Abstract
Drug courts began in 1989 in Miami-Dade County, FL. Due to their success in treating substance use disorders and reducing criminal recidivism, they have expanded globally and are currently operating in countries such as Australia, Canada, and Scotland, to name a few. Drug courts can be a key intervention in addressing the opioid epidemic. This is the first known qualitative study to ask drug court participants (n = 38) who have opioid use disorders questions related to their lived experiences in drug court, as well as direct questions related to the use of medication-assisted treatments (MATs) in drug court. Overall, drug court participants felt that MATs were helpful for treating their opioid use disorders; however, some participants reported using other drugs while on MATs and they viewed their recovery through a harm reduction lens. Additionally, participants emphasized the importance of using MATs in combination with counseling that used cognitive and behavioral therapies. Implications for drug court practice and future research are discussed.
Keywords
The United States (U.S.) is currently experiencing an opioid epidemic that is having devastating consequences on individuals and families, the health-care system, criminal justice system, and overall economic well-being of the country. In 2015, more than 33,000 Americans died prematurely from an opioid-related drug overdose (The Council of Economic Advisers, 2017). Overall, the estimated economic impact of the opioid epidemic on the U.S. is 504 billion dollars; this estimate includes all consequences of the opioid epidemic including overdose deaths and other expenses such as increased criminal justice costs for the policing, arresting, and incarceration of individuals who possess or sell illicit opioids (The Council of Economic Advisors, 2017).
While the negative consequences of the opioid epidemic seemed to have appeared rapidly, the epidemic is actually an unintended consequence of U.S. medical trends that began approximately three decades ago (U.S. Department of Health and Human Services [HHS], 2018). During the 1990s, prescriptions for opioids began to increase and become one of the standard, first options for treating pain. Recent data show that U.S. pharmacies dispensed 214,881,622 opioid prescriptions in 2016, resulting in 66.5% of Americans receiving a prescription opioid that year (Center for Disease Control and Prevention, 2017). In 2017, opioid addiction was declared a national public health emergency (HHS, 2018).
As the number of opioid prescriptions has climbed, the rates of opioid use disorders have increased, too. Although not a process that happens for everyone, prescription opioid use can progress to illicit drug use via the development of tolerance and withdrawal, two primary symptoms of a substance use disorder (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). For instance, an individual who has been taking an opioid (e.g., Vicodin) as prescribed may develop a physiological tolerance to the drug and therefore need more of the drug to get the desired effect. They may take more of their medication than prescribed and therefore not have enough to last an entire month, leading to withdrawal when they no longer have the medication. To avoid powerful and overwhelming withdrawal symptoms, the individual may turn to illicit behavior such as buying heroin or fentanyl illegally. This pattern is common, and many illicit opioid users originally began their use with prescription opioids (Center for Disease Control and Prevention, 2017). Thus, if effective treatment is not an option, many opioid-dependent individuals may resort to criminal behavior to sustain their substance dependence. Besides the resultant increased risk of criminal justice involvement, users of illicit opioids are also at higher risk of overdose and death due to the powerful nature of these drugs and the difficulty in estimating their strength when buying illegally; U.S. opioid–related overdoses are currently at an all-time high (Rudd, Seth, David, & Scholl, 2016).
The U.S. criminal justice system is overburdened with people who have been convicted of drug-related crimes, yet lacks the ability to effectively treat substance use disorders. Nearly, half a million Americans were incarcerated for drug-related offenses in 2016 (The Sentencing Project, 2018). At the federal level, nearly half of the prison population is comprised by people who had drug-related convictions. However, only about 15% of inmates who have drug use disorders receive needed treatment (Bronson, Stroop, Zimmer, & Berzofsky, 2017). The opioid epidemic has contributed to these rates, and approximately 22% of incarcerated individuals report regularly using heroin or other opiates prior to their incarceration (Bronson et al., 2017).
