Archive for the ‘Government Behaving Badly’ Category

Judges Behaving Badly

aaaaaaaaaaaaStepping Stone memo from Judge Ginn (2)

 

Methadone and buprenorphine treatment for opioid use disorders saves lives. Over five decades, we’ve accumulated more studies to support this treatment than any other medication, device, or intervention that I can think of. And yet, opioid use disorder appears to be the only disease where medically untrained people dictate medical treatment. The above memo from a judge of the 24th District Court in North Carolina illustrates this all too well.

Let’s change that sentence in the middle of Judge Ginn’s memo: “Therefore, effective immediately, the use of insulin as a treatment for diabetes will no longer be allowed as a part of any probationary sentence in the 24th Judicial District.”

It wouldn’t make any sense, would it? People would wonder why a judge was involved in a patient’s medical care. They might even be tempted to believe a judge had no authority to dictate medical care.

I worked in Boone, North Carolina, when this memo was issued, and it caused a great deal of suffering for patients. These patients, contrary to the judge’s beliefs, were doing well on medication-assisted treatments. They were no longer injecting drugs or committing crimes to support their active addiction. Their involvement with criminal justice system almost always pre-dated their entry into treatment. Yet the judge proclaimed they must stop the very medications that were helping them become productive members of society again!

I wrote letters of advocacy and information, citing studies that support MAT. I encouraged patients, and told them to expect their lawyer to advocate for them on this issue. The patients said their lawyers often advised them just to do what would make the judge happy. Patients, understandably, were timid about pushing against a judge with so much power over their lives.

Ironically, many of the people Judge Ginn thought were doing well in his court were also our patients. It was widely known that probation officers’ drug tests didn’t detect methadone or buprenorphine at that time. Unless the offender told the truth about being in treatment on buprenorphine or methadone, the court never knew. I’d estimate that dozens of people successfully passed through Judge Ginn’s court while being treated with buprenorphine or methadone, without him ever knowing about it, due to inadequate drug testing. The people who told the truth were penalized by being told to quit life-saving medication.

I know Judge Ginn is now retired, but I suspect attitudes and beliefs of the judiciary in that area haven’t changed much.

One of the opioid treatment programs in the area tried to advocate for their patients, by seeking some sort of censure against Judge Ginn, but I don’t know what came from that.

The National Institute on Drug Abuse (NIDA) and Substance Abuse and Mental Health Services Administration (SAMHSA) both strongly recommend expanding opioid addiction treatment with medications to criminal justice participants. Congress just passed a bill that recommends spending money to treat opioid addiction in jails and prisons That bill pushes for people with opioid use disorder to get treatment instead of jail sentences. Experts everywhere advocate for expanding medication-assisted treatments to patients involved with the legal system, whether in jail, on parole, or on probation.

All of these actions are great. But Judge Ginn is an example of the many obstacles to implementation of the evidence-based treatments that experts recommend. Particularly in rural Appalachian areas, people in positions of power actively thwart life-saving medical treatments.

I don’t understand how judges can get away with such irresponsible actions. To me, it appears Judge Ginn practiced medicine without a license. If I somehow lost my medical license but continued to practice, I’d be committing a felony.

What if Judge Ginn commanded a patient stop buprenorphine or methadone, and the patient died in a relapse? Would Judge Ginn have any liability, civil or criminal?

I don’t know what can be done about judges like him, but don’t they have to answer to someone? Are they appointed, or elected? If elected, perhaps we need to start understanding judges’ positions on medical treatments before we vote for them.

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Inmate Dies From Withdrawal, FBI will investigate

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An interesting article from this week’s issue of Alcoholism & Drug Abuse Weekly caught my eye today. On page 4 is the article, “Video of jail drug-withdrawal death leads to FBI inquiry.” This seized my attention, since I view the awful treatment of U.S. prisoners as one of our nation’s biggest moral failings. I get particularly agitated when patients enrolled in medication-assisted treatment for addiction are denied access to medical care.

This story is heart-wrenching.

In June of 2014, David Stojcevski , 32 years old, was jailed in the Macomb County, Michigan, jail for thirty days for failure to pay a traffic ticket. He was denied access to his usual medications; news sources said he was being prescribed methadone, Klonopin, and Xanax for the treatment of addiction. No mention was made of whether he was a patient of an opioid treatment program.

David died seventeen days into his thirty day sentence. His autopsy listed the cause of death as “Acute withdrawal from chronic benzodiazepine, methadone, and opiate medication,” and also mentioned seizures and dehydration as contributing factors.

