MEDICAL PRACTICE Courts: A Primer for the Family Physician J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from

James E. Lessenger, MD, and Glade F. Roper, JD

Background: Drug courts are a judicial response to drug-related crimes. They combine the coercive powers of the judiciary with drug treatment. This article is intended to familiarize physicians with the reasons why drug courts exist, what they are, and how physicians can assist their patients who are cli- ents of a drug court. Methods: Methods for this article are based upon personal experience and a search of the literature using the key words “drug rehabilitation,” “drug abuse,” and “criminal justice system.” Results: Using a three-phase approach, drug courts emphasize urine drug testing, rapid punishment for specific infractions, and therapeutic interventions. Drug courts have greatly reduced criminal and drug-using recidivism. Conclusion: Drug courts are effective in resolving the criminal and drug-using behaviors in drug- only, nonviolent offenders. Family physicians can become involved in the drug court process by provid- ing treatment for patients with both drug and mental health diagnoses. In addition, as pa- tients withdraw from , it is important to treat withdrawal symptoms to prevent recidivism and encourage participation in the program. (J Am Board Fam Pract 2002;15:298–303.)

Drug courts are a judicial response to the increas- sponse to rampant drug use, drug-related crime, ing numbers of drug-related crimes in the criminal and jail overcrowding.1 justice system. They combine the coercive powers of the judiciary with drug treatment to resolve the Methods http://www.jabfm.org/ criminal action by helping defendants withdraw Methods for this article are based upon personal from drugs and keep them drug-free. experience and a search of the literature using the This article is an introduction for family physi- key words “drug rehabilitation,” “drug abuse,” and cians caring for drug court clients in their practices. “criminal justice system.” One author (GFR) is a Physicians might be called on to assist in the treat- judge in the superior court of Tulare County, Calif, ment of addiction, medically assist patients in with- with considerable experience in the local drug on 29 September 2021 by guest. Protected copyright. drawal, provide treatment for patients with the dual court. The other author (JEL) has been in clinical diagnoses of mental illness and addiction, and treat practice and has had patients who were defendants diseases associated with drug-use, such as tubercu- in the drug court. losis, hepatitis, and human immunodeficiency virus (HIV) infection. The Drug Court Process Drug courts are limited to nonviolent defen- Although drug courts have distinct differences, the dants arrested for drug-only offenses, such as pos- following process, derived from the Tulare County session and transportation of drugs, intoxication, Adult Drug Court in California, is typical. Figure 1 and possession of paraphernalia. Typically excluded displays the steps leading from arrest to drug court. are offenses involving drug sales, violence, or a victim other than the person using the drugs. Drug Arrest courts originated in Dade County, Fla, as a re- When arrested for a drug-related crime, detainees are either released on their own recognizance or incarcerated in the county jail, depending on the Submitted, revised, 15 October 2001. From the Family Practice Department (JEL), Kern Med- crime and circumstances of arrest. The arresting ical Center, Bakersfield, and the Superior Court (GFR), officer transmits a report to the prosecuting attor- Tulare County, Calif. Address reprint requests to James E. Lessenger, MD, Morinda Medical Group, 841 West Mor- ney’s office, where a complaint is prepared and filed ton Ave, Porterville, CA 93257. with the court.

298 JABFP July–August 2002 Vol. 15 No. 4 rgCut 299 Courts Drug

Figure 1. Outline of the drug court process.

P.O. – probation officer.

J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from from Downloaded 2002. July 1 on as published first Pract: Fam Board Am J http://www.jabfm.org/ on 29 September 2021 by guest. Protected by copyright. by Protected guest. by 2021 September 29 on Table 1. Organization of Drug Court Through the Phases.

Minimum Recovery Education J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from Phase Length Court Dates Individual Therapy Group Class NA/AA

I 2 mo Weekly Weekly Weekly Weekly 5/wk 2/wk II 4 mo Every other week Every other week Weekly Weekly 5/wk Weekly III 6 mo Monthly Every other week Weekly Monthly 3–4/wk Weekly Graduation: diploma given at ceremony Aftercare 6 mo Every 3rd month 2/mo 2/wk 2/mo

Note: Clients needing residential treatment are placed in slightly different program until they enter an accelerated outpatient program, which starts after the three phases. NA— Anonymous, AA—.