Medication-assisted treatments (MATs) are a harm-reduction approach taken to reduce the risk of morbidity, mortality, or other negative consequences of chronic opioid misuse. With MATs, opioid agonist medications are prescribed and closely monitored to control the level of medication ingested, thereby reducing drug-seeking behaviors and intense highs and withdrawal periods associated with illicit drug use (National Institute on Drug Abuse [NIDA], 2018; SAMHSA, 2018; Volkow, 2014). Prescribed opioid agonists have been found to decrease risk of mortality, illicit opioid use, infectious disease transmission, and criminal activity as well as increase employment for people who are dependent on opioids (NIDA, 2018). However, these medications are not always used or encouraged by the criminal justice system due to an abstinence-based philosophy of drug treatment or concerns about potential drug diversion (Friedmann et al., 2012).
Use of the Criminal Justice System for Treatment
The criminal justice system can play a key role in addressing the opioid epidemic, particularly by providing enhanced treatment and recovery services to individuals coming in contact with the system. A priority of the HHS is to address the opioid epidemic through enhanced treatment and recovery services for people with opioid use disorders (HHS, 2017). Drug courts are one such option for ensuring that treatment- and recovery-related services are combined with the criminal justice system, both in the U.S. and internationally.
Drug courts are specialized programs that target offenders with substance use disorders or drug-related crimes. These programs are problem-solving courts that provide screening and assessment, treatment and recovery services, monitoring, and progressive incentives/sanctions to provide support for recovery. Drug courts have seen tremendous growth both inside and outside the U.S. since beginning in 1989, and there are now approximately 3,100 drug courts in the U.S. (U.S. Department of Justice, 2018). Drug courts have expanded globally, operating in countries such as Australia, Brazil, Canada, England, Ireland, Jamaica, and Scotland (Holst, 2010).
Three decades of evidence have shown that drug courts appear to be more effective than traditional criminal justice interventions (such as probation) at reducing criminal recidivism rates for individuals who have substance use disorders and arrests for nonviolent offenses. The evidence that drug court participants recidivated at lower rates than comparison and control groups is highlighted in quasi-experimental studies of single drug courts (Brown, 2011; Gallagher et al., 2015), rigorous evaluations that used experimental research designs (Gottfredson & Exum, 2002; Gottfredson, Najaka, & Kearley, 2003), and meta-analytic reviews (Mitchell, Wilson, Eggers, & MacKenzie, 2012; Shaffer, 2011). More recent research has moved beyond quantitative outcome studies to focus qualitatively and primarily on understanding barriers to and improving outcomes for certain populations that drug courts serve, such as women or African Americans (see Gallagher & Nordberg, 2017; Gallagher & Wahler, 2018; Vandermause, Severtsen, & Roll, 2013). However, no known studies have examined the lived experiences of drug court participants who have opioid use disorders.
Drug Courts and Treatment of Opioid Use Disorders
Although designed to ensure offenders receive needed drug treatment, U.S. drug courts have been criticized for sometimes failing at this goal (Matusow et al., 2013; Mehta & Møllmann, 2017). A recent survey of drug courts in the U.S. found that nearly all drug courts surveyed (98%) served participants who had opioid use disorders, yet only 56% offered or allowed MATs (Matusow et al., 2013). Observed barriers to using MATs in drug court included cost but also opposition from key stakeholders such as the drug court judge and prosecutor (Matusow et al., 2013). In a similar study, Friedmann and colleagues (2012) also found that MATs were infrequently allowed or used in criminal justice settings such as drug courts, probation, and parole. When used, MATs were most frequently used by pregnant women who had opioid use disorders and were in opioid withdrawal. This is most likely because of federal and international guidelines urging the use of MATs for opioid-dependent pregnant women due to the associated reduction in risk and harm to the fetus (American College of Obstetricians and Gynecologists, 2017). Friedmann et al. (2012) found that nonpregnant drug court participants or individuals reentering the community after incarceration were commonly denied or did not have access to MATs, despite the benefit these populations could also gain from these treatments.
