Legal and Ethical Issues in Heroin Diagnosis, Treatment, and Research

Click to increase image sizeClick to decrease image size Dr. Loue holds secondary appointments in the Departments of Bioethics, Psychiatry, and Global Health. She was the 2003 Dr. Arthur Grayson Distinguished Visiting Professor of Law and Medicine at Southern Illinois University School of Law. Dr. Ioan holds a medical degree and license and a doctoral degree from Romania and an M.A. in Bioethics. Much of her empirical research focuses on substance use. Dr. Ioan has written extensively on substance use and ethical issues in the research and clinical contexts Notes 1. National Institute on Drug Abuse, Pub. No. 05-4165, Research Report Series: Heroin Abuse and Addiction 1-2 (2005). 2. United States Department of Health and Human Services, Summary of Findings from the 1999 National Household Survey on Drug Abuse 31 (2000). 3. Humberto Fernandez, Heroin 37 (1998). 4. Jeff Stryker, IV Drug Use and AIDS: Public Policy and Dirty Needles, 14 J. Health Pol. Pol'y & L. 719 (1989) (defining "mainlining" as an injection into the vein). 5. Fernandez, supra note 3, at 53. 6. Oakley S. Ray & Charles Ksir, Drugs, Society and Human Behavior (1990). 7. Id. This practice of subcutaneous injection is known as "skin popping." 8. H. Thomas Milhorn, Jr., Chemical Dependence: Diagnosis, Treatment, and Prevention 168-71 (1990). 9. Lester Grinspoon & James Bakalar, Cocaine: A Drug and Its Social Evolution 177 (1985). 10. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 197 (2000) [hereinafter DSM-IV]. In the past, the term "dependence" was used interchangeably with the term "addiction," defined as a "chronically relapsing [disorder] characterized by compulsive drug taking, an inability to limit the intake of drugs, and the emergence of a withdrawal syndrome during cessation of drug taking (dependence)." George F. Koob et al., Neuroscience of Addiction, 21 Neuron 467 (1998). For other definitions of drug abuse used within the scientific, regulatory, and enforcement spheres, see James Zacny et al., College on Problems of Drug Dependence Taskforce on Prescription Opioid Non-Medical Use and Abuse: Position Statement, 69 Drug & Alcohol Depend. 215, 217 (2003). This lack of consensus regarding the nature of dependence hinders both research and treatment. 11. Tolerance is characterized by a need for increased amounts of the substance to achieve either intoxication or desired effect or by a diminished effect of the substance with the use of the same amount. DSM-IV, supra note 10, at 197-98. 12. Withdrawal is manifested by a set of symptoms resulting from the cessation of, or a reduction in the use of, a particular substance or by the use of the same or a closely related substance to avoid these symptoms. Id at 201-09. 13. Id. at 197-98. 14. Id. at 198. 15. See Solomon H. Snyder, Drugs and the Brain 164-66 (1996). 16. Milhorn, supra note 8, at 172. 17. DSM-IV, supra note 10, at 199. 18. Id. 19. Id. at 456-63. 20. Id. at 460. For a discussion of the similarities in mechanism between compulsive behavior and substance dependence, see David E. Comings et al., A Study of Dopamine D 2 Receptor Gene in Pathological Gambling, 6 Pharmacogenetics 223 (1996); David E. Comings, The Molecular Genetics of Pathological Gambling, 3 CNS Spectrums 20 (1998). 21. Adrian Furnham & L. Thomson, Lay Theories of Heroin Addiction, 43 Soc. Sci. & Med. 29, 30 (1996). There are also integrated theories and models of drug abuse that attempt in various ways to address the multifactorial nature of substance use and abuse and incorporate elements of one or more of these more basic models. Examples include: the biopsychosocial model that integrates biological, psychological, and social processes; the triadic influence theory, which encompasses interpersonal, intrapersonal, and attitudinal/cultural domains; and the hedonic treadmill model, which posits that drug use represents a pursuit of pleasure that has gone awry. For additional discussion of these integrated theories and models, see generally Steve Sussman & Susan L. Ames, The Social Psychology of Drug Abuse 78-88 (2001). A study of lay perceptions of the causes of heroin addiction found that, in general, respondents attributed the addiction to psychological and social pressures rather than biological or genetic factors or moral shortcomings. Additionally, study responders indicated a preference for treatments that utilize counseling and social support rather than isolation in drug-free communities. Furnham & Thomson, supra note 21, at 38. 