Lebanon, Va. — LATE on Christmas night 2013, April Hileman was summoned for a drug test. She had broken the curfew imposed on her by a drug court and relapsed with the opioid pills she’d been hooked on for six years. Earlier that day, Ms. Hileman had driven to a neighbor’s house here in far southwestern Virginia to buy a handful of Suboxone pills, or “Box,” as the drug is sometimes called. After she tested positive, Judge Michael Moore of Russell County ordered her to jail, and her 3-year-old daughter spent the rest of the holidays with relatives.
Like methadone, Suboxone prevents “dopesickness” and reduces cravings, without getting you high. It is now the gold standard for opioid addicts in medication-assisted treatment, or M.A.T. A combination of the opioid buprenorphine and the anti-overdose drug naloxone, Suboxone is supposed to give addicts a chance to get their lives together before they taper off it.
But Suboxone can get you high if you inject it or snort it or take it in combination with benzodiazepines, a sometimes fatal blend. And Ms. Hileman, then 24, did all those things.
Judge wants to use hand-held breath analyzer that you can carry in your pocket 'We have to make sure that the recovery is foremost,' said Judge Michael Barrasse, who oversees the county's treatment courts.
Among public health officials, the effectiveness of M.A.T. has become an article of faith; after all, treatment with buprenorphine and methadone has been found to cut opioid overdose deaths in half when compared to behavioral therapy alone, and it’s hard to argue with that. An addict treating his opioid disorder with Suboxone, many argue, is no different from a diabetic taking insulin. But increasingly, law enforcement officials — and many former addicts and their families — are lining up on the other side, arguing that Suboxone only continues the cycle of dependence and has created a black market that fuels crime.
Many judges in Virginia’s drug treatment courts are refusing to approve Suboxone treatment, especially for those who have already abused the drug. But last year the White House Office of National Drug Control Policy announced that it would not fund drug courts that cut off access to M.A.T. Judges who won’t comply will be forced to scale back or scare up additional state and county funds. And now President Obama’s proposed 2017 budget includes $1 billion for the expansion of M.A.T. What looks like a common-sense investment in Washington looks more complicated here in Appalachia, where the OxyContin “hillbilly heroin” epidemic began back in the 1990s and where opioid overdose death rates remain among the highest in the nation. These are the “Box Wars.”
The problem is the plethora of cash-only Suboxone clinics that operate without proper counseling or monitoring procedures. Oversight is crucial because drug testing alone doesn’t effectively reveal whether a participant is taking more Suboxone than prescribed.
For years Ms. Hileman had been “Box shopping”: Addict friends drove her to clinics across the Tennessee border, in Kingsport or Bristol, and paid her visit fees of $100 to $150 in exchange for six or seven Suboxone pills or films, which dissolve in the mouth. Eventually the drug court cut off her M.A.T. But even with a prison sentence of two years and nine months hanging over her head for drug-related felony thefts if she didn’t obey the drug court’s rules, she continued using and selling black-market Suboxone.
Ms. Hileman’s judge, Judge Moore, doesn’t believe in treating people who have abused Suboxone with Suboxone, instead favoring abstinence with rigorous drug counseling and testing, and near daily monitoring by drug-court probation and surveillance officers.
“I know people Suboxone has helped, but unfortunately a lot of the clinics are not forthright in trying to taper people off,” said Mark Mitchell, the Lebanon police chief and a member of Judge Moore’s drug court team.
For some clinics, losing customers means jeopardizing profits. Chief Mitchell’s town had three clinics before one was shut down in 2014 for poor record-keeping and excessive prescribing. “For a town of 3,400 people to have three Suboxone clinics?” he asked. “That’s absurd.” (While the Drug Enforcement Administration is pursuing pill mills nationwide, representatives from the agency and the United States attorney’s office in nearby Abingdon declined to comment on continuing investigations.)
In a region where Suboxone seems to have replaced coal as the economic driver, 80 percent to 90 percent of all crimes committed in Russell County are drug-related, most involving black-market Suboxone, law enforcement officials say.
When residents and law enforcement agencies point to these numbers as proof that M.A.T. isn’t working, public-health officials argue they are ignoring science. Why allow the criminal element to trump life-or-death concerns?
