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Butte County ReVia® Project
Hon. Darrell Stevens, Judge of the
Butte County Superior Court Acknowledging the generous assistance of Percy Menzies & DuPont Pharmaceutical In 1996, Butte County Probation and the Butte County Superior Court teamed with members of the community to begin the ReVia Project. Initially planned as a 90-day trial project, ReVia quickly demonstrated value for a specific population of offender: the repeat drinking driver. Based upon that first series of cases, the ReVia Project was extended. It is now approximately two years out, and the results appear distinctly promising. In some cases, the results have been astounding. A preliminary review of the data reveals that ReVia is far and away the most successful method of dealing with high blood alcohol, repeat drunk drivers. Butte County was one of three courts in the United States who directed the use of ReVia (generic name: naltrexone) as part of a court ordered treatment model. The model was designed as an expedited case processing system, where identified alcoholics would be moved quickly into the treatment process. Key to this treatment process was ingestion of ReVia (naltrexone).
Alcohol and Crime in Butte County Butte County, California has just over 200,000 citizens. It is located in the north central valley of California, approximately 70 miles north of the state capitol, Sacramento. The area is predominately rural. The County has five major population areas, distributed in distinct areas of the county. The largest population is found in the Chico Urban Area (90,000). Chico is home to California State University, Chico. This university has struggled for years with the reputation of being on of the top 10 party schools in the nation. Alcohol use plays a prominent role in the local culture. In California, the presumptive level for driving under the influence (DUI) is .08. State law mandates jail sentences for DUI cases, with increased penalties for prior convictions, or a higher blood alcohol level upon arrest. A DUI with 3 prior convictions can be charged as a felony, and the defendant faces the California state prison system. Persons who have an extensive list of prior convictions and cannot perform safely in the community are sent to state prison. Arrests in Butte County for driving under the influence, and alcohol related fatalities have been unacceptably high. During 1996-1997, 25 people died in DUI cases. To address this issue, focused efforts of the California Highway Patrol, and the local police included increased patrol strategies, public education, DUI checkpoints and specialized training in early detection of drivers under the influence. The Chico Police Department developed the powerful nationally honored "Every 15 Minutes" intervention program. Utilizing members of the entire community, this program teaches high school students about the community wide impact which follows the choice to drive after drinking. It is noted that "Every 15 Minutes" someone is killed or injured by a person who chooses to drive after drinking. The Chico Police have also received special funding to address alcohol outlets. Using enforcement and educational strategies, they have reduced the level of excess consumption, and sales of package liquor to underage drinkers. Many of these efforts have paid off. There is increased awareness regarding the issue of alcohol abuse and driving. However, there remains a core group of addicted drivers who continue to pose grave danger to the public, and occupy a significant portion of the community resources through health care, emergency services, police, court, jail and probation criminal justice costs. For these offenders, Butte County has created the ReVia Project.
ReVia is a medication utilized for many years as a highly effective opiate treatment (referred to as an opioid receptor antagonist). Recently, it was determined that the brain pathways utilized by alcohol and opiates may be the same. Because of this, ReVia reduces or stops the cravings experienced by alcoholics during treatment. It is these cravings (physiological reactions which are triggered by behavioral cues) which interfere with an alcoholic's ability to complete a treatment program. While on ReVia, they can maintain sobriety long enough to successfully establish a pattern of behavior modification. At the end of 180 days, the client is examined for reduced use of ReVia. Essentially, ReVia functions as a tool to aid recovery and treatment. It is not a "stand alone" treatment. While being utilized by these recovering