A jail nurse, noting his medical condition upon intake to the jail, recommended he be sent to a medical detox unit, but her recommendations were not heeded. Instead, when Mr. Stojcevski began behaving in unusual ways, he was sent to a mental health cell, where he was monitored with video around the clock. He was supposed to have personnel checking on him every fifteen minutes. Apparently his withdrawal symptoms were so severe he declined meals and lost 50 pounds within these eleven days. He had what appear to be seizures as he lay on the jail floor dying.

Understandably, David’s family was livid. In order to illustrate the jail’s indifference to their son’s suffering, they posted all 240 hours of the video monitoring on the internet, where it went viral. David’s family is seeking to change the way prisoners on medications are treated, to avoid senseless deaths like David’s. They have also filed a wrongful death lawsuit against the county and against Correct Care Solutions, the company which was supposed to have provided medical care to prisoners in the county jail.

I have often heard my patients describe the callous indifference jailers have toward them as they withdrawal from legally prescribed medication, but it’s quite another thing to actually watch this man die slowly. I only saw a few clips from the local news program above, and was horrified. It does not take any medical knowledge to see how this man was suffering. He became thinner, wasn’t eating, and didn’t get off the jail floor for the last two days of his life. At the very end, he has some agonal respirations, what looks to me like seizure activity, and then becomes still.

Then jail personnel crowd into his cell.

Too little, too late. He’s already dead and can’t be revived.

Some of the frames were televised on the area’s local news segment and can be seen here: http://www.clickondetroit.com/news/man-jailed-for-ticket-dies-in-custody/35452790
Be warned this segment is not for the faint of heart.

This man died from a treatable condition, opioid and benzodiazepine withdrawal.

An addiction expert interviewed by the area’s local television statement called the treatment of this man “unconscionable.”

I could quibble about the appropriateness of prescribing two benzodiazepines to a person with addiction in the first place, but since that’s not the point of this blog post, that’s all I’ll say about that.

Just yesterday, local TV news said the ACLU had filed a request for a formal Justice Department investigation of the Macomb County jail, saying prisoners are having their civil rights violated by the actions at the jail. The ACLU has also asked for an investigation into the judge’s decision to imprison David after he was unable to pay his traffic ticket, creating what was in essence a “debtor’s prison.”

A representative of the ACLU said anyone watching the video could deduce there was “Something systemically wrong at the Macomb County Jail.”

Recently, the Justice Department in Washington, D.C. contacted the FBI, asking them to investigate this case for evidence of criminal behavior on the part of Macomb County jail staff.

Macomb County officials steadfastly maintain they did nothing wrong, have nothing to hide, and welcome investigations into David Stojcevski’s death.

What I saw on this video clip appears criminal to me. The neglect, the reckless disregard for the wellbeing of another human is a far more serious crime than David’s traffic ticket. Every person who worked in that jail who turned a blind eye to the dying man belongs on the other side of the bars.

I am grateful to David’s family for their decision to post this painful video. That had to be a hard decision, but David’s graphic suffering causes more impact than written descriptions. I wonder if the ACLU, Justice Department, and FBI would have gotten involved had his family not publicized David’s gradual death, and had it not gone viral.

This behavior on the part of law enforcement is stupid, inhumane, and egregious. Do these law enforcement personnel have no shame, no basic human decency? Are we in a third world country where prisoners have no rights?

I will follow this story and give updates when possible.

I’d love to see the FBI investigate, and I hope criminal charges are filed. I hope the family sues and wins millions of dollars. I hope something can finally change in county jails across the nation, so that people who are incarcerated are no longer denied medical care.

A Letter to Law Enforcement About Medication-assisted Treatments

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Dear Officer Zealous:
First of all, thank you for patrolling our streets and highways and your efforts to keep them safe. I know you have a hard job and I deeply appreciate your willingness to take on this responsibility.

However, please stop arresting my patients for whom I’ve prescribed methadone and buprenorphine (better known under the brand names Suboxone, Subutex, or Zubsolv). You mistakenly think all people taking these medications have no right to be driving, and you are wrong. I’m writing this letter to give you better information that you can use to do your job better.

Our nation is in the middle of a crisis. Opioid addiction is an epidemic, and too often its sufferers die of overdoses. Medication-assisted treatment with methadone and buprenorphine works very well to prevent overdose deaths, and it’s been proven to help patients have a better quality of life in recovery.

I doubt you’ve been provided any information about medication-assisted treatment, so I want to help you learn some facts. Methadone has been around for fifty years and has a proven track record. It’s been studied more than perhaps any other medication, and we know it does a great job of treating opioid addiction. Buprenorphine has only been available in the U.S. for about 13 years, but has been used in Europe for decades.

