-Dade county, what many folks don't don't know is they started out of pretrial intervention, PTI. So most of the folks in the initial treatment courts were first, or maybe second time offenders. By the time that we get to the late 1990s, there are a little shy of... In 1999, there are a little shy of 500 treatment courts in the country. And again, as I mentioned that they now include that point in time, juvenile and family and other models. But what we've also seen by the end of the 1990s is a dramatic shift in who's coming into these programs. 

You see folks who are not first time offenders, you see folks who are more serious felony offenders coming into the programs and you see more research coming out. And you see the programs even before the research is coming out, start talking to each other about how they're shifting to a population of folks who have been in the justice system for longer may have extensive criminal records and who are having tremendous success in these programs. They may have been justice system before, they may have been for example, on probation before, and referred to treatment and possibly didn't have success then. And then when they come back in, they're referred to drug court and they have great success. and so there was questions about that and then further expanding the model to follow the research as things progressed. And I know that Terrence had some specific work with that when he was in DC.

Terrence Walton:
When I think about sort of how we have evolved, I do think about, one of the issues that often comes up is about target population, is about who are treatment courts for. And it's interesting when I was in DC and my first drug court was a pretrial court, and we had a a pretrial component was a misdemeanor diversion component. And then over time, we also developed a felony component that began to take individuals who were charged with felony offenses and more serious offenses. And we had our own real example of how you can tailor treatment court to meet some of the risk and needs of the people that are there. And as we understood better how to have the kind of impact and outcome that drug court's promise, we really had to invest in our felony component and provide help for the higher risk individuals. 

Dr. Christina Lanier:
And would you say that that sort of shift in who treatment courts were targeting was based on the research that was coming out about these programs and their effectiveness?

Terrence Walton:
Well, I think so. Because if you think about it, and Carson described how drug courts started, treatment court started, these were pretrial diversion programs and, no prosecutor... Carson was a prosecutor, no prosecutor community is going to be willing to try something, which is this non-intuitive with a population that is higher risk at first. And so, we learned how to do drug courts with a population that people were willing to see get diversion in exchange for doing the best they can in treatment. And that certainly showed outcomes, but as programs began to take individuals who had more serious charges, as we began to focus more on the need to assess risk level, to determine who needs treatment court and begin to see not just outcomes that were equal for people who were higher risk, actually seeing outcomes that were better for those or a higher risk, they begin to transform, of course, how in NADCP trained on this, but how communities begin to look at the population they should be targeting for their program.

Dr. Christina Lanier:
For sure.

Carson Fox:
And it's fascinating for me. I mean, Terrence and I have known each other and worked together for years. And to hear his story about what happened in DC and how similar it was to the story that I saw happening in the 11th Circuit in South Carolina, we started our program and very quickly developed a track for folks who were on probation and also very quickly developed a track for folks who were probation revocation cases. And those were folks who essentially could have one foot in the prison door because they'd been placed on probation and they may have had multiple violations. And if the violations were due to a substance use disorder, then they were brought into treatment court and given the opportunity to continue and we had tremendous success. Tremendous success with those folks. 

And I remember back in the late 1990s, the National Drug Court Institute at that point in time asked me to come on as faculty and I went around and talked to other prosecutors about how we were having tremendous success in South Carolina with those folks. Many of the folks in our drug court had had very long criminal records. They had criminal records and I remember we had some folks who had even been in prison before, and they had never gotten help with their substance use disorder. And I can remember many of them back in the day telling me that that was what continued to bring them back in, that continued that cycle of them coming back into the justice system. And then watching folks turn their lives around and seeing, for example, having arresting officers come to graduations and then hugging the folks who they maybe have arrested, not only before the person came into drug court, they might have known for years because of the person's involvement in the justice system. 

And just seeing the transformation and seeing the arresting officer hug the graduate and seeing the relationships there and seeing the folks bring their kids to the graduation and having them bring their kids to court. And just seeing that... Just an amazing transformation and hearing from law enforcement that they might never have expected this individual to turn their lives around and just being amazed by the success of the program. I'm kind of with Terrence, I remember us talking about it when we were doing our drug court back in the day that we wanted to have the greatest impact possible, but I remember in some of the training that we were provided, that we were told that having the greatest impact possible would be with folks... You wanted to keep folks from coming back into the justice system who had the most serious problems. 