22. Institute of Medicine, Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research 37 (2001). 23. Id. 24. Jack R. Cooper et al., Cellular Foundation of Neuropharmacology, in The Biochemical Basis of Neuropharmacology 9 (Jack R. Cooper et al. eds., 8th ed. 2002). 25. Id. 26. Gaetano Di Chiara & Assunto Imperato, Drugs Abused by Humans Preferentially Increase Synaptic Dopamine Concentrations in the Mesolimbic System of Freely Moving Rats, 85 Proc. Nat'l Acad. Sci. U.S.A. 5274 (1988). 27. Charles P. O'Brien, Drug Addiction and Drug Abuse, in Goodman and Gilman's The Pharmacological Basis of Therapeutics 557 (Joel G. Hardman & Lee Limbird eds., 1996); see also Robert Mathias, Rate and Duration of Drug Activity Play Major Roles in Drug Abuse, Addiction, and Treatment, 12 Nat'l Inst. Drug Abuse Res. Findings 23 (1997), available at http://www.streetdrugs.org/pdf/NNHeroin.pdf. 28. O'Brien, supra note 27, at 557. 29. Institute of Medicine, supra note 22, at 46. 30. O'Brien, supra note 27, at 557. 31. Paul Gendreau & L.P. Gendreau, The "Addiction-Prone" Personality: A Study of Canadian Heroin Addicts, 2 Can. J. Behav. Sci. 18 (1970). 32. Rebecca Schilit, Drugs and Behavior: A Sourcebook for the Human Services (1991). 33. Patrick Zickler, Nicotine Craving and Heavy Smoking May Contribute to Increased Use of Cocaine and Heroin, 15 Nat'l Inst. Drug Abuse Res. Findings 1 (2000). 34. Lee N. Robins & Sergey Slobodyan, Post-Vietnam Heroin Use and Injection by Returning U.S. Veterans: Clues to Preventing Injection Today, 98 Addiction 1027 (2003). 35. Joan Moore, The Chola Life Course: Chicana Heroin Users and the Barrio Gang, 29 Int'l J. Addict. 1115 (1994); Kathleen R. Marikangas et al., Familial Factors in Vulnerability to Substance Abuse, in Vulnerability to Drug Abuse 75 (Meyer D. Glantz & Roy W. Pickens eds., 1996). 36. J. David Hawkins et al., Risk and Protective Factors for Alcohol and Other Drug Problems in Adolescence and Early Adulthood: Implications for Substance Abuse Prevention, 112 Psychol. Bull. 64 (1992); Charles E. Dodgen & W. Michael Shea, Substance Use Disorders: Assessment and Treatment 85 (2000). 37. See Howard B. Kaplan & Robert J. Johnson, Relationships Between Initial Illicit Drug Use and Escalation of Drug Use: Moderating Effects of Gender and Early Adolescent Experiences, in Vulnerability to Drug Abuse, supra note 35, at 299. 38. Lisa Kaplan, Working with Multiproblem Families (1986). 39. Patricia Cohen et al., Common and Uncommon Pathways to Adolescent Psychopathology and Problem Behavior, in Straight and Devious Pathways from Childhood to Adulthood (Lee N. Robins & Michael Rutter eds., 1990). 40. Terry E. Dielman et al., Health Locus of Control and Self-Esteem as Related to Adolescent Health Behavior and Intentions, 19 Adolescence 935 (1984); Richard Jessor & S.L. Jessor, Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth (1997). 41. Robert E. Booth & Yiming Zhang, Conduct Disorder and HIV Risk Behaviors Among Runaway and Homeless Adolescents, 48 Drug Alcohol Depend. 69 (1997). 42. Fernandez, supra note 3, at 53. 43. William S. Cartwright, Cost of Drug Abuse to Society, 2 J. Mental Health Pol'y & Econ. 133, 134 (1999), available at http://www.icmpe.org/test1/journal/issues/v2pdf/2-133__text.pdf; Larry Gostin, The Interconnected Epidemics of Drug Dependency and AIDS, 26 Harv. C.R.-C.L. L. Rev. 113, 115 (1991). The probability of infection as the result of each injection with a shared, contaminated needle has been estimated at .0067, based on data from the New Haven, Connecticut legal needle/syringe exchange program. Edward H. Kaplan & Robert Heimer, A Model-Based Estimate of HIV Infectivity Via Needle Sharing, 5 J. Acquired Immune Deficiency Syndromes 1116 (1992); Edward H. Kaplan & Robert Heimer, HIV Prevalence Among Intravenous Drug Users: Model-Based Estimates from New Haven's Legal Needle Exchange, 5 J. Acquired Immune Deficiency Syndromes 163 (1992). 44. Harvey W. Feldman & Patrick Biernacki, The Ethnography of Sharing Needles Among Intravenous Drug Users and Implications for Public Policies and Intervention Strategies, in Needle Sharing Among Intravenous Drug Users: National and International Perspectives 28 (Nat'l Inst. on Drug Abuse Research Monograph Series, 1988). 