“Overwhelming evidence shows that Suboxone improves outcomes in people with opioid-use disorders,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse. She cited a 2014 study of opioid addicts that found that after 42 months, 31.7 percent were clean and no longer on M.A.T., and 29.4 percent were also clean but still receiving M.A.T. But almost 31 percent were off treatment and back on illicit opioids. (The relapse rates for patients who don’t receive M.A.T., though, are likely worse; a 2015 study of heroin addicts who used methadone or buprenorphine found a relapse rate 50 percent lower than among patients who did not get the medication.)
“Let’s be clear,” said Dr. Andrew Kolodny, a longtime Suboxone prescriber in New York and executive director of Physicians for Responsible Opioid Prescribing. “The real crisis is the severe epidemic of opioid addiction and overdose deaths that’s devastating families across the country.”
Dr. Kolodny ranks anti-Suboxone judges like Judge Moore in a category with climate-change deniers and people who believe vaccines cause autism. “When there’s really dangerous heroin on the streets, I’d rather see Suboxone out there, even if it is being prescribed irresponsibly or is being sold by drug dealers,” he said.
I’ve encountered zero climate-change deniers among the M.A.T. critics I’ve interviewed. Rather, I found police officers routinely putting in unpaid overtime and probation officers called to work on Christmas Day. Judge Moore himself serves Thursday night dinners to addicts — including Ms. Hileman — who meet in the basement of his church.
Ms. Hileman, now 26, insists that quitting Suboxone saved her life. The last time she relapsed, in September 2014, her probation officer sent her back to jail after she tried to fake a drug test by hiding her daughter’s urine in her jeans. Now she works two jobs, has regained custody of her daughter and moved to another town, away from her old drug crowd.
Others are not so lucky. In heroin-inundated Roanoke, where I live, I first ran into the Box Wars last year, while driving a 26-year-old heroin addict whom I’ll call Erica to weekly recovery meetings. I tracked her ups and downs, and walked her baby around in the back of the room when he got fussy.
She was arrested on suspicion of stealing plumbing equipment from Lowe’s with the intention of pawning it to buy heroin. At the local jail, she was so strung out she had no idea that she was five months pregnant until a sheriff’s deputy handed her a prenatal vitamin after a routine pregnancy screen. She delivered a healthy, opiate-free baby while in treatment, and started attending a Narcotics Anonymous meeting led by Vinnie Dabney, a recovering heroin addict who also leads Suboxone support groups.
“If you’re a regular opioid user, and you decide you want to stop, Suboxone can be a bridge that allows you to get where you want to be,” he said. “But if you stop on the bridge and get stuck there, it’s not so good.”
Will Erica get stuck on the bridge, or cross to the other side?
She recently stopped going to meetings and returning my calls. “Too tired, falling asleep,” she texted me one Saturday before I was to drive her to an N.A. meeting.
She denied that she had relapsed. “I think she’s gone back to using, but she won’t admit it, ” her mother told me. “I found papers in the bathroom, like what heroin comes in.” She added, “And she went through her brother’s room and stole his clothes — that’s what addicts do.” A judge recently decided to transfer custody of Erica’s baby to his grandmothers.
While Erica’s mother was initially hopeful about her daughter’s use of M.A.T., she was unable to secure appointments with a doctor who monitored its use rigorously and accepted insurance. (The ones who did had waiting lists, having reached their federally mandated 100-patient cap.) “Lots of money to be made for suppliers, doctors and medication,” her mother said. “The only addicts I have met who are still successful in recovery are addicts that chose to bite the bullet and detox.”
My friend Jamie, whose two sons are recovering heroin addicts who had also abused Suboxone, was equally conflicted. Her younger son claimed he had figured out how to separate the opiate from the naloxone inhibitor, injecting pure buprenorphine to get high, until he “decided it was more productive to sell it on the street for $25 and buy a cheaper bag of heroin instead,” she told me.
He finally got clean without M.A.T., but only after long stints in inpatient rehab centers at a total cost of about $60,000.
