Drug Treatment Courts: An Evidence-Based Review with Recommendations for Improvement

www.ccsa.ca • www.ccdus.ca

November 2023

Policy Brief

Canadian Centre on Substance Use and Addiction • Centre canadien sur les dépendances et l’usage de substances Page 1

Policy Brief

Drug Treatment Courts: An Evidence-Based Review

with Recommendations for Improvement

The Issue

Improving the design, implementation and evaluation of current drug treatment court (DTC) models

used in Canada is needed to achieve their intended outcomes for participants. A DTC is a diversion

model that keeps substance use–related issues within the criminal justice system while providing

people with alternatives to incarceration. Overall, many approaches used by DTCs to manage

substance use disorders (SUDs) do not align with current evidence and healthcare-based best

practices. Currently, the federal government is developing a guideline for substance use treatment

programs.

For DTCs to improve their effectiveness, their programs must be ethical and evidence-

based, and address social determinants of health. There is also a fundamental concern that DTCs

address substance use within a justice context, rather than aligning with current evidence that it

should be addressed as a public health, health and social issue.

DTCs have become a popular policy alternative in responding to substance-related offences for

individuals whose criminal activity is directly or indirectly related to their substance use. However,

there is a lack of strong evidence establishing the effectiveness of DTCs in reducing criminal

behaviour and substance use.

There are additional questions about their effectiveness in

participant retention, the ethics of their approach and their cost-effectiveness. As national

discussions shift to acknowledging substance use as a public health, health and social issue and not

a criminal one, retaining substance use–related issues within the criminal justice sphere poses its

own set of challenges.

This brief examines existing evidence to see whether DTCs meet their intended purpose, while also

exploring factors that influence the health and well-being of people who use drugs. It defines what

DTCs are; situates them within the current substance use environment in Canada; and reviews

issues related to DTC evaluations, the evidence of the effectiveness of DTCs and factors that

influence outcomes.

The primary audiences of this resource are policy and decision makers, service

providers, and justice professionals who support and oversee DTCs. This brief is also intended for

researchers, staff at non-profit organizations, and those interested in the impacts of DTCs. The brief

provides these audiences with evidence-based information and response options to improve DTC

programs. It is complementary to another brief, Comparing Drug Treatment Court Principles to

Evidence-Based Practice.

What Are Drug Treatment Courts?

Drug treatment courts, or DTCs, offer court-appointed treatment in partnership with community

addiction programs and services as an alternative to traditional court sanctions (e.g., fines,

penalties, incarceration) for drug-related offences, including offences related to alcohol in some

Canadian locations (e.g., Windsor-Essex DTC).

The first DTC in Canada opened in Toronto in 1998.

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Since then, DTCs have opened in some municipalities across the country with funding being provided

by the federal government and sometimes in partnership with provincial and territorial

governments.

5,6

Each DTC in Canada has its own structure and process for who it accepts as

participants and how the program is run. This customization is done by DTCs with the intent to meet

local needs.

The purpose of DTCs is to reduce criminal charges for individuals who have an identifiable substance

use challenge and whose criminal activity is either directly or indirectly related to their use of alcohol

or other drugs. DTCs seek to do this by facilitating court-monitored treatment and community service

support for eligible people who have been charged under the Controlled Drugs and Substances Act

(CDSA) or the Criminal Code. Probation officers, federal and provincial prosecutors, duty counsel and

judges are all involved in the DTC process.

Individuals charged with a non-violent crime under the CDSA and who have a court-acknowledged

SUD that directly or indirectly contributed to the offence(s) are permitted to apply to DTC programs.

A person’s eligibility for a DTC program is screened by the Crown. Each DTC has its own eligibility

criteria established by an interdisciplinary team. In general, an individual will be deemed ineligible for

admission into a DTC program if they:

• Have been charged with a violent crime (e.g., gun or knife crime);

• Have a recent or significant history of violence;

• Have been charged with trafficking drugs for commercial benefit;

• Have committed a drug offence that puts others at risk, such as drug-impaired driving,

threatening to use or using a weapon, or conduct that poses a risk to a young person; or

• Are an associate or member of a gang or criminal organization.

