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Drug Courts Redefined How we Approach the Heroin Epidemic; Besieged in Lorain County, a Judge Confronts the Crisis 

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The Lorain County Justice Center is not inviting in any sense of the word; but, for an hour each week, at least one corner of the place is a friendly sanctuary, a haven where the future is honored above the past. In Room 702, Judge John Miraldi presides over Thursday morning status hearings that hold a certain reverence.

By 10 a.m., the hallway outside is abuzz with members of a new support system connecting over the past week's tribulations and assuring one another that, yes, it will all be okay. The congregation trickles into the courtroom without waver for another notch in their personal histories to be struck into the record.

This is the weekly courtroom gathering of the Lorain County Drug Court, though Miraldi doesn't use that phrase. He says "recovery court." With a gentle, fatherly voice, he'll tell you that "recovery" is the very simple goal here.

A row of windows runs along the northern side of Room 702, which is unusual for a courtroom like this. It doesn't seem to be sunny very often amid Lorain County's late winter hustle, but when the sun shines, it is welcome.

"You look good," Miraldi tells a young man from Elyria, the first participant to stand before the judge this morning and update the court on his progress. He's one of 15 men and women currently participating in the 6-month-old program. "How was your week?"

It's been a good week, he says. This man has been sober for 58 days, and his treatment supervisor tells the judge that his coping skills have been improving. He's becoming more "altruistic," a probation case manager chimes in. He's nearing the end of his stay at the Community Based Correctional Facility, and there's a bit of anxiety over where he might go next. Home, or whatever home is receding in his life's rearview, isn't an option. Questions like that are where the drug court's sense of responsibility for these men and women comes into play. In time, answers will reveal themselves.

The morning rolls on, not without a few familial laughs, and Miraldi sees to it that those who've voluntarily entered this world remain on the right path. Sobriety — the reclamation of a life — is not an easy or simple task, and the judge knows this. Since opening the docket last fall, he's given himself publicly to the rigorous study and accountability that come with tackling an opiate epidemic.

And yet: "To say it's an epidemic is an understatement," he tells Scene after the morning's work is done.

***

In 1989, a small group of legal professionals organized the first drug court in Miami-Dade County, Florida. The development of a "problem-solving court" came amid the surge of crack-cocaine use and the booming War on Drugs in that decade. ("It all seems like a million years ago, and it seems like yesterday, that we launched this crazy idea where we would treat individuals as individuals; we would not treat them as a class," Justice Policy Institute director Tim Murray said on the 25th anniversary of the Miami-Dade drug court.) Currently, there are nearly 3,000 such drug courts operating in the U.S.

A "drug court" is a specialty docket that exists within a broader county or municipal court (much like a veterans court, for example). The aim is to reroute criminal defendants rung up on felony charges — defendants who are suffering from addiction — onto a judicially supervised path toward sobriety and recovery. In doing so, the philosophy goes, defendants will "graduate" with a clean record and a clean body. They'll return to society as functioning and contributing members of their community and workforce. There are detractors, as with all arenas of criminal justice, but the success rate on face value is clear. (Nationwide, 75 percent of drug court graduates remain arrest-free at least two years after leaving the program, according to the National Association of Drug Court Professionals.)

It's that national context and the glaring drug epidemic in Northeast Ohio that led Miraldi and a host of Lorain County officials last year to look into the process of opening a drug court for adults. For years now, best practices have been laid as groundwork for this alternative take on justice (like immediate sanctions for violations and rewards for healthy progress over time). The Ohio Supreme Court holds certification standards and the final stamp of approval, and Miraldi and his team spent time studying the methods that might put a dent in Lorain County's booming opiate problem.

With Smart Ohio grant funds that flow through the Lorain County Adult Probation Department, the docket was born. Currently, the court is applying for a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to expand its working budget.

By September 2015, the first participants were being screened. Memorably, one of them, a man who has since been clean for more than 160 days as of press time, passed out during an orientation session before the judge. ("[The judge] will never forget him sitting there," probation case manager Sarah Malik tells Scene, expounding on how impactful the experience has been.)

"Truthfully, we're late to the game," Miraldi says. There are 85 drug courts in Ohio alone, as of January 2016. Cuyahoga County, since 2009, and Cleveland Municipal Court, since 1998, each maintain these specialty dockets, as well.

