and welcome to Recommended Practices for Incorporating Medication for Opioid Use Disorders in Courts. Our presenter today is the Honorable Robert Russell. Some of you who are fans of treatment courts probably know him. He started a drug treatment court, a mental health court, and he created and presided over the nation's first veterans treatment court. After serving 30 years as an associate judge for Buffalo City Court in New York, he retired from the bench just last year. He's received actually numerous awards but received the Vietnam Veterans of America 2010 Achievement Medal, and he serves as the Region 2 ABA Judicial Outreach Liaison and joined our faculty here at the college just this year, and we're very grateful to the judge. And with that, Judge Russell, I'm going to give you the power to move your own slides, and you can take it away. Thank you, and hello, everyone. It's a pleasure and honor to be here and give this presentation. Curious, where are you joining from? Let's test out the pointer tool for me. And if you would, just click on it. All righty, wonderful. We have a good cross-section of the country. I am from Buffalo, and, yes, we receive a lot of snow. And we're going to – well, I wasn't sure if everyone had the opportunity to go ahead and click on. I know we got a lot more attendees that clicked onto the map, but we got a good feel. And just welcome everyone from whatever part of the country that you're from. Our learning objectives today is we're going to work to identify and describe the commonly used medication for the treatment of opiate use disorders, what are the recommended practices to incorporate medication, opiate use disorder treatments, gain knowledge to dispel the myths, and some of these myths, they're a doozy, and how medication maintenance treatment leads to improved outcomes, and understand that the federal government, if you're seeking a grant for one of your treatment programs, treatment court programs, you cannot preclude participation by one of the individuals that would like to come into your program because they are on medically-assisted treatment under the supervision of a doctor. So that's important to know. But let's talk a little bit about SAMHSA. Now, SAMHSA stands for the Substance Abuse and Mental Health Services Administration. And it is an agency within the U.S. Department of Health and Human Services. And they come out with what they call the TIPS. And these TIPS are a series, and it's consistent with SAMHSA's mission by providing science-based, best-evidence guidance in the behavioral health field. And this TIPS 63, which is specifically addressing opioids, highlighted a couple of factors that I think that is important for us, and that is the opioid epidemic is extremely costly for our society. $504 billion, that's in the year 2015, and what it had cost our society. The number of opioid deaths that you see there, the number of people that are dependent on opioids, whether it's prescription opioids, heroin, similar substances. I think what's also crucially important is the number of emergency department visits due to the fact of opioid use, abuse, so forth. And the fact that opioid-related inpatient hospital stays increased by 117% nationally from the years of 2005 to 2016. This is an interesting slide from the standpoint that the SAMHSA and, I'm sorry, as far as for this came out from the CDC, which is the Center for Disease Control. And the Center for Disease Control looked at certain, what they call distinct waves with respects to opioids and are not too distant past. When we look at the years in which they described as the first wave in the 1990s, what they noticed was an increase of opioids being prescribed in the 1990s. And with that, overdose deaths increased involving prescription opioids. I think what's interesting is that in the late 1990s, pharmaceutical companies kind of gave some assurance to the industry, the medical industry, that patients would not become addicted to prescription opioids, pain relievers. And healthcare providers, based on the type of information they were receiving, actually increased at a greater rate the prescription of opioid medications. And then the second wave, which they described in 2010, really seen a marked rise and increase in heroin use and at the same time heroin overdose deaths. And heroin is described as illegally manufactured opioids. And then the third wave, which has really brought us to where we are today, and that is a marked rise in the synthetic opioid overdose deaths. Typically, it's going to be related to fentanyl and other similar illicitly made substances that are similar to opioids. I'm sorry, similar to fentanyl. So first question, does medication-assisted treatment substitute one addiction for another? What do you think? I think you'll use your pointer tool like you did earlier to tell us where you were from. If you don't have the feature, the pointer tool feature, please feel free to send your answer in via the chat tool and I'll let Judge Russell know. Don't worry, I'm enjoying this, and that's why this is wonderful to be with you all today as we discuss this. It's a question that we often hear or discuss in our communities, don't we? That medication-assisted treatment might substitute one addiction for another. What do you think? And Judge Russell, we had another judge through the chat to let us know that he voted