The Massachusetts Trial Court has agreed to stop ordering and pressuring its drug court defendants to take a specific medication for opioid use disorder, and will instead leave medical decisions to licensed prescribers and treatment programs.
Massachusetts U.S. Attorney Rachael Rollins' office received a complaint that the drug courts were violating the Americans with Disabilities Act by discriminating against people with opioid use disorder, a recognized disability under federal law. The complaint alleged that staff were forcing drug court participants to stop taking other prescribed medications in favor of naltrexone, known by the brand name Vivitrol, without individual medical assessment as to whether that would be the best treatment option. Rollins' office and the court reached a settlement Thursday over the allegations.
Drug courts offer alternatives to incarceration, including mandated treatment, to people charged with nonviolent, drug-involved crimes. The first drug court in Massachusetts opened in 1994.
“Judges are experts, but they are not doctors,” Rollins told GBH News. “Essentially what would happen is when you were in drug court, there would be personnel who are not licensed medical professionals or providers, that would be encouraging individuals or forcing individuals exclusively to [take] Vivitrol, as opposed to the three different types of FDA-approved medications prescribed by licensed medical providers to assist with opioid use disorders.”
Dr. Andrew Kolodny, the medical director for the Opioid Policy Research Collaborative at Brandeis University's Heller School for Social Policy and Management, said it’s common in the United States for drug court staff and judges to lay out specific treatment plans, including which medication to take.
”Even though, of course, they were not licensed or they had not gone to medical school, but they were prescribing treatment,” Kolodny said. “And maybe that would have been less of a concern if they were prescribing the right treatment, but they weren't.”
Vivitrol, which is made by Waltham-based Alkermes, blocks the effects of opioids through a once-a-month shot. The other FDA-approved medications for opioid use disorder are buprenorphine and methadone. Both of those medications are taken by mouth, daily or sometimes twice a day, and work by delivering long-acting controlled doses of opioids that don’t create a high.
Kolodny said evidence for the effectiveness and safety of buprenorphine and methadone is much stronger than for Vivitrol, but that those first two medications face stigma.
“Sometimes they are wrongly seen as simply substituting one drug for another, not really being treatment,” Kolodny said, “whereas this monthly injection was certainly more attractive to criminal justice staff; and the drug company that manufactures Vivitrol marketed it aggressively within the criminal justice system, and played up the bias against using buprenorphine and methadone as treatment.”
Kolodny also said buprenorphine in particular is considered the first-line treatment for opioid use disorder. It can be picked up at a pharmacy, and it's considered safer and has fewer side effects than methadone, which is dispensed at clinics.
“The evidence supporting the effectiveness of Vivitrol is much weaker,” Kolodny said, “and there is evidence that in patients with severe opioid use disorder, exposure to naltrexone [the active ingredient of Vivitrol] could potentially increase the risk of death.”
In a statement, an Alkermes spokesperson said the company believes people living with opioid use disorder should have access to all FDA-approved medications because "no one medication is right for everyone." The statement also said the company believes medications should be decided upon in collaboration with a health care provider.
The settlement between the state’s trial court system and Rollins’ office details that while the courts don’t admit violating the ADA by discriminating against people with opioid use disorder, the drug courts will implement a new policy within 30 days that includes barring drug court personnel from interfering with treatment plans, assessments or medications decided upon by a licensed prescriber or treatment program.
Rollins emphasized that there was no “bad intent” by staff in Massachusetts drug courts, and that she is personally aware of many successes in the system.
“I have gone to so many drug court graduations as the district attorney — and quite frankly, as a sibling or the loved one of somebody who was struggling with an opioid use disorder, as well," she said.
Rollins said she believes that Massachusetts drug courts can now be the “gold standard” for how drug courts should operate across the country.