The Case for Medication-Assisted Treatment: An Ethical Priority

It is no secret that a significant proportion of the criminal justice population has an issue with addiction. So what is being done about it?

SUBSTANCE USE DISORDERS

Substance use disorder (SUD), including opioid use disorder (OUD), impacts a significant proportion of the American population—20.3 million people (7.4%) of all Americans aged 12 years or older had a SUD in the past year.1 Of these, 2 million people had an OUD with either heroin and/or misuse of prescription pain relievers. Yet, while medication-assisted treatment (MAT) with methadone, buprenorphine, or naltrexone for OUD is the most efficacious, evidenced-based treatment that is recommended by the National Institute of Health, Substance Abuse and Mental Health Services Administration (SAMHSA), and the World Health Organization, only 11% of patients with an OUD are prescribed approved treatment.

Limited access to MAT has been cited as a substantial barrier for patients with OUD, while inequities across ethnic and sociodemographic groups speak to the health disparities evident in our society. The provision of appropriate treatment, and lack thereof, is even more troublesome when considering the vulnerable populations that bear the disproportionate burden of SUD/OUD—namely, those with corrections system involvement and mental illness (SMI). It is no secret that a significant proportion of the criminal justice population has a SUD.1,2

Between 62% and 86% of individuals arrested test positive for recent drug use.3 And, 64% to 76% of arrestees meet diagnostic criteria for SUD. More than half of individuals with a prescription OUD or heroin use in the past year report contact with the criminal justice system.2 Similarly, in terms of mental illness, 9.2 million Americans over 18 years old, or 3.7% of all American adults, had co-occurring SUD and any mental illness in 2018.1 (see Table)

In line with the goal of reducing recidivism, a proportion of the criminal justice population is often diverted to drug courts. According to SAMHSA, there are 2700 operational drug courts in United States today.1 These courts adjudicate cases involving substance-involved offenders, or individuals who were arrested for a drug-related offense and/or are eligible to enter a drug court program. Typically, an offender is followed by a drug court for a period between 12 to 18 months. The National Drug Court Institute reports that over 116,000 criminal offenders were served by a drug court program in 2009.4 However, only 56% of drug courts offer MAT to participants.5 Additionally, most individuals with SUD do not receive treatment while they are incarcerated, or they are forced to withdraw from treatment they were receiving before incarceration.2

Ethical considerations around MAT in caring for these patients can be examined through lenses of health care as a source of harm, paternalism, violation of rights through a refusal to provide access to appropriate care, or through the intersection of medicine and epidemiology. These considerations include: (a) issues around access to MAT and (b) context in which consent to MAT is obtained from those to whom it is offered.

MAT is an approved treatment for OUD by the Food and Drug Administration. The underlying pharmacology of drugs used in MAT and their physiological effects on individuals are well understood. MAT is known to assist in diminishing the cravings, and some can alleviate the withdrawal symptoms associated with OUD. However, many drug courts and prison facilities do not afford provisions for MAT on those who are incarcerated.2,5 Such practices are harmful and therefore not beneficent. In the absence of MAT, individuals with OUD are forced to undergo detoxification with full exposure to the negative physiological and psychological symptoms of withdrawal.

When incarcerated and not offered MAT, patients with OUD experience easily avoidable withdrawal symptoms, such as nausea, vomiting, diarrhea, agitation, anxiety, and suicidality.3 This lack of access to approved and indicated therapy for a disease process, could be construed as a punitive measure and borderline cruel and unusual punishment. In fact, it should be noted that detoxification in the absence of MAT is less efficacious than MAT and harmful to human health.4

Surveys of drug courts and the United States prison systems do find practical reasons for a lack of provision of MAT, the cost of MAT and lack of access to local providers. However, courts not permitting MAT due to a lack of knowledge and stigma around OUD is still a pervasive factor. Many drug court teams are uncertain about the underlying physiological mechanisms of opioid receptor agonists used in MAT, and their efficacy in treating OUD. Some report that they feel that those with OUD use MAT to get “high,” and not for treatment of OUD.4 Further, others report feeling that using MAT for OUD is essentially replacing one addictive substance with another.4

The false narrative that MAT reinforces addiction or replaces one illicit substance (heroin) with MAT has a negative impact on individuals who instead undergo the psychological and physical harm associated with drug-free detoxification.3 Additionally, the intersection of medicine and epidemiology can be found when those with SUD/OUD with no access to MAT end up turning to unsafe practices, such as the use of unclean needles to inject impure heroin or heroin laced with synthetic fentanyl. This leads to increased morbidity and mortality, additionally adding to public health issues of increased transmission of infectious diseases.3

The other side of the coin: being processed by a drug court and given the option of either incarceration or MAT. Being asked to consent to treatment with a mentally incapacitating illness brings in to question autonomy, and validity of consent. Informed consent, by definition, should be voluntary and free of coercion.6,7 It should be obtained from someone with capacity, or the ability to make a decision, after he/she has an understanding of the risks and benefits of all available options. Consent under the threat of incarceration, or while incapacitated, is not informed consent and compromises individual autonomy.6,7

Many individuals with OUD/SUD do choose Narcotics Anonymous, Peer Support, Drug-free toxification, or treatment modalities other than MAT.3 Assuming a binary disposition, MAT versus drug-free detoxification, is overly punitive and a violation of voluntariness and self-determination of these individuals.

Patients with SUD/OUD often contend with unfavorable correctional system interactions as well as SMI, and they predominantly consist of minorities from low income or educational backgrounds with limited social support. They are a vulnerable population that society has largely marginalized.2 Their rights are threatened, and they are being afforded subpar and borderline unethical care. The underlying reasons behind this unsettling phenomenon is a lack of health literacy around MAT and stigma associated with OUD in non-clinical settings.

An ethical framework is needed, as well as best practice guidelines highlighting the efficacy of and science behind MAT specifically directed at the correctional system. It is essential to address limitations in knowledge base and highlight shortcomings in protecting the rights of incarcerated individuals, in partnership with all stakeholders (eg, incarcerated patients, rights groups, judges, the correctional system, medical bodies).

Mr Kaleka is a 4th-year medical student at Central Michigan University College of Medicine, Saginaw, MI. Dr Perzhinsky is associate professor of medicine atCentral Michigan University College of Medicine.

References

1. Key Substance Use and Mental Health Indicators in the United States: Results From the 2018 National Survey on Drug Use and Health. (HHS Publication No. PEP19‑5068, NSDUH Series H‑54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2019. Accessed August 11, 2020. https://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2018-national-survey-on-Drug-Use-and-Health/PEP19-5068

2. Winkelman TN, Chang VW, Binswanger IA. Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use. JAMA Network Open. 2018;1(3).

3. Ludwig AS, Peters RH. Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review. Int J Drug Policy. 2014;25(6):1041-1046.

4. Matusow H, Dickman SL, Rich JD et al. Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes. J Subst Abuse Treat. 2013;44(5):473–480.

5. Substance Abuse and Mental Health Services Administration. Adult Drug Courts and Medication-Assisted Treatment for Opioid Dependence. In Brief. 2014;8(1). Accessed August 11, 2020. https://store.samhsa.gov/product/Adult-Drug-Courts-and-Medication-Assisted-Treatment-for-Opioid-Dependence/sma14-4852

6. D’Hotman D, Pugh, J, Douglas T. When is coercive methadone therapy justified? Bioethics. 2018;32(7):405–413.

7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York: Oxford University Press; 2019.