false. So you have five judges who said false. Okay. Well, fantastic. And thank you all for participating. The CDC had presented this chart here. And with respect to this chart, what it notes is the graphic shows the rate of opioid deaths with the three categories of opiates as well as all opiates overall. The rates and deaths involving natural, semi-synthetic opioids, and methadones are combined in one category, which is called commonly prescribed opioids. And that does give us a flavor. But notice that the other synthetic opioids, fentanyl, Tramadol, are significantly much higher it is from those of commonly prescribed opioids or even heroin itself. And that's from the time period of 1999 to 2019. Notice with regards to this chart from the National Institute on Drug Abuse, and what I wanted to just highlight on this is the male and the female. The female is in the yellow line, and the males are in the brown line, with respect to death as a result of using opioids. And that excludes non-methadone synthetics. So that's just kind of painting the picture for us. I think when we look at this particular chart here, the opioid epidemic by the numbers, and this is from the 2019 National Survey on Drug Abuse and Health. This was the Health and Human Services Agency that developed this chart. But understanding that in 2019, over 70,000 people died as a result of overdosing. But note that 48,000 from that 70,000 was attributed to overdosing on synthetic opioids. And we're going to talk about what synthetic opioids are, other than methadone. And then you add 14,000 additional just overdosing on heroin itself. So what you have is those manufactured in the lab are significantly much higher than what you would think of just opioids, I'm sorry, of just heroin itself. It's a big, huge problem. A huge problem, the number of people who are dependent on opioids. 1.6 million people had an opioid use disorder in the past year. The number of people who misused prescription pain relievers or tried them for the first time and misused them. People misused prescription opioids in the past year have it over 10 million. That's significant. And this is the issue that we're presented with. But I think if you note that from this chart, out of the 70,000, and over 70,000 people who had overdose, 62,000, over 62,000 were a result of opioids. Does medication-assisted treatment increase the risk for overdosing patients? What do you think? I'm going to use our pointer tool again. I love it. And we have a judge who said no with the red X tool, which is another option if you don't have the pointer tool available to you. Don't be shy. All right. And thank you very much. All right, crew. Now, in 2019, which is like related to the other chart that we've seen, of those over 70,000 people who died as a result of a drug overdose, just know that over 70% was involved in the opioid use. This is an interesting chart because I think it's really impacting overdose and how overdose is related to not only opioid use, but the illicitly manufactured fentanyl. Notice on the chart that fentanyl, like when you've got 19.8% overdose, it resulted in death just by fentanyl alone in your system. And when you move over to the 10.5%, and this is something we need to be cognizant of, fentanyl is just not being mixed with opioids. But in addition, you notice that 10.5, that next column, it's with fentanyl mixed with cocaine. 10.3% fentanyl mixed with heroin. And then you move down to the 5.1%. You have fentanyl coupled with heroin, coupled with cocaine. Fentanyl coupled with methamphetamines. Fentanyl coupled with other prescription opioids. So 76.9% of overdose deaths, the 10 most frequently occurring opioids in stimulant combination accounting for those deaths, is illicitly manufactured fentanyl. Fentanyl has been a tremendously troublesome It is highly potent. Matter of fact, potent to the extent that the synthetic opioid fentanyl is considered to be 100 times more powerful than morphine, 50 times stronger than heroin. That's almost unconscionable when we think about the potential risk. So if someone specifically is seeking out fentanyl, they risk their lives every time they use it. But the other problem that we need to be cognizant of is that many times people do not realize that in the substance that they're using, that it's being cut with fentanyl. So they're using what they think is their typical amount for the substance, whether it's cocaine, whether it's regular opiates, whether it's heroin, whether it's methamphetamine. A lot of times these dealers are cutting it with fentanyl. True, to seek to get them a greater high or a greater rush, but at the same time, each time it's being used, someone is risking their life. This is another chart that kind of breaks it down. The IMF is the Illegally Manufactured Fentanyl. It goes through what we already discussed, so I'll go to the next chart. This is interesting. Transient characteristics of drug overdose death involving illicitly manufactured fentanyl. Now, from the time period, and this document was released in 2021, and this has also captured the information from the CDC. What it does indicate for us is that between the time period of May 2020 and April 2021, there was an estimate number of drug overdose deaths that exceeded 100,000. This is that period of the pandemic. We asked one of our clients, one of our participants, about those that we had