IN Tazewell County, the jurisdiction neighboring Judge Moore’s, I spoke to Jack Hurley Jr., a Circuit Court judge who is chairman of the operations committee for the statewide drug court advisory committee. He allows Suboxone when the court psychiatrist recommends it, which is for about 35 percent of participants. Among the 16 on his docket: a 48-year-old disabled coal miner who abused opiate pills for a decade, is not on Suboxone and is thriving, finally, after several relapses; and a 26-year-old mother who for six years abused opioid pills, including black-market Suboxone, and now takes 10 milligrams of prescribed Suboxone a day and has not relapsed.
Though he’s had a handful graduate after being weaned off Suboxone, many don’t, and those inconsistencies weigh on him. And yet he’s counted 13 drug-free babies born while he has run Tazewell’s drug court, several to mothers on M.A.T. (Like Erica, they took a drug called Subutex because Suboxone is not recommended for pregnant women.) “How do you put a price on that?” he asked.
Judge Hurley invited me to sit in on a recent open drug court session. The last to report was the newest participant, a 37-year-old man who showed the judge an 11-inch scar on his arm from decades of injecting crushed-up opioids. Though he’d taken prescribed Suboxone during a nine-day detox, he did not have a prescription for M.A.T. and swore he had not taken any drugs since.
“I have a big question: How clean are you going to be today?” Judge Hurley asked.
“Should be nothing,” the man said.
Minutes later, the bailiff returned with the results from his test: positive for Suboxone.
“Well, he’s going to spend the night,” Judge Hurley said. “Let him out in the morning. And tell him not to look me in the eye and lie again.”
Judge Hurley shook his head. He has known the man’s family for 20 years.
“Is it right to put him on the drug he wants to be on?” he asked.
But if the court psychiatrist recommended it, Judge Hurley said he would allow the man the use of M.A.T.
In Allegheny County, Judge Lester Nauhaus sees his drug court as an alternative to the carnage of the drug war.
Drugs drive crime. But locking up addicts doesn't stop crime. Nor does it stop drug addiction.
“Nail ‘em and jail ‘em wasn't working,” Nauhaus told PublicSource in an interview. “All it was doing was costing everybody a fortune.”
Instead of locking up defendants, drug courts allow prosecutors, public defenders, judges and others to work together to get defendants to much-needed drug treatment.
But there are clashing opinions about how drug courts should operate.
Many judges, including Nauhaus, ban drug court participants from using treatments like methadone and buprenorphine, calling such medications a “chemical crutch.” He requires participants to focus on abstinence.
That puts the judge and his court in direct conflict with national drug court standards and federal officials, who condemn the banning of medications.
It also puts Nauhaus at odds with Lackawanna County Judge Michael J. Barrasse, who championed the creation of the county's drug court in 2000 and has supervised it since its inception.
Barrasse said his court is a believer in medically assisted treatment but evaluates potential participants on a case-by-case basis to make sure medications are necessary and appropriate.
The court would seek an alternative medication for someone who, for example, cites a need for Suboxone to treat pain as opposed to heroin addiction, he said.
“There are cases where we don't take people, but it's not based on medically assisted treatment. It's based on their abuse of medication,” Barrasse said, pointing out it would be difficult to successfully complete the drug court program “if you're high the entire time.”
Luzerne County's drug treatment also allows medically assisted treatment, such as methadone or suboxone, as long as the defendant is in an approved treatment program, said Assistant District Attorney Jim McMonagle, who is also the president of the Pennsylvania Association of Drug Court Professionals.
He acknowledged the debate about whether to allow such treatments, but said the court's steering committee — which is comprised of prosecutors, defense attorneys, probation officers and a judge, among others — decided to follow the standards of the National Association of Drug Court Professionals, which allows them.
“We do prefer abstinence rather than being on it, but we try our best to follow the national standards so that we are doing what the science says we should be doing,” McMonagle said.
The majority of defendants in Luzerne County drug court are not taking methadone or suboxone, but the committee will allow it in cases where there is a medical need and the person is working with a licensed treatment program, he said. The court closely monitors compliance, and defendants could face termination from the program for violating the rules, he said.
Ideally, the defendant would leave the program completely substance free, although it's possible in rare cases someone could graduate while still taking methadone, he said.