The diversion of criminal penalties through participation in a DTC requires the accused to enter a

guilty plea.

Each DTC defines success differently. However, common criteria include a period of abstinence from

substance use (informed by frequent and random drug testing), no criminal behaviour or convictions,

and achieving social stability (e.g., stable housing and employment). DTCs use incentives, such as

phase advancement ceremonies, and sanctions and penalties, such as jail time, to drive behavioural

change. Graduates from DTC programs are eligible to receive a reduced sentence, as recommended

by the DTC team (e.g., a suspended sentence with a period of probation).

Current Environment

Canada is experiencing an ongoing and serious drug toxicity crisis where the unregulated drug supply

is significantly increasing the risk of harm and death for people who use drugs.

The federal

government has responded with a variety of programs and services to attempt to address this crisis.

The Substance Use and Addictions Program provides funding for projects addressing harm

reduction, treatment and substance use. Federal and provincial ministries focused on mental health

and substance use have been created, leading to initiatives such as establishing guidelines for

substance use treatment programs. Both diversion and decriminalization models are being adopted

nationally and regionally. In 2022, the federal government adopted a diversion model that includes

continuing to make DTC the default option for first-time non-violent offenders.

1,10

Additionally, British

Columbia received an exemption from the federal government to pilot the decriminalization of

personal possession.

The re-signing of the Canada Health Transfer in 2023 made mental health

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and substance use services a shared priority between the provincial and territorial governments and

the federal government. Despite these changes, there are significant gaps in access to care,

particularly for historically marginalized populations. Innovative responses and increased access to

evidence-based substance use services are urgently needed.

Issues Related to DTC Evaluations

The degree of confidence placed in the effectiveness of DTCs has been debated on two main factors:

• The quality of the research and evaluation studies of DTC effectiveness, and

• The quality of the treatment provided to DTC participants.

Understanding these factors is crucial to evaluating DTC outcomes, especially around reducing

criminal offending, substance use and incarceration.

This section explains and reviews study quality and some of the factors that influence DTC

evaluation findings. It also defines treatment quality and discusses the model needed for effective

DTC programming. Suggested responses to determine study quality and improve treatment quality

are provided.

Study Quality

Study quality can be determined by the degree of bias built into the study design and the degree of

confidence that can be placed in evaluation outcomes.

Bias refers to flaws or limitations in the

design, conduct and analysis of research that can alter the study findings. Although bias is usually

unintentional, it can lead to wrong conclusions.

One effective research method for evaluating the

effectiveness of DTCs is to compare the outcomes of people who have participated in DTCs to those

who have not.

Several evaluation methods used for DTCs have biased designs and artificially overestimate their

effectiveness.

Below are several factors applicable to DTC evaluation studies that impact study

quality:

• Study design: Random assignment studies randomly assign participants to either a “treatment”

(DTC) group or a “control” (non-DTC) group. They are considered the highest-quality studies for

determining whether the treatment caused the intended outcome, such as a reduction in

reoffending. However, it is difficult to use randomized studies with DTC participants due to

ethical, legal and practical limitations.

15,16

Because of this, non-random designs (such as quasi-

experimental designs) are used instead,

2,13

resulting in weaker conclusions. This is because

differences between treatment and control groups may account for how effective the treatment

is, especially in studies where participants are assigned to groups based on situational

characteristics (e.g., type of arrest) or personal traits (e.g., motivation, risk level). These

differences can influence the outcomes of each group rather than the treatment itself.

• Incomparable comparison groups: Where random assignment is not possible, researchers often

use comparison groups to compare the outcomes of treatment. Ideally, the treatment and non-

treatment groups should be as similar as possible, except for their participation in the treatment.

