Female Opioid Court Participants' Narratives of Siloed Medical, Legal, and Social Service Sector Interactions to Inform Future Integrated Interventions

Abstract

A gap exists regarding how to design gender-specific interventions for women charged with opioid use disorder (OUD)-related crimes. National recent efforts include opioid courts. Treatment courts present opportunities for earlier intervention for women under judicial supervision. We interviewed 31 female participants in the first known opioid court so they could inform cross-sector integrated approaches to address their needs. Data reveal the complexity of participants' involvement with myriad cross-sector organizations, given the duality of their roles as simultaneous lifetime victims and as OUD-related perpetrators. Participants have difficulty trusting systems intended to help them due to systematic failures to prevent or address abuse and neglect over their lifetimes. The opioid crisis cannot be solved without an understanding of early missed intervention opportunities and a cross-sector approach.

Introduction

A gap in the literature exists regarding strategies to support women with opioid use disorders (OUD) and approaches to create, test, and implement gender-specific interventions. National efforts exist to reduce the criminalization of OUD-related crimes, including opioid courts. However, the opioid crisis cannot be solved by one sector in isolation, nor without a greater understanding of women's early and ongoing trauma and comorbid illnesses. Through cross-sector partnerships, clients may be empowered and intrinsically motivated to seek help, engage with care, and change the trajectories for themselves and their children (Morse et al., 2017).

There is futility in using punitive systems for women charged with crimes who have OUD after suffering abuse across their lifetimes. Often, their crimes are related to their trauma and substance use disorders (SUDs) (Hayes, 2015). Further, without addressing their children's needs, we run the risk of “growing” the next generation of court-involved individuals (Bowen et al., 2018; Jones et al., 2020).

The socioecological model suggests that individuals are nested within relationships, communities, and societies (Brofenbrenner, 1979). This is particularly true of women drug court participants, who face internal, relational, community, systemic, and policy-level barriers for health, and have done so since childhood (Morse et al., 2014, 2015). When we encounter individuals charged and held on crimes related to opioid use, how can we intervene beyond a punitive individual approach to crime prevention and instead expand to a systemwide multidisciplinary model?

This article explores female opioid court clients' experiences with multiple sectors throughout their developmental trajectories to inform potential approaches to close the gap on missed opportunities to intervene early, using a family and cooperative cross-sector approach rather than an individual, criminogenic, and noncooperative systems approach.

Method

We conducted our study in partnership with an opioid intervention court (Court), the first of its kind in the nation that began in May 2017. During January and July 2019, research assistants recruited potential study participants in the Court lobby. The staff shared that they were part of a research team and invited women to participate in a confidential (including to court staff) project (see Fig. 1). Inclusion criteria included being 18 years or older, English speaking, female-identified, and Court program participants.

Fig. 1.

Recruitment consort.

Following consent, participants self-administered two questionnaires and completed one in-person, semistructured qualitative interview. To ensure fidelity to the interview protocol, one researcher conducted the first three interviews while being observed via Zoom™ by other members of the team who provided feedback until the interviews met team standards. Thereafter, senior team members periodically checked fidelity and assessed saturation. The interviews lasted an average of 45 minutes, and they were digitally audio-recorded and professionally transcribed.

The multidisciplinary team analyzed the data using consensual qualitative research analysis (Hill et al., 2005). When disagreements arose, we used a consensus process to arrive at a common understanding. Once we created a final codebook, we coded the remaining transcripts and explored intercoder reliability. For more information on the interview design and coding process, please see Morse et al. (2022). For this article, we focused on opportunities for early intervention. Participants discussed their cross-sector involvement: interactions with the legal, medical, and SUD treatment sectors.

One university institutional review board approved the study protocol, and the second university approved the protocol as a multisite study. We reimbursed participants $60 and four public transit passes.

Results

The sample comprises 31 participants. The average participant age was 30.9 years (standard deviation [SD] = 6.8). The sample was mostly White, with 9.7% self-identifying as Hispanic and Latina. Approximately 68% achieved a General Educational Development (GED) or high school diploma. Almost three-fourths of the sample was unemployed. A little over half the sample reported being heterosexual, one participant was lesbian, and 25% reported having sex with both women and men (see Table 1).

