It’s not a flashy place. The Toronto Drug Treatment Court, tucked away in a corner of Old City Hall, has plywood sheets on the walls, wires dangling where ceiling tiles should be, and a microphone that only works sporadically. Today is one of the days it doesn’t.

Justice Mary Hogan promises to speak loudly so everyone can hear her from her seat above the crowd, and the clients come to the front, one by one, to report their progress over the previous week. Her judgments sound more like a speech from mom: “You can do it,” she says to a man who’s about to go to withdrawal treatment. “It’s not a sanction. It’s an opportunity.”

She encourages those who’ve slipped to keep trying, and often repeats her cardinal rules: stay honest and stay in touch. She gently admonishes some, and applauds others. Literally.

“Any use?” is her first question. Anyone who answers “no” is greeted with a round of applause from Hogan, the court staff and the other clients in the audience. Today, one of those is A.J., who has spent more than two years in the program for heroin-related charges. (He asked for his full name to be withheld.) He steps up to the front.

The relationship with the judge is one key to the participants’ success. “For a lot of them I’m the first person in authority they feel who’s ever cared about them,” says Hogan. “Their victories are mine, and when something bad happens to them, I feel it too.”

Since 2004, this court and others across the country have been funded as part of the federal Treatment Action Plan of the National Anti Drug Strategy. But the federal funding is only promised until March, when it’s expected to change.

There is no doubt drugs are a pervasive problem, causing many cases in the justice system. But while anecdotally it seems positive, the research on success rates from drug treatment courts is mixed. Is a separate court system the right answer?

A lengthy path to graduation

The people in the courtroom know each other well: In addition to reporting to the court, they attend therapy at the Centre for Addiction and Mental Health (CAMH) together. They participate in the program for a minimum of one year, but most are there for 18 months to two years, according to Robin Cuff, the program’s manager at CAMH.

After they apply for drug treatment court through their lawyer or duty counsel, the crown attorney screens them. To qualify, people must have committed a nonviolent crime that was motivated by drug use. Then they are interviewed in the holding cells at Old City Hall by CAMH staff. “Normally we say yes,” says Cuff. Common reasons for refusal are the person not thinking they have a problem with drug use, being actively psychotic, or being at minimum risk of recidivism, making the program overly intensive for them.

Joining is a leap of faith, says Cuff. “They trust us when they have no reason to trust anyone.” The program takes about 50 people total at a time, and it’s always full. There’s currently a wait list of about two to four weeks.

Those who join must plead guilty, though they can reverse the plea within 30 days if they decide the program’s not for them. The treatment begins with an introductory phase, where clients are becoming more stabilized but often still using. They attend group and individual sessions at CAMH three days a week, as well as court two days a week. That’s followed by an intensive phase, which may include a residential stay at CAMH or a five-day-a-week program that “kick-starts turning the corner into more abstinence,” Cuff says. That’s followed by a maintenance phase, which lowers to one day a week of court and two days at CAMH.

A year – or longer – is necessary for change, Cuff says. “Most of our clients have complex issues, like homelessness, trauma, or brain injuries [in addition to addiction] … nothing is a quick fix.”

Throughout, participants submit to random urine drug screening. If they’ve reported their use, there are no penalties. If they haven’t, the judge and CAMH team decide on an appropriate consequence, from community service to being removed from the program.

Meanwhile, participants also work on finding permanent housing, if needed, and reconnecting with family supports, with the help of a peer-support worker at CAMH. (Though some grow up middle class, by the time they reach the court, most struggle with poverty.) They also address criminal urges with various treatments, including cognitive behavioural therapy.

To graduate, people must have been in the program for at least a year, and not have acquired criminal charges in the past three months. They also cannot have used drugs in the last three months – though substances like methadone are allowed. And they must have housing and be working, volunteering or going to school.

Some clients graduate, while others who don’t quite qualify – they may, for example, still be using pot – get “successful completion” instead. Those who don’t manage either but have made progress may receive a conditional sentence or suspended sentence if eligible. Still others, like those who’ve stopped participating or have lied about drug use, will go to jail. “There’s a lot at stake,” says Cuff.

The history of Drug Treatment Courts

The Toronto court, started by Justice Paul Bentley in 1998, was the first in Canada and was modeled after U.S. ones that began in the late ’80s. Now, there are over 1,500 drug courts in the U.S., and courts across Canada, in Vancouver, Calgary, Edmonton, Regina, Ottawa and Toronto.

Unlike a regular court, at drug treatment court, a pre-court meeting brings everyone involved together, where they discuss what’s best for the clients – the preferred term, rather than “the accused.” “It’s more of a therapeutic model, trying to combine the health system and the criminal justice system,” says Hogan.

