Response to the heroin epidemic: 4. Tough love from drug court

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for courtroomaddicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

druggiesincourtThe judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

……………………………………

I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

jailcardAny individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

 

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.

 

51 thoughts on “Response to the heroin epidemic: 4. Tough love from drug court

  1. wrenn ballard May 19, 2016 at 9:42 am #

    It is interesting to find the word “coerce” within the text above. A friend and I have argued the benefits of coercion of addicts from our different points of view–both of us are non-addicts and relatively uneducated regarding solutions for addictions.

    One of us contends an addict should be held in involuntary confinement with mandatory therapy until such a one is able to make a “rational” decision about returning to their addiction or not.

    The other contends that while detox and accompanying therapy should be mandatory with addicts who are in the court system, after release, the addict should free to go and that rational thought can never be achieved by an addict. In short, behaviour needs to be modified over a long period of time and involuntary confinement is not right after the court law has been fulfilled.

    We are both “cits” ” on the doorstep” of addiction knowledge, and will greatly appreciate any helpful comments.

    • matt May 20, 2016 at 11:25 am #

      I think a first step is not to think of this in terms of rationality or irrationality. All humans are intrinsically “irrational” beings, addicts or not. Successful treatment has to do with meeting people where they are, meeting their needs, and giving them the knowledge, strategies, and experience to navigate/negotiate a successful recovery– i.e., a fulfilling life. It helps me to start from the premise that everybody is addicted to something. It’s just a matter of degree and the relative consequences of the behavior, whether it’s music, handwringing, or heroin.

    • Terry May 22, 2016 at 6:27 pm #

      do we coerce sports stars to quit because they are spending too much time training and neglecting their families? do we coerce anyone other than drug users via justice systems? the same occurs in Australia. the result is the real problem gets lost in a justice issue and the attitude to drug use remains the same, governed by an intolerant and bigoted society who fail to address the real issues of poverty, unemployment, housing stress, racism, stigmatisation and failed parenting amongst other things. get justice out of the picture, change the laws and the attitude and the result will change dramatically. why don’t we try the obvious, why do we keep trying what ahs so far failed to make any difference at all.

  2. Gina May 19, 2016 at 10:16 am #

    Wow, I have plenty of thoughts about this, especially now that my own daughter is in a drug court program. I’ll return later with a more detailed response about our experiences, both positive and negative, after I’ve had a chance to gather my thoughts. In the meantime, the following is an excellent article by Maia Szalavitz, who points out the serious drawbacks of drug courts for many:

    https://psmag.com/how-america-overdosed-on-drug-courts-a813ff745a6e#.11m6i4700

  3. Maia Szalavitz May 19, 2016 at 10:21 am #

    Xyprexa might be best for a heroin addict? Who was she educated by, pharma commercials???? That’s an antipsychotic that has never been found successful for addiction— while the World Health Organization, the Institute of Medicine, ONCDP, NIDA, CDC, UK’s NICE and every other agency that has ever looked at the question has found that methadone and buprenorphine reduce death rates, 50-70% or more.

    If the person also has schizophrenia, maybe that might help— but it is a seriously overprescribed drug that actually increases death risk, unlike maintenance.

    Judges need to stop practicing medicine and quit thinking that they can determine better than medical professionals what treatments are “recovery” and what treatments aren’t. I’m glad she seems to have some humility in recognizing that she’s not a doctor and shouldn’t meddle in prescribing decisions— but her comments on methadone make me suspect that she probably still does, with the idea that doctors are unaware of the possibility of diversion.

    Regarding coercion, there is abundant data on the question: it’s usually only seen as “necessary” when treatment is confrontational, humiliating and can’t manage to get people in the door by being respectful and humane. The data shows coercion is *not* more effective than voluntary treatment, and there is some suggestion that it is less so.

    • Jeffrey Skinner May 19, 2016 at 1:26 pm #

      You really ought to rethink your response. The judge made it clear that she is NOT a doctor and needs help with medical issues. I find her attitude very refreshing. There is nothing to be gained from piling on medical details. I wish we had more like her.

    • Marc May 20, 2016 at 9:56 am #

      Hi Maia, Note that the judge acknowledged her mistake. She really is a good soul stuck in a broken system. So the dialogue is useful — to her as well as others — as people look for some middle ground between the draconian status quo and other alternatives.

    • Addict no more October 3, 2016 at 1:35 pm #

      Maybe you should have read the rest of the article before becoming overly critical.

  4. Jeffrey Skinner May 19, 2016 at 1:34 pm #

    This is an excellent piece. There is much of value in debating the neuroscience of addiction, but the courts and hospitals are where the rubber meets the road and real change happens for addicts. My daughter is an RN who has to deal with addicts, her least favorite patients mostly. She says it’s hard to accomplish anything clinically with someone who is apparently solely motivated by finding drugs. Maybe she could talk about her experience here. I’m sure she would benefit by constructive input from this community.

  5. Donnie May 19, 2016 at 1:41 pm #

    As always , Tom Waits sang about it years ago .

    “Two dead ends and you still have to choose”

    Just wondering if one has to plead guilty to the index offence before entry to drug court?

    • Marc May 19, 2016 at 2:59 pm #

      Excellent question. Allison, if you’re reading this, please enlighten us!

