An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated

Abstract

Opioid use disorder (OUD) is highly prevalent among persons who are incarcerated. Medication treatment for opioid use disorder (MOUD), methadone, buprenorphine, and naltrexone, is widely used to treat OUD in the community. Despite MOUD’s well-documented effectiveness in improving health and social outcomes, its use in American jails and prisons is limited.

Several factors are used to justify limited access to MOUD in jails and prisons including: “uncertainty” of MOUD’s effectiveness during incarceration, security concerns, risk of overdose from MOUD, lack of resources and institutional infrastructure, and the inability of people with OUD to provide informed consent. Stigma regarding MOUD also likely plays a role. While these factors are relevant to the creation and implementation of addiction treatment policies in incarcerated settings, their ethicality remains underexplored.

Using ethical principles of beneficence/non-maleficence, justice, and autonomy, in addition to public health ethics, we evaluate the ethicality of the above list of factors. There is a two-fold ethical imperative to provide MOUD in jails and prisons. Firstly, persons who are incarcerated have the right to evidence-based medical care for OUD. Secondly, because jails and prisons are government institutions, they have an obligation to provide that evidence-based treatment. Additionally, jails and prisons must address the systematic barriers that prevent them from fulfilling that responsibility. According to widely accepted ethical principles, strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of security, cost, and feasibility. We conclude that making MOUD inaccessible in jails and prisons is ethically impermissible.     

Ethical issues in research on the treatment of adolescent substance abuse disorders

Treatment research on adolescent substance use disorders raises a number of important ethical and legal concerns which have not been widely acknowledged. This paper explores these concerns as they relate to fundamental ethical principles in the conduct of human research. The issues discussed include tensions between conflicting regulations governing informed consent for research and treatment of adolescents, the capacity of adolescents to give informed consent, potentially coercive elements related to research on substance use treatment, problems associated with confidentiality and release of information, research vulnerability associated with substance use, and ethical implications of distinctions between effectiveness and efficacy research. Suggestions for ways investigators may address these concerns are provided.     

Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives

The U.S. is experiencing an alarming opioid epidemic, and although American Indians and Alaska Natives (AI/ANs) are especially hard hit, there is a paucity of opioid-related treatment research with these communities. AI/ANs are second only to Whites in the U.S. for overdose mortality. Thus, the National Institute on Drug Abuse convened a meeting of key stakeholders to elicit feedback on the acceptability and uptake of medication assisted treatment (MAT) for opioid use disorders (OUDs) among AI/ANs. Five themes from this one-day meeting emerged: 1) the mismatch between Western secular and reductionistic medicine and the AI/AN holistic healing tradition; 2) the need to integrate MAT into AI/AN traditional healing; 3) the conflict between standardized MAT delivery and the traditional AI/AN desire for healing to include being medicine free; 4) systemic barriers; and 5) the need to improve research with AI/ANs using culturally relevant methods. Discussion is organized around key implementation strategies informed by these themes and necessary for the successful adoption of MAT in AI/AN communities: 1) type of medication; 2) educational interventions; 3) coordination of care; and 4) adjunctive psychosocial counseling. Using a community-based participatory research approach is consistent with a “two eyed seeing” approach that integrates Western and Indigenous worldviews. Such an approach is needed to develop impactful research in collaboration with AI/AN communities to address OUD health disparities.     

Intent to Refer: Exploring Bias Toward Specific Medication-Assisted Treatments by Community Corrections Employees

