In the 15th Judicial District of Louisiana

Introduction and Review of Relevant Literature

During the second half of the twentieth century, two opposing views of drug use and abuse began to coincide. First, the disease concept of drug abuse and addiction became commonplace, as seen in the action of Congress passing the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act in 1970. This led to the designation of monies for federal treatment programs, while simultaneously major health insurers began to include treatment plans for same in their coverage (Lemanski,2001). As a result, the numbers of treatment facilities increased dramatically.

Second, there was a simultaneous increase during this time period in the criminalization of drug use, with harsh penalties attached to drug related crimes (Andrews et al, 1990). The consequence was a growth in the criminal justice system’s control over drugs, resulting in a dramatic increase of drug-related incarcerations (Lock et al., 2002). Recognition of the futility of the effort to use entirely punitive measures, and overcrowding in correctional facilities and court systems has led to a search for viable alternatives. Into this abyss has entered the drug court treatment program.

The first such program began in Miami in 1989, and by the year 2000, more than 650 drug courts were in existence across the country (Dechenes et al., 2002). A decade later, there were 2,038 fully operational drug courts in the United States and 226 that were in the planning stages, as of July 2009 (Office of National Drug Control Policy, 2010). The U.S. Department of Justice, in association with the National Association of Drug Court Professionals has defined ten key components for the establishment of drug court programs, though some variation exists from program to program.

Specifically, eligibility and suitability requirements vary, as well as what types of treatment are offered. Essentially, drug courts are a compromise between punitive and treatment strategies (Dorf and Fagan, 2003). These programs combine the extensive supervision of punitive models of justice with the treatment model of drug addiction to seek a reduction in criminal recidivism and improve the life chances of participants (Belenko, 1998; Gottfredson et al., 2003). Empirical evidence has supported the view that recidivism is reduced, as well as the corresponding monetary spending on drug cases throughout the justice system (Banks et al., 2003; Gottfredson et al., 2003; Hora et al., 1999; Kalich and Evans, 2006).

The evaluation of the effectiveness of drug court programs has been necessitated by the tremendous proliferation of such programs across the United States. This paper is a follow-up report of one such program, upon the request of the program particularly due to the amount of time that has passed since program inception and also due to the
implementation of a particular type of therapy into the program (moral reconation therapy). At a time when drug court monies may be looked to for utilization in other budgetary locations, it is especially important to know whether drug court participants fare better than non-participants who qualified for drug court but refused to participate
and were instead assigned to either straight probation supervision or to a modified educational probation supervision. In only this way is it possible to really begin to address any possible savings in terms of criminal recidivism and therefore monetary and other costs. The report detailed below also examines the perceptions of drug court
graduates toward the drug court program, in order to investigate the meaning and impact of the program on the lives of its participants. The most rigorous evaluations of drug court programs compare drug offenders who enter the program to those who qualified but chose not to enter the program. Additionally, rigorous studies include those that randomly assign clients to receive drug court services. These have consistently indicated lower recidivism rates for drug court participants and graduates (Deschenes, et al., 1995; Finigan, 1998; Gottfredson et al., 1997; Peters and
Murrin 2000, Wolfe et al., 2002).

The two primary components of all drug court programs are intensive supervision and drug treatment. The implementation of these two components varies across jurisdictions. Intensive supervision typically combines elements such as small caseloads for probation officers and frequent court appearances and urinalysis testing. Treatment typically fuses several well documented types of drug abuse treatment programs. Very few studies have attempted to differentiate the impact of these two components on drug court participants and even fewer have specifically focused on long-term effectiveness. However, they do suggest the need for further evaluation of drug court outcomes, with particular attention to identification of predictors of those outcomes.

Background of the F.I.S.T. Drug Court Program and Parameters for this Study

The general criminal justice system in the 15th Judicial District is actually one which
utilizes two types of drug courts via what is known as Tract 1 and via the F.I.S.T.
(Focused Intervention Through Sanctions and Treatment) Drug Court Program.
However, of the two, only the F.I.S.T. Drug Court Program is eligible to receive federal monies from the 1994 Crime Act, and it is restricted further by that Act to accept only defendants with drug-related crimes and no history of violent offenses. Tract 1 processes all other drug defendants. Thus, Tract 1 remains the traditional adversarial drug tract, with the F.I.S.T. drug court technically under that tract as a special non-adversarial court to which eligible non-violent felony offenders may be referred (if identified as eligible by the Assistant District Attorney assigned to Drug Court).
The prosecutor is obliged to prosecute only when there is proof of guilt. Consequently, prior to declaring a defendant eligible, he is to check all available information to insure the appropriateness of prosecution. Eligibility also depends upon the lack of exclusionary factors. Exclusionary criteria for entry into the program include: violent criminal history and conviction of four or more felonies. Misdemeanor offenders are usually excluded unless they aggressively seek inclusion.

Upon referral to the Drug Court by the prosecutor, potential participants are then
clinically screened for suitability using the Substance Abuse Subtle Screening Inventory (SASSI3), the Substance Abuse Questionaire, and a personal interview. Clinically, exclusionary criteria for entry into the program include: mental illness that has not received clearance from a doctor indicating participation will not negatively affect the illness (for example, no schizophrenia diagnoses are accepted into the program because the clinical structure of the program has been deemed unacceptable for said diagnosis). Acute health problems are excluded on a case-by-case basis,

depending on the level of function present. If deemed suitable, the offender is referred for a consultation with the public defender or a privately retained defense attorney. After consultation with a defense attorney, if the offender is interested in participating in the drug court program, the defense attorney notifies the F.I.S.T Drug Court prosecutor, who files a Bill of Information. Some offenders choose to participate in drug court as a condition of probation (after admitting to the crime and receiving a suspended sentence), while others choose to remain in Tract1 and go to trial, or plead guilty and receive a suspended sentence with less intensive conditions of probation. Still others opt to participate in drug court as a condition of bond, while awaiting motion hearings in Tract 1. If found guilty in Tract 1, the probationers must attend drug education classes, monthly meetings with the judge, and comply with periodic random drug screens. One year of sobriety completes the program for these individuals.

However, if the random test is positive for drugs, drug treatment is ordered (drug
education has proven insufficient) and graduated sanctions are imposed. At the third
positive drug screen, and pending a positive determination of both eligibility and
suitability for Drug Court, probationers in Tract 1 (as of August 2002) will be given a
coerced choice: participate in drug court or go to jail for one year. This choice will not
be offered, however, if the defendant was offered drug court before entering Tract 1 and rejected that treatment option. Such rejection is final, and is justified by the F.I.S.T. Team on the grounds that although addiction to drugs is an illness, the choices individuals make also have consequences. The goal of such a stance is to encourage responsible decision-making; therefore, if an addict chooses against treatment, he/she must endure those consequences. Thus, at this stage in Tract 1, if the choice of entering the F.I.S.T. program has never before been offered, and if the probationer chooses jail rather than treatment, upon the fourth positive drug screen, probation is revoked, and a sentence is imposed.

If, however, the probationer chooses drug court at any point, the sanctions for continued positive drug screens increase according to the F.I.S.T drug court schedule of sanctions. Unless the individual has been rearrested for another felony or violent offense, no definitive point marks the termination of a drug court client=s participation. When revocation from drug court does occur, the previously suspended sentence is reinstated, minus any reductions the probationer may have earned for compliance to program requirements up to that point.

Drug court participants who are initially offered and choose drug court must plead guilty to their crime in order to receive a suspended or deferred sentence and participate in the program as a condition of probation, the outcome of their sentence pending the successful completion of the F.I.S.T. Drug Court Program. Individuals deemed eligible and suitable can also try the F.I.S.T. Drug Court Program as a condition of bond, while awaiting the outcome of their case in Tract 1. All drug court participants have 30 days to opt out of the program and to choose adjudication via Tract 1. Incentives to remain are strong, such as dismissal of the prosecution upon satisfactory completion of the drug court program (the equivalent of an acquittal) and expungement of the charge from the participants record. Defendants in the F.I.S.T. Drug Court Program, then, are voluntary participants, who agree to comply with a number of general and special conditions of their suspended sentence with active supervised probation and treatment.
A third option also exists for drug offenders in the 15th JDC, aside from the assignment to Drug Court or Tract 1. Individuals may be deemed both eligible and suitable but refuse to participate in drug court and receive supervised probation instead. In this case, the individual must report to the probation officer, comply with random urinalyses, and otherwise not violate the conditions of his/her probation. These individuals are on Tract 3 or “straight probation.” Successful completion of probation means that probation is not revoked, nor is a sentence imposed.