“We hope they're hope to get able to abstinence from that as part of their treatment,” McMonagle said. “There is some science showing that there is a small population of addicts who, if they're not on some small dose of methadone or suboxone, they immediately fall back to addictive behaviors.”
To Nauhaus, medication is simply replacing one drug with another. And that drug can be abused, just like heroin, and sold on the street.
So a heroin addict in Pittsburgh has to give up medications that help stave off addiction to get treatment through drug court.
Both the federal government and the National Association of Drug Court Professionals say that approach ignores science.
“Saying ‘we are abstinence only' is in direct violation of the best practices,” Doug Marlowe, chief of science, law and policy at the national association, told PublicSource.
And though the state estimates that more than 70 percent of all inmates suffer from untreated addiction, only 32 Pennsylvania counties currently have adult drug courts. The state's remaining 35 counties have little choice but to lock offenders up.
Pennsylvania spends $5.3 billion on the costs of addiction.
A bargain
Drug courts offer defendants a bargain. Enter treatment, stay off drugs and avoid jail and prison, at least in the long run. Or serve your time, miss out on treatment and return to the life of an addict that brought you to court.
Since 1998, scores of serious but non-violent offenders in Allegheny County have been given that choice every year.
Success means keeping offenders out of court — and jail — in the future.
“I generally don't see them back in the system,” said Rebecca Hudock, an assistant public defender who has been involved in Allegheny County's drug court for six years.
Another measure of success is the taxpayer money saved. For 2012, supervising an inmate on probation cost an average of $3.20 per day, according to the court. Jail time would cost $68.17 each day. State prison would cost $116, the court said.
Last year, the Allegheny County drug court had 235 total participants. Of those, 54 offenders failed or withdrew, 28 graduated, and 153 were still in drug court at the end of the year.
Offenders can stay in drug court for more than two years. Those who fail get sentenced for their crimes, to which they've already pleaded guilty.
Luzerne County created its treatment court in 2006, after a study showed 85 percent of inmates arrested for drug- or alcohol-related crimes were rearrested for similar crimes after their release.
On Friday, with snow blowing down on the first day of spring, drug treatment court defendants packed the benches in a courtroom at Penn Place in Wilkes-Barre. Most wore street clothes — some sported torn jeans and sweatshirts — reflecting the less formal atmosphere of the court.
From the bench, Luzerne County Judge Joseph Sklarosky Jr. focused on the progress of each defendant, encouraging their successes and chiding their digressions.
The first defendant of the day was a man graduating from the program.
By way of congratulations, Sklarosky gave him a gift card for coffee and a doughnut before getting off the bench to shake hands and present the man with a certificate.
The man, who asked not to be identified, was facing jail time for a bar fight and said the program had given him a fresh start. After “intensive” counseling and treatment — which early on entailed multiple Alcoholics Anonymous meetings a week — he has now been sober for 2½ years, he said.
“I didn't realize how my drinking had affected my life and my family,” he said as he prepared to leave the building a free man. “I owe a lot to the program. It really turned my life around.”
The story was not so cheery for the next man to step before the judge. Saying he had seen only “more of the same” in the case, Sklarosky terminated the man from the program and ordered him to be sentenced in May. The man had not attended hearings he had been ordered to attend, the judge said.
“You've lost the benefit of this program,” Sklarosky said, noting the defendant had expressed concern about losing custody of his child. “If you're heading in the direction you're heading, you risk losing custody. So if you need motivation, there it is.”
Success varies from court to court. The national association says three-quarters of all drug court graduates are arrest free after two years. The state has yet to publish statistics.
More than 500 individuals have graduated from Lackawanna County's drug court program, and there are 212 now enrolled, according to statistics supplied by coordinator Barbara Durkin.
The program has a post-graduation recidivism rate of 11 percent, which Barrasse said is among the lowest in the state.
“I think we are very successful,” he said. “Apples to apples, oranges to oranges, I would compare us to anybody.”
But success rates can vary depending who is participating in the program, Barrasse said. A drug court that concentrates just on the easy cases may have a far different outcome than one like Lackawanna's that also takes “the hardest of the hard,” he said.
