International Journal of Drug Policy 25 (2014) 1041–1046
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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Commentary
Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review Ariel S. Ludwig a,∗ , Roger H. Peters b a b
Institute for the Medical Humanities, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA Department of Mental Health Law and Policy, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, USA
a r t i c l e
i n f o
Article history: Received 27 May 2014 Received in revised form 20 August 2014 Accepted 25 August 2014 Keywords: Prison Jail Ethics Medication-assisted treatment Opioid
a b s t r a c t Opioid use disorders are a pressing health concern that disproportionately impacts the United States (U.S.) correctional population. Medication-assisted treatment (MAT) is an evidence-based standard of care for opioid use disorders. Despite its availability in the community, MAT and MAT medications (buprenorphine and methadone) are largely unavailable and/or inaccessible for the treatment of opioid use disorders in U.S. prisons and jails. Given that the ethical principles have served as justification for limiting access to MAT on “moral” grounds, this article examines the implications of current correctional policies through the ethical principles of: (1) beneficence/non-maleficence; (2) distributive justice (equivalence-of-care); and (3) autonomy (informed consent). Special attention is paid to the five components of informed consent (capacity, disclosure, understanding, voluntariness, and access), as this facet has been used most often to justify policies that limit access to MAT in the past. Findings highlight that these core ethical principles support the adoption of correctional policies that include MAT. Furthermore, our findings demonstrate that autonomy is maximized during the informed consent process when MAT is available as a treatment option. © 2014 Elsevier B.V. All rights reserved.
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;
∗ Corresponding author. Tel.: +1 646 202 3232. E-mail addresses: [email protected], [email protected] (A.S. Ludwig). http://dx.doi.org/10.1016/j.drugpo.2014.08.015 0955-3959/© 2014 Elsevier B.V. All rights reserved.
(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, Fletcher, & Volkow, 2009; Knight, Dwayne, Chatham, & Camacho, 1997; Leukefeld & Tims, 1993; Van den Brink & Haasen, 2006). One of the most efficacious and well-established interventions, for both detoxification and treatment, is medication-assisted treatment (MAT; Gowing, Ali, & White, 2009; Mattick, Breen, Kimber, & Davoli, 2009; Mattick, Kimber, Breen, & Davoli, 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
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Table 1 Ethical principles established by the Belmont Report. I. Beneficence and non-maleficence – Beneficence and non-maleficence are often understood as different sides of the same coin. Beneficence refers to the obligation to benefit patients, whereas non-maleficence refers to the duty to prevent suffering and harma , b II. Distributive justice and equivalence-of-care – Distributive justice is the principle that protects equitable access to needed health resources.a , b It is this principle that gives rise to, and protects, equivalence-of-carec A. Equivalence-of-care – Equivalence-of-care refers to the obligation of correctional facilities to provide health care that meets the proven standard of care in the communityc , d III. Autonomy – Autonomy is defined as the freedom to act in accordance with one’s beliefs and values without undue internal or external coercione A. Informed consent – Informed consent in clinical settings is the legal and ethical process by which patients are provided with a robust understanding of their health status and treatment optionsf a
Cassell (2000). National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Bethesda, MD (1978). c Larney and Dolan (2008). d Niveau (2007). e Osman (2010). f Walker et al. (2005). b
(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 & 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 & 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/nonmaleficence, (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, Beauchamp, & King, 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.
Ethical principles to guide the use of MAT in correctional settings 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 particularly detrimental to vulnerable populations including pregnant inmates, inmates who are immuno-compromised (e.g., with HIV/AIDS), or who have other comorbid health conditions (e.g., diabetes, hepatitis; Goodman, Brunton, Chabner, & Knollmann, 2011). Second, studies have found that withholding medication assistance leads to an increase in unsafe injecting practices (e.g., sharing needles) in correctional settings (Magura et al., 2009). This presents a public health concern with significant ethical implications, as it increases the transmission risk of blood-borne pathogens such as HIV and hepatitis C. Additionally, inmates who receive MAT in the community, and who wish to continue treatment during their incarceration but are unable to do so, may experience withdrawal symptoms from therapeutic medications (Bruce & Schleifer, 2008). There is evidence that this abrupt discontinuation of MAT not only precipitates withdrawal symptoms, but also harms attitudes towards this treatment modality, raising further questions about non-maleficence (Zule & Desmond, 1998). Taken together, this suggests that having MAT available as a treatment option provides the most efficacious and compassionate treatment (beneficent), while reducing negative
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withdrawal symptoms and public health risks (non-maleficent) (Stallwitz & Stöver, 2007). Although some may argue that abstinence from such medications contributes to inmates’ beneficence as they are “drug-free”, the previously cited research indicates that it can be dangerous, and potentially life-threatening, to withhold available medications.