Statement of Purpose
The primary goal of this evaluation is to explore the effectiveness of the F.I.S.T. Drug
Court Program at reducing recidivism rates of participants when compared to nonparticipants of varying kinds. The universe of offenders who were deemed both eligible and suitable and who were offered the F.I.S.T. Drug Court Option is the population under examination. This examination will determine whether the outcome target has been met (the number and % of participants who achieve the outcome, in this case, lower recidivism rates) for all eligible and suitable individuals, regardless of the tract to which they belong. Tests of significant differences between the tracts will also be determined between the previously described tracts: Tract 1 completers (Prevention Plus), Tract 3 completers (Straight Probation), and Drug Court Completers. In the analyses that follow, the Drug Court population is further divided into two groups, those who completed the Program prior to the introduction of MRT (Moral Reconation Therapy), and those who completed the program with the MRT component in place. All analyses are controlled for time in tract and recidivism rates are calculated from time of initial arrest for which Drug Court was offered to 6 months, 6 months to 12 months, and 12 plus months. Finally, Drug Court Alumni are interviewed about their drug court experiences.

Methods
Data were obtained from several sources: F.I.S.T. Program Records, Tract 1 Program
Records, the State of Louisiana Office of Probation and Parole, and F.I.S.T. Alumni
interviews. Only variables available for all offenders were included in these analyses.

F.I.S.T. Program records have been maintained since program inception in 1998. As
such, a list of names and identification information was available for use by the Office of Probation and Parole to locate arrest records for each individual. For some individuals no records were found by the Office of Probation and Parole,and
therefore, these individuals were excluded from the analyses due to missing information. Similarly, some participant names were on some lists and not others, or on multiple lists. In each of these cases, the participants were excluded from the analyses. All coding was double coded and entered by hand into an SPSS database in electronic format. While it is possible that some bias might be present in the resulting dataset, this is not likely, as excluded cases were statistically examined for patterns in demographics or other key variables of interest. None were identified. Descriptive statistics were performed using SPSS to produce percentages, averages, and frequencies. Additionally, tests of significance were performed using the Chi Square statistic
.
In addition, qualitative interviews were obtained from 30 F.I.S.T. Alumni who were
willing to be interviewed. The interviews were conducted in Spring 2010 via

telephone. Not all participants who were contacted were willing to be interviewed (n=5), and not all of the phone numbers were still working and accurate numbers (n=22). However, it is important to note that this information was given voluntarily, and did not take place under the supervision of any Drug Court Personnel.

Findings

Most of the sample was not re-arrested in the first six months after the initial eligible drug court arrest (79%). However, the re-arrests were nearly 3 times as many for drug arrests as for violent or other crimes (n= 362 v. 143 v. 79). During the 6-12 months after the initial eligible drug court arrest, again, 79% of the total sample was rearrested. Again, the pattern emerged of nearly 3 times as many drug re-arrests than violent or other crimes (n= 376 v. 138 v. 89). Thus, the pattern emerges that for all persons in the sample, during the first year after the initial eligible drug court arrest, most re-arrests were drug related.

However, these initial data are over-general and need to be examined more closely to
identify the makeup of each tract within the drug offending population. Specifically,
when examining the total dataset by tract, it becomes clearer that those who choose to
complete drug court are slightly older than those completing Tract 1 or Tract 3 (52% are age 26 and older v. 46% and 49%, respectively). In addition, those who choose to
complete drug court are much more likely to be white (64%) than those completing Tract 1 (54%) or Tract 3 (53%). Finally, those who choose to complete drug court are much more likely to include females (31%) than what is found in Tract 1 or 3 (15% v. 20%). This pattern of older, more white and more female participants may suggest that drug court is a more appealing choice for such a population to choose to complete, or to complete successfully.

Drug Court Completers V. Prevention Plus/Tract 1 Completers
In any evaluation of outcomes, it is important to evaluate the differences between groups for statistical significance. This component of the evaluation seeks to examine the differences between drug court completers and Tract 1 completers in terms of statistical significance. Recall that participants in drug court are subject to rigorous educational and therapeutic tools, while there is a small educational component in Tract 1. First, the data were analyzed for statistically significant differences in age, and the differences that were found were found not to be significant (chi square < .12). However, this changes when the data are analyzed according to race and gender there is clearly a significant difference between completers in Tract 1 and
Drug Court completers in that Drug Court completers are significantly more likely to be white. Likewise, there is a significant difference between completers in Tract
1 and Drug Court completers in that Drug Court completers are significantly more likely to be female.

More importantly, when examining the effectiveness of these two programs with regard to recidivism, statistically significant differences are found in re-arrest records.
Specifically, when comparing Tract 1 completers to Drug Court completers
Tract 1 completers are twice as likely to be re-arrested within the first six months than are Drug Court completers This is especially the case with drug crimes,
where Tract 1 completers are nearly 5 times more likely to recidivate a drug crime than are Drug Court completers.

Finally, when looking at long term completers of either Tract 1 or Drug Court where re-arrests occur at 12 plus months, those participants who complete Drug
Court are significantly less likely (30% v. 52%) to be rearrested after 12 months,
especially for drug crimes and violent crimes than are those participants who complete Tract 1.it is clearly significant that more completers of Tract 1 are re-arrested for drug crimes than are Drug Court completers (37% v. 20%) at this point in time. It is clearly also the case that completers of Tract 1 are significantly more
likely to be re-arrested for violent crimes than are Drug Court Completers at this time
(25% v. 12%).

Drug Court Completers V. Straight Probation/Tract 3 Completers

This component of the evaluation seeks to examine the differences between drug court completers and Tract 3 completers in terms of statistical significance. Recall that participants in drug court are subject to rigorous educational and therapeutic tools, while there is no therapeutic or educational intervention in Tract 3. First, the data were analyzed for statistically significant differences in age, and the differences that were found were found not to be significant (chi square < .45). However, this changes when the data are analyzed according to race and gender .
There is clearly a significant difference between completers in Tract 3 and
Drug Court completers in that straight probationers are significantly more likely to be
non-white . Likewise, there is a significant difference between completers in
Tract 3 and Drug Court completers in that Drug Court completers are significantly more likely to be female.

Furthermore, when examining the effectiveness of these two programs with regard to
recidivism, statistically significant differences are found in re-arrest records at all levels. Specifically, when comparing Tract 3 completers to Drug Court completers in
Tract 3 completers are nearly 6 times more likely to be re-arrested within the first six
months than are Drug Court completers (28.3% v. 5.4%, Chi square <.00).
This is especially the case with drug crimes, where Tract 3 completers are nearly 8 times more likely to recidivate a drug crime than are Drug Court completers. Likewise, straight probationers are 3 times more likely to recidivate a violent
crime than are Drug Court completers within this time period . Likewise, straight probation completers are significantly more likely at the 6-12 month
time period to recidivate, and especially to recidivate drug and violent crime when
compared to completers of Drug Court .

Finally, straight probation completers on Tract 3 are also statistically more likely to reoffend after one year than are drug court completers, and they do so with both drug and violent crimes .In sum, then, Drug Court completers have a better recidivism rate at all times and for all crimes, especially drug and violent crimes in comparison to both groups of eligible and suitable persons who were offered drug court during the same time period. These other groups, tracts 1 and 3, are interesting comparisons further in that the former offers some prevention education and seems to have a better rate of recidivism than does the latter which offers no prevention education and which has the worst rate of recidivism.

Certainly these findings offer strong support for the continued use of drug courts and
prevention education to reduce recidivism rates in the communities where they are
provided.

Drug Court: Pre v. Post Moral Reconation Therapy

As part of this evaluation, analyses were conducted within the Drug Court Completer
population by further subdividing the population into those who finished the program
before Moral Reconation Therapy (MRT) was introduced (n=74) and those who finished the program after MRT was introduced in February 2005 (n=112). MRT is conducted via structured facilitated groups in order to overcome problems encountered in individual therapy for substance abusers, such as over-exploration of a client’s past and over discussion of their feelings at a particular time. MRT is a cognitive-behavioral group method which allows problems such as this to be avoided.

Furthermore, the use of MRT as a group treatment is economical and efficiently incorporates more clients with fewer hours by the group counselor. Group sessions have always been a part of Drug Court, but the MRT group is special in that it is goal oriented and present-focused. For these reasons, analyses were conducted to determine if clients receiving MRT have a lower recidivism rate than do clients receiving more traditional drug court therapies. It is important to remember, however, that regardless of the subgroup analyses, Drug Court Completers are significantly lower in recidivism than other drug crime offenders.

For the analyses between pre-MRT and post-MRT completers, the total sample of
completers (n=186) was subdivided. Each group was compared for significant
differences in age, race, and sex, and no statistically important differences in the two
groups were identified. Furthermore, time since completion of the program was
statistically controlled (as with the above analyses). Interestingly, there are no significant differences between pre and post MRT completers at time periods less than 12 months (analyses available upon request). However, over the long term, post-MRT completers appear to respond better and to recidivate less frequently than do pre-MRT completers, especially in drug and violent crimes. Thus, it seems in the short term there is no MRT advantage but over a longer period of time the advantage is statistically significant.