Arraignment they are monitored by drug tests, probation offic- At arraignment the defendants are formally charged, ers, and treatment providers (Table 1). Defendants and a defense counsel is arranged. Either at the are required to attend self-help meetings, such as arraignment or in subsequent hearings, the defen- (NA) and Alcoholics Anon- dants’ eligibility for drug court is determined. If the ymous (AA). Drug rehabilitation counselors pro- defendants do not enter drug court, one of three vide individual therapy, group therapy, educational things can happen: (1) the case is dropped for lack sessions, and job training. The clients are expected of evidence, (2) the defendants plead guilty and are to graduate from high school or the equivalent. incarcerated, or (3) the defendants plead not guilty Pregnant clients are enrolled in special detoxifica- and the case goes to trial. tion and residential programs. Treatment providers are professionals with cre- Probation Interview dentials and experience in drug and treat-

The defendants seeking admission to drug court ment. They run the group sessions, individual ther- http://www.jabfm.org/ are interviewed by a probation officer, who makes a apy sessions, and educational classes. Clients sign a recommendation for eligibility based on legal fac- waiver of confidentiality authorizing providers to tors, the defendants’ answers to questions, the de- give information about the clients to the court and fendants’ criminal justice computer report (rap to work with the court and probation officers, pro- sheet) and a gut reaction to the defendants’ de- viding insight into the clients’ particular problems. meanor and criminal history. The bulk of the in- Drug court is typically held in the same court- on 29 September 2021 by guest. Protected copyright. terviews are spent in explaining costs and how hard room on the same day of every week. The judge is the defendant will have to work in the program. a jurist who is especially motivated and can bond The defendants have the option of rejecting with the clients. Knowledge in drug and alcohol drug court and returning to a criminal court for abuse problems, rehabilitation, and drug testing is adjudication if they think the costs in time, money, essential. The probation officers and treatment and emotional turmoil are too great. The defen- providers are also in attendance. Clients are called dants might also be in denial, they might want to to the front of the courtroom and talk with the continue using drugs, or they might be innocent. judge, who reviews the treatment providers’ re- ports. The probation officer checks the clients’ at- Judgment tendance cards for AA or NA meetings. Specific Once the defendants accept drug court, they appear recommendations or congratulations are given to before the drug court judge and plead guilty to the the clients, and appointments are made for the next crime. The defendants are then placed on proba- hearing. Alternatively, clients can be jailed for in- tion, and once the agreement is signed, they be- fractions. come clients of drug court. The process might take only a few minutes, and some clients immediately return to work or school. Drug Court More often, clients sit through the hearings of Clients are expected to comply with a rigorous many other clients before they are called before the program organized into three phases during which judge. The group process creates a synergism. Les-

300 JABFP July–August 2002 Vol. 15 No. 4 sons are learned when clients see others lie to the Graduation judge and receive jail time or hear others tell how Many drug court clients have never completed any- their so-called friends gave them drugs, leading to thing important in their lives and think of them- J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from a . Friends might be placed in handcuffs and selves as losers. The graduation ceremony at the led away to jail or prison. Positive end of the third phase is typically held in an audi- includes seeing clients awarded T-shirts and torium, often with more solemnity than a college cups for advancement. graduation. The judge presides with bailiffs in at- The unsung by-product of drug courts is that tendance. Local politicians and representatives of clients and graduates live in the drug-using com- the legal, medical, and law enforcement communi- munity and spread antidrug sentiments and actions ties attend. Popular personalities might be invited into that culture. They often invite drug-using to speak. For example, in Tulare County, Calif, family members and friends to drug court to see the David Crosby, a member of the rock band Crosby, consequences of continued use and . Many Stills, Nash, and Young and a recovering alcoholic work in a self-help group to keep other participants and addict himself, has spoken at two graduations. . Each graduate is handed a diploma by the proba- During the progression through the phases of tion officers and congratulated by the dignitaries. drug court, clients are subject to specific sanctions Graduation gives the clients a sense of accom- by the court for failure to follow the rules set down plishment and instills the concept that they can in the probation agreement and for lying or dis- complete a difficult task. The ceremony puts them honesty. Missing one drug court session will result on public notice that continued drug-using behav- in a bench warrant. When the clients are returned ior would not only be a failure on their part but a to custody, they could be returned to drug court or source of grave disappointment to the judge and sent to jail or prison, depending on the circum- the members of the audience. This social expecta- stances of the arrest, time lapsed, initial crimes, and tion can be a stronger deterrent to drug use than subsequent offenses, if any. the threat of incarceration.