Distributive justice and equivalence-of-care Distributive justice is the ethical principle that protects equitable access to needed health resources (NCCHC, 1978; Cassell, 2000). It is this principle that gives rise to, and protects, equivalenceof-care (Larney & Dolan, 2009). Equivalence-of-care refers to the obligation of correctional facilities to provide health care that meets the proven standard of care in the community (Larney & Dolan, 2009; Niveau, 2007). In the 1976 Estelle v. Gamble case, the Supreme Court determined that equivalence-of-care is protected by the Eighth Amendment of the United States Constitution (Estelle v. Gamble, 1976; Posner, 1992). Gamble was a prisoner who experienced an occupational injury, and initiated a pro se lawsuit to address what he considered to be a failure to provide adequate and appropriate care. The U.S. Supreme Court found that the “deliberate indifference” to the serious medical needs of a prisoner constitutes “unnecessary and wanton infliction of pain”, which is proscribed by the Eighth Amendment (Estelle v. Gamble, 1976). The breadth of this ruling was expanded to pre-adjudication settings, such as jails, in which equivalence-ofcare is protected by the Fourteenth Amendment (Bell v. Wolfish, 1979). Although equivalence-of-care appears straightforward from an ethical and public health perspective, it becomes far more complicated when applied in correctional settings. For instance, persons often experience limited access to health care in the community prior to arrest and incarceration (Niveau, 2007). Using a literal interpretation of equivalence, inmates without access to care in the community would not be entitled to care during their incarceration (Niveau, 2007). In order to protect human rights, U.S. and international laws have established that inmates should not have differential access to quality health or mental health care based on their previous access to health care or incarceration status (Bruce & Schleifer, 2008; United Nations, 1990). This indicates that correctional facilities have an obligation to provide access to comprehensive, evidence-based care. Additionally, U.S. courts have consistently supported the duty to treat serious medical needs and to alleviate suffering, including withdrawal symptoms from drugs or alcohol (Boretti v. Wiscomb, 1991; Estelle v. Gamble, 1976; Greeno v. Daley, 2005; Schaub v. VonWald, 2011). This legal standard acknowledges that forced, abrupt withdrawal from opioids (e.g., prescribed methadone, heroin, prescription opioids) can lead to immense suffering, and places inmates at risk of victimization, self-incrimination and even death (Bruce & Schleifer, 2008). While correctional policies that exclude MAT may be wellintentioned, they may not meet the standards of equivalence-ofcare. For instance, if an individual were to seek treatment for an opioid use disorder in the community they would likely be given the option to receive MAT. Furthermore, when equivalence-of-care is viewed from a public health perspective, it implies an obligation for inmates to receive equal protection of their health (e.g. prevention of HIV or hepatitis C; Calzavara et al., 2003; Dolan, Hall, & Wodak, 1996; Dolan, Kite, Black, Aceijas, & Stimson, 2007). Additionally, by providing equivalent treatment, inmates can access a continuum of care that provides linkage to community MAT programs upon release. Ultimately, in order for equivalence-of-care to be honored, correctional facilities must have policies that support
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evidence-based treatment and prevention approaches available in the community, including MAT. 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 condition will deteriorate and hasten death, the patient retains the right to refuse treatment (Osman, 2010). The practical application of autonomy is reflected in the informed consent process, which is comprised of five primary domains: (a) capacity, (b) disclosure, (c) understanding, (d) voluntariness, and (e) access (Carter & Hall, 2008; Osman, 2010). Until the 1960s, it was common for physicians to make treatment decisions based on what they believed was in the best interest of their patients (Faden et al., 1986). This approach persisted for many years in the mental health, substance use, and correctional health fields (Faden et al., 1986). Today, informed consent is understood as an important strategy to maximize autonomy (Carter & Hall, 2008). This is reflected in the reconceptualization of informed consent in mental health and substance use disorder treatment from the rote signing of forms to a dynamic therapeutic process that builds rapport (Carter & Hall, 2008; Walker, Logan, Clark, & Leukefeld, 2005). The NCCHC recognized the importance of informed consent in correctional health care, especially given the inherent limitations of autonomy (e.g. freedom of movement, limited selection of providers; Birmingham et al., 2006). The NCCHC established standards that require general consent at the time of intake/admission, and additional consent prior to treatment that involves risk of adverse outcomes and/or requires informed consent in the community (NCCHC, 2008a, 2008b). In essence, here the NCCHC applied the principle of equivalence-of-care to the informed consent process. The primary ethics rationale for limiting access to correctional MAT has been the belief that inmates lack the autonomy to consent. For example, some have suggested that individuals with opioid use disorders inherently lack the autonomy to consent to MAT because they experience excessive coercion in the form of drug cravings (Caplan, 2006; Cohen, 2002; Elliott, 2002). The ability of inmates to consent to MAT will be examined further in the context of five components of informed consent, described in the following section (Table 2). Capacity Capacity is necessary for consent to substance use treatment, irrespective of the therapeutic approach (i.e., with or without medication assistance). However, the argument has been made that individuals with substance use disorders are unable to consent to MAT because their autonomy has been significantly diminished by their disorder (Caplan, 2006; Cohen, 2002; Elliott, 2002). As a corollary, some have asserted that it is ethically acceptable for correctional administrators to mandate substance use disorder treatment, as treatment must either be forced or cannot be provided at all (Caplan, 2006). These arguments are rooted in the “brain disease” model of substance use disorders (Dackis & O’Brien, 2005; Volkow & Li, 2004), which has perhaps led to decreased stigma and facilitated treatment engagement, but has been interpreted by some as meaning that patients who have substance use disorders neurologically lack decisional capacity (Caplan,
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Table 2 Five components of informed consent. (a) Capacity – Capacity is the prerequisite to informed consent, and is defined as the ability to make the required decisiona (b) Disclosure – Disclosure pertains to the responsibility of the provider to explain necessary information about reasonable treatment options so that an informed choice can be made. This includes risks, benefits, expected duration, alternatives, patient responsibilities, expected treatment outcomes, and availability of treatment after releasea (c) Understanding – Understanding pertains to ensuring comprehension of treatment options including the personal implications of those options.a This goes beyond simply listening, and implies an application of the information to self (d) Voluntariness – Voluntariness pertains to the ability to select a treatment free from undue internal or external coerciona (e) Access – Access is a more recent addition to conceptual models of informed consent, and pertains to equitable access to the full gamut of effective and appropriate treatment options. This facet also requires that the treatment options be sufficiently resourced in order to meet standards of careb a b
Osman (2010). Carter and Hall (2008).