Qualitative Component: Drug Court Completers Perceptions of Drug Court
In this final component of the evaluation, Drug Court Completers were interviewed and asked a series of questions about their experience with drug court. Thirty interviews were obtained with detailed responses for these interviews. Each interviewee was asked the following set of open-ended questions:

1. How did you feel when you were assigned to drug court?
2. If pleased, what pleased you…
3. If disappointed, what was disappointing…
4. What was the first session like for you?
5. What do you feel worked best for you in the program?
6. Why was , best for you in the program?
7. What do you feel did not work?
8. Why do you feel did not work?
9. How did you feel when you finished?
10. If you will miss the group, why?
11. If you are just glad it’s over, why?
12. What benefits did you receive from this program?
13. Do you have any suggestions for changes to the program?

Below, a random representation of the comments given in the responses are presented in composite form for qualitative purposes.

Interview 1: I felt lucky when I was assigned to drug court; my choice was drug court or jail. I was lucky to go to drug court. What worked best for me in the program was
putting me in jail because I had never been in jail where I could not bond out and this
time I couldn’t. It’s not that drug court does not work; it’s that you don’t want it to work. If not for drug court, I would not be clean today.
Q: Do you have any suggestions for change for the program? Yes, I believe they should have more involvement with the people who graduate because I disagree with [the person] running the alumni program. She is a self admitting crack head and still drinks to this day, and if you go to NA they will tell you alcohol is a drug too. Everybody else, except for her, was very helpful to me.

Interview 2: My counselor worked best for me. He enlightened me and let me know that there was life without dope and I am grateful for that. I think it worked. I have a life. I have been clean and I am grateful I have had the same job for over two years. The day I graduated I felt good, it was the first time I had finished something in a long time. I felt accomplished. I am still active with Drug Court because I want to share with others what I learned about structure, honesty, and integrity. I have my family back in my life and God I live without drugs, life is good. I’m back in school getting my Master’s.
Q:Do you have any suggestions for change for the program? Just maybe offer the
program to more people; it will benefit them. The doors should maybe be opened to
repeat offenders so they may have this opportunity. The criteria should maybe be looked at.

Interview 3: The thing that worked best for me was the complete package. It was
probably at the very beginning they left no room for failure; it was very intensive. They had all the bases covered and there was no time to go out and relapse. I don’t think there was any part that was a waste of time. When I graduated, I was elated but scared but I had my support group in place so that when I left their nest I still had people who I could call on. I also still have a few friendships that were forged. There is a certain sense of being glad it is over due to the fact that it was time consuming, but it needed to be.
Q:What benefits did you receive from this program? The program gave me the tools I needed to continue recovery. It made me confident to become a contributing part of society. There are also legal benefits and one being having my record expunged
Q: Do you have any suggestions for change in the program? They are out-growing the building they were in; they need more space. It’s an awesome program – well worth it – it saved my life – it gave it back to me.

Interview 4: Q: What was the first session like for you? It was probably the hardest because I was miserable. I wanted to get high. I was fearful of the unknown. The first session was overwhelming. I was still loaded. I had several sanctions that were due to my use. I was still confused. But Drug Court gave me the structure to save my life. That was what worked best for me. The structure of drug court and the length of time. The different phases are really strenuous and we need the structure, we need the time because it takes all of that. What did I feel did not work? What does not work is the individual. Drug court works. It’s not drug court that failed me, but me that failed drug court. I have the experience of knowing today that at first the sanctions don’t work and then it happens that you stop and surrender to the program.
Q: If you are glad it’s over, why? One of the reasons I’m glad it’s over is because now I get to use what they taught me. I get to get back into society and make amends for the wrong I’ve done.

Interview 5: There are two types: those that need and those that want it. The ones who want it stay sober. Drug court is a long treatment that not only gives you a stable
environment but it gives you guidance. There are people like me who have flaws and
drug court has given me all of the tools I could ever need to keep me going. Now with
this change, everybody whose life I touch is better because of my experience with drug court. I am just so grateful. I was a convicted felon looking at 60 years. Drug court gave me a chance.

Interview 6: What worked best for me was the MRT book was absolutely wonderful. By the time I reached the 40th meeting it started to all click for me. I got a sponsor and saw how the MRT’s worked with the 12 steps. The discipline worked really good.
Q: How did you feel when you graduated? Relieved. I felt I had learned so much. I had high respect for the counselors there. Actually I wanted to cry. I had bonded with the people there – it was kind of sad. I love group and I still make 4 meetings a week. I really would not feel right if I didn’t go to at least 3 meetings a week, so I’m still working the 12 steps. Q: What benefits did you receive from this program? Definitely I kicked my addiction, I also quit smoking, I was given an opportunity to look at myself living life on life’s terms. I just never realized how it affected my spiritual growth. Q: Any suggestions for change to the program? I would incorporate the 12 steps into the program. The MRTs are important but I would add the 12 steps, and the meetings are very important. Something else I would add is alternate NA and AA to the meetings and what it is that the alcohol began you on your journey to drugs.

Interview 7: What worked best for me was the MRT book and the involvement of the
counselors. The book explains how and talks about social and moral responsibilities.
The involvement of the counselors gave you someone who was not your peers to
encourage you and go over things with. Q: Any suggestions for change to the
program? In some respects I think they should have more restrictions on how they
present themselves to society.

Interview 8: After graduation, I felt great, but a little nervous about stepping out into the world without being drug tested. Twenty five months sober, I feel good! Q: Are you glad it’s over? Well because of the time it took you know, to leave work early and go and UA or go to a meeting. Q: What did you learn from this program? I learned to not depend on drugs. I learned tools about what I can do when I’m stressed out about a situation instead of using.

Interview 9: Q: What do you feel worked best for you in the program? Having a
very close set of peers, because as peers it’s easier for them to relate to you on the same level. What did NOT work for me was the numerous meetings because Phase 1 is 4 of everything a week. There is no time to do anything else. Q: Any suggestions for change to the program? I think they should let people choose. I went because I wanted to andothers were forced and it makes it difficult going through phase 1 and 2 for those that want to be there. Everyone is grown enough to make their own decisions.

Interview 10: Everything worked – if you work the program it will work you. When I was finished I was happy but felt like I was losing a family. Q: What benefits did you receive from the program? I got an apartment, job, a bank account, friends, my
respect, dignity, family, peers. I benefitted a lot. Q: Any suggestions for change to the program? If they could just not have call in everyday – not weekends – and it could give people the chance to be responsible to come back on Monday. It’s too much everyday; they need to want for themselves.

Interview 11: Q: What was the first session like for you? I honestly can’t tell you
because I didn’t want to be there. I closed my mind and one week later I got sanctioned and went to the halfway house. When I came back from the halfway house I was so ready to change until I was ready to do anything and everything they told me to do. I can’t think of anything that didn’t work. Probably the assignments for each phase worked best because it got deep into the way reality really was; it helped me to be a better mother and daughter. I got my GED, I held a job for almost 2 years, I became independent, I got engaged, I mended the wounds between my parents and I, I became a friend and sponsor. They gave me my life back. I was able to keep my little girl and I really feel that if not for Drug Court I would probably be dead on the side of the road.

Interview 12: I think what worked best for me was the MRT book – it made me go deep into ME and not just blaming other people but holding myself accountable. Everything worked, but especially the MRT book. Q: How did you feel when you finished? I was proud of my accomplishment, it was the first thing I ever accomplished in my life. It will forever be a part of my life. I wear a shirt that says DRUG COURT WORKS. Q: What benefits did you receive from the program? That drug court introduced me to Narcotics Anonymous. Q: Do you have any suggestions for changes to the program? Drug court has changed a lot and now the clients are doing different drugs and they’re taking coricidin as a drug. I learned this through Narcotics Anonymous.

Interview 13: Q: What do you feel worked best for you? The meetings – they got me to interact with a bunch of people just my kind. Q: What do you feel did not work? Sanctions because I felt that drug court was being vengeful for my actions. I think they need to do away with the sanctions. What benefits did you receive from this program? Sobriety, gained new sober friends, much more clearer thinking, a new aspect on life, a greater relationship with God.

Interview 14: Q: What do you feel worked best for you? The immediate consequences if you do something wrong. Q: What do you feel did not work? They have stuff that they make you do like case management and gender group. It’s the same thing over and over. I’m sure that with their time they can come up with more and you see the same people over and over like housing – you can learn something else. Q: Any suggestions for changes to the program? Yes, just for the upper part of the program – be more equal – don’t let personal feelings get in the way they treat people.

