Family Drug Courts: Combatting the Opioid Epidemic

Some jurisdictions are tackling the challenges identified above through the use of family drug courts.¹¹ Family drug courts wield the coercive power of the judiciary and provide both a carrot and stick to facilitate parent sobriety. Through intensive judicial monitoring, wrap-around services, and substance use treatment, family drug courts support parents as they work towards the goal of reunification. During frequent status hearings, a judge reviews the parent’s progress and issues rewards and graduated sanctions. Meanwhile, interdisciplinary teams address underlying factors that drive substance use, including mental illness, unemployment, unstable housing, educational barriers, parenting deficits, and a lack of connection to the community. Family drug courts are finding that when supervision and treatment are available, many parents battling addiction can continue to care for their children.¹²

However, among the more than 350 family drug courts in existence, there is wide variability in how courts are operated. Some family drug courts are integrated with child welfare proceedings.¹³ Other family drug courts utilize a “parallel” model that separates decision making related to termination of parental rights and drug treatment compliance. The scope and use of sanctions and rewards also differ, as does the breadth of wrap-around services and treatment.¹⁴ Lastly, there is significant variability in the extent to which family drug courts integrate best practices regarding substance use disorders, including in the use of medication-assisted treatment such as methadone.¹⁵ Variations in family drug court practices range from “reasonable minds can differ” to dangerous practices grounded in misconceptions about addiction. While family drug court research is still in its infancy, over time, these differences will provide an opportunity to examine what specific blend of judicial oversight, monitoring, and treatment produces the best outcomes for parents with opioid use disorders.

This Article will begin with a discussion of opioid use and the effects of opioids on parenting, neonatal abstinence syndrome, and medication-assisted treatment. Next, family drug courts will be discussed, including differences in family drug court models, challenges, and the implications of the Adoption and Safe Families Act.¹⁶ Lastly, three family drug court models will be explored.

I. The Effect of Opioid Use Disorder on Parenting

A. The Neurobiological Effects of Opioids on Parenting

In considering the trajectory that leads parents with opioid dependence to become involved with family drug courts, it is important to note that most opioids are initially legally obtained and used for moderate to severe pain.¹⁷ While long-term use of opioids is associated with an elevated risk of addiction, only a small proportion of those who are legitimately prescribed opioids end up in the throes of addiction.¹⁸

When an individual does become opioid dependent, significant changes occur in the brain.¹⁹ Disruption of the brain’s reward circuit produces powerful cravings and a blunting of pleasure in other areas of one’s life.²⁰ As a consequence of these neurobiological changes, the pleasure from opioids is experienced as more satisfying than other experiences typically perceived as pleasure-inducing, such as relationships, food, and sex.²¹ Addiction also suppresses the benefits of traditional caregiving rewards, rewards that a non-opioid dependent parent would otherwise experience as pleasurable. For example, the neural disruption from addiction can change the extent to which a parent experiences pleasure from an infant’s signals and cues such as smiling.²² These neurobiological shifts can lead parents to stop responding to common pleasure-inducing parenting incentives, causing disruptions to attachment in the parent-child dyad.²³

It is clear that opioid dependence can impact the parent-child relationship in meaningful ways.²⁴ Parents with an opioid use disorder frequently experience parenting skills deficits and tend to view themselves as less effective parents.²⁵ A parent with an opioid use disorder is at heightened risk of diminished caregiving skills, neglect, and abuse.²⁶ A research review by Virginia Peisch et al. identified several studies that have found significant differences in parents with opioid dependence in sensitivity to their child’s needs, warmth, and level of involvement.²⁷ Overall, parents tended to engage in fewer positive parenting behaviors and display more negative parenting behaviors.²⁸ Further, parents with opioid use disorders were found to be more likely to evidence harsh parenting styles and use nonpreferred tactics such as humiliation.²⁹

Opioid dependence also has implications for a parent’s emotional well-being, social functioning, physical health, and financial stability.³⁰ Job loss, housing instability, and food insecurity are common consequences of addiction, further increasing stress and impeding the parent-child relationship.³¹ Parents with substance use disorders are also likely to experience negative feelings, including parental guilt, anger, anxiety, and a lack of control.³² These emotional difficulties can further disrupt the parent-child relationship and attachment.³³ As discussed below, opioid use during pregnancy presents unique implications.

B. Opioid Use During Pregnancy, Neonatal Abstinence Syndrome, and Medication-Assisted Treatment

In tandem with the rise in opioid dependence, the last decade has seen a substantial increase in the prevalence of pregnant women with opioid use disorders.³⁴ Opioid use during pregnancy is associated with poor outcomes, including fetal underdevelopment and other medical and developmental issues.³⁵ A frequent outcome is neonatal abstinence syndrome (NAS), which has increased nearly fivefold in recent years.³⁶ NAS occurs when a fetus is exposed to certain drugs during pregnancy and then experiences withdrawal symptoms as a newborn.³⁷ Symptoms of NAS include tremors, feeding difficulties, inconsolable crying, hyperirritability, and poor sleep.³⁸ Newborns with NAS often require substantial medical attention.³⁹ Due to NAS-related symptoms, these infants can also be difficult to parent, and their symptoms can hinder parent-child attachment.⁴⁰ However, research suggests that children with NAS whose mothers are prescribed medication-assisted treatment tend to fare better.⁴¹ Compared with newborns of pregnant women who are untreated for opioid dependence, infants born to mothers receiving methadone or buprenorphine are less likely to have a diagnosis of low birth weight and experience other negative outcomes.⁴² Further, women receiving medication-assisted treatment, such as methadone or buprenorphine can generally safely breastfeed, which provides health benefits to the newborn.⁴³ For example, a study conducted by Elisha Wachman and her colleagues in 2013 found that newborns exposed to methadone or buprenorphine who were breastfed had shorter hospital stays and less need for NAS-related medical treatment.⁴⁴ Breastfeeding also yields meaningful benefits to attachment. Post-birth, medication-assisted treatment yields positive neurobiological implications. In a 2018 study conducted by An-Li Wang and others, researchers found that individuals with opioid dependence who were prescribed naltrexone were found to display brain-reward center responses.⁴⁵ Yet studies show that due to barriers to medication access, stigma, and misconceptions about methadone and buprenorphine, those facing opioid dependence during pregnancy are unlikely to receive treatment, often resulting in NAS as an expected outcome.⁴⁶ Further, despite well-documented benefits, some family drug courts bar participants from using medication-assisted treatment altogether, including during pregnancy.

