While I'm trying to learn a little new philosophy, I have decided to write a series of posts on topics related to my job. This first one, as promised to Dave, is about the Nashville/ Davidson County Drug Court. Future planned topics include: the trials and tribulations of TennCare, the Tennessee supplement to Medicaid health insurance and the role spirituality in addiction treatment. I may think of others along the way, or I may get back to philosophy once these are written. Here's the Drug Court piece:
Even though there are weird judges in the country, in general it often seems that the members of the Judiciary Branch of government tend to be the most reasonable and well-educated voices that we hear on many issues. Time and again, judges are the ones to stop some misguided congressperson on a mission in his or her tracks. (Ever think about the fact that this is the single governmental position which requires an advanced education? You’ll never see an actor or failed businessman appointed to be a judge, unless he also has a law degree.) Judges have done a lot over time to insure that legislative programs don’t go too far awry. The hero in this particular story is Judge Seth Norman of the Division IV Criminal Court in Davidson County, Tennessee.
Judge Norman, along with probably every other criminal court judge in the country, was fed up with the War on Drugs by 1995. From his point of view, the War was causing overcrowding in the jails, a massive increase in the number of cases on his docket, and little in the way of improvements in the situation on the streets. Statistics showed that 80% of the cases he was hearing involved drugs or alcohol in some way, and 60% of the people in those cases had a chemical dependency. Most of them were repeat offenders.
The rationale behind the longer stays in jail for drug offenders was that this period of forced abstinence would break the cycle of addiction and reduce recidivism. The view from the Judge’s bench disproved this assumption. Forced abstinence was no more effective in treating drug addiction than it had been in the 1920's when alcoholics were confined to sanitariums. When returned to freedom, the addicts picked up just where they left off and soon stood before the same judge again being tried for the same crime or something worse. Even addicts who wanted to quit using were returning to jail. There had to be a better way.
So the Judge did some research, and he found a grant to institute a special Drug Court which monitored probationers from drug-related cases while they attended outpatient treatment. Judge Norman got one of these grants and set up what is called the Day Reporting Center to provide outpatient treatment for addicts, along with a special Drug Court which met in the evenings to monitor their progress. And this was a very good thing, so far as it went. The Judge almost immediately noticed, however, that this system didn’t begin to help anyone with very serious problems, either because they were simply ineligible for any programs which required being released from jail, or because they were unable to maintain the abstinence required in an outpatient program and were consequently returned to jail due to a dirty urine screen.
After two years of watching the successes and inadequacies of this system, the Judge decided to branch out on his own and create an inpatient treatment program for the individuals involved in more severe drug related cases. There was no funding for this, however, and the Judge had to get permission to use a crumbling county-owned facility which had stood vacant for many years, to clean it with volunteer labor from the inmates who would eventually get treatment in it, and to furnish it with beds and desks which were salvaged from this building and other unusable buildings on the abandoned property. In this humble setting, the first (and still the only, I believe) court-operated inpatient treatment center for addicts in the U.S. began providing services in 1997.
The official name for the program is Davidson County Drug Court Residential Program, but it is better known by its nickname, DC4, which is derived from: Davidson County Drug Court, Developing Character, During Confinement. The program was developed through a series of trials and errors, but the successes were early and lasting, and the program has become an integral part of the local system of criminal justice and addiction treatment. When Dell offered to buy the property upon which the old building sat, the county built a new 3 million dollar facility for DC4 on another piece of county property.
One of the significant changes which the residential treatment program has undergone in the trial-and-error development stage is revealing– both about the deficiencies of the usual method of handling those incarcerated under the Drug War laws, and about the deficiencies of the treatment industry as it exists outside of the criminal justice system, i.e.– the one which is largely funded by insurance companies. Judge Norman discovered that although his hardest cases– the cocaine addicts– weren’t getting any better in jail, they still weren’t getting better with six months of residential treatment, either, which was the original protocol for DC4 treatment. Now, the insurance companies figured this out long ago– they couldn’t find a treatment system which worked consistently with cocaine addicts, and they have consequently defined and re-defined their admission policies in such a way that cocaine addicts cannot get inpatient treatment for their problem at all, anymore, if they depend upon an insurance company to pay for it. Perhaps I should write a little more about the history of the insurance companies and payment for addiction treatment, so that you can see why this has happened. (Some of this is probably only true in Tennessee, but I expect that the situation is similar in all but the most enlightened states– and maybe even there.)
In the sixties and seventies, the standard treatment for alcoholism or addiction, through one of the newly created treatment centers, was a 28- to 30-day stay as an inpatient, followed by voluntary attendance at 12-step meetings. The insurance companies, naturally, watched this system for efficacy, and they found that the results weren’t that great, relative to the expense. Some people improved, but some people would return for treatment again and again, and there was never any guarantee that they wouldn’t be back for yet another go round. Sensibly, the insurance companies began imposing limits– from, at first, limiting the number of days in a lifetime that they would pay for inpatient treatment for one person all the way down to the present limits: limiting inpatient treatment to days when there was a medical necessity for 24-hour supervision, and consigning everyone else to the much less expensive outpatient treatment. Medical necessity means the presence of acute medical symptoms, which means the high blood pressure that alcoholics get during detox, or the nausea and painful cramps which are experienced by opiate and benzodiazepine addicts in acute withdrawal. Once these medical symptoms are stabilized, the insurance company will send everyone to outpatient treatment (and some of them will go). Since hospitals are under ethical constraints, they must admit anyone who wants to detox, as many times in their life as they want to do it, and the insurance companies will pay for that. They will not, however, pay for much more treatment in an inpatient setting, and every inpatient counselor that I know, spends a good portion of their time on the phone with the insurance companies negotiating for more days of treatment for their patients. (Outpatient counselors have to do something similar, but it’s all paperwork and faxing for them.)