That’s because the justice system is notoriously bad at helping addicts. “Prison is pretty well useless as a cure. But what we find is a complete separation of the criminal justice system from the treatment system,” says Meldon Kahan, medical director of the Substance Use Service at Women’s College Hospital. “It makes no sense to put someone in jail when the very act of incarceration increases their risk of relapse.”

“It should be the standard of the judicial system to divert people from the criminal justice system to the health system for drug-related offences,” agrees Philip Berger, medical director of the Inner City Health Program at St. Michael’s Hospital.

The evidence behind the system

Evidence that the Canadian drug treatment courts work is thin. A 2007 review of the evidence around Canadian drug treatment courts found two substantial studies on them. One was a three-and-a-half year review of the Vancouver court that found that 10.6% of participants graduated over that time period, 2.5% otherwise completed the program and 19.9% were still participating. More than half voluntarily withdrew or had been expelled.

They also compared drug treatment court participants with a control group in jail and a virtual cohort, which matched on five variables but not others – the comparison group was older, had more men and were less likely to have drug offences, for example. The researchers found that there were no statistically significant changes between these groups in the number of charges participants had during their time in the program or in the six months after it. They did not evaluate drug use after the program.

A study of the Toronto court found its participants fared slightly better, with 15.6% of participants graduating. But 84.4% withdrew from the program or were expelled. They were also compared to a control group who were eligible for the court but chose not to participate. Those who attended drug court reduced their rate of charges and convictions after the program – but the comparison group also had a similar, significant drop. This study also did not offer reliable information about post-court drug use.

In both the Toronto and Vancouver studies, the methodology faced “profound problems,” according to Dan Werb, director of the International Centre for Science in Drug Policy, who wrote the review. “People [in the Toronto one] who were in the drug treatment court arm were definitely more likely to have better outcomes, because they were more motivated to reduce their drug use,” he explains.

Those in the program argue graduation isn’t the best way to determine success. “Graduation is great, and successful completion is almost as great, but even those who go through the program and don’t graduate or successfully complete have a number of successes,” says Hogan. “The fact that they have substantially reduced their drug use, that they have not committed a crime, those are all really significant and on their own are signs of success.”

The review also points out that while it’s cheaper per year to have people in drug treatment court than in jail, at $3,000 to $5,000 annually for the court and $48,000 to $52,000 annually  for incarceration, that’s not a fair comparison, since drug treatment court is often longer. The median length of incarceration for possession, for example, is only 15 days.

Recent research from the U.S. shows more promising results. A 2012 meta analysis found that people who had gone through drug courts in the States were less likely to re-offend, especially for courts that target adults who had committed non-violent crimes. But some drug courts have also been criticized for being overly focused on abstinence, with one survey finding 50% of drug courts in the U.S. didn’t allow methadone maintenance treatment.

Werb says while some courts are helpful, the evidence does not yet prove that they are effective, particularly because of low graduation rates. “The onus is on people who advocate for these programs to provide evidence that a judge and a prosecutor, with this kind of hierarchical approach, where people are supported, but also coerced, and sometimes browbeaten by people outside of the medical sphere is somehow better than a model with doctors and social workers and other front-line workers offering treatment,” he says. He believes people would be better served by expanded treatment options in the community for all people struggling with addiction.

Critiques of the process

In Toronto, some have argued that the intervention comes at a time when people might not be ready for it. Kahan would like to see it offered when people go to jail, when they’re in jail, and upon their release. He would also like to see judges have the discretion to assign people to treatment rather than jail in all situations, instead of the “highly proceduralized, expensive, formalized system” of separate drug treatment courts.

“Some people may be ambivalent about recovery or may not be ready when they are first accepted,” acknowledges Cuff, adding that people are welcome to return to CAMH when they’re ready – and that some come after jail.

And many have raised concerns about the abstinence-based model. Cuff herself would like to add a harm-reduction option that would focus on reducing, not stopping, use. But while abstinence is technically necessary to graduate, there’s still a focus on harm-reduction principles throughout. “Our philosophy is treatment isn’t about stopping use, it’s about learning to live, to manage your life and relationships,” says Cuff.

The Toronto program also has no punishment for use, though it does delay graduation. “We don’t sanction you for using at all,” explains Hogan. “But you have to report, because that’s part of your recovery. And if you lie to us, we’ll find out.”

She remembers the small victories – like someone who came up to her last Christmas and told her it was the first Christmas in 20 years he hadn’t been in jail. “We have a lot of people like that,” she says. “Their circumstances are not easy, and their lives have been changed.”

Werb wonders, however, about those it doesn’t reach. “For me the issue is the comparative effectiveness of the drug court treatment model to [other] therapy. And the other issue is, is the criminal justice system the best provider of medical treatment? I would argue strongly that it’s not.”

Back in the courtroom, for A.J. at least, it’s working. He proudly answers “no use” to Hogan. He has been clean for the past seven weeks.

Everyone applauds.