II. Family Drug Court Models and Challenges

In considering the impact of opioid use disorder on parenting, family drug courts are one potential intervention. Across the country, states are using family drug courts to provide parents with the monitoring, tools, and services they need to work toward recovery and become responsible caregivers. Through non-adversarial family drug courts, judges, clinicians, and practitioners work together to construct an individualized roadmap to help parents with addiction while also protecting children.⁴⁷ While there are substantial differences in family drug court models, the framework is generally the same: Parents with a pending abuse or neglect matter attend frequent status hearings where a judge reviews their progress and issues rewards or graduated sanctions.⁴⁸ The underlying stressors that fuel addiction and relapse are addressed through substance use treatment, mental health treatment, job support, housing assistance, educational support, parenting classes, and community networks. Team members include a judge and other providers such as social workers, case managers, substance use counselors, probation officers, job coaches, supportive family members, and prescribers.⁴⁹ Research suggests that family drug courts produce better outcomes than traditional family courts.⁵⁰ Family drug court participation is associated with higher treatment completion rates, a greater likelihood of reunification, and fewer months in out-of-home placements.⁵¹ However, while many family drug courts are indeed observing higher reunification rates, family drug courts differ widely in their practices and the extent to which they are observing positive results.⁵²

A. Parallel versus Integrated Program Models

One area where family drug courts differ substantially is in their breadth of decision-making power. Some courts employ what is known as an “integrated court model” or “unified family court model,” while other courts utilize a “parallel model.”⁵³ Under the integrated court model, the same judge oversees (1) drug court proceedings, including compliance with substance use disorder treatment and drug testing and (2) child welfare proceedings and dependency matters such as visitation and termination of parental rights.⁵⁴ Alternatively, under the parallel model, a family drug court judge does not make a decision regarding termination of parental rights or reunification. Instead the judge solely presides over drug court with a focus on facilitating the parent’s compliance with substance use treatment and managing collateral issues such as housing and employment. At present, there is insufficient research to draw conclusions about the efficacy of one model over the other. However, key considerations include coordination, communication, and ethical issues such as confidentiality.

B. Medication-Assisted Treatment

An additional difference across family drug courts is the extent to which medication-assisted treatment is provided, permitted, or prohibited. Despite a strong consensus in medical and scientific communities that medication-assisted treatment is a safe and effective treatment for opioid dependence, several family drug courts effectively bar such medications.⁵⁵ Some family drug courts decline to admit participants on methadone or buprenorphine or insist that the participant taper off the treatment. The explanation given for banning medication-assisted treatment ranges from concerns about misuse or abuse, questions about efficacy, a shortage of prescribers, a dearth of relationships with prescribers, infrastructure issues, and cost.⁵⁶ While there is limited research on family drug courts and medication-assisted treatment, a 2013 study on drug courts in general indicated that forty-seven percent of drug courts provided methadone or buprenorphine.⁵⁷ This was a sizable increase from the percentage identified in a 1999 study, which found that medication-assisted treatment (methadone) was offered in only thirty-nine percent of drug courts.⁵⁸

The absence of medication-assisted treatment in certain family drug courts is perplexing given the extensive research indicating that these medications significantly reduce opioid use and relapse rates.⁵⁹ In discussing the apprehension surrounding medication-assisted treatment, the director of the National Institute on Drug Abuse, Mora D. Volkow, M.D., reflected, “Studies show that people with opioid dependence who follow detoxification with no medication are very likely to return to drug use, yet many treatment programs have been slow to accept medications that have proven to be safe and effective.”⁶⁰ Several organizations have advocated increasing access to medication-assisted treatment. For example, the World Health Organization (WHO) considers it a “best practice” for all individuals with opioid dependence to have free access to medication-assisted treatment, including methadone and buprenorphine for maintenance, naltrexone to prevent relapse, and naloxone for overdose.⁶¹ The WHO further indicates that it is a “minimal requirement” that medication-assisted treatment is financially accessible to all, including disadvantaged individuals.

WORLD HEALTH ORGANIZATION RECOMMENDATIONS FOR TREATMENT FUNDING AND AVAILABILITY⁶²

.MINIMAL REQUIREMENTS

• Pharmacological treatment of opioid dependence should be widely accessible; this might include treatment delivery in primary care settings. Patients with comorbidities can be treated in primary health-care settings if there is access to specialist consultation when necessary.
  
• At the time of commencement of a treatment service, there should be a realistic prospect of that service being financially viable.
  
• Essential pharmacological treatment options should consist of opioid agonist maintenance treatment and services for the management of opioid withdrawal. At a minimum, this would include either methadone or buprenorphine for opioid agonist maintenance and outpatient withdrawal management.
  

BEST PRACTICE

• To achieve optimal coverage and treatment outcomes, treatment of opioid dependence should be provided free of charge, or covered by public health-care insurance.
  
• Pharmacological treatment of opioid dependence should be accessible to all those in need, including those in prison and other closed settings.
  
• Pharmacological treatment options should consist of both methadone and buprenorphine for opioid agonist maintenance and opioid withdrawal, alpha-2 adrenergic agonists for opioid withdrawal, naltrexone for relapse prevention, and naloxone for the treatment of overdose.
  

