Drug courts and treatment programs have a symbiotic relationship: These days, with so much treatment funding flowing through the criminal-justice system, it's fair to say that neither can long survive without the other.

But as a recent conference shows, the relationship between the courts and treatment programs remains uneasy. Experts at the New England Association of Drug Court Professionals annual meeting, held in July in Bristol, R.I., indicated that trust and understanding -- or a lack thereof -- remains a critical issue for both sides.

William Brownsberger, J.D., associate director for public policy at the Harvard Medical School's Division on Addictions and a former Massachusetts assistant attorney general, said that drug courts need to play an active role in assuring the quality and appropriateness of the treatment programs to which they refer clients.

"Not all treatment works well ... and not all treatment works well for all people," said Brownsberger. For example, he said, programs that have counselors who aren't used to dealing with prison populations or don't share the cultural background of inmates may be less effective. Conversely, programs that grow too dependent upon criminal-justice referrals can develop an unhealthy "inmate culture," Brownsberger said.

High turnover rates also can turn a good program into a bad one, meaning treatment programs require constant review. "It's just not safe to assume quality," said Brownsberger.

On the other hand, he said, some programs do a good job but appear to be failing simply because they deal with the toughest clients. "It's hard to tell from the outside," Brownsberger said.

Quality control suffers because drug courts sometimes are overly deferential to treatment providers, he said. "If anyone without a J.D. says something, it's likely to be believed," stated Brownsberger. Moreover, defense attorneys tend to be happy with anything that keeps their clients out of jail, while complaints by clients are often dismissed out of hand.

"Don't automatically label complaints about treatment as a bad attitude or relapse," Brownsberger told drug-court leaders. "It may be true -- the place may be failing and the counselors may be jerks. You have to crave that feedback or you really aren't doing what's right for your clients."

Even when there is a treatment person on the drug-court team, said Brownsberger, their advice can be supply driven: "They only show up when they have beds to fill."

To improve quality control, Brownsberger suggested that drug courts pool treatment referrals with other agencies, such as probation and parole departments, to achieve economies of scale that would allow for a case-management system to be established. Such a system would provide unbiased referrals, generate honest feedback, allow for re-placement of clients where necessary, and measure and reward program outcomes.

"Nobody's doing that for drug courts in many areas," said Brownsberger. "We need to identify the best performers in the community."

Brownsberger's comments touched a few raw nerves in the audience, particularly among treatment providers.

"I don't think anything is looked at as closely as treatment programs other than a nuclear waste site," said Rick Froncillo of Discovery House, a Providence, R.I., methadone-treatment provider. "I'm worried that some in the audience will say, 'How did they get away with this for so many years?' I think the majority of providers are good ... Patients complain about programs and counselors when the program is starting to make progress with the clients. They want to get away from the counselor because they're finally starting to do some good [recovery] work."

Craig Stenning, executive director of the Rhode Island Division of Behavioral Health Care, said many of the oversight mechanisms suggested by Brownsberger do exist in better drug courts.

"Assessment should be clinical, not done by a lawyer," he said. "We are developing new behavioral healthcare licensing standards [and] the providers and consumers put together more stringent requirements than I would have."

The Methadone Bone of Contention

Methadone maintenance is another bone of contention between drug courts and treatment providers. Brownsberger said that many courts refuse to utilize opiate-replacement medications -- "It's against our religion," he joked -- even though it is the only treatment that has been proven through rigorous study.

Vermont drug courts, for example, don't work with methadone programs. "How do we look at the drug-court model and then the absence of methadone and make sense of this?" asked one state drug-court official. Replied Stenning: "If unbiased referrals are being done, there certainly is a segment of the population who will benefit from methadone maintenance."

Some in the audience suggested that drug courts' refusal to use methadone reflected the stigmatization of heroin users, prompting Quincy, Mass., probation officer Jo Rothman to reply: "I don't think my feeling that methadone maintenance is incompatible with drug courts is prejudice.

"The conclusion that I have come to is that people in drug court find it counterproductive to be with methadone clients," said Rothman. "The people in drug courts say if I have an addiction and am struggling every day to live, how come Sally Smith can use this and I can't do it. I think some people can't be in drug court as it is constituted now."

What Makes Drug Courts Work?

Despite such statements of certitude, and the continued faith in the drug-court concept shown by policymakers, funders, and criminal-justice officials, it's still unclear what elements of drug courts themselves are effective in getting offenders to turn away from crime and addiction.

Douglas Marlowe, J.D., Ph.D., a researcher with the Treatment Research Institute at the University of Pennsylvania, said that many credit the "power of the robe" for swaying clients. But judges can also be a hindrance to treatment success, he said.

"They can stifle other professionals if they impose their will too strongly," according to Marlowe.

The National Association of Drug Court Professionals has developed a list of key elements for successful drug courts, but while Marlowe praised the list as "very intelligent guesses," he pointed out that there is no empirical evidence to support the compilation.

In a study funded by the National Institute on Drug Abuse, Marlowe and colleagues tried to determine if there frequency of contact with a drug-court judge had anything to do with treatment success. One group of study participants met biweekly with a judge through status conferences, while another group only saw a judge on an as-needed basis.

"It was risky, because we took one of the most critical elements of drug courts and essentially removed it," said Marlowe.

The study found that both groups attended counseling at about the same rate and had more clean urines over time. And the as-needed group actually did somewhat better in a 6-8 month post-treatment drug screening than the group that met regularly with the judge.

When controlled for clients who had a prior history of treatment, however, the study showed different results. "The clients with a prior treatment history seeing the judge [regularly] did much better than those seeing the judge as-needed," according to Marlowe.

"Why does the judge matter?" said Marlowe. "I still don't know, but they do."

The Court of Public Opinion

One place where judges -- and other drug-court professionals -- definitely do matter is in the court of public opinion. And their voices are needed in the battle to ensure that drug-court graduates can succeed in life after treatment, according to David Rosenbloom, director of Join Together.

"Public support for treatment over incarceration is really growing quite dramatically," said Rosenbloom, "and as times get tough more state legislators are beginning to believe, too."

But, he warned, policymakers also are growing more interested in what happens to drug-court graduates after they are released, and "the effects of discrimination may overwhelm what you are trying to do to get people clean and sober."

Rosenbloom pointed out that researchers like Thomas McLellan conclude that treatment success should be measured not just by sobriety but by the ability to hold a job, maintain stable family relationships, and other quality-of-life factors. But federal laws currently prohibit people with drug convictions from living in public housing, collecting food stamps, getting educational loans, or accessing other means of support. Moreover, employment disclosure requirements present an effective barrier for ex-offenders looking to get a job.

"The drug conviction alone may condemn [drug-court graduates] to failure," said Rosenbloom. "You may have to stop having guilty pleas if the conviction itself is what prevents recovery."

"Even without discrimination, your clients face huge problems, but with the discrimination that comes with conviction they face overwhelming odds," Rosenbloom told the drug-court officials and treatment experts.