45. National Institute on Drug Abuse, Series 1, No. 11-B, 1992, Annual Medical Examiner Data 1991: Data from the Drug Abuse Warning Network (DAWN) (1991). In some jurisdictions, the number of deceased persons who have tested positive for heroin use has increased markedly in recent years. See Nancy E. Walker et al., Drug Policies in the State of Michigan: Economic Effects 15 (Apr. 2003). 46. Michael T. French & Robert F. Martin, The Cost of Drug Abuse Consequences: A Summary of Research Findings, 13 J. Substance Abuse Treatment 453, 459 (1996). 47. Id. at 455-58. 48. Benedikt Fischer et al., Illicit Opiates and Crime: Results of an Untreated User Cohort Study in Toronto, 43 Can. J. Criminology & Criminal Justice 197, 201 (2001); United States Department of Health and Human Services, Drug Abuse and Drug Abuse Research: Third Triennial Report to Congress (1991). 49. Fernandez, supra note 3, at 16. 50. Id. at 20 (citing Ben Attias, History of Opium 2, available at The number of individuals addicted to opiates increased even more with the inadvertent addition of Civil War soldiers who became addicted to the morphine used to soothe the pain from their war wounds.Footnote 52 http://www.csun.edu/∼hfspc002/xxx.html). 51. Id. at 17. 52. Fernandez, supra note 3, at 20. 53. Attias, supra note 51, at 1. 54. Julian Durlacher, Heroin: Its History and Lore 8 (2000). 55. Id. at 9; Fernandez, supra note 3, at 19, 25. 56. David F. Musto, The American Disease: Origins of Narcotic Control 3 (3d ed. 1999). Prior to this time, it was not uncommon for private physicians to treat their opiate-addicted patients by prescribing narcotics. Nat'l Inst. of Health, Consensus Development Statement: Effective Medical Treatment of Heroin Addiction (1997), available at http://consensus.nih.gov/1997/1998TreatOpiateAddiction108html.htm. 57. 38 Stat. 785, ch. 1, Comp. Stat. 1916, 6287h. 58. An editorial in American Medicine harshly condemned this new law: Narcotic drug addiction is one of the gravest and most important questions confronting the medical profession today. Instead of improving conditions, the laws recently passed have made the problem more complex. Honest medical men have found such handicaps and dangers to themselves and their reputations in these laws … that they have simply decided to have as little to do as possible with drug addicts or their needs. … The druggists are in the same position and for similar reasons many of them have discontinued entirely the sale of narcotic drugs. [The addict] is denied the medical care he urgently needs. … See Durlacher, supra note 54, at 16. 59. Alfred W. McCoy, The Politics of Heroin: CIA Complicity in the Global Drug Trade 18 (1991). 60. Fernandez, supra note 3, at 37. 61. Durlacher, supra note 54, at 30-35 & 42-44. 62. McCoy, supra note 59, at 18. 63. Fernandez, supra note 3, at 37. The purity of heroin has increased during the last decade, facilitating use by smoking and snorting it. Drug Enforcement Administration & The National Guard, Drugs of Abuse 13 (1997). It has been estimated that the prevalence of heroin ingestion by smoking or snorting increased from 55% in 1994 to 71% in 1997. Office of Nat'l Drug Control Policy, Pulse Check: National Trends in Drug Abuse 30 (Summer 1998). 64. Vernon E. Johnson, I'll Quit Tomorrow: A Practical Guide to Alcoholism Treatment (rev. ed. 1990). 65. Id. 66. Terence T. Gorski & Merlene Miller, The Phases and Warning Signs of Relapse (1993). 67. Id. 68. James O. Prochaska & C.C. DiClemente, Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change, 51 J. Consult. Clin. Psychol. 390 (1983) (discussing the transtheoretical model). Other models of motivation include the direction-energy model and the self-regulation model. See generally Sussman & Ames, supra note 21, at 111-12. 69. G. Alan Marlatt, Harm Reduction: Come As You Are, 21 Addict. Behav. 779, 785 (1996). 