alcoholics, ReVia functions in two manners: (1) it blocks cravings (2) there is no pleasure derived from drinking alcohol when the addict "tests" the medication. There is no "buzz" and no reward for drinking. Thus, if an alcoholic is sincerely working on behavior changes through treatment, true progress can be made. In contrast to the results for traditional treatment and the utilization of Antabuse, the ingestion of ReVia suppresses the desire of alcohol (and the pleasure from consumption). Therefore, it allows traditional methods of substance abuse treatment to take hold. We have found that utilization of ReVia as part of the probationary terms and conditions blocks the cravings and allows the behavioral modification to take effect. The Court and Probation have adopted a high intensity probation model to deal with repeat DUI cases. Based on the theory that the power of criminal justice system can be used as a therapeutic tool, the terms of probation are used as a "bottoming out" process to encourage sobriety. Strict accountability is required. The model is quite similar to that of Drug Court. ReVia can be given with Antabuse, but we have not found that to be necessary. No physical or psychological dependency is attributed to the use of ReVia during the treatment period. DuPont Merck conducted a 12-week, double blind, placebo based trial of ReVia. When combined with traditional therapy, ReVia was significantly more successful (61%) than the placebo with the same therapy (22%) in preventing relapse. (Archives of General Psychiatry, 1992; 49:881-887) Further, those who did drink, did so on fewer days than the placebo group (2 and 6 days respectively) over the same 12 week period. Persons who drink alcohol while taking ReVia can become intoxicated. ReVia does not interfere with the absorption of alcohol-it only interferes with the pleasure and cravings. Persons who are given ReVia must be screened through a liver panel prior to issuance of a prescription and administration of the medication. There are specific physical conditions that are not compatible with the administration of ReVia. Additionally, it cannot be given to active opiate addicts. ReVia can be extremely dangerous if administered unknowingly to an active heroin or opiate addict. It is absolutely critical to make certain that the client is not using opiates, or has had a specified period of abstinence prior to the administration of opiates. ReVia can seem expensive: up to $535.00 per month. However, compared to the cost of alcohol, or a jail bed, it is quite inexpensive. Some defendants have had assistance with the costs from their families. Also, purchasing a supply one-week at a time assists with "sticker shock". The cost of a one-month supply will frighten many clients. It is easier to have them obtain a smaller amount. We have learned that close physical monitoring by a physician will allow us to address any side effects which may occur without having to drop the person from the project. The "standard" dosage needs to vary slightly with the unique physiology of the probationer. As always, public safety remains the #1 priority. Field visits to the homes of ReVia clients have been helpful. There have been occasions when arrests have been necessary. Terminations have resulted from new criminal charges (such as a child endangerment case) during the project, and for medical reasons.
Butte County has utilized a Drug Court for the past three years. the Drug Court has been quite successful and has wide spread community support. It was recently recognized as one of eight COPS mentor Drug Courts by the National Association of Drug Court Professionals (NADCP). The judge who partnered with Probation to create the ReVia Project is the presiding Judge of the Butte County Drug Court. The next step for the ReVia Project is stabilizing funding, and creation of a specialized ReVia track within the Butte County Drug Court. Upon review, it is believed that improved outcomes could be achieved by moving ReVia directly into a Drug Court format. Within the next few months, ReVia will be fully incorporated into the Butte County Drug Court program. Under the Drug Court design, weekly contracts and expectations on ReVia clients will increase, and the intensity of treatment will increase accountability even further. More frequent testing will occur, but perhaps more importantly, ReVia clients will experience the immediate sanctions, excellent camaraderie, support and frequent praise which distinguishes Drug Court. This will reduce isolation, and assist in long term reinforcement for recovery.