Further, the National Association of Drug Court Professionals (NADCP) suggests that pursuant to NADCP best practice standards, medication-assisted treatment should not be a barrier to drug court participation.

NATIONAL ASSOCIATON OF DRUG COURT PROFESSIONALS⁶³

BEST PRACTICE STANDARDS

• If adequate treatment is available, candidates are not disqualified from participation in the Drug Court because of co-occurring mental health or medical conditions or because they have been legally prescribed psychotropic or addiction medication.

In addition to the above, in July 2011, the NADCP Board of Directors passed the following resolution entitled, “On the Availability of Medically Assisted Treatment (M.A.T.) for Addiction in Drug Courts.” In emphasizing the crucial role of medication-assisted treatment, the NADCP stated:

1. Drug Court professionals have an affirmative obligation to learn about current research findings related to the safety and efficacy of M.A.T. for addiction.

2. Drug Court programs should make reasonable efforts to attain reliable expert consultation on the appropriate use of M.A.T. for their participants. This includes partnering with substance abuse treatment programs that offer regular access to medical or psychiatric services.

3. Drug Courts do not impose blanket prohibitions against the use of M.A.T. for their participants. The decision whether or not to allow the use of M.A.T. is based on a particularized assessment in each case of the needs of the participant and the interests of the public and the administration of justice.⁶⁴

Yet, in spite of clear best practice standards and a general consensus that medication-assisted treatments can be a useful tool, some family drug courts continue to prohibit participants from using such treatment. However, moving forward, family drug courts could jeopardize federal funding if they choose to continue to bar medication-assisted treatment. Family drug courts receiving federal funding through the Substance Abuse and Mental Health Services Administration and the Adult Drug Court Discretionary Grant Program are now required to attest that medication-assisted treatments will not impede drug court participation.⁶⁵ It remains to be seen whether this requirement will engender widespread changes in family drug court policies.

C. Adoption and Safe Families Act (ASFA)

One often-cited challenge for family drug courts is federal timeframes.⁶⁶ Passed in 1997, the federal Adoption and Safe Families Act (ASFA) imposed strict time limits for resolving dependency cases.⁶⁷ With the ultimate goal of permanence—and to prevent children from languishing in foster care—AFSA required quick resolution of cases through reunification or termination of parental rights.⁶⁸ Specifically, a permanency hearing was required to be held within the earlier of twelve months of a neglect finding or fourteen months of the removal of the child.⁶⁹ ASFA further provided that parental rights must be terminated if a parent is not ready for reunification and the child has been in foster care for fifteen of the last twenty-two months.⁷⁰ In considering the implications of ASFA for parents with opioid use disorders, ASFA time limits are considerably shorter than the period of time most individuals take to enter stable recovery.⁷¹ Thus, even for parents receiving effective, evidence-based treatment, the goal of operating within this timeframe is often unreachable. In practice, despite concerns about feasibility, most family drug courts have responded to ASFA requirements by creating treatment plans that accommodate the short federal timeframes.⁷²

III. Examples of Family Drug Courts

As discussed above, while family drug courts are generally constrained by ASFA timeline requirements, there is considerable variability in family drug court models. Below, the following three family drug court models will be described and explored: the Second Judicial District Court’s Family Treatment Court (Reno, Nevada); the Franklin County Family Drug Court Session of the Franklin County Probate and Family Court (Greenfield, Massachusetts); and the Dependency Drug Court in the Unified Children’s Court of the Eleventh Judicial Circuit of Florida (Miami-Dade County, Florida).

A. The First Family Drug Court in the United States: Washoe County Family Drug Court, Reno, Nevada

The first family drug court was created in 1994 in Washoe County in Reno, Nevada, and employed an integrated model.⁷³ The Washoe County Family Drug Court, now called the Second Judicial District Court’s Family Treatment Court [hereinafter Washoe County FTC], shares many common features with other family drug courts. While enrolled in the Washoe County FTC, each participant attends court sessions regularly for fifteen months, during which the judge has contact with the participant and reviews his or her progress.⁷⁴ In addition, at least twice per week, all participants are given random drug screens. Included on the Washoe County FTC team are a judge, social worker, substance use treatment provider, various supportive service professionals, Child Protective Services attorney, the district attorney, and a parent attorney.⁷⁵ Washoe County FTC’s services include inpatient and outpatient treatment, individual and group counseling, parenting education, vocational rehabilitation, support for finding employment, and housing assistance.⁷⁶ The Washoe County FTC has also partnered with the nonprofit organization Step 2 to provide specialized services for women and their children, including residential treatment services where mothers receive treatment while retaining custody of their children.”⁷⁷ To participate in the Washoe County FTC, the parent must have a child placed in the child welfare system due to child abuse or neglect. Until approximately one year ago, a parent with opioid dependence was ineligible to participate in the Family Treatment Court if he or she was using methadone.⁷⁸ The following criteria are set forth in the Family Treatment Court Policy Manual, which address custody requirements, treatment motivation, and citizenship:

1. Candidate has a child in the legal or physical custody of WCHSA.

2. Candidate must want treatment for substance abuse and or mental health and be motivated.

3. Candidate must submit or admit to one of the allegations of the Petition for custody, which will be sustained by the court for jurisdictional purposes.

4. If the case has been open 6 months or less, the Candidate is eligible for enrollment to the FTC. If the case has been open for 6 to 9 months, the Candidate’s eligibility for enrollment is discretionary with the Court. If the case has been open for more than 9 months, the Candidate is not eligible for enrollment in FTC.