      • Allison Krehbiel May 19, 2016 at 5:10 pm #

        Drug courts vary from pre-conviction to post-conviction models. Most prosecutors prefer a post-conviction court for a variety of reasons. Remember, drug courts are part of the criminal justice system which in the past focused primarily on punitive responses. In my counties, it took months of effort for the prosecution to even consider participating in a drug court program. Just like judges, prosecutors and law enforcement are not trained in the medical field. Addicts are often seen as purposefully disobeying court orders and breaking the law when they continue to use after arrest and release. A conviction assures the prosecution that prison is the last stop for a non-compliant participant. That said, there is some statutory relief for first-time drug crimes that stays adjudication of the guilty plea. A convicted felon doesn’t qualify for government assisted housing, student loans etc. and finding quality employment is difficult. Educating criminal justice professionals regarding addiction is the answer to this issue. I talked earlier about compassionate coercion. Sometimes I have to “coerce” prosecutors to find a little compassion, but that it is an uphill battle.

        On a side note, I mistakenly referred to Xyprexa when I meant Suboxone. It doesn’t change my position, but does demonstrate my admitted lack of medical knowledge. I’d love to have a doctor on my drug court team!

        • Marc May 20, 2016 at 10:10 am #

          Allison, It would be absurd to require you to be knowledgeable about the nest of pharmaceutical interventions that can (sometimes) help the myriad and complex problems of chemical dependency. So the team approach is surely vital, as you emphasize.

          Yet I think we can’t help but wonder how such an interdisciplinary team works. There are certainly built-in biases and norms that must be difficult to see past. For example, the leakage of methadone you mention is clearly a hazard of the system itself. Is it best to look at this as an infraction or as a powerful need finding an available outlet? Check out my recent post describing a methadone clinic where the staff were able to bend with such “infractions” rather than respond to them with punitive consequences.

          It seems to me that the partnership between doctors and judges can only be a first step. You need psychologists and insightful addiction counselors, community workers and social workers, and “advocates” for your clientele as well. In fact the medical-legal partnership is strikingly top-heavy. Given that culture of authority (you’re all accustomed to telling others what to do), it must be hard to respond flexibly to the often disturbing, even defiant, behaviors of your clients.

    • Gina May 19, 2016 at 3:43 pm #

      Jurisdictions may vary in their approach to this, but in our county, you are required to plead guilty as a condition of being accepted into the drug court program. You then sign a contract that outlines the expectations for participation in and completion of the program and that details the outcome of the pending charges upon successful completion of the program.

      Unfortunately, this means the charges will appear in a criminal background check for the duration of the program (18 months to 2.5 years), adding an extra challenge to finding a job (a typical program goal). The charges are dropped upon successful completion, but often the penalties are much more severe than they otherwise would have been for participants who are kicked out or who drop out of the program.

  6. Percy Menzies May 19, 2016 at 6:33 pm #

    I can best describe Maia as the Donald Trump of the addiction field! She has opinions of every topic related to addiction and if you differ, you are going to be the recipient of her wrath!

    A good example is the sarcastic remark about Zyprexa! The judge did not prescribe the Zyprexa. She relied on a ‘professional’ physician who probably believed that this patient was using heroin to self-medicate his/her psychiatric symptoms. Rather than treat both symptoms simultaneously, the patient was sent back to the drug court on just one medication. This patient is almost certain to continue using heroin. We see this all the time.

    I am a speaker for the National Association of Drug Court Professionals (NADCP) on Medication Assisted Treatment (MAT) and I go all over the country training judges and treatment professionals on the use of MAT. I am shocked at the illiteracy of so called addiction professionals on MAT. Many don’t know the difference between a full agonist, partial agonist and an antagonist. We have dozens of drug court clients sent to our clinics for treatment. In my earlier article [last week’s post] I described in details how we offer patients treatment choices.

    It is quite OK to use compassionate coercion or as some judges like to call it ‘leveraged negotiations’ to get the patient off drugs and restore self-autonomy. Drug courts are often hampered by the poor training and knowledge of the ‘treatment’ providers. The biases and lack of knowledge negatively impact outcomes and if the patient fails or relapses, it is always viewed as the patient’s fault.

    Maintenance treatment with methadone and buprenorphine is seriously undermined by the ubiquitous presence of illegal opioids including heroin. The temptation to sell or trade the buprenorphine for heroin is way too strong and we see it day in and day out. The goal of treatment has to be abstinence from the offending drug. More and more drug courts are embracing the two-step approach of buprenorphine for a few weeks to a month and then transitioning to Vivitrol (the monthly injection of naltrexone). Here is the link to a great post written by a drug court judge:

    http://www.huffingtonpost.com/judge-david-a-tapp/sooner-rather-than-later_b_9366774.html

    It would be nice if patients adhered to the medication, be it methadone, buprenorphine or naltrexone. They don’t; the lure to use illegal opioids is way too strong. What is the judge going to do when a patient repeatedly diverts buprenorphine and tests positive for heroin? Helping patients overcome addictions is contingent on behavioral modifications and teaching these patients to live without drugs.

    Going back to my comments in the previous posts, I would invite anyone including Maia to come to our clinics in St Louis and see how well patients do when they are offered treatment choices.

    • Rebecca Breiman May 29, 2016 at 5:55 pm #

      Percy,

      I am surprised by your assertions that patients don’t adhere to their medication and wonder if that is something that you inform judges and other professionals of when you do trainings? If so, that would certainly raise a large concern for me since all I can find on that is anecdotal evidence that changes state to state and provider to provider.

      • Percy Menzies May 29, 2016 at 7:29 pm #

        Rebecca,

        Why are you surprised that patients don’t adhere to the medications? This goes to the very heart of the problem. Most patients coming to treatment programs come for the secondary consequence of their addiction. This may be a second or third DUI; an ultimate from the spouse; treatment or lose a job etc. Once this ‘problem’ is taken care of, there is strong tendency to go back to drinking or drug use in a ‘controlled’ fashion! This is the reason methadone is administered in a clinic setting; physicians need to obtain a DEA waiver to prescribe buprenorphine. Even with these restrictions the diversion of buprenorphine is very troublesome. The FDA just approved a buprenorphine implant that lasts for six months. We are looking forward to this device but there are going to be challenges. We face a similar problem with Vivitrol, the monthly injection of naltrexone. Patients think they are ‘cured’ and will not take the shots for a longer periods.

