The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- (...) and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually. (shrink)

Two nurses diagnosed with opioid addiction launched legal action after being found guilty of unprofessional conduct due to addiction‐related behaviors. When covered by the media, their cases sparked both public and legal controversies. We are curious about the broader discursive framings that led to these strong reactions, and analyze the underlying structures of knowledge and power that shape the issue of opioid addiction in the profession of nursing through a critical discourse analysis of popular media, (...) legal blogs and hearing tribunals. We argue that addiction in nursing is framed as personal choice, as a failure in the moral character of the nurses, as decontextualized from addiction as disease arguments, and as an individualized issue devoid of contextual factors leading to addiction. Our investigation offers a critical case study of a nursing regulatory body that upheld popular assumptions of addiction as an autonomous, rational choice replete with individual‐based consequences – a framing that is inconsistent with evidence‐based practice in health‐care. We put forth this critical interrogation to open up possibilities for counterdiscourses that may promote more nuanced and effective responses to the issue of addiction in nursing. (shrink)

Charland's article suggests that we need to think more about whether decision-making capacity is impaired in severe addiction, working from the idea that drug dealers rely on this understanding of addiction to draw in their clients. Charland argues that it is possible to make a choice without being in control (to make decisions without having decision-making capacity). I argue in support of Charland's ideas by examining the reasons supporting a medical model of addiction and its importance. (For (...) Charland's article and the full set of commentaries, please see the Research Gate link). (shrink)

Artificial intelligence-based (AI) technologies such as machine learning (ML) systems are playing an increasingly relevant role in medicine and healthcare, bringing about novel ethical and epistemological issues that need to be timely addressed. Even though ethical questions connected to epistemic concerns have been at the center of the debate, it is going unnoticed how epistemic forms of injustice can be ML-induced, specifically in healthcare. I analyze the shortcomings of an ML system currently deployed in the USA to predict patients’ likelihood (...) of opioid addiction and misuse (PDMP algorithmic platforms). Drawing on this analysis, I aim to show that the wrong inflicted on epistemic agents involved in and affected by these systems’ decision-making processes can be captured through the lenses of Miranda Fricker’s account of hermeneutical injustice. I further argue that ML-induced hermeneutical injustice is particularly harmful due to what I define as an automated hermeneutical appropriation from the side of the ML system. The latter occurs if the ML system establishes meanings and shared hermeneutical resources without allowing for human oversight, impairing understanding and communication practices among stakeholders involved in medical decision-making. Furthermore and very much crucially, an automated hermeneutical appropriation can be recognized if physicians are strongly limited in their possibilities to safeguard patients from ML-induced hermeneutical injustice. Overall, my paper should expand the analysis of ethical issues raised by ML systems that are to be considered epistemic in nature, thus contributing to bridging the gap between these two dimensions in the ongoing debate. (shrink)

While much of the social and political attention surrounding the nationwide opioid epidemic has focused on the dramatic increase in overdose deaths among white, middle-class, suburban and rural users, the impact of the epidemic in Black communities has largely been unrecognized. Though rates of opioid use at the national scale are higher for whites than they are for Blacks, rates of increase in opioid deaths have been rising more steeply among Blacks than whites over the last five (...) years. Moreover, the rate of opioid overdose deaths among Blacks already exceeds that of whites in several states. The lack of discussion of Black overdose deaths in the national opioid discourse further marginalizes Black people, and is highly consistent with a history of framing the addictions of people of color as deserving of criminal punishment, rather than worthy of medical treatment. This article argues that, because racial inequalities are embedded in American popular and political cultures as well as in medicine, the federal and state governments should develop more culturally targeted programs to benefit Black communities in the opioid crisis. Such programs include the use of faith-based organizations to deliver substance use prevention and treatment services, the inclusion of racial impact assessments in the implementation of drug policy proposals, and the formal consideration of Black people's interaction with the criminal justice system in designing treatment options. (shrink)

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are (...) concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment. (shrink)

