North Carolina Specialty Courts, Treatment Access, and the Substance Use Crisis: A Promising but Underfunded Model

More than 20 million Americans had an alcohol or drug use disorder in the past year, of whom only about 10% received treatment (1). A subset of those with such disorders is at high risk for repeated involvement in the criminal justice system, partly as a consequence of their untreated illnesses. Treatment courts, also known as recovery and specialty courts, offer an alternative to traditional prosecution and sentencing for individuals with behavioral health needs and a high risk for reoffending. Treatment courts have proliferated throughout the United States since the 1980s. As of 2014, approximately 4,300 treatment courts served 127,000 clients in all 50 states and the District of Columbia, including >3,000 drug treatment courts (2).

These courts have gained new relevance and attention in North Carolina and other states as a potential tool to address the opioid crisis. As of June 2020, North Carolina had 59 recovery courts in 32 counties, including 29 adult drug treatment courts (ADCs), eight family drug treatment courts (FDCs), three youth drug treatment courts (YDCs), seven driving while intoxicated (DWI) courts, seven mental health courts, four veteran treatment courts, and one tribal court. Even courts that are not explicitly dedicated to drug treatment are likely to serve individuals whose mental health problem co-occurs with a substance use disorder. But are treatment resources available in communities most affected by substance use disorders to enable drug and other treatment courts to effectively meet the new challenges posed by the opioid epidemic and other health crises?

The treatment court model requires collaboration among professionals with different roles—judges, court coordinators, prosecuting and defense attorneys, probation officers, and treatment providers—to provide a mix of incentives, sanctions, treatment, supervision, and case management in order to address client needs and reduce their risk for recidivism. Establishing a treatment court requires funding for court team members to coordinate the program, operate the oversight, support the referral and tracking functions of the court, and connect to treatment resources. A crucial element is connecting clients to effective treatment and supervision. Long-term recovery often requires availability of a range of treatment options such as residential treatment, individual and group psychosocial treatment, medications, and treatment for related mental health issues such as trauma and depression. However, adults involved in the criminal justice system very often lack health insurance, including those participating in recovery court (3). Without health insurance, the treatment provided through treatment courts must be funded by state and local resources or grants or be paid for by clients themselves (4).

In North Carolina, treatment courts are funded differently by each county, sometimes with federal grants and most often with city and county resources. The North Carolina General Assembly enacted the Drug Treatment Court Act in 1995 and for >15 years provided some financial support for recovery court programs, including treatment costs for uninsured clients and program costs, such as hiring a court coordinator. In 2011, court funding from the legislature was terminated, first by cutting $2.2 million of program costs and then $2.2 million of treatment costs. As a result of these budget cuts, five courts closed (personal communication with Yolonda Woodhouse, North Carolina Administrative Office of the Courts, November 26, 2019). Most survived with a combination of city, county, and federal grant funding, but six currently operate with no funding, that is, no additional resources beyond the existing services of the judge and attorneys and community corrections personnel. Budget cuts primarily affected adult, youth, and family drug courts. How these budget cuts may have affected services, treatment access, and outcomes such as graduation rates or new arrests is unknown, partly because the withdrawal of state funding meant that courts were no longer required to submit relevant data via legislative reports. In the absence of data for North Carolina, here we considered the perceptions of professionals from all North Carolina treatment courts, whom we asked to reflect on current court operations, outcomes, resources, and treatment.

Perspectives of Treatment Court Professionals

After a statewide conference and training event, a Web-based survey was conducted with conference registrants, including judges, attorneys, health care providers, probation officers, court coordinators, court administrators, and others whose professional roles touched on specialty court operations in North Carolina. More than half of the 72 respondents (N=40) worked in ADCs, about a third in FDCs or YDCs (N=14 and N=6, respectively), and the remainder (N=11) in other courts (DWI, veteran, or mental health courts) or did not report their court affiliation (N=1). The sample was generally representative of conference registrants and North Carolina specialty courts (see an online supplement to this column for further detail).

Clear majorities of respondents agreed that their courts were effective and useful. More than 80% of the respondents agreed with positive statements about their court’s improving clients’ chances of remaining in the community without another offense (60 of 71), avoiding jail or prison (58 of 71), and moving toward long-term recovery (60 of 71). Three-quarters or more approved of their court’s use of sanctions for program violations (53 of 71), the referral process (53 of 70), termination decisions (58 of 71), and the admissions process (59 of 71). Fully 90% (64 of 71) endorsed statements that there was a “productive collaboration between the legal and treatment/services aspects of our court program” (64 of 71) and that “[b]y participating in our court, clients have better access to treatment” (66 of 72).

However, fewer respondents agreed that available resources were sufficient to meet client needs, including treatment needs. More than one-third (26 of 72) did not agree that their program had all the resources needed to meet clients’ needs effectively, and the same proportion (26 of 72) did not agree that clients had access to all the treatments they needed. Just over one-half (39 of 72) agreed with both statements, and more than one-quarter of the respondents (19 of 72) endorsed neither.

Professionals working in drug treatment courts appeared to be more concerned about treatment access and resources than were those working in DWI, veteran, or (combined) mental health courts. Drug court professionals had a statistically significantly more negative view of program resources (p=0.012), treatment access (p=0.013), and availability of mental health providers (p=0.011). Just over one-half of ADC professionals (22 of 40) thought that their program had the necessary resources, and 58% (N=23) thought that their clients had access to necessary treatment, with similar proportions for the combined FDC and YDC group (12 of 20 regarding resources and 11 of 20 regarding treatment access). With regard to the availability of specific types of providers, FDC and YDC professionals appeared to be the most concerned, with just over one-third (7 of 20) endorsing adequate availability of mental health providers and about one-half (10 of 19) endorsing adequate availability of substance use disorder providers. By contrast, all or all but one of the 10 respondents working in either mental health, veteran, or DWI courts endorsed every positive statement.