5. If the candidate is in the country illegally they are not eligible for the program.

6. If the team is aware the candidate has capacity to parent issues they may not qualify. This will be looked at case by case, depending on what the capacity to parent evaluation indicates.⁷⁹

Medication-assisted treatments are approved on a “case by case basis.”⁸⁰ In the event a participant relapses, the court employs graduated sanctions and relapse prevention education. Regarding court-instituted consequences, the Family Treatment Court Policy Manual sets forth the following:

Consequences for positive drug tests or a failure to comply with treatment are tailored to individual participants on a case by case basis with the goal of effective therapeutic intervention. Graduated sanctions are used to discourage repetitive behavior and to maximize the effectiveness of the chosen intervention. The safety of children in the family is paramount in the decision-making process.

The range of consequences include imposed or suspended jail or community service, increased level of treatment, written assignments, daily check ins with the Specialty Courts Officer, and extending time in the FTC Program.⁸¹

For each court session that a parent is in compliance with the program, the parent is rewarded with positive verbal recognition from the judge and raffle tickets for prizes. Upon graduation, the participant receives a “Certificate of Achievement” to recognize his or her accomplishments.

Regarding federal timelines, Washoe County FTC describes itself as in “full compliance” with ASFA.⁸² The Family Treatment Court Policy Manual states, “ASFA goals of improving the safety of children, promoting adoption and other permanent homes for children who need them, and supporting families are of the utmost importance to the Court.”⁸³ A challenge reported by the Washoe County FTC is the complexity of the population. Participants often have co-occurring mental health issues, and most parents are dependent on more than one substance.⁸⁴ While the FTC initially struggled with coordination of services, over time the FTC has increased collaboration with mental health providers resulting in more positive outcomes.⁸⁵

B. Family Drug Court Session, Franklin County Probate and Family Drug Court, Greenfield, Massachusetts

While the Washoe County FTC discussed above uses an integrated model, the newly created Family Drug Court Session of the Franklin Probate and Family Drug Court (“Franklin County FDC”) in Western Massachusetts uses a two-track model depending on whether the case arises out of juvenile court or probate and family court.⁸⁶ From 2013 to 2015, Franklin County observed a fifty-percent increase in the number of fatal opioid overdoses, and from 2011 to 2014, the county also experienced a three-hundred-percent increase in the use of Narcan by EMTs.⁸⁷ After a surge in the number of family court cases involving opioid dependence, the Franklin County FDC was established and became the first family drug court in Massachusetts.⁸⁸

Prior to the founding of the Franklin County FDC, parents in Franklin County who had lost custody of a child were managed much as they would be in other family courts: They were provided with a service plan, referred to substance use services, and given minimal oversight.⁸⁹ Without case management and monitoring to facilitate access to treatment, parents often struggled.⁹⁰ Challenges included insurance barriers, transportation issues, and long waiting lists.⁹¹ Further, as is the case in other family courts, ASFA time requirements left few options for parents with addiction who wanted help but could not access treatment. With federal grant funding, the Franklin FDC now provides comprehensive substance use treatment and wraparound services, including comprehensive case management, peer support, educational support, and vocational support.⁹² Notably, the Franklin FDC encourages the use of medication-assisted treatments and offers participants integrated treatment for co-occurring disorders, including mental health treatment and trauma informed care.⁹³ In reflecting on the mission of the court, Franklin Probate and Family Court First Justice Beth Crawford stated, “The Family Drug Court is not just about problem-solving. It is about healing. It is about doing something immediate to save lives, and to improve outcomes for families and our Franklin County community. In one way or another, we are all impacted by the opioid crisis.”⁹⁴ As the Franklin FDC continues to grow, one identified challenge is how best to support parents who successfully complete the program.⁹⁵

C. Dependency Drug Court, Miami–Dade County, Florida

Like the Washoe County Family Treatment Court, the Dependency Drug Court in Miami–Dade County employs an integrated, “one judge” model. Established in 1999, the Dependency Drug Court was founded after it was discovered that eighty percent of dependency cases involved substance use.⁹⁶ Utilizing a twelve-to-fifteen-month time frame, the Dependency Drug Court provides evidence-based interventions and trauma-focused care for both parents and children. Services include assessment of the parent and children, family therapy, substance use treatment, mental health treatment, domestic violence counseling, peer support, housing support, employment support, and assistance with medical and dental costs.⁹⁷ Additionally, child developmental screenings are used up to age three to ensure children are meeting their developmental milestones and, if necessary, have access to early intervention.⁹⁸ A rather unique feature of the Dependency Drug Court is the court’s emphasis on fostering the parent-child bond by keeping children in regular contact with their parents. When children cannot stay in their parents’ care, the court has partnered with organizations that offer supervised parenting time up to three times per week.⁹⁹

Through judicial monitoring and community supports, the Dependency Drug Court bridges several spheres of a parent’s life.

Not only does the dependency drug court judge monitor each case closely through frequent court visits, progress reports, and contact with the extended families, but the judge also monitors the system of service provision. Thus, the judge maintains close relationships with treatment providers and community agencies, thereby ensuring that the system of services continues to meet the needs of clients and positively impacts lifestyle changes for the family.¹⁰⁰

A major challenge faced by the Dependency Drug Court involved identifying effective programs and service providers that produced favorable outcomes. To address this challenge, the Dependency Drug Court began measuring intervention efficacy by studying the outcomes produced by programs and service providers with whom the court contracts. ¹⁰¹ For example, through various pilot programs, the Dependency Drug Court found that the parent skills groups that produced the best outcomes emphasized empathy and a parent’s “own ability to self-nurture,” as opposed to deficit-based didactic programming.¹⁰² Through trial and error, the Dependency Drug Court has found that wrap-around services are most successful when providers are flexible, are culturally competent, and have training in co-occurring mental health issues.¹⁰³

IV. Conclusion

While each of the three family drug courts discussed above differs in scope of judicial power, provision of services, and extent of the use of evidence-based practices such as medication-assisted treatment, each court approaches parents holistically and seeks to address the underlying context of addiction. Through judicial monitoring, case management, interdisciplinary teams, and wrap-around services, family drug courts strive to provide parents with the supervision, services, and support necessary to sustain recovery. However, despite the growing popularity of family drug courts, it is still not well-understood which of these approaches generates the best outcomes. It remains to be seen which judicial models, service plans, rewards, sanctions, and interventions are the most likely to facilitate continued sobriety and reunification. Yet research suggests that family drug court participation is associated with better outcomes than traditional courts.¹⁰⁴ Parents in family drug court have higher reunification rates, and children tend to spend fewer months in foster care.¹⁰⁵ As family drug courts continue to play an important role in addressing parent opioid addiction, efficacy research on existing family drug courts is necessary to clarify precisely which practices cultivate healthy parent-child relationships and recovery. While questions still remain, the initial successes of family drug courts show promise in revolutionizing the way family courts navigate opioid dependence.