It is common for physicians who prescribe opioids for chronic pain to have their patients sign an opioid contract in order to receive opioid therapy. A vast majority of these contracts contain a stipulation requiring patients to submit to random drug testing which screens for both licit and illicit drugs. Physicians who prescribe opioids may be concerned about prosecution and disciplinary actions; medication abuse and misuse; and addiction. Steven Passik et al. write, “…physicians still fear the risk (...) of abuse or addiction as well as the potential legal consequences of their prescribing.”Issues surrounding OC/RDT need a closer look with a focus on enforceability and efficacy of the opioid contract; accuracy and complications of drug screens and their interpretation; and the importance of trust between patient and physician. In addition, it is vital to dispel fears with facts regarding prosecutions, nonmedical use of prescription opioids, and addiction. (shrink)

Among those who discuss America's opioid crisis, it is popular to claim that we know what we, as a society, ought to do to solve the problem—we simply don't want it badly enough. We don't lack knowledge; we lack the will to act and to fund the right policies. In fact, I've heard two versions of this. Among those who focus on prescription opioids, it is clear that we ought to stop prescribing so many powerful opioid painkillers. And (...) among my public health colleagues focusing on illicit drug use, it is clear that we ought to expand addiction treatment and harm‐reduction services. The problem, however, is that the second claim is not obvious (and, indeed, is denied by many Americans), and the first claim probably isn't even true (at least, not in so crude a form). In short, the opioid crisis presents not only a problem of political will but also one of ethics. It will take work to discover or justify our normative claims in this arena. (shrink)

During the past decade, debate has intensified about the role of long-term opioid therapy in the management of chronic nonmalignant pain. Specialists in pain management have discussed the issues extensively and now generally agree that a selected population of patients with chronic pain can attain sustained analgesia without significant adverse consequences. This perspective, however, is not uniformly accepted by pain specialists and has not been widely disseminated to other disciplines or the public. Rather, the more traditional perspective, which ascribes (...) both transitory benefit and substantial cumulative risk to long-term opioid therapy, continues to predominate. According to this perspective, the inevitability of tolerance limits the possibility of sustained efficacy, and other pharmacological properties increase the likelihood of adverse outcomes, including persistent side-effects, impairment in physical and psychosocial functioning, and addiction. If accurate, these outcomes would indeed justify the withholding of opioid therapy for all but the most extreme cases of chronic nonmalignant pain. (shrink)

During the past decade, debate has intensified about the role of long-term opioid therapy in the management of chronic nonmalignant pain. Specialists in pain management have discussed the issues extensively and now generally agree that a selected population of patients with chronic pain can attain sustained analgesia without significant adverse consequences. This perspective, however, is not uniformly accepted by pain specialists and has not been widely disseminated to other disciplines or the public. Rather, the more traditional perspective, which ascribes (...) both transitory benefit and substantial cumulative risk to long-term opioid therapy, continues to predominate. According to this perspective, the inevitability of tolerance limits the possibility of sustained efficacy, and other pharmacological properties increase the likelihood of adverse outcomes, including persistent side-effects, impairment in physical and psychosocial functioning, and addiction. If accurate, these outcomes would indeed justify the withholding of opioid therapy for all but the most extreme cases of chronic nonmalignant pain. (shrink)

Mortality rates for middle-aged whites in the U.S. are rising due to drugs, alcohol, and depression. Unique to our country, these “deaths of despair” disproportionately occur among the under-educated, who are at particular risk for dying young. At one time, less-educated persons aspired to work in the same factory as their parents, at union wages, with benefits. Those jobs, and the sense of community and prosperity and security they allowed, are evaporating. Many former workers suffer from chronic pain, which underlies (...) America's ongoing opioid overdose epidemic. The pain is not only physical. It is psychic, spiritual, and economic. (shrink)

In “Revive and Refuse,” Marshall et al. (2024) argue that many individuals who are revived from opioid overdoses have diminished decision-making capacity (DMC), given that so many of them have opio...

Bioethicists have sometimes regarded the opioid epidemic as a problem with obvious answers and thus no need for the field's conceptual analysis. Yet, as three essays in the July‐August 2020 issue of the Hastings Center Report demonstrate, the opioid crisis contains a knot of distinctions and puzzles to be sorted out. Travis N. Rieder examines, for example, what is fundamentally driving the crisis—access to the drugs or large societal problems such as poverty and joblessness. The role of choice (...) in addiction, the effects of moral condemnation on approaches to addiction, and what treatment should look like are among the puzzles Hanna Pickard explores, while Daniel S. Goldberg focuses on the common and harmful conflation of the public health problems of substance misuse and pain. These philosophical and bioethical questions point in widely different directions, lying both inside and outside bioethics. They point toward systemic societal factors that determine health and well‐being yet have seemed outside bioethics' largely clinical boundaries. And they point toward a deeper look at the very idea of autonomy—an examination of a topic clearly within bioethics yet occurring at the fringes of its usual constructs. (shrink)