Table 1.

Participant Characteristics (N = 31)

Characteristics	n (%)
Age (M [SD])	30.9 (6.8)
Ethnicity
Hispanic/Latina	3 (9.7)
White	28 (90.3)
Educational attainment
≤GED or high school diploma	21 (67.7)
>High school diploma	10 (22.3)
Employment status
Full- or part-time	9 (29.0)
Unemployed	27 (71.0)
Housing status
Stable	29 (93.5)
Unstable	2 (6.5)
Sexual activity
Sex with men	17 (54.9)
Sex with women	1 (3.2)
Sex with men and women	8 (25.8)
Not sexually active	5 (16.1)

GED, General Educational Development; SD, standard deviation.

Three themes emerged related to participants' interactions across systems where earlier intervention may have been possible to disrupt the SUD paths: (a) negative interactions with the legal system, (b) comorbid mental health diagnoses, and (c) differing OUD trajectories. We discuss each theme in greater detail with representative quotes.

Negative Interactions With the Legal System

Many participants had interacted with the criminal justice system before opioid court, most often for drug-related offenses, minor infractions, or public intoxication. These early interactions were described as quite negative. There were many reasons for these perceptions. Some participants reported that the system dehumanized them. For others, the arrest itself was traumatic and involved being assaulted by law enforcement.

Went a couple of times … to jail. I went to jail two years ago. I was arrested, and I was drunk. I was on a lot of pills, and I ate a lot of pills in the back of the cop car. I was basically overdosing, and I took out eight officers by myself.

I mean because when you go in, they're like “Oh, just another junkie coming in. Make sure you use your gloves. They might have something….” It just makes you feel like nothing and you go get high and you feel better.

We're just sitting there. Yeah, we're doing a bad thing but we're not harming anyone else, at least not directly. But when I finally accepted to get out of the vehicle, I was tackled by four grown police officers. It took four of them to get me down. And once they did, they hurt me so bad. They hurt me so bad that they charged me with excessive noise because I was screaming so loud.

While many participants had numerous prior interactions with law enforcement, they were not always arrested. Even when arrest and incarceration occurred, substance use often continued inside correctional facilities.

I've gotten arrested like thirteen times for stealing. I got arrested the one time and I was put on probation but it did nothing for me because I ran away from probation and the cops in my neighborhood knew me. … but I did get arrested the one time and I got locked up for ninety days. But when I got locked up for ninety days, they were sneaking shit inside the jail and so that really didn't help out much neither. Like this whole system is fucking crazy…there's drugs everywhere.

Data reveal the complexity of participants' involvement with organizations over their lifetimes, given the duality of their roles. Participants present as lifetime victims (i.e., abused or neglected as children and adults, as well as gender-based violence victims) and simultaneously as perpetrators (i.e., neglecting children while using drugs or committing an OUD-related crime). Related to negative experiences as children, parents, and prior interactions with the criminal justice system, help-seeking was difficult. Some participants were afraid of incarceration, so they avoided necessary court interactions. Others sought OUD treatment and were receiving medication for OUD, but they continued to experience legal problems (see Table 2).

Table 2.

Representative Narratives: Negative Interactions With the Legal System

1. Lifetime exposure of violence and victimization My father being in prison basically my whole life could have been [a link to my drug use]. He was in and out of my life a lot, so that could have been a big trigger of my drug use, too, and he was also an addict and used. I feel like he triggered me a lot, but right now, my father is an amazing guy. He's been clean, and he maxed out of prison, and now, he's been nothing but a good father to me… Even though it sucked what I went through growing up, and I feel like that's why I don't like cops so much is because they were always at our house, and that's why I have the charges that I have, I feel like when I see cops, I just go back into a different state of mind. You know what mean? I feel like he triggered a lot of my drug use growing up with the drinking, and the smoking weed, and stuff. But I've never blamed anybody for my drug use. I chose to do what I did, but there's all underlying reasons why I did what I did… When I'm not on my medication, I get violent because people provoke me or they trigger me into a PTSD matter, and I get violent…