        Any disorder that impacts biological instincts of survival is tough to treat. Look at obesity. How many people stick to diets! Look at the challenge of educating diabetic patients to check blood sugar and stick to a diet! Addiction is memory and the lure to going back to an intoxicating drug is very strong. It takes 5-7 treatment episodes to get a patients off opioids.

        • Rebecca breiman May 29, 2016 at 10:42 pm #

          Percy,

          I know. I work in a clinic and have been in substance abuse for years.

          My concern is this: if we are so concerned with diversion on drug court, daily liquid methadone dosing and suboxone strip dosing- waiting at the window for it to be dissolved- is the option our clinic takes and we contract with drug court. So if we are concerned about sharing methadone doses and diversion, daily dosing and not dosing the BUP but rather the strips alleviates these concerns greatly.

          Vivitrol and the implant have always run the risk of failure to return, but cost is also interruptive to ongoing care with those meds- $1000 a shot for vivitrol is unsustainable.

          Best of luck to your clinic going forward-

        • Carlton May 30, 2016 at 8:25 am #

          Addiction has an additional, and a different aspect that these examples may not have.

          A person can believe and feel that the addiction is not only an essential, but a critically positive element of existence.

          As an addict that had gone to detoxes and hospitals about a decade ago, It was perplexing to experience professionals trying to treat, “cure” me. They clearly were not understanding the feelings surrounding addiction.

          The addiction had become the one thing actually worth living for, and to voluntarily not keep it in ones life, despite the consequences, was inconceivable, Its like leaving someone you love.

          The statement:
          “It takes 5-7 treatment episodes to get a patients off [an addiction], is decided more on what the person wants, not what a treatment does.

          One reason many people that recover , eventually leave a recovery group or program, is because it becomes harder and harder to relate to this feeling of preciousness, and you no longer feel part of a recovery group.

          • Shaun Shelly June 1, 2016 at 3:00 pm #

            Carlton, I agree with what you are saying. Most commentators are making huge assumptions based on beliefs that may not be true to the individual. Most people who use drugs in a dependent manner do not need treatment at all. They resolve these issues as their life and outlook changes, in their own time. Very few people consider the protective factor of drugs. For many the use of drugs and all that goes with it holds deep meaning. To simply legislate against that is absolutely futile and cruel.

            Instead we should be creating enabling environments and ameliorating the risks until people decide to reduce their use.

    • Matthew E McRee August 28, 2016 at 1:13 am #

      Percy,
      As a result of your professional background, I can understand your perceptions of the behavior of buprenorphine and methadone patients who are also drug court participants. However, the fact is that in contrast to the widespread belief that illicit or prescription full opioid agonists are somehow so tempting and seductive that patients rarely remain medication-compliant and sell their medication to buy heroin (etc.), the vast majority of Suboxone/Subutex and Methadone Maintenance Therapy patients remain free from non-authorized opiates for a many months or even years. First off, any Suboxone patient who takes at least approximately 8 mg per day or so will feel virtually none of the effects from nearly any alternative mu-opioid agonist (except for the extremely rare compounds that happen to significantly possess greater binding affinity than buprenorphine itself), thus it makes no sense for any patient in this category to seek out other opioids like heroin – unless they had specifically set aside a few days of withdrawal symptoms to allow their body to detoxify enough for other opiates to be at least somewhat effective. In the case of the two drugs Suboxone and Subutex, for people who are physically dependent on opiates and at the doses taken for OST, there are really none of the subjective feelings of “being high”, euphoria, etc. that are associated with recreational opiate use – rather, patients simply do not experience the immense discomfort that results from opioid withdrawal symptoms.

      Where I disagree with you is in your assertion that abstinence must always be the goal of treatment. While indefinite treatment is not preferable from the standpoint of either the patient or the treatment provider, opioid dependence is one of the most difficult substance use disorders to treat – with extremely high rates of relapse back to the patient’s opiate of choice and often intravenous use (which comes, of course, with many additional dangers beyond that of the effects of opiates themselves, e.g., HIV infection). If a patient is stabilized and functioning with methadone or buprenorphine, why push for them to taper off and begin abstinence, risking the far more serious outcome of full relapse into for example, heroin use? Furthermore, if the risk of diversion is such a problem, why do people choose to divert their medications in the first place? Of course, some diversion will take place for the purpose of obtaining other drugs on the street, but this will happen under any sort of system that focuses on the CONTROL of drug use, regardless of what measures are taken to prevent diversion. It appears that you and many other people related to the criminal justice system focus too heavily on the risk of diversion itself, without bothering to examine why it occurs. For example, because methadone is difficult to obtain outside of daily attendance at a methadone clinic, it has a high value on the street. As people who choose to start methadone maintenance therapy tend to be relatively poor (due to the often prohibitive costs of buprenorphine maintenance by comparison), there is an incentive for these often poor patients to sell their medications in order to pay for necessities outside of their daily “fix”. By taking economic and social inequities out of the picture, we largely miss the broader problems that lead to addiction in the first place – problems that we all are at least somewhat complicit in creating or perpetuating. Also, by ignoring these broader problems in our analysis of why drug addiction happens and our analysis of the problems within a treatment paradigm such as OST, not only is it easier for us to blame others for their problems (e.g., assuming that patients who divert their medications are not serious about their treatment or just want to make money), it also increases the likelihood that we will miss the broader solution to all drug addiction types.