See, Miraldi didn't start from scratch. He followed the rigorous set of evidence-based best practices, based on 20 years of data pertaining to behavioral modification, as prescribed by the National Association of Drug Court Professionals. He and his team traveled to Washington, D.C., last year for the NADCP's annual conference. More than 5,000 legal and medical professionals and former addicts congregated to celebrate the legacy of drug courts. Miraldi was sold.

"So, the word's out: There's a recovery court in Lorain County," Miraldi says, thinking back to last fall. Often, the jail or another judge or a defense attorney — even a family member — refers someone to Miraldi's courtroom. It didn't take long for the voluntary participants to begin flooding his way.

***

Here's how it works: An inmate suffering from drug addiction and tagged with at least one felony will come before Miraldi and plead guilty — with the caveat that successful completion of the recovery court program will wipe away that guilty plea and result in no conviction. That's the obvious carrot. The deeper motivation is sobriety and a new life.

After the plea, the inmate will be brought back to Miraldi's courtroom during the next status hearing for "orientation." Here, the judge will sit with the inmate and his or her attorney, usually off to the side of the courtroom, after the hearing, and explain precisely what lies ahead.

There are three rules: 1. Show up. 2. Tell the truth. 3. Try.

"It's a second-chance court," Miraldi tells a young woman clad in a green county jail jumpsuit. "We can't help you with addiction if you don't show up. As long as you're still engaged, we can help you through that."

This is, after all, a voluntary program. During February and March, when Scene was attending status hearings, Miraldi said the program was maintaining a participant count around 15, with 20 referrals still pending. Informally, there's an anticipated ceiling of 50 or so. Miraldi tells the inmates that the court sees about a 50/50 track record of prospects who remain interested after hearing the orientation rundown.

Once they're in, there are three phases. Phase I involves "intensely supervised" sobriety — most publicly, this amounts to weekly status hearings before the judge. The centerpiece is the three random drug tests each week. Participants will be evaluated and directed either to outpatient treatment (like Lorain County Alcohol and Drug Abuse Services Inc.) or residential treatment (like the Timothy House).

They meet in Miraldi's courtroom every Thursday morning.

"The most important thing about recovery court is how it plays into behavioral modification," Miraldi says. For instance, when a participant graduates from Phase I to Phase II, they're given a certificate and a gas card. If they fail a drug test or break a rule at their residential treatment center, the punishment comes hard and fast. Jail time is possible. "Sanctions or praise," Miraldi says, employing the psychological terms at the bedrock of behavioral sciences.

Phase I demands 90 days of sobriety before the participant advances.

In Phase II, "we pull back a bit," Miraldi says. Participants are in court every other week, and the burden of responsibility is shifted to their shoulders. Here, participants are engaging with GED classes, perhaps, or employment services. This phase demands an additional 120 days of sobriety on top of Phase I's 90 days. That's seven months, more or less.

Phase III, which has yet to really begin, given the nascency of Lorain County's program, involves participants "going out into the world and being productive again," Miraldi says. In this phase, participants will cross the crucial nine-month threshold, a point where the physiological makeup of the brain begins to repair itself. ("Nine months sounds better than two years," the woman says, referencing the potential jail time if she doesn't opt into drug court.) Courtroom appearances drop to once each month, and random testing continues.

"Heroin comes from other problems in life," Miraldi says, getting to the root of the recovery court's ethos now. "If we get you sober and don't treat that, you're going to relapse."

That's why, when participants discuss their week with treatment officers or Miraldi himself, any potential red flag — a death in the family, an argument with a supervisor — is immediately dealt with.

"You need to decide if you care about yourself enough to come in," Miraldi says.

"This was nice, really positive," the jumpsuit-clad girl says before being whisked back to her cell. She's been using for the past four years. The man next to her, also hearing out Miraldi's orientation guidelines, had been using for nine years, but he'd cleaned up for most of the past 15 months. When his children were taken from him and his ex-wife recently, he relapsed out of sobriety. Then he landed back in court.

Later, Miraldi tells Scene: "Ultimately, it's about getting them ready for life without us. And most importantly, if we treat this addiction correctly, they're not back in the system."