And so we turned to probation and probation revocation cases fairly rapidly. At the same time, and I'm not exactly sure when the research first started coming out, but we started to see as Terrence has referenced, that we started to see research coming out on what is the right target population for these courts. 

And Terrence mentioned high risk and high need and what that kind of means on kind of more colloquially is that these are folks who are at high risk for re-offending. They're more likely to recidivate. They're more likely to come back into the justice system. If they don't get an appropriate level of care and then high need, these are people with serious substance use disorders, and more often than not many of the early courts and all the courts now too, are also dealing with folks who may also have a mental health disorder. You could have courts that are helping folks with both and again, having tremendous outcomes, but that was a departure. And there were folks who didn't necessarily believe that it would work but it did and the research showed that. And I don't know, Terrence, what's your-

Terrence Walton:
Carson, you mentioned this high risk need piece. And part of the reason why treatment courts matter so much is that there are a number of factors that put a person at higher risk or failing under regular supervision and incarcerated. But for our population, a big part of that is driven by the need, driven by the substance use disorder, driven by the addiction. And so the real important piece here though, one of the important pieces here is that if we are serving the right population, who both have significant substance involvement, who are living with addiction, and who are at higher risk for failure without the structure and services of a treatment court, that it's important the treatment courts get it, right. If you're treating lower risk folks who have lower level substance use issues, you can perhaps do a number of things that you hope will help, but the bar is higher because public safety is at risk, and the need to really provide effective recovery management. 

And that includes for most people, effective professional treatment. It becomes paramount that the risk of not doing so are too great to the community and to the person. So I guess what I'm saying is if we are treating... And some of our listeners out there are working treatment court, and we are treating the right population. Those who are high risk and high need, it becomes even more important that we implement drug court consistent with the model. 

Dr. Christina Lanier:
Sure.

Carson Fox:
I can remember something that Terrence said a few minutes ago, just talking about how the model, and as it moved to this new population and folks fairly quickly, for some folks, it was counterintuitive. And I always think back to, there was so many folks who came through the drug court that we had who were successful. And that maybe there were some people who didn't believe that they would be, and I always remember this one individual, and she came into the drug court... But talk about counterintuitive. We had an active and successful drug court, and this was someone who was not pre-identified to come in to drug court. She was actually in front of the judge being sentenced. She had a serious substance use disorder. She had many, many charges that she had pled guilty to.

She was in front of the judge. And this judge was also the same judge who presided over the drug court. And he tells the story of how he had already filled out her sentencing sheet. She was going to be going to prison for two years, but he had not yet signed the sheet. So he looked up to the attorneys in front of him and to the young woman and he asked if she had been assessed for drug court. And they said that she had not been. And so he asked that they do that and they step aside and she ended up coming into the drug court. And I talked to her years later when she was at actually applying for Law School. And her life was in a whole different place. And we talked about that and how she talked about going through the assessment and coming into the drug court and not thinking even maybe herself, that she would be able to succeed. And she took several months to get through the program, but after she got through it, again, and she was tell me, she felt like a totally different person. 

And then I left South Carolina. I moved to work at NADCP and like I said, I heard from her years later when she had gotten into Law School, but that was just one of so many examples. I know Terrence has these stories. I have these stories. At our national conferences there are graduates every year speak and tell their own stories. But I think probably almost every drug court practitioner I know has one story that sticks with them. Just one story that stands out. And I think of her story. And I just think that her story started with... Even in a jurisdiction with a successful, active drug court, she was not considered to be somebody to refer there until the question was asked at that point in time, and it turned her entire life around.

Dr. Christina Lanier:
Yeah, that's powerful. And that discussion about sort of someone on the verge of going to prison for two years versus drug court raises I think an issue that is worth talking about around the cost benefit. There's been obviously studies done around the cost benefit of treatment courts. So can you talk a little bit about the state of that literature and the cost savings come with treatment courts versus paying for incarceration?