      The reality is that the War on Drugs has been an abject failure based on Victorian-era moralism, a societal misunderstanding of each individual psychoactive drug’s risks and benefits (e.g., MDMA is a Schedule I drug, despite a substantial body of evidence proving MDMA’s efficacy in the psychotherapeutic setting, its relative safety to the user when compared to many legal prescription drugs like oxycodone, and its low risk of addiction due to neuropharmacological mechanisms that lead to self-regulation of use, etc.), the War on Drugs’ targeting of specific groups of people (most notably, African-Americans and Latinos) leading to mass incarceration the likes of which the world has never experienced before and that has destroyed millions of families and ruined any chance for certain people to work in legitimate jobs leading to a forced return to criminal activities, and finally, the War on Drugs’ complete and utter hypocritical disregard for “cognitive liberty” even as other forms of liberty are seen as sacred in this country (most notably: religious liberty, but the most sacred of all – property rights, also known euphemistically as “economic liberty”, meaning the right to make as much money as possible under as few regulations as possible, regardless of the negative impacts on society and individual people). If a person is a recreational drug user, but is not an addict, lives a normal and physically/psychologically healthy existence, and is contributing to society in some manner, what legitimate reasoning is there for drug use not to be a legal option for them?

      If certain drugs shall continue to be illegal, shouldn’t we at least have to demonstrate that these drugs are actually dangerous and have no accepted medical use? I mentioned MDMA earlier and as I said at that point, MDMA had a well-accepted medical use among clinical psychologists and psychiatrists who felt so strongly that it was helpful for their patients that they chose to protest the DEA scheduling meetings of the early 1980’s in order to ensure its legality. However, the Reagan-era DEA judge disregarded all professional opinions and made MDMA a Schedule I drug along with heroin. In contrast, alcohol has virtually no medically accepted use when consumed and worse, it is now established that alcohol is toxic to virtually all human organs including the brain, liver, kidneys, and so on; in addition to having a high propensity for abuse and dependence, and causing great social harm via the promotion of antisocial behaviors and violence against oneself and others. MDMA may be illegal, but it promotes PROsocial behavior, empathy towards others, introspection into the issues of one’s life, and prevents violence, thus causing almost no social harm of any kind.

      My point is this: don’t just fall into the trap of accepting what are seen as problems by the moralistic people in our societal elite and mainstream media figures trying to gain viewers, instead use academic findings and some form of philosophical lens to reach the answers closest to the truth. Addicts are looked down upon enough, and saying that medication compliance is low all because patients are somehow not smart enough and/or don’t care enough about themselves to make the smarter choice, is unfair to OST patients and demonstrates a prejudice of sorts that a person in your position can not have.

      Sincerely,
      Matthew E. McRee – future Ph.D Clinical Psychologist and well-informed Buprenorphine Maintenance Therapy Patient

      • Percy Menzies August 28, 2016 at 5:34 pm #

        Dear Matt,

        Thanks for your comments and let me begin by congratulating you for not only overcoming a disorder but coming close to being a Ph.D, candidate.

        We need to be clear about what constitutes abstinence. Abstinence is when patients stop using the offending substance like heroin or drugs obtained illegally. You are abstinent and so is a patient who is on methadone or naltrexone. The definition of ‘abstinence’ promoted by certain groups that true abstinence is only achieved when patients stop all medications is highly irresponsible and has no place in the treatment of addictive disorders. This rather rigid stances comes from some of the AA groups that erroneously consider OST (opioid substitution treatment) as substituting one addiction with another. This may have come from the past attempts to use addictive and abusable drugs like benzodiazepines as long-term treatment for alcoholism.

        The field of opioid treatment is strongly divided into ideological camps and often attack each other. The methadone clinics believe that methadone is the ‘gold’ standard and will rarely offer patients burepnorphine, naltrexone or Vivitrol. Physicians who have obtained the DEA waiver to prescribe burepnorphine will rarely offer naltrexone or Vivitrol. No chronic disorder is ever treated in this manner. I have mentioned in some of posts that the War on Drugs was a disaster but now we have to declare war on bad treatment.

        Patients that come to our clinics have so many medical and social problems. Many have not seen a physicians for years and the opioids have masked the symptoms of serious conditions that require urgent care. They have financial, legal, employment and martial problems and if we do not address these issues, the patient is certain to fail. For many their lives are a never-ending cycle of use, arrest and rearrests. The critical component of treatment is addressing both the addictive disorder and the behavioral component. The clinic has to offer these patients help with jobs, vocational training, housing, enrollment in insurance programs etc. How often does this happen?

        Why have my clinics done so well? We offer patients treatment choices starting with medical detox. It may come as a surprise to many that the vast majority of patients are not offered medical detox and it is euphemistically called ‘social detox’. It is high time that we critically look inward and set aside our biases and prejudices. Sadly, the last remaining war is the internecine war in the treatment of opioid use disorder.

  7. Dawn May 20, 2016 at 8:01 am #

    What I find interesting in the legal perspective is that drugs – and the medical model – are the answer to human problems.

  8. Maia Szalavitz May 20, 2016 at 10:36 am #

    I’m glad to see that Judge Krehbiel recognized and acknowledged her mistake— but it makes my point further, particularly the fact that these courts can operate without doctors! All I am calling for is that judges recognize that trying to determine for themselves whether methadone maintenance is acceptable or not and making claims about coercion being necessary is having medical opinions without knowing the data.
    The data is utterly overwhelming showing that maintenance with buprenorphine or methadone saves lives— there’s no such data about any other approach, including Vivitrol.

    It’s absolutely fine for judges to determine that getting help for addiction should be a condition of sentencing for crimes that are associated with addiction. It is not at all fine that they have any more say in what that treatment is than it is for them to have a say in whether Xyprexa or Haldol is used for schizophrenia or which treatments are acceptable for heart disease.