***

Heroin overdoses killed 10,574 Americans in 2014, while prescription painkiller abuse led to an additional 18,893 deaths the same year, according to the National Center on Health Statistics. Ohio alone clocked 2,744 overdose deaths in Ohio, the fifth highest among U.S. states per capita and an 18.3 percent increase in overdose deaths from 2013 to 2014.

Outside of the rise of drug courts, there's little evidence that the trend will slow down or reverse. That's especially true in places like Lorain County where, for instance, Elyria police reported 14 drug overdoses between Feb. 19 and March 2, three of which were fatal. The new typical heroin user is white and living outside of a major city, where access to the heroin trade is easy and access to activities that improve quality of life is lower.

"Obviously, these drugs affect all walks of life, and right now, we see a lot of it hitting people in their late teens and early 20s," Elyria Sgt. James Welsh said during a recent press conference, which followed the arrests of nine alleged "high-level" drug traffickers in Lorain and Elyria. "It takes a toll on the families of the victims involved. Obviously, it's one of the reasons that we put so much time, effort and resources into the drug problem because of how it affects society."

Heroin deaths breach Cuyahoga County borders, as well. The Cuyahoga County Medical Examiner recently reported that heroin deaths in Cuyahoga County decreased by more than 7 percent since 2007, to 183 in 2015. The county's fentanyl death total for 2015 "nearly tripled from 2014, with 89 ruled cases, with 41 of those cases containing both heroin and fentanyl." From March 10 to March 14, Cuyahoga County reported 13 heroin- or fentanyl-related overdose deaths.

At the time Miraldi was beginning to see potential participants last fall, Lorain County Drug Task Force commander Dennis Cavanaugh — who is not involved in the drug court program — told the Chronicle-Telegram that drug crimes in the county comprise an estimated 85 to 90 percent of the cases his officers were investigating. "It doesn't look like it's getting better anytime soon," he said.

"So many other crimes are driven by this," Miraldi says. These aren't typically offenses of violence, though. Crimes like forgery, theft, breaking and entering: These spike as heroin rings expand in a given area.

Because low-level charges carry with them low levels of supervision, opiate addicts rung up on small-time forgery bits are freer than the county would prefer to go score a fix and endanger themselves and others. It becomes cyclical. As Miraldi puts it, these defendants tend to be the "highest-need" subjects of the criminal justice system.

"I'm recognizing that these people are not criminals: They are by statute, but we've got to really ramp up the supervision," Miraldi says. "If you're on normal intervention, you're going to see your probation office maybe once a month. You're going to be drug-tested maybe once a month. And then when you do test positive, it's going to be two to three months before you're in front of me on a probation violation hearing. Now? You're going to be tested at least three times a week. If you test positive, you're going to see me next week. So they know: immediate consequences, immediate sanctions.

"The people who are doing well are getting encouragement — some of them for the first time in their life," Miraldi says, quickly deflecting credit to the treatment team and the roster of sponsors in Lorain County. "You see them well up."

But it's a constant process, and one that truly never ends, as evidenced by the testimonials of former addicts at the annual NADCP meetings. Miraldi says that the 90-day mark — the conclusion of his court's Phase I — brings with it a "pink cloud," a psychological term that indicates a sense of premature freedom from disease. "You think you've got it licked, and you're at your weakest," Miraldi says. About half of his court's participants have crossed the line to Phase II so far.

***

Before the advent of drug courts — and outside their walls — the reclamation of a former addict's life has always been an all-hands-on-deck undertaking. Brenda Stewart, founder of the Addict's Parents United, a statewide group that connects the parents of drug users, knows this well.

She's the parent of two children "with the disease of addiction," she says. One is four years clean; another is in jail. "So many parents feel so alone, because of the stigma that's still attached to it," Stewart says. Drug courts seem to at the very least bring the heroin epidemic more into the public and recovery-based realm. The basis for public discourse is more readily available in communities with an active drug court.

"Personally — from my own experience — my son was the project of a drug court here in Franklin County, and he graduated and his felony was dropped," Stewart says. "He actually has a life now. It gives them an opportunity that they would not have had going to prison." (Most drug courts, including Lorain County and Cuyahoga County, drop felony charges upon completion of the drug court program.)

"With the drug court, you actually have that accountability," Stewart says. "A lot of drug courts offer the Vivitrol shot or some other means — if heroin is their drug of choice, and there are all sorts of drugs out there. It's not just heroin. That seems to be the flavor of this year, but it changes.

