WASHINGTON -- Kentucky will no longer require opioid addicts to stop taking prescribed treatment medications as a condition of participating in the state's drug court program, according to a motion filed in federal court.
The state court system had previously mandated that addicts taper off such medications within six months in order to remain in drug court -- a policy that contradicted established medical research and best practices.
Connie Payne, who helps oversee Kentucky’s drug court program, stated in an April 3 affidavit that changes to the Kentucky Supreme Court's drug court rules were approved on March 24.
The policy change follows a Huffington Post investigation into Kentucky’s drug treatment system in January. The story highlighted the state’s drug court policy and how it defied the conclusions of mainstream addiction science. Medications such as methadone and buprenorphine (which is sold under the brand name Suboxone) not only ease withdrawal symptoms for heroin and other opioid addicts but reduce the cravings that can lead to relapses. Forcing an addict off such medications can lead to a fatal overdose.
But Kentucky judges have relied instead on abstinence-based drug treatment, which is widely viewed as ineffective for all too many opioid addicts. The Huffington Post investigated overdose deaths in three Northern Kentucky counties during 2013 and found the vast majority of those who died had previously experienced such abstinence-only treatment. While the World Health Organization has listed methadone and buprenorphine as essential medicines, judges in Kentucky viewed them as no better than heroin itself.
Following the Huffington Post story, the White House’s Office of National Drug Control Policy announced in February that it would not fund drug courts that cut off access to medication-assisted treatments. “We've made that clear: If they want our federal dollars, they cannot do that,” said Pamela Hyde, administrator of the Substance Abuse and Mental Health Services Administration, during a conference call with reporters. "We are trying to make it clear that medication-assisted treatment is an appropriate approach to opioids.”
If they continued to force addicts off methadone and Suboxone, a handful of Kentucky drug courts would thus be facing funding cuts.
The pressure on the state to act became even more acute in March when a pair of law firms sued Kentucky in federal court over the medication issue. Their client Stephanie Watson, a Johnson County nurse with an opioid addiction, had been arrested on burglary and drug charges. As a condition of her pretrial release, she was barred from taking medications to treat her addiction, even if prescribed by her doctor.
Watson’s lawyers argued that the Kentucky court policy violates the federal Americans with Disabilities Act. If she had diabetes, they pointed out, she could take medications, but because her illness is opioid addiction, she can't.
The affidavit from Payne about the rules change was filed as part of the state’s motion to dismiss the Watson case. Attorneys for the state argued that with the policy change, Watson’s “claims have been rendered moot.”
Douglas L. McSwain, a lawyer representing Kentucky, told The Huffington Post that the state's change was made in response to the new federal rules. “The policy falls right in line with exactly what the White House Office of Drug Control Policy said,” McSwain explained.
Similarly, he wrote to the judge in the Watson case, “Due to a very recent change in federal grant application-for-funding terms and an announcement by the White House Office of National Drug Control Policy made in February 2015, indicating that state Drug Courts receiving federal dollars should not prohibit the use of MAT [medication-assisted treatment] drugs, the Kentucky Supreme Court has now amended its Drug Court Rules as of March 24, 2015.”
What exactly this means for opioid addicts entering Kentucky’s judicial system, whether through drug court or otherwise, is not clear yet.
McSwain suggested the rule means that on a case-by-case basis, judges should consider and potentially allow medication-assisted treatments.
But Kentucky drug court judges have long favored abstinence-only approaches to treating addiction, and so leaving it to the judge's discretion may mean little change on the ground. At least one judge has recently started allowing defendants to take Vivitrol, an opioid antagonist given in the form of a shot that can block cravings. That's a small step, but it still means the judge is favoring one medical intervention over others.
The Kentucky courts are specifically looking to expand the use of Vivitrol. The state's Administrative Office of the Courts held a presentation on the medication on Thursday, said spokeswoman Leigh Anne Hiatt. She added that 20 to 25 drug court judges are interested in possibly allowing the medication to be used. She said that judges are open to it because the medication cannot be diverted or abused, and does not interfere with drug tests, unlike Suboxone and methadone.
While Vivitrol looks promising based on some limited results, there is far less consensus in the medical community on the drug’s effectiveness compared to methadone and Suboxone. Addiction specialists view the latter medications as better treatments for those with more severe addictions -- for example, opioid addicts with criminal records who end up in drug court.
Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, said too many judges ignore the scientific research. “The problem is there is this sort of magical thinking that creeps into these debates,” he said. “That’s what you have to be on guard for -- the magical thinking.”
He recalled one judge saying he liked Vivitrol because of its antagonist properties. According to Parrino, the judge liked “the way ‘antagonist’ sounds.”
Parrino said many drug court judges don’t know the differences between methadone, buprenorphine and Vivitrol. He pointed to an April 2012 study of drug court judges in which sizable percentages admitted to having limited knowledge on the whole subject. For one question on whether buprenorphine was more effective than abstinence-only treatment, 58 percent were “uncertain.” Sixty-three percent of judges were not sure if a “stable dose” of methadone could impair a person’s driving ability. Roughly 20 percent thought methadone or Suboxone “rewards criminals for being drug users.”
Ned Pillersdorf, a lawyer for Watson, sees the state’s policy change as window dressing that won’t change how opioid addicts are actually treated. He predicted that judges will still order addicts into abstinence-only programs and forbid them from taking medications. “Most judges are philosophically against Suboxone and methadone,” he said.
He also noted that Kentucky's new rule does not appear to cover addicts not yet admitted to drug court, like Watson. “If you are on bond in Kentucky, you cannot get Suboxone and methadone without jumping through all these hoops,” Pillersdorf said.
More often than not, these aren’t so much hoops as immovable barriers. Pillersdorf sent HuffPost a copy of the boilerplate rules Kentucky defendants must agree to before they are released on bond. The court document, dated Oct. 14, 2014, stated, “Defendant shall not under any circumstance consume, ingest or introduce to his/her body any type or form of methadone or Suboxone or any similar drug.”
HuffPost showed the document to Michael Botticelli, director of the White House Office of National Drug Control Policy, who had announced the funding change aimed at eradicating such bias against medication-assisted treatment. “Wow,” he said, scanning the document. “I don’t think I’ve ever seen it in writing before.”
Pillersdorf said they are pushing forward with the Watson case because the state's rule change doesn't go far enough.
“It’s really a battle between the courts and the doctors,” he said. “The doctor-patient relationship is sacrosanct. The courts should get out of the way.”
Ryan Grim contributed reporting.