Some DTC studies have not adequately controlled for differences between the treatment and

non-treatment groups. Although it is common to compare groups based on demographic factors

such as gender or age, studies rarely compare groups on risk-related factors, such as the

severity of substance use or socioeconomic status.

This calls the effectiveness of some studies

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into question because it is unknown whether the differences in outcomes between groups are

due to the program or to the pre-existing group differences.

Creating similar comparison groups can also be an issue due to the voluntary nature of DTCs,

where participants must choose to participate in the program. This has the potential to introduce

“self-selection” bias to the study if not addressed (e.g., listed as a limitation in the study), as it

may not include the entire population of people eligible to participate, and there may be

differences between those who choose to and those who chose not to participate in DTCs.

• Exclusion of participant incompletion rates: Some DTC studies have not included participant

incompletion rates as part of their analyses. Incompletion rates in DTC programs are upward of

50 per cent.

17-19

This means that only program graduates are considered in some DTC analyses.

This overestimates the effectiveness of a program by not considering participants who did not

complete the program and their reasons for leaving. Individuals who do not complete the

program typically reoffend more than participants who graduate.

Not including the reoffending

rates of participants who did not complete the program in the analysis of DTCs inaccurately

portrays higher effectiveness.

20,21

• Differences between definitions of key factors: Some studies compare the findings of several

studies despite the variations in definitions of key factors. For example, there are differences in

what the term “reoffending” means in a public safety context. Some studies define reoffending

as an arrest, whereas others define it as a conviction or incarceration. This can result in arrest

data overestimating reoffending rates by including arrested individuals who were not convicted

of an offence.

22,23

Additionally, using convictions to measure reoffending may underestimate

reoffending rates by excluding cases with insufficient evidence to convict, or cases that resulted

in a plea bargain. How success is defined and measured by a DTC impacts the outcomes of any

evaluation. This applies both to the success of individual participants and to the success of the

program.

• Differences in follow-up time: Variations in participant follow-up time can also impact study

comparability. Generally, longer follow-up periods reveal higher reoffending rates as individuals

have more time at risk to reoffend. However, most DTC evaluations track reoffending only during

the period of participant involvement in the DTC or shortly thereafter. Therefore, DTCs’ long-term

impact and success is unclear.

24,25

Future evaluations of DTC effectiveness should consider the influence that the factors noted above

may have on study results. Below is a list of recommendations to guide the design and conduction of

future evaluations.

Response Options

The following is a list of questions to consider when reviewing DTC research or reports of DTC

effectiveness. While not exhaustive, these can help provide insights into understanding findings from

studies.

1. Can the study’s quality be evaluated with the information provided?

A study should describe the participants, define variables and concepts (such as “reoffending”),

and explain how data was collected, gathered and analyzed. Studies that provide insufficient

information should be interpreted with caution.

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2. Did participant follow-up time extend beyond the period of participant involvement in a DTC?

The assessment of outcomes will depend on follow-up information. Ideally, DTC studies should

include long-term follow-up well beyond the period of participant involvement in a DTC

(e.g., years). Generally, studies with longer follow-up periods report higher recidivism rates, as

individuals have more time at risk to reoffend.

3. Were differences between DTC and non-DTC comparison groups accounted for, such as offence

severity, criminal history, age, gender and substance use history?

A study should account for differences in factors between DTC and non-DTC groups to determine

with greater confidence which changes or outcomes (e.g., reduced reoffending) are due to DTC

programs and not some other factors.

4. Were participant incompletion rates considered in the analysis of results?

A study should consider participant incompletion rates in the analysis of the results. Results from

studies that do not do this should be interpreted with caution, as they may overestimate the

effectiveness of a DTC program.

5. Do studies that compare the findings of several studies attempt to control for differences in the

definitions of key factors such as “reoffending” or “success”?

A study that compares the findings of multiple studies should control for definitions of key

factors, as different definitions have an impact on the outcomes of any DTC evaluation

(e.g., reoffending and graduation rates). Any lack of standardization in definitions must be

considered when attempting to determine why estimates of DTC effectiveness vary among

studies.