With both methadone and buprenorphine, the proper dose of medication should make the patients feel normal. Patients should not feel intoxicated or high, and should not feel withdrawal symptoms. Methadone and buprenorphine are both very long-acting opioids, and they both give the opioid addicts a fairly steady level of opioid, compared to short-acting opioids usually used for intoxication. Therefore, using methadone to treat opioid addiction is not “like giving whiskey to an alcoholic,” as has incorrectly been asserted. The valid difference lies in the unique pharmacology of methadone. Opioid addicts can lead normal lives on this medication, when it is properly dosed.

In addition, both of these medications block other opioids at the opioid receptor. When a patient is on an adequate dose, she won’t feel euphoria from another opioid. Both methadone and buprenorphine deter use of other opioids for the purpose of getting high.

Treatment of opioid addiction with methadone and buprenorphine is endorsed by the CSAT (Center for Substance Abuse Treatment) branch of SAMHSA, by the U.S.’s Institute of Medicine, by ASAM (American Society of Addiction Medicine), by AAAP (American Association of Addiction Psychiatry), and by NIDA (National Institute of Drug Addiction. In study after study, methadone has been shown to reduce the risk of overdose death, reduce days spent in criminal activities, reduce transmission rates of HIV, reduce the use of illicit opioids, reduce the use of other illicit drugs, produce higher rates of employment, reduce commercial sex work, and reduce needle sharing. Medication-assisted therapy is also high cost effective.

Indeed, the current debate of government officials at the highest levels has been how best to expand medication-assisted treatment with methadone and buprenorphine, not to make it less available. So please don’t do anything which may discourage opioid addicts from receiving life-saving treatment.

Over the years, many studies have been done on methadone and buprenorphine to see if patients are able to drive safely on either of them. In study after study, data show patients on stable doses of both medications can safely drive cars, operate heavy equipment, and perform complex tasks. Please see the list of references at the bottom of this letter if you wish to investigate for yourself.

I’m not saying, however, that patients on methadone or buprenorphine can’t become impaired. Impairment can occur if patients are given too high a dose of methadone or buprenorphine, which most often occurs during the first two weeks of treatment. For that reason, patients are warned not to drive if they ever feel sedated or drowsy.

Patients on medication-assisted treatment can also become impaired if they mix other drugs or medications with their methadone or buprenorphine. In fact, benzodiazepines (like Xanax, Valium, Klonopin) and alcohol act synergistically with maintenance opioids. They can cause impairment with smaller amounts of alcohol or benzos than expected. And of course, patients can still become impaired with other drugs, such as marijuana.

As you probably know, a urine drug screen isn’t adequate to detect impairment. The urine screen only tells you if the person has taken a given drug or medication over the last few days to weeks. Drugs are detectable in the urine long after the impairing effect wears off, so you must demonstrate the presence of drugs with a blood test at the time of the questioned impairment.

My family and I drive these roads too, and I don’t want impaired drivers on our highways any more than anyone else. I just think you have mistakenly targeted patients on medication-assisted treatment for the disease of opioid addiction.

I know you have formed bad opinions about methadone and buprenorphine patients from seeing both drugs misused on the street. I hate that, because you probably rarely get to see more typical patients on medication-assisted treatments.

The vast majority of my patients have jobs, families, and responsibilities that they meet, despite having this potentially fatal illness of opioid addiction. If you are fortunate enough to encounter one of my patients on a random traffic stop, please don’t give them a hard time. Please congratulate them on having the courage to find recovery from addiction, and tell them to do what works for them. In some patients, that’s medication.

Thanks for reading this long letter and thanks for all you do in the name of keeping our roads safe. If you want to know more about how we treat opioid addiction at our facility, please call our program manager at xxx-xxx-xxxx and we would be happy to provide you with an after- hours tour and lots of information.
Sincerely,

Jana Burson M.D.
Member of the American Society of Addition Medicine
Board certified in Internal Medicine
Certified by the American Board of Addiction Medicine

P.S. And please don’t attempt to intimidate patients from coming to get help for this fatal illness of opioid addiction by parking your squad car just outside our facility’s entrance. Some of these patients may have old warrants, but by stalking them where they come for help, you discourage people who want to escape addiction and want to better their lives. If you do park near us, you should expect a staff member to approach you with a smile, a cup of coffee, and a pile of information about opioid addiction and its treatment.

ATTACHMENT:

Methadone and Driving Article Abstracts
Brief Literature Review
Institute for Metropolitan Affairs
Roosevelt University 2/14/08

1. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE
BABST, D., NEWMAN, S., & State, N. (1973). DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE,
When a comparison was made within specific age groups, it was learned that the accident and conviction rates were about the same for methadone maintenance clients as for a sample of New York City male drivers within the same period. The findings from other related studies discussed in this booklet are consistent with the results in this study.

2. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving.
Lenné, M., Dietze, P., Rumbold, G., Redman, J., & Triggs, T. (2003, December). Drug & Alcohol Dependence, 72(3), 271.
These findings suggest that typical community standards around driving safety should be applied to clients stabilized in methadone, LAAM and buprenorphine treatment.

3. Maintenance Therapy with Synthetic Opioids and Driving Aptitude.
Schindler, S., Ortner, R., Peternell, A., Eder, H., Opgenoorth, E., & Fischer, G. (2004). Maintenance Therapy with Synthetic Opioids and Driving Aptitude. European Addiction Research, 10(2), 80-87
Conclusion: The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls in the majority.

4. Methadone-substitution and driving ability
Forensic Science International, Volume 62, Issues 1-2, November 1993, Pages 63-66
H. Rössler, H. J. Battista, F. Deisenhammer, V. Günther, P. Pohl, L. Prokop and Y. Riemer
The formal assertion that addiction equals driving-inability, which is largely practiced at present, is inadmissible and therefore harmful to the therapeutic efforts for rehabilitation.

5. Methadone substitution and ability to drive. Results of an experimental study.
Dittert, S., Naber, D., & Soyka, M. (1999, May).
It is concluded that methadone substitution did not implicate driving inability.

6. Functional potential of the methadone-maintenance person.
Gordon, N., & Appel, P. (1995, January). Functional potential of the methadone-maintenance person. Alcohol, Drugs & Driving, 11(1), 31-37.
Surveys on employability and driving behavior of MTSs revealed no significant differences when compared to normal population. It is concluded that MM at appropriate dosage levels, as part of treatment for heroin addiction, has no adverse effects on an individual’s ability to function.

New Book About the War on Drugs

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I’ve got a great new book to recommend to anyone interested in the U.S.’s failed war on drugs. It’s “Chasing the Scream: The First and Last Days of the War on Drugs,” by Johann Hari. Published in 2015, I heard about this book at an Addiction Medicine conference when it was highly recommended by one of my colleagues.

As the title implies, the first part of the book describes how the war on drugs was initiated, not by the Reagans, but by Harry Anslinger, our first drug war general, back in the 1930’s. Anslinger is portrayed as an arrogant man, close-minded, filled with hubris, and lacking in compassion. He played on the public’s worst prejudices in order to get draconian drug laws passed, and showed no mercy enforcing them. He fanned the flames of public fears of drug-intoxicated minorities in order to expand his scope of power and prestige. His statements, preposterous from a medical point of view, still echo in the mouths of politicians today.

The author says Anslinger helped to create U.S.’s first drug lord, Arnold Rothstein, who is only the first of many ruthless gangsters to follow. Demand for drugs in the face of strict drug laws creates irresistible opportunities for criminals. The book describes how the war on drugs re-incarnated Anslinger and Rothstein with each generation; the names change but the tactics and destruction remain the same.

It’s an interesting concept.

Part Two of the book describes the lives of drug addicts. The author shows how people with addiction are forced to behave like sociopaths in order to maintain their supply of drugs. For example, many addicts deal drugs on a small scale to help finance their own drug use, an action they would be unlikely to undertake without the strong motivation of their own addiction.

The author goes on to illustrates how police crackdowns on drug dealers actually lead to increased gang violence. When top drug-dealing gang members are jailed, it creates a power vacuum, which leads to increased violence as rival gang members jockey for positions of power. Ultimately, the amount of drug dealing remains the same.

His reasoning does make sense, and is backed by interviews from urban bystanders in the violence of drug wars, both in the U.S. and Mexico.

This section of the book also discusses the inequalities of the drug war. The war on drugs is really a war on people who use drugs, and minorities are much more likely to targets of the drug war. Black drug dealers are more likely to be arrested than white dealers. People with money and influence aren’t targeted, while police go after the downtrodden, less likely to mount legal defenses if treated unfairly. Police do this in order to meet arrest quotas with less trouble from those targeted.

I could believe this, but then in the same section, the author also accuses police of expanding their budgets by confiscating high-dollar cars and homes from the rich people caught in the drug wars. So that was a little contradictory.

The author points out how a youngster who gets arrested for a drug offense is unemployable for the rest of his life, and how he can’t get student loans or public housing. To me that sounded a little overblown, since I know people who have managed to go to school, get their GED, then get a college education and even an advanced degree. I’m sure having a crime in one’s background makes this more difficult, but not impossible. That makes me question the accuracy of the author’s other assertions. For example, I have no idea if a drug charge eliminates all possibility of public housing.

Part three of the book is hard to read. In it, the author describes inhumane treatment of addicts who have been jailed. Arizona is noted for being a particularly brutal state for addicted inmates.
Inmates in general in the U.S. are treated horribly but no one seems to care, since few people have compassion for criminals.