Interview 15: Q: How did you feel when you got assigned to Drug Court? I was
glad. I had been in jail for 8 months. It was like a ticket out of jail at first. Q: What
was the first session like for you? It was kind of questionable; it was like how could
these people really help me – I like getting high. It was something I had to do to stay
free. Q: What worked best for you? It would have to be the rules that they gave me. I had to make 4 meetings, I had to UA, I had to attend meetings and go to the outside
meetings. This was what stood out to me and what helped me because my life had no
rules. I had nowhere to be. I had no structure. You see, I just lived. I would be out all
night, so when I had rules then I was there you make meetings and you hear things that relate to your life and you get exercises. They did a lot of exercises that would make you think about your life. It gave me structure. I spent a year and a half in drug court, and you know I never missed one group, I wasn’t glad it was over, but I was glad I had finished something because you know I didn’t finish much in my life. I had accomplished something. Q: Do you have any suggestions for change to the program? If it’s not broke, don’t fix it. If my car comes with a certain type of rims, and I like it, I ‘m not going to put any 20’s on it.

(Interviews 16-30 available upon request)

Conclusions and Key Findings

While different interviewees preferred different parts of the program, it seems that all
agreed that drug court worked for them and changed their lives for the better. In the U.S. we house proportionately more of our population in prison than does any other country and for longer periods of time than do many countries (Tischler, 1999). Recidivism rates of inmates suggest that prison is not successful at rehabilitation, and alternatives to incarceration such as the F.I.S.T. drug court therefore seem to offer a more viable and affordable option to the thousands of dollars spent per year on housing individual prisoners. This evaluation supports a previous evaluation completed in 2005 for the F.I.S.T. program in which findings strongly suggest the success rate of the program supersedes that of other alternatives to incarceration such as Tracts 1 and 3. Furthermore, the effect is stronger over the long term when participants have been exposed to the MRT component of the program.

Re-arrest rates are dramatically and statistically significantly lower for Drug Court completers than for Prevention Plus (Tract 1) or Straight Probation (Tract 3). This is especially true for drug crimes and violent crimes. While there may be some differences in the population of drug court versus these programs, these differences fail to explain the success of the program relative to the other two programs. This, along with the interviews of graduates of the program demonstrate overall positive perceptions
on the part of the participants. The findings of this evaluation should clearly show that a need for continued financial support of the F.I.S.T. Drug Court Program will be money well spent.

Source: www.ind.com 6th August 2010

References

Andrews, D.A., I. Zinger, R.D. Hoge, J. Bonta, P. Gendreau and F. Cullen. 1990. “Does
Correctional Treatment Work? A Clinically Relevant and Psychologically Informed
Meta-Analysis.” Criminology 28(3): 369-404.
Belenko, S. 1998. “Research on Drug Courts: A Critical Review”. National Drug Court
Institute Review 1(1): 1-43.
Deschenes, E.P., S. Turner, and P.W. Greenwood. 1995. “Drug Court or Probation? An
Experimental Evaluation of Maricopa County’s Drug Court.” The Justice System Journal
18: 55-73.
Deschenes, E., Peters, R., Goldkamp, J., and S. Belenko, 2002. Drugs courts. In J.
Sorenson, R. Rawson, J. Guydish, & J. Zweben (Eds.), Research to practice, practice to
research: Promoting scientific clinical interchange in drug abuse treatment. Washington,
D.C.: American Psychological Association.
Dorf, M.C. and J. Fagan. 2003. “Problem-Solving Courts: From Innovation to
Institutionalization.” The American Criminal Law Review 40(4): 1501-1511.
Finigan. M.W. 1998. “An Outcome Program Evaluation of the Multnomah County
S.T.O.P. Drug Diversion Program.” Portland, ORE: NPC Research Inc.
Gottfredson, D. C., K. Coblentz, and M.A. Harmon. 1997. “A short-term Outcome
Evaluation of the Baltimore City Drug Treatment Court Program.” Perspectives (Winter):
33-38.
Gottfredson, D.C., S.S. Najaka and B. Kearley. 2003. “Effectiveness of Drug Treatment
Courts: Evidence from a Randomized Trial.” Criminology and Public Policy 2(2): 401-
426.
Lemanski, M. 2001. A History of Addiction and Recovery in the United States. Tucson,
AZ: See Sharp Press.
Lock, E., J. Timberlake, and K. Rasinski. 2002. “Battle Fatigue: Is Public Support
Waning for ‘War’ –Centered Drug Control Stategies?” Crime and Delinquency 48: 380-
398.
Office of National Drug Control Policy. 2010. “National Criminal Justice Reference
Service.”http://www.ncjrs.gov/spotlight/drug_courts/facts.html Accessed 15 June 2010.
Peters, R. H. and M. R. Murrin. 2000. “Effectiveness of Treatment-Based Drug Courts in
Reducing Criminal Recidivism.” Criminal Justice and Behavior: 27(1): 72-96.
21
Wolfe, E., J. Guydish and J. Termondt. 2002 “A Drug Court Outcome Evaluation
Comparing Arrests in a Two Year Follow-Up Period.” The Journal of Drug Issues: 1155-
1172.
References
Andrews, D.A., I. Zinger, R.D. Hoge, J. Bonta, P. Gendreau and F. Cullen. 1990. “Does
Correctional Treatment Work? A Clinically Relevant and Psychologically Informed
Meta-Analysis.” Criminology 28(3): 369-404.
Belenko, S. 1998. “Research on Drug Courts: A Critical Review”. National Drug Court
Institute Review 1(1): 1-43.
Deschenes, E.P., S. Turner, and P.W. Greenwood. 1995. “Drug Court or Probation? An
Experimental Evaluation of Maricopa County’s Drug Court.” The Justice System Journal
18: 55-73.
Deschenes, E., Peters, R., Goldkamp, J., and S. Belenko, 2002. Drugs courts. In J.
Sorenson, R. Rawson, J. Guydish, & J. Zweben (Eds.), Research to practice, practice to
research: Promoting scientific clinical interchange in drug abuse treatment. Washington,
D.C.: American Psychological Association.
Dorf, M.C. and J. Fagan. 2003. “Problem-Solving Courts: From Innovation to
Institutionalization.” The American Criminal Law Review 40(4): 1501-1511.
Finigan. M.W. 1998. “An Outcome Program Evaluation of the Multnomah County
S.T.O.P. Drug Diversion Program.” Portland, ORE: NPC Research Inc.
Gottfredson, D. C., K. Coblentz, and M.A. Harmon. 1997. “A short-term Outcome
Evaluation of the Baltimore City Drug Treatment Court Program.” Perspectives (Winter):
33-38.
Gottfredson, D.C., S.S. Najaka and B. Kearley. 2003. “Effectiveness of Drug Treatment
Courts: Evidence from a Randomized Trial.” Criminology and Public Policy 2(2): 401-
426.
Lemanski, M. 2001. A History of Addiction and Recovery in the United States. Tucson,
AZ: See Sharp Press.
Lock, E., J. Timberlake, and K. Rasinski. 2002. “Battle Fatigue: Is Public Support
Waning for ‘War’ –Centered Drug Control Stategies?” Crime and Delinquency 48: 380-
398.
Office of National Drug Control Policy. 2010. “National Criminal Justice Reference
Service.”http://www.ncjrs.gov/spotlight/drug_courts/facts.html Accessed 15 June 2010.
Peters, R. H. and M. R. Murrin. 2000. “Effectiveness of Treatment-Based Drug Courts in
Reducing Criminal Recidivism.” Criminal Justice and Behavior: 27(1): 72-96.
21
Wolfe, E., J. Guydish and J. Termondt. 2002 “A Drug Court Outcome Evaluation
Comparing Arrests in a Two Year Follow-Up Period.” The Journal of Drug Issues: 1155-
1172.

The last few months have seen a dramatic increase in use of –
and media interest in – ‘legal highs’, especially mephedrone or ‘miaow/meow’.
David Gilliver takes a look at a legislative minefield

When the government announced its intention last year to ban a range
of ‘legal highs’ and make them class C drugs, Release accused it of
‘chasing its tail’ in an attempt to ‘stay ahead of the demand for drugs
and those who supply them’ (DDN, 7 September 2009, page 4).
The chemicals were BZP and related piperazines, GBL and a related chemical
and the synthetic cannabinoids used to make smoking products like Spice.
Release’s accusation seemed to be vindicated very quickly, however. Anecdotal
evidence soon started to filter through about a sharp increase in use of the
stimulant mephedrone (4-methylmethcathinone), known as ‘miaow’. After the drug was implicated in the death of a young woman in Brighton late last year, there was a rash of mephedrone stories in the press, followed – a couple of weeks later – by stories about how that coverage had led to a huge boost in sales, with many online suppliers selling out altogether. Luci Hammond is a young person’s alcohol worker at Brighton-based service ruok? She started to notice a very sharp increase in miaow use in the second half of last year. ‘It just hit very quickly,’ she says. ‘We started getting reports of it being used by young people and we had parents and professionals asking questions about it, but since then we’ve had a lot of young people coming to us themselves.’

