The National Methamphetamine Drug Conference

The National Methamphetamine
Drug Conference

Workgroup 5
Drug Courts: Cooperative Efforts In Enforcement And Treatment
PRESENTATION SUMMARIES:
"Initiating a Drug Court: Lessons Learned"
Judge Richard Shull, Municipal Court
Wichita, Kansas
Key components of Drug Courts:

Drug courts integrate treatment in lieu of probation/prosecution. The judge forms a team with drug treatment facilities and the courts.

People and commitments are the keys to success.

Personnel must be long term in the project.

A non-adversarial, team-based approach is required.

Identify potential participants early, as soon as they enter the court system on the first or second appearance. Otherwise, they may forget the impact the arrest made on their lives. They are looking at jail time and must want to do something to stay out of jail.

Regular, consistent drug testing is important. Some participants are tested a few times a week, and some are tested daily. Computers are valuable when it comes to this process. Special software can network the entire process together for treatment, court information and drug testing. Dade County has this software.

Evaluating each case is important. Most drug courts do not accept violent abusers.

Intervening is important before users become violent.
Prior to the use of drug courts, a person would plead guilty or was found guilty and sentenced to jail time. There was no follow-up, and the judge may never have seen this person again. With the advent of the drug courts, the drug user now comes into court for evaluation and gets into treatment. The judge continues to see the person at least once a month. The treatment facility lets the judge know how the person is progressing with treatment.
As the weeks and months pass, the person may be doing well in treatment, and the judge moves the person through varying levels of care. If the person "tests hot," the judge may extend him or her in the program 6–12 months. However, the offender must pay for it, which is often difficult for the person to afford. These people may need to see the judge once a week. Limited facilities are also a concern as courtroom space is critical.
Federal grants may be used to pay for drug treatment if the person cannot pay. The person should pay, if possible, because he or she buys into the process to a greater extent if he or she must pay for the tests. The Kansas program is only for misdemeanor offenses. Fines increase and jail time is required for pleading guilty—this prevents people from simply pleading out.
Regarding the issue of in-prison treatment programs, many law enforcement officials agree that these programs would be helpful. Yet, without an effective measuring system in place, how do we know the treatment works?

There is extensive research in this area, but the best measure is the opinion of the judge who monitors the performance of the person. If the person fails, the person will likely be rearrested. Most drug courts are trying to treat people who are minor, nonviolent abusers, who otherwise would not be going to jail. Domestic violence cases are sensitive; perhaps drug courts should take these types of cases, also. Each drug court is different, and they have all started in different ways. American University is an excellent source for additional information.

"Tracking Drug Court Persons with Methamphetamine Psychosis,"
Tom Leland, M.D., Psychiatrist, Community Care Services, Honolulu, Hawaii
Dr. Leland is the Medical Director of a managed-care program with a carve-out for the Medicaid severely mentally ill in Hawaii. He found himself on the fast track to look at treatment resources for chemically-dependent persons with a dual diagnosis of mental illness. The "ice" epidemic started about 15 years ago in Honolulu; batu was everywhere. The emergency rooms are filled with methamphetamine toxicity cases each day; people are hallucinating and delusional. Dr. Leland became concerned about the issue of methamphetamine-induced psychosis as he observed people having persistent hallucinations and delusions a year after sobriety.
Dr. Leland's main concerns:

Is methamphetamine-induced psychosis persistent? Does it cause latent schizophrenia?

Does the brain damage caused by methamphetamine disappear over time?

There is heavy use of anti-psychotic medicine to stop the hallucinations and abuse; this cycle is lethal.

Users are at risk for unsafe sex and HIV

Methamphetamine is very addictive.

The brain's supply of dopamine drops to zero, and when methamphetamine depletes amino acids, there is long-lasting dysphoria.