70. Id. For a more in-depth review of the moral model and the basis for this perspective in Christian theology, see Bill Bush & Max Neutze, In Search of What Is Right: The Moral Dimensions of the Drug Debate (2000), available at http://www.ffdlr.org.au/ethics/InSearchOfRight.htm. 71. Sussman and Ames have asserted that the disease model of addiction is open to dispute because neither the drug use nor its resulting behaviors indicate the processes that underlie the use and behaviors, drug use falls along a continuum rather than simply being present or absent as is the case with many diseases, the wide variation in behavioral symptoms of drug abuse may reflect different underlying processes, and specific etiologic factors for substance abuse have not been identified. Sussman & Ames, supra note 21, at 22. Twelve-step programs, such as Narcotics Anonymous, also view addiction as a disease, but one that is spiritual in nature, as well as physical, mental, and emotional. Alcoholics Anonymous, Alcoholics Anonymous (1976). These programs are premised on the belief that individuals must turn to a higher power to assist in their recovery. The mutual support of members is deemed essential to recovery and the avoidance of relapse. These interventions are not addressed in this article because they are outside the scope of patient care. Also, because of their emphasis on anonymity, they are often outside of the reach of formal research undertaken to evaluate efficacy and effectiveness. Although reliance on such programs consequently may not raise legal and ethical issues in the context of treatment from a health care provider or the conduct of research, the lack of data relating to their efficacy and effectiveness should raise ethical issues for judges, who often order participation in such programs. 72. Marlatt, supra note 69. 73. Institute of Medicine, supra note 22, at 83. Other modalities include therapeutic communities and outpatient drug-free communities. Id. Buprenorphine has been touted as a desirable alternative to methadone because it has weaker opiate effects. However, as of March 2004, only 3,951 physicians in the United States were eligible to prescribe buprenorphine to more than the 900,000 existing chronic heroin users. National Institute on Drug Abuse, supra note 1, at 6. Other pharmacological interventions include clonidine, lofexidine, naloxone, and naltrexone. Id. A broader range of pharmacological interventions may be available in other locales, such as the United Kingdom. Harold John Melville & P.C. McLean, Acceptability and Availability of Pharmacological Interventions for Substance Misuse by British NHS Treatment Services, 97 Addiction 59 (2002); see Nicky Metrebian et al., Survey of Doctors Prescribing Diamorphine (Heroin) to Opiate-Dependent Drug Users in the United Kingdom, 97 Addiction 1155 (2002) (finding a large proportion of physicians licensed to dispense heroin refrain from doing so). 74. Grinspoon & Bakalar, supra note 9, at 243. 75. Alan I. Leshner, Addiction Is a Brain Disease, and It Matters, 287 Science 45 (1997). 76. Grinspoon & Bakalar, supra note 9, at 244. 77. Marlatt, supra note 69, at 785. 78. Id. 79. G. Alan Marlatt, Basic Principles and Strategies of Harm Reduction, in Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors 49, 51 (G. Alan Marlatt ed., 1998). 80. School of Public Heath, University of California Berkeley & Institute for Health Policy Studies, University of California-San Francisco, The Public Health Impact of Needle Exchange Programs in the United States and Abroad: Summary, Conclusions and Recommendations (Oct. 1993). The federal government continues to oppose the establishment of needle exchange programs and the use of federal funding to support such programs, despite scientific evidence documenting the benefits of such programs to the addicts, their families, and the larger community and, in most cases, the absence of research on this The of Health & Human Services needle exchange the government not it or support it in be do not that are often the they that reduction the of drug users. and to and to them even more as a of a more of and of and in of R. et al., Harm from the 12 Int'l J. Drug Pol'y 3, 8 (2001). Benedikt Fischer et al., Treatment as a to the Public Health Problem of 12 J. Pub. Health (2002); Treatment, J. Drug 2002). The is In the United methadone is as an it the of a to a biological and, as a its use is with the use of In the of it was found that many persons to the heroin with in on the Medical Prescription of (1997). & B. and in Treatment for Opioid Dependence 1 & L. eds., 1999). 