CommentaryMedication-assisted treatment for opioid use disorders in correctional settings: An ethics review
Introduction
Substance use disorders are a pressing health concern in the United States (U.S.), and impact a considerable portion of the correctional population. For instance, between 62 and 86% of arrestees test positive for recent illegal drug use (Zhang, 2003), with 64–76% meeting diagnostic criteria for a substance use disorder (James & Glaze, 2006). Opioid use disorders affect up to 23% of recent arrestees, and pose a significant risk due to dangerous withdrawal symptoms (Zhang, 2003). As rates of opioid use disorders are projected to rise drastically with the rising rates of prescription opioid abuse, the burden placed on the correctional health system to address these disorders will likely only increase (Drug Enforcement Administration, United States Department of Justice, & United States of America, 2013).
While opioid use disorders present a growing problem for the criminal justice system, high rates of opioid withdrawal during incarceration pose a considerable health concern as inmates may experience physical (e.g., nausea, vomiting, diarrhea) and psychological distress (e.g., extreme agitation, anxiety, suicidality; (Center for Substance Abuse Treatment (CSAT), 2005). The National Commission on Correctional Health Care (NCCHC) identified acute opioid withdrawal as a particular concern as it may result in unnecessary suffering and interruption of medical care if left untreated (NCCHC, 2012). Beyond psychological and physiological symptoms, acute opioid withdrawal can increase the risk for self-incrimination among pre-trial jail inmates (Fiscella, Moore, Engerman, & Meldrum, 2005).
Despite the challenges of providing substance use treatment in correctional settings, there are several empirically supported approaches (e.g., therapeutic communities, contingency management, motivational interviewing) with demonstrated efficacy in reducing recidivism, relapse, and risk behaviors (Chandler et al., 2009, Knight et al., 1997, Leukefeld and Tims, 1993, Van den Brink and Haasen, 2006). One of the most efficacious and well-established interventions, for both detoxification and treatment, is medication-assisted treatment (MAT; Gowing et al., 2009, Mattick et al., 2009, Mattick et al., 2008). MAT is an evidence-based practice that refers to the combined use of pharmacotherapies, behavioral therapies, and supplementary core services (Kresina, Litwin, Marion, Lubran, & Clark, 2009).
The U.S. Food and Drug Administration (FDA) has approved medications (e.g. methadone and buprenorphine) for use in MAT (SAMHSA, 2009). These medications target the neurotransmitters that serve as the physical dependence mechanisms for opioid use disorders, thereby diminishing withdrawal symptoms and reducing cravings (SAMHSA, 2009). The empirical support for MAT across settings has led to recommendations by NCCHC that correctional systems change their policies to permit this treatment (NCCHC, 2012). They note that this policy change could play a key role in easing avoidable suffering, reducing risk, and preventing mortality (NCCHC, 2012).
Despite its effectiveness and support, MAT is underutilized or unavailable in most U.S. jails and prisons (Friedmann et al., 2012). Surveys indicate that only 2% of U.S. jails provide access to methadone or other opioid medications for detoxification (Fiscella et al., 2005). Similarly, less than 55% of U.S. prisons report providing methadone, and primarily only in limited circumstances, such as for pregnant inmates or those prescribed methadone for pain relief (Nunn et al., 2009). Furthermore, only 12% of jails report access to methadone treatment for inmates who previously received methadone maintenance in the community (Fiscella et al., 2005).
Instead of utilizing recommended detoxification protocols, survey data indicates that correctional policies favor “drug-free” detoxification and treatment (Friedmann et al., 2012), “Drug-free” detoxification is the management of withdrawal symptoms without the use of opioid medications, often relying on either a “cold turkey” approach or supportive treatment for specific symptoms (e.g. over-the-counter nausea medications) (Bruce and Schleifer, 2008, Fiscella et al., 2005) It is not uncommon in jails across the U.S. for inmates to be placed in cells and left to experience the physical and emotional effects of withdrawal (Bruce & Schleifer, 2008).
As “drug-free” detoxification and treatment have been demonstrated to be less effective than MAT, and in some cases even harmful, adopting treatment policies that are restricted to this method raises ethical concerns (Bruce & Schleifer, 2008). One reason for the ‘disconnect’ between correctional healthcare standards and drug-free detoxification policies is the perceived moral or ethical conflict arising from the perception that methadone and buprenorphine “just substitute one addiction for another” (Magura et al., 2009, McMillan and Lapham, 2005, Nunn et al., 2009). Given this rationale for limiting access to MAT in correctional settings, there is a clear need to examine this treatment modality from an ethics perspective (Table 1).
In 1974 the National Research Act was passed in response to several highly publicized cases of unethical human subjects research and human rights violations. This law created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, also known as The National Commission (NCPHSBBR; 1978). NCPHSBBR was tasked with identifying ethical principles for research and establishing guidelines to protect human subjects. They codified these principles in the Belmont Report (NCPHSBBR, 1978). Although the Belmont Report was initially created to protect research subjects, its utility across settings was quickly realized, and it now serves as the ethical framework for protecting persons involved in research and receiving public health and other biomedical and behavioral services, including MAT (Cassell, 2000, Kass, 2001).
The ethical framework established by the Belmont Report identifies three fundamental principles: (1) beneficence/non-maleficence, (2) distributive justice (equivalence-of-care), and (3) autonomy (informed consent) (NCPHSBBR, 1978). Together, these principles have been deployed in diverse settings (e.g., institutional review boards, hospital ethics review committees) to address and resolve ethical conflicts that arise when providing biomedical and behavioral health services (Cassell, 2000). Once adopted in clinical care, these ethical principles were codified in professional standards and reinforced through several landmark court cases (Beauchamp, 2011, Cassell, 2000, Faden et al., 1986). When applied, practitioners, researchers, and policymakers are tasked with viewing these principles holistically, carefully balancing them in order to maximize the benefits and limit risks across domains. The following section synthesizes available information and reviews the implications of these ethical principles for the use of MAT in correctional settings.
Section snippets
Beneficence and non-maleficence
Beneficence and non-maleficence pertains to helping patients (doing good) and preventing harms (doing no harm) (Cassell, 2000). These intertwined principles are essential to providing evidence-based treatment for substance use disorders in correctional settings. First, the preventable physical and psychological harms caused by drug-free detoxification can violate a correctional health system's duties surrounding beneficence and non-maleficence (Bruce & Schleifer, 2008). This modality can be
Autonomy
While beneficence, non-maleficence, and equivalence-of-care highlight the ethical imperatives supporting access to MAT, the principle of autonomy has often been used to limit access to this treatment. Autonomy is often characterized as the dominant principle in Western medical ethics, as the rights of the individual prevail over what may be in a patient's clinical “best interest” (NCCHC, 2012). For instance, even when a health provider is reasonably certain that without treatment a patient's
Conclusions
Opioid use disorders are a pressing health concern for U.S. correctional populations, which will likely increase due to the growth of prescription medication abuse (Drug Enforcement Administration, 2013, Nunn et al., 2009). Correctional settings present a unique opportunity to treat opioid use disorders. However, MAT continues to be largely unavailable in U.S. correctional facilities. Given that MAT involving methadone and buprenorphine has demonstrated considerable effectiveness for opioid use
Conflict of interest statement
The authors declare that there is no conflict of interest.
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