Treatment Quality

The risk-need-responsivity (RNR) model is an evidence-based approach in the development of

effective correctional programming, including DTCs, by governments in Canada and around the

world.

13,26

This model describes three main principles: the risk principle, the need principle and the

responsivity principle. The risk principle states that the intensity of services should match the

individual’s risk level. The need principle outlines the importance of assessing and targeting factors

directly related to reoffending. Lastly, the responsivity principle asserts that services should be

tailored in a manner beneficial to an individual’s learning ability and style.

A leading research article on DTC quality evaluated treatments used by the programs by assessing

adherence to the RNR model.

RNR principles have been shown to be a more effective approach in

improving community reintegration and reducing reoffending for justice-involved people.

However,

despite governments across the country using this model, many studies on DTC program quality

demonstrate poor adherence to the three RNR principles. DTCs rely on treatment programs offered

in the community, which may make communication about quality assurance between the courts and

treatment programs more difficult.

Positive participant outcomes, such as reduced reoffending, are

increased when the level of treatment or supervision intensity is matched with the severity of

substance use and level of risk.

29–35

Research has shown that DTC programs that target high-risk offenders were the most successful in

reducing reoffending.

34,36

There are concerns that lower-risk individuals are applying for DTC

programs.

This has resulted in DTCs having net-widening effects

where low-risk or low-need

people receive more intense supervision, criminal sentences or treatment than is appropriate for

their needs. The result is individuals who may otherwise have had their cases dismissed are instead

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enrolled in DTC programs, receiving high-intensity supports and services that do not align with their

risks and needs. In addition to this, the RNR model has been criticized for over-emphasizing risk

factors at the expense of helping individuals meet their basic human needs and live more fulfilling

lives.

In line with these concerns, there has been interest in developing alternative approaches to

offender rehabilitation that support the development of an individual’s knowledge, skills,

opportunities and resources that reduce the risk of future criminal behaviour. The Good Lives Model

is an example of a strength-based approach, which is increasingly being adopted and integrated into

offender rehabilitation as an alternative to the risk-based approach of the RNR model.

Response Options

1. Properly screen. DTCs should seek to adopt the use of standardized intake screening tools to

assess participant risk and need and implement support plans that include the use of the risk-

needs-responsivity model. This should include identifying the specific service(s) required to meet

individual participant needs and establishing the intensity and duration of specific treatments,

modifying over time as needed. The plan for supervision must also be specific to the individual’s

risk and need.

2. Explore alternative programming models. DTCs should explore the use of alternative

programming models, such as the Good Lives Model, to improve the lives of individuals during

DTC participation and after completion. The model is a restorative framework for offender

rehabilitation that seeks to improve the outcomes of correctional intervention by helping

participants live meaningful and fulfilling lives that are not aligned with future offending.

emphasizes personal growth rather than solely addressing substance use or criminal behaviour.

Integrating strengths and motivations in assessments, as outlined by the Good Lives Model,

allows treatment providers to build upon personal strengths and improve well-being by meeting

universal human needs.

Limited empirical research on the effectiveness of the Good Lives

Model shows promise.

3. Avoid net-widening. Concerns have been expressed that lower-risk individuals are applying to

DTC programs. Moving forward, DTCs should examine whether an increased number of lower-risk

individuals are being admitted to programs and focus admission on individuals who would have

otherwise gone to prison.

A Review of the Evidence on DTC Outcomes

This section reviews the evidence on the ability of DTCs to:

• Reduce criminal reoffending and substance use, and

• Reduce incarceration rates and costs.

These outcomes are currently the two most common criteria that researchers and governments use

to evaluate DTC effectiveness. Suggested responses for improving the quality and outcomes of DTCs

based on these criteria are included. However, as this section outlines, evaluation should be

broadened beyond these two areas to fully understand the impact of DTCs on individuals.