Comparisons with such a small group can be difficult. Small fluctuations can change the results dramatically, thus, more study is needed. However, the preliminary data between the two closest demographic groups show that ReVia is far more effective than Antabuse and standard probation with AA terms and conditions. Of particular interest, ReVia has the lowest recidivism rate, the longest period of time prior to recidivism, and the lowest rate of persons "at warrant". Probation and Court records were reviewed to provide data on ReVia clients. Every participant studied was tracked through the records of the Department of Motor Vehicles, city police, and court records to verify if any persons re-offended. Re-offense was defined as any new criminal offense other than an infraction. The Butte County study has one advantage over previous studies on ReVia. Other studies covered a 4 to 12 week cycle, with monitoring for 6 months after ingestion. Butte County studied participants for an average of 29 weeks of ingestion and an average of 10 months since completion. Some offenders have now been tracked for almost 2 years. No initial interviews were done on offenders to document their drinking patterns prior to acceptance. Random anecdotal information from clients includes admissions of drinking ¾ of a quart of whiskey per day, being drunk every day for 15 years, etc. Four distinct groups were studied:
Only one judge participates in the ReVia Project at this time. Other judges in the county have dealt with DUI offenders during this time period and used other sentencing options. Antabuse and AA standard DUI cases are not sent to Probation for formal supervision. In order to evaluate ReVia, every DUI file in the Chico court for the past 2½ years was reviewed. Those with prior DUI convictions that were ordered to ingest Antabuse, or attend AA were selected. Certain demographics were kept consistent: all studied cases were heard during the same time period ReVia was being used. All cases were heard in the same jurisdiction as the ReVia cases, and all cases involved the same age range as ReVia participants (20-56 years old). The populations in the Antabuse and ReVia study were closest. ReVia participants were slightly older than Antabuse (average age 35 and 31 respectively). There were similarities in length of program (7.2 months - 6.8 months), similar number of prior convictions (.03 difference on average), and similar blood alcohol levels (average difference: .02BAC). However a significant difference appeared in the length of time between completion of their program, and re-offense. ReVia recidivists committed new crimes 11 months after completion. On Antabuse, re-offense occurred within one month. Moreover, 75% of the Antabuse new crimes were drug/alcohol related. 25% of the ReVia crimes were drug/alcohol related. It is clear that utilization of Antabuse did not impact the addictive behavior to the degree ReVia did. Behind all of the statistics and summaries, there is one simple and sterling clear fact: ReVia works on this group of offenders far better than any other supervision model. It is obvious in dealing with this client base. Over the progression of weeks: they look better, walk better, smile more, and are restored. Many ReVia graduates resemble Drug Court graduates: stable employment & better health. Like Drug Court, this is a reality-based model. Relapse is expected and Drug Court must plan for setbacks and recognize that public safety sometimes calls for incapacitation through incarceration. Using this model Butte County has had more success than anything else we have tried. We can improve our outcomes through additional modifications. Our recidivism rate in Drug Court hovers between 10-11%. By moving into the Drug Court program as a new track, we hope to drop our recidivism rate to a similar level... or better.
Court process summary: (Formal Protocol is given to each participant with maps to the medical facilities, and waiver forms.) 1. Upon conviction or plea, the Court places the defendant on formal supervised probation. 2. The defendant is mandated to contact a physician immediately, to receive an examination and a prescription for ReVia. Ingestion is initiated and a log signed by the pharmacist or physician. 3. The defendant reports forthwith to Probation to be seen by specific probation officers to present proof of the prescription and ingestion to the probation officer. 4. The defendant is directed to participate in alcohol treatment programs as ordered by the Court, or Probation; to return every two weeks at a minimum, to submit to urine testing, search and seizure, abstention from all use or possession of alcohol, controlled substances, or entry into places where alcohol is sold or is a primary focus of business. Reviews before the court occur every 7 weeks, or as directed by the probation officer. 5. Probation officers conduct field searches, and are expected to arrest ReVia clients who are violating the protocol and presenting a danger to the public. 6. After 24 weeks, the Court examines the status of the probationer to determine if the supervision level will be reduced.
This is a community based, and supported project. Due to funding constraints, the local Drug and Alcohol Agency declined to participate. Butte County does not have the financial capability of supporting this project. Probation carved out a small amount of time in a supervision unit to try this project on a pilot basis. More recently, it was moved into the already burdened Drug Court division. Because of the unique requirements of the medical protocol, we turned to the local community. A local hospital, the Enloe Medical Center, agreed to accept shipments of ReVia. (The Court cannot accept and distribute a prescription drug.) Their pharmacy has been instrumental in assisting with distribution of the medication to clients. Other local physicians and pharmacists in other cities of the country have assisted Probation and the Court by volunteering to observe ingestion of the medication. These pharmacists personally observe the ingestion, sign the log of the offender, and keep a separate log to document and compare. Customary safeguards are taken to protect against false ingestion attempts. Clients were directed toward their own physicians and insurance companies for funding of liver panels and prescriptions whenever possible. A local immediate care clinic also volunteered to assist, offering lower cost screening, explanations about ReVia to clients, and to observe ingestion on a walk-in basis. DuPont generously assisted with informational support, and temporarily made a limited amount of the medication available to the truly indigent. They also provided assistance with gathering the statistics on the outcomes of this project.