2006; Cohen, 2002; Elliott, 2002). This neuro-essentialist approach has been termed the “addiction-as-compulsion” model, and suggests that there are cognitive circuitry changes that occur with addiction that either wholly eliminate or severely restrict resistance to their coercive compulsions (Buchman, Skinner, & Illes, 2010). Endorsement of the “brain disease” model has profound implications for capacity, as it relies on a categorical construct (having vs. lacking capacity), which may oversimplify the highly nuanced, variable, and multi-dimensional nature of substance use disorders (Buchman, Illes, & Reiner, 2011; Buchman et al., 2010). There is significant evidence that capacity waxes and wanes for individuals with these disorders, but is not wholly diminished (Buchman & Russell, 2009; Carter & Hall, 2008). For instance, capacity may be temporarily impaired while intoxicated or experiencing acute withdrawal symptoms. Alternatively, after prolonged drug use, there may be longer-lasting changes in the brain that may impact capacity (Rogers & Robbins, 2001). However, research indicates that most long-term users have attempted self-detoxification at least once for a variety of reasons, demonstrating their ability to make decisions contrary to the influences of their substance use disorders (Gossop, Battersby, & Strang, 1991; Neale, 2002; Noble, Best, Man, Gossop, & Strang, 2002; Watson, 1999). Additionally, in heroin trials in Switzerland only approximately 38% of individuals who had experienced treatment failure accepted a prescription for heroin (Perneger, Giner, del Rio, & Mino, 1998). Furthermore, this facet cannot be used to support “drug-free” treatment policies, as capacity is a prerequisite for all forms of treatment. In summary, using this component to justify limiting access to MAT relies on a false dichotomy by suggesting that treatment without the use of medication does not require the same degree of capacity. Disclosure Effective disclosure maximizes autonomy and can provide the ancillary benefit of actively engaging patients in the treatment process. Given that treatment providers must disclose treatment options, even ones that are not immediately available, this attribute of informed consent cannot be used to limit MAT. However, correctional health policies that prohibit MAT run the risk of inhibiting disclosure if providers, knowing they cannot provide MAT, do not explain the full array of recommended treatments. Given that inmates already face limitations in their health care options and level of health education, increasing both of these through the
process of disclosure can bolster inmate autonomy (Niveau, 2007; White, 2008). Understanding Although there has been little research addressing this concept in correctional settings, it can be surmised that when complete information and options (including MAT) are not disclosed, understanding cannot take place. Furthermore, in comparison to the general population, U.S. inmates have higher rates of intellectual disabilities, lower levels of educational attainment, and are more frequently burdened by mental health disorders (Fazel, Xenitidis, & Powell, 2008; Harlow, 2003; James & Glaze, 2006). While this facet of informed consent requires specialized approaches in correctional settings, the attendant obligations do not change based on the treatment modality (i.e. with or without medication). Voluntariness Voluntariness is the component of informed consent that has proved most contentious. Some neuroethicists have argued that individuals with substance use disorders cannot consent to treatment that relies on medications that act upon the same biological pathways as their drug(s) of choice (Caplan, 2006; Cohen, 2002; Elliott, 2002). This conceptualization has been termed the “addiction-as-compulsion” model and suggests that there are neurocognitive changes elicited by substance use that either wholly eliminate or severely restrict resistance to coercive compulsions (Levy, 2006). When applied to the correctional setting, this logic suggests that inmates would always accept MAT in order to obtain the “next best thing” (i.e. methadone or buprenorphine), as they have limited or no access to opioids (Magura et al., 2009; Nunn et al., 2009). This belief underpins current correctional policies limiting MAT, but is not borne out in reality (Friedmann et al., 2012). Indeed, many individuals with substance use disorders elect to participate in a variety of treatment modalities other than MAT, such as Narcotics Anonymous or other 12-step/peer support groups, or even decide to forego treatment, and cease drug use on their own (Neale, 2002; Watson, 1999). While substance use disorders influence coercion (e.g., physical/psychological compulsion to pursue the drug), its impact is nuanced and dynamic, waxing and waning over time (Buchman & Russell, 2009; Levy, 2006). Furthermore, inmates with opioid use disorders can face several forms of coercion specific to their incarceration. For example, in pre-adjudication settings there may be real or perceived legal coercion if a jail inmate believes that accepting treatment will influence the disposition of criminal charges (McCrady & Bux, 1999). Alternatively, an inmate may choose to pursue treatment in order to obtain secondary gain. Secondary gain refers to advantages obtained as a result of entering treatment, beyond direct therapeutic effects (Howe, Froom, Culpepper, & Mangone, 1977). For example, some facilities may create “therapeutic communities” or other residential units, which may provide ancillary benefits such as air conditioning or more desirable mealtimes. These benefits may seem minor, but can increase coercion. On the other hand, there has been concern that secondary gain related to opioid use disorders may lead to MAT medications being sold or traded (Kinlock, Battjes, & Schwartz, 2002; Magura, Rosenblum, & Joseph, 1992). While concerns about diversion of medications and related coercion are valid, these concerns can be allayed through planning and oversight that includes inventory and reporting procedures (CSAT, 2010; Travis & Sommers, 2004). Ultimately, despite some concern about potential coercion related to secondary gain, this outcome may be less harmful than eliminating an important treatment option for inmates. Special care should be