Reducing Criminal Reoffending and Substance Use

Reoffending is the most common outcome measured in DTC evaluations. Several meta-analyses

(i.e., studies that combine the results of multiple studies)

2,42–45

and independent evaluations

46–51

have found that DTC participants have lower rates of reoffending than non-participants. However, the

accuracy of these findings has been questioned, as the methods of some of these studies do not

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stand up to rigorous review. Declines in reoffending are the lowest among the evaluations using the

most rigorous methods.

24,45,50

Studies with the strongest methods have found reductions in

reoffending of eight per cent. Studies with less rigorous methods have found reductions in

reoffending ranging between 14 per cent and 50 per cent.

2,13,43

Several studies support the ability of DTC programs to effectively reduce substance-related

offences.

2,30,51,52

Several studies have also noted that DTC programs are effective in reducing

substance use during treatment by participants compared to those who are processed through the

traditional system.

53–58

Limitations in the design of these studies do not allow for conclusive support

of these findings.

Response Options

1. Implement evaluation plans. DTCs should have evaluation plans to measure their effectiveness.

Monitoring and evaluation processes will allow DTCs to measure the achievement of program

goals and gauge effectiveness. See Comparing Drug Treatment Court Principles to Evidence-

Based Practice

for a comprehensive set of key principles and standards to support and guide

the evaluation of services.

2. Collect better data on DTCs. Data on DTC participation and success is limited, making

evaluations of the effectiveness of DTCs difficult to measure. More data that is standardized and

well-defined can lead to better evaluations and recommendations for best practices in DTCs,

providing policy makers with the information necessary to choose where to spend limited funds.

DTC program evaluation data should be broken down by sex, gender and other demographic

characteristics, so specific considerations can better guide service provision and policy

development. Data on other important factors related to DTC outcomes should be collected,

including participant completion rates, wait times for care, appropriateness of care and

participant readiness for change.

3. Seek partnerships. Administrators of individual DTC programs should seek partnerships or

consultations with organizations that can conduct or consult on improved monitoring and evaluation.

4. Dedicate resources to data collection. Resources should be dedicated to collecting adequate

data, including a core set of indicators collected across all DTCs, as well as obtaining feedback

from participants and team members.

5. Use the data. DTC administrators should use the evaluation plans and subsequent data to guide

and adapt the provision of care through DTCs.

6. Expand outcome measures. DTCs should seek to establish or adopt performance measures

beyond typical outcome measures of reoffending to include social determinants of health

(e.g., secured housing and employment, reduced substance use).

7. Evaluate current DTC policies and practices. DTC administrators should continuously evaluate

policies on participant eligibility to prevent practices that lead to higher failure rates for certain

groups, especially Indigenous people, women and sex workers. Regular and improved evaluation

will help increase knowledge about successes and challenges that lead to more equitable and

effective programs.

Reducing Incarceration Rates and Costs

The evidence in support of DTCs’ ability to reduce incarceration rates and provide cost-effective

alternatives to imprisonment is mixed.

57,59–61

As such, the extent to which DTCs reduce incarceration

is currently unclear.

24,62–64

A review of 19 studies found that while the average DTC reduced the rate

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of incarceration, it did not reduce the average amount of time DTC participants spent incarcerated

because of sanctions imposed during their participation in the program.

The potential cost savings

achieved by DTCs in Canada ranged from 20 to 88 per cent if incarceration was assumed. However,

if incarcerated individuals receive a probationary sentence, DTCs have the potential to cost

substantially more.

Additional information on expenses and longer-term benefits of DTCs is needed to evaluate the cost

advantages of DTCs over incarceration. A more in-depth analysis of the potential cost savings

requires information on DTC participants and a comparison group of longer-term outcomes, such as

employment and reoffending, other potential costs, such as social assistance and health care, and

sentencing patterns should participants reoffend.

Response Options

1. Focus on DTC diversion for those who are facing a likely prison sentence. If a person would have

received a prison sentence, then a DTC program can act as a true diversion, saving the federal,

provincial and territorial governments money and protecting public safety through a more

intensive period that includes both treatment and supervision.