their cases adjourned in our court system because of the pandemic. How are people utilizing, spending their time? Some, as we know, the pandemic has taken a toll on our society, but also the drug-using public have been finding themselves at greater risk during that same time period. This information came from the CDC, the Center for Disease Control and Prevention. But I think what's also telling is when we talked about how it is spreading throughout our country, when we look at the eastern part of the United States, it's been fairly consistent, but there's been a marked increase in drug overdose deaths sharply, significantly, in the midwestern, southern, and western states. This I found fascinating, still giving our backdrop to our further discussion. This was a research publication that was published in 1981 entitled The Criminality of Heroin Addicts When Addicted and When Off Opioids. I think what I find really fascinating about this publication is that they took data from a pool of over 4,000 known opioid users in the Baltimore area and selected by random 243 male opioid addicts. From that, they looked at an 11-year period, and that 11-year period in the study, however, they collected the data not only through court records, but through interviews and so forth. It was estimated that the addicts in the study had committed over 500,000 crimes during the 11-year period. Of course, significantly large sum was with respect to death-related offenses as they were looking to commit theft, sell the property in order to support their addiction, but some also involved drug sales and other crimes. The finding did reach the conclusion that addiction was the principal force that increased criminality, regardless of whatever type of offense that they committed. This finding is also supported by a tremendous number of research that's been done by other researchers. A big part is, what do we do about it? What do we do as judges? What do we do as practitioners in the justice field? Can we have a role? Should we have a role? If so, how do we go about doing it? What are the things that we should do to change behavior of the people that we're seeing coming before us, that each and every day they may be risking their lives through the use of substances? Let's start specifically when we talk about opioids. What type of substance are we talking about? Well, there are three categories. I want to talk about. The first one is natural opioids. Natural opioids are those that specifically come from nature. They come directly from the poppy plant. When you look at that picture of the flowers, it looks fairly attractive. But from that plant, we receive opioids. We also have the category of what's called semi-synthetic opioids. Now, they're a combination of the natural opiates and synthetic opiates. They use the same chemicals from the opiate plant as a base, and then they add other ingredients from the laboratory through the chemistry part to create the semi-synthetic opioids. Now, what's interesting about semi-synthetic opioids, they have most of the same effects that other opioid medications do and drugs do. And what are synthetic opiates? Synthetic opiates are drugs strictly manufactured in the laboratory. But they design them with a similar structure, chemical structure, as if it came from the poppy plant itself. And they have the same effect. It affects the same areas of the brain as opium and produce may. All right. What are the opiate subcategories, Sam? Natural opiates, those strictly coming from the plant. We have morphine and codeine. And when you think about codeine, typically you think about the substance that you may get in cough syrup, in certain cough syrup, prescribed cough syrup, to deal with coughs. And then when you look at semi-synthetic opioids, these are semi-synthetic. Part of it you get from the plant, part you develop in the laboratory. You have oxycodone. And typically we may hear the phrase of oxycodone. So oxycodone, when you talk about marketed, marketed as oxycodone. Hydrocodone, a lot of times when we hear the phrase hydrocodone, it might be prescribed in that way as oxycodone. Or at the same time, it might be, that's what you'll see it as typically. And then you have hydromorphone. That is typically what we hear as the line, as marketed as the line. And oxymorphone, a lot of times we hear it as opano. And those are the semi-synthetic. Methadone, it's all synthetic, but for our government purposes, it is categorized on its own in official data. So it's just listed as methadone rather than as synthetic opioids under the category of, like, tramadol and fentanyl. So those other than methadone, it's going to be fentanyl, tramadol. We heard that fentanyl can be 50 times stronger than morphine. I'm sorry, 100 times stronger than morphine, 50 times stronger than heroin. And heroin is strictly a synthetic opioid made in a laboratory, manufactured and illegally manufactured. Addiction medication, what do you think? Are they a crutch that prevents true recovery? All right, judges. Select your pointer tool and choose the answer you think is correct, or you can send it through the chat tool again. Thank you very much. And don't worry, we'll discuss the queries that I have a little bit later on in the presentation. When we think about opioids and its impact on the brain, and some of you I know have seen some of these studies, but brain imaging