Carson Fox:
Sure. It's a great question. I guess, first of all, there's the societal benefit. There's the benefit to that individual. There's the benefit to their family and there's no way we can put a cost on that. As you mentioned, when we talk about this young woman who was going to go to prison and when I heard from her again, and she contacted me, she was in Law School. Her life turned around and there's no way to put a cost on that. But at the same time, as you mentioned, there have been any number of cost benefit analysis when on treatment courts because you have the upfront cost, you have cost of operating the courts. And of course, there's the question is so what's the benefit? What's the cost benefit of these courts?

And it's interesting. I remember several years ago there were separate jurisdictions who ran cost benefit analysis. I remember Dallas in particular. So Dallas did, Portland did, and those two jurisdictions ran cost benefit. They had cost benefit analysis done of their treatment courts, and separate than independently, they both found about the same return on investment, which was rounded up. It was about for every dollar invested somewhere between $9 and $10 per se. I remember that, and I was a much younger practitioner hearing those numbers and had been being so impressed by that return on investment. And then later on, we got even more progress and much more comprehensive evaluations done, national evaluations done of treatment courts. Probably the most comprehensive of all was the national Institute of justices, a multi-site drug court evaluation, which is cited all over all over the country about treatment courts.

And it had a cost benefit element in it. And that cost benefit element showed that there was a considerable savings for taxpayers. Over $6,200 per participant and up to $27 return for every dollar invested. What had also showed though on that benefit that it's impossible to put a cost on was the increase in the rate of babies who are born drug free. The fact that the programs promoted family reunification, that they reduced foster care placement. The fact that they reduced drug use and crimes significantly, fact that these programs improved education, they improved employment, they improved housing, they improved the financial stability of the individuals going through the programs. And so in addition to the cost benefit, you also get those benefits that are impossible to put a price tag on.

Terrence Walton:
Carson, that's such a powerful points. And while there are lots of reasons why treatment courts make sense for the right population, for people who are concerned about the and cents the cost effectiveness is a strong argument, but you will never get that cost effectiveness if we are not treating and servicing the high risk high need population. It really is the getting people who would be in and out of the system on the right path, it really is diverting people from incarceration where you actually get to cost savings. There's other reasons why we need to just treat the right people in treatment courts, but if the desire is to be cost effective, that's a big argument for being sure we're treating the right folks.

Dr. Christina Lanier:
Thanks to both of you. That was a great discussion around really thinking about how we can ensure that programs are serving the intended population as well as adhering to the fidelity, to the model. Relatedly to that, one of the topics that comes up often is ensuring that programs are serving all the people. And so by all the people meaning the issue around equity and inclusion in treatment courts. Can you talk a little bit about this topic or this issue and a little bit about the research findings around equity and inclusion, and perhaps provides some and resources for our treatment court practitioners within this area?

Terrence Walton:
I think that's a really important topic and it's one that NADCP as well as our other partners who are involved in helping to lead this field spend a lot of time on. Listen, there is no question that treatment courts have not been in immune from the inequities that plague the entire justice system. But what we can say, and Carson and I have an inside perspective where we both, and those who work in this organization have contact with hundreds and hundreds of treatment courts who are grappling with this issue. Treatment courts are in a very real way of facing up to the inequities that exist in the larger system, but in particular where equities exist in treatment courts? So we, through our own surveying and through other research that we have digested, it's very clear that there are inequities in some treatment courts, both on who gets in treatment courts and who does well once they're there. That they're still too many programs where black people, people of color, males especially, are underrepresented and who don't graduate at rates that are equivalent to others.

That's true in lots of programs, but it's not true in all of them. And part of our focus has been focusing on those drug courts who are showing that black people or people of color and other minorities do well or even better than other populations. And looking at the kinds of services they're offering, the kinds of targeting they do, the way they structure their programs, to be sure that everyone who is eligible for and needs a drug court has an equal opportunity to get into or drug court and do well. Drug courts accept the fact that it's not good enough not to know. We have an affirmative obligation to know whether our programs are equitable. And if we find that they're not, taking whatever steps is necessary to correct it. Carson, I know you've done some work on this issue too and you think a lot about.

