To test the effects of drug court participation on long-term mortality risk.During 1997-98, 235 individuals charged with a non-violent offense were randomly assigned to Baltimore City Drug Treatment Court (BCDTC) or traditional adjudication. Heroin was the predominant substance of choice among the sample. Participant mortality was observed for 15 years following randomization.Over 20% of participants died during the study, at an average age of 46.6 years, and 64.4% of deaths were substance-use related. Survival analyses estimated that neither mortality from any cause nor from substance use-related causes significantly differed between BCDTC and traditional adjudication.Frequent and premature death among the sample indicates that this is a high-risk population in need of effective substance use treatment. Roughly half of drug treatment courts are now estimated to offer medication assisted treatment (MAT), which is currently the most effective treatment for opioid use disorders. In this study of BCDTC implemented over 15 years ago, only 7% of participants received MAT, which may explain the lack of program impact on mortality. Historical barriers to providing MAT in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma. Drug treatment courts should implement best practice standards for substance use treatment and overdose prevention, including increased access to MAT and naloxone, and training to reduce stigmatizing language and practice.