studies show physical changes in the areas of the brain when a drug is ingested that are critical to that person's judgment, decision making, learning and memory, and behavioral control. Now the changes alter the way the brain works and help explain why people have become compulsive to pick up, use, continue to use, despite the fact of the negative consequences. And what's also fascinating when you look at the science of it, that when it's ingested, the brain converts mostly all opioid-type drugs into morphine. Just naturally done. From there, these drugs stimulate certain key brain cell sites, which help in reducing pain, pain-relieving chemicals. That's what many of the manufactured opioids was designed for. Now the natural opiate drug works to depress brain and central nervous system. We talked about what the natural, that came straight from the poppy plant, but in addition, we know that the synthetic opioids that's designed in the laboratory work similarly. But what happens over time? What happens over time is that the brain, which releases its own chemical, its natural reaction of our brain to deal with harm, to deal with pain, is to release its own chemicals. In order to fight diseases, in order to fight pain, in order to deal with stress, things of that sort in the central nervous system. Well opioids activates those. And after a while, the brain does not work as it had done before. That's why it is a brain disease. Because it does not work like it used to. And after a while, you continue to use. We build up a tolerance. And when we build up a tolerance to the substance, what do we do in order to impact it? We begin to use more. And that dependency cycle continues and continues and continues. And the brain reaches a point where it's not able to regulate chemical processes normally without the drug. The drug begins to supplant what the brain had done naturally. And now things are out of whack. How do we get things on track? That's the big part. How do we get things on track? Now our brain, by the use of opioids, it can remain in balance. Even if we remain absent, it can remain in balance, our brain, before it begins to restore itself. Months, possibly years after a person has stopped using. That's why it's so critical that we get people linked to counseling treatment programs and medication for opioid use disorder can assist us and assist our clients, assist our participants in our treatment program to correct these chemical imbalances, which can hopefully lead them to a life of recovery and to function more effectively. Have any of you, any of the individuals in your court, been on medication-assisted treatment? Great, judges, this is when you will use that green check or red X to denote yes or no. Looks like the answers are coming. Or you can use your pointer tool if you'd rather do it that way. Looks like we have more yeses. The majority of the bench is saying yes. Five and then eight. So eight said to say yes, nine, ten. And only two are saying no. All righty. Thank you so much, Brooke. Thank you. Let's get into the details now. What are the medications for opiate use disorder? You have three. You have buprenorphine, methadone, and naltrexone. Now, buprenorphine, what's interesting is that the medications that's used to treat opiate use disorder acts for a longer period of time than individuals who pick up substances off the street, whether it's heroin, whether it's certain pills that they may pick up, opiate pills. But let's talk about the different drugs. What is buprenorphine? One is buprenorphine helps to suppress and reduce cravings. Oftentimes it might be combined with naloxone to prevent our participants or those in the community from injecting it. A lot of times if you're working with those in the addicted community, whether you have a drug court program, whether you have a treatment court program, whether you're working with individuals that might be on probation, whether you have some pretrial diversion program, you may hear different names that is used when we talk about buprenorphine and how it is marketed, how it is packaged. Some buprenorphine may go by the name of Subutex. A lot of times you see Subutex being utilized in tablet form for females who are pregnant. The most common one you'll probably hear is Suboxone. There's also Zublox, which is in the tablet form, and Sublocate. Sublocate is an extended-release buprenorphine. High-dose buprenorphine has been found more effective than low-dose in maintaining a long-term treatment. What about methadone? I mean, there's been a lot of discussion on the feeling of methadone. Now methadone is a full opioid receptor activation, so it actually activates those sites in the brain that you would have in your opiates from nature, synthetic opiates. What's interesting is that it is good to reduce opiate cravings and withdrawals, and blunt or blocks the effect of the opiates to a certain degree. How and why is that important for us? Many times our individuals who are using heroin, opiate substance in the street, they're hurting. After the drug itself begins to wear off, they begin to feel the effects of the pain, begin to have withdrawal feelings, things of that sort, which a number of times will prompt them to go back out to pick up and to use. Methadone is a good tool to reduce the cravings and withdrawals. As a matter of fact, all three of these work to similar effects. The