Carson Fox:
This is an issue that's been critical at NADCP for as long as I've worked there. As we've done training across the country, we've trained on equity and inclusion to every court we've trained on. Our board of directors issued a resolution towards ensuring equity, racial equity and treatment courts back into 2010. There is just been a continual emphasis from NADCP, but like Terrence has said, we're not there yet. There's a lot more work to be done. We've done a lot of work recently partnering with our federal partners and the national center for state courts, working on equity inclusion tools to assist courts in going in and determining what issues they might have, and then also helping them correct those issues. And while we we've done a lot of work in the past, there's more work to be done. And there certainly is an opportunity in treatment courts to lead the way on this and to lead the way on ensuring fairness and equity in all programs in the justice system.

Terrence Walton:
Carson, there is no topic that we get more requests for training integral systems than this topic. That there is, especially, because our adult drug course best practice standard's the second standard. The first standard is target population because that's where it all begins. The next standard is equity and inclusion. And the emphasis of that standard is you have to know, look at your data. Your data will tell you whether or not you have an issue with equity in terms of who gets in, in terms of the kind of treatment they receive, in terms of the responses to behavior they receive, and in terms of graduation. And so as people across the field, as programs across the field have began to implement that standard, if they see inequities by and large, they begin reaching out and asking for help. And we have a number of ways we can assist them that I'd like to talk about at some point before we finish our discussion today.

But I also want to say one thing, what we know about this issue is evolving and what I've most appreciated about treatment court field is me being a part of the field, that matters a lot to me personally. As a black man living in America, I appreciate the fact that from judges and decision makers across the country, in all regions of the country, there's a real willingness to discuss this issue and to make the kind of changes that are necessary. That gives me hope for my young son moving up. And if heaven forbid, either my children who are small now, whatever be facing this issue end up in the justice system. I want them to have the same chance of getting into a drug court and getting their charges dismissed and avoiding prison as anyone else. And so I'm hopeful about the future because of the way treatment courts are addressing this issue head on.

Carson Fox:
And Terrence is the expert on training on this and he's such a brilliant master trainer. And he inspires me when I listened to him train on this and he was... Many of the things he's talking about are also by design, Terrence and I both had the opportunity to work on the committee that developed as best practice standards. And as he said, the first standard was on targeting, which we talked about earlier. And the idea behind that was that if you don't have that right population in your program, then all the other standards to follow might not necessarily mean as much or make sense. So first of all, you have to start with the correct population. You have to start with people who have a serious substance use disorder. You have to start with people who have a higher risk of recidivating. 

If you don't get them to the proper level of care who are going to be more likely to come return to the justice system. And then secondarily as Terrence at the second standard is equity and inclusion that you to be sure of that... And he was talking about how, when folks see this in their programs but another thing that Terrence trains on all the time and that you'll find in the standards is that there is a duty on courts that's created for courts to find that. So even if you don't see it, you need to look for it because it could be hidden. And that programs have an affirmative duty to find out if there had been equity, are there folks who are not getting into your program who should be in the courts and the court should be looking for that and then rectifying it. And as we said earlier, we work with national center for state courts in our federal partners to create tools, to help the courts go in and find those inequities and then correct them. 

Terrence Walton:
I think that bears really empathizing the tools that have just been developed, because one of the things that's been in some ways, frustrating for myself as a trainer and the hundreds of consultants and staff who trained for us across the country is on this topic. If we get before a team and they become convinced, "Yeah, we care about this. We want to do something about it." And if we don't have any way of helping them. So there's a couple of things. So these are all available at nbci.org and it's a piece of our main website is allrise.org but the piece that practitioners go into the resources is in the nadcp.org. If that web site is crossed we have a toolkit of various resources that will help people address issues on this topic. And a part of that, there's also an assessment tool way, a previous formula formatted, really Excel spreadsheet to help people to collect and track numbers about who's coming in based on all of the important demographics who is getting out successfully, that alone has been so important, especially if it's the world program or small programs. 