Background: As opioid use increases in the United States, especially in the correctional population, the most effective treatment approaches need to be utilized. Research has shown that medication-assisted treatment (MAT) provides better outcomes than traditional treatment approaches alone, but is underutilized among correctional-supervised populations. Objective: This article looks at how previously identified barriers to implementing MAT can create potential biases regarding the intent to refer individuals to either buprenorphine or methadone among treatment and correctional staff within community corrections. The varying advantages of each medication are discussed to highlight the importance of individualized treatment planning. Methods: Data were collected from 959 treatment specialists and community-corrections officers between 2010 and 2013. The participants were employed by one of 20 community corrections agencies that were selected and randomized within a cluster design. The data were part of a larger study that tested how the experimental condition of organizational linkages impacted the use of MAT in the criminal justice system. In order to analyze the data, multinomial logistic regression was used. Results: Results showed that some community corrections employees were likely to refer clients to use methadone, but not buprenorphine (or vice versa) which was influenced by work setting, level of education, training, and negative perceptions of MAT as a substitute addiction. However, these biases could be minimized by proper training. Conclusion: These findings suggest that proper training should be mandatory for these employees and include information about various MATs while also addressing the negative perception that MAT is a substitute addiction.     

Outcomes from the International Survey Informing Greater Insights in Opioid Dependence Treatment (INSIGHT) project

Aims: The International Survey Informing Greater Insights in Opioid Dependence Treatment (INSIGHT) study evaluated the implementation of opioid dependence treatment across different countries to assess treatment delivery, quality of care and outcomes. Methods: A questionnaire-based survey was used to gather data in nine countries across Central and Eastern Europe, South Africa and South-East Asia, from patients with opioid dependence receiving medication-assisted treatment (MAT), healthcare professionals (HCPs) who cared for opioid-dependent patients and opioid users not receiving MAT. Findings: There was substantial variation between countries, but overall results suggest that several aspects of MAT can be improved, such as access to treatment (conditions to start or remain in treatment), quality of care (availability/awareness of treatment options and appropriate medication dosing) and treatment outcomes (on-top use, misuse and diversion). Conclusions: This analysis highlights key priorities that should improve the quality of opioid dependence care and access to treatment. These priorities include: acknowledging opioid dependence as a chronic medical condition requiring long-term treatment; recognition by policymakers of the cost-effectiveness of treatment; making available, to those who want them, psychosocial interventions and educating HCPs to prescribe the safest, least divertible forms of medications available at optimal doses in order to reduce opioid use, misuse and diversion.     

“One guy goes to jail,two people are ready to take his spot”: Perspectives on drug-induced homicide laws among incarcerated individuals

BackgroundAs overdose deaths have increased in the United States, some lawmakers have explored punitive, “supply-side” interventions aimed at reducing the supply of fentanyl. While a rationale of seeking to protect people who use drugs is often given to justify harsh sentences for fentanyl distribution, there is no research to our knowledge on perceptions of the effect of drug-induced homicide laws among people who use drugs.MethodsWe conducted semi-structured, qualitative interviews with 40 people with opioid use disorder (OUD) who were enrolled in a medication for addiction treatment (MAT) program in a unified jail and prison system in Rhode Island on attitudes surrounding increased sentences for distribution of fentanyl, including recently enacted drug-induced homicide laws. Codes were developed using a generalized, inductive method and interviews analyzed in NVivo 12 after being coded by two coders.ResultsMost participants stated that drug-induced homicide laws would not be an effective strategy to stem the overdose crisis. We identified key themes, including discussions surrounding the autonomy of people who use drugs, widespread fentanyl prevalence as a barrier to implementation of drug-induced homicide laws, discussions of mass incarceration as ineffective for addressing substance use disorders, feelings that further criminalization could lead to violence, criminalization as a justification for interpersonal loss, and intention as meaningful to categorizing an act as homicide.ConclusionsFindings highlight the importance of centering the experiences of people with OUD in creating policies surrounding the overdose epidemic, potential unintended health consequences of drug-induced homicides laws such as deterrence from calling 911 and increased violence, and how drug-induced homicide laws may undermine advances made in expanding access to OUD treatment for people who are criminal justice-involved.     