This same section of the book also describes the horrible violence in Mexico brought about by the U.S. demand for illicit drugs. With so much profit to be made, drug cartels become ruthless. The author says in order to make sure other potential rivals stay in fear, dealers must engage in ever-increasing violence and depravity.

The fourth section of the book presents interesting ideas. First of all, the author claims the desire to get high is nearly universal. Far from being a deviant desire, the author advances the theory that the desire for intoxication is found in all humans in all civilizations at all times of human existence. He questions the goal of eliminating all drug use, and says it isn’t realistic.

I agree with him. The desire for euphoria is hard-wired into humans. When that urge runs amok, we may seek to satisfy that desire incessantly with drugs or other destructive behaviors.

The author then describes how life events affect the risk of addiction as if this were something new, but we’ve known for years that stress affects addiction risk. People who have experienced abuse and deprivation as children are more susceptible. But then the book connects our society’s present method of dealing with addiction, which is to shame addicts and cause them more pain. This approach is, predictably, counterproductive.

He says the more drug addicts are stressed, forced to live in poverty, are ostracized and shamed, the less likely they are to be able to find recovery.

Then the book goes into a weird tangent, saying that opioid withdrawal really isn’t all that bad, and the withdrawal is mostly mental in nature. He quotes some scientists who say that people living interesting and productive lives don’t get addicted, because they are happy. The book implies that the biological model has been overblown and scientists ignore the psychosocial components that cause addiction.

He’s wrong. Experts in addiction and its treatment haven’t forgotten the psychosocial components of addiction. But for decades, people have argued addiction is just bad behavior. They say addicts need punishment, rather than coddling in treatment programs. These people completely denied scientific components of the disorder. As a result, scientists interested in treating addiction poured money, time, and energy into proving the scientific portion of the disease. But now the same people who said there was no science to support addiction as a disease complain that scientists ignore the role of psychosocial factors that cause addiction.

In reality, both biologic AND psychosocial factors influence who becomes addicted. It isn’t either/or but both/and. It isn’t productive to argue about which is more important, because both types of causative factors need to be addressed in the disease of addiction.

The fifth part of the book is the most interesting. Chapters in this section describe the changes that occurred when drug addiction was treated more as a public health problem and less like a crime.

In a grass roots organization in Vancouver, Canada, a heroin addict managed to mobilize people to approach heroin addiction in a completely new way. This addict unified addicts and the people who care about them to create political pressure. This group attended town meetings, protested, and organized people who cared about the marginalized addicts of Downtown Eastside of Vancouver. Eventually, this organization managed to create such a stink that the mayor of Vancouver met with this addict-leader, and was so impressed by the insights and arguments that he authorized the establishment of a safe injection house.

Ultimately, Vancouver had one of the most progressive and harm-reduction oriented policies on drug addiction. Their overdose death rate plummeted. Health status of addicted people improved.

Similar harm reduction policies were enacted in Great Britain and in Switzerland, with similar reduction in overdose death rates and in improved health status for drug addicts. In Great Britain, physicians could legally prescribe heroin for opioid addicts for a period of time, from the mid-1980’s until 1995, when this program was ended. All of the health gains – reduced overdose deaths, reduced crime, reduced gang activity, and improved physical health for the addicts – were instantly reversed as soon as the program was stopped.

An entire chapter is dedicated to the changes seen in Portugal, where drugs are now decriminalized, but not legalized. This means thought drug use is not a crime, selling these drugs is still illegal. This chapter describes the changes that happened in Portugal, where harm reduction and public health strategies were enacted beginning in 2001. The nation has one of the lowest rates of illicit drug use in the world, though it’s important to understand that heroin has traditionally been the main drug of this country. Addicts’ lives are more productive and death rates are down. Crime rates dropped, and now the whole country supports these harm reduction strategies to the draconian drug laws that Portugal had in the past.

Near the end of the book is a chapter about what is happening in Uruguay, a small South American country where drugs are now not only decriminalized but legalized.

Anyone interested in the creation of a sound drug policy needs to read this book. It’s extensively researched, and the author spoke with many of the key individuals responsible for changes in drug policy all over the world. I haven’t critically researched all data he quotes in his book about the results of drug decriminalization and legalization, but he gives references for much of what’s contained in the book so that any interested reader can do so.

This book is uniquely interesting because the author combines data and statistics with personal stories of various addicts and their families. This technique combines the power of individual story with the facts of a more objective and detached view.

I don’t agree with all of the authors conclusions. For example, when he tries to say addiction is more about a person’s socioeconomic and emotional status rather than about the drugs…nah. Addiction is not all about the addictive nature of the drug itself, but it is a major factor. When you discount the euphoric attraction of opioids, cocaine, and the like, you risk misunderstanding a huge part of addiction. When a substance produces intense pleasure when ingested, it’s more likely to create addiction. After all, we don’t get addicted to broccoli…

It’s important to know this author has been in hot water in the past, accused of plagiarism. Knowing this made me a little distrustful of his interviews with people throughout the book, but I think the ideas illustrated by the interviews are still valid.