The lack of MATs used in some drug courts may contribute to participants who have opioid use disorders having poorer outcomes such as lower graduation rates or higher relapse or criminal recidivism rates. A recent study by Gallagher and colleagues (2018) found that participants who identified opioids as the primary drug used were 80% less likely to graduate, as compared to drug court participants who identified nonopioids as their primary drug. Only 30% of participants who primarily used opioids successfully completed drug court, whereas nearly 70% of participants successfully completed who primarily used nonopioids. In addition to MATs, another key intervention in treating opioid use disorders is requiring drug court participants to attend treatment for their substance use disorders. Drug court participants should be receiving treatments that are cognitively and behaviorally based and treatments that have demonstrated effectiveness in treating substance use disorders and improving well-being (National Association of Drug Court Professionals [NADCP], 2018). Unfortunately, recent qualitative studies have suggested that some drug court participants were dissatisfied with the quality of treatment they received (Gallagher, Nordberg, & Lefebvre, 2017) and not receiving adequate care for their mental health symptoms that commonly co-occur with substance use disorders (Gallagher, Nordberg, & Gallagher, 2018).
Developing an in-depth understanding of drug courts and how they serve participants who have opioid use disorders is a priority. The drug court for this study treats individuals who have been arrested for nonviolent offenses and have substance use disorders. Drug court participants are, most commonly, arrested for possession of a controlled substance, possession of drug paraphernalia, and acquiring possession of a controlled substance by fraud and theft. Additionally, participants are accepted into drug court based on evidence that their drug use, or substance use disorder, was associated with their criminal activity (e.g., forging prescriptions to gain access to opioids for personal use). A key aspect of drug court that differs from traditional criminal justice interventions (e.g., probation) is that drug courts employ a multidisciplinary judicial team. The drug court team for this study includes a judge, drug coordinator, chief probation officer, case managers, prosecuting and defense attorneys, researcher, social workers, recovery coaches, addictionologist, and addiction and mental health treatment providers. As previously mentioned, an addictionologist is part of the drug court team, and having access to a physician who can prescribe MATs is certainly a strength of the program.
Furthermore, consistent with best practice standards, the drug court requires participants to attend counseling for their substance use disorders, attend status hearings with the drug court judge, submit urine drug screens on a random and frequent basis, and advance their educational (e.g., earn a General Education Diploma [GED]) and employment (e.g., gain and sustain a job) status (NADCP, 2004). The drug court is an abstinence-based program, meaning it requires participants to abstain from drugs and alcohol. However, if relapse occurs, the drug court model sees that as an opportunity to intervene in a therapeutic way (e.g., increase treatment), as compared to punitive interventions (e.g., long-term incarceration). The length of the program varies based on participants’ progress in meeting their treatment goals. The norm, however, is 12–24 months, and if participants complete the program successfully, their criminal case is dismissed. The current study is the first known qualitative study to explore the lived experiences of drug court participants who have opioid use disorders and their opinions about the use of MATs in drug court. This study is guided by the following research question: What are drug court participants’ perceptions on the most helpful aspects of drug court in treating their opioid use disorders, how the drug court could be more helpful in treating their opioid use disorders, and their thoughts and experiences on the use of MATs to support recovery?
Method
Qualitative Research Design and Sampling
This study is part of a larger evaluation that used the same methodology (Gallagher, Marlowe, & Minasian, 2019). This study was approved by the institutional review board at the authors’ university. The population of interest was drug court participants who had opioid use disorders, so all participants were recruited from this group and were identified as having a moderate to severe opioid use disorder. Participants were asked the questions in Table 1, focused on their perceptions of helpful aspects of drug court, how drug court could be more helpful, the benefits and challenges of using MATs, and whether drug court effectively uses MATs to treat people who have opioid use disorders. These questions were asked in focus groups, which are recommended when research participants have similar characteristics, such as being a member of drug court and having an opioid use disorder, and, due to these similarities, may complement one another’s experiences and add to an in-depth understanding of a particular phenomenon (Padgett, 2016; Rubin & Babbie, 2008).
Focus Group Questions.
Note. MATs = medication-assisted treatments.