2. Arrested by law enforcement I was walking across the street. A cop recognized me and the person I was walking with because that's who I got arrested with the last time, and pulled over, and before I knew it, me and him both felt somebody pull up on us, and we turned around. I thought I was getting robbed or something. I didn't know it was a cop, [who said] “Hey, what are you guys doing?” I was literally walking to my friend's house, not a drug house, a friend, a clean friend, a good friend of mine, a block away. I almost made it there. “Well, what are you guys doing? Well, we got a call that there's some people in the neighborhood breaking into buildings,” and it had nothing to do with us. But because I was there, and again, the same thing, got searched. I had things on me I shouldn't have had. I went to jail again and that was that. Those were the only two times I was arrested both within a couple of months of each other. The first time, it got dismissed because I have no record… It got dismissed. The second time, they said, “Well,” and then they put me in opioid court.

3. Perpetuation of Criminality and Drug Abuse I was arrested for robbery in 2017 and I was given a county year for that. After I got out of jail doing the county year, I began using again which led to an arrest back in December. I spent the night in jail and was released on my recognizance. I never went back to court and that led to me having a warrant for my arrest and on June 19th of this year, I was arrested on that warrant and I had a new possession charge for possession of a crack stem and methadone and I was put into the opiate treatment court.

4. Drug use while interacting with the system I tried to get clean before and the court forced me, 3 years ago, and they told me, you'll know when you're ready… And one day I woke up and all the sudden I just needed to get clean… I'm not even getting high anymore. I'm using four grams of heroin a day, not even getting high… That's crazy. And I ended up not having health insurance in June. I had to wait'til July to go into rehab… It's like a light bulb turns on in your head and you're ready. Because you can't force an addict. They have to be ready. Anybody can say I want you to do this and an addict's going to look at you like yeah, okay. Sure. Yeah. I'm going to do it. I'm going to fake it'til I make it for court. That's what normally happens with a lot of us that are court-mandated. And they just don't want it and it's sad. But then again, a lot of drug dealers are getting into drug court and opiate court now because they're saying they're users and they're not, and they send them to rehab, these drug dealers, and that's where they meet the addicts, and it's a big revolving circle. It's insane… I have been through that. I've met dealers at rehabs. I've been to six different rehabs. And they do, they go through drug court and act like they're users because they've been caught with big amounts of stuff.

PTSD, Post-traumatic Stress Disorder.

I spent a year in jail and therefore, when I had the warrant, part of why I didn't go back to court was because I feared going back to jail and I don't like jail. Nobody likes jail and that's why I'm doing this program and making sure that I show up every day.

I've been arrested probably ten times for possession. The first time I ever got arrested … was the state troopers…And then that same week I got arrested again … And then it just kept going and kept going. It was like once you're in the system you're stuck. But I'd get caught with heroin or needles. And then if you have the needle card, some of them wouldn't even take it. They'd just arrest you anyway until you went to court. And then it would get dropped.

Comorbid Mental Health Diagnoses

Mental health was a critical component of the initiation and maintenance of substance use for many participants. Most described mental health challenges beginning in childhood, whereas symptoms arose during emerging adulthood for others, almost all inadequately treated by the various systems they encountered. Many participants reported traumatic experiences that brought on or exacerbated their symptoms.

PTSD came after he strangled me to death. I relive it in my sleep. I have night terrors. And then depression and anxiety. I was diagnosed when I was 14. And then out of counseling my whole life because I couldn't find a counselor that I actually liked.

Diagnoses ranged from depression to post-traumatic stress disorder to bipolar disorder. Many participants cycled in and out of mental health treatment, but their underlying concerns persisted. “I've been in mental health counseling since I was a kid when my parents got divorced. I always had behavioral problems. I was always aggressive.”

As a result, some described using substances as a coping strategy until they could get appropriate treatment and/or prescription medication, but substance use was ongoing due to not getting that treatment (see Table 3).

