When an old offense caught up with 28-year-old Robert Lepolszki last year, he had a full-time job and had kicked heroin. But Frank Gulotta Jr., the Nassau County judge assigned to his case, forced him to end the only treatment that had ever worked: methadone maintenance. Judge Gulotta said that methadone does not enable a defendant “to actually rid him or herself of the addiction.” Complete abstinence programs were the only treatments his court allowed. Not long after stopping the medication, Mr. Lepolszki was dead from an overdose.
The judge’s position on methadone is common among those who administer drug courts, which are aimed at helping defendants get treatment and avoid prison. Only a third allow maintenance use of methadone or a newer medication called buprenorphine (Suboxone) and 50 percent ban maintenance outright. But they are ignoring medical evidence showing that maintenance is the best approach to opioid use disorders, which involve drugs in the same class as heroin, like OxyContin and Vicodin.
The confusion is both national and local; for example, the Manhattan Treatment Court still rejects maintenance. But right now, Gov. Andrew M. Cuomo of New York and Gov. Chris Christie of New Jersey are considering whether to sign bills that have passed their State Legislatures to force all courts to allow this treatment. They should sign the bills.
There is still widespread prejudice against maintenance, in part because many treatment providers disapprove. More than 80 percent of American addiction treatment is centered on the abstinence-based 12 steps of Alcoholics Anonymous, which means that affiliated counselors often don’t see maintenance as “real recovery.”
In the scientific literature, however, there’s no question that maintenance works. Every expert group that has ever studied it — from the Centers for Disease Control to the Institute on Medicine and the World Health Organization — has determined that, for opioids, ongoing maintenance is superior to abstinence.
That’s because maintenance is the only treatment known to reduce drug-related mortality, which it cuts by more than 70 percent. For a disease that kills 2 to 3 percent of its victims annually, that’s a remarkable benefit. Maintenance is also proven to reduce crime, stop the spread of disease and increase employment, so long as the medication is continued without interruption. Mr. Lepolszki’s death was not an isolated incident — it was a likely outcome of denying access to a treatment that the W.H.O. has called “essential medicine.”
Since it involves substituting a similar opioid drug for heroin, critics of indefinite maintenance argue that it’s just “replacing one addiction with another.” They incorrectly conclude that patients who are in substitution programs are always impaired because both methadone and Suboxone can produce a “high” in people who take extra doses or who aren’t already addicted.
Opioid addiction, however, is unique and should not be confused with the more general concept of physical dependence. Addiction is not simply needing a substance to function: If that were the case, we would all be considered addicted to food, water and air.
Instead, addiction involves compulsive behavior in the face of negative consequences; obsessively pursuing a drug or experience even though it is ruining your life. Maintenance replaces unhealthy behavior with simple dependence, the need to take a drug to avoid withdrawal. And that is not a problem with a legal, safe supply.
These properties allow people with opioid addictions to get on with their lives, functioning as well as anyone else. The drug becomes similar to an antidepressant — indeed, in some cases, it may be treating underlying depression. It is needed daily, but is not an obsessive focus. On maintenance, people can work and flourish. Maintenance even reduces overdose risk during relapse.
Drug courts were first offered as an alternative to punishment at the height of the war on drugs in Florida in 1989. Today, they serve around 120,000 defendants. If their goal is actually to treat addiction, they need to offer individualized treatment that meets a higher standard of care and gives participants the best odds of survival and recovery. Mr. Cuomo and Mr. Christie should act immediately and sign their states’ bills.
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