2. Improve cost-effectiveness. This may include improving the selection process to find those who

will benefit from the program, dismissing participants early on who are unsuited to the program,

improving the match between treatment programs and participants, creating more realistic

graduation criteria, and improving the management and accountability of varying agencies

involved in the program.

It is also dependent upon strong data collection and ongoing

structured evaluation of this data to flag when programs need restructuring or further attention.

3. Provide a spectrum of care. There has been recognition across Canada that effective treatment

of SUDs needs to be integrated, comprehensive, evidence-based and innovative. This approach

includes providing a spectrum of treatment options that meet set criteria of standards of care for

participants remaining enrolled in the program. This includes changing strict abstinence

requirements, as this could increase the number of people opting for support and choosing DTCs

over the traditional criminal justice system. It is also important to examine why program

incompletion rates are so high, including possible contributing factors such as participant

readiness for change.

Factors That Influence DTC Effectiveness

Social and Demographic Factors

Several social and demographic factors may have impacts on DTC program completion and

reoffending, including housing,

lower education levels,

17,67–69

, employment,

67,70,71

family support,

transportation,

child care,

gender,

68,75,76

age,

58,75,77–84

ethnicity,

54,77,82,84–89

and severity and

duration of substance use.

53,56,57

Researchers have not reached consensus concerning which factors

identify people who will succeed or benefit most in DTCs.

Despite mixed findings around DTCs outcomes, addressing the multi-faceted needs of individuals

with SUDs can improve treatment retention and outcomes, including reducing problematic

substance use and reoffending.

There is significant variation in the ability of a DTC to provide the

services required to meet multi-faceted needs. For example, funding for DTCs and access to local

services vary across the country

. DTCs serving rural and Indigenous communities often lack public

transportation, supportive housing or specialized practitioners and services.

Despite the variation

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in quality and type of services and support available within communities, program compliance,

including abstinence, is expected.

Best practices note the importance of providing relevant treatment based on ethnicity, age, gender,

mental health and other participant characteristics.

This is in line with recommendations to ensure

that treatment is more responsive to participants’ needs to be effective. However, DTCs are

experiencing difficulties reaching these intended target groups, such as Indigenous people, women

and sex workers.

Participants in DTCs have reported that support is needed to improve their social

determinants of health, including finding employment and housing.

This highlights the need for

partnership with people with lived or living experience of substance use to develop programs that

have the appropriate services and supports to achieve meaningful outcomes. However, there is

currently no known documented involvement from people who use drugs in the design, operation or

evaluation of DTC programs. There is also a need for a comprehensive and integrated approach that

recognizes substance use as part of a complex and interconnected set of needs.

Response Options

1. Seek early input. DTCs should seek early input from participants on what support they need to be

successful in the program. This should be for sentencing purposes and to assess needs related

to social determinants of health.

2. Increase investment in substance use–related programming, services and supports. For

diversion to be effective, there must be places with adequate staffing and support where people

can be diverted to. Sustained investments at all levels of government to ensure the capacity for

comprehensive social and healthcare services and programs is a critical component of a

diversion model. This includes investing in substance use–specific training for providers of care

within communities across the country.

3. Provide appropriate access to services. To ensure appropriate access to services, only people

who need these services should be “diverted” to them. This can be supported by having referrals

to programs made by medical practitioners and social service providers with expertise in

substance use. Currently, it is common for DTC court officials to influence treatment pathways

rather than trained medical and social experts. The people sent to these services must be willing

to actively participate in them and should not be coerced to participate.

4. Improve access to housing. DTCs should improve access to independent, stable housing by

working with support in the community to secure stable housing for participants while also

funding treatment beds, transitional housing and supportive housing. Housing should also follow

the Housing First model, which recognizes housing as a fundamental human right, not something

conditional based on substance use, mental health or legal status.