Research participants (n = 38) were recruited in 2018 from one drug court located in a Midwestern state in the U.S. Two researchers attended six drug court hearings, which were held every Monday, to recruit research participants. The two researchers facilitated one focus group each Monday immediately after the hearing for consenting participants; therefore, they attended multiple drug court hearings to assure all who were eligible to participate in the research had an opportunity to do so. During the recruitment process, the researchers introduced themselves, described the research question and format of focus groups, highlighted that participation in the research was voluntary and confidential, and mentioned the inclusion criteria. Inclusion criteria were (1) must be a current participant in the drug court; (2) must be able to comprehend, speak, and read English; (3) must be 18 years of age or older; and (4) must have an opioid use disorder. Individuals who met the inclusion criteria and volunteered to participate were scheduled for the focus group after their hearing. In order to promote convenience for the research participants, the focus groups were facilitated in the same building as the drug court but on a different floor. Focus groups were facilitated in a private, closed conference room on a secure floor.
The focus groups were co-facilitated by two researchers and audio reordered. The focus groups were semistructured; specifically, research participants were asked the five open-ended questions noted in Table 1, and probing questions were used to develop an in-depth understanding of their lived experiences in drug court. For example, the researchers used validating statements and probing questions such as, “It sounds like Vivitrol has helped you maintain abstinence from opioids. Could you please describe how maintaining abstinence from opioids has impacted your life?” and “Balancing all the responsibilities of drug court with life seems to be a challenge. Could you please further describe the specific challenges you face?” It is important to note that the questions in Table 1 guided the focus group discussions, but participants were free to share any thought, opinion, or experience that related to the treatment of opioid use disorders or participation in drug court. Informed consent was received by all those who chose to participate in a focus group.
Qualitative Data Analysis Plan
The audio recordings of the focus groups were transcribed verbatim and uploaded to NVivo (Version 10), which is a qualitative data analysis software. According to Miles, Huberman, and Saldana (2014), qualitative data analysis is theoretically driven; the data from this study were analyzed through a phenomenological lens. Phenomenological analysis explores the lived experiences of research participants, as well as the context of those experiences (Padgett, 2016). In this study, research participants were asked questions about their lived experiences in drug court and also encouraged to elaborate on how the experiences have impacted their lives or perhaps the lives of others. The qualitative data analysis followed a four-step process (Miles, Huberman, & Saldana, 2014; Rubin & Babbie, 2008) and strategies, such as negative case analysis, were used to increase the rigor of the data analysis and validity of the findings (Padgett, 2016). First, to promote immersion in the data, the researchers read the transcriptions on four occasions over a 2-week period. During this time, and consistent with phenomenological analysis, the lived experiences of drug court participants were continuously compared and contrasted to develop insight into the research question. Second, concept mapping was used to group data, identify codes, and provide a conceptual framework for the findings. Third, codes were grouped as themes, the number of research participants who contributed to each theme was quantified, and direct codes from the research participants were used to conceptualize each theme. Fourth, data that did not demonstrate consistent responses from the research participants were considered outliers and used for the negative case analysis.
Four strategies were used to increase the rigor of the data analysis and validity of the findings (Padgett, 2016). First, the data collection and analysis were completed by researchers from different disciplines (criminal justice, psychology, and social work) offering interdisciplinary triangulation. Second, peer debriefing was used for confirmation purposes. Specifically, the researchers shared their preliminary codes and themes with colleagues who had expertise in qualitative research to seek their feedback on the logic of the data analysis and preliminary findings. Peer debriefing was completed via e-mail and phone calls. Those involved in the peer debriefing process had access to all the transcripts, which were in anonymous format, meaning no names or other identifying information was on the transcripts. Third and fourth, negative case analyses and audit trails were completed for each theme, and the negative cases are presented in the Findings section. It is important to note that negative cases were only identified when participants shared specific thoughts, opinions, or lived experiences that conflicted with the theme. Hence, having no comment on a particular question or topic did not count as a negative case. The negative case analyses promote a balanced interpretation of the findings, and the audit trails provide an additional avenue to verify the findings.