Table 3.

Representative Narratives: Comorbid Mental Health Diagnosis

1. Early onset of challenges Q: When did you start feeling those emotions [of depression]? A: When I was younger. I've got severe bipolar depression so it's been a while and I finally just recently got back on my meds.

2. Seeking intervention and treatment during crises So, when I was 15 I got in a fight with my parents. They found a bunch of pills that I had left or something like that and basically, I kind of flipped out and it was going to be the same thing all over again. My dad had called the cops on me because I more or less told him to and then he filed a report, then he was going to leave, and when he was leaving I'm like want to take me with you? Because I knew I didn't want to be there. So, I told him I was going to kill myself but I wasn't; I just knew they have to take you if you say you're a threat to yourself or others type thing. So, he took me, went to XXXX Adolescent Psychiatric Unit, stayed there for 2 weeks until they got me a bed and an inpatient, so my whole sophomore year in high school I was in rehab. It was different.

3. Reliance on illicit substances Anybody that's ever done it can pretty much attest to the fact that especially when you switch from sniffing it to going to a needle, anybody can tell you that it's like an orgasm times 10. When you feel that for the first time, it's just an amazing feeling. You have no pain, physical pain. It takes all your physical pain away and a lot of mental pain, certain things you don't want to think of. For me, it numbed a lot of things. When my father died and stuff, it made my drug use a lot more because I was just trying to forget about what happened to the point where when you finally get clean, and you stop using, it was so many memories come to the surface.

4. ADHD Q: I know you mentioned that you have ADHD. Do you feel that played into you starting to use drugs? A: Yeah, with the stimulants, I feel like that. That's one of my main triggers for cocaine is because of my ADHD, and I know that if I do cocaine, I'll feel normal. You know what I mean? It's a struggle out here every day for me and having ADHD, not being able to remember things, and forgetting things, and moving too fast, and losing things. It sucks, but it's hard to get on a prescribed medication for my ADHD because of my history abuse. Now, it's like I'm stuck dealing with this right now, and I've never had to deal with it a day in my life. Q: Is that something you take medication for now? A: No. They don't have me on any meds for my ADHD right now. Q: That's because of your history for substance abuse or just because you haven't? A: I overdosed on Adderall when I was 15 years old.

5. Anxiety I have Medicaid transportation so it's pretty much more of myself that stops me from going. I have a really bad anxiety disorder so there are days when I have a hard time leaving the house or I won't be able to go anywhere by myself and that prevents me from making it to my appointments and unless like I have a new therapist at my psychiatric center and she doesn't really know me so she doesn't understand what I'm going through so when I miss with her, she automatically runs to the doctor and now I have all these restrictions with them like they're going to be toxing me and I can't miss any appointments and just a lot of extra stuff that's being put on me so that's another reason why the program is going to be a good thing because it will help me stay clean for my psychiatric part and for my substance program part which will then help me get custody back of my son.

ADHD, Attention-deficit hyperactivity disorder.

I need to get in to a psychiatrist. That's what they keep telling me, but it's so hard to get in to a psychiatrist out here. They're all full. I'm just looking for a psychiatrist right now that's going to give me the meds that I need to get because I feel like … if I get back on my Ritalin … I'm going to be really stable. That's what the struggle is with not using cocaine is knowing that it's going to make me feel normal, and I'm going to be able to function because I can't function right now.

Differing OUD Trajectories

Participants had unique paths into OUDs, but they shared the impact of an uncoordinated medical system with regard to opioid prescribing. Paradoxically, they found that courts required cookie-cutter, rather than individualized, approaches to the SUD that consequently developed and the various systems of care did not communicate the women's needs to each other to facilitate care. Participants described varied trajectories to OUD that arose from unintentional injuries; were secondary to illnesses; and followed legally prescribed pharmaceuticals, developmental challenges, and trauma. Complex medical systems also failed in prescribing and treating consequent SUD.

One participant had suffered a high school sports injury.