5. Expand outcome measures. DTCs should seek to establish or adopt performance measures

beyond typical outcome measures of reoffending to include social determinants of health

(e.g., secured housing and employment, reduced substance use).

6. Evaluate current DTC policies and practices. DTC administrators should continuously evaluate

policies on participant eligibility to prevent any practices that lead to higher failure rates for

certain groups, especially Indigenous people, women and sex workers. Improved and higher-

quality evaluations will help lead to more equitable and effective programs.

7. Increase equity. DTCs should provide all defendants who meet the eligibility requirements the

same opportunities to participate and succeed in DTC regardless of demographic factors such as

ethnicity, gender and age.

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8. Improve data collection. DTC program evaluation data should be broken down by sex, gender

and other demographic characteristics, so specific considerations can better guide service

provision and policy development.

Individual Treatment

There is a strong body of evidence that shows recovery looks different for each person, and success

is greatly improved if individuals determine their own goals of treatment with the support of a care

provider.

Access to a spectrum of services and support, including a variety of harm reduction

services, supportive housing, as well as both non-abstinence and abstinence-oriented support, are

crucial factors to determine a DTC’s ability to respond to substance-related challenges.

A legally

coercive model of abstinence-based recovery that DTCs impose does not take an evidence-based

approach to care and can have stigmatizing, harmful and even deadly outcomes for the individuals

involved. While

the impact of the requirement of abstinence in DTCs on program effectiveness is

understudied,

the evidence for an increase in mortality rates immediately after abstinence-based

treatment discharge is strong.

This increase is often explained, in part, as being a result of

decreased tolerance caused by a prolonged period of abstinence.

Some DTCs focus on specific

drugs that build physiological tolerance in the individual with use over time, such as opioids, cocaine,

crack cocaine and methamphetamines. The requirement of abstinence puts the person at serious

risk for non-lethal or lethal drug poisoning if they consume these drugs again at previous levels of

dosage following a period of non-use.

In addition to decreased tolerance, this model ignores

evidence that behaviour change is rarely sustained.

100

In any behavioural change process, including

substance use, it is common to revert to previous behaviour despite the motivation to change.

100

DTCs should adopt a model that assumes a return to substance use is often a normal part of the

behavioural change process. Providing greater leniency than is currently offered to DTC participants

is necessary to support individuals in achieving sustainable behaviour change (e.g., reduced

substance use) and reducing stigma. Stigma can act as a barrier to treatment for individuals who

use substances if treatment facilitators (e.g., DTC staff) or providers (e.g., primary care providers)

react with negative judgment and negatively biased views, such as the belief that individuals who

use substances are poorly motivated to change.

101

This can be problematic, as research has shown

that individuals who experience discrimination are much more likely to engage in or return to

behaviours that are harmful to their health and well-being.

102

Medications for opioid use disorder (MOUD), including methadone, buprenorphine and naltrexone,

are one of the important components of the evidence-based medical practice for treating opioid use

disorder.

103

Research has reported improved outcomes for justice-involved people with an opioid use

disorder who receive MOUD, including reduced illicit opioid use, reoffending rates and risk of drug

poisoning or death. However, many DTCs do not recommend, or even allow for the use of MOUD for

opioid use disorder.

104

Some medical practitioners and court officials are reluctant to view MOUD as

acceptable in an abstinence-based program and view these medications as replacing one addictive

drug for another.

103

Others believe forced withdrawal from opioids is part of the process of

treatment.

105

These views, however, do not align with evidence-based medical treatment. Although

DTC programs rely mainly on medical professionals for medication-based treatment decisions, court

staff who typically lack medical training can set practices or policies barring participants who have

been prescribed MOUD from advancing through DTC programs and phases or from graduating. In

some cases, the use of MOUD is banned entirely. Some DTCs exclusively refer individuals to

healthcare providers who do not use MOUD.

106

Although efforts have been made to promote MOUD

in DTCs, stigma, cost and availability continue to hinder its implementation.

