Ethical and human rights imperatives to ensure medication-assisted treatment for opioid dependence in prisons and pre-trial detention

Abstract

Opioid dependence is a complex medical condition affecting neurocognitive and physical functioning. Forced or abrupt opioid withdrawal may cause profound physical and psychological suffering, including nausea, vomiting, diarrhoea, extreme agitation and/or anxiety. Opioid-dependent individuals are especially vulnerable at the time of arrest or initial detention, when they may, as a result of their chemical dependency, be coerced into providing incriminating testimony, or be driven to engage in risky behaviour (such as sharing needles in detention) in order to avoid painful withdrawal symptoms. Upon incarceration, many opioid-dependent prisoners are forced to undergo abrupt opioid withdrawal (both from legally prescribed agonist therapy such as methadone as well as illicit opioids). Physical and psychological symptoms attendant to withdrawal may impair capacity to make informed legal decisions, and cause prisoners to risk HIV and other blood-borne diseases by sharing injection equipment. Although prisons must provide at least the standard of care to prisoners that is available in the general population, medication-assisted treatment, endorsed by international health and drug agencies as an integral part of HIV prevention and care strategies for opioid-dependent drug users, is unavailable to most prisoners. Medication-assisted treatment is a well-studied and validated pharmacological therapy for the medical condition known as opioid dependence. The failure to ensure prisoner access to this medical therapy threatens fundamental human rights protections against cruel, inhuman or degrading treatment and rights to health and to life. It also poses serious ethical problems for health care providers, violating basic principles of beneficence and non-maleficence (i.e., do good/do no harm). Governments must take immediate action to ensure access to opioid substitution to prisoners to ensure fulfilment of ethical and human rights obligations.

“I Kicked the Hard Way. I Got Incarcerated.” Withdrawal from Methadone During Incarceration and Subsequent Aversion to Medication Assisted Treatments

“…Participants in our study also reported insomnia lasting for months and suicidal ideation. Similar findings were reported in another study, which suggested that “the trauma of imprisonment, coupled with severe opioid withdrawal, can also increase the risk of suicide in opioid dependent individuals with co-occurring disorders” (Bruce & Schleifer, 2008). Withdrawal symptoms, such as severe diarrhea and vomiting, could contribute to spread of infectious diseases (Mitchell et al,2009).…”

Within-prison drug injection among HIV-infected Ukrainian prisoners: Prevalence and correlates of an extremely high-risk behaviour

“…Despite international guidelines recommending its provision, evidence-based treatment for opioid dependence, including opioid substitution therapy (OST) using methadone or buprenorphine, is only rarely available in prisons (Bruce & Schleifer, 2008). OST serves two key purposes, distinct but closely related.…”

Public Health and the Epidemic of Incarceration

“…Incarceration contributes more to adverse outcomes related to addiction and mental illness than to the transmission of infectious diseases. Although methadone is widely used to treat opioid addictions, few correctional facilities are willing to initiate or continue that treatment for inmates already on methadone upon entry (16, 34, 54, 60, 62, 70, 92), leaving the addicted subject to withdrawal during incarceration and more vulnerable to overdose upon release. Those with behavioral issues are more vulnerable to placement in “supermax” facilities, an environment particularly hazardous to the mentally ill (36, 69).…”