I didn't use anything until I was 16. I tore my ACL and MCL and then they put me on Lortabs and I was on them for like 6 or 7 years and then they … just took me right off of them. I was already addicted at that point, being on them for 6 years and so I started to run the streets for pills and then it just got to heroin and when I was 16, my boyfriend introduced me to coke and smoking weed and stuff like that.

Another discussed how her pain management medications came to an abrupt halt.

I ended up seeing [a pain management doctor] for like a month and all of a sudden I go back for my next appointment and he's no longer there. No letter, no nothing. He left. And so, they had another doctor there that was supposed to be managing the whole practice and he ended up using the prescriptions himself. So, they closed the office and there I am, once again, with no doctor, no meds. That's when I started using the heroin.

Similar to the sports injury example, some participants shared that their OUD experiences followed motor vehicle crashes.

The car accident brought upon more use of pain medication. I had two herniated discs in my lower back, three herniated discs in my lower back, and a lot of nerve damage from the car accident. So that's how I ended up on more pain medication. And then the one doctor I was seeing, they threw me out of pain management because the insurance company never paid them what they were supposed to pay them.

This participant then turned to illegal pain relief substitutions. See Table 4 for additional examples of trajectories to SUD.

Table 4.

Representative Narratives: Differing Opioid Use Disorder Trajectories

1. Increasing severity of drug of choice Things just got worse. You can't just use one drug. You can't just start using weed and think that's all you're going to use because eventually that weed is not going to get you high anymore and that's what happened to everyone I know. Everyone can tell you they do not just use one drug if it's weed or alcohol or whatever the case may be, you always need more. I never heard that until I went to twelve meetings and groups and stuff and they'd be like “hi, my name is whatever and my addiction,” and they don't even say they're an addict “and I want more.” I'm like what the hell do they mean but then I sat there and thought about it through the whole hour and I was like oh, it's like anything just to get high. So yeah, that's how I got it was that guy. I was 16 years old when I smoked that but at 16, I was already sniffing cocaine. I had already tried ecstasy pills. I had already took benzos. I was already smoking pot. I even smoked PCP. That's a lot of stuff for a 16-year-old to have done already.

2. Parental influence I didn't even want to take them then. I was very hesitant on taking them but I just hurt so bad that I couldn't handle it and I took one and I was like alright, it took away some of the pain. My mom was like “Well take another one. Take another one so you can get up and actually maybe enjoy your life for a day.” I had a … brace on for 6 weeks. That was awful. … We lived up on a hill so it was like torture getting down and up. She was like “Well why don't you take two and just sit and relax and chill for a minute” and I took two and I was like hey, this makes me feel alright. I'm happy. I don't really feel like shit anymore. After that I started taking two at a time and then it was like three and then I told the doctor that the fives weren't working any more like a year later and he put me on the 7/5s and then I moved up to the tens and then like 2 years later is when he cut me off so it was absolutely that. Absolutely. If I wouldn't have been on that I really don't even know if I'd be in the position I am now.

3. Postsurgical pain A lot of it, like I said, these doctors, these people, don't understand. They put you on all these medications and I have a need for medications. It's not like I'm trying to get high. I've had 10 surgeries. I'm in pain every day. It's awful. I never expected to be—I'm still walking but I never expected to be handicapped like this because most of my life before this—but I'm still walking so I have to be thankful. But now I have a vertebra sticking out of my back right now because the scoliosis is so bad from all the surgeries. So, it's tough.

4. Childhood Traumatic Injury Like I said, I was 15, 13, 15. Well I was 15 years old, I'm sorry. I got pushed off the cliff. I was drinking and I was making out with my girlfriend's boyfriend and I was like “No, what am I doing? I'm just drunk. Please get away from me” and then he pushed me off a 15-foot cliff. I broke my back. I have a slipped disc in my neck, back and broke my neck so that's what really led me to all my problems like I said because I got prescribed the Oxys when I was 15 years old so I just wanted more and more. I kept eating more and more.

5. Childhood sexual abuse It's like once you stop using, just all these things that I didn't want to remember start coming to the surface of things maybe like sexual abuse, or physical abuse, or something. Those things start coming, becoming more clear, and you don't want to remember it, but then now, all of a sudden, I have to deal with it instead of just taking drugs to forget it….

