There’s no question that opioid use disorder (OUD) is extremely common in incarcerated people. And yet, this group rarely receives medication treatment for OUD (MOUD).
Moreover:
- Each year, about one-third of people who have a heroin addiction are incarcerated
- This pool—this target population, easy to access—presents an opportunity to help many people who need it
- Methadone, buprenorphine, and naltrexone are effective, FDA-approved treatments, and are widely used to treat OUD in the community
- And yet—fewer than one percent of U.S. jails and prisons provide MOUD regularly
- Clearly, the situation is inherently unfair—especially in the eyes of those who have a good grasp of opioid addiction and its treatment, along with a strong ethical sense
And that brings us to the source of the data cited above: an article recently published in Substance Abuse: “An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated.” The paper’s three authors are affiliated with Montefiore Medical Center in New York, an institution whose population has strong ethical leanings. The Center describes itself as a national leader in its efforts to deliver state-of-the-art medical care to a vulnerable population. The paper’s lead author is Emma R. Brezel, MBE (Master of Bioethics); the second author, Tia Powell, MD, is Director of the Montefiore Einstein Center for Bioethics.
So, Why Are Incarcerated People Being Denied MOUD?
The authors pull no punches. They say the relative lack of MOUD in jails and prisons “reveals how competing concerns are prioritized over providing evidence-based medical treatment.” They list as among those who may be responsible: stakeholders who influence accessibility: “policymakers including legislators, judges, and correctional medical directors; and policy enforcers such as institutional medical staff and correctional officers,” whose priorities are dictated by different goals, responsibilities, and expertise. The authors recommend closely examining the ethicality of severely limiting the availability of the medications.
Part I of the published article asks why MOUD is rarely offered; Part II looks at the ethicality of the answers to Part I.
Part I: Factors Limiting Availability of MOUD
Stigma. Stigma appears to be the source of many—possibly most—of the problems discussed here.
Stigma can block the acceptance of MOUD. It can paint people with OUD as bad, or as morally compromised, so they face discrimination. And it can lead to the denial of basic rights, such as employment and housing.
Conditions that feed stigma. Using stigmatizing language and seeing addiction as “a willful choice or moral failing” feed stigma. Methadone and buprenorphine can have euphoric effects in people who lack physical tolerance to opioids, and some critics see this as a reason to delegitimize these medications, calling their use “trading one addiction for another”—a phrase all too familiar—and distressing—to those in the field.
Additional factors limiting accessibility of MOUD. The authors also cite uncertainty about MOUD’s effectiveness in incarcerated people, concerns about the risks of diversion, insufficient staff to ensure safety, concerns about overdose risks, lack of medications, problems associated with transporting patients, and opposition to MOUD on the part of administrators. Some requests for MOUD are turned down because people with OUD are deemed unable to provide informed consent—and yet, physicians can obtain the right to treat such patients, even if the patients refuse treatment.
Part II: The Ethical Imperative to Provide MOUD in Jails and Prisons
Looking at one of the themes of the Montefiore Medical Center: “Our actions are the result of a deep belief in fairness to those we serve”—it’s easy to understand the authors’ impatience with the current situation.
Montefiore Einstein Center for BioethicsThe Montefiore Einstein Center for Bioethics addresses value-laden issues at the interface of medicine, law and public policy and focuses on issues most likely to improve patient care, human subjects’ research, and health policy. We draw together expertise that promotes reasoned analysis of ethical issues in health care, both at the level of the individual patient and clinician, and at the level of society as a whole. |
In making their case—which they call “the ethical imperative”—the authors draw upon the four pillars of bioethics. The four are listed below, along with the obligation associated with each pillar. Definitions have been drawn from the article and several other sources.
The Four Pillars of Bioethics
|
The authors underscore the urgent need to provide MOUD in jails and prisons.
- The obligations to act in patients’ best interest and to do no harm extend to those who are incarcerated
- People who are incarcerated “have the right to evidence-based medical care for OUD”
- Jails and prisons are government institutions; as such, they and their employees are obligated to provide evidence-based treatment
In addressing public health concerns, clearly a major consideration at Montefiore, the authors make several points. Government agencies have an ethical responsibility “to create and enforce policies that aim to protect and promote public health.” Because treatment reduces crime and the use of health care resources, reaching people who are incarcerated would be cost effective. And the public-health benefits are obvious.
MOUD reduces all-cause mortality and the incidence of fatal overdoses post-release; if barriers stand in their way, jails and prisons must address those barriers.
Conclusions
“Common justifications for restricted use of MOUD in jails and prisons violate widely accepted ethical principles. . . . Strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of health risks, security, costs, and feasibility.”
In closing, the authors make such a strong case for reform: “One of the great tragedies of the current opioid overdose crisis is that the most effective tools to reduce overdose, including MOUD, have not been rapidly deployed in the United States. Improving access to MOUD in jails and prisons is ethically imperative.“
Reference
Brezel ER, Powell T, Fox AD. An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated. Subst Abus. 2019; Dec 4:1-5. doi: 10.1080/08897077.2019.1695706.
