Promising Sentencing Practice No. 9
Drug Therapy

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By Judge Stephen E. Benson and Gregory Lynch (California)

Overview
To assist convicted DWI offenders in maintaining sobriety while attempting to change the behavioral patterns leading to their alcohol abuse, a court may consider requiring the offenders to take naltrexone or Antabuse, drugs that have been used in the treatment of alcoholism for many years. Generally, it is recommended that the drug therapy be combined with psychosocial therapies for the most benefit.98

What Is Naltrexone?
Naltrexone (ReVia) is a non-addictive medication that reduces cravings for alcohol, and has been approved by the FDA as a treatment for alcoholism. It is intended to be used in connection with psychosocial treatment to reduce the risk of relapse. One study concluded that offenders who are treated with naltrexone in combination with cognitive behavioral therapy drank less, took longer to relapse, and had more time between relapses. They also exhibited more resistance to and control over alcohol-related thoughts and urges. Finally, 62% of those taking naltrexone did not relapse into heavy drinking, in comparison with 40% of the placebo group.99

Naltrexone has few adverse side effects, but should not be taken by pregnant women, people with severe liver or kidney damage, or people who are dependent on opiates such as heroin or morphine.

The recommended initial course of treatment is three to six months. Thereafter, the need for further treatment should be evaluated on the basis of the person’s degree of improvement and continued concerns about relapse.

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What Is Antabuse?
Antabuse (disulfiram) is a drug that produces unpleasant side effects when a person drinks alcohol while taking the drug. It has been found to be less effective than naltrexone, and also has toxic qualities that have led to major medical complications.

Although Antabuse and naltrexone can be used together, their combined usage is not ordinarily recommended. Antabuse may be used in conjunction with naltrexone to abate persistent complaints of craving or with patients who have continued to drink periodically in order to help them break this cycle and achieve a sustained period of abstinence. It may also be used to establish an initial period of abstinence before initiating naltrexone therapy, at which time its use is discontinued.

Benefits of Drug Therapy
Naltrexone reduces or stops the cravings for alcohol that interfere with an alcoholic’s ability to complete a treatment program. The medication may enable the patient to maintain sobriety for a sufficient period of time to successfully establish a pattern of behavior modification through psychosocial treatment.

Although psychosocial treatments for alcoholism have been shown to increase abstinence rates, a significant proportion of alcoholics find it difficult to maintain initial treatment gains and eventually relapse. Naltrexone, when used in addition to psychosocial therapies for alcohol abuse, can reduce the percentage of days spent drinking, the amount of alcohol consumed, and relapse to excessive and destructive drinking.100

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One Court’s Experience with Naltrexone
As part of its HIDE (High Density DUI/DWI Enforcement) Program, Butte County (California) Superior Court requires offenders placed in the program to participate in a drug treatment program that requires the offender to take naltrexone. This program is designed primarily for multiple DWI offenders, and accepts offenders who are granted probation for DWI with priors and DWI with injury cases in which there is a significant alcohol or drug abuse problem.

Butte County has been requiring the use of naltrexone by certain DWI offenders since 1996. Its ReVia Project began as a 90-day trial project, which was extended based on the positive results achieved with repeat DWI offenders who were part of this project. The Butte County Court found “that ReVia is far and away the most successful method of dealing with high-blood-alcohol, repeat drunk drivers.” It found that:

  • Use of the drug as part of the probationary terms and conditions for repeat DWI offenders allows behavioral modification to take effect.

  • ReVia [naltrexone] is far more effective than Antabuse and standard probation with Alcoholics Anonymous (AA) terms and conditions.

  • Offenders taking ReVia had the lowest recidivism rate and the longest period of time before recidivism as compared to offenders taking Antabuse and offenders on probation with AA terms and conditions.

  • A key aspect of the drug treatment program is strict accountability.

The procedure used by the court is as follows:

  • On conviction or plea, the court places the defendant on formal supervised probation.

  • The defendant is ordered to contact a physician immediately, to receive an examination and a prescription for ReVia. Ingestion of the drug is initiated and a log is signed by the pharmacist or physician.

  • Defendants are required to present proof of prescriptions and ingestion to their probation officers. In some cases, pharmacists personally observe the ingestion, sign the log of the offender, and keep a separate log to document and compare. Customary safeguards are taken to protect against false ingestion attempts.

  • The defendant is also ordered to participate in a specified alcohol treatment program, to submit to urine testing at specified intervals, and to abstain from all use or possession of alcohol or controlled substances and from entry into places where alcohol is sold or is a primary focus of business.

  • Court review of the defendant’s compliance with all orders is conducted at regular intervals.

  • Probation officers conduct field searches, and are authorized to arrest any defendant who is violating the terms of probation.

  • After six months, the court reviews the case to determine if the supervision level will be reduced.101
 
98 O’Malley, Stephanie, “Naltrexone and Alcoholism Treatment,” U.S. Department of Health and Human Services, Treatment Improvement Protocol Series 28, p. xv (1998).
99 Anton, R.F.; Moak, D.H.; Waid, L.R.; et al., “Naltrexone and Cognitive Behavioral Therapy for the Treatment of Outpatient Alcoholics: Results of a Placebo-Controlled Trial,” American Journal of Psychiatry, Vol. 156, No. 11, pp. 1758-1764 (1999).
100 For further discussion of using naltrexone in combination with psychosocial therapies, see O’Malley, Stephanie, Naltrexone and Alcoholism Treatment, Treatment Improvement Protocol (TIP) Series No. 28, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment; Kranzler, H.R. and J. Van Kirk, “Efficacy of Naltrexone and Acamprosate for Alcoholism Treatment: A Meta-Analysis,” Clinical and Experimental Research, Vol. 25, No. 9, pp. 1335-1341 (2001); Garbutt, J.C., et al., “Pharmacological Treatment of Alcohol Dependence: A Review of the Evidence,” Journal of the American Medical Association, Vol. 281, No. 14, pp. 1318-1325 (1999).
101 For further information about the Butte County ReVia Project, see http://www.aca-usa.org/reviaproject.htm, and “DWI/Drug Courts: Defining a National Strategy,” Appendix B: ReVia Project, National Drug Court Institute (March 1999).