There has been much talk about the drug’s growing use in clubs, with people
turning to it because of the poor quality of available ecstasy and cocaine – as little as 2 per cent purity in the latter case (DDN, 21 September 2009, page 5).
However, what Hammond has found – and what the press has been quick to pick
up on – is the worrying popularity of the drug among children. So far, her youngest client to have used miaow is 12. The majority are 14 and up, but ‘14 is common’ she says. Where are they taking it – presumably they can’t get into nightclubs? ‘The majority of them can’t, but there are under-18 nights where they use it, as well as at parties and out on the streets. They’ll sit in parks and cemeteries, so they’re putting themselves at risk just through the location.’
And what about other legal highs? ‘This is the big one. We’re hearing bits about
BZP and Spice but nothing compared to this.’ John Ramsey runs the TICTAC drug-testing database at St. George’s, University of London, and has seen a dramatic increase in the use of legal highs. ‘We analyse the contents of club amnesty bins and we test purchase stuff from websites – that’s how we come to be pretty up-to-date on new and emerging compounds,’ he says. ‘We’ve been doing this for ten or 15 years and at one time it was really unusual to find anything new. Now we find something new virtually weekly. We go to Glastonbury each year and there were huge amounts of mephedrone there last
time – there was one seizure of 120g. Two or three years ago there wasn’t any.’
Legal highs are available in ‘head’ shops but anecdotal evidence – and the
scale of use being reported – would suggest that most people are buying them
quickly and easily online. Indeed, many of the press mephedrone stories have
practically been guides to getting hold of the drug, couched in obligatory
disapproving language. ‘If you go online and put in ‘legal highs’ you get hundreds of results,’ says Renato Masetti, training coordinator at Suffolk DAAT, who puts on conference workshops to essentially it’s an online phenomenon – you’ve got comments, forums, you can write in and say which one was good and which wasn’t, just like on Amazon. There’s a whole community out there – the online forums have gone mad.’

But presumably most 13 and 14-year-olds aren’t buying the drugs online,
unless they’re using their parents’ credit cards? ‘A lot of our young people are
getting it from friends, but we’re hearing of dealers specialising in miaow and
selling it to school-age children,’ says Hammond. ‘They’re buying it in bulk online,
possibly cutting it, and selling it on. We’ve also heard reports of young people
dealing because they think it’s risk-free, a legal substance. At the start the reports were “you get no comedown, it’s all legal”. It was seen as pure – everything sounded lovely. Now it’s being used more frequently we’ve discovered it’s not so lovely.’ She’s started to see behaviour change in her clients, like paranoia, aggression and anxiety, and even signs of dependency. ‘We’ve heard about shakes and poor co-ordination with withdrawal,’ she says. How widespread is the problem in Brighton? ‘I would say in terms of speaking to young people, it’s probably about five a day,’ she says. ‘One young person will tell us that their friends are doing it, or a teacher will ring up and say that the whole class is talking about it. I’m a young person’s alcohol worker but almost all my clients have tried miaow, even the ones who’ve always said “I’d never do drugs”,
because it isn’t considered a dangerous drug. This is the message we’re trying to
get across – that it does seem to be a dangerous drug.’ How are they taking it? ‘Most are snorting, which is what we’re trying to advise against – if you are going to use it we’d rather it was bombed [swallowed]. We’ve had people smoking it as well, in a bong or cone. But it’s really painful to snort, and we’re hearing of nosebleeds that recur for days afterwards, as well as spinal and joint ache. And miaow isn’t enough now – they want to do it with ketamine or acid or nitrous oxide. There seems to be a cocktail culture out there.’

Clubbers of the ’80s and ’90s were sometimes described as the ‘guinea pig
generation’, as no one really knew what effects long-term ecstasy use might have. But with mephedrone and other legal highs – anecdotal chat room accounts aside – there really is no information, because there’s been no research. ‘How can there be – who’s going to pay for it?’ says John Ramsey. ‘For example the cannabinoids in things like Spice are completely untested and yet they clearly work – the legislation has got to control about 240 of the things. Who can research 240 new chemical compounds?’ Indeed even the names seem something of a moveable feast, with a variety of drugs passed off as miaow depending on who’s selling it and in what part of the country. ‘There are fewer dealers in the chain and there does seem to be some evidence of people selling allegedly illegal drugs which when they’re tested are found to be legal, so you have this fascinating phenomenon of the illegal market pinching from the legal market and pretending it’s illegal – because people think illegal stuff is better,’ says Masetti. ‘We’ve been told that miaow can be made up of different compounds, and it’s also being mixed with stuff now,’ says Hammond. ‘It started off a few months ago at £15 per gram and now it’s £3.50. You can get pure mephedrone but you don’t really know from mix to mix what you’re getting.’ However the miaow John Ramsey has tested has been consistent. ‘Every time we’ve analysed it it’s been 4-methylmethcathinone, and there appear to be vast amounts of it about. I get a lot of calls from police officers who are being asked what they’re going to do about it. Of course the answer is “nothing”, because it’s not illegal.’

The legal status does really appear to mean that many people think the drugs
are safe and harmless. ‘We’ve had parents saying “we’re telling our kids not to do
illegal things” and they’re saying “but it’s not illegal” says Hammond. ‘I don’t think many teenagers would think that they could buy something from a high street head shop that’s going to cause them to end up in an A&E department,’ says Ramsey. ‘They wouldn’t think people would be allowed to sell things that would do that.’ And A&E, it seems, is not an exaggeration. Luci Hammond visits regularly and whereas before her clients were there through drink or illegal drugs, now it’s often miaow. ‘We’re starting to see people coming in with miaow overdoses – anxiety, excessive aggression, disturbed sleep, being sick. One parent brought her child in because he was screaming and shaking in his sleep and they put that down to a miaow overdose. One client did it at a party and kept collapsing – his knees would just buckle underneath him.’ ‘I’ve seen a couple of forums where there was talk about it causing blue knees and blue elbows,’ adds John Ramsey. ‘That means it could be an inhibitor of muscle metabolism – that’s not beyond the realms of possibility.’ Does he think the government is really chasing its tail when it comes to legislating on legal highs? Won’t the chemists just come up with a slightly different compound? ‘To some extent, but the new legislation includes piperazines – BZP and that whole family – and it is proper generic classification, not a list of compounds, so it should cut off the piperazines as a family. While there’s always scope for somebody to innovate something that hasn’t been foreseen, it makes it much more difficult to do that. But obviously the legislation completely ignores the cathinones, like mephedrone, which haven’t even been risk-assessed yet. The alternative is to do nothing, but you’ve got teenagers buying chemicals which are completely untested for safety and using them as drugs – you’ve got to try and prevent that.’ ‘It’s an interesting challenge,’ says Renato Masetti. ‘I think we need to be creative about other responses, rather than just straight legislation. You’ve got the example of GHB and GBL – GHB was made class C a while back and yet you found the same amount of seizures of GHB as GBL. The fact that you’ve classified doesn’t seem to have made much difference. Legislation is a very heavy hammer, and it’s too clumsy with chemicals that can be altered quickly. Legislation becomes really difficult because if it’s too broad it captures useful products in industry.’ He’s also unconvinced that people are switching to these drugs on a large scale because of the declining quality of cocaine and ecstasy. ‘That upshares/downshares has been going on for ages – purity rates go up and down. I think to some extent this
is probably a separate thing – experimental people who don’t wish to break the law and are looking for legal alternatives. This happened years ago when there was a big ‘herbal highs’ thing, but they were awful, caffeine-based things. I think people have been quite surprised this time – they’ve found that actually they’re effective.’

In the myriad of online forums, the effects of mephedrone are often described
as a kind of mix of amphetamine and MDMA, but with a shorter-lasting effect than the latter. ‘The chemical structures are based on the khat plant, but the
compounds have nothing to do with the plant – they’re modifications of a molecule derived from the plant – so from a chemical point of view you’d predict that it’s going to be a stimulant,’ says Ramsey. ‘I can’t see how it’s likely to be
empathogenic like MDMA, it’s more likely to be like amphetamine or even
methylamphetamine. But it’s never been used as a drug before so there’s no data
on its half-life, its potency or anything.’ The similarity with methylamphetamine/ methamphetamine is borne out by the behaviour of Hammond’s clients. ‘We’re hearing of people aged 14 or 15 who are doing three-day binges, seven-day binges. They’re not able to go to school and we’ve had people saying “I feel like I’m dying, I can’t stop.” We’ve had people who’ve used illegal drugs saying this is the most addictive thing they’ve ever had.’