    • Marc May 20, 2016 at 10:43 am #

      That’s very clear, and I think it provides an excellent model for how the legal system could interface with treatment systems without compromising the efficacy of those systems. These are distinctly different domains of knowledge, rules, and expertise.

    • Allison Krehbiel May 20, 2016 at 8:41 pm #

      It took me five years and two grants to get a therapist on my team. I have a psychologist that works with us but does not come to pre court staffings. I have 1.5 hours a month of a psychiatrist’s time (which I prefer to use on partcipants’s med reviews). If I could find a doctor that we can afford, I’d be more than delighted. The issue is money. The next best thing is for appropriate team members to have the ability to speak with the doctors. If anyone has suggestions on how drug courts could team up with doctors, my courts will be the first in line.

      • William Abbott May 25, 2016 at 2:40 pm #

        I am a retired MD. I know of many physicians who might be able to help and maybe even do it pro bono if not too taxing. Some I know well
        ( including me } are very active in other aspects of recovery

        Finding them is the hard part and Ill give that some thought

        • matt May 27, 2016 at 5:54 am #

          Hi Bill

          Might it be feasible to even work it into the rotations in medical training? Addiction medicine is a part of many medical programs now. Could integrating the legal and medical aspects at the training level for both doctors and lawyers be a good idea?

          • William Abbott May 27, 2016 at 9:56 am #

            Its a dandy idea but realistically unlikely– med school curricula are now stressed by getting enough of the enormous bioscience deemed essential to medical core knowledge and practice. Addiction as a topic even today doesnt get much attention as wed like although that is slowly improving

            We have to be careful– unless you want to call addiction a disease. Ha !

            • matt May 27, 2016 at 1:12 pm #

              Or a crime. Or a moral failing. I don’t want to call it a disease. But as they say, “If nothing changes, nothing changes.” We have to start somewhere. Why does a curricular strand in something like “integrative addiction medicine” seem unrealistic? It could have modules that include all the areas of expertise that become involved and potentially effect treatment for good or ill. Or even a survey course. Right now the right hand generally doesnt know what the left is doing, and sometimes it’s reaching into the wood chipper. If we don’t start thinking outside the box, we’re living in a box.

  9. matt May 21, 2016 at 10:48 am #

    One of the things that’s frustrating about this, is that there is so much contention about what is wrong with approaches to addiction and treatment that we fail to connect the dots on where we agree as much as to where we differ. And this just muddies the water. It’s a multi-faceted problem which requires a multi-faceted, interdisciplinary approach to find solutions. These include psychology, medicine, law, social work, education, and on and on…

    I think Judge Kriehbiel’s team approach at least recognizes this complexity. It’s going to require better communication between all the well-meaning tentacles of the societal octopus to come up with alternatives that work for everyone. Communication over antipathy. The Open Dialogue approach that has been mentioned before in this blog, is one that tries to bring all the players together on the same page and in the same room as the person who is struggling. That intersection and connection is where real healing can begin.

  10. Rebecca Breiman May 22, 2016 at 1:39 pm #

    I appreciate you sharing this-
    I think where she sways of course is the tendency- sometimes even subtly- for drug court judges to practice out of their scope. Her “opinion” on methadone or suboxone doesn’t matter. The rule of law does- and she has no business extending or applying her undecided opinion upon her participants.

    While drug court judges him-and-haw about medication assisted treatment and defers to addiction professionals that would also be a failing on behalf of their court. Doctors are the professionals when it comes to medications- I’m an addiction professional in a medication assisted treatment center and when it comes to dosing, milligrams, increases or tapers, that is in the hands of licensed MD’s. Which is appears she has not checked in with yet. Anyone can share their methadone- that’s a personal offense to the system and not a determinant of the appropriateness of the drug being used in the courtroom.

    It’s been a notorious problem with drug court judges that they fail to recognize where their interpretation of the law and drug court policies end and the work of other professionals begins. I’ll admit that that she is more liberal than some though won’t lower my standards of what a drug court judge should back away from.

    In my city, felony drug court finally approached my clinic and asked for help. Their opiate addicts were dying while enrolled in the program and they had to turn to medication assisted treatment to aid in drug court being effective. The bottom line is that they asked us for help: they came for information on efficacy and a trial program. If she wants interaction with the medical community, ask for it. If you’re going to talk about suboxone, get your facts straight. It is disappointing to me that a judge who is not decided on whether or not to allow medication assisted treatment doesn’t actually know the name of the drug that she’s so intent on reserving approval for.

    Drug court is a good program that is just BARELY catching up with evidence based practice and client centered care. Like I said, she seems more liberal than most but so long as judges are using the gavel to dictate treatment approaches rather than the other way around, drug court may be consistently one step behind recovery. And we simply can’t afford that.

    • Marc May 24, 2016 at 7:41 am #

      Very powerful argument, Rebecca. Thank you.

      I have no idea of the sorts of constraints Allison has to cope with….but it seems clear that many of them are financial, and that reflects society’s continuing contempt for addicts and their woes.

      I do like your conclusion: that treatment centers should dictate to courts rather than the other way around. Still, isn’t it a two-way street in the present context?

      I think Johann Hari should be required reading by the middle of high school. Attitudes have to change big-time before individuals can make meaningful advances in dealing with the specifics.

      • Percy Menzies May 24, 2016 at 4:47 pm #

        Having worked with drug courts for so many years, the problem stems from a lack of standardization of treatment. Judge may send a patient to a residential treatment program and nobody knows what happens there. The vast majority of patients receive no medical treatment, which puts them at a high risk of overdose (as Gina pointed out) when they return home.

        Treatment centers working with drug courts have their own biases. Some are very open to medical detox, stabilization and maintenance meds. Others are strongly opposed. Most patients are forced to attend self-help groups like AA or NA.