The visual presentation of a ReVia case is profound. The project has had 15-year alcoholics successfully returned to stable sobriety. The changes in the physical appearance and attitude of these offenders is stunning in the level of contrast between before and after. While ReVia is not the "silver bullet" which will cure alcoholism, it is far and away the most effective tool used in Butte County to assist with treatment and reduce the extraordinary level of danger presented by the drinking driver. It is believed that the utilization of ReVia (naltrexone) will be useful in a number of other contexts. The Court also orders ReVia treatment in domestic violence cases. It has obvious applications in the public inebriate, self-medicating mentally ill and homeless populations which plague most American cities. Most importantly, it offers real hope of control to an extremely dangerous population: the repeat drinking driver.
1. Each defendant assigned to ingest ReVia through the Court's DuPont ReVia project will be placed on formal supervised probation. 2. At the time the defendant is
sentenced by the Court, s/he will be provided with a form of ReVia Log and
ordered to:
(b.) Show the physician the probation order so the physician
(c.) Upon issuance of the prescription for ReVia, the defendant
(d.) The defendant is to provide the Enloe Pharmacist, or his
(e.) The pharmacy will be available for dispensing of ReVia and
(f.) Ingest ReVia three times per week, at Enloe Hospital
(g.) The ReVia must be ingested at the Enloe Pharmacy unless 3. Each probation order shall provide that the defendant is to:
(a.) Follow all orders and directions of the probation officer
(b.) Commence and continue a drug, alcohol, or other program
(c.) Totally refrain from the use, possession, etc, of alcohol
(d.) Appear in court for his/her first review on a date 7 weeks 4. At the 7 week review, the Court will be provided with a progress report from the Probation Officer and a recommendation as to whether or not the defendant should be continued on the ReVia program for the balance of the recommended three month regimen. If the defendant is continued on the program, at the 7 week review, a further review will be scheduled for a date which is 3 months from the date of the original sentencing. 5. The defendant will report to the probation officer, or her designee, every two weeks at the beginning of the program. Such reporting requirement will be at the discretion of the Probation Officer. 6. Each defendant is responsible for, and shall pay for, all medical expenses incurred for the cost of obtaining the prescription for ReVia. The drug itself is available through Medi-Cal, private insurance, or at your own expense. All laboratory tests and physician or clinic expenses will be paid by the defendant at the time s/he obtains the prescription for ReVia. 7. The Court is informed that most physicians (and certainly Chico Immediate Care) will require each defendant to be examined every 30 days for a new prescription. 8. Each defendant, of course, is free to consult any physician of his or her own choice. Defendants are to be informed that if they do not have another physician or clinic they wish to visit, the Court has discussed the ReVia project with Chico Immediate Care Medical Center, and that such clinic is familiar with the Court's requirements. Any physician with any questions should contact Officer Lopez, at the Probation Department. 9. A review will be scheduled for a date three months from the date of sentencing. At the time of this review, the Probation Officer will report to the Court on the defendant's performance of the terms of probation, and will provide the Court with a recommendation as to what further programs the officer believes are appropriate. 10. At the subsequent three-month review, the Probation Officer will provide the Court with a progress report and recommendation for future treatment. Specifically, the Probation Officer will make his/her recommendation for possible requirement of inpatient/outpatient treatment, counseling, continuation of the ReVia project, Antabuse, AA, NA, etc: and whether the defendant should, then, be terminated from Formal Probation and placed on informal court probation. 11. The Court will expect COMPLETE AND FULL compliance with all terms of probation and directions of the probation officer by each defendant. The Probation Officer will be expected to institute a violation of probation proceeding pursuant to PC Section 1203.2 and to take any non-complying defendant into custody as the Probation Officer in his/her discretion (and as authorized by law) deems appropriate. Any defendant placed in custody for a violation will be produced in court at 12:30 p.m. on the next Wednesday following the date the defendant is placed into custody. If the defendant has not been taken into custody, she/he will be ordered to appear on the next Wednesday at 8:30 a.m. for further proceedings and action as deemed appropriate. If the defendant is on probation pursuant to an order made by the Oroville Court, the defendant will be produced in court at the next available date and time. 12. A copy of this protocol will be provided to each defendant placed in the ReVia Project. Home
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