So what’s the answer – is it better education? ‘Absolutely, but it’s a fine line
between educating and promoting,’ says Ramsey. ‘We’re used to that in the drug
field, but we do need some sort of generic education.’ What about the FRANK ‘crazy chemist’ campaign launched last year? (DDN, 5 October 2009, page 4). ‘That’s not based on any sound knowledge,’ he says. ‘Just anecdotal observations.’ ‘I’m a trainer so I’m biased but I think training is really important,’ says Masetti. ‘It’s important for drug teams to know the specifics about these drugs, but not because treatment is going to be any different from what they’re doing already – it’s more around confidence-building. I’d like to see awareness-raising in services so they can engage with these clients who don’t see themselves as traditional illegal drug users. We know very little about these drugs but because they’re synthetic mimickers that work similarly to the illegal drugs they’re mimicking, the treatments will be very similar – you don’t need to learn any special techniques. But we do need to get some research going on these drugs asap, along with general harm reduction advice.’ Late last year two members of the Advisory Council on the Misuse of Drugs (ACMD) told The Times that the council had serious concerns about drugs like mephedrone and was proposing a more rapid system of appraisal, and the ACMD had in fact constituted a working group on cathinone compounds of which John Ramsey was a member. ‘But all of that’s collapsed now because everybody’s resigned,’ he says. Sacked ACMD chair Prof David Nutt has said his new organisation, the Independent Council on Drug Harms, plans to produce guidance on legal highs, but they will be operating outside of government (see page 4). ‘It’s definitely getting to the “something must be done” stage,’ says Ramsey. ‘It’s not going to go away, and it’s not likely to be controlled by the Misuse of Drugs Act in the foreseeable future as they can’t legislate under that without ACMD.

ACMD would normally conduct a risk assessment and then recommend control or
non-control but, given the disarray ACMD seems to be in, the alternative is the
same process through the EMCDDA in Lisbon. They’ve collected information about
these compounds, and it may well be that they’ll do a risk assessment and
recommend control throughout Europe, with all member states expected to follow.’ In fact the EMCDDA has called Britain the online capital of Europe for legal highs, with 37 per cent of all retailers operating from the UK compared to just 14 per cent in the Netherlands. ‘True, but we bought some from a website that had a UK address – the credit card was debited in France and the material was shipped from New Zealand,’ says Ramsey. ‘But one thing is certain – there’s very big money in it.
Source: drinkanddrugsnews 18 January 2010

 

Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial.

In the first randomised trial, implants which block opiate-type drugs for months helped heroin addicts in Norway avoid relapse after detoxification. If these or allied products gain a UK licence, they could help pave the way to abstinence for the minority of suitable addicts.
Abstract Naltrexone is a medication which blocks the effects of heroin and other opiate-type drugs. Its considerable potential in helping to prevent post-detoxification relapse has not been realised because patients generally refuse to take it or quickly discontinue. However, these limitations apply to the oral formulation which has be taken daily. Longer-lasting formulations in the form of a depot injection or an implant inserted under the skin avoid the need to take the medication daily. This is the first randomised trial of an implant whose opiate-blocking effects last for about six months.
Over 18 months from January 2006, staff at inpatient drug clinics in south-eastern Norway invited opiate-dependent patients on abstinence–oriented programmes to participate in the study. Patients who agreed were contacted by researchers at the end of their detoxification or residential treatment. The 56 who joined the study were told that for the first six months they would be randomly allocated to the implant or to usual aftercare arrangements, but that then all would be offered (re)implantation. Typically they were male injectors in their 30s who had used heroin for on average seven years; nearly all also used other drugs.

Three of the implant group left the clinic before they could be implanted and another three had the implants removed. All but three of the surviving (there were two deaths) patients were reassessed six months later. The main analysis included all the patients whether or not they had received or retained their implants. Over the six months of the follow-up, usual-care patients recalled using opiate-type drugs on average on 97 days, the implant group on just 37 days chart. This differential remained in the last month of the follow-up, when the corresponding figures were 17 and six days, a statistically significant difference. Average frequency of use was also significantly higher among the usual-care patients. At the six-month follow-up assessment, 18 out of 27 usual-care patients but just 9 of the 29 implant patients continued to meet criteria for opioid dependence. In line with this, implant patients were much less likely to experience craving. Nevertheless, during the study over half (18 of 29) tried opioids at least once.
In the last month of the follow-up, implant patients scored significantly lower on an index of multiple drug use and injected less often, but there were no significant differences in drinking or use of non-opioid drugs. Over the follow-up, usual-care patients averaged significantly more repeat detoxifications (0.71 versus 0.21); there were no significant differences in outpatient treatment attendance or use of aftercare services. By the end of the follow-up, implant patients expressed greater satisfaction with their lives but there were no significant differences in levels of depression, work, or criminal activity.
One patient in the implant group reported three non-fatal overdoses (there were four in the usual-care group) while using combinations of opioids, amphetamines and benzodiazepines. Three had implants removed due to infection, discomfort or side-effects. In another two, wound-opening required antibiotic treatment, and three had allergic reactions treated with antihistamines. The single death among patients allocated to implants was an overdose prior to implantation. There was also one overdose death among the usual-care patients.
The authors concluded that naltrexone implants safely and significantly reduced opioid use in a motivated population of patients.
As with oral naltrexone, the main limitation of the treatment is its acceptability to patients. In Norway acceptability will have been heightened by restricted access to substitute prescribing programmes, particularly for people unwilling to contract to forgo not just heroin, but persistent substance use of any kind. Nevertheless, recruitment to the study seems to have been slow. The 56 out of 667 patients who joined the study were probably unusually highly motivated to sustain abstinence from opiates, yet over half the implant patients tried resuming opiate use, and those who did used for on average 60 days. This degree of persistence seems incompatible with the implant having totally eliminated opiate-type effects. The reduction in multiple drug use seems to have been mainly due to the effect on opiate use, since drinking and use of other drugs were not significantly affected. As this study shows, implants and depot injections do not guarantee abstinence. Implants can be removed and both these and depot injections can be sidestepped by turning to non-opiate drugs (as may have happened in Australia) or overridden by very high doses of opiate-type drugs, attempts which risk overdose.
The implants were compared against relatively weak aftercare arrangements; more active and structured aftercare (for example, regular monitoring, continued well organised care from the initial service, or active referral) might have narrowed the differences between the groups. However, highly motivated patients and imperfect aftercare arrangements probably reflect the conditions in which implants would be deployed in normal practice, as does the fact that patients knew whether they had an active implant; unlike some other studies, there was no placebo comparison group.
Of the 26 patients who were implanted, eight (nearly 1 in 3) experienced complications which led three to have the implant removed. One other potential problem is that implants impede opiate-based pain relief. To cater for this, participants were given a card to carry which specified the presence of a naltrexone implant, its expected duration, possible pain relief options, and contact details for study staff. Without this (as reported in Australia) hospital staff sometimes make futile attempts to relieve pain using opiate-type medications. The same report of hospital admissions after implantation identified severe withdrawal symptoms after rapid detoxification to the point where hospitalisation was required. Long-acting naltrexone means the most effective way of relieving these symptoms (using opiate-type drugs) is denied to the patient.
Other occasionally severe reactions to implants and injections have been observed, but generally these are mild and/or short-lived and treatable. As with any abstinence-based treatment, overdose due to lost tolerance to opiate-type drugs is a serious concern. However, the few studies to date suggest these products protect against overdose while they are active, and that in caseloads prepared to undertake these procedures, opiate overdose reductions can outlast the active period of the implants. These findings are consistent with findings from Britain (1) and elsewhere (1 2 3 4 5) tentatively suggesting that long-acting naltrexone can be used to create an opiate-free period which extends beyond the initial blockade, sometimes aided by further administrations (1 2). In the UK, neither implants nor depot injections of naltrexone have been licensed for medical use; they can still be (and have been; 1 2 3 4) used, but patient and doctor have to accept the added responsibility of a product which has not yet been shown to meet the safety and efficacy requirements involved in licensing. See background notes for more on these important issues of adverse effects and overdose protection.
Among the studies is another randomised trial of a different long-acting form of naltrexone conducted in the USA. Compared to placebo, this injection lasting four weeks nearly doubled the time heroin dependent patients were retained in aftercare following inpatient detoxification. On the credible assumption that drop-outs relapsed, there was a similar impact on heroin use. At the four-week choice point when the naltrexone patients could have refused the second set of injections, few did so, most committing themselves to another period without (or with reduced) opiate effects. Though encouraging, multiple exclusions (such as psychiatric conditions or dependence on other drugs) and the recruitment procedures (partly through newspaper ads) meant the patients may not have been typical of usual caseloads.
A criticism of trials to date is that they included highly selected patients. However, in this they may have reflected normal practice. Patients will only opt for such procedures if they are prepared (irreversibly in the case of depot injections) to commit to weeks or months without the effects of heroin or other opiate-type drugs, or with severely attenuated effects requiring higher than usual doses. From the control groups in naltrexone implant/depot studies, we know that even in these caseloads, treatment drop-out and relapse are common. Long-acting naltrexone helps these highly motivated patients sustain their resolve. The clearest candidates for the treatment are patients who are motivated to return to a life without opiate-type drugs (including prescribed substitutes), have the resources, stability and support to sustain this, are unlikely to simply use other drugs instead, but who when free to experience heroin and allied drugs cannot resist using them, possibly reflected in their poor compliance with oral naltrexone regimens. The treatment may also be considered for unstable patients at very high risk of overdose, but who will not accept or do poorly in substitute prescribing programmes.
Thanks for their comments on this entry in draft to Nikolaj Kunøe of the Norwegian Centre for Addiction Research, Liv Langberg of the Drammen Council Drug Addiction Prevention Centre in Norway, and Duncan Raistrick of the Leeds Addiction Unit. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Source: Drug and Alcohol Findings July 2009 British Journal of Psychiatry: 2009, 194, p. 541–546.