Drug Treatment Courts: An Evidence-Based Review with Recommendations for Improvement

Canadian Centre on Substance Use and Addiction • Centre canadien sur les dépendances et l’usage de substances Page 11

Response Options

1. Develop individualized treatment plans. Treatment plans for DTC participants should not impose

abstinence. Treatment should be medically informed and customized to the specific needs of the

participant, which includes setting individual goals and identifying the specific services required

to meet those goals.

2. Expand outcome measures. Include individualized treatment goals (e.g., reduced substance use)

in performance measures beyond typical reoffending outcomes. This can be achieved through

multiple pathways to program completion, including a non-abstinence track, and graduation

criteria that include health and social outcomes. Outcome measures may include housing and

income stability, new community connections (e.g., community kitchens), reduced use, safer use

or abstinence from all or certain substances, vocational activities (school, work, training,

volunteering), improved relationships, improved financial status, desistance from or significant

reduction in criminal activity, and improved quality of life.

107

3. Embed MOUD within DTCs. DTCs should ensure access to all Health Canada–approved

medications (e.g., methadone, buprenorphine, naltrexone) for participants. This should include

partnerships with registered opioid treatment programs and other providers of MOUD in the

community. This work can address barriers related to misinformation, stigma, treatment access,

phase advancement, graduation and collaboration with community treatment providers. MOUD

access should also be available to individuals who violate the DTC program and serve jail time. It

is also strongly encouraged that a more thorough review of MOUD access in the justice system

across the country for all people serving jail and prison sentences be done, and existing

provisions and policies be amended accordingly. MOUD access should also be available to

individuals who are serving jail sanctions.

Conclusions

This brief examined the evidence to understand whether DTCs are meeting their intended purpose

while also examining factors that improve the health and social well-being of people who use

substances. Research examining the effectiveness of DTCs has serious limitations concerning

evaluation methods, treatment quality and the ability to address the multi-faceted needs of

individuals with SUDs. Despite widespread claims that DTCs serve as an effective alternative to

imprisonment by reducing incarceration rates and substance use, the evidence in support of these

conclusions is mixed. Additionally, DTCs have not demonstrated cost-effectiveness when compared

to alternative models of service delivery (e.g., treatment in prisons). Findings are mixed in supporting

the idea that DTCs are more cost-effective than traditional means, and further examination is

needed to use this as a justification for policy makers’ decisions.

Several factors may contribute to success or failure in DTC programs and post-program outcomes

among participants, including participant risks and needs, social determinants of health (e.g.,

housing and employment), ethnicity, age, gender and prior substance use. Although researchers

have not reached a consensus on which factors identify people who will succeed in DTCs, it is critical

that DTCs address the multi-faceted needs of individuals with SUDs. Lastly, ethical issues arise from

the high mortality rates immediately following abstinence-based treatment, raising concerns about

effectiveness of forced abstinence as a requirement in DTC programs. This requirement contributes

to DTCs barring participants from using MOUD, which is a common evidence-based medical practice

for treating opioid use disorder. There is an immediate need for better quality evaluations to

determine DTC program effectiveness and best practice assessment and treatment models when

Drug Treatment Courts: An Evidence-Based Review with Recommendations for Improvement

Canadian Centre on Substance Use and Addiction • Centre canadien sur les dépendances et l’usage de substances Page 12

addressing substance use and criminal acts. This includes centring the feedback from participants

and team members on how to make DTC programs better at supporting the goals of participants.

As regions across Canada begin to explore decriminalization and diversion as a model to address

substance use, the question remains as to whether keeping substance use–related issues within the

criminal justice system through diversion programs like DTCs is an effective measure and best

practice. The response options included in this brief provide ways to improve the evaluation, delivery

and assessment of DTCs for policy and decision makers, as well as researchers and evaluators.

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Suggested citation: Berg, D., & Burke, H. (2023). Drug treatment courts: An evidence-based review

with recommendations for improvement [Policy brief]. Ottawa, Ont.: Canadian Centre on Substance

Use and Addiction.

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