"Most of the judges who are doing this truly do have that compassion and truly do want to see these kids make a difference. That is the key, in my opinion."

A lot of it depends on your zip code and what court you're going into, Stewart says. Some jurisdictions are comfortable with this alternative path through the justice system — like Miraldi and his team. Others aren't.

Scott VanDerKarr certainly is. He's the former Franklin County judge who stepped down in January to pursue the creation of new drug courts around the state, and he was one of the first judges in Ohio to preside over this sort of specialty docket. He says it's the future of the justice system.

His drug court opened in 2009 with weekly hearings. By the time he stepped down, he was holding five hearings a week: one general drug court, and four opiate-focused hearings. With a focus on accountability and medically assisted treatment, the success rate grew steadily year after year, from an average "graduation" rate of 30 percent to upwards of 70 percent, he says.

VanDerKarr now is working with a number of groups, including Stewart's Addict's Parents United, to travel around Ohio and open drug courts in county and municipal courthouses in need. Beyond that, he's hoping to expand outside of the state.

His words echo Stewart's sense of hope: "I said, 'Look, I'm affecting about 200 kids at any one time. And I love the contact, just absolutely love the contact.'

"One story I'll give you: On the last day I'm there, a lady walks up with a teddy bear. I'm sitting at my desk. Little teddy bear. She said, 'My son wants me to give you his teddy bear.' I said, 'I can't take your son's teddy bear.' She said, 'No, my son says you gave him back his mother. He wants you to have his teddy bear.' You just want to break down in tears at that point. It really affects lives."

***

There is, then, of course, the backlash to the very concept and operation of drug courts nationwide. No one that Scene spoke with expressed an outright opposition to drug court programs, but there's a growing conversation over whether judges and treatment officials who aren't licensed medical professionals should be dispensing health regimens.

Just this month, for instance, SAMHSA issued an updated advisory on the use of medication-assisted treatment (MAT) for what the group calls opioid use disorder. In short, the administration loosened the reins a bit on whether best practices should involve medication, like Vivitrol shots.

"Neither medication-assisted treatment of opioid addiction nor the cessation of such treatment by itself constitutes recovery," recovery experts A. Thomas McLellan and William White write, in an opinion cited by SAMHSA. "Recovery status instead hinges on broader achievements in health and social functioning — with or without medication support."

SAMHSA's statement adds: "Despite ... widespread endorsement, side-by-side with a clear interest in MAT by potential patients, SAMHSA emphasizes the significant gap between the need for and the availability of this treatment."

In Lorain County, Miraldi says that properly supervised medication has a place along the path to sobriety. He points to the aforementioned Vivitrol, a monthly shot that blocks certain opioid receptors in the brain and eliminates the pleasurable feelings associated with taking opioids. (In a December feature, New York magazine writer Genevieve Smith described the drug's active ingredient, naltrexone, perfectly: "It fits the keyhole where heroin would bond to the brain's receptors, but it won't turn the knob.") In the past few years, Vivitrol has caught on with gusto in drug courts and reentry programs across the country. In October 2015, the Obama administration kickstarted a new $133-million federal program to combat heroin use and, among other goals, widely improve access to treatment regimens like Vivitrol shots. (The drug costs $1,500 for a single dose, without insurance.)

Vivitrol presents an intriguing future, one in which the often painful trip into sobriety can be made much, much easier. Even in jail. But it's not all gravy. First, an addict must rid his or her body of opiates, thereby entering withdrawal, which is a harrowing prospect for anyone.

"They wish they were dying," Malik says of the withdrawal symptoms. "In layman's terms, let's say you break your arm. You take a painkiller, and it numbs the pain, right? Basically it deadens your nerve endings. So when someone abuses heroin forever, their nerve endings in their whole body are deadened — for however long they were using. When they go into active withdrawal, every nerve ending in their body comes alive."

That's what makes the voluntary aspect of Miraldi's drug court all the more admirable, really. These folks want to be here. Often, they've overdosed several times before landing on the matter of fact that they have to/want to get clean. The new path forged by Miraldi's courtroom is one they hadn't had before.

"I can't think of anything more important than the criminal defendant who's at risk of dying from an addiction," Miraldi says. "Don't they deserve the help, the best help that we can give them? We may be the last line."

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