We don't have lots of resources whose existing database isn't able to track that for them. It's just been a big help. And we appreciate our collaboration with the National state courts in developing that assessment tool, is going to allow practitioners to know programs, to know what's happening and as far as submitted. And I think it bears repeating that in drug courts we accept the fact that we have an affirmative obligation to know if our programs are equitable.

And if we don't know that alone is a problem, not knowing where we are on this issue is in fact a violation of adult and other drug court best practice standards. This is a really important issue and both Carson and I had the benefit of being a part of the group that developed the adult drug courts, best practice standards. And they have been out now for several years, are widely regarded as the statement of facts regarding not just the two reports work, but how they work and what programs should be doing if they want to get the outcomes the drug courts promise. Our first standard is target population because it all starts from there, but the next standard is equity and inclusion. And that emphasizes how important this organization and the field believes this issue is. 

And I guess the biggest instruction from that standard, the biggest guidance from that standard is not knowing whether you are equitable, not knowing whether your program is equitable is in itself a violation of the standard. Treatment courts have an affirmative obligation to know if in fact their programs are giving equal opportunity for people both to enter the treatment court and to do well while they're there and have good final outcomes.

That's an affirmative obligation is outlined in the standard. I know we don't have a lot of time but just really quickly, the standard essentially indicates that you want to know that based on demographics that minorities, and women and others who had the past faced discrimination, have an ability to get into treatment court just as readily as anyone else. So in terms of equity and getting in, but also what happens once they're in the treatment court, the kind of responses to their behavior, the incentives and sanctions that are issued, the kind of treatment they receive that mean equitable treatment of all kinds, residential treatment, comparing demographically people who have similar need levels, what kind of treatment they get their access to medications, all of that is a part of what treatment courts need to track and understand how folks are doing.

And then, ultimate outcomes what happens to people who graduate? The graduation rates, as well as what happens following graduation, the standards outline all of that as items that treatment courts should collect data on, and that if they find discrepancies, take action and that's happening all across the field right now, we may have already talked about some of the resources that are out there to help programs do that. The toolkit that we've developed on equity and inclusion, it has several different resources, so people can respond to any problems that they find in terms of equity or inclusiveness. 

And equally important is an assessment tool that helps people to collect the information in the first place that say an Excel spreadsheet with a formulas in tech that help people to enter information regarding who's getting into their program? What's happened to them? And then while they're in it, and then what happens down the line so we can take action. We are happy that we've collaborated with the national center for state courts in developing that tool. And it's really transformed how programs are able to both know if they have equity, as well as to respond to any problems they find.

Dr. Christina Lanier:
I liked how you described the multiple ways in which folks can assess for equity and inclusion. I think a lot of times they look at graduation rate and that might be it. Terrence. We wanted to talk about one of the issues within equity and inclusion, and maybe expand upon that a little bit, and that is equity and treatment. So one of the areas that we've seen in the past few years that has been recognized as important and relevant for treatment courts is the use of medication for addiction treatment. Can, can you all talk a little bit about this and how it's used in treatment courts and just what kind of resources are available?

Terrence Walton:
Well, Christine, I'm happy to do that. I mentioned earlier, I was thinking about it earlier, that when it comes to equity and inclusion, that's one of our most popular requested topics for TTA, for training technical assistance. This is probably the second highest and that is programs who are looking for ways to make medications for addiction treatment more available throughout their programs to everyone who needs them. Now, we don't have a recent study on this to know what's happening in treatment courts today. The best Betty we have is one that was really a decade ago. I think it was 2011, 2012 study shows that most drug courts even then offered a one or more of the FDA approved medications for the treatment of addiction. In fact, urban courts that made about 76% of urban courts that had a long history with opioid use disorders, heroin addiction 76% provided MAT, I think around 58% of suburban courts, 45 or so rural courts.

We certainly saw that if even in best study, the most drug courts were providing some level of medication. I think we saw even a decade ago that most treatment courts allowed medications. We also know that even today, as it was then, that a treatment court participant is more likely to receive medications in addition to their other treatment than they would be if they were anywhere else in the justice system, if they run a regular probation or pretrial supervision, but maybe even more surprisingly than a treatment court participant back then, and now is more likely to receive medications as a part of the treatment than they would if they were just walking off the street into a treatment center. Part of that is because, drug court started in 1989 and many of the treatment providers that exist today, they develop relationships and protocols based on treating crack cocaine addiction.