Findings
Thirty-nine drug court participants met the inclusion criteria and 38 chose to participate, providing a response rate of 97%. From May to July 2018, the researchers facilitated six focus groups. On average, six to seven participants were in each focus group and the focus groups lasted for nearly an hour. A brief demographic survey was given at the start of each focus group. The average age of focus group participants was 34 years old and the majority were male (63% male, n = 24; 37% female, n = 14). Almost three fourths of the sample were White (71% White, n = 27; 29% non-White, n = 11). The focus group questions (Table 1) were related to participants’ thoughts and experiences in drug court and the use of MATs to support recovery. All (100%, n = 38) of the research participants had a moderate to severe opioid use disorder (American Psychiatric Association, 2013), and the majority (58%, n = 22) had been on a MAT at some point in their life. Furthermore, 37% (n = 14) of the research participants were on a MAT at the time of the focus group. For the participants who were on a MAT at the time of the focus group (n = 14), 50% (n = 7) were on Suboxone (buprenorphine/naloxone), 29% (n = 4) on Vivitrol (naltrexone), and 21% (n = 3) on methadone. Peer debriefing provided confirmation that there were no significant differences in focus group themes generated by participants receiving MAT compared to those not receiving MAT. Peer debriefing also provided confirmation of the two themes discussed below.
The Importance of Combining MATs With Cognitive and Behavioral Therapies
Half of the participants shared thoughts, opinions, and lived experiences emphasizing the importance of combining MATs with psychosocial treatments such as cognitive and behavioral therapies. This theme is demonstrated through the quotes below. The participants shared that one of the most helpful aspects of drug court in treating their opioid use disorders was participating in treatment. One participant, for instance, shared that whether or not you are on a MAT, cognitive or behavioral treatment is helpful in many areas of life such as family relationships and employment. She also mentioned the importance of learning healthy coping skills that tend to be taught through cognitive and behavioral therapies. Specifically, she said: I’m in the women’s matrix program at [name of treatment center] and it’s a lot different than IOP [intensive outpatient program]. We talk about different life skills, how to cope with drugs, family life, work life, everything. Whether you are on a medication-assisted treatment or not, for us with heroin addictions, it’s important for us to attend treatment each week. It’s good to get into treatment right away. It gives you at least a head start, you know? Trying to go through all of this with being sick and being out there on the streets is impossible. We need Suboxone or whatever else helps and treatment. Like I said, it gives you a head start. The counselors teach you how to think clear because when you’re using drugs, you aren’t thinking straight. Your mind changes completely, you know, and it gets your mind thinking, I can start life again. You need to work a program. I need to work a program and that involves using a medication, Vivitrol, and going to counseling and meetings [recovery support groups]. Unless you’re working a program, it’s not going to work. Going to counseling, you know, working on your head stuff is what you need. Vivitrol isn’t going to change your head stuff, like thinking about getting high.
Overall, the participants felt that one of the most helpful aspects of drug court in treating their opioid use disorders was participating in psychosocial treatments. Participants, whether or not they were on a MAT, provided examples on how the use of cognitive (e.g., cognitive restructuring) and behavioral therapies (e.g., relapse prevention) supported their recovery, and they felt that MATs should be used in combination with these types of treatment. The negative case analysis revealed that only three (8%) participants had experiences that conflicted with the theme. All three comments, however, were related to difficulties with balancing the demands of psychosocial treatment with other responsibilities, as compared to viewing these additional treatments as unhelpful. For example, a participant shared this lived experience: They [psychosocial treatment] don’t understand a lot with all the stuff we have to do. They [psychosocial treatment] set it up to make sure, you know what I mean, that we are busy. With all the counseling we have to attend, it gets stressful and, ask everybody, it’s a hell of a lot of stress to stay sober.