The key to success in drug court lies in the http://www.jabfm.org/ clients’ bonding with the judge and the probation officers. Relapse is a foreseeable part of rehabilita- After Graduation tion, especially during the first phase. A positive The aftercare program consists of less-frequent ap- drug test or missing a drug test, drug court appear- pearances before the court, continued attendance at ance, treatment session, or meeting will result in AA or NA meetings, and attendance at alumni sanctions (including possible time in jail) but not in association meetings. Aftercare for clients rein- on 29 September 2021 by guest. Protected copyright. dismissal from the program so long as the partici- forces habits created during the formal program pants are honest, committed to recovery, and mak- and develops a new culture devoid of habits and ing progress. Involuntary termination usually oc- friends that contributed to addiction. If after 6 curs only when participants are perceived as months the clients have paid all fines and expenses, unwilling or unable to achieve and maintain total attendance has been perfect, and there has been no abstinence or when they commit another crime new crime or positive drug test, the charges can be against person or property. dismissed. If at any time during the aftercare program cli- ents are arrested on drug charges, they are sen- Drug Tests tenced to jail. On release, they may be re-evaluated Reliable urine drug testing is the key to account- for drug court. If they decline drug court or com- ability. Clients are required to take two random mit another offense, they are incarcerated. tests a week during the first phase. The tests are usually done at a central collection point designated by the court. The tests monitor levels of alcohol, Outcomes , opiates, (PCP), lysergic acid Drug testing and treatment while in jail is common. diethylamide (LSD), , and ben- Seventy-one percent of jails test inmates for drugs, zodiazepines, and they can be adjusted to detect a and 72% have treatment programs. Criminal recid- current street drug to add specificity. ivism for drug-related crimes, however, is approx-

Drug Courts 301 imately 25% within 1 year. Drug-use relapse is cians can assist with education regarding the rela- estimated at 82% within 1 year.2 tion between mental health problems and sub- Although within prisons 75% of state and 80% stance abuse. In some situations, family physicians J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from of federal prisoners are alcohol- or drug-involved might be responsible for prescribing psychoactive offenders, only 25% of state and 50% of federal medications. prisoners receive alcohol treatment after admission. Nearly 50% of all drug offenders sentenced to Medication Support of Withdrawal prison for drug-related crimes were arrested for a Participants who are toxic and who have been ad- felony offense within 3 years of release, and one dicted to high amounts of drugs for a long time half of these arrests were for drug-only crimes. Of might need supportive medication during with- all those on probation (not just for drug crimes), drawal. Particularly important are antidepressants one third were arrested for a drug offense within 3 and antianxiety medications to tide patients over 3–5 years. withdrawal from methamphetamines and cocaine.8,9 As of May 2001, there were 688 drug courts, including adult, juvenile, and family drug courts, Medical and Dental Needs and 31 tribal drug courts in operation. Program Medical problems, including hepatitis, HIV infec- completion rates nationwide for drug courts aver- tion, tuberculosis, and , require early age 47%. Criminal and drug-use recidivism rates diagnosis and aggressive treatment. Particularly for are difficult to measure because programs are not those addicted to , cocaine, and standardized, but rates from 5% to 22% have been opiates, dental abscess and pain can become severe reported. The expense of a community-based drug as clients detoxify. If this pain is not adequately court program is approximately 25% of the cost of treated, the patient will probably return to drug- incarceration in a jail or prison, including jail time using behavior.10,11 for sanctions.6