Ethical issues in schizophrenia: considerations for treatment and research

Clinicians who treat patients with schizophrenia may encounter a variety of ethical issues related to both psychiatric and medical treatment of patients. While informed consent is a crucial aspect of the care of all patients, it may present special challenges for patients with schizophrenia. Schizophrenia is a severe mental illness that is frequently accompanied by neuropsychological deficits. These impairments, as well as psychotic symptoms and lack of insight, can affect patients' abilities to make fully informed decisions about their own care. Ensuring that consent for treatment is informed, voluntary, and competent can thus become a more difficult endeavor. The ethical principles underlying treatment of these patients, however, are the same as those guiding treatment of all patients. Informed consent, as an embodiment of these ethical principles, represents the expression of individual rights in both clinical and research contexts. Attention to the process of informed consent as an ongoing dialogue strengthens the clinician-patient relationship, improves adherence, and helps the patient clarify options, values, and preferences. In the research setting, psychiatric researchers are increasingly concerned with maximizing the abilities of individuals with severe mental illnesses such as schizophrenia to provide meaningful informed consent for protocols. This review addresses decision-making abilities of people with schizophrenia in both treatment and research contexts.     

“You are not clean until you're not on anything”: Perceptions of medication-assisted treatment in rural Appalachia

BackgroundMedication-assisted treatment (MAT) is an evidence-based strategy to treat opioid use disorder (OUD). However, MAT-related stigma reduces MAT uptake, which is particularly low in rural areas. To date, perceptions and attitudes towards MAT in rural settings have not been described.ObjectiveThis qualitative study aims to characterize perceptions and attitudes towards MAT and the environmental factors contributing to these views in Appalachian Ohio.MethodsFrom February to July 2018, semi-structured interviews were conducted with 34 stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement agents and judicial officials, and 3 members of relevant organizations) in three rural counties in Appalachian Ohio. Interviews were transcribed, coded, and analyzed to characterize the risk environment and participants’ perceptions and attitudes towards MAT.ResultsParticipants expressed or described pervasive MAT-related stigma in the region. Participants consistently described three elements of the environment affecting stigma: (1) a “conservative” culture in which abstinence is necessary to be in recovery successfully, (2) fear of medication diversion and abuse, and (3) drug court policies that keep MAT out of the criminal justice system.ConclusionMAT-related stigma will need to be addressed to tackle the opioid epidemic through evidence-based treatment effectively.     

Ethics in clinical research: the Indian perspective

Ethics in clinical research focuses largely on identifying and implementing the acceptable conditions for exposure of some individuals to risks and burdens for the benefit of society at large. Ethical guidelines for clinical research were formulated only after discovery of inhumane behaviour with participants during research experiments. The Nuremberg Code was the first international code laying ethical principles for clinical research. With increasing research all over, World Health Organization formulated guidelines in the form of Declaration of Helsinki in 1964. The US laid down its guidelines for ethical principles in the Belmont Report after discovery of the Tuskegee's Syphilis study. The Indian Council of Medical Research has laid down the 'Ethical Guidelines for Biomedical Research on Human Subjects' in the year 2000 which were revised in 2006. It gives twelve general principles to be followed by all biomedical researchers working in the country. The Ethics Committee stands as the bridge between the researcher and the ethical guidelines of the country. The basic responsibility of the Ethics Committee is to ensure an independent, competent and timely review of all ethical aspects of the project proposals received in order to safeguard the dignity, rights, safety and well-being of all actual or potential research participants. A well-documented informed consent process is the hallmark of any ethical research work. Informed consent respects individual's autonomy, to participate or not to participate in research. Concepts of vulnerable populations, therapeutic misconception and post trial access hold special importance in ethical conduct of research, especially in developing countries like India, where most of the research participants are uneducated and economically backward.     