NIDA NOTES Staff Writer

NIDA, joined by the National Cancer Institute (NCI) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), sponsored a symposium on drug discovery. development, and delivery as part of the 2003 Annual Meeting of the Society for Research on Nicotine and Tobacco. More than 300 researchers, treatment providers, and policymakers attended the 1-day meeting on February 9 in New Orleans. The symposium featured discussions of current efforts to discover new targets for potential medications, the development of medications based on existing knowledge of nicotine’s effects in the brain and factors that might speed the delivery of new treatments to smokers who want to quit.

During the discovery section of the program, speakers discussed recent findings in nicotine receptor biology and the role of neurotransmitters such as gamma-aminobutyric acid (GABA) and glutamate, in nicotine’s effects on the brain. The presentations on medication development provided a background on the drug development process; emerging medications, such as antidepressants and nicotine vaccines; and an overview of medications now in development. The delivery portion of the symposium focused on strategies to create widespread medication access and use by individual smokers and within the health care system.

Discovery. Dr. William Corriigall director of NIDA’s Nicotine and Tobacco Addiction Program and symposium moderator, described the neurobiological targets of current research: genes and gene products that play a role in the structure and response of nicotinic receptors and in brain signalling pathways that involve the neurotransmitters dopamine, GABA, serotonin, and glutamate. Dr. Caryn Lerman. of the University of Pennsylvania in Philadelphia further explored the genetic factor in nicotine research, describing studies on the effect of genetic variations on the activity of enzymes that metabolize nicotine (see ‘Genetic Variation May Increase Nicotine Craving and Smoking Relapse p. 1.)

Dr. Marina Picciotto, of Yale University in New Haven, Connecticut. discussed research that has expanded our understanding of the role of nicotine receptors—the sites at which nicotine attaches to brain cells. This portion of the program also featured discussions of the possibility that neurotransmitters other than dopamine might represent new avenues for pharmacotherapy. For example, Dr. Julie Staley. also of Yale University, described current investigations into the treatment possibilities represented by medications known to act on the serotonin system. The GABA neurotransmitter system, which normally acts to limit dopamine’s effect in the brain’s pleasure centre, might also help in smoking cessation treatment, according to Dr. George McGehee of the University of Chicago. He discussed the mechanism by which nicotine simultaneously stimulates dopamine release and depresses the effect of GABA.

Development. Dr. Frank Vocci, director of NIDA Division of Treatment Research and Development, described the steps involved in the development of new medications and their approval by the Food and Drug Administration (FDA)—a process that may require a decade of research and testing, at a cost as high as $500 million per medication. Accelerating the process at any stage, from basic research to human clinical trials, will speed the availability of new treatments. Dr. John Hughes, of the University of Vermont in Burlington, suggested that psychiatric medications already approved for treating neurochemical imbalances in the brain might hold clues for developing medications to treat the neurochemical effects of smoking.

Dr. Charles Grudzinskas, of Georgetown University Medical Centre in Washington, D.C., summarized potential medications now in FDA phase I, II, or III trials. These medications include additional nicotine replacement therapies and nicotine vaccines. Dr. Paul Pentel of the Hennepin County Medical Centre in Minneapolis Minnesota, described progress in the development of one type of nicotine vaccine—antibodies that bind to nicotine in the blood, preventing it from crossing the blood brain barrier and reaching the areas of the brain that underlie addiction. Vaccines may be particularly effective as relapse-prevention medications for smokers who are trying to remain abstinent.

Delivery. Dr. Scott Leischow, chief of NCI’s Tobacco Control Research Branch, discussed barriers to delivery and utilization of current tobacco cessation treatments. These include the high relapse rate associated with current treatments and the cost and ‘hassle’ factor that deter patients from using nicotine replacement therapy. which they contrast to the simplicity of nicotine delivery by cigarettes To address barriers to use, Dr. Saul Shiffman of the University of Pittsburgh discussed strategies that might increase utilization of existing treatments, including regulatory changes that make cigarettes more expensive and increased advertising and education to encourage more smokers to try to quit.

Providers and insurers also need to address barriers within their control, noted several speakers. Dr. Richard Hurt, of the Mayo Clinic’s Nicotine Dependence Centre in Minneapolis. Minnesota, discussed the limitations of current clinical treatment. He noted that relatively few medications are available, clinicians are not familiar with them, and patients are reluctant to begin treatment because of embarrassment, inadequate relief from withdrawal, and the difficulty of complying with instructions for use of gum. inhalers, or nasal sprays. Dr. Susan Curry of the University of Illinois at Chicago suggested steps that insurers and health care organizations could take to improve the delivery, utilization, and effectiveness of treatment. For example, she said, health care .systems should adopt a chronic disease model to treat smoking, and insurers should include the cost of medications in coverage that provides comprehensive pharmacological and behavioural treatment.

In concluding remarks, Dr. Corrigall noted that the enthusiastic response to the day-long discussion illustrates broad support for steps that will increase and accelerate available treatment options for smokers. “Clinicians and patients need better treatment options. and this symposium represents a significant first step in a collaboration that can help speed the process of getting new and more effective medications to smokers who want to quit.”

 

Drug use can interfere with memory, sensation, and perception. Drugs distort experience and can cause a loss of self-control that can lead users to harm themselves or others. They interfere with the brain’s ability to take in and analyze information. Drug use erodes self-discipline and motivation which is essential for learning. The Court has noted that maturing nervous systems are more critically impaired by intoxicants than mature ones are, and childhood losses in learning are lifelong and profound. Children grow chemically dependent more quickly than adults, and their record of recovery is depressingly poor. (Several of the Amici are parents who had lost children to drugs).
A strong correlation between drug use and juvenile delinquency is documented in a study sponsored by the United States Department of Justice’s Office of Juvenile Justice and Delinquency Prevention. The study found that the more involvement a youth had with drugs, the more likely that youth was involved in delinquency. Substance use creates danger in classrooms and increases the risk of accidents when students drive to and from school.
Students who avoid drug use during their high school years are not likely to subsequently use drugs; but if they later do, they more easily can stop using them. Drug testing can help students stay away from drugs. It gives students a reason to say “no” when their peers ask them to use drugs.

Drug testing is an extremely effective deterrent as was demonstrated by the Hunterdon Central Regional High School in Flemington, New Jersey, by surveys taken before and after implementing random drug testing for all student athletes. Approximately half of the student body participated in athletics. In the two years between surveys when there had been no changes in the school anti-drug program except the introduction of random testing, drug use went down in 20 of 28 categories. In the highest risk drug use category of “Multi-Drug Users” the rates went down as follows: 57% for 9th grade, 100% for 10th grade, 14% for 11th grade, and 52% for the 12th grade. Drug testing in other contexts has also enjoyed remarkable success, e.g., drug use in the U.S. Navy dropped from 47% in 1981 to 4% in 1984 after implementation of a drug prevention program including random testing.

 

One reason may be that it is easier to kick a man when he’s down, and if the polls are anything to go by, Mr Blair is nearer the floor than George at present. Even despite the WMD farrago and much excitement from the Democratic hustings, Mr Bush continues to float at around a 50% approval rating.

Another defensible explanation is the greater stranglehold that liberal – or frequently libertarian – thinking in Britain has on life in the professions which take a particular interest in drug abuse; social services, counselling and treatment agencies, prevention agencies, police, the media, and – not least – the teachers (and their unions). And that other vitally important group who are not graced with the title of ‘professional’ – the parents.