83. Id. at 10. must the to which and of rather than This has been as the medical model of methadone which some is in the the of a drug with the emphasis on Treatment of Drug than 23 (2000). The medical model of methadone is premised on the that methadone to a resulting from opiate dependence, it the for the drug and the of a is for an of time, and in health and are and to the of the Id. at 22. In the model of methadone which is in the United Kingdom, of methadone as a drug that the need to other drugs. A is with the that the be to from it in health and are attributed to cessation of use and on the and only to the of Id. treatment in or the of methadone or during which the a of and also known as during which the is and of the drug is and and in Treatment for Opioid supra note at 53. The of and Heroin in the United Med. (2000). T. & T. in Treatment Results from a National (1992). L. & The of in Treatment for Opioid supra note at 38. L. & Other Substance Use Disorders in and in Treatment for Opioid supra note at supra note at See J. in Alcohol & Drug Addiction Services of Heroin and Other Opioid and for the New 27, 29 (Oct. 1999). As an are only methadone treatment in the of and these are in Id. As of were only methadone programs in the which Institute of Medicine, of Treatment supra note at B. & George E. and Policy in Treatment for Opioid supra note at 15. The of methadone treatment to 1994 is the treatment for methadone treatment is French & Martin, supra note at and Heroin and 37 Substance Use Misuse See R. The Risk of the Public Implications of a 19 J. & Justice Nancy in Cost and Pol'y Inst. & Susan S. Cocaine: Programs (1994); Joan et al., Public and (1985). substance use is an opiate and Buprenorphine are opiate and to and treatment modalities are and they be used or in at different and supra note at 29. it that and heroin were not in this despite the evidence effectiveness in supra note at Needle Exchange supra note at Rebecca American College of Medicine Public Policy on Programs to and 18 J. Med. (2000). et al., The Legal Strategies in Exchange Programs in the United J. Pub. Health (1996). supra note at et al., The of a on of A J. Pub. Health et al., Needle Needles Come J. Pub. Health (1991). et al., Needle There (1993). Richard H. and Needle Exchange Southern Med. J. (1993). et al., Risk of and Among Injection Drug Users in the Exchange 85 J. Pub. Health et al., and an HIV Drug Users in New 1992, W. et al., The Impact of Treatment on Among Heroin J. Pub. Health (2001). & Medical Prescription of Heroin to Heroin in Sci. Int'l 23 (2001); Health of Treatment for Opioid Report Richard Heroin and the Int'l J. Drug Pol'y (1993). Office of Public Health, Treatment with Prescription Heroin: the on the on the Medical Prescription of Heroin with et al., and of Heroin Prescription for Opioid A (2001); Results of the The in of Treatment, supra note at supra note & Prescribing Drug of to Illicit Heroin Users: The of a Drug 13 J. Substance Abuse Treatment (1996). supra note Thomas et al., HIV and Among Drug Users in a Heroin Prescription J. Pub. Health (2001). supra note et al., Effects of Heroin Prescription on Among Drug Addicts, 6 J. Pol'y & Research (1998). et al., New in the Treatment of Heroin Dependence with to 163 This ethical from the the and various by the for International of Medical of the Principles of International Law by the of the Res. 2, at Medical Association, 19 L. Med. & Health Medical Association, of 19 L. Med. & Health for International of Medical International for Research Human available at see generally Michael Origins of the in The Doctors and the Human in Human J. & Michael eds., Thomas L. & James F. Principles of that may a being as a in research … the has the of the or the 45 et al., A History and of Alan et al., Toward a Model of the Legal of 134 J. is a that continues from the of and the of the to perceptions that it only the of a supra note In some the to the data may be the is to a of from the National of Health. The is at Although one found that this mechanism research data from it is to the of research data from enforcement on the basis of this federal & and the of J. Res. (2000). For a discussion of and of with research see and 45 The May the for a 52 J. Clin. This is known as the the and for An 9 Stat. Med. Susan S. in New J. Med. John & Rebecca and in 43 See Thomas L. et al., for

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.