It’s a book filled with food for thought.

Methadone and Buprenorphine During Incarceration

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I recently got this comment to my blog and I hope the writer won’t mind that I’m highlighting his comment. This comment represents one of my pet peeves: patients in recovery from opioid addiction who dose with methadone/buprenorphine are frequently denied their medication if incarcerated.

“Hello, i was recently convicted of an addiction related crime that happened over a year ago, since the indecent I’ve cleaned up my act, have been taking suboxone for over 12 months, 8mg, 3 times a day and now have to go to jail were I’m going to be denied my medication by jail officials/laws, I’ve been in jail before and i kno they do next to nothing for withdrawing opioid patients? From what i hear, it could take months for that type of dosage to get out of my system? Now being a former i/v heroin user of about 7 years, I’ve done a#on my body and feel my health isn’t exactly top notch, i am legitimately concerned about this withdrawal! Should there be sum kind of law protecting us patients? Aren’t these dangerous withdrawal symptoms? Thanks in advance for your response in this matter!”
I am so sick of hearing about patients on methadone or buprenorphine being denied their treatment while incarcerated! I’d love to see someone sue the excrement out of a jail or prison for denying this life-saving medical treatment.

Most counties jails in rural North Carolina won’t allow patients who are prescribed methadone or Suboxone for opioid addiction to take their medication while in jail. I hear (second-hand) that some jails allow chronic pain patients with opioid prescriptions to take their medication, though this may vary according to the county.

As a health care provider, of course I’m opposed to any refusal to treatment a patient while incarcerated. I think it’s a violation of the 8th Amendment about cruel and unusual punishment, but since I’m no legal scholar, I’ve searched the internet for more information about this situation. I found a great article co-authored by a doctor and a lawyer. They make the point that opioid addiction is a complex illness, and forced withdrawal causes severe physical and psychological suffering. Also, because opioid withdrawal makes people especially vulnerable, they may be coerced into giving testimony that incriminates themselves. They are less able to make decisions. (1)

Prisons are charged to provide as much care as is available to prisoners as general population, yet opioid addicts are denied access to medication-assisted treatments for addiction. These treatments are, as you probably know if you’re a regular reader of this blog, one of the most evidenced-based medical treatments in all of medicine.

Jails face legal implications for the prisoners under their control if adverse health consequences occur during withdrawal. A healthy young person usually won’t die from opioid withdrawal, but a medically fragile patient may die. Then the jail can be sued successfully for wrongful death, as happened in Orange County, Florida. But what a shame that it has to come to that to see any change in jail protocol.

A few years ago, I wrote to both the Tennessee and North Carolina chapters of the ACLU (American Civil Liberties Union), thinking if any legal organization would be willing to take up this issue, it may be them. One person with the NC chapter wrote back that in order to take up a case, they need a specific person with a specific case, and that person needs a local lawyer with whom they can work.

I other words, as a physician, I can’t get something stirred up. It has to be a person who is denied treatment with methadone or buprenorphine while in jail.

That’s what I’m hoping to do with my blog post. My readers know many people. If you are reading this and know someone facing incarceration who will be denied their usual medical treatment of methadone or buprenorphine while incarcerated, encourage them to get a lawyer, and ask that lawyer to ask for outside help.

Here’s the website for North Carolina: http://www.acluofnc.org/

As one might imagine, Tennessee’s chapter of the ACLU has many issues to keep them busy, so check it out at http://www.aclu-tn.org/ On their homepage, there’s an article about Tennessee’s contract with a corrections company that operates facilities in that state. It’s interesting reading, and may help us make sense of some of Tennessee’s horrible decisions around addiction issues (follow the money!). Also check out the TN ACLU’s article of protest against the recent law that makes using drugs during pregnancy a crime instead of a health issue.

I know that AATOD (American Association for the Treatment of Opioid Dependence) works with the Legal Action Center in New York, and they have a great website: http://www.lac.org You can read about their advocacy efforts nationwide, and check out their blog, which has advocacy information about this specific issue of medication-assisted treatment behind bars. I believe that the Legal Action Center works with local lawyers nationwide to serve as a resource. I don’t think the LAC actually takes on the cases of patients in states other than New York, but they also may be able to offer help and resources to other lawyers.

My patients tell me it’s difficult to find a local lawyer willing to take on the case of medication-assisted treatment behind bars. Often, such patients are seen as “bad” for having the disease of addiction. Some lawyers may not want to risk the working relationships they have with the judges in their area by advocating for an issue that the lawyer may not find compelling.
Additionally, it’s easy to intimidate many patients on MAT because they already feel shame and stigma. They have a legitimate fear of making their situation worse if they protest poor treatment by the criminal justice system.