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taken to minimize coercion and maximize autonomy, especially for vulnerable populations such as inmates. Access One cannot freely select a treatment unless made aware of and given access to effective treatment options (Carter & Hall, 2008). This component directly addresses the ethical perils of correctional policies that preclude the use of MAT on “moral” grounds (Carter & Hall, 2008). Specifically, it establishes that the elimination of effective, quality options inherently impinges upon autonomy. In the correctional setting this has further implications, as access to care depends on incarceration status and the particular correctional facility. Similarly, when inmates are unable to access the medication-assisted treatments for which they were compliant in the community, their autonomy in making treatment decisions is clearly restricted. In summary, the ethics principle of autonomy and the related application of informed consent have been used as grounds for maintaining “drug-free” treatment policies in correctional settings. Although capacity and voluntariness have been used to limit access to MAT, a detailed review suggests a far more nuanced waxing and waning of capacity and coercion, indicating that inmates can make voluntary treatment decisions. Indeed, upon closer review, each of the components of informed consent provides sufficient and compelling evidence to suggest that limiting inmates’ access to MAT hinders informed consent, and therefore autonomy. 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 (DEA, 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 disorders and serves as the standard of care in the community, this treatment should also be available in correctional settings. Here we examined the core ethical principles that have been used to limit the availability of MAT in correctional settings. Findings indicate that access to MAT supports the principles of beneficence and non-maleficence, as it is an effective and compassionate treatment. Furthermore an examination of distributive justice, and specifically equivalence-of-care principles suggests that correctional facilities need to implement policies and practices that provide access to care that meets community standards. Given that MAT is the standard of care in the community, there is a clear need to make it available in correctional facilities. Moreover, the application of equivalence-of-care would facilitate a continuum of services that promote improved treatment outcomes across correctional and community-based settings. Lastly, an examination of autonomy and informed consent reveals that inmates with substance use disorders possess the ability to make autonomous decisions and consent to MAT. Although capacity and voluntariness (components of informed consent) have been used to justify limiting access to MAT, a closer review demonstrates support for this modality in correctional settings. Furthermore, while there is concern about coercion arising from secondary gain (e.g., privileges related to placement in specialized treatment programs, diversion of medication), these concerns can be mitigated by the implementation of careful monitoring and oversight. Thus, when considering these ethical principles holistically, it is clear that each supports the use of MAT in correctional settings.
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Although there is considerable ethical support for correctional MAT, there is a great need for further research in this area. First, there is limited information regarding existing informed consent practices in correctional substance use disorder treatment. Second, there has been little examination of inmate autonomy, and while there is evidence that inmate autonomy is not wholly diminished (as suggested by advocates for the “medication-free” approach), the level of autonomy and ability to engage in informed consent may be dependent on other factors. Further research is needed to identify effective tools to assess inmate autonomy and ability to consent, and could prove useful in other institutional treatment settings (e.g., civil and forensic hospitals). Additionally, it would be beneficial to examine if there is perceived coercion related to inmates’ decisions to engage in MAT. Similarly, further research is needed to develop guidelines for improving inmates’ understanding of different aspects of health care, including treatment for substance use disorders. It may also be useful to gauge correctional health care providers’ awareness and perceptions of the unique obligations and potential for conflicting aims arising from health care and public health ethics, as they relate to substance use disorder treatment. Finally, the ethical principles should play an important role in guiding the development of a correctional health care system. An examination of an operational ethical framework that reflects the ethical principles described here would prove useful in guiding policies and improving care. To achieve this, staff training might incorporate the use of vignettes to highlight ethical dilemmas that arise in providing correctional MAT. Training curricula and workshops developed by national correctional organizations (e.g., American Correctional Association, American Jail Association, National Institute of Corrections) would also reinforce these principles. On-line training modules may be a cost-effective way to accomplish these goals. Existing practice guidelines and standards developed by national health care agencies (e.g. National Collaborating Centre for Mental Health and the American Psychiatric Association) could be expanded to incorporate these ethical principles, and to encourage the use of MAT. Additionally, correctional health care policies and procedures could directly refer to the ethical principles that support the use of MAT. Such interventions have the potential to greatly improve access to MAT and related treatment services, as well as the quality of health care provided in correctional institutions.