6. Human trafficking and partner's drug use After that year, I finally escaped from the house and was able to contact the police. They came to the house, and I was out on the front lawn half-clothed and told them what had happened; that I had been held prisoner for the past year. They told me that because I was on his property that they would arrest me and not him because he wouldn't answer the door obviously. They told me I had to leave or they were going to arrest me because it looked like I was harassing him because I was on the front lawn. Obviously, I wasn't working at this point. Then, pretty much since 2009 until as of a few months ago, I was working as a call girl/prostitute making money to support my drug habit. I was also with my boyfriend for the past 10 years, so he helped me pay for my drug habit and then ultimately, he ended up getting involved in drugs. He's 65 years old, so he started using heroin, sniffing it. We've both been on drugs now for 9 years, and then this whole thing with me going in the hospital and almost losing my life basically woke us up, and we've been clean ever since then.

PCP, Phencyclidine.

Discussion

Despite innovative courts and the criminalization of SUDs, mortality rates as a result of prescription and synthetic opioids and heroin continue to rise. Figure 2 depicts the growing rates of related deaths (Bipartisan Policy Center, 2020). The rising rate in deaths suggest that society must approach OUDs differently. A legal solution is not enough.

Fig. 2.

Opioid and heroin-related deaths.

Our data suggest that participants have numerous interactions with the medical, legal, and social service systems during their journeys to developing and treating OUDs. These interactions provide opportunities for early intervention, which may be more effective than waiting for arrests—or worse, deaths—to occur. Once an arrest does occur, early interventions could potentially address the needs of not only the women with OUDs, but their children as well. Such developmentally appropriate screening and interventions could support multigenerational caretaking within extended families who often care for incarcerated women's children (see Fig. 3).

Fig. 3.

Developmentally appropriate preventive screening and assessment.

Future interventions housed in the legal domain, such as specialty court, jail, and prison settings, might benefit from partnerships with social service agencies that allow intergenerational engagement of clients with OUD and their children.

Participants describe heterogeneous cross-system trajectories in relation to their SUDs. With those different journeys, they may have myriad support systems, resources, abilities to return to court and treatment programs on time, and connections to family or friends who can financially support them. Conversely, they may have experienced multiple complex experiences and levels of abuse, deprivation, mental health problems, or unremitting drug dependence that were inadequately addressed by the various systems they encountered.

For example, some with long sex work histories may be unable to access safe shelter, housing, food, and needed treatment and have traffickers present in court who use surveillance to control female drug court participants postarrest.

Our data indicate that SUD and recovery journeys occur over a period of years, across multiple systems that are disconnected and require improved cross-system communication. Many opioid courts, treatment providers, and correctional facilities use manualized intake processes and procedures. On system entry, there are required assessments, contracts, and treatments (Ferguson et al., 2019).

However, due to the specificity of each participant's journey, the Court may need a personalized approach for each client, similar to patient-centered care, which has proved beneficial (Epstein & Street, 2011). This individualized approach needs to include complementary systems, which has been an effective model for those with serious mental illness who enter court systems but has not been used with women in drug courts (Lamberti, 2007).

By the time our participants entered treatment court, they had often experienced numerous challenges and traumatic experiences. They may not willingly share their histories with care providers unless directly asked. However, peer navigators or community health workers (CHWs) may be helpful in assisting the court's clients without shame, as peers may have similar experiences. In a recent report (McBain et al., 2021), authors noted the intersection of SUDs, mental health, and social determinants of health. The report focused on improving mental health through pathways to care and evidence-based interventions. Peers were noted as a noteworthy intervention for mental health recovery.

Likewise, peer CHWs have been employed to address the needs of women who have been incarcerated or criminal justice involved. The CHWs help with navigating complex health and social systems, offer support and advocacy, and provide evidence-based interventions addressing SUD and HIV risk reduction. There is evidence that one such program (Women's Initiative Supporting Health [WISH]) has improved access to needed health services for this population while advancing the professional development of the peers (Bedell et al., 2015).