I understand all of that, and I’d probably feel the same way. But what’s being done to patients on MAT – forced withdrawal from life-saving treatments of methadone/buprenorphine – isn’t right, and it’s an abomination to human rights. Let’s support these patients in every way possible. Get lawyers, ask them to advocate for you. If they won’t, contact some of the above resources and write back to me about what their response was.

If you are a friend or relative of a person in such a situation, make noise. Write politicians, call the jails, and call judges, particularly those that are elected. Tell jailers how appalled you are at the senseless suffering of patients denied their usual medical treatment.

Most importantly for this issue and others: register to vote. Find out your elected officials’ positions on the legal issues surrounding addiction, and vote accordingly. If you are an addict in recovery, vote. If you are a friend or family member of someone in recovery or in addiction, vote. Let politicians know you will vote against them if they fail to make good laws based on science.

As for me, I have a standard letter I’m willing to send to my patients’ lawyers and to the judges hearing their cases, advocating strongly for them to be allowed to continue their evidence-based treatment with methadone/buprenorphine.

And yes, I vote.

1.Bruce RD and Schleifer, RA, “Ethical and Human Rights Imperatives to Ensure Medication-Assisted Treatment for Opioid Dependence in Prisons and Pre-trial Detention, International Journal of Drug Policy, 2008, February; 19(1): 17-23.

Criminally Pregnant In Tennessee, Part II

pregnant caucasian woman portrait attached with handcuffs isolated studio on white background

Today my guest blogger Dr. Fedup weighs in on my last entry, “Criminally Pregnant,” with his own unique point of view. He gives counterpoints to my arguments, as he feels Tennessee’s law is a good idea. I’ll let him explain his reasoning. His political leanings are somewhat right of center, as you will read.

“I applaud Tennessee’s new law, which makes it a crime to expose a pre-born baby (I don’t believe in using that word fetus, since life begins at conception) to drugs. Too many babies are born with neonatal abstinence syndrome, so obviously Tennessee has grown too soft on crime for this to be happening.

“Bill number 1391, already passed by the state’s legislature, needs only the governor’s signature to become law. In short, this bill says a mother can be prosecuted for “an assaultive offense or homicide if she illegally takes a narcotic drug while pregnant and the child is born addicted, is harmed, or dies because of the drug.”

“Their governor, Bill Haslam, goofed last year when he passed that Safe Harbor Law, which eliminated criminal charges for pregnant women who went into treatment. This new law corrects and cancels that law. Some people have said that’s inconsistent, and not enough time passed since the Safe Harbor Law to see if it was going to work or not.

“I say it’s OK to be inconsistent so long as you are putting people in jail.

“There’s nothing in the new bill to prevent pregnant, opioid addicted women who are in methadone or buprenorphine programs from being prosecuted as well, though bill 1391 does say, “Illegally take a narcotic drug while pregnant.” Women who enter such treatments have already taken illegal narcotics while pregnant, or they wouldn’t need treatment.

“My only problem with the new bill, SB 1391, is that it doesn’t go far enough. We should put the drug addict babies in jail, too.

“Think about it. You know those little suckers enjoyed the drugs they were getting through the placenta, and they need to be punished for that. They’re born addicts. Start punishing them right out of the womb. That way, the state can teach them right from wrong as they grow up, right there in the prison system, like we do with all other inmates in Tennessee jails.

“Some people criticize my idea. Some people say we already put too many people in jail. But I say if U.S. history teaches us anything, it’s that taxpayers are always happy to spend more money on jails.

“We must be willing to incarcerate more people, because U.S. citizens are more evil and criminal than people in other parts of the world. They must be, because we put more people in jail per capita than anywhere else. Circular logic? I don’t care, as long as it puts bad people in jail.

“It was a happy day when the U.S. could finally brag that we incarcerate more people per capita, than even Russia or Rwanda. We’re Number One! We put 716 people out of 100,000 into jails or prisons, and Russia only puts 484 out of 100,000 in prisons. We’re beating them almost two to one! [1]

“Lots of bleeding heart liberals will complain about how Tennessee jails aren’t set up for infants. I say we can fix that. After all, aren’t play pens just jail cells, only prettier? These addict babies don’t deserve anything too pretty, and they’ll get used to the bars soon enough.

“No measure is too severe if it will fix the drug problem. My critics point to all the information collected since the 1950’s which indicates incarcerating addicts does nothing to help addiction rates. But I’m telling you that this new send-an-addict-baby-to-jail program will work.