Conflict of interest statement The authors declare that there is no conflict of interest.
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Commentary
Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review Ariel S. Ludwig a,∗ , Roger H. Peters b a b
Institute for the Medical Humanities, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA Department of Mental Health Law and Policy, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, USA
a r t i c l e
i n f o
Article history: Received 27 May 2014 Received in revised form 20 August 2014 Accepted 25 August 2014 Keywords: Prison Jail Ethics Medication-assisted treatment Opioid
a b s t r a c t Opioid use disorders are a pressing health concern that disproportionately impacts the United States (U.S.) correctional population. Medication-assisted treatment (MAT) is an evidence-based standard of care for opioid use disorders. Despite its availability in the community, MAT and MAT medications (buprenorphine and methadone) are largely unavailable and/or inaccessible for the treatment of opioid use disorders in U.S. prisons and jails. Given that the ethical principles have served as justification for limiting access to MAT on “moral” grounds, this article examines the implications of current correctional policies through the ethical principles of: (1) beneficence/non-maleficence; (2) distributive justice (equivalence-of-care); and (3) autonomy (informed consent). Special attention is paid to the five components of informed consent (capacity, disclosure, understanding, voluntariness, and access), as this facet has been used most often to justify policies that limit access to MAT in the past. Findings highlight that these core ethical principles support the adoption of correctional policies that include MAT. Furthermore, our findings demonstrate that autonomy is maximized during the informed consent process when MAT is available as a treatment option. © 2014 Elsevier B.V. All rights reserved.
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;
∗ Corresponding author. Tel.: +1 646 202 3232. E-mail addresses: [email protected], [email protected] (A.S. Ludwig). http://dx.doi.org/10.1016/j.drugpo.2014.08.015 0955-3959/© 2014 Elsevier B.V. All rights reserved.
(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, Fletcher, & Volkow, 2009; Knight, Dwayne, Chatham, & Camacho, 1997; Leukefeld & Tims, 1993; Van den Brink & Haasen, 2006). One of the most efficacious and well-established interventions, for both detoxification and treatment, is medication-assisted treatment (MAT; Gowing, Ali, & White, 2009; Mattick, Breen, Kimber, & Davoli, 2009; Mattick, Kimber, Breen, & Davoli, 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
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Table 1 Ethical principles established by the Belmont Report. I. Beneficence and non-maleficence – Beneficence and non-maleficence are often understood as different sides of the same coin. Beneficence refers to the obligation to benefit patients, whereas non-maleficence refers to the duty to prevent suffering and harma , b II. Distributive justice and equivalence-of-care – Distributive justice is the principle that protects equitable access to needed health resources.a , b It is this principle that gives rise to, and protects, equivalence-of-carec A. Equivalence-of-care – Equivalence-of-care refers to the obligation of correctional facilities to provide health care that meets the proven standard of care in the communityc , d III. Autonomy – Autonomy is defined as the freedom to act in accordance with one’s beliefs and values without undue internal or external coercione A. Informed consent – Informed consent in clinical settings is the legal and ethical process by which patients are provided with a robust understanding of their health status and treatment optionsf a
Cassell (2000). National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Bethesda, MD (1978). c Larney and Dolan (2008). d Niveau (2007). e Osman (2010). f Walker et al. (2005). b
(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 & 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 & 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/nonmaleficence, (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, Beauchamp, & King, 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.
Ethical principles to guide the use of MAT in correctional settings 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 particularly detrimental to vulnerable populations including pregnant inmates, inmates who are immuno-compromised (e.g., with HIV/AIDS), or who have other comorbid health conditions (e.g., diabetes, hepatitis; Goodman, Brunton, Chabner, & Knollmann, 2011). Second, studies have found that withholding medication assistance leads to an increase in unsafe injecting practices (e.g., sharing needles) in correctional settings (Magura et al., 2009). This presents a public health concern with significant ethical implications, as it increases the transmission risk of blood-borne pathogens such as HIV and hepatitis C. Additionally, inmates who receive MAT in the community, and who wish to continue treatment during their incarceration but are unable to do so, may experience withdrawal symptoms from therapeutic medications (Bruce & Schleifer, 2008). There is evidence that this abrupt discontinuation of MAT not only precipitates withdrawal symptoms, but also harms attitudes towards this treatment modality, raising further questions about non-maleficence (Zule & Desmond, 1998). Taken together, this suggests that having MAT available as a treatment option provides the most efficacious and compassionate treatment (beneficent), while reducing negative
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withdrawal symptoms and public health risks (non-maleficent) (Stallwitz & Stöver, 2007). Although some may argue that abstinence from such medications contributes to inmates’ beneficence as they are “drug-free”, the previously cited research indicates that it can be dangerous, and potentially life-threatening, to withhold available medications.