Considerations for the Family Physician Piling On http://www.jabfm.org/ The family physician should remember that, unlike Clients of drug court typically have additional legal, other drug and alcohol recovery programs, drug mental health, and medical needs in jurisdictions or court is a criminal process. The consequence of clinics apart from the drug court treatment pro- clients’ failure to follow the rules is incarceration, gram. It is common for clients to have matters possibly for many years. Medical interventions before family or juvenile court requiring counseling must be coordinated with the clients’ programs and or courses in stress reduction and child care. Men- on 29 September 2021 by guest. Protected copyright. supportive of withdrawal, sobriety, and continu- tal health programs might require group and indi- ance of the program. There are four main areas in vidual therapy in addition to classes as part of treat- which family physicians can help: treating mental ment. Legal jurisdictions require multiple court illness, supporting drug withdrawal with medica- appearances for traffic or other infractions. Clients tion, attending to medical and dental needs, and might be referred to more than one medical clinic avoiding piling on. for treatment. These additional demands pile re- quirements and responsibilities on the clients who Mental Illness are already with withdrawal from addiction. Between 25% and 47% of all drug users have a Good programs coordinate the family court, men- diagnosed mental illness, including schizophrenia, tal health treatment, judicial processes, and child , depression, and anxiety.7 One ad- protective services with drug court. The family vantage of drug court is the coordination and inte- physician needs to coordinate treatment with cli- ents’ existing programs and not pile on a redundant gration of legal and medical resources. To enhance 12 the benefit of psychiatric treatment, especially dur- treatment. ing the first phase, clients receive mental health services as close as possible to the drug court loca- Conclusions tion and as soon as clients are released from jail. After a decade, drug courts clearly represent a new Treatment is coordinated with the drug court and effective paradigm in drug treatment for crim- counselors and probation officers. Family physi- inal offenders. The success of drug court derives

302 JABFP July–August 2002 Vol. 15 No. 4 from being community based, structured, and mul- ton, DC: Office of Justice Programs, Bureau of Jus- tidisciplinary and having clear-cut consequences tice Statistics, US Department of Justice, 1989. for failure. The power of the judiciary can cut 4. Drugs and crime facts, 1994. Washington, DC: Of- J Am Board Fam Pract: first published as on 1 July 2002. Downloaded from through petty agency rivalries to achieve the de- fice of National Drug Control Policy, Bureau of Justice Statistics, US Department of Justice, 1995. fined goals of sobriety and decreased criminal re- 5. Mumola CJ. and treatment, state cidivism. and federal prisoners, 1997. Washington, DC: Office For the family physician the challenges of treat- of Justice Programs, Bureau of Justice Statistics, US ment are especially important because medical care Department of Justice, 1999. must be integrated into the three-phase process. 6. Belenko S. Research on drug courts. A critical re- Treatment of mental illness, withdrawal, and med- view, 2001 update. New York: The National Center ical illness can be critical to the retention of clients on Addiction and Substance Abuse at Columbia Uni- versity, 2001. and the eventual success of the program. This new 7. Miller NS. Psychiatric diagnosis in drugs and alcohol paradigm of criminal justice and treatment is de- addiction. Alcohol Treat Q 1995;12(2):75–92. pendent on cooperation among diverse professions, 8. Miller NS. History and review of contemporary ad- timely treatment, and an understanding that re- diction treatment. Alcohol Treat Q 1995;12(2):1–22. lapse is part of recovery. 9. Miller NS. Pharmacotherapy in . Alcohol Treat Q 1995;12(2):129–52. References 10. Belenko S. Research on drug courts: a critical review. 1. Hora PF, Schma WG, Rosenthal JTA. Therapeutic New York: The National Center on Addiction and jurisprudence and the drug treatment court move- Substance Abuse at Columbia University, 1998. ment: revolutionizing the criminal justice system’s 11. Gostin LO. Compulsory treatment for drug-depen- response to drug abuse and crime in America. Notre dent persons: justifications for a public health ap- Dame Law Rev 1999;74:439–537. proach to drug dependency. Milbank Q 1991;69: 2. Wilson DJ. Drug use, testing, and treatment in jails. 561–93. Washington, DC: Bureau of Justice Statistics, US 12. Mee-Lee D. Matching in treatment: How Department of Justice, 2000. do we get there from there? Alcohol Treat Q 1995; 3. Recidivism of prisoners released in 1983. Washing- 12(2):113–28. http://www.jabfm.org/ on 29 September 2021 by guest. Protected copyright.

Drug Courts 303