As physicians, we are bound by four ethical principles. Beneficence (acting for the benefit of the patient), nonmaleficence (avoiding the harm of the patient), autonomy (respecting patients’ right to make their own decisions), and justice (fair and equitable treatment of patients). When people think of the ethical principles that guide physicians, “First, do no harm” comes to mind.
Unfortunately, our medical system in the United States is violating all four of those principles by not routinely treating substance use disorders in the criminal justice system, particularly those patients with opioid use disorder, given the increased risk of fatal overdose with opioid use disorder compared to other substance use disorders. We, ethically, can no longer stand by and watch the unnecessary suffering and death of patients with substance use disorders in the criminal justice setting. It is time to change how we treat incarcerated patients with substance use. They deserve treatment for their substance use disorders. We will describe two clinical cases that are illustrative of how treatment for substance use disorders in patients in the criminal justice system must change.
Case 1. A 40-year-old male presented to the emergency department (ED) with a chief complaint of a “medication refill.” The patient had a history of opiate use disorder and methamphetamine use disorder. He was incarcerated in the prison system, where he was treated for his opiate use disorder with buprenorphine/naloxone. He, upon discharge from prison, was given a 30-day prescription for buprenorphine/naloxone. As he was due to run out of his prescription, he presented to the emergency department. He was seen in the Emergency Department, where he reported to the provider, “suboxone saved my life.” He had no desire to use opiates, and denied any symptoms of opiate withdrawal. The ED physician provided the patient with a short-term refill of his buprenorphine/naloxone and referred the patient to a local addiction treatment program. The patient, due to conflicts with his new job, was unable to schedule an appointment with the clinic, and had to return to the ED for a refill. However, once settled in his new job, the patient was able to follow up with the addiction medicine clinic and remains in treatment on buprenorphine/naloxone.
Case 2. A 29-year-old female presented to the emergency department with CPR in progress after an opioid overdose. The patient had a history of opiate use disorder. The patient was incarcerated in the jail system and was not treated with any medication. She was forced to endure opioid withdrawal without treatment. Upon release from jail, she – within a few hours of release – resumed the use of illicit fentanyl. Her family found her unresponsive and called 911. She was treated with naloxone, and CPR was initiated. She was brought to the ED, where she was resuscitated and admitted to the intensive care unit (ICU). Unfortunately, due to prolonged hypoxia during her overdose, she was ultimately determined to be brain dead due to anoxic brain injury. Care was withdrawn, and she died after she was able to be an organ donor.
In Case 1, the medical providers in the criminal justice system treating the patient observed all four of the ethical principles. They treated the patient for his opiate use disorder (beneficence). They prevented him from relapsing immediately after release and therefore potentially prevented an overdose (nonmaleficence). They respected his desire to stop using drugs and get treatment for his substance use disorder (autonomy). And they treated him for his substance use disorder despite his involvement in the criminal justice system (justice). In Case 2, the medical providers in the criminal justice system treating the patient violated all four of the ethical principles, and we now know the result – the patient’s untreated opiate use disorder led her to relapse and caused what ultimately turned out to be a fatal opioid overdose. Medical providers in the criminal justice setting can no longer be considered acceptable to deny patients with substance use disorders treatment.
Overdose deaths are killing Americans at an unprecedented rate. From April 2021 to April 2022, 108,174 Americans died from a drug overdose, with 81,692 of those deaths being from opioid overdose. It is painful to write those numbers while knowing that there are safe and effective treatments for opioid use disorder that can drastically reduce death from opioid use disorder. Buprenorphine, which is now able to be prescribed by all practitioners in the United States as of 2023, has been shown to reduce the mortality of opioid use disorder from overdose by 70 percent. That’s a number needed to treat – to save a life – of 1.4. And this has already been tested in other countries. In France, during an epidemic of illicit opioid use in the 1980s and 1990s, the widespread use of buprenorphine by physicians in France lead to a reduction in overdose deaths from opioids by 79 percent.
In summary, we have outlined how not treating patients with substance use disorders in the criminal justice setting is a violating of all four of the core ethical principles of medicine and causes direct patient harm. We have also outlined how buprenorphine is an effective treatment for opioid use disorder that is available, as of 2023, to all physicians in the United States. It’s time for the treatment of patients with substance use in the criminal justice system to become the standard of care. Ethically, we – as physicians – have no other choice.
Casey Grover and Reb Close are emergency physicians.
