Court-mandated opioid rehab rarely meets medical standards

(Reuters Health) - Fewer than one in 20 people with opioid addiction problems who are ordered into rehab programs by the courts receive methadone or buprenorphine, two drugs doctors consider the best treatment option, a U.S. study suggests.

Only 4.6 percent of people referred to opioid treatment programs by U.S. courts received methadone or buprenorphine, compared with almost 41 percent of patients outside the criminal justice system, researchers note in Health Affairs.

This disparity sets court-mandated rehab patients up for failure, said lead study author Noa Krawczyk of the Johns Hopkins Bloomberg School of Public Health in Baltimore.

“A wide evidence base documents the effectiveness of medication treatment among justice-involved individuals in decreasing risk for overdose, reducing HIV and hepatitis C transmission, and improving criminal justice outcomes,” Krawczyk said by email.

What they’re getting instead – treatment focused only on abstinence with peer counseling or psychotherapy – is less effective, he said.

“This does not address the adaptation in the brain or body that has occurred as part of the opioid addiction,” Krawczyk added. “Indeed, there is a vast amount of evidence documenting the effectiveness of ongoing medication treatment over non-medication-based treatment on a range of outcomes, including better retention in care, reduced illicit opioid use, reduced overdose, reduced criminal justice involvement and overall better functioning.”

For the study, researchers examined 2014 data from drug treatment programs in all 50 states, the District of Columbia, and Puerto Rico. They focused only on adults in rehab for overuse of opioids, including heroin as well as nonprescription methadone.

Out of about 72,000 patients receiving opioid treatment, 24 percent had been referred through the criminal justice system, the study found.

When the courts ordered treatment, patients’ odds of getting medication were more than 90 percent lower than for people outside the criminal justice system.

The analysis only included clients receiving treatment for the first time, and it’s possible the odds of medication use might be different for people who are repeat rehab patients, the authors note.

The study also didn’t include data on buprenorphine prescribed by primary care providers outside a rehab setting, and researchers lacked data on patients’ health insurance status, which might have influenced the treatment options available to them.

Even so, the findings add to evidence that people in the criminal justice system receive substandard opioid addiction treatment, said Andrew Rosenblum, executive director of the National Development and Research Institutes (NDRI), a New York-based think tank.

While approaches like peer counseling and psychotherapy may help patients recover from addiction, they’re often not enough, Rosenblum said by email.

“Despite the advantages of psychotherapy such as strengthening insight, resolve, and coping, they may not be able to prevent drug craving and subsequent drug use,” Rosenblum added. “Patients who receive psychosocial treatment have higher relapse rates and are more likely to leave treatment than patients receiving agonist therapy.”

Including buprenorphine and methadone in treatment has been shown to increase the odds that patients stick with treatment and to reduce the odds that they will return to opioids in the future or die from an overdose, said Dr. Marc LaRochelle of Boston Medical Center’s Grayken Center for Addiction, who wasn’t involved in the study.

“These medications have the strongest evidence base and should be a treatment option for all patients,” LaRochelle said by email.

“The most concerning finding of this study to me is that the source of referral for treatment is such an overwhelmingly strong predictor of what treatment is received,” LaRochelle added. “The choice of treatment should be up to the patient and their treatment providers – not criminal justice system practitioners or judges who have no medical training to support their influence on treatment.”

SOURCE: Health Affairs, online December 4, 2017.