Endnotes

1. The Centers for Disease Control and Prevention [hereinafter CDC] estimates that in 2016 there were 52,898 deaths from drug overdose, and in 2017 this number rose to 64,070 deaths. See CDC, Nat’l Ctr. for Health Statistics, Provisional Counts of Drug Overdose Deaths, as of 8/6/2017 (Aug. 2017), https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf [hereinafter CDC Overdose Statistics 2017]; see generally German Lopez, In One Year, Drug Overdoses Killed More Americans Than the Entire Vietnam War Did, Vox (Jan. 8, 2017), http://www.vox.com/policy-and-politics/2017/6/6/15743986/opioid-epidemic-overdose-deaths-2016.

2. Deaths from fentanyl have increased opioid deaths to previously unheard-of rates. Fentanyl is fifty to one hundred times more potent than morphine. CDC Health Advisory: Increases in Fentanyl Drug Confiscations and Fentanyl-Related Overdose Fatalities, CDC: CDC Health Alert Network (Oct. 26, 2015), http://emergency.cdc.gov/han/han00384.asp.

3. Opioid use disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as the repeated occurrence within a twelve-month period of two or more of the following: tolerance, inability to control opioid use, heightened focus on opioids, cravings, a failure to carry out important roles due to opioid use, continuing to use opioids despite a negative impact on one’s life, and withdrawal. Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013).

4. In a study of the impact of opioid, alcohol, and cocaine addictions, researchers concluded based on a sample of 183 mother-child dyads that mothers with substance use disorders were more likely to experience difficulties with parenting, discipline, and parent-child interaction. See Natasha Slesnick et al., Parenting Under the Influence: The Effects of Opioids, Alcohol and Cocaine on Mother-Child Interaction, 39 Addictive Behav. 897 (2014), https://www.ncbi.nlm.nih.gov/pubmed/24589871.

5. Commonly experienced family problems associated with substance dependence are child neglect, domestic violence, family dissolution, economic issues such as unemployment and housing instability, child behavioral problems, and psychological disorders. See Dennis C. Daley, Family and Social Aspects of Substance Use Disorders and Treatment, 21 J. Food & Drug Analysis (Supplement) S73, S73 (2013), https://bit.ly/2HjbwAY.

6. Many individuals with opioid use disorders are also dependent on other substances. See generally Deborah Dowell, Tamara M. Haegerich & Roger Chou, CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, 65 CDC: Morbidity & Mortality Weekly Rep. (MMWR) 1 (Mar. 18, 2016), https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.

7. Methadone is a prescribed medication-assisted treatment used to treat individuals addicted to opioids. The World Health Organization has established that access to free medication-assisted treatment is a best practice. World Health Org., Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (2009), https://www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf.

8. Kentucky recently passed legislation that expands the grounds for termination of parental rights to include a diagnosis of neonatal abstinence syndrome, a condition that occurs when a child is repeatedly exposed to a substance in utero and then experiences withdrawal symptoms post-birth. See Tom Latek, Bill Overhauling Adoption, Foster Care in Ky. Moves to Governor’s Desk, KentuckyToday (Apr. 2, 2018), https://bit.ly/2HkRYjK.

9. In 2015, seventy-one percent of states experienced an increase in the number of children in foster care placements; 428,000 children were in foster care nationwide. See Press Release, Admin. for Children & Fam. Archives, U.S. Dep’t Health & Human Servs., Number of Children in Foster Care Increases for the Third Consecutive Year (Oct. 27, 2016), https://www.acf.hhs.gov/archive/media/press/2016-number-of-children-in-foster-care-increases-for-the-third-consecutive-year.

10. While some children must be placed in foster care to ensure their safety and well-being, the disruption and potential trauma of removing a child from his or her home must also be considered. Along with concerns of foster care–related physical abuse, sexual abuse, and neglect, in jurisdictions that are unable to keep up with the influx of children in foster care, children have been at times, for example, “shipped off to prisonlike institutions,” left “sleeping in social workers’ offices,” or allowed to “bounce among multiple foster homes.” See Sherry Lachman, Opinion, The Opioid Plague’s Youngest Victims: Children in Foster Care, N.Y. Times (Dec. 28, 2017), http://www.nytimes.com/2017/12/28/opinion/opioid-crisis-children-foster-care.html.

11. See Kristen Linnartz, Trial Court Opens First Family Drug Court in Massachusetts, WWLP.com (June 17, 2016), https://www.wwlp.com/news/local-news/franklin-county/trial-court-opens-first-family-drug-court-in-massachusetts/1043608729 (“The program is built on the premise that families are systems . . . . The illness of one member has profound effects on others in that family,” said Trial Court Chief Justice Paula M. Carey); see generally Eleventh Jud. Cir. of Fla., Dependency Drug Court, http://www.jud11.flcourts.org/Dependency-Drug-Court [hereinafter Dependency Drug Court].