There’s no question that opioid use disorder (OUD) is extremely common in incarcerated people. And yet, this group rarely receives medication treatment for OUD (MOUD).
Moreover:
- Each year, about one-third of people who have a heroin addiction are incarcerated
- This pool—this target population, easy to access—presents an opportunity to help many people who need it
- Methadone, buprenorphine, and naltrexone are effective, FDA-approved treatments, and are widely used to treat OUD in the community
- And yet—fewer than one percent of U.S. jails and prisons provide MOUD regularly
- Clearly, the situation is inherently unfair—especially in the eyes of those who have a good grasp of opioid addiction and its treatment, along with a strong ethical sense
And that brings us to the source of the data cited above: an article recently published in Substance Abuse: “An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated.” The paper’s three authors are affiliated with Montefiore Medical Center in New York, an institution whose population has strong ethical leanings. The Center describes itself as a national leader in its efforts to deliver state-of-the-art medical care to a vulnerable population. The paper’s lead author is Emma R. Brezel, MBE (Master of Bioethics); the second author, Tia Powell, MD, is Director of the Montefiore Einstein Center for Bioethics.
So, Why Are Incarcerated People Being Denied MOUD?
The authors pull no punches. They say the relative lack of MOUD in jails and prisons “reveals how competing concerns are prioritized over providing evidence-based medical treatment.” They list as among those who may be responsible: stakeholders who influence accessibility: “policymakers including legislators, judges, and correctional medical directors; and policy enforcers such as institutional medical staff and correctional officers,” whose priorities are dictated by different goals, responsibilities, and expertise. The authors recommend closely examining the ethicality of severely limiting the availability of the medications.
Part I of the published article asks why MOUD is rarely offered; Part II looks at the ethicality of the answers to Part I.
Part I: Factors Limiting Availability of MOUD
Stigma. Stigma appears to be the source of many—possibly most—of the problems discussed here.
Stigma can block the acceptance of MOUD. It can paint people with OUD as bad, or as morally compromised, so they face discrimination. And it can lead to the denial of basic rights, such as employment and housing.
Conditions that feed stigma. Using stigmatizing language and seeing addiction as “a willful choice or moral failing” feed stigma. Methadone and buprenorphine can have euphoric effects in people who lack physical tolerance to opioids, and some critics see this as a reason to delegitimize these medications, calling their use “trading one addiction for another”—a phrase all too familiar—and distressing—to those in the field.
Additional factors limiting accessibility of MOUD. The authors also cite uncertainty about MOUD’s effectiveness in incarcerated people, concerns about the risks of diversion, insufficient staff to ensure safety, concerns about overdose risks, lack of medications, problems associated with transporting patients, and opposition to MOUD on the part of administrators. Some requests for MOUD are turned down because people with OUD are deemed unable to provide informed consent—and yet, physicians can obtain the right to treat such patients, even if the patients refuse treatment.
Part II: The Ethical Imperative to Provide MOUD in Jails and Prisons
Looking at one of the themes of the Montefiore Medical Center: “Our actions are the result of a deep belief in fairness to those we serve”—it’s easy to understand the authors’ impatience with the current situation.
Montefiore Einstein Center for BioethicsThe Montefiore Einstein Center for Bioethics addresses value-laden issues at the interface of medicine, law and public policy and focuses on issues most likely to improve patient care, human subjects’ research, and health policy. We draw together expertise that promotes reasoned analysis of ethical issues in health care, both at the level of the individual patient and clinician, and at the level of society as a whole. |
In making their case—which they call “the ethical imperative”—the authors draw upon the four pillars of bioethics. The four are listed below, along with the obligation associated with each pillar. Definitions have been drawn from the article and several other sources.
The Four Pillars of Bioethics
|
The authors underscore the urgent need to provide MOUD in jails and prisons.
- The obligations to act in patients’ best interest and to do no harm extend to those who are incarcerated
- People who are incarcerated “have the right to evidence-based medical care for OUD”
- Jails and prisons are government institutions; as such, they and their employees are obligated to provide evidence-based treatment
In addressing public health concerns, clearly a major consideration at Montefiore, the authors make several points. Government agencies have an ethical responsibility “to create and enforce policies that aim to protect and promote public health.” Because treatment reduces crime and the use of health care resources, reaching people who are incarcerated would be cost effective. And the public-health benefits are obvious.
MOUD reduces all-cause mortality and the incidence of fatal overdoses post-release; if barriers stand in their way, jails and prisons must address those barriers.
Conclusions
“Common justifications for restricted use of MOUD in jails and prisons violate widely accepted ethical principles. . . . Strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of health risks, security, costs, and feasibility.”
In closing, the authors make such a strong case for reform: “One of the great tragedies of the current opioid overdose crisis is that the most effective tools to reduce overdose, including MOUD, have not been rapidly deployed in the United States. Improving access to MOUD in jails and prisons is ethically imperative.“
Reference
Brezel ER, Powell T, Fox AD. An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated. Subst Abus. 2019; Dec 4:1-5. doi: 10.1080/08897077.2019.1695706.