The Uneasy Relationship Between Harm Reduction and Drug Court Programming
Half of the participants shared thoughts, opinions, and lived experiences that contributed to the theme of an uneasy relationship between harm reduction and abstinence-based drug court programming, demonstrated through the quotes below. The participants had favorable views toward harm reduction. In this case, harm reduction was conceptualized as reducing or abstaining from illicit opioid use, such as heroin, even if continuing to use other substances, and they viewed MATs as an important intervention in achieving this goal. The problem, however, is that the drug court in this study is guided by an abstinence-based philosophy of treatment, consistent with the majority of U.S. drug courts. Therefore, participants who maintain abstinence from opioids but use other drugs could face sanctions from the drug court, which may include incarceration. Throughout the focus groups, multiple participants shared their observations that other drug court participants have abstained from opioids in drug court but began to use other substances. One participant, for instance, shared this observation: One of the other downfalls is the shift in the drug of abuse, or drug of use. The switch from opiates over to methamphetamine. Stuff like that. That is one thing we’ve seen a lot more of, more positive drug tests with the medication-assisted treatment guys, especially positives for methamphetamine. There is a perception because heroin is so devastating, so fast, that even highly addicted people with very advanced substance use disorders know that, oh my god, I got to get off this. They take the med [medication-assisted treatment], they’re off heroin and start thinking, alright, now I can do these other things. Alcohol was never my problem, or weed should be legalized anyway, or what’s wrong with a little cocaine, it’s not heroin. I have known people who were using heroin and they don’t want to relapse on heroin, so they’ll go find somebody who has Suboxone and they’ll use their Suboxone instead of relapsing on heroin. They think that’s a better alternative than going back and using heroin. They still kind of look down upon it, of course, because, you know, it’s still you failed [positive drug test] for something, but they still do high-fives and congratulate you because you didn’t do your drug of choice. You’re still clean this long from your drug of choice. I’ve been 8 months clean off heroin. So, for me, as long as I don’t use heroin, I am doing good.
The negative case analysis revealed that only one (3%) participant shared an experience that conflicted with the theme, and this conflicting statement was specific to the use of buprenorphine/naloxone and methadone. The participant shared: I feel like Vivitrol would help because you can’t get high if you have that, but in my personal opinion, I don’t feel like you should take a medication [buprenorphine/naloxone or methadone] because it’s just going from one drug to another, like using it as a crutch.
Discussion
As a whole, the drug court participants for this study were actively involved in the focus groups, as evidenced by their ability to share their thoughts, opinions, and lived experiences related to the use of MATs in drug court. Focus groups seemed to be an effective methodology, as it provided an avenue for participants to complement each other’s experiences, adding additional insight into the research question. Participants felt that medications such as Suboxone (buprenorphine/naloxone), Vivitrol (naltrexone), and methadone were helpful to use in drug courts, particularly when they were used concurrently with counseling. This theme was promising because it provided validation that using MATs in combination with psychosocial treatments is perceived by drug court participants as an effective approach for treating opioid use disorders. This finding aligns with the guidelines and recommendations of the American Society of Addiction Medicine for treating opioid use disorders (Kampman & Jarvis, 2015).
Since drug courts have not often supported the use of MATs and have traditionally created barriers to the use of these treatments, it was promising that participants still perceived these treatments to be helpful despite messages they might receive otherwise. For example, despite the evidence that MATs and counseling are effective interventions in treating opioid use disorders, many U.S. drug courts do not allow participants on opioid agonists and some judges or other stakeholders order participants to discontinue medications, even when they are recommended by a medical professional (Knopf, 2015). The magnitude of this problem has warranted intervention from the U.S. Federal Government, and the SAMHSA recently released a statement emphasizing that SAMHSA-funded drug courts can no longer deny individuals admission into drug court because they are on an opioid agonist or mandate individuals to discontinue the use of MATs (Knopf, 2015). Despite these barriers, the participants from this study provided validation that MATs are viewed as helpful in combination with psychosocial therapies such as cognitive restructuring, motivational interviewing, and relapse prevention. Therefore, it is recommended that drug courts allow participants to take MATs and also refer them to treatment providers who have expertise in cognitive and behavioral therapies.
Participants’ responses also highlighted a discrepancy between drug court expectations and the harm reduction approach used by some participants and the way both parties defined and conceptualized harm reduction. For example, the drug court in this study acknowledges that the use of full (e.g., methadone) or partial (e.g., buprenorphine) opioid agonists to support recovery is consistent with a harm reduction model and permitted in the drug court when used under medical supervision. Some of the drug court participants in this study, however, reported another form of harm reduction that is not permitted in the drug court. After taking MATs, some participants reported that they discontinued opioid use but then began using other drugs. This would be consistent with a harm reduction approach to the treatment of substance use disorders, as the risk of overdose and death is greatly diminished if an individual is no longer using opioids.