This paper traces the unspoken, implicit white racial logic of the brain disease model of addiction, which is based on seemingly universal, disembodied brains devoid of social or environmental influences. In the United States, this implicit white logic led to “context-free” neuroscience that made the social hierarchies of addiction and its consequences invisible to, and thus exacerbated by, national policies on opioids. The brain disease model of addiction was selectively deployed among the white middle-class population that had (...) long accessed narcotics and pharmaceutical treatments for narcotics disorders from biomedical clinics, as opposed to from illegal sources subject to law enforcement. In turn, new treatments for opioid addiction were racially marketed to the same white clientele to which newly patented opioid analgesics were marketed, tapping into a circumscribed but highly lucrative consumer base that has long benefited from a legally protected, racially segregated safe space for white narcotics consumption. The connecting thread for the contemporary white opioid “crisis,” therefore, is white race as a ghost variable in addiction neuroscience and in its pharmaceutical and biotechnological translation. (shrink)

In August 2017, a group of activists erected in Ottawa's downtown a tent as a first overdose prevention site as a response to what the public and the activists perceived as an epidemic—a devastating wave of opioid and fentanyl overdoses in Canada. The Ontario premier was urged to declare an emergency that would provide increased funding for harm reduction and also send a message to survivors and families that the lives of their loved ones mattered. Thus, the discourses around (...) the so‐called opioid crisis used a language of moral sentiments to legitimate political action. This “new humanitarianism” is considered a priori as good, but in this article, I ask what is politically at stake if we base our actions on the logic of humanitarian reason. The new universalism of humanitarian organizations is based on the individualism of human rights and thus on a moral imperative that replaces the political. Initiatives like the OPS movement often fill the gaps in social services in the absence of the state and address social problems as emergencies and public health issues, thereby transforming them into medical problems—performing the medicalization of sociopolitical problems. This is what I call the NGOization of the opioid crisis. This form of humanitarianism is a universalism of the temporal present without any universal promise for a better future or the amelioration of human conditions—it is a humanitarianism of emergency. What characterizes new humanitarianism is that it responds to situations of suffering that are the result of increasing inequality and injustices without addressing the root causes of this suffering. Not addressing these causes means to be complicit in perpetuating the inequalities and to restrict visions of possible alternatives. (shrink)

Supervised injectable opioid assisted treament prescribes injectable opioids to individuals for whom other forms of addiction treatment have been ineffective. In this article, we examine arguments that opioid-dependent people should be assumed incompetent to voluntarily consent to clinical research on siOAT unless proven otherwise. We agree that concerns about competence and voluntary consent deserve careful attention in this context. But we oppose framing the issue solely as a matter of the competence of opioid-dependent people and emphasize (...) that it should be considered in the context of inequities in access to siOAT as a medical treatment. Consequently, we suggest that bioethics literature on nonexploitation, which focuses on clinical research in low-income countries, is helpful due to locating ethical issues within systemic social conditions. Finally, we consider the implications of our argument for the ethics of clinical research on siOAT. (shrink)

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are ‘drug seeking’, ‘abusing’ and ‘diverting’ prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have (...) received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient–physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient–physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient–physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients’ subjective knowledge in enhancing physicians’ self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain. (shrink)

Prescription opioid policies too often reflect over a century's worth of moralizing about the nature of opioid use disorder, the value of pain, and the meaning of suffering. The social and legal penalties to prescribers run in one direction—avoid overprescribing, however defined, at all costs. The lack of shared definitions is problematic for formulating and evaluating opioid policy. For example, the variant definitions of “misuse,” “abuse,” and “addiction” complicate estimates of morbidity. There are also no widely (...) accepted definitions of misprescribing and overprescribing. I offer here a modest attempt at the categorization of misprescribing: inadvertent overprescribing, corrupt overprescribing, qualitative overprescribing, quantitative overprescribing, multiclass overprescribing, and underprescribing. (shrink)