He said individuals in the 18- to 24-year-old age group can be problematic because they believe they are immortal, he said. Similarly, some female participants can be difficult because they often have added stresses, such as a past sexual trauma or trying to raise children on their own.
“They are single and they have three kids and no income and we can't get them into housing because they have a past drug conviction,” he said. “It's a vicious circle.”
Although drug courts have been around for decades, they are still a relatively novel concept in the world of criminal justice, Barrasse said.
“I tell everybody it is a work in progress. ... There are a lot of things we have to work on, but I'm thrilled with the progress we have made to date,” he said.
Allegheny abstinence
With very few exceptions, all of Allegheny County's drug court defendants are required to be abstinent. No medications to help with their cravings, though offenders can be accepted to the program on medication if they agree to taper off.
Court officials and treatment experts say the meds are dangerous. Suboxone, for instance, is a heroin-replacement pill to lessen cravings. It's not supposed to get a user high.
Allegheny County's tough approach is not rare.
The joint Union and Snyder County drug court has strict bans on certain medications, including many opiates, but it allows rare medication-assisted treatment.
The national drug court association found that only 56 percent of more than 2,700 drug courts use medications like Suboxone. However, about 25 percent more would use them, they found, if medications were available locally or were more affordable.
The Administrative Office of Pennsylvania Courts oversees drug courts, but mostly lets them set their own rules. It does not take a stand on medication-assisted treatment. Neither does the Pennsylvania Association of Drug Court Professionals.
But both point to standards published by the national association. That organization takes a firm and explicit stance.
Recently, the White House, along with several federal health and treatment agencies came out against programs that ban medication-assisted treatment, going so far as to exclude drug courts with bans from federal funding.
In Montgomery County, Judge Steven O'Neill's drug court allows the meds. If closely monitored — and coupled with therapy — medication can be effective.
Addiction is a disease, he said. Willpower can't fix that.
An opioid addiction feeds itself by causing physical dependence. Not getting heroin or pills will cause violent physical sickness. He compares an addict's craving opiates to a diabetic whose pancreas has stopped producing insulin.
Both need medication.
“You're not going to say ‘Toughen up. I'm not going to give them insulin,'” said O'Neill, who previously served as president of the Pennsylvania association.
Taking a recovering addict off medication can lead to relapse, which can be especially deadly if the body has lost its tolerance for opiates.
Erica Bartlett, an assistant public defender in Philadelphia, which started the state's first drug court in 1997, said there's no justification for a blanket ban.
Each defendant should be evaluated individually to see if medication is appropriate, said Bartlett, who was a member of the state committee that developed accreditation criteria for drug courts.
Nauhaus contends that his court has been effective without those chemical aids.
Barrasse said one of the issues in Lackawanna County is access to treatment. His court has been fighting to get naltrexone, which is used to treat opioid addiction by blocking receptors in the brain, on the formulary list “so it is approved for people in treatment.”
“We need better access to medically assisted treatment, naltrexone being the number one thing we don't have,” he said.
Not enough courts
The debate over medications that help with cravings is only relevant in places that actually have drug courts.
In most counties in the state, defendants have no choice but to go to court and jail, where many of them are destined to return. Over and over.
If counties don't invest, taxpayers pay for addiction one way or the other. Remember that $5.3 billion number? Meanwhile, offenders don't get treatment.
Karen Blackburn, the state's coordinator for drug and other problem-solving courts, said she'd expect to see more drug courts if more money were available.
The Pennsylvania Commission on Crime and Delinquency contributes some money that can be used for drug courts. Federal money is also available, but grants are competitive, and officials have made clear that they won't give money to programs that don't agree to use medication-assisted treatment.
Meanwhile, the state budget gives little money to problem-solving courts.
So while drug courts are increasingly accepted as a normal part of the justice system, they exist only if they can be paid for by counties.
That's not true in neighboring New Jersey, which sets aside millions for drug court staff and treatment funding, and recently expanded eligibility for offenders.
That system isn't perfect, but Bartlett and other advocates said mimicking New Jersey could lead to reduced crime, lower costs and more help for offenders.
“It's in their budget,” Bartlett said. “I think that's what the Commonwealth needs.”
James Halpin and David Singleton, staff writers, contributed to this story.
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