duration for methadone goes from one to two days. It can only be provided through a licensed opioid treatment program, and typically it's going to be in liquid form. Now, Trexone. Now, Trexone is interesting because it blocks the euphoric and sedative effects of opioids and prevents the feelings of euphoria. Now, the other two, it helps with the cravings and so forth, but if it's prescribed in an effective way, in the appropriate dosage, you would also avoid the euphoria feeling. That's something the physician and the prescriber will work on, what is the right balance for the individual that they're working with. Now, Trexone, it's available as an oral tablet, and typically you'll find the number of quarts that like the extended release injectable called Vivitrol, because Vivitrol is typically for 28 days, 30 days, the injection. Now, the oral form of the Trexone is found to be cheap, or should I say less expensive than the injectable form, but it has, as some would say, low treatment compliance. To have someone get an injection for 28 days, 30 days, and it actually blocks the opioid from reaching the areas of the brain that would activate that portion of the brain. Now, Trexone actually blocks that, so it's a great medication. However, each of these medications, the treating provider will find what is best suited for that person, because some medications will not be appropriate for them, and that's something where we have to always consult with our prescribers. And let's talk a little bit about Naloxone. Now, Naloxone is a lifesaving medication approved by the Food and Drug Administration. What it is designed to do is rapidly reverse opioid overdose. It's considered an opiate antagonist, which means, as we talked with Naloxone, that it binds to the opiate receptors and can reverse and block the effects of other opiates. But Naloxone is a temporary treatment. In other words, a person may receive multiple injections during the midst of an overdose in order to save their lives, but it has a short life or acting span. So therefore, it's critical that that person be taken to the emergency room, to the hospital, to receive appropriate care. It's recommended, and you'll see a number of agencies that might provide those who use opiate Naloxone care as far as giving them the device to actually administer if they're in the company of someone who is overdosing. The medication can be given by nasal spray, intramuscular venous injection. So, all in all, all of these approaches to dealing with medication for opiate use disorder is not a tool in and of itself. In other words, it has to be coupled with counseling if we're looking to put a person on the road to recovery. So, we talked about methadone, naltrexone, and buprenorphine. What is an agonist, antagonist, and partial agonist? Those are the comparison when we look at these drugs, so methadone, naltrexone, and buprenorphine. Now, agonist is a substance that actually stimulates the same areas. It binds to the same area and receptors in the brain to produce a response, a biological response. So, when we look at the antagonist, agonist causes an action, and antagonist actually blocks the action. So, we talked about methadone actually stimulates the similar sites that you would have other opioids. However, it's a long-acting full opioid agonist. It's taken daily. It's available in liquid, powder, and diskette form. Though it occupies and activates the same opioid receptors, it does so more slowly than other opioids. And in an opioid-dependent person, treatment does not produce euphoria, the high, those same feelings, drug-seeking feelings that they would go out in the street to purchase these various substances and euphoria. That's why methadone has been utilized for years. We heard of methadone. There's been different myths. Some people, I don't want my folks on methadone. It's a tremendous substance, and people have found success and been on methadone for years. It helps them to manage their lives where they're able to function, where they're able to work, where they're able to take care of their families. That is methadone. Buprenorphine, when we talk about a partial agonist, it means that it binds to those same opioid receptors, but it activates them less strongly than the full agonists do. Like methadone, it helps in reducing their craving and withdrawal symptoms, which a lot of times is the main challenge in getting folks into treatment and recovery that are opioid dependent. When you talk about, oh, just go through your withdrawals, go through your clinical care, and then just go to your counselor. That sounds well, but some folks need medication to deal with some of the symptoms related to the withdrawal, related to the body. We talked about how the brain is missing certain chemical responses to deal with certain things that's happening in the body, in the nervous system. Things of that sort. Medically assisted treatment can help them with that journey, and at least creating some degree of normalcy in the brain as we work to get the brain functioning and restored to the point or close to the point where it was before they started and became dependent on substances. Now, naltrexone, and we talked about how naltrexone and you have Vivitrol, other substances, similar substances, is an opiate antagonist, which means that it works to actually block the opioids from stimulating that part