12. For example, a study conducted in 2014 assessing North Carolina family drug courts revealed that children of parents who completed family drug court had shorter stays in foster care than children of referred parents who failed to enroll. See Elizabeth J. Gifford et al., How Does Family Drug Treatment Court Participation Affect Child Welfare Outcomes?, 38 Child Abuse & Neglect 1659, 1666 (2014), http://www.ncbi.nlm.nih.gov/pubmed/24736039.

13. See, e.g., Dependency Drug Court, supra note 11.

14. The Dependency Mothers Drug Court in Clark County, Nevada, for example, implemented a family strengthening program and child psychosocial assessment to promote healthy parent-child attachment. See Dependency Mothers Drug Court (DMDC), Nat’l Ctr. on Substance Abuse & Child Welfare, U.S. Dep’t Health & Human Servs., https://ncsacw.samhsa.gov/technical/rpg-i.aspx?id=68.

15. In the Family Treatment Court in Washoe County, Nevada, for example, until approximately one year ago, the court required that a “[c]andidate must not be involved in any methadone maintenance treatment.” Second Judicial Dist. Court, Washoe Cty., Nev., Family Treatment Court Policy Manual 12 (2012) [hereinafter Washoe Cty. FTC Policy Manual], https://www.washoecourts.com/OtherDocs/SpecialtyCourts/FTC/Policy_Manual_12.pdf; email from James A. Popovich, Specialty Courts Manager, Second Judicial District Court, to Stephanie Tabashneck (Jan. 18, 2019) (on file with author); see Second Judicial Dist. Court, Washoe Cty., Nev., Family Treatment Court Policies (2019), https://www.washoecourts.com/OtherDocs/SpecialtyCourts/FTC/Policy_Manual_19.pdf; see also Sam Choi, Family Drug Courts in Child Welfare, 29 Child & Adolescent Soc. Work J. 447 (2012) (explores the evolving nature of family drug court approaches and program models).

16. Adoption and Safe Families Act of 1997, Pub. L. No. 105-89, 111 Stat. 2115 (codified in scattered sections of 42 U.S.C.) (imposing strict deadlines and conditions for termination of parental rights) [hereinafter ASFA].

17. See Dowell et al., supra note 6.

18. Chronic use of opioids is associated with a morbidity rate that is six to twenty times greater than the general population. Yih-Ing Hser et al. Long-Term Course of Opioid Addiction, 23 Harv. Rev. of Psychiatry 76 (2015).

19. See generally Vasiliki Mitsi & Veneita Zachariou, Modulation of Pain, Nociception, and Analgesia by the Brain Reward Center, 338 Neuroscience 81, 88–89 (2016).

20. Id.

21. Id.

22. Micol Parolin et al., Attachment Theory and Maternal Drug Addiction: The Contribution to Parenting Interventions, 7 Frontiers in Psychiatry 152 (2016).

23. Id.

24. For example, research suggests that mothers with opioid use disorders are more likely to utilize ineffective discipline strategies when parenting older children. See Natasha Slesnick et al., supra note 4.

25. Id.

26. Virginia Peisch et al., Parental Opioid Abuse: A Review of Child Outcomes, Parenting, and Parenting Interventions, 27 J. Child & Fam. Studies 2082 (2018), https://link.springer.com/article/10.1007/s10826-018-1061-0.

27. Id.

28. Id.

29. Id.

30. See, e.g., Rebecca Mirhashem et al., The Intervening Role of Urgency on the Association Between Childhood Maltreatment, PTSD, and Substance-Related Problems, 69 Addictive Behavs. 98, 98–103 (2017), https://www.ncbi.nlm.nih.gov/pubmed/28219827 (finding an association between opioid addiction and emotional abuse in a sample of eighty-four individuals with a history of heroin use or opioid misuse lasting longer than a year).

31. “[M]any of the children who remain in the care of addicted parents are growing up in mayhem. They watch their mothers and fathers overdose and die on the bathroom floor. They live without electricity, food or heat when their parents can’t pay the bills. They stop going to school, and learn to steal and forage to meet their basic needs.” Jeanne Whalen, The Children of the Opioid Crisis, Wall St. J. (Dec. 15, 2016), https://www.wsj.com/articles/the-children-of-the-opioid-crisis-1481816178.

32. Julie Quinlivan & Sharon Evans, Impact of Domestic Violence and Drug Abuse in Pregnancy on Maternal Attachment and Infant Temperament in Teenage Mothers in the Setting of Best Clinical Practice, 8 Archiv. of Women’s Mental Health 191, 191–99 (2005).

33. Id.

34. Since 2002, prescriptions for opioids during pregnancy have increased significantly. See S.L. Klaman et al., Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance, 11 J. Addiction Med. 178, 179 (2017), https://www.ncbi.nlm.nih.gov/pubmed/28406856.

35. See generally Stephen W. Patrick & Davida Schiff, Policy Statement: A Public Health Response to Opioid Use in Pregnancy, 139 Am. Acad. of Pediatrics 1, 2 (2017), http://pediatrics.aappublications.org/content/early/2017/02/16/peds.2016-4070; see also Davida M. Schiff & Stephen W. Patrick, Comment & Response, Treatment of Opioid Use Disorder During Pregnancy and Cases of Neonatal Abstinence Syndrome, 171 J. Am. Med. Ass’n Pediatrics 707, 707 (2017), http://www.ncbi.nlm.nih.gov/pubmed/28459976.

36. See Schiff & Patrick, supra note 35, at 707.

37. Id.

38. Scott L. Wexelblatt, Opioid Neonatal Abstinence Syndrome: An Overview, 103 Clinical Pharmacology & Therapeutics 979 (2018), https://www.ncbi.nlm.nih.gov/pubmed/29285767.