“While we are on the topic of evil pregnant women who harm their babies, let’s discuss nicotine addiction. There’s more medical evidence to show tobacco smoking harms babies than there is to show cocaine harms babies. Let’s put all those mothers who smoke into jail, too, since they are intentionally harming their pre-borns.

“Then let’s take this train of thought to its logical conclusion. In the latest issue of the Journal of the American Medical Association, there was a great article about the harm maternal obesity does to the fetus. This article reviewed all of the studies of how obesity affects fetal death and infant death. The conclusion was, “Even modest increases in maternal BMI were associated with increased risk of fetal death, stillbirth, and neonatal, perinatal, and infant death.” [2]

“Sounds to me like it’s time to build jails for the fatties, too. Because the state of Tennessee believes that jail time corrects bad behavior.

1. http://en.wikipedia.org/wiki/List_of_countries_by_incarceration_rate
2. Aune, et al, “Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death: a Systematic Review and Meta-analysis,” JAMA, 2014; 311(15):1536-1546.

Criminally Pregnant

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I usually don’t post a new entry so soon after the last, but this topic is time-sensitive.

I’m getting tired of writing about Tennessee’s crazy politicians but this time their insanity is so egregious that I can’t let it pass without comment.

The Tennessee house and senate passed a bill that allows a woman to be criminally charged if her baby is born drug dependent. If their Governor Haslam signs this bill, it will become law.

As we know, Tennessee has a terrible opioid addiction problem with one of the highest overdose death rates in the nation. Opioid addiction afflicts men and women in nearly equal numbers, and most of those women are in their child-bearing years. Thus, Tennessee has many pregnant women who have the disease of drug addiction.

Naturally, hospitals have seen a growing number of infants born with opioid withdrawal. Small rural hospitals may not have physicians who are educated about how to treat these babies. It’s a frightening situation, and the response is fear-based: make drug use during pregnancy a crime.
Politicians promote draconian laws that will punish these women, who are probably the most vilified segment of society, and gain favor with voters who don’t understand the underlying issues.

So now Tennessee has a law that makes getting pregnant a crime, if you have the disease of addiction. (By the way, there are other illnesses that can harm the fetus if the mom becomes pregnant, but we have no laws making pregnancy illegal for those patients.)

Supporters of this new insane law probably say it should encourage pregnant addicts to get help before their babies are born. That could be true, if Tennessee had adequate treatment programs in place. As we know, methadone and buprenorphine are the best treatments for opioid-addicted pregnant women, yet under this law, this gold-standard of treatment may also be considered illegal.

So should pregnant moms “just say no” and stop using opioids? We know that going through opioid withdrawal while pregnant is associated with bad outcomes for mom and fetus, what with increased risks of preterm labor, placental abruption, and low birth weights. Over the last fifty years, multiple studies repeatedly show better outcomes when you maintain the mom of a stable dose of methadone, or more recently buprenorphine, during the pregnancy.

If this bill is signed into law by Tennessee’s governor, we can predict what will happen.

After all, what would you do, if you are a pregnant addict and know you will be prosecuted if anyone discovers you’re drug user? You avoid prenatal care. Maybe you get an abortion, even if you really want a baby, because you don’t want to go to jail. Maybe you try to stop using opioids on your own, go into withdrawal, and have one of the complications we know to be common in such a situation. Maybe you have preterm labor at 30 weeks and your baby ends up in the intensive care unit for many months. Worse, maybe your baby doesn’t make it. Or your baby does make it, but is taken away from you at birth, because authorities say an addict can’t care for a baby. Your baby enters the foster care system, with its pitfalls.

In short, this law discourages medical care in the very population of women who can benefit the most from medical care and treatment of addiction!

But wait…this law says the woman can be charged if the baby is born dependent. What about pregnant women who smoke? The infants are technically dependent on nicotine, so that meets this law’s criteria. These women can also be criminally charged. Probably Tennessee would have to build a new jail just for those women, and of course Tennessee’s taxpayers would be happy to pay for their incarceration, right?

In the past, laws against drug use in pregnancy have been unevenly implemented. If you look at the cases that have been prosecuted, nearly all involved poor, non-white mothers. Maybe that’s because law enforcement knows that people of higher socioeconomic status can afford hire a lawyer to defend themselves against these ridiculous laws, which always get struck down on appeal, though that can take years.

Policies that inflict criminal penalties on pregnant women with the treatable disease of addiction cause harm to everyone. Hospitals have higher costs when a mom with no prenatal care arrives on their door step ready to deliver, with much higher rates of perinatal complications. Taxpayers end up paying the high costs of incarceration for these women. But most of all, the babies and their moms are harmed.

Let Governor Haslam know how you feel by writing to him: bill.haslam@tn.gov or call at: (615-741-2001)