Any ethical inquiry into addiction research is faced with the preliminary challenge that the term “addiction” is itself a matter of scientific and ethical controversy. Accordingly, the chapter begins with a brief history of the term “addiction.” The chapter then turns to ethical issues surrounding consent and decision-making capacity viewed from the perspective of the current opioid epidemic. One concern is the neglect of the cyclical nature of addiction and the implications of this for the (...) validity of current psychometric instruments used to evaluate decision-making capacity in addiction. Another is the apparent discrepancy—possibly an ethical double standard—in the manner in which society and addiction researchers view the mental capacity and vulnerability of individuals who suffer from severe addiction. On the whole, the main ethical concern of the chapter is the puzzling lack of clinical research on decision-making capacity in research on addiction. (shrink)

This investigation develops in three steps. First, we seek to complexify the opioid crisis in a way that helps us to see how the issues of misguided desire and misplaced attachments are fundamentally important for a theological account of opioid addiction.1 Second, acknowledging the connections between pain and opioid addiction, we explore some of the ways in which our understanding of pain can influence our understanding of and responses to opioid use. Finally, we offer (...) some tentative reflections on the theological and ecclesial dimensions of the opioid crisis which hold the potential to influence the nature of a Christian response to the issues. Having laid out these steps, we argue for the church’s calling, where she complexifies the narratives about the opioid crisis and provides individuals suffering from opioid use “homeful” encounters with God and the community. (shrink)

There is overwhelming evidence that the opioid crisis—which has cost hundreds of thousands of lives and trillions of dollars (and counting)—has been created or exacerbated by webs of influence woven by several pharmaceutical companies. These webs involve health professionals, patient advocacy groups, medical professional societies, research universities, teaching hospitals, public health agencies, policymakers, and legislators. Opioid companies built these webs as part of corporate strategies of influence that were designed to expand the opioid market from cancer patients (...) to larger groups of patients with acute or chronic pain, to increase dosage as well as opioid use, to downplay the risks of addiction and abuse, and to characterize physicians’ concerns about the addiction and abuse risks as “opiophobia.” In the face of these pervasive strategies, conflict of interest policies have proven insufficient for addressing corporate influence in medical practice, medical research, and public health policy. Governments, the academy, and civil society need to develop counterstrategies to insulate themselves from corporate influence and to preserve their integrity and public trust. These strategies require a paradigm shift—from partnerships with the private sector, which are ordinarily vehicles for corporate influence, to a norm of separation. (shrink)

Graphical AbstractThis commentary discusses the novelty of the preclinical opioid choice model published in Heinsbroek et al., Nat Commun, 2021, and the potential influence of altitude on the reported findings. The studies were performed in the Mile High City of Denver, Colorado, where a unique subpopulation of heroin-choosing rats were noted.

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a “pure” antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a (...) dominant explanatory and therapeutic model for addiction was likewise unsettled. After naloxone’s discovery, new dichotomizing language arose in the “War on Drugs,” in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief. (shrink)

Growing opioid misuse in the United States has resulted in more children living with an adult with an opioid use history. Although an abundance of research has demonstrated a link between opioid misuse and negative parenting behaviors, few intervention efforts have been made to target this underserved population. The Family Check-Up has been tested in more than 25 years of research, across multiple settings, and is an evidence-based program for reducing risk behavior, enhancing parenting skills, and preventing (...) the onset of substance use. It is designed to motivate parents to engage in positive parenting practices and to change problematic parenting and has been tested across a variety of ages including early childhood and adolescence. It is highlighted in NIDA’s Principles of Substance Use Prevention for Early Childhood: A research-based guide as one of only three effective selective prevention programs for substance abuse among families with young children. Recently, we developed an online version of the FCU that has now been adapted for early childhood and families with opioid use histories. The online platform and telehealth model allow for wide-scale dissemination, ease of training with community providers, and increased public health reach for families in remote, rural areas. This is particularly important when targeting families with opioid misuse and addiction because there are high rates of addiction in remote areas, yet few services available. In this article, we describe the FCU Online and review new content in the model that targets a population of young adult parents with substance abuse histories, including opioid use. New modules include content focused on harm reduction for this high-risk population of parents, such as safety in the home, substance use while parenting, and managing conflict with partners and friends. (shrink)

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration. Annual registration is