        Patients with addictive disorders are very good at manipulating the physician in giving them what they want. It usually involves intoxicating medications like opioids, benzo and stimulants. The patient may trade or take too much of the meds. What is the judge supposed to do? Just shut up and listen to the treatment professional? What is the judge supposed to do if the patient doctor shops and starts taking these meds inappropriately claiming these were prescribed by a doctor? Drug legalization/decriminalization sounds romantic and may draw applause, but there are way too many practical challenges we face in the trenches of treatment.

        The success of the drug court is going to be based on forming a true treatment team comprising the drug court and treatment provider. Medication Assisted Treatment is a relatively new approach that is not clearly defined and standardized and judges like Allison are needlessly caught up in the controversy. Lonny Shavelson, a medical doctor who followed the lives of several patients addicted to drugs and alcohol, wrote a well-received book titled: Hooked and said it very well: “The secret lies not only in coercing addicts into treatment, but coercing the programs to do rehab right”.

  11. Dave May 22, 2016 at 6:50 pm #

    Is there a presumption by the drug court that everyone who comes before the court is an addict? How is the determination of addiction made?

    If no determination of addiction is made, can the judge make the determination that a person is better off without treatment, or without probation? For example, if someone is not an addict, then allowing charges to appear on someones records for 2.5 years (as another poster stated) would make their chances of finding employment much more difficult and create a greater risk of addiction for that person. I am curious what a judge can do in a situation like that.

  12. Gina May 23, 2016 at 6:53 pm #

    Maia and Rebecca hit on many of the points I wanted to raise, so I won’t repeat them here, but instead will focus on my personal experience with drug courts.

    My daughter is finishing up her first year in our county’s drug court program and I must say that as drug court programs go, ours is fairly progressive (despite its many limitations). At the very least, they do have a clinical psychologist heading up the program and they’ve allowed my daughter to remain on the methadone that is working SO incredibly well for her. They also allowed her to attend a harm-reduction oriented intensive outpatient program during the first phase. For that, I’m grateful. However, even though attendance at 12-step meetings is ostensibly not required (and she refuses to attend because she was stalked and sexually assaulted by someone she met at a meeting), the judge and the PO continue to strongly pressure her to attend meetings and she receives something barely above a level of scorn for choosing not to. This, despite all her other life accomplishments—she sees a therapist 1x week, attends weekly DBT skills training, is going to school, just got a job, etc. and has had only one minor slip since beginning the program.

    Her boyfriend’s experience with the same drug court has been abominable. He’s overdosed once already waiting for an evaluation by the drug court to assess his medical needs, which took months. Not surprisingly, he ended up back in jail where he sat for several months, supposedly until a bed became available at a state-funded inpatient facility they’d selected. When he was finally released, however, instead of going to the inpatient facility, he went to a sober living facility, where he receives no treatment (just 12-step meetings on site every night), has a strict curfew, but is not allowed to remain on the premises during weekday business hours because he is supposed to be looking for a job or working (even though he had neither a job nor a car to look for one upon his release, but did have a criminal record, thanks for the pending charges). So, they let a young man whom they knew had a 10-year history of opiate addiction, and whom they also knew had overdosed just months earlier, go directly from jail to a sober living facility where he would be completely unsupervised off-site and left to his own devices for 8+ hours each weekday. That’s another overdose waiting to happen and is inexcusable, so this really undermined my faith in this particular drug court program. As far as I’m concerned, they have [inadvertently] set him up to fail (and possibly OD). I certainly hope I’m wrong.

    So, while I certainly do appreciate this judge’s fairly progressive and thoughtful stance on the issue, some of the positions she intimates in this post (already pointed out by Maia and Rebecca above) and certainly the experience of my daughter’s boyfriend and others I know personally, are among the many reasons I see a great cognitive dissonance in allowing the courts to play any role whatsoever in the “treatment” of addiction and problematic drug use, which are first and foremost health issues, not criminal ones (so long as that person causes no legal harms to others).

    In an ideal world, the mere use and possession of all drugs would be decriminalized (at a minimum), making drug courts mostly, if not entirely, unnecessary, hopefully making way for more effective, science-based, compassionate and humane ways of of dealing with the public health issue that drug use sometimes presents.

    Below is a link to a well-researched paper by the Drug Policy Alliance, an organization that does some really fantastic work in the area of drug policy reform, which really highlights some of the flawed research on which drug court “successes” are based and examines 1) what if any impact drug courts have had on the problem they were created to address; and 2) how they compare with other policy approaches to drug use in terms of reducing drug arrests, incarceration and costs as well as problematic drug use. The answers are eye-opening and raise many more questions about what we could do better:

    http://www.drugpolicy.org/sites/default/files/Drug%20Courts%20Are%20Not%20the%20Answer_Final2.pdf

    • Marc May 24, 2016 at 7:34 am #

      Gina, thanks for sharing these perspectives on drug courts. The stories are powerful and their implications seem very convincing to me. I can fully agree that the criminal justice system should play no part in addiction treatment per se. Which means that using has to be decriminalized. But is there a grey area, when people with addictions are busted for non-drug crimes…e.g., B&E and theft (that was me years ago)? Under those circumstances, could there be a role for courts as intermediaries in treatment?

      • Gina May 24, 2016 at 5:47 pm #

        Marc, I don’t necessarily see that as a grey area. If you harm another (in the legal sense), you should deal with the consequences whether you were under the influence or not (we pretty much do this with alcohol). Everyone should be held accountable for those actions that harm others, without question, including those who do so under the influence of drugs or alcohol. To your point, though, I do think that the presence of addiction can and perhaps should be a mitigating factor in charging and sentencing, particularly when it comes to most “drug seeking” crimes (typically theft). In such cases, diversion into treatment makes sense, perhaps along with some form of community service or restitution and, yes, perhaps even jail time, depending. Maybe drug courts could play a role there, but we still need to clean up the problems with them or we’ll get nowhere.

