Friday, February 09, 2007

ETHICAL ISSUES SURROUNDING COERCED TREATMENT” OF OPIOID-ADDICTED INDIVIDUALS WITH IMPLANTED NALTREXONE

The following letter was emailed to the well-known and widely respected medical ethicist Dr. Arthur Caplan of the University of Pennsylvania. Dr. Caplan has been invited to respond – and assured that if he does so his response will be posted on this blog with no edits. To date he has not accepted this offer to have the last word.

EMAILED TO DR. CAPLAN ON 17 JANUARY 2007

Dear Dr. Caplan:

Regarding your recent article endorsing coercion of opiate dependent persons to accept naltrexone implants in lieu of incarceration (“Ethical issues surrounding forced, mandated, or coerced treatment,” J Subst Ab Treat, 31:117-120, 2006):

You state at the outset that it is your goal to suggest “a way in which self-determination may not conflict so strongly with the compulsory use of drugs for prisoners.” I believe it is not appropriate for ethicists to help researchers and clinicians climb what you describe as “a very steep ethical hill” by suggesting rationalizations to overcome “… the emphasis that has been placed in American bioethics on the values of personal autonomy and respect for patient self-determination.”

A number of aspects of the proposal to implant “depot naltrexone” through coercion applied by the Criminal Justice System (CJS) are of particular concern:

1. It seeks to force individuals to accept treatment for the explicit reason that it has such limited attraction on a voluntary basis.
2. It would employ a medication whose efficacy is unimpressive, to say the least, even for the limited number of patients who accept it without coercion (and thus, presumably, have some genuine motivation).
3. It would utilize a “delivery system” – implantation of a drug whose pharmacological action persists for months – for the specific purpose of rendering patients incapable of opting out, regardless of the subjective response(s) they may have to the medication.
4. It relies heavily on the CJS (parole and probation officers, and perhaps also judges and prosecutors) to decide who is “sick” and thus qualifies for and needs “treatment” – and this pharmacological treatment in particular. Not only do the criminal justice gatekeepers lack the qualifications needed to make such clinical decisions, the interests they are sworn to represent are first and foremost those of the general society, and not the “patients” (or “subjects”).
5. There is an inherent illogic in this as in all forms of coercion involving the “choice of prison vs treatment.” When clinicians and the care they provide are unsuccessful, it is the subject who pays the price! Ironically, evidence of drug use per se, which merely confirms the existence of the clinical condition being “treated,” is generally what triggers the process leading to incarceration or reincarceration.

Regarding some of the key assumptions underlying your conclusions, you are simply misinformed. Your concept of drug dependent persons being individuals “in the throes of addiction and who [therefore] cannot choose anything . . .” is wrong, as is the implication of the rhetorical question you pose, “Can drug addicted individuals be autonomous when they are addicted . . .?” First, drug dependent people do make decisions all the time – including decisions without legal duress to seek and accept a broad spectrum of treatment services. In fact, lack of treatment availability is probably a far greater deterrent to delivery of care than lack of motivation or decision-making capability on the part of drug users. Furthermore, whatever constraints on autonomy addiction imposes, they are not eliminated by a period of abstinence, whether enforced or voluntary. “Addiction” and the clinical challenge of craving are as much a reality after six months of abstinence (with or without naltrexone) as when an individual is on the streets shooting up with heroin several times a day. Ironically, the undisputed fact is that naltrexone, whatever its degree of efficacy, has no effect whatsoever on the critical phenomenon of craving.

I will not comment on your views concerning methadone, which you contrast with naltrexone by stating, “Breaking the back of addiction is a better moral choice than maintaining addiction at a lower cost,” and your contention that “many [supporters of opiate maintenance] believe that it is better to use substitute drugs that are not as expensive as heroin . . .” I respectfully suggest, however, that you review with some objective experts in the field your perception of addiction treatment that includes the medication methadone.

And finally, an observation concerning one of the premises of your paper - that forcing treatment on people against their will is defensible because it allows them to make choices following “adaptation to the new state of affairs.” Such thinking would allow one to ignore almost any decisions made by patients. Thus, the adamant refusal to have amputation of a gangrenous limb could be overruled with the rationalization that the patient should have the surgery and then be “allowed to adapt” to a prosthesis, with the option of suicide available if adaptation is unsuccessful.

Sincerely,
Robert Newman, MD, MPH

7 Comments:

At 2:31 AM, Anonymous Heroin Rehab said...

I agree with the points you raised about moral freedom and judgment. I believe that heroin addiction or substance abuse is not a disease but a condition that impairs drug dependents with their ability to resist use of the illicit substance. However, drug addicts in heorin rehab don't deserve to be treated like guinea pigs in heroin rehab but should be encouraged to make the right decisions for themselves. Medications only provide half of the success in heorin rehab. I beleive more in self-empowerment. I wish you could enlighten more people with your blog posts on this topic.
-may

 
At 2:07 PM, Anonymous Anonymous said...

I'd just like to say that I've known a couple of people who have been on naltrexone implants after undergoing UROD, who found the experience so distressing that they literally cut the implant out with a razor blade.

Not much chance of doing that if the implant is court mandated - or if you do, you're going to jail.

 
At 10:45 PM, Anonymous W. Farid said...

Dr Newman,

Your email to Dr Caplan may not have received a response for a number of reasons. Perhaps it was never read because it went into Dr Caplan's junkmail box, or perhaps he inadvertently deleted it, or perhaps he read it and felt he didn't have to justify himself to you. Afterall, what consequences would ensue? You have put your email on a blog-site, but then again, anyone can post their ideas on a blog. If you think your response has merit, shouldn't you submit it to J Subst Ab Treat for publication as a letter response? This may even entice Dr Caplan to respond. Of course, you would need to appropriately justify your statements.

I believe the following statement warrants elaboration:

"It would utilize a "delivery system” – implantation of a drug whose pharmacological action persists for months – for the specific purpose of rendering patients incapable of opting out, regardless of the subjective response(s) they may have to the medication"

I also would advise you to exercise caution in making the following statement:

"It would employ a medication whose efficacy is unimpressive, to say the least, even for the limited number of patients who accept it without coercion (and thus, presumably, have some genuine motivation)."

The efficacy of sustained-release naltrexone appears to relate to it's duration of action, and other factors, such as the implementation of appropriate psychosocial treatment in the recovery program. Accordingly, some clinics report impressive rates of opioid abstinence. Thorough empirical studies are warranted, and are currently being undertaken.

Finally, I do agree with your overall ethical objection to forced/coerced treatment with naltrexone. In addition, there are significant safety concerns with non-compliant patients who attempt to override the implant with high opiate doses.

W. Farid

 
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At 11:38 PM, Anonymous Anonymous said...

Hi I have just read your piece on forced treatment and have a scenario I want to take through the courts that involves a subject secretly transfered onto bup after 16 years of reasonably successful methadone treatment by a team of vigilantes in a remote australian outpost.
The subject become both physically and mentally ill, severely physically ill in fact and could not work out why her methadone treatment had ceased to have any effect.
What followed was 3 years of illness that never really resolved, post traumatic stress syndrome type effects including flashbacks, and a strong desire to take this scenario through the court system.
I was wondering, whether your ethical reading has led you to any precedents along these lines?
I have worked in the sector and have not come across a scenario like this before, but Im sure there are precedents.
You can reach me on jendoe@live.com.au

Thanks and all the best.

Jen Robertson

 

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