It is impossible for one sector to stop the opioid crisis. It is also difficult to solve a problem without first understanding its depth and breadth, what evidence-based interventions offer possible solutions, and whether an intervention is being implemented with true fidelity. Even within a sector, there are many potential approaches to fighting the opioid crisis.

The Network for Public Health Law convened a group of attorneys representing different legal sectors who met for almost 18 months to explore how statutory changes might help the problem. For instance, do we need different tax laws, innovative zoning laws for clinics, practice and licensure changes to address the provider shortage?

These are just a few ideas presented in the report A Cross-Sector Approach to Removing Legal and Policy Barriers to Opioid Agonist Treatment (Bernstein et al., 2020). To respond to the opioid crisis, the authors suggest eight systems that need to consider legal changes: health care, criminal justice, housing, zoning, transportation, education, employment systems, and family law. The recommendations suggest that parking this crisis at the doors of the criminal justice system will be ineffective without transformational change in the systems that also interact with people who face SUDs, mental health disorders, joblessness, and homelessness; thus, the notion of peers who can help women facing SUD navigate across systems.

Other partnership considerations might include academic institutions that offer potential strategies to help launch and evaluate interventions. In addition to students eager to engage in community service, faculty are demonstrating greater interest in community-based participatory research, which includes designing and conducting studies with community partners and clients (Israel et al., 2001). Furthermore, a field of “public impact scholarship” is emerging, suggesting that academia leave university walls and seek community change as a result of their work (Sliva et al., 2019). Basic principles include reciprocity, conversation, and research combined with teaching and service. Many academic institutions encourage such endeavors.

Academic–legal partnerships are also mutually beneficial. Court and correctional systems have clients to serve, data to be analyzed, and state and federal funders who want to know whether they are meeting milestones. Academics aim at analyzing data, testing interventions, and disseminating their work. While many such academic–community partnerships exist, the opioid crisis provides new opportunities to be innovative and consider correctional settings as windows to not only provide care to the clients, but also offer prevention to their children.

Limitations

This study was conducted in one location, with an innovative approach to treating OUD. In addition, this community venue is at the forefront of OUD treatment, creating the first such specialty court, so it is not generalizable to other treatment courts. Our small sample was all female by design, and any recommendations are thereby limited. Our sample was primarily White and heterosexual. Future work might expand participant diversity.

Beyond the scope of this article are professional sectors that encounter children with opioid addicted parents, including, but not limited to, teachers, pediatricians, and child abuse prevention workers. Despite these limitations, our sample serves as a basis for sound qualitative research purposes to begin a dialogue around intervention development and enhancement.

Conclusions

The very systems designed to “help” participants as children become part of a failed and then untrusted lifelong structure to prevent or address abuse and neglect, including legal and mental health systems.

By crossing sectors (see Fig. 4) and engaging academic partners, we can envision a legal system in which courts and correctional facilities are more than the first stop on a train to a downward physical and mental health spiral, but rather an intervention opportunity when clients find themselves embroiled early in their correctional trajectories for petty crimes and family turmoil. Many participants experienced numerous court and correctional interactions throughout their early lives and subsequent substance use trajectories when a detailed assessment, engagement, and referral might have made a difference.

Fig. 4.

Transdisciplinary approach to working with women simultaneously criminal justice involved and opioid use disorder patients.

Many of our participants were parents. A parent who is criminal justice involved places her child at risk for increased morbidity and mortality as an adult, as discussed above. This warning sign of a parent arrested for SUD might be a chance to intervene earlier in the life of a child with cross-sector engagement. It is possible that cross-sector engagement could have made a difference in our participants' lives as children, in addition to a peer for them as adults: Someone who has stood in the participant's shoes might provide support and offer hope and a light at the end of the tunnel.

Author Disclosure Statement

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

Funding was received from the University of Rochester Center for AIDS Research Grant P30AI078498 (NIH/NIAID) and the Susan B. Anthony Center at the University of Rochester.