of the brain. So, instead of controlling withdrawal and craving, it actually treats the opiate use disorder by preventing the drug itself from producing reward effects, such as the euphoria. So, addiction, it's a biological disease. Three medications are approved by the government for the treatment of opiate addiction. We covered the naltrexone, the methadone, the buprenorphine, but know, all in all, that this is only part of how we work to treat those who are opiate dependent, opiate use disorder. Only part. We have to be coupled with treatment. I have a question for you. Are courts in a better position to decide appropriate drug treatment? What do you think? All right, judges, you'll want to use your pointer tool here, or you can send your answer in through the chat tool as well. We have a couple of judges registering false via the chat tool, Judge Russell. All righty. Thank you. All right. Thank you very much. Now, the National Association of Drug Court Professionals, NADCP, it is the largest membership organization for treatment court professionals. Its membership includes judges, prosecutors, defense counsel, treatment providers, probation, court personnel, those in recovery, and its board of directors passed a resolution with respect to medically assisted treatment. And this resolution, for the thousands of those involved in treatment courts, that we as in those involved in the treatment court agreement, and I would just venture to say, for those even if you're not involved in treatment court, if you are working in the court system and have an involvement with individuals that you know are likely suffering from dependency on substances, that there is an obligation to learn about what is the research says about the efficacy of medically assisted treatment for addiction. We should make reasonable effort to attain reliable expert consultation on the appropriate use of it for the people that we're seeing and working with in our justice system programming. And we just can't impose a blanket prohibition. It is against the evidence and evidence-based practices to say that people cannot have medication that would assist them to move forward to the point of recovery. But that is something the treatment professionals will make a determination on after they do a full workup with regards to the person that you're working with. The risk, as we've seen, over 500,000, last year over 100,000 died as a result of opiates and the use of opiates. If medically assisted treatment will help that person on their journey to getting stable, to getting to the point of abstinence in the future, if that is likely, then some need the medication to assist them as they work with a treatment counselor and provider to get to the point of being able to effectively manage their life. And that is found appropriate whether a person has a mental health disorder coupled with a substance order, the use of medically assisted treatment through research. So the Judicial Benchbook, which is published by the National Drug Court Institute, which is a division of the National Association of Drug Court Professionals. And the Judicial Benchbook indicates that addiction medications, they are definitely grossly underutilized in our criminal justice system. They don't support the effectiveness of medically assisted treatment. And this highlighted portion is that it's imperative that our court use every tool available to help to save lives. We have to move past some of our personal biases, let's say, if they do exist, to say what does the best evidence show? And realize too many people are dying out here. And if there are tools that can be able to assist to save another life, we as judicial personnel can really make a difference. And the Judicial Benchbook also, as you can see highlighted, the time has come for the criminal justice system, the substance abuse treatment system to apply. EBP is evidence-based practices, which includes incorporating medically assisted treatment in the work that we do in our court program. The Adult Drug Court Best Practice Standards, the National Association of Drug Court Professionals is contracting a number of researchers, studies done. After a four-year period, they looked at all the research that was done in the country. And from that, they compiled what are the best practice standards when we're talking about working in a judicial system. And we have a treatment court. And Volume 1 had a text revision in 2018, it came out in 2013. But medically assisted treatment can improve outcomes. The research is firm with regards to that. It reduces the drug use, reduces rearrest, parole violation, and reincarceration rates. So the evidence is clear. I think it's really urging the field to take the steps necessary to ensure that it is incorporated. By the way, have any of you ever attended the National Association of Drug Court Professionals National Conference for Treatment Courts? Could you use your tool? You can use your pointer, but you also can use your yes, no tool, which is the green check for yes, or the red X. Oh, someone said through the chat tool, two years in a row, that's great. But the majority of the judges on today have not. All righty. I would invite you to at least go to their website, which is www.nadcp. And Brooke, if you could just put it in the chat, the website. Because these different publications that I'm mentioning, you can just