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Is coerced treatment ever justified

Opiate addiction and other mental disorders in the criminal justice population
Charles P. O’Brien, M.D., Ph.D. Sponsored by the National Institute on Drug Abuse Hosted by the University of Pennsylvania Persons who are incarcerated or recently released on parole have a high frequency of substance abuse and other mental disorders. Despite significant advances in the science of diagnosis and treatment of these disorders, relatively few prisoners receive the latest in treatment techniques. Medications for addictive disorders have been found to be effective but rarely used for this population. Medications that have opiate effects such as methadone or buprenorphine are opposed by many in the prison and parole system as being too close to heroin. Most are not aware of an FDA approved medication named naltrexone that specifically prevents relapse to opiate addiction, but has no opiate effects of its own. Naltrexone is a safe and effective medication that completely blocks all effects of exogenous opiates. Unlike methadone, naltrexone is a full opiate antagonist that is non-addictive and non-psychoactive. Although the FDA approved naltrexone in 1985 for the treatment of opiate addiction, it is infrequently prescribed in clinical practice, and is almost never prescribed in criminal justice settings. The criminal justice population is a major locus of adolescents with emotional and behavioral problems. It falls heavily on minorities as it has been estimated that 25% of African American males between the ages of 18 and 25 are in prison or on parole. The major problem with naltrexone treatment is poor adherence to the medication regimen. The criminal justice system provides an excellent forum for improving adherence by making naltrexone ingestion a condition of early release from prison, or of diversion from prosecution, for non-violent, opiate-addicted offenders. Moreover, the recent development of a depot preparation for naltrexone will make it easier to monitor ingestion and ensure offenders maintain a blockade dosage. Between 5 and 10% of the 2 million persons incarcerated in the United States suffer from opiate addiction. Most of them relapse shortly after release into society. There are a number of barriers to prescribing naltrexone in this manner. Criminal justice professionals are generally unaware of its therapeutic potential; moreover, they need to be educated about how naltrexone differs fundamentally from agonist medications such as methadone or buprenorphine that may be politically inexpedient. Judges and attorneys may also have an instinctive aversion to coerced medical treatment, given the historical injustices that have been visited upon prisoners. Finally, a body of law is developing that prohibits the use of medications such as Depo-provera with prisoners, in part because they may have serious side effects or infringe on fundamental human functions such as reproduction. The side-effect profile of naltrexone must be contrasted with these other medications that have been the subject of extensive litigation. This invited symposium will assemble a panel of nationally renowned clinicians, pharmacologists, law professors, ethicists, and criminal justice professionals who will explore the clinical, legal, and ethical issues surrounding depot naltrexone treatment in lieu of criminal prosecution or incarceration. Presenters will submit a 20-page double-spaced manuscript, which will be distributed in advance to discussants and moderators who will comment on the salient points during the symposium. A transcript will be taken of the symposium, and the prepared speeches and comments will be published as a monograph available to professionals working in the criminal justice system. Opiate addiction and other mental disorders in the criminal justice population
Location: The Inn at Penn, University of Pennsylvania Campus
January 4, 2005
9:00 The promise and pharmacology of naltrexone Charles O’Brien, M.D., Ph.D., University of Pennsylvania 9:30 Discussant: Redonna Chandler, Ph.D. National Institute on Drug Abuse 10:00 Ethical issues surrounding coerced treatment Arthur Caplan, Ph.D., University of Pennsylvania 10:30 Discussant: 11:15 Legal issues surrounding coerced treatment Richard Bonnie, L.L.D., University of Virginia 11:45 Discussant: Judge Louis Presenza, The Philadelphia Municipal Court 11:55 General 12:30 Lunch (on your own-a list of neighborhood restaurants will be provided) 2:00 A scientific and behavioral analysis of “coercion” Doug Marlowe, J.D., Ph.D., University of Pennsylvania 2:30 Discussant: David Farabee, J.D., Ph.D. 2:40 General Discussion 3:00 How could a naltrexone program for parolees and probationers be implemented? 3:30 Discussant: Carol Boyd, Ph.D. University of Michigan 3:40 General Discussion 4:15 Adjournment

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