There is no medication, no FDA approved medications for treating that. So in some cases, the providers themselves that the places treatment courts rely on to get treatment for their folks don't have existing protocol for medications. So since that study and before there's been lots of effort from NACP and others to improve the numbers of treatment courts who as best they can make medications available to any participant who is diagnosed to need it. Now from that study 10 years ago and what we've seen since then, they're really, I think are three big reasons why sometimes treatment courts aren't providing all the medications that are FDA approved one is about availability for the most part, the vast majority of treatment courts don't have their own treatment program. They rely upon the treatment program that exists in the communities already.

And in so many communities access to all three of the medications, that's Methadone, that's Buprenorphine that's extended release Naltrexone that in many communities, one or more of those, it's just not available. There's not a doctor who will prescribe it, maybe there's not a methadone clinic. And so treatment courts are unable to provide what's not there. Sometimes it's about availability, sometime it is about awareness that the team members themselves and perhaps even their treatment providers don't fully understand medications, don't fully understand how medications are used in conjunction with psychosocial treatment. Don't have a full awareness of how essential medications are for saving lives. For those who are living with opioid use disorder. 

And then sometimes it's about attitudes. Sometimes there is bias that bias might come from the participants themselves who don't want to be medicated, or sometimes from treatment professionals or other professionals on the teams who don't fully understand that medication is not another addiction, medication is how so many people get better. So with that in mind, our organization, and we can talk about it later, if you want to, but our organization has really worked on the two parts of that we have the most influence over. And that is on helping to raise awareness to this issue and to educate people in a way where it limits biased against medications. 

Carson Fox:
I think that Terrence was talking about access, and I saw not too long ago on a website from health and human services. And I believe that the numbers are still pretty accurate, that only about 5% of communities in the country actually have access to all three FDA pre-medications. And so when we've had very large sessions that our national conference, where everybody attended sessions on MAT, and the questions that I get more often than not after those sessions are from folks who are in communities, where they don't have access. They don't know how to get access and they're trying to find out how to increase access in their communities to medications that they don't have. There's been obviously with the opioid epidemic over the last several years a large focus on that, not only in communities, not only in the justice system, but also particularly in treatment courts. There are I think... Well in a research study done recently about 98% of treatment courts indicated that they have folks in their treatment court who are opioid addicted. 

And so it's very much a lot of the professionals who work in treatment courts feel like they are on the front lines in many cases at the opioid crisis. And so they are looking, as Terrence said, they're looking for the tools. So one thing that in NDCP really, really has tried to do a full court press on is to increase access to treatment across the board, but there needs to be access to treatment, including the medications.

And that's something that we continue to work on not only educating on them, but also providing access. And that's an ongoing battle because in many jurisdictions out there in many communities out there as Terrence has said Treatment courts rely on the treatment that's available in the community. And so treatment courts do a really good job with partnering with their treatment partners in the community to increase the availability of evidence-based treatment. 

Terrence Walton:
Many drug boards embrace medications early on, this studies show that. And really the drug courts who did saw and got the outcomes they were looking for with some of the toughest evictions to treat heroin addiction that helped to define best practices standard by in our adult drug court best practice standards is the one on use disorder treatment, making it clear that for both legal clinical and clinical as well as ethical reasons that participants, if doctors make decisions that folks can benefit from medications to help treat their addiction that should happen and drug court should do everything in their power to support that and do nothing to block it.

And that's what's happening by and large. There are resources though, to help with that, that we don't find courts asking us today, why is this necessary? Just not getting those questions? And I was ready for those questions. I was ready with a list of brass and owl. I got all the stats on how the use of medications reduces overdose and death. And that how essential it is that if we want people to stay alive long enough for treatment according to work, we need to use the best tools that are out there. I was ready with all the rationale regarding medication assisted recovery and how being able to live free of addiction with the help of medications that help to balance the brain and help people have a fighting chance just to be on the journey we are all up, I was ready with all that, and I've had to use it sometimes, but especially in the last five or six years, maybe all of the requests we get and all the questions I have to feel. 

