Time for Drug Courts To Equip Participants with Naloxone
Individuals who use opioids after a period of abstinence are at a higher risk for overdose due to a lowered tolerance, a circumstance in which drug court participants with a history of opioid use may find themselves.
In light of this significant risk, the National Drug Court Institute (NDCI) released a fact sheet late last year titled “Naloxone: Overview and Considerations for Drug Court Programs” along with an online naloxone training course. The new fact sheet and course are follow-ups to the National Association of Drug Court Professionals’ (NADCP) resolution in 2015 encouraging the distribution of naloxone to drug court participants who may witness or experience an opioid overdose.
Data on drug court naloxone distribution are sparse, with no meta-analysis available on naloxone distribution through the 3,000 drug courts that operate across the U.S. No resources on naloxone are located on the National Drug Court Resource Center website, nor is naloxone distribution included in the report on best drug court program design. Widespread use of naloxone in drug courts is likely limited by a combination of budget constraints and the antiquated belief that naloxone distribution is incompatible with abstinence-based treatment programs.
With national attention increasingly focused on local responses to the opioid epidemic, drug courts have an opportunity to save the lives of overdose victims, even when many state-level policies fail to acknowledge drug court program enrollees as one of the highest risk populations, due to their lowered drug tolerance following a period of abstinence.
The distribution of naloxone to drug court participants is limited by the availability of the medication and the protections offered to people who use it to save lives. In these areas, the characteristics of state naloxone access laws notably diverge. For example, Colorado has one of the most comprehensive naloxone laws in the country. In contrast, Oklahoma’s law only explicitly addresses prescribing through standing orders and to third parties. Oklahoma does not grant immunity to prescribers, dispensers, or administrators and does not provide protection for the offenses of possession or distribution of naloxone. Unsurprisingly, states with higher restrictions on naloxone and fewer protections have fewer reversals in community settings.
Even state policies designed to protect lay people who administer naloxone often fail to acknowledge the difficult choices faced by individuals on probation and parole. Such individuals may risk violating their probation or parole by contacting the police during an overdose. Medical amnesty policies (also known as “Good Samaritan” laws) are designed to encourage witnesses of a drug overdose to seek medical assistance. Medical amnesty laws can vary dramatically, but major components can include: immunity for possession of controlled substances, immunity for possession of paraphernalia, and immunity for other violations (including parole or probation).
In many states, medical amnesty laws don’t provide immunity to individuals on probation or parole. For example, if an individual participating in a drug court program in Florida calls emergency services during an overdose, he/she is not explicitly protected from arrest, charges, or prosecution for the possession of controlled substances or paraphernalia because he/she will be participating in the program under a probationary agreement that prohibits such behavior. This conflict of interest creates a deterrent for program participants who might otherwise call for help in the event of a medical emergency.
The staff of drug court programs are uniquely positioned to provide training and resources to drug court participants, as the intent of these programs is to provide an alternative to incarceration for drug-related crimes. The NDCI encourages drug courts “to get naloxone directly into clients’ hands at the time they receive overdose education.” This is an implicit acknowledgment that simply providing direction to clients about how to access naloxone through their physician or pharmacy fails to overcome the most prominent barrier to acquiring the medication: engagement with prescribers. In states that do not provide for naloxone distribution, the medical director of a drug court can prescribe naloxone to clients directly.
Cost can be another barrier. For many, any copays associated with a naloxone prescription create an additional barrier to acquisition, thus strengthening the case that drug courts should provide naloxone products directly to clients (if legally permissible). In some communities, outside organizations or government agencies provide drug court participants with free or affordable naloxone, serving as valuable partnerships that can provide low-income clients with a literal life-saver.
Hawaii is one of the best examples of a state that has both an excellent naloxone law and a comprehensive medical amnesty policy. The state has the legal framework for drug court programs to provide take-home naloxone for participants to be protected legally if they call for medical assistance in the event of an overdose. Implementation of take-home naloxone programs in all Hawaii drug courts would be a logical next step in overdose prevention efforts. However, at this time, there is no evidence from Hawaii’s drug court website to suggest that naloxone is currently provided to participants.
Drug courts can progress on this issue even if their state-level naloxone policies aren’t ideal. In states where naloxone and medical amnesty laws are restrictive, drug courts have an opportunity (if not a duty) to help clients navigate the barriers to acquiring naloxone. More generally, drug courts in any state can improve outcomes by ensuring that their programs properly equip participants with overdose prevention tools and education that could save lives.