- Open Access
The Ethics in Substitution Treatment and Harm Reduction. An Analytical Review
Public Health Reviewsvolume 34, Article number: 16 (2012)
The ethics of opiate substitution treatment (OST) modalities for heroin addiction have been abundantly criticised but also have equally strong supporters. This analytical review addresses three main arguments against such treatments: 1) the social nature of the issue involves a misuse of the medical care; 2) the aim is one of social control (as opposed to a “cure”) and therefore is a perversion health care; and 3) prescribing the very substance (or a substitute) that caused the addiction is ethically questionable. Additionally, the generic criticism against the philosophical/theoretical framework under which they operate, “harm reduction” (HR) as an operational goal of therapy, is also addressed here.
A summary review of the history of addiction supports the argument that, indeed, drug addiction “as a problem” was socially created. Equally clear is that one of the aims of OST and all drug-addition treatments is the social control of individual behaviours. However, neither of these two aspects justifies refusal to provide health and social care. OSTs are legitimate therapeutic options because they comply with the four principles of bioethics—autonomy, nonmaleficence, beneficence and justice. The argument that such treatments and the HR approach, in general, align with the principle of consequentialism—the aim justifies the means—and therefore is ethically questionable is a disingenuous criticism. Consequantialism is based in the implicit assumption that harms are accepted to reach certain objectives as the lesser of two evils. OSTs have been extensively proven as to their safety with benefits margins both at the individual (retention, reduction of illicit drug use and better social adjustment) as well as at the population levels (e.g., HIV incidence reduction). Heroin-substitution based treatment is the latest case of moral resistance to provide patients with the most effective option in spite of sound evidence on its effectiveness and safety. As in other cases of spurious resistance to public health and medical innovations, it is only a matter of time and endurance until such treatments are fully integrated among standard therapeutic options for heroin dependent individuals.
Buchman DZ, Skinner W, Illes J. Negotiating the relationship between addiction, ethics, and brain science. AJOB Neurosci. 2010;1(1):36–45.
Hall W, Lucke J. Legally coerced treatment for drug using. offenders: ethical and policy issues. Crime and Justice Bulletin. NSW Bureau of Crime Statistics and Research. Contemporary Issues in Crime and Justice. No 144. September 2010.
Have HT, Sporken P. Heroin addiction, ethics and philosophy of medicine. J Med Ethics. 1985;11:173–7.
Access. An ‘inside’ view of methadone. Newsletter of the access project–sharing knowledge and good practice. Winter 2011/12. Issue 1. p.7.
Elovich R, Drucker E. On drug treatment and social control: Russian narcology’s great leap backwards. Harm Reduct J. 2008;5:23.
Casey E. History of drug use and drug users in the United States. From Facts About Drug Abuse–Participant Manual–The National Drug Abuse Center for Training Resource and Development. 1978. Available from URL: http://www.druglibrary.org/schaffer/history/casey1.htm (Accessed 21 November 2012).
Kandall SR. Women and addiction in the United States–1850 to 1920. In: Substance and Shadow: A History of Women and Addiction in the United States -1850 to the Present. Cambridge, MA: Harvard University Press; 1999.
Public Acts of the Sixty-Third Congress of the United States. Harrison Narcotics Tax Act, 1914. Public law no. 223. Approved, December 17, 1914. Available from URL: http://www.druglibrary.org/Schaffer/history/e1910/harrisonact.htm (Accessed 21 November 2012).
Courtwright D. Dark Paradise: Opiate Addiction in America before 1940. Cambridge, MA: Harvard University Press; 1982.
New York Medical Journal Editors. Mental sequelae of the Harrison Law. N Y Med J. 1915;102:1014.
Rainey HT, (Congressman). Chairman to the Committee appointed to look into the claims about the worsening situation. 1918. In: Brecher EM, et al. The Consumers Union Report on Licit and Illicit Drugs. Chapter 8. The Harrison Narcotic Act (1914). 1972. Available from URL: http://www.druglibrary.org/schaffer/library/studies/cu/cu8.html (Accessed 21 November 2012).
King R. The Yale Law Journal. 1953. In: Brecher EM, et al. The Consumers Union Report on Licit and Illicit Drugs. Chapter 8. The Harrison Narcotic Act (1914). 1972. Available from URL: http://www.druglibrary.org/schaffer/library/studies/cu/cu8.html (Accessed 21 November 2012).
Council of European Union. EU drug strategy, 2005–2012. Brussels, Belgium: 22 November 2004. p.4.
PHG Foundation. Moral theories–introduction. 2008. Available from URL: http://www.phgfoundation.org (Accessed 21 November 2012).
PHG Foundation. Moral theories–principles of bioethics. 2008. Available from URL: http://www.phgfoundation.org (Accessed 21 November 2012).
Dole VP, Marie Nyswander M. A medical treatment for diacetylmorphine (heroin) addictiona clinical trial with methadone hydrochloride. JAMA. 1965;193:646–50.
Connock M, Juarez-Garcia A, Jowett S, Frew E, Liu Z, et al. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technol Assess. 2007;11:1–171, iii-iv.
Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin-dependent individuals. Cochrane Database Syst Rev. 2010;(8):CD003410. John Wiley & Sons, Ltd.; 2012.
Newcombe R. The reduction of drug related harm: a conceptual framework for theory, practice and research. 1992. Available from URL: http://www.drugtext.org/Various-general/the-reduction-of-drug-related-harm-a-conceptual-framework-for-theory-practice-and-research.html (Accessed 21 November 2012).
The Canadian Centre on Substance Abuse (CCSA). 1996. Available from URL: http://www.ccsa.ca/Eng/Pages/Home.aspx (Accessed 21 November 2012).
Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 2004;8:2295–303.
Trujols J, Aceijas C. El reinado del ensayo clmico controlado y la ética paternalista. [The randomized clinical trial’s kingdom and the paternalistic ethic]. Centro de Documentación de Drogodependencias (CDD). November 2003; 101. Available from URL: http://www.gizartegaiak.ej-gv.net/GizarteGaiakContenidos/pdf/revista/revista%20n.101.pdf (Accessed 21 November 2012)_.[In Spanish]
Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blättler R, Pfeifer S, (editors). Prescription of narcotics for heroin addicts: main results of the Swiss National Cohort Study. Basel: Karger Verlag; 1999.
Strang J, Metrebian N, Lintzeris N, Potts L, Carnwath T, Mayet S, et al. Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial. Lancet 2010; 375:1885–95.
March JC, Oviedo-Joekes E, Perea-Milla E, Carrasco F, PEPSA team. Controlled trial of prescribed heroin in the treatment of opioid addiction. J Subst Abuse Treat. 2006;31:203–11.
van den Brink W, Hendriks VM, van Ree JM. Medical co-prescription of heroin to chronic, treatment-resistant methadone patients in the Netherlands. J Drug Issues. 1999;29:587–608.
van den Brink W, Hendriks VM, Blanken P, Koeter MWJ, van Zwieten BJ, van Ree JM. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ. 2003;327:310–6.
Haasen C, Verthein U, Degwitz P, Berger J, Krausz M, Naber D. Heroin-assisted treatment for opioid dependence: randomised controlled trial. Br J Psychiatry. 2007;191:55–62.
Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, et al. Diacetylmorphine versus methadone for the treatment of opioid addiction. N Engl J Med. 2009;361:777–86.
Small D, Drucker E. Policy makers ignoring science and scientists ignoring policy: the medical ethical challenges of heroin treatment. Harm Reduct J. 2006;3:16.