Heroin refusal self-efficacy and preference for medication-assisted treatment after inpatient detoxification

ObjectiveAn individual's self-efficacy to refuse using heroin in high-risk situations is believed to minimize the likelihood for relapse. However, among individuals completing inpatient heroin detoxification, perceived refusal self-efficacy may also reduce one's perceived need for medication-assisted treatment (MAT), an effective and recommended treatment for opioid use disorder. In the current study, we examined the relationship between heroin refusal self-efficacy and preference for MAT following inpatient detoxification.MethodParticipants (N = 397) were interviewed at the start of brief inpatient opioid detoxification. Multiple logistic regression was used to estimate the adjusted association of background characteristics, depressed mood, and perceived heroin refusal self-efficacy with preference for MAT.ResultsControlling for other covariates, depressed mood and lower perceived refusal self-efficacy were associated with a significantly greater likelihood of expressing preference for MAT (versus no MAT).ConclusionsPerceived ability to refuse heroin after leaving detox is inversely associated with a heroin user's desire for MAT. An effective continuum of care model may benefit from greater attention to patient's perceived refusal self-efficacy during detoxification which may impact preference for MAT and long-term recovery.     

An open future? The principle of autonomy within medical ‘codes of conduct’ versus the heteronomy effects of predictive medicine

Traditionally, the average code of conduct within Western health care starts from the autonomy of the patient. In addition, medicine today is ‘evidence based’ and the patient is an ‘informed consent’. Yet, the individual autonomy of the patient in health care is not simply enhancing today. Quite a few fundamental changes have and are currently at work within health care, which I will summarize here with the paradigm of predictive medicine. One of the characteristics of this paradigm is the increase of medical consults which are not autonomously chosen by an individual. For reasons of public health and diminishing of health risks or for reasons of prevention, on one hand we are dealing with ethical codes centered around the autonomy of patients and the face-to-face relations with health care workers, on the other, we are dealing with a society that takes an increasingly greater medical initiatives. Therefore, the question arises if predictive medicine confronts us with the limits of an ethical code as we know it today. Is there not an urgent need for a political code of conduct in health care?     

Patterns of buprenorphine use and risk for re-arrest among highly vulnerable opioid-involved women released from jails in rural Appalachia

Aims: Opioid use is common among correctional populations, yet few inmates receive treatment during incarceration or post-release, particularly in rural areas. This article examines associations of buprenorphine use, licit and illicit, health services use, and risk for re-arrest within 3 months of jail release among rural opioid-involved women.

Methods: Women were randomly selected from three rural Appalachian jails. Those with moderate to severe opioid-involvement on the NM-ASSIST, and data on patterns of buprenorphine use (N?=?188), were included in this analysis. Logistic regression analyses examined predictors of re-arrest within 3 months of release.

Results: Median age was 32, all were White. At follow-up, 39 (22.7%) had been rearrested; 9 (5.2%) reported receiving MAT, all with buprenorphine. Significant risk factors for re-arrest included: number of days high, injection use, number of illicit buprenorphine days, and withdrawal symptoms in the follow-up period. The sole protective factor was having a regular source of healthcare at follow-up.

Conclusions: Rural opioid-involved women released from jail are highly vulnerable to re-arrest, and lack access to supportive care systems for substance treatment. Innovations to integrate MAT into reentry to improve access is recommended.     

Ethical issues in the conduct of longitudinal studies of addiction treatment

Many complex ethical issues arise in the day-to-day conduct of longitudinal studies of addiction treatment. These issues are rooted, in part, in the sustained and potentially ambiguous relationship between research staff and study participants, the frequently changing clinical and legal status of study participants, the assertive methods required to generate high follow-up rates, and the numerous systems of care and control in which participants are involved. To identify common ethical issues that arise in such studies, the authors conducted individual and group interviews with seasoned members (case trackers, field trackers, interviewers, and supervisors) of the research team. The ethical dilemmas identified through these interviews fell into seven broad arenas: (1) informed consent for research participation, (2) confidentiality and information disclosure, (3) relationship boundaries between study participants and research staff, (4) duty to warn/report responsibilities, (5) questions of autonomy and privacy, (6) issues related to compensation for research participation, and (7) data integrity. Case studies that illustrate common ethical dilemmas within each of these seven areas are presented and discussed. Ethical dilemmas in the study of addiction treatment can be effectively managed via ethically informed research protocols, staff training in ethical decision-making, monitoring and supervision, and collective debriefing of critical events.