And that of my colleagues is how and what we do. We don't have this, or we can't find a doctor. How do we write a contract to ask for this? And so much resources that are available at nbcp.org is a full section on medications for addiction treatment that has multiple webinars that has a number of resources. We produce in conjunction with the American society of addiction medicine, three pocket guides on this one, or the people who provide treatment and drug courts is, again, most of those providers don't do medications themselves. So we have to develop relationships with physicians and others who prescribe medications. So we have one pocket guy for drug court treatment counselors.

We have another pocket guy for the other team members, for judges and for prosecutors and defense attorneys, so they can understand medications. And here's the one I'm most pleased about. We have one for participants and their peers, their family members, their AA sponsors so that all can span what medication assisted recovery looks like and their response to those three. we couldn't keep them in stock by goodness. They're also available for free electronic download because of the demand for that. I want to talk about one other thing, one of the resources available for this, and this is something which is coming soon. We appreciate the support of all of our federal funders. All of our, all the BJA has done to help make this possible, but also the white house office of national drug control policy, the drugs are as office has funded our work with ASAP and this year and next. We are working with our partners at ASAP to recruit a group of physicians with addiction, specialty, or interested in working more effectively with the justice system or who... They sell more training on how to work with both the population and the system.

And then we're going to begin connecting treatment courts with physicians in their area who want to be a part of a team to help, not just with medications, with all aspects of substance use disorder treatment, it's going to be a game changer. And we are looking forward to that more information coming on that, but the resources, the pocket guides, the webinars that's available. There's a toolkit, that's available right now at NBCI that'll work. 

Carson Fox:
I agree with Terrence. And I think that one thing that I want to add on the discussion about medically assisted treatment, that I think that a lot of folks don't know about that in grant applications that drug courts can apply for both available through the justice department and through SAMHSA substance abuse and mental health services administration, you can actually apply for resources to bring to your community physicians who are trained in prescribing Buprenorphine.

That's just one example of partnerships that the drug court community can bring to their own community. As Terrence mentioned, they're working with their communities because of that, the drug court can help bring that resource in. That's not a resource that's available just for the drug court. It can help the entire community. So there's a host of... And Terrence mentioned this, there's a host of resources out there. And we do a lot of work on this and the national drug court resource center obviously has tons of work on this center for court innovation children and family features. There are a number of partners who do a ton of work on this, but without the major federal partners that we have, that just wouldn't happen without the bureau of justice assistance or the substance abuse and mental health services administration or the office of national drug control policy, these resources would not be available.

And I think that courts need to realize that... They need to realize that they're not in this alone. That you've got all these resources out there and that not only can you access them, you should. Because for example, at the national association of drug court professionals, the court practitioners are our members. And so we have a duty to those folks to be sure that we get everybody the most accurate, timely information we can. And that's our calling that's our life's purpose. So we do that. So I guess what I would ask folks to do is what Terrence has said, and just underscore that as underscored again and again if you have a question, contact us for the answer. If we don't have the answer, we'll do everything we can do to find you the answer.

But also, and I can tell you when I was a practitioner, I did this. Sometimes I didn't necessarily have questions because I didn't know what I didn't know. And I would go to an NACP then just to read the information. And I just learned just from reading because sometimes it provided me even with questions I didn't know existed. So there's the amount of information and Terrence has referenced tons of that. There's just so much information out there that you can learn. And I think that one thing that we want treatment courts to do is to always be better, to provide the absolute best services that you can for the absolute best outcomes for your participants and for your communities. 

Terrence Walton:
The support from our federal partners really matter. And these topic of medications has reminded me of how much it matters. I may that we've got this study from a decade ago. We have a little indication of how things are today and can be with the right support and resources. So the bureau of justice assistance has funded many, many treatment courts to improve their services. And in a recent study of those treatment courts look back to their compliance with best practices between 2016 and 17 and 18 and 19, they had lots of findings that indicated that programs that receive federal funding are so much more able to apply the drug court model in a way that works. But I just want to focus on the medication piece for all of the grantees who were funded by BJA between 16 and 94% of them. By the time they were surveyed after receiving the funding and making changes, provide access to all three medications or anyone in their treatment court who was assessed to need it. That's really good news.