Distributive justice and equivalence-of-care Distributive justice is the ethical principle that protects equitable access to needed health resources (NCCHC, 1978; Cassell, 2000). It is this principle that gives rise to, and protects, equivalenceof-care (Larney & Dolan, 2009). Equivalence-of-care refers to the obligation of correctional facilities to provide health care that meets the proven standard of care in the community (Larney & Dolan, 2009; Niveau, 2007). In the 1976 Estelle v. Gamble case, the Supreme Court determined that equivalence-of-care is protected by the Eighth Amendment of the United States Constitution (Estelle v. Gamble, 1976; Posner, 1992). Gamble was a prisoner who experienced an occupational injury, and initiated a pro se lawsuit to address what he considered to be a failure to provide adequate and appropriate care. The U.S. Supreme Court found that the “deliberate indifference” to the serious medical needs of a prisoner constitutes “unnecessary and wanton infliction of pain”, which is proscribed by the Eighth Amendment (Estelle v. Gamble, 1976). The breadth of this ruling was expanded to pre-adjudication settings, such as jails, in which equivalence-ofcare is protected by the Fourteenth Amendment (Bell v. Wolfish, 1979). Although equivalence-of-care appears straightforward from an ethical and public health perspective, it becomes far more complicated when applied in correctional settings. For instance, persons often experience limited access to health care in the community prior to arrest and incarceration (Niveau, 2007). Using a literal interpretation of equivalence, inmates without access to care in the community would not be entitled to care during their incarceration (Niveau, 2007). In order to protect human rights, U.S. and international laws have established that inmates should not have differential access to quality health or mental health care based on their previous access to health care or incarceration status (Bruce & Schleifer, 2008; United Nations, 1990). This indicates that correctional facilities have an obligation to provide access to comprehensive, evidence-based care. Additionally, U.S. courts have consistently supported the duty to treat serious medical needs and to alleviate suffering, including withdrawal symptoms from drugs or alcohol (Boretti v. Wiscomb, 1991; Estelle v. Gamble, 1976; Greeno v. Daley, 2005; Schaub v. VonWald, 2011). This legal standard acknowledges that forced, abrupt withdrawal from opioids (e.g., prescribed methadone, heroin, prescription opioids) can lead to immense suffering, and places inmates at risk of victimization, self-incrimination and even death (Bruce & Schleifer, 2008). While correctional policies that exclude MAT may be wellintentioned, they may not meet the standards of equivalence-ofcare. For instance, if an individual were to seek treatment for an opioid use disorder in the community they would likely be given the option to receive MAT. Furthermore, when equivalence-of-care is viewed from a public health perspective, it implies an obligation for inmates to receive equal protection of their health (e.g. prevention of HIV or hepatitis C; Calzavara et al., 2003; Dolan, Hall, & Wodak, 1996; Dolan, Kite, Black, Aceijas, & Stimson, 2007). Additionally, by providing equivalent treatment, inmates can access a continuum of care that provides linkage to community MAT programs upon release. Ultimately, in order for equivalence-of-care to be honored, correctional facilities must have policies that support
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evidence-based treatment and prevention approaches available in the community, including MAT. 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 condition will deteriorate and hasten death, the patient retains the right to refuse treatment (Osman, 2010). The practical application of autonomy is reflected in the informed consent process, which is comprised of five primary domains: (a) capacity, (b) disclosure, (c) understanding, (d) voluntariness, and (e) access (Carter & Hall, 2008; Osman, 2010). Until the 1960s, it was common for physicians to make treatment decisions based on what they believed was in the best interest of their patients (Faden et al., 1986). This approach persisted for many years in the mental health, substance use, and correctional health fields (Faden et al., 1986). Today, informed consent is understood as an important strategy to maximize autonomy (Carter & Hall, 2008). This is reflected in the reconceptualization of informed consent in mental health and substance use disorder treatment from the rote signing of forms to a dynamic therapeutic process that builds rapport (Carter & Hall, 2008; Walker, Logan, Clark, & Leukefeld, 2005). The NCCHC recognized the importance of informed consent in correctional health care, especially given the inherent limitations of autonomy (e.g. freedom of movement, limited selection of providers; Birmingham et al., 2006). The NCCHC established standards that require general consent at the time of intake/admission, and additional consent prior to treatment that involves risk of adverse outcomes and/or requires informed consent in the community (NCCHC, 2008a, 2008b). In essence, here the NCCHC applied the principle of equivalence-of-care to the informed consent process. The primary ethics rationale for limiting access to correctional MAT has been the belief that inmates lack the autonomy to consent. For example, some have suggested that individuals with opioid use disorders inherently lack the autonomy to consent to MAT because they experience excessive coercion in the form of drug cravings (Caplan, 2006; Cohen, 2002; Elliott, 2002). The ability of inmates to consent to MAT will be examined further in the context of five components of informed consent, described in the following section (Table 2). Capacity Capacity is necessary for consent to substance use treatment, irrespective of the therapeutic approach (i.e., with or without medication assistance). However, the argument has been made that individuals with substance use disorders are unable to consent to MAT because their autonomy has been significantly diminished by their disorder (Caplan, 2006; Cohen, 2002; Elliott, 2002). As a corollary, some have asserted that it is ethically acceptable for correctional administrators to mandate substance use disorder treatment, as treatment must either be forced or cannot be provided at all (Caplan, 2006). These arguments are rooted in the “brain disease” model of substance use disorders (Dackis & O’Brien, 2005; Volkow & Li, 2004), which has perhaps led to decreased stigma and facilitated treatment engagement, but has been interpreted by some as meaning that patients who have substance use disorders neurologically lack decisional capacity (Caplan,
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Table 2 Five components of informed consent. (a) Capacity – Capacity is the prerequisite to informed consent, and is defined as the ability to make the required decisiona (b) Disclosure – Disclosure pertains to the responsibility of the provider to explain necessary information about reasonable treatment options so that an informed choice can be made. This includes risks, benefits, expected duration, alternatives, patient responsibilities, expected treatment outcomes, and availability of treatment after releasea (c) Understanding – Understanding pertains to ensuring comprehension of treatment options including the personal implications of those options.a This goes beyond simply listening, and implies an application of the information to self (d) Voluntariness – Voluntariness pertains to the ability to select a treatment free from undue internal or external coerciona (e) Access – Access is a more recent addition to conceptual models of informed consent, and pertains to equitable access to the full gamut of effective and appropriate treatment options. This facet also requires that the treatment options be sufficiently resourced in order to meet standards of careb a b
Osman (2010). Carter and Hall (2008).
