“Are ethical concerns impairing the treatment of opioid addicts with criminal history?” asked Charles O’Brien, M.D., Ph.D., at the International Neuroethics Society meeting’s opening panel on addiction neuroethics. O’Brien, a Dana Alliance member and a pioneer of addiction research, is working with the Philadelphia prison population, where 18 percent of parolees have an opioid addiction. To reduce reincarceration for these parolees, O’Brien supports the use of the drug naltrexone, FDA approved for alcohol addiction in 2006, and recently approved for opiates. It carries minimal side effects and no withdrawal symptoms, he said. By prescribing this drug to addicted parolees, “you’re guaranteeing they can’t become re-addicted,” stated O’Brien.
In a pilot study funded by the Dana Foundation, O’Brien tracked 111 randomized subjects. Results were positive–parolees on naltrexone were less likely to relapse and less likely to be reincarcerated. Only 8 percent tested positive for opiods in a urine test, versus 30 percent in the control group. Additionally, only 26 percent of those on naltrexone returned to prison, while 56 percent of the control group returned.
O’Brien’s argument is that naltrexone not only helps the individual to reenter society, but it also saves taxpayer money. In a 2011 Dana grantee interview with O’Brien he noted that “Prison costs between $40,000 and $60,000 yearly, per bed.” Not an insignificant sum.
So far, it’s seems like a win/win situation, so where do the ethical concerns weigh in? For O’Brien, resistance to forced medication is a primary concern. After his group received an NIH grant to further the parolee study, and the trial was approved by noted ethicists Arthur Caplan, Ph.D., (another Dana grantee) and Richard Bonnie, J.D., the NIH Study Section took issue with the way subjects were recruited. O’Brien was working with a parole officer to identify candidates for the study, but the Study Section felt that this could be viewed as coercion, since the officer is in a position of authority.
In response, O’Brien and his colleagues stopped working with the officer and recruited parolees on a volunteer basis. The study was approved and O’Brien now has close to 250 patients. Interim results have been positive, with 80 to 90 percent naltrexone retention among subjects after six months.
For O’Brien, and others at the INS meeting, arguments countering the ethical concerns over court-mandated medication were two-fold. The first is that legally sanctioned coercion already exists in prison. The specific example given was that of prescribed injections for sex offenders, to reduce testosterone levels. It was noted, though, that these inmates are usually willing participants.
The second argument in favor of court-prescribed medication was nicely stated by Steve Hyman, M.D., INS president and Dana Foundation board member: “With pharmacological treatments, we could return autonomy to individuals compromised by drug addiction.” Rita Goldstein, Ph.D. (part of the addiction panel), echoed this notion, saying that the question is not about coercion, but autonomy and choice; in the long-run, people on naltrexone or similar drugs will enjoy increased autonomy when their lives are no longer dictated by their addictions. She also pointed out that we already live in a restricted society where we’re required to do many things meant to make us more independent, such as attend school up to a certain age.
The addiction neuroethics panel really set the stage for a thought-provoking day of panel discussions and lively debate. Stay tuned for my report on the final INS panel of the meeting, “Brains in Dishes: Animats and Hybrots.”
The Dana Foundation is a supporter of the INS and has been since its inception.
-Ann L. Whitman