It's suggested with the right resources, with the right technical assistance to actually help people, help drug courts, develop relationships that connect people when treatment that's a really important to find you and I think a hit that if we can do more of that, if we can make more resources available and the people avail themselves of that, that we can get on top of this issue even more. 

Carson Fox:
And I want to do a quick plug because I know that one, there are hundreds of DWI courts in the field, and I know that this particular podcast is not on DWI courts. And so one federal partner we haven't talked about much on this particular podcast is NITSA and all the work that NITSA has done in this area, working with the national center for DWI courts which is located at any DCP and the DWI courts across the country.

And so for those practitioners listening in on this call, who work in DWI courts, Nettie maybe you work in a treatment court an adult drug court and a DWI court. There are resources out there, but I didn't want to leave out NITSA as one of the partners. I know that there's that kind of goes beyond the scope of this particular podcast, but they've done so much work and had been such tremendous, tremendous supporters of DWI courts that I would feel remiss if I didn't I didn't give them a call out.

Dr. Christina Lanier:
Terrence, we would like to provide listeners with a call to action of sorts. Do you have any thoughts about how listeners can and should translate the information that we've discussed around target population equity and inclusion and medication for addiction treatment into practice.

Terrence Walton:
We've talked about a lot in this little time together. And for me, I guess the sort of bottom line is knowledge matters. And I appreciate, and I think all my fellows to incorporate citizens appreciate, we've got lots of information, but treatment courts are the most research independent in the justice system by far. No question about that. Our adult drug court best practice standards the juvenile drug treatment guidelines of families frequent court standards are research-based and research driven. We have all this information, but my real call, I guess my real focus is helping individual collaborators actually implement what we now know works by any means necessary. I encourage treatment court professionals and those who are around us to really not just embrace the research, but make use of the resources that are at our website in NPCI.Org, as well as it's available from the national drug court resource center.

And anywhere else, you can find tools and resources to help you actually put research into action. Research is like love. It's one thing to feel love for your community and feel love for the clients you serve. But that only really matters if it's put into action and we can demonstrate that in ways that actually change people's lives. And I am encouraged Carson, but I have seen courts across the country really taking in all of it. We've offered and others offer to try and actually put into action the research that's out there, but we need to do more. We all need to get on board and be sure that we are not assuming we're doing all we can and become committed to being sure that if there's any weak area in our program, we've addressed it.

Dr. Christina Lanier:
Well, we would like to thank our guests, Carson Fox and Terrence Walton for joining us today. Really appreciate your time and your willingness to share your experience in your history of working with treatment courts to better understand where we are today, knowledge regarding how the movement has evolved over time is critical to understanding where we are today and yet where we need to be moving forward. So our listeners, thank you for being here. We hope this information regarding the state of the treatment court field is useful to you and that you can begin to implement the information that you've learned into your work in whatever capacity that is. Please join us on the NDCRC Justice to Healing discussion board, to continue the dialogue about target population equity and inclusion and medication for addiction treatment. 

As a reminder, this is the first episode in a series focusing on various treatment court types, future episodes, we'll focus on juvenile drug courts, veterans treatment courts, family treatment courts, DWI courts, tribal healing to wellness courts at will health, ports, and others. Please join us next month or another episode of justice to healing and always remember to do better.

Voice Over [Outro]:
To our listeners. We thank you for listening and we hope you enjoyed the show. Be sure to hit subscribe, stay updated on the podcast. Follow us on Facebook, Twitter, and LinkedIn, to stay engaged with us and check out our website, ndcrc.org. Thanks again. Catch you next time on Justice to Healing. 

The Justice to Healing podcast is presented by the National Drug Court Resource Center and was supported by Grant No. 2019-DC-BX-K002 awarded by the Bureau of Justice Assistance, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of views or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.