2006; Cohen, 2002; Elliott, 2002). This neuro-essentialist approach has been termed the “addiction-as-compulsion” model, and suggests that there are cognitive circuitry changes that occur with addiction that either wholly eliminate or severely restrict resistance to their coercive compulsions (Buchman, Skinner, & Illes, 2010). Endorsement of the “brain disease” model has profound implications for capacity, as it relies on a categorical construct (having vs. lacking capacity), which may oversimplify the highly nuanced, variable, and multi-dimensional nature of substance use disorders (Buchman, Illes, & Reiner, 2011; Buchman et al., 2010). There is significant evidence that capacity waxes and wanes for individuals with these disorders, but is not wholly diminished (Buchman & Russell, 2009; Carter & Hall, 2008). For instance, capacity may be temporarily impaired while intoxicated or experiencing acute withdrawal symptoms. Alternatively, after prolonged drug use, there may be longer-lasting changes in the brain that may impact capacity (Rogers & Robbins, 2001). However, research indicates that most long-term users have attempted self-detoxification at least once for a variety of reasons, demonstrating their ability to make decisions contrary to the influences of their substance use disorders (Gossop, Battersby, & Strang, 1991; Neale, 2002; Noble, Best, Man, Gossop, & Strang, 2002; Watson, 1999). Additionally, in heroin trials in Switzerland only approximately 38% of individuals who had experienced treatment failure accepted a prescription for heroin (Perneger, Giner, del Rio, & Mino, 1998). Furthermore, this facet cannot be used to support “drug-free” treatment policies, as capacity is a prerequisite for all forms of treatment. In summary, using this component to justify limiting access to MAT relies on a false dichotomy by suggesting that treatment without the use of medication does not require the same degree of capacity. Disclosure Effective disclosure maximizes autonomy and can provide the ancillary benefit of actively engaging patients in the treatment process. Given that treatment providers must disclose treatment options, even ones that are not immediately available, this attribute of informed consent cannot be used to limit MAT. However, correctional health policies that prohibit MAT run the risk of inhibiting disclosure if providers, knowing they cannot provide MAT, do not explain the full array of recommended treatments. Given that inmates already face limitations in their health care options and level of health education, increasing both of these through the
process of disclosure can bolster inmate autonomy (Niveau, 2007; White, 2008). Understanding Although there has been little research addressing this concept in correctional settings, it can be surmised that when complete information and options (including MAT) are not disclosed, understanding cannot take place. Furthermore, in comparison to the general population, U.S. inmates have higher rates of intellectual disabilities, lower levels of educational attainment, and are more frequently burdened by mental health disorders (Fazel, Xenitidis, & Powell, 2008; Harlow, 2003; James & Glaze, 2006). While this facet of informed consent requires specialized approaches in correctional settings, the attendant obligations do not change based on the treatment modality (i.e. with or without medication). Voluntariness Voluntariness is the component of informed consent that has proved most contentious. Some neuroethicists have argued that individuals with substance use disorders cannot consent to treatment that relies on medications that act upon the same biological pathways as their drug(s) of choice (Caplan, 2006; Cohen, 2002; Elliott, 2002). This conceptualization has been termed the “addiction-as-compulsion” model and suggests that there are neurocognitive changes elicited by substance use that either wholly eliminate or severely restrict resistance to coercive compulsions (Levy, 2006). When applied to the correctional setting, this logic suggests that inmates would always accept MAT in order to obtain the “next best thing” (i.e. methadone or buprenorphine), as they have limited or no access to opioids (Magura et al., 2009; Nunn et al., 2009). This belief underpins current correctional policies limiting MAT, but is not borne out in reality (Friedmann et al., 2012). Indeed, many individuals with substance use disorders elect to participate in a variety of treatment modalities other than MAT, such as Narcotics Anonymous or other 12-step/peer support groups, or even decide to forego treatment, and cease drug use on their own (Neale, 2002; Watson, 1999). While substance use disorders influence coercion (e.g., physical/psychological compulsion to pursue the drug), its impact is nuanced and dynamic, waxing and waning over time (Buchman & Russell, 2009; Levy, 2006). Furthermore, inmates with opioid use disorders can face several forms of coercion specific to their incarceration. For example, in pre-adjudication settings there may be real or perceived legal coercion if a jail inmate believes that accepting treatment will influence the disposition of criminal charges (McCrady & Bux, 1999). Alternatively, an inmate may choose to pursue treatment in order to obtain secondary gain. Secondary gain refers to advantages obtained as a result of entering treatment, beyond direct therapeutic effects (Howe, Froom, Culpepper, & Mangone, 1977). For example, some facilities may create “therapeutic communities” or other residential units, which may provide ancillary benefits such as air conditioning or more desirable mealtimes. These benefits may seem minor, but can increase coercion. On the other hand, there has been concern that secondary gain related to opioid use disorders may lead to MAT medications being sold or traded (Kinlock, Battjes, & Schwartz, 2002; Magura, Rosenblum, & Joseph, 1992). While concerns about diversion of medications and related coercion are valid, these concerns can be allayed through planning and oversight that includes inventory and reporting procedures (CSAT, 2010; Travis & Sommers, 2004). Ultimately, despite some concern about potential coercion related to secondary gain, this outcome may be less harmful than eliminating an important treatment option for inmates. Special care should be