Yet another, but simpler reason is that the USA schools have been involved in a testing programme for several years now. Not all the results are good, but enough of them are, to allow Mr Bush to celebrate their impact. 400, 000 fewer kids use drugs now, he said, and drug testing can take the credit for that. He has seen the future, and it works, he asserted. The truth is not that simple, or problem-free, but he was not unreasonable in taking encouragement from what successes there were.

In the punch-up which followed Mr Blair’s announcement the police generally kept their collective head down, probably relieved that here was one aspect on which they could avoid the flak. But everyone else got into the fight … each quoting the selection of figures that suited them … the old parliamentary jibe, that some people use statistics as a drunk uses a lamp post; more for support than enlightenment, comes to mind.

Some teachers dismissed the scheme as unworkable, and a waste of academic teaching time. This fear of being tested would also damage trust between pupil and teacher, it was said – but some of those saying it went on to say that they would automatically exclude any pupil found in possession. So, fear of testing, bad; fear of exclusion, not bad. Hmm.

NDPA Director Peter Stoker tried to pick some peace from the conflict by suggesting that the way forward was to examine the successes – and failures – of the American experience, and elsewhere, such as Australia. Stoker’s colleague in the Institute for Global Drug Policy, Dr Ivan van Damme, who works out of Belgium, is currently making an international study of the practice. Another NDPA colleague, Stuart McNeillie, runs Restorative Justice Consultants, specialising in what to do with young people you have found to be errant in some way – quite often including drugs. The indications are that linking Restorative Justice to random testing, as well as nurturing a far better system of drug prevention than most British schools currently bother with, could produce a benefit far greater than the sum of its parts.

There can be pro-active and positive slants to drug testing. In the Houston area of Texas, and with the support of the student bodies, pupils joined a scheme whereby they could volunteer to sign up for a ‘drug-free identity card’. To qualify for the card one had to be willing to undergo a random test at any time. Holders of the card were given substantial discount at major stores and leisure facilities in the region which supported the scheme. The usual safeguards as to proof of identity were applied. Discuss !

Reviewing the various arguments put forward in the past few days, Peter Stoker offers the following guide through
the Random Drug Testing jungle ……

- a good practice if properly administered. A useful addition to the wider array of initiatives. Not a cure-all on its own.

- has disincentive value, like visible speed cameras.

- allows pupils to resist peer pressure to use … “I would, but we have testing in our school”.

- must be part of a wider policy of prevention and intervention – and , we would say, Restorative Justice.

- must not be merely a punitive practice, or an excuse to sack pupils the school would like to be rid of.

- response to discovery of use must be graded to severity of discovery. Not all need ‘treatment’ as Blair implies; a talk may be enough, with involvement of counselling, or just a good talking-to, being other options.

- police should not need to be involved, unless there is discovery of aggravating circumstances … the person is dealing; involved in crime etc.

- ample evidence of success in USA, over 1000 schools using it. Times editorial today (23 February) reported indifferent outcomes – on average – from a Michigan study, but it is likely that outcomes were better in some schools, worse in others, depending on general calibre of prevention in each.

- one US school encountered a hostile parent body, so they suspended the scheme, only to find that use soared; on reintroducing the scheme use was greatly reduced, and parents became strong supporters of it.

- one teaching union, said it would damage trust. Our response is that ‘trust’ based on turning a blind eye is trust not worth having, and the young are attuned to smelling out this kind of hypocrisy. Trust is something you have to earn; not to be cheaply given.

- “Invasion of personal liberty” ? No; read John Stuart Mill ‘On Liberty’ – personal actions which affect the liberty of others are not acceptable.

- “Because cannabis stays in your body longer, youth will switch to cocaine or heroin, simply to beat the test”. This is scare-mongering; no evidence of this in the US experience.

- “It won’t work” – see above.

 

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If state legislators wrote a bill outlawing a critical remedy to help kids avoid a disease like tuberculosis, there would probably be a major effort to boot every single one of them out of office. Recently, the state Senate did something just as asinine — except the condition in question was drug use by kids, far more prevalent than TB. Bowing to pro-drug interest groups, a bill is making its way to the governor’s desk that would stymie efforts by local schools to test students for drugs. Unlike lawmakers in other states, Sacramento bureaucrats would like to control the way schools drug-test students, making such testing voluntary and placing restrictions on how it is administered.

Drug testing sounds costly, unnecessary, uncompassionate, even unconstitutional. Those who want to legalize and legitimize drug use caricature drug testing as a draconian policy designed to catch kids using drugs and throw them into jail.

It’s time to set the record straight. At a time when drug abuse in California plagues many students, it makes sense to drug-test students as a part a comprehensive drug-prevention program (which includes after-school programs). Since addiction is spread from peer to peer, drug testing gives a student another more credible reason to say “no” when offered drugs by his or her friend.

Unfortunately, the sponsors of Senate Bill 1386 miss the point of random drug testing when they assume that the practice is unnecessary because it is already easy to detect drug use: “You come into class, your eyes are red, you’re falling asleep, and yesterday you weren’t like that,” argues Assemblywoman Jackie Goldberg, D-Los Angeles, who coauthored the bill with Sen. John Vasconcellos, D-Santa Clara.

But drug testing is not meant to catch the kid who “everyone knows” is using drugs. The purpose of testing is to get those kids who have yet to show symptoms of their drug use the help they need before their “recreational fun” turns into dependence or addiction. It’s meant to prevent the scenario described above so that the student and his or her peers don’t have to live with the consequences of their classmate coming to school on drugs.

Drug testing is also not intended to detect drug use for punitive purposes — in fact, the U.S. Supreme Court prohibited that in its recent landmark ruling defending random drug tests for kids involved in activities at school. No student goes to jail as a result of a positive drug test. Instead, the family’s privacy is respected and the child is referred to get help to stop his or her use. Consequences entail being denied involvement in sports or other extra curricular activities during the treatment period and until the child tests negative for drugs.

Employing this carrot-and-stick method works. For example: After two years of a drug testing program, Hunterdon Central High School in New Jersey saw significant reductions in 20 of 28 drug use categories, including a drop in cocaine use by seniors from 13 percent to 4 percent. The U.S. military saw drug-use rates drop from 27 percent in 1981 to 3 percent today, thanks to the introduction of random drug testing. Schools like St. Patrick’s High in Chicago are seeing a total change in the culture of education at their school as a result of drug testing.

Compared to other health interventions, drug testing is cheap. It costs roughly $10 to $50 per student, per year. Most parents would gladly pay that small fee in exchange for knowing that their child was safe. In addition, the federal government has proposed $25 million to help school districts offset the costs.

Unfortunately, opponents of random drug tests (many of whom carry mission statements dedicated to legalizing drugs) can claim some victories in our state. Already, schools such as Bret Harte Union High School in Angels Camp (Calaveras County) have said that they will pull their effective drug testing program if SB1386 passes.

Principals, teachers and parents who employ an effective drug-testing program at school realize it is a valuable tool to deter kids from delving into drug use in the first place and to refer troubled teens to help. Our elected officials should not make that tool harder to use with this misguided legislation.

Source: Kevin A. Sabet. Former chief speechwriter for the Bush administration’s drug czar. A Marshall scholar at Oxford University, Sabet and is writing on book on drug use.

Background
3.4 methylenedioxymethamphetamine (MDMA, ‘Ecstasy”) is a popular recreational drug that selectively damages brain serotonin (5-HT) neurons in animals at doses that closely approach those used by humans. We investigated the status of brain 5-HT neurons in MDMA users.

Methods
The study enrolled 14 previous users of MDMA who were currently abstaining from use and 15 controls who had never used MDMA. It used positron emission tomography (PET) with the radioligand carbon-11-labelled McN-5652, which selectively labels the 5-NT transporter. It analysed whether there were differences in 5-HT transporter binding between abstinent MDMA users and participants in the control group. Blood and urine samples were taken and tested to check for abstinence.

Findings
MDMA users showed decreased global and regional brain 5-HT transporter binding compared with controls. Decreases in 5-HT transporter binding positively correlated with the extent of previous MDMA use.

Interpretation
Quantitative PET studies with a ligand selective for 5-HT transporters can be used to assess the status of 5-HT neurons in the living human brain. The study shows direct evidence of a decrease in a structural component of brain 5-NT neurons in human MDMA users.

Source: U D McCann, Z Szabo, U Scheffel, R F Dannals, GA Ricaurte – Biological Psychiatry Branch, National Institute of Mental Health,- Bethesda, Maryland, USA (U D McCann MD); and Departments of Radiology (Z Szabo MD, U Scheffel ScD, R F Dannals PhD) and Neurology (G A Ricaurte MD), Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA – published: The Lancet Vol 352, Oct 98. (Correspondence to: Dr G A Ricaurte)