        That said, it’s worth noting that the Swiss have managed to all but eliminate drug seeking crimes (I.e., theft, etc) among those who are prescribed heroin maintenance (a form of highly controlled legalization I’m firmly in favor of), so perhaps we should consider taking a few steps back to see this from a broader policy perspective.

        Finally, I don’t want anyone to misunderstand that I think all crimes committed “under the influence” should come with mitigated charges and sentencing just because someone happens to have a drug problem. This is particularly not true when it comes to violent crime (which, fortunately, is relatively rare among even problematic drug users).

        To illustrate, an 8th-grade classmate of mine who happened to be the daughter of a fairly successful 70s soul singer (who shall remain nameless) is serving a 37-year prison sentence for strangling a 55-year-old widow to death in a botched robbery attempt (allegedly to obtain money to buy crack). It’s such an incredibly tragic situation all around, and while I have a great deal of compassion for this young woman I used to pass notes to in class, it’s hard for me to argue that she isn’t exactly where she belongs.

        • Marc June 4, 2016 at 7:14 am #

          Hi Gina. Yikes! Your comment is moving and thought-provoking. Yes, probably your former classmate is where she belongs. It’s a rat’s nest trying to figure out where “blame” lies in a massively complex system of interacting causal factors. (imagine if we tried to lay blame one one species or another in an evolving ecosystem!) So we humans use a set of rules, based on a normative consensus of what’s okay and what’s not. And I can’t think of any better alternative.

          That said, my crimes were not “under the influence”. Rather, I desperately wanted to be under the influence — a point you also discuss. So, indeed, the Swiss solution would have worked really well for me: If I can get the drugs I (seem to) need then I will be a lot happier and so will those I burglarized. (and I’m sure I would have gotten bored and quit eventually, as do the people under prescription heroin in Switzerland, and as I did myself, even without the boredom incentive)

          I think Johann Hari is right, all the way down the line, and that the War on Drugs is the fundamental culprit. I was under the influence of craving, nothing more, nothing less.

          That said, I think my crimes (and maybe those of your former classmate…maybe…) are comparable to the crimes of a stalker — someone who loves someone they can’t have, so much that they commit grave wrongdoings. But then you could maybe say the same thing about pedophiles, and on and on, which is why I end up where I started: in agreement with you. That crimes against people have to be punished or otherwise dealt with AS crimes against people…regardless of whatever’s going on in the motivational system of the brain.

  13. recoverycnt May 24, 2016 at 3:04 am #

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  14. William Abbott May 25, 2016 at 2:30 pm #

    Late in catching up to this and what a breath of fresh air it is. These days the drug courts are getting a very bad rap inspite of the fact that some, like this one are really good, and sure seems a better alternative for some than the older way .

    Offering people a choice is a huge motivator towards them starting to take action and make the changes to lead them to a better life.

    Thanks Marc and our enlightened Judge

  15. matt May 27, 2016 at 6:43 am #

    …and as Marc frequently points out: pride, arrogance, compassion, and social responsibility are neither genetically predetermined nor are they diseases. But they all come into play in the high stakes realm of addiction and its far reaching effects on individuals, families and society. Change has to come, and getting all the relevant areas of expertise together (law, medicine, psych, social work, education, etc. etc…) would go a long way toward the de-balkanization of theories of addiction and treatment.

  16. Shaun Shelly May 29, 2016 at 2:36 pm #

    I think that this whole thread makes one thing abundantly clear: Trying to rely on courts to determine what the best response is for some one who uses drugs, with or without an “addiction” or SUD is not in the least appropriate. Even with Allison’s desire to do the right thing, she does not have the resources or the training for this and these decisions are life-changing and life-long sentences on a person’s life.

    Drug use should not be part of the criminal justice system. Full stop. End of story.

    And Percy, to call Maia the “Donald Trump” of Addictions is just insulting. She is by far the most intelligent commentator on addiction related issues in the mainstream press. You may not agree with everything she says, but her points are supported by the data.

    And as for the comment: “The goal of treatment has to be abstinence from the offending drug.” RUBBISH! Not even according to the DSM5 or SAMHSA or the UK Commission is abstinence the measure of treatment success.

    Drug courts CAN only be coercive and a violation of human rights.

    • matt May 30, 2016 at 7:23 am #

      Amen, Sean. The goal of treatment is to live a balanced, “happy” life. It’s not about trying NOT to do something and proscription.

    • Gina May 31, 2016 at 1:30 pm #

      I second everything Shaun said.

  17. Rebecca Breiman May 29, 2016 at 5:48 pm #

    In response to above by Percy-

    Your hesitancy of medication assisted treatment is based on distrust of the medical system failing to run appropriate DOPL reports, coordinate with drug court providers and treatment centers, and the hesitancy there is understandable but not enough to detract from the necessity of medication supported treatment for the many thousands that pass through drug court every year.

    In many ways I agree with you aside from the idea of the judge being caught in controversy- I strongly believe it is the legal system not producing solid, evidenced supported decisions that create controversy. The evidence is there: it works. And it’s not a huge population out of the overall drug court participants that will qualify.

    I harp on this point perhaps too often, but do we really have a bunch of time to sit around and think- one person every 24 minutes.

    I also wonder as to the necessity of addressing Maia so negatively in several of your posts- it’s a bit off-putting.

    Thank you for your post-

    Rebecca

  18. Elisa Kits May 31, 2016 at 9:43 am #

    I think more knowledge about drugs needs to come out to the public. I think more blogs like this one will raise awareness of drugs and will help get them off the streets and start to save more lives.