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taken to minimize coercion and maximize autonomy, especially for vulnerable populations such as inmates. Access One cannot freely select a treatment unless made aware of and given access to effective treatment options (Carter & Hall, 2008). This component directly addresses the ethical perils of correctional policies that preclude the use of MAT on “moral” grounds (Carter & Hall, 2008). Specifically, it establishes that the elimination of effective, quality options inherently impinges upon autonomy. In the correctional setting this has further implications, as access to care depends on incarceration status and the particular correctional facility. Similarly, when inmates are unable to access the medication-assisted treatments for which they were compliant in the community, their autonomy in making treatment decisions is clearly restricted. In summary, the ethics principle of autonomy and the related application of informed consent have been used as grounds for maintaining “drug-free” treatment policies in correctional settings. Although capacity and voluntariness have been used to limit access to MAT, a detailed review suggests a far more nuanced waxing and waning of capacity and coercion, indicating that inmates can make voluntary treatment decisions. Indeed, upon closer review, each of the components of informed consent provides sufficient and compelling evidence to suggest that limiting inmates’ access to MAT hinders informed consent, and therefore autonomy. 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 (DEA, 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 disorders and serves as the standard of care in the community, this treatment should also be available in correctional settings. Here we examined the core ethical principles that have been used to limit the availability of MAT in correctional settings. Findings indicate that access to MAT supports the principles of beneficence and non-maleficence, as it is an effective and compassionate treatment. Furthermore an examination of distributive justice, and specifically equivalence-of-care principles suggests that correctional facilities need to implement policies and practices that provide access to care that meets community standards. Given that MAT is the standard of care in the community, there is a clear need to make it available in correctional facilities. Moreover, the application of equivalence-of-care would facilitate a continuum of services that promote improved treatment outcomes across correctional and community-based settings. Lastly, an examination of autonomy and informed consent reveals that inmates with substance use disorders possess the ability to make autonomous decisions and consent to MAT. Although capacity and voluntariness (components of informed consent) have been used to justify limiting access to MAT, a closer review demonstrates support for this modality in correctional settings. Furthermore, while there is concern about coercion arising from secondary gain (e.g., privileges related to placement in specialized treatment programs, diversion of medication), these concerns can be mitigated by the implementation of careful monitoring and oversight. Thus, when considering these ethical principles holistically, it is clear that each supports the use of MAT in correctional settings.
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Although there is considerable ethical support for correctional MAT, there is a great need for further research in this area. First, there is limited information regarding existing informed consent practices in correctional substance use disorder treatment. Second, there has been little examination of inmate autonomy, and while there is evidence that inmate autonomy is not wholly diminished (as suggested by advocates for the “medication-free” approach), the level of autonomy and ability to engage in informed consent may be dependent on other factors. Further research is needed to identify effective tools to assess inmate autonomy and ability to consent, and could prove useful in other institutional treatment settings (e.g., civil and forensic hospitals). Additionally, it would be beneficial to examine if there is perceived coercion related to inmates’ decisions to engage in MAT. Similarly, further research is needed to develop guidelines for improving inmates’ understanding of different aspects of health care, including treatment for substance use disorders. It may also be useful to gauge correctional health care providers’ awareness and perceptions of the unique obligations and potential for conflicting aims arising from health care and public health ethics, as they relate to substance use disorder treatment. Finally, the ethical principles should play an important role in guiding the development of a correctional health care system. An examination of an operational ethical framework that reflects the ethical principles described here would prove useful in guiding policies and improving care. To achieve this, staff training might incorporate the use of vignettes to highlight ethical dilemmas that arise in providing correctional MAT. Training curricula and workshops developed by national correctional organizations (e.g., American Correctional Association, American Jail Association, National Institute of Corrections) would also reinforce these principles. On-line training modules may be a cost-effective way to accomplish these goals. Existing practice guidelines and standards developed by national health care agencies (e.g. National Collaborating Centre for Mental Health and the American Psychiatric Association) could be expanded to incorporate these ethical principles, and to encourage the use of MAT. Additionally, correctional health care policies and procedures could directly refer to the ethical principles that support the use of MAT. Such interventions have the potential to greatly improve access to MAT and related treatment services, as well as the quality of health care provided in correctional institutions.
Conflict of interest statement The authors declare that there is no conflict of interest.
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