U.S. drug courts will most likely not see this as an acceptable harm reduction approach to recovery, though, since most U.S. drug courts are guided by an abstinence-only philosophy of treatment. Reducing drug use or switching from more harmful drugs (e.g., opioids) to less harmful drugs (e.g., marijuana) may not be seen as progress in U.S. drug courts. Continued drug use of any type could result in progressive sanctions and potentially termination from drug court. Whether a drug court operates under an abstinence-based or harm reduction lens of treatment and recovery, it is important for drug courts to be aware of the behavior identified in this study and, consistent with the drug court model (NADCP, 2004), respond in a nonadversarial, therapeutic manner. Perhaps the best approach is to end the dichotomy of harm reduction and abstinence-based programs and accept that recovery is best understood on a spectrum (Gallagher et al., 2019). Even in U.S. drug courts where the norm is abstinence, reductions in drug use or using less harmful drugs can be an opportunity to intervene in a rehabilitative manner, and perhaps harm reduction is the path to abstinence for some drug court participants.
The abstinence-only philosophy is not universal, however, particularly with non-U.S. drug courts (Holst, 2010). Irish drug treatment courts are one example (Loughran, Hohman, Carolan, & Bloomfield, 2015). If a drug court participant enters the Irish Program using opioids and eliminates their opioid use throughout treatment, yet continues to use alcohol and/or marijuana, this may be viewed as progress and could still lead to program completion. In Ireland, the drug treatment court places tremendous value on assisting participants to develop skills for employment and enhancing their education. This is promising because employment and having at least a high school diploma or equivalent are consistently strong predictors of drug court completion and nonrecidivism (Gallagher, 2013; Gill, 2016; Shaffer, Hartman, Listwan, Howell, & Latessa, 2011). Drug court programming and polices vary from one country to the next, presumably to meet the individualized needs of the participants they serve.
Limitations and Future Research
This study has several limitations. First, the findings of this study cannot be generalized beyond the research sample. The findings are limited to the 38 drug court participants who chose to participate in a focus group, and the themes drawn from the data are only applicable to the one drug court in this study. With that stated, however, it is plausible that the themes from this study, such as some drug court participants practicing harm reduction, are applicable to other drug courts and the discussion may help guide drug court programming and future research. It is recommended that all drug courts incorporate qualitative methodologies into their program evaluations to assess their participants’ experiences in drug court. Additionally, program evaluation is a key component of the drug court model (NADCP, 2004), and incorporating qualitative methodologies into program evaluations will capture data that quantitative methodologies simply cannot, such as the benefits of and barriers to using MATs in drug court.
MATs are an established and effective intervention for treating opioid use disorders. However, MATs have limitations and barriers to service delivery, particularly in the criminal justice system. The experiences and opinions of drug court stakeholders, who play a key role in the service delivery of MATs in drug court, are not captured in this study. Some stakeholders may have ambivalence, misinformation, or other barriers related to MATs and incorporating harm reduction into drug court programming. Therefore, it is recommended that future research collect data on stakeholders’ views on the use of MATs and other harm reduction strategies in drug court. Stakeholders in the U.S. may have different views than stakeholders from other countries. As a result, collecting data from multiple drug courts, both inside and outside the U.S., will offer an international perspective on the use of MATs in drug court programming and allow researchers to compare and contrast findings. Last, future qualitative research should also compare and contrast how important demographic variables, such as sex and race, are impacted by the treatment of opioid use disorders in drug court. Previous research, for instance, has demonstrated that in some drug courts, racial disparities exist in graduation outcomes, where African Americans graduate less than their White counterparts (Gallagher & Nordberg, 2018). Therefore, it is important to assess whether racial disparities also exist in access to and utilization of MATs.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a grant from the Indiana University, School of Social Work, Center for Social Health and Well-Being.