download them from their website. If you do attend the National Conference, they will typically have these publications in a hard copy, hardbound publication. So it's a great tool to take back to your jurisdiction. Some of these, if they're still doing it, I'm not sure. But at one time, some of the publications, like the Benchbook, you could be able to order and they would mail it to you. Otherwise, if not, you can just download it and print it out yourself. So it's a great site to be able to get some of these tools. All right. Thank you. All right. Let's talk about, and these are somewhat related to some of the myths that we talked about. What an assisted treatment does is substitute one addiction for another. When it's actually properly prescribed, the medication will reduce the craving and prevent relapse without causing a tie that you're for you. And that's what we want. We don't want folks walking around high. We want them to be stable, want them to be able to get the counseling so they can work to manage their disease or disorder. And medication for the opiate use disorder can help these people to stop that drug seeking and of course, committing and reoffending and appearing back to our criminal justice system. So it is considered a myth. It increases the risk for overdose in patients. Actually the opposite is true because the medication for opiate use disorder actually works to help prevent overdose, overdosing from occurring. Just know that when we think about someone who has detox, if they go back down on the street and use again, that single use can result in overdose. And we heard about the impacts of fentanyl and what the potential and possibility and risk involve. So it does not increase the risk for overdose, but actually helps to reduce the risk. Providing that will only disrupt and hinder a patient's recovery process. I mean, you heard that, right? I believe in total sobriety, it's going to hinder them and the recovery process. But the research has shown that actually medically assisted treatment actually assists the person in recovery and helps them to improve their quality of life, get stability in their life, helps to increase their level of functioning and to handle stress without going out in the street, picking up and using, and which is tremendous, it helps to reduce the mortality, people dying. Addiction medication are a crutch. Some say, ah, you know, they're taking buprenorphine now, methadone, that's merely a crutch. And of course, that's some personal feelings and biases. But when you explore, look at the research, individuals stabilize on medication for opiate use disorder can actually achieve what the researchers, what the scientists, what specialists say is true recovery, because they can actually lead a productive, functioning life without experiencing that euphoria, that high, sedation, or other impairment of their functioning. It's important that we couple that with counseling. It can't be just, here, have your medication, and you move forward. No, we need to also incorporate counseling, counseling to address the behavior modification, counseling to address the people, places, and things, counseling to work on that sober lifestyle, sober living. We want people to be able to have productive lives, functioning lives, but they need help in that journey. This is, medically assisted treatment is a tool in a tool bag to be coupled with professional counseling for our participants. And that question, courts are in a better position to decide appropriate treatment. I know folks, sometimes folks say, well, you know, I see this person in court, so I think they need residential. I think they need inpatient. I think they don't need to be on medication. The fact is, we're not trained in that arena. We're not physicians. And just as we wouldn't tell people, for example, who have diabetes to stop taking their insulin, and what they should do is just exercise more and diet more, because we know we put them at risk of what, death, serious harm. The same with regards to this arena. We need to, and what was recommended by the National Association of Drug Court Professionals, whether it was in this board resolution, whether it is in its best practices, whether it's in the judicial bench book, whether from all the research that's been done, is we need the treatment-related professionals to assist and guide us. So we need to incorporate them, have them as part of our team in court, whether we want a treatment court or not, and say, look, I want your assistance to assist and help us with regards to the population that we've seen coming in our justice system. Now, when administered along with other services, medication for opioid use disorder is highly effective treatment for a basic problem of opioid use disorder. Now, this was a study that was done and came out in August of 2021 from the Center for Court Innovation, where they looked at the first opiate treatment court in the state and in the country at that time, opiate, just strictly dealing with opiate use disorder. And they found that patients stand a much stronger chance of full recovery when courts provide medication for opiate use disorder. And that particular court was designed because people, we had a significant increase in our county, where Buffalo is located, Erie County, of people dying from opiate use disorder. So one of the approaches was, is that when a person