To understand what may drive these concerns, we examined the written responses to the open-ended question, “What elements of your recovery court could be improved?” When ADC professionals cited specific concerns, these concerns were most often about inpatient and residential facilities: “We need inpatient treatment that is affordable,” “[We need] more long-term and inpatient treatment residential long-term options for mental health clients,” and insurance needs to cover longer inpatient stays because “no person in recovery will be cured after a 28-day inpatient stay.” Related comments included, “Should decrease the use of jail . . . as holding place while waiting for inpatient treatment,” and concern about people “being forced to come off of [medication-assisted treatment (MAT)] script” (prescription for MAT) when hospitalized or incarcerated. In addition, a few mentioned access to MAT, drug testing (a need for “more thorough and monitored drug screens more frequently”), psychosocial mental health treatment (including at methadone clinics), housing options, and money to provide court incentives.

FDC and YDC professionals identified a need for intensive outpatient programs for youths, for a drug court coordinator to enable follow-up outside of court, and for more flexible treatment options. One raised serious concerns about the match between the program and client needs: “The juveniles that are forced into the program are not appropriate and have basic needs that are not being addressed.” Another raised a serious concern that “[t]reatment providers in our area are not governed or audited for standards of care. We have grave concerns that some treatment providers are truly not providing quality treatment with adequately trained staff.”

Implications for State Policy

The above survey results provide a snapshot of attitudes from professionals working with North Carolina recovery courts and have implications for state policy decision making. Although large majorities of respondents reported that the court programs improved treatment access, far fewer thought that access was sufficient to meet clients’ needs. This response pattern indicates that client access to treatment and resources was a major concern for some drug treatment courts and points to some potential state-level policy solutions.

Professionals from drug courts voiced more concerns than those from other courts. One reason may be that ADC clients lack access to health insurance. Individuals in DWI courts typically have fewer treatment needs and are more likely to be insured, veterans may have access to benefits offered through the U.S. Department of Veterans Affairs, and people with serious mental illness may receive Supplemental Security Income or Social Security Disability Insurance and thereby have Medicaid insurance. ADC clients in North Carolina are unlikely to be insured; they experience employment barriers related to behavioral health problems and criminal justice involvement, and any employment they might have may not provide benefits.

As noted above, each county’s recovery court is managed and funded by local initiatives. Courts that have received federal grants may offer MAT or other services, but these grants are time limited. Even with grant funding, courts must also rely on client self-pay, contracts with providers, and miscellaneous other resources. In the absence of federal or state funding, Medicaid expansion is a key state policy reform that could help recovery courts better meet the treatment needs of their clients. Individuals with opioid use disorder living in states that have expanded Medicaid are far more likely to be insured (5) and to receive buprenorphine treatment (6). Under Medicaid expansion, nondisabled, childless adults who are younger than 65 years would be eligible for insurance coverage if their earnings are <138% of the federal poverty level.

Medicaid expansion has been described as the “single most effective tool” to fight the opioid crisis (7). North Carolina Medicaid provides broad coverage of many of the clinical services that are of high priority to the specialty court population, including co-occurring disorders programs and group and individual cognitive-behavioral therapy to address antisocial cognitions. North Carolina is also transitioning to Medicaid-managed care plans that address housing, food, and transportation under a Medicaid waiver. Funds are far more limited for uninsured individuals who are covered by state and local funds or grant programs. Restoring state funding for recovery courts and client treatment resources would also help. Before funding for court positions was cut, the North Carolina Administrative Office of the Courts funded court coordinator positions for ADCs, FDCs, and YDCs. County and city funds that currently support these positions could be used to improve and expand court operations, including housing support, peer support, and others. Restoring treatment service funding would also expand treatment access.

Respondents cited problems of insufficient provider capacity and quality. Many specialized services—MAT, intensive outpatient, residential services, co-occurring disorders programs, and programs that address criminogenic needs—are in very short supply and unevenly distributed in nonmetropolitan areas. Although expanding Medicaid and funding recovery courts may not directly solve these problems, Medicaid expansion and increased funding could have indirect effects. Behavioral health prescriber shortages and waiting lists for scarce inpatient and residential treatment are well-known issues; for example, Mental Health America has ranked North Carolina 44th out of 51 in access to mental health care. Medicaid expansion and state funding of recovery courts would expand incentives and regulatory capacity to promote standards of care, including MAT access across state-operated facilities and opioid treatment programs.

If court clients do not have access to evidence-based practices (EBPs) that are appropriate to their individual level of recidivism risk and treatment need, court participation may be counterproductive for these clients, not only failing to address the underlying disorder but potentially discouraging clients from continuing treatment or seeking help in the future. Increasing state funding of treatment courts would improve monitoring and regulating quality, while Medicaid expansion would increase access to available local behavioral health providers. Last, county disparities in the availability of EBPs such as MAT (8) should be addressed to give states such as North Carolina the tools it needs to overcome the crisis. In the context of the opioid crisis and an expanding population of people meeting criteria for recovery courts, greater attention is needed to deliver EBPs for uninsured court clients.

Conclusions

Our survey responses from North Carolina court professionals suggest that some programs have not been adequately implemented. Public funding for treatment courts has been unstable and insufficient, both for the purpose of administering the programs through the judicial system and for providing the mandated treatment services through the behavioral health system. Medicaid expansion offers a key opportunity for states to meet this need and prevent recidivism. Perhaps the opioid and COVID-19 crises will motivate policy makers to consider greater investment in these lifesaving programs.