39. See generally Kelly S. McGlothen, Lisa M. Cleveland & Sara L. Gill, “I’m Doing the Best That I Can for Her”: Infant-Feeding Decisions of Mothers Receiving Medication-Assisted Treatment for an Opioid Use Disorder, 34 J. Human Lactation 535 (2018), https://journals.sagepub.com/doi/abs/10.1177/0890334417745521?journalCode=jhla.

40. Id.

41. Tomas Binder & Blanka Vavrinková, Prospective Randomised Comparative Study of the Effect of Buprenorphine, Methadone and Heroin on the Course of Pregnancy, Birthweight of Newborns, Early Postpartum Adaptation and Course of the Neonatal Abstinence Syndrome (NAS) in Women Followed Up in the Outpatient Department, 29 Neuroendocrinology Letters 80 (2008), https://www.ncbi.nlm.nih.gov/pubmed/18283247.

42. Id.

43. See Elisha M. Wachman et al., Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder: One Institution’s Experience, 32 J. Human Lactation 382–87 (2015), https://doi.org/10.1177/0890334415613823.

44. See Elisha M. Wachman et al., Association of OPRM1 and COMT Single-Nucleotide Polymorphisms with Hospital Length of Stay and Treatment of Neonatal Abstinence Syndrome, 309 J. Amer. Med. Ass’n 1821, 1821–27 (2013), https://www.ncbi.nlm.nih.gov/pubmed/23632726.

45. In the Wang study, participants examined pictures of infants, and participants with an opioid use disorder who were given naltrexone were found to have more neural activity in the brain’s reward centers. An-Li Wang et al., Sustained Opioid Antagonism Modulates Striatal Sensitivity to Baby Schema in Patients with Opioid Use Disorder, 85 J. Substance Abuse Treatment 70 (2018), https://www.ncbi.nlm.nih.gov/pubmed/29146290.

46. See generally Caitlin E. Martin, Nyaradzo Longinaker & Mishka Terplan, Recent Trends in Treatment Admissions for Prescription Opioid Abuse During Pregnancy, 48 J. Substance Abuse Treat. 37, 37–42 (2015), http://www.ncbi.nlm.nih.gov/pubmed/25151440 (describing medication-assisted therapy as the standard of care for opioid-dependent pregnant women and referring to the low levels of medication-assisted treatment as “disconcerting.”).

47. “Family drug treatment courts aim to reduce maltreatment by treating the underlying substance use problem through the collaborative efforts of treatment professionals in child welfare, the courts, and substance abuse agencies.” Gifford et al., supra note 12, at 1660.

48. To be eligible to receive services in family drug court, one generally must have a pending neglect, abuse, or custody issue. Id. (“Because a parent or guardian must have a pending abuse, neglect, or dependency case, FDTCs use the retaining or regaining of child custody as an incentive for participants to enroll in and complete the program.”).

49. Id.

50. Id.

51. See Nat’l Family Drug Courts Training & Tech. Assistance Program, Office of Juvenile Justice & Delinquency Prevention (OJJDP), Literature Review: Family Drug Courts (2016) [hereinafter OJJDP Literature Review: Family Drug Courts], https://www.ojjdp.gov/mpg/litreviews/Family_Drug_Courts.pdf.

52. See generally Emmeline Chuang et al., Effect of an Integrated Family Dependency Treatment Court on Child Welfare Reunification, Time to Permanency and Re-Entry Rates, 34 Child. & Youth Servs. Rev. 1896 (2012), http://www.courts.ca.gov/documents/BTB_23_3J_9.pdf.

53. Some courts use a hybrid, dual-track model whereby parents only participate in family drug court if they fail to comply with court orders. OJJDP Literature Review: Family Drug Courts, supra note 51.

54. See generally Chuang et al., supra note 52.

55. See David A. Fiellin, Gerald H. Friedland & Marc N. Gourevitch, Opioid Dependence: Rationale for and Efficacy of Existing and New Treatments, 43 Clinical Infectious Diseases (Supplement) S173, S176 (2006), https://www.ncbi.nlm.nih.gov/pubmed/17109303.

56. See generally Harian Matusow et al., Medication Assisted Treatment in US Drug Courts: Results from a Nationwide Survey of Availability, Barriers and Attitudes, 44 J. Substance Abuse Treatment 473, 473–480 (2013), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602216/.

57. Id.

58. Elizabeth A. Peyton & Robert Gossweiler, Drug Crts. Program Off., U.S. Dep’t Justice, Treatment Services in Adult Drug Courts (2001), https://bit.ly/2qOv0r8.

59. For highly motivated individuals who have discontinued use of opioids, naltrexone yields benefits in terms of preventing relapse. See Suzanne Gelber Rinaldo & David W. Rinaldo, Advancing Access to Addiction Medicine: A Project of the American Society of Addiction Medicine (2013).

60. The National Institute on Drug Abuse study compares the buprenorphine/naloxone combination to extended-release naltrexone. Press Release, Nat’l Inst. on Drug Abuse, Nat’l Inst. of Health, Opioid Treatment Drugs Have Similar Outcomes Once Patients Initiate Treatment (Nov. 14, 2017), https://www.drugabuse.gov/news-events/news-releases/2017/11/opioid-treatment-drugs-have-similar-outcomes-once-patients-initiate-treatment.

61. World Health Org., Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (2009), https://www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf.

62. Id.

63. Nat’l Ass’n of Drug Court Prof’ls, Adult Drug Court Best Practice Standards Vol. 1 (2018), https://www.nadcp.org/wp-content/uploads/2018/12/Adult-Drug-Court-Best-Practice-Standards-Volume-I-Text-Revision-December-2018-1.pdf.

64. Nat’l Ass’n of Drug Court Prof’ls, Resolution of the Board of Directors on the Availability of Medically Assisted Treatment (M.A.T.) for Addiction in Drug Courts (2010), https://ndcrc.org/resource/resolution-of-the-board-of-directors-on-the-availability-of-medically-assisted-treatment-m-a-t-for-addiction-in-drug-courts/.