  19. Jordan June 1, 2016 at 9:08 am #

    Thanks for sharing this. I think the comments here do show how divided people are on the best way to handle heroin addicts in the court system. There’s a variety of opinions out there and tons of theories on what should be done.

  20. martha June 3, 2016 at 5:21 am #

    Following the discussion and learning a lot on the impact of drugs and peoples perspective about them and also how the court handles these cases.

  21. Alexandria June 6, 2016 at 8:05 pm #

    While I think she did an excellent job outlining our experiences with drug court already, I wanted to add a bit to my mom’s (Gina’s) comments here with a few more details as well as my own thoughts on the subject.

    I apologize in advance for the length of my comment; I’m afraid I’m not terribly good at being concise when talking about these issues.

    As my mom mentioned earlier, my boyfriend and I are both in our county’s drug court program–he signed his contract in January, and I signed mine last September. During that time (and actually starting in July, when I decided to go back on methadone), things have been going very well for me, aside from a minor slip I had about five months ago for which I was sanctioned–thankfully not with jail time, although I was required to do more frequent drug tests, attend two meetings through probation and complete a second round of IOP for 30 days.

    Contrast this with my boyfriend’s experience in the same drug court. He was incarcerated from June through November of last year, and because he hadn’t been formally accepted into drug court just yet, he was released without any real plan or support structure in place, unless you count myself and his father. Unsurprisingly, he was using again by the time he signed his contract and tested positive for opiates twice in the first week. He was supposed to have an intake appointment at another IOP program coming up, and apparently the drug court staff believed that would be enough to help him, as they chose not to sanction or even reassess him despite knowing that he was actively using again at that point. However, the night before his appointment (and only a week and a half after starting drug court), he was arrested in another county for possession and DUI when they found him passed out behind the wheel after injecting (this was his first DUI, and thankfully no one was hurt and no damage was done). The possession charge was dropped, and but for our drug court’s new prosecutor (a woman our lawyer referred to as “flighty” on several occasions), the DUI would likely have been dropped as well. However, she decided to put in a petition to terminate him from drug court as a way to essentially coerce him to, in her words, “take his weight” and plead guilty to the DUI at his first court date for that case. If he didn’t and tried to fight or delay the case instead, the prosecutor said she would have him terminated from drug court, which meant he would have to serve a minimum of six years in prison. (Of course, we had no way of knowing at the time if she was planning on terminating him regardless). Ultimately he took the plea, received court supervision for the DUI and has been in a halfway house since his release in April.

    I should add that at some point during all this, he was told by his public defender that he would not be allowed to try MMT because it was drug court policy that participants cannot start methadone treatment while in drug court, and that they made an exception for me because I began MMT prior to signing the contract.

    While he is doing incredibly well now–I couldn’t be more proud of him–and I suppose one could argue that he may not be doing so well now if not for the way things unfolded with drug court, I still take serious issue with more than a few aspects of what happened. For instance, I understand why they wanted him to take responsibility for his actions, but what about the drug court staff taking responsibility for their own actions (or lack thereof)? Why didn’t anyone working in their program think to intervene when they first realized he was still struggling with active substance use, before things got to the point that they did? Isn’t that the whole point of drug court? I can’t help but think that everything could have been avoided had they done something sooner, rather than waiting until it was too late and laying the blame solely on him. In my eyes, they set him up to fail from the start, even if it wasn’t intentional. As a result, he now has no leeway to be anything short of a model participant for the nearly two years he has left of the program, because even a minor infraction of drug court rules means a lengthy prison sentence–which, it’s worth noting, would be much longer than what he would’ve received had he not gone through drug court at all.

    And this leads me to a larger issue I have with drug courts and drug criminalization that disturbs me a great deal. I look at my boyfriend, a wonderful person whom I love dearly, and who would not be a “criminal” if not for our wayward policies, is facing six or more years in prison for essentially nothing more than the fact that he has struggled greatly with a long-term, severe addiction–or at least, an addiction to the “wrong” thing. (If he didn’t also happen to be white, I have a strong feeling he would already be serving that prison sentence, as there seem to be very few people of color who are accepted into our drug court program despite the disproportionate number of them in jail.) Additionally, I would not be a “criminal” either if not for my own struggle, and neither would millions more otherwise innocent people.

    Then I look at people like the Stanford boy who was recently given a paltry six-month sentence in county jail plus three years probation for sexually assaulting an unconscious woman behind a dumpster (and it’s a miracle he’s even been convicted and ordered to serve any jail time at all, considering well over 90% of rapists never spend a day behind bars, including both of the men who sexually assaulted and abused me). How can it be that people like us are made to serve years behind bars for the “crime” of having a vice that, by sheer accident of history, happens to be illegal and carry frequently harsh sentences, while people who commit the violent and heinous crime of rape and sexual assault–a crime with true victims who will have to live with that trauma for the rest of their lives–go unpunished (and are allowed to victimize still more people)? Why is it that being a highly accomplished person with good grades is enough to avoid harsh punishment for being a rapist, but not a person living with addiction? To this day, I have spent more time in jail as a result of the sex crimes committed against me–a large part of how my addiction developed was in response to trauma and PTSD–than both of the men who violated me combined. And yet, strangely, when my “coping mechanism” was an eating disorder, the police never showed up at my door to arrest me for that, nor did I get placed in “eating disorder court.”

    Sometimes I feel like the more I learn about our justice system, the less I understand it.

  22. rachel yuri June 7, 2016 at 9:51 am #

    The evidence is there: it works. And it’s not a huge population out of the overall drug court participants that will qualify. Drug use should not be part of the criminal justice system That intersection and connection is where real healing can begin.

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