is seen in court, that they're at the arraignment, if through our pre-child services, other inquiries, it's likely that the person was dependent on opiate substances. If so, we will work with them, see them daily, get them on the medically-assisted treatment, and then get them to the point where we can work to save their lives, get them stable, get them in counseling so they can move forward in an appropriate way with their life. I think as we, as you explore the work that you do, if at any point in time you're seeking a federal grant, or you've already received a federal grant, you would know this, but the Department of Justice Bureau of Justice Assistance have stated, and they would, it's also part of the frequently asked questions and their response. They require that those who apply for a grant must develop the capacity to access medically-assisted treatment for all treatment court participants. In addition, they also indicated an applicant operating a treatment court that has an active policy that prohibits a participant's access to all available medically-assisted treatment, will be inconsistent with the Department of Justice Bureau of Justice Assistance program, and as a result, the applicant would not be eligible to receive a grant award under BJA Drug Court Program Office, and that's going to be the same for SAMHSA. So, just understand, they've taken a strong position that medically-assisted treatment will save lives. When we talk about for the Medicaid for Opioid Use Disorder, it definitely has proven to save lives, that we need to take those steps in order to not only save lives, but helpfully and hopefully put a person on the path of recovery. I was going to just let you know you had four minutes left. If anyone has any questions, there's a couple ways you can ask them. You can chat them in via the chat tool, or if you want to raise your virtual hand next to the green checkmark, I can come out and unmute you if you want to ask it directly of the judge. I know sometimes there's a delay in the chats coming through, so I'll scroll down and look for any hands, if anyone has any questions. Somebody just said, I want to thank you for this valuable presentation. Someone else wrote, therapeutically speaking, medications used to treat an opioid use disorder is really about providing wellness. Someone asked, and I don't know if you can answer this, judge, but since you're not a medical provider, I've been hearing concerns about the long-term effects of medication for opioid use disorder on a person's biology. Do you have any thoughts on that? I think my thought is this, what is going to be the best option for that person? We know when we hear about any medication, matter of fact, it's kind of interesting, isn't it? When we're watching our television programs and they do an advertisement for any medication, they then go through the long list of potential risk involved. I think in any medications, there's some potential risk that the reward outweighs the potential risk and potential side effects. Particularly, when we talk about opiate use disorder, for the opiate use disorder and the substances that's been created in the laboratory, the synthetic substances that's been imported into our country, specifically fentanyl and the number of substances that mirror fentanyl that's been developed by other countries and sent to this country, that people are dying. What's also fascinating, if you think it is, is that some folks are taking this substance unknowingly because it's being cut with other substances that they think that they're going to be more safer in using, such as cocaine. They say, well, people are not really overdosing on cocaine, so I'm using cocaine. Where they received it from, it's been cut with fentanyl. Now they're at risk, considerable risk. Marijuana, we see it now. Folks would say, no, I never use fentanyl. Well, what did you use? Marijuana. I use cocaine. I don't use fentanyl. Well, guess what? Fentanyl is in your system because it's being cut with that. All right, so the more dangerous substances that are being developed, when we look at medically-assisted treatment that might help a person find some degree of stability and then go into counseling, I think the reward outweighs the potential risk. Any other thoughts or questions? I'm not seeing any, and I don't see any hands up. I just want to make one final announcement to everyone on the webinar that in the next couple of, later today or tomorrow, you'll receive an email from me, Brooks and Pell, that will have a link to a short survey or evaluation. Once you complete that, it will redirect you to a new link where you can download both the materials, which include these slides and Judge Russell's full biography, as well as the CLE or CJE attendance form. Just want to make sure you use the correct one for your state, whether or not it's on the 50-minute hour or the 60-minute hour. Thank you all very much for attending, and thank you especially to Judge Russell for making time to talk to us about this. Thank you for having me, and to my fellow colleagues and judges, they continue best in the work that you do. Thank you for attending this webinar.

Judge Robert Russell

medication-assisted treatment

opioid use disorders

treatment courts

learning objectives

recommended practices

opioid epidemic

common myths

SAMHSA

waves of the epidemic

evidence-based practices