65. Bureau of Justice Assistance, U.S. Dep’t of Justice, OMB No. 1121-0329, Adult Drug Court Discretionary Grant Program FY 2017 Competitive Grant Announcement (Dec. 20, 2011), http://www.bja.gov/funding/DrugCourts17.pdf.

66. 42 U.S.C. § 675(5)(c) (2012) (imposing strict deadlines and conditions for termination of parental rights); see generally Gifford et al., supra note 12, at 1660.

67. “[B]etween 1986 and 1995, the number of children in foster care increased from 280,000 to nearly 500,000. Child welfare policies were not equipped to adequately address the influx of children entering the foster care system. Foster care became a revolving door for many children who entered care during the 1980s and 1990s. Some children failed to achieve permanency after several months and even years. Thus, the need to increase child safety, well-being, and permanence served as the impetus for the creation of the ASFA.” Chereese M. Phillips & Aaron Mann, Historical Analysis of the Adoption and Safe Families Act of 1997, 23 J. Human Behav. in Soc. Env’t 862, 864 (2013) (internal citations omitted), https://doi.org/10.1080/10911359.2013.809290.

68. Id.

69. 42 U.S.C. § 675(5)(c) (2012).

70. Id.

71. See Michael Gossop et al., The National Treatment Outcome Research Study (NTORS): 4–5 Year Follow-Up Results, 98 Addiction 291, 299 (2003), https://www.ncbi.nlm.nih.gov/pubmed/12603229 (indicating that while treatment can dramatically enhance sobriety, “[r]elapse to problematic patterns of drug misuse can occur at any time, even after prolonged periods of abstinence”).

72. See Gifford et al., supra note 12, at 7.

73. Washoe Cty. FTC Policy Manual, supra note 15.

74. Id.

75. Id.

76. Id.

77. See Step 2, About Us, http://step2reno.org/about-us/.

78. Second Judicial Dist. Court, Washoe Cty., Nev., Family Treatment Court Policies 12 (2012), https://www.washoecourts.com/OtherDocs/SpecialtyCourts/FTC/Policy_Manual_12.pdf.

79. Washoe Cty. FTC Policy Manual, supra note 15.

80. Id. at 8.

81. Id. at 19–20.

82. Id. at 3.

83. Id.

84. Cynthia Lu, Family Drug Court: An Alternative Answer, 21 Child. Legal Rts. J. 32, 36 (2001); Washoe Cty. FTC Policy Manual, supra note 15.

85. Deborah Schumacher, The Creation of a Family Mental Health Court, CASAforchildren.org (Summer 2014), http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.9167969/k.8D6D/JP6_Schumacher.htm.

86. The Franklin County FDC judge is cross-designated to hear both probate and family court cases and juvenile court cases. If the case arises through Probate and Family Court, unless a party requests recusal, the same judge hears both the drug court action and the underlying case. If the case is heard through juvenile court, no evidence admitted in FDC is admissible for the care and protection proceeding unless the evidence is presented by the party enrolled in drug court. Email from Judge Beth Crawford, Franklin County Probate and Family Court, to Stephanie Tabashneck (Jan. 7, 2019) (on file with author).

87. Project Abstract Summary: SAMHSA Grants to Expand Substance Abuse Treatment Capacity in Family Treatment Drug Courts, No. TI-17-004 (Nov. 17, 2017) [hereinafter SAMHSA Project Abstract] (on file with author).

88. See Press Release, MassLive, Massachusetts Trial Court Awarded Federal Grant to Significantly Expand Franklin County Family Drug Court: $2.1M Grant Will Allow Franklin Family Drug Court to Expand by 300% (Sept. 18, 2017), http://www.mass.gov/news/massachusetts-trial-court-awarded-federal-grant-to-significantly-expand-franklin-county-family.

89. See Shira Schoenberg, Franklin County Family Drug Court Gets $2.1 Million for Major Expansion, MassLive (Sept. 18, 2017), https://www.masslive.com/politics/index.ssf/2017/09/franklin_county_family_drug_co.html.

90. SAMHSA Project Abstract, supra note 87.

91. Id.

92. Id.

93. Children of opioid-dependent parents are screened for trauma and, if necessary, referred for more comprehensive assessment and services. Family Drug Court Session, Franklin County Probate and Family Drug Court, Greenfield, Mass., Franklin Family Drug Court Handbook 16 (2018) (on file with author).

94. SAMHSA Project Abstract, supra note 87.

95. Id.

96. Dependency Drug Court, supra note 11.

97. See Jeri Beth Cohen, Nat’l Crt. Appointed Special Advoc. Ass’n (“CASA”), Dependency Drug Court Demonstrates Success with Evidence-Based Holistic Interventions, casaforchildren.org (Summer 2014), http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.9167973/k.F3F4/JP7_Cohen.htm; OJJDP Literature Review: Family Drug Courts, supra note 51, Peer Learning Court Program: Miami-Dade County Dependency Drug Court (2013), http://www.cffutures.org/files/PLC_Profile_MiamiFL.pdf.

98. See Jeri Beth Cohen, supra note 97; Jaime L. Dice et al., Parenting in Dependency Drug Court, 55 Juv. & Fam. Ct. J. 1, 3 (2009), https://doi.org/10.1111/j.1755-6988.2004.tb00164.x.

99. See Jeri Beth Cohen, supra note 97.

100. Jaime L. Dice et al., Parenting in Dependency Drug Court, 55 Juv. & Fam. Ct. J. 1, 3 (2009), https://doi.org/10.1111/j.1755-6988.2004.tb00164.x.

101. Id. at 5–7.

102. Id.

103. Id. at 8.

104. See OJJDP Literature Review: Family Drug Courts, supra note 51; see generally Chuang et al., supra note 52.

105. See Gifford et al., supra note 12.