The problem with this system, if you’re a cocaine addict, is that there aren’t acute medical symptoms associated with cocaine detoxification. There is serious depression, and there is typically a need for food and sleep, but usually these don’t require hospitalization, unless the depressed person is seriously suicidal. We do a lot of ‘social detox’ of cocaine addicts at our respite houses, but that is a three-day stay with no real treatment– mainly respite is a place for mental health stabilization outside of the hospital, and it’s a relatively new addition to the treatment continuum as well. For the most part, cocaine addicts go straight into outpatient treatment, with no inpatient stay at all. In this way, the insurance companies get what they want– they don’t have to pay for any inpatient treatment for the most recalcitrant addicts: the cocaine addicts. Naturally, anyone who can afford it can pay for inpatient treatment for any addiction, and they can stay in as long as they want. And there are (local) government grants which pay for cocaine treatment for the poor in regular 21-day treatment facilities. But what Judge Norman was finding was that his DC4 cocaine addicts needed at least twelve months of counseling, supervision, job training, and abstinence before he felt comfortable even letting them move into a halfway house. So this is what DC4 now gives them: at least twelve months of inpatient treatment.
The great thing is this: Judge Norman was in a position to see this for what it is: a cost saving device. Putting someone in treatment for twelve months is quite a lot cheaper than keeping them in jail for twelve months– and much, much less expensive than putting them in jail for 90-day stays over and over again ("doing life in prison on the installment plan", as one of my clients described it). Inpatient treatment is more expensive than outpatient treatment (which is all that the insurance companies see), but it is much easier to afford than incarceration and all of the legal processes which accompany it. Therefore, adding treatment centers to the criminal justice system actually makes it more effective at a lower cost, and a cocaine addict’s best chance of getting effective treatment in Nashville today might actually be by getting arrested and going to jail. (I have had one client wait for almost a year for a bed in the DC4 program, because it was his best and only real chance of making a change in his life– he turned down probation at about seven months and waited another four to get in. I hated keeping him in jail this long, but there was really no other program in the city that I could refer him to, that would give him the same advantages. He’s in the program now and very happy with the decision that he made.)
For all of the things that are wrong with the War on Drugs, and there certainly are many things wrong with it, this system seems to be working, and part of the reason that it does work is because it has a Judge with the power to throw rule-breakers and relapsers back into jail, which gives the inpatients an additional incentive to try to stay abstinent. On the one hand, it is commonly acknowledged that accumulation of negative consequences helps an addict build the desire to recover, so repeated trips to jail can sometimes be helpful in building their resolve. Additionally, many of the pitfalls of traditional inpatient treatment can be avoided when the program director has the power to incarcerate.
Obviously, patients go back to jail for bad drug screens, fighting, or any very uncivilized behavior. But, to provide a kind of silly, but revealing, example: every treatment center struggles with the problem of "fraternization", which is a kind word for men and women meeting up while in treatment, "falling in love", and spending all of their time trying to arrange trysts or daydreaming about each other instead of learning how to deal with their problems. You’d think people would have more sense than to try to find a life partner, or even a sex partner, in a treatment center, but the combination of feeling uncomfortable in early recovery, the return of long-anaesthetized feelings, and an all-too-human preference for sex and romance over facing all of the difficulties in life generates this scenario over and over again. These couplings are not only a bad idea for common sense reasons, but the stresses of a new "relationship" eventually cause most people to relapse in their addiction. So all treatment centers make rules keeping men and women separate as much as is reasonable, and the addicts, being the rebels that they are, find more and more creative ways to break the rules. In the DC4 treatment program, this nonsense is virtually eliminated with a simple "If you do that, we’ll put you back in jail". Consequently, the addicts focus more on their treatment and get more out of it, and the ones who cannot focus are removed, and do not distract the ones who are earnestly trying.
This may sound heartless or patronizing, but remember that if the addicts were left to do what they wanted, they would eventually die. I have seen people whose brains were destroyed by alcohol or drugs, but who still walk around alive, searching for the next hit, and it is not a happy way to exist. And make no mistake about it– it is very, very difficult to break a crack addiction. Crack addiction is a lot like cigarette addiction, but instead of giving a feeling of tranquility and focus the way a cigarette does, every hit off the crack pipe delivers an immediate, orgasmic feeling of physical and mental elation. These addicts need a lot of support and training in stress management in order to go back to facing daily life (usually a decimated daily life) without resorting to that instant, fantastic escape. The threat of going to jail for infractions just gives them that little bit of extra focus on the things they need to do if they are to survive.
So, the War on Drugs may not be a total loss after all, if more Judges around the country can follow Judge Norman’s example with DC4. Providing treatment instead of simply locking addicts up is showing good early results in managing the drug problem and proving to be cost effective as well. The DC4 treatment program is only a part of a Drug Court system which includes education for first-time offenders and outpatient treatment for those on probation, but for the hardest addicts, this residential program sponsored by a judge and the jails is providing the best chance out there for a return to normal life.
10:37:23 PM 
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