The drug is inexpensive and easily attainable.
Many patients presented to the emergency room with methamphetamine use were given brain scans, and the results were very alarming to physicians. However, the follow-up for a second scan was zero. Dr. Leland would prescribe Risperidone, which stops the psychosis and is preferable to Haldol. After taking Risperidone, the methamphetamine user would feel a bit calmer, but there was no further follow-up.
Dr. Leland's team would like to see follow-ups, to see if brain damage is persistent over time. Specialists at the nuclear medicine department at Queens Medical Center studied areas of the brains of methamphetamine users. They found the brain had such diminished blood flow that the pattern looked like Swiss cheese. The "holes" showed places in the brain with reduced blood flow. Damage was very extensive and might not repair itself once the person stopped using. This information may be useful in educating kids about drugs.
Methamphetamine is very addictive; the prognosis of addiction is poor. Addicts have done well in residential treatment but start using again after treatment. No one knows what the outcome would be with managed-care programs that pay for addiction treatment with no limit to bed days and number of visits. Thus, the treatment process does not give much optimism. It seems that psychiatry has little to offer this group of addicts.
The driving force for Dr. Leland to turn to the drug courts was to find a clean and sober population and have access to patients for repeat PET scans. Criminals are difficult to transport to the hospital for repeat scans. Dr. Leland offers treatment to drug court candidates, and Dr. Charles Brodahn performs neuropsychological testing.
Judge James Aiona operates the drug court in Hawaii, and he sees clients weekly. He has a large treatment team, and he is assertive and enthusiastic about the program. The drug court started 18 months ago after two years of extensive planning. At the end of the first year, 11 persons graduated. In two weeks, the program will graduate another 24 people. Seventy percent of drug court candidates were using stimulant drugs, half of which were methamphetamines.
Judge Aiona's court specializes in pre-trial or post-conviction felons. The adult probation division manages most of them. The carrot that he uses is dropped charges; the stick is prison. The Hawaii drug court has an active staff, an outpatient program, weekly drug screens, and supervised living for high-acuity persons. The prosecutor screens out violent felons. As long as the drug courts are in place, researchers can get more scans and, in a year or two, should produce a study about brain damage prognoses.
"Matrix Model of Treatment,"
Alice Huber, Ph.D., The Matrix Institute, Los Angeles, California
Dr. Huber is a clinical psychologist specializing in substance abuse treatment and treatment research. The Matrix Institute is affiliated with UCLA and conducts considerable research and also trains health-care professionals. The program is unique in that it was founded by psychologists using treatment methods proven to be successful. Comprehensive treatment manuals are used at Matrix; these manuals were developed by listening to addicts and learning what is working.
Methamphetamine dependence is a disease that causes changes in the brain. PET scans show the use of methamphetamine causes the brain to function poorly, and this damage persists over a very long period. Willpower alone will not cure these addicts. There are psychiatric, social and biological components to dependence. Sharing this information with patients is important.
Methamphetamine addicts get over the worst of the withdrawal period very quickly. However, the "wall" period lasts 6–8 months. This is a period where recovering addicts feel down, fuzzy-headed, and are thinking, "If this is what life is like, I should go back to using." Addicts must know they have a long road ahead of them. Although there is severe impairment, with time, the person can get back to fairly good functioning.
The methamphetamine problem in California has increased, although it has been there a long time. One Matrix clinic in California treated 724 stimulant abusers from 1991–95. A chart review at this site indicated that the age of first methamphetamine use has decreased; many users start in early adolescence. Smoking and snorting the drug are the most common methods of ingestion in California.
More women are likely to start using methamphetamine than cocaine. Users often have a perception that methamphetamine is not really a drug. Initially, people use methamphetamine to control weight and to get more accomplished; they are then surprised to become addicted. In southern California, Caucasians are using more methamphetamine than any other ethnic group. Intravenous users tend to have even more problems than other users.
The organizing principles of the Matrix treatment model provide:

Explicit structure and expectations.

Establish a positive, collaborative relationship with the patient.

Teach information and cognitive behavioral concepts.

Reinforce positive behavior changes.

Provide corrective feedback when necessary.

Educate family regarding the patient's recovery.

Combine individual, family and group sessions.

Use a program that lasts six months.

Design in phases that decrease in intensity.
The Matrix experience is that inpatient programs are not as effective in treating methamphetamine addiction; 30 days of treatment alone is insufficient. At Matrix, 50 percent of patients are in treatment for at least 12 weeks; these people receive a meaningful treatment experience. After a 1-5 year follow-up, 80 percent deny use, and 20 percent are using.
If there is a good program in place for cocaine, one can probably use something similar for methamphetamine users. Stages of recovery include immediate withdrawal and then a honeymoon period during which patients feel they are better; then comes the "wall" period during which patients do not feel right. Treatment personnel need to help patients understand they must get past this period. Key relapse issues are similar to that of cocaine use and include other drug and alcohol abuse and being around drug-using friends. Dr. Huber advises that judges know the program to which they are referring patients. The program must know how to treat methamphetamine addiction specifically.
"Criminal Justice and Methamphetamine,"
Judge James Livingston, District Judge, Grand Island, Nebraska
Judge Livingston discussed the effect of drug courts in criminal justice systems in relation to methamphetamine use. The district court is the highest level of trial court in the state of Nebraska. At this point, courts that ultimately define a remedy for the individual and the community do not have resources available to them to resolve the problems that exist.
The justice system is very reactive; the criminal element is always in front of the justice system, always dictating what judges need to do. Methamphetamine addiction is relatively new in Nebraska; by the time resources are committed to the methamphetamine problem, it will exist in a different form. Existing programs are not trained to treat abusers of methamphetamine. Ninety-five percent of these people do not have insurance. The methamphetamine abuser is not in treatment voluntarily, and sending them to treatment as a condition of probation or sentence is difficult.
It is difficult for the judge to say to a person, "Do not violate your probation or you will go to jail for committing a crime against yourself." What happens when a report is received from the treatment center stating the person does not believe he truly has a problem—does the judge put the person in prison at this point? The judge does not have the resources to handle offenders in this area. The psychiatric make-up of these addicts has changed; people are more violent, and judgment is more clouded. Rural areas have even more difficulty in finding good programs to treat these kinds of addictions.
"Prosecution Issues,"
Larry Ferrell, J.D., Assistant U.S. Attorney, St. Louis, Missouri
The State of Missouri ranks second only to California in terms of methamphetamine labs seized in the past year. Southeast Missouri accounts for a large portion of the seizures. The national media is going to Southeast Missouri for information on the methamphetamine cases, including not just production but other crimes associated with the use of methamphetamine. Clearly, methamphetamine is becoming the drug of choice. Methamphetamine is not necessarily an urban problem; much of the problem lies in non-urban areas. Most who make the drug are not exporters; they are able to use and sell it in the small communities in Missouri.
Federal and state funding for drug courts is dependent on the volume of cases. As a result, there are no drug courts in non-urban areas in the Missouri. Funding must be prioritized for multi-jurisdictional drug courts in non-urban areas; a current Weed and Seed initiative in Southeast Missouri is working to create a multi-jurisdictional drug court. The key is to find judges and prosecutors who will take the idea and run with it. Methamphetamine is a highly- addictive drug, and those who are addicted to it are in need of highly-structured rehabilitative programs. These programs are best implemented through the drug court system because drug courts are directed toward the users and the addiction, not toward trafficking and production. A regional strategy to develop drug courts would help non-urban areas.
Discussion—Questions and Comments

Can drug courts effectively handle the meth addict?

What are the impediments to drug court expansion?

What are your recommendations for improving the treatment process?

More types of treatment need to be integrated in the drug court process.

Drug courts add structure and accountability on a regular basis.

How do we evaluate the different programs that are available? Most drug courts have a single treatment provider, which may not be the right approach. We need to get clinical input before deciding which treatment program to use.

Financial payment requirements may cause the treatment dropout rate to increase.Judges need to be careful in this assessment.

Separate the assessment from the treatment and the drug testing. Be sure the testing program will catch people who are relapsing. Methamphetamine disappears from the blood system within 48-72 hours.

Insurance/managed-care programs may be a source of help to pay for treatment.

It is hard to be responsive because small programs do not serve many patients. Designing different treatment approaches in these small communities is difficult. A regional approach would be more effective for training and treatment methods. This would help rural areas that do not have the population base to operate specialized programs.

Judges must accept that relapses will happen. Prudent evaluation is needed.

Drug courts should be set up at different levels, some of which deal with violent criminals.

Treatment should be available while a person is in jail to increase the successful ability to be paroled. Fifty percent of those in jail are there due to drug-related offenses.

Use federal funds for the inception of the program as seed money to hire staff. Allow matching state/local funds for staff to run the program and search for treatment funds elsewhere.

It is important that the immediateness of sanctions and the immediacy of treatment occur.

We should design programs to meet employment, scholastic and social needs. Drug courts can be used as the impetus to go beyond evaluation and treatment.

Many managed-care programs have declined to pay for substance abuse treatment, and we must change this. Costs get dumped on the courts. Recommend at the federal level that insurance companies not be allowed to exclude coverage for drug abuse treatment.

Many organizations have free publications that we should obtain and distribute in our communities. Take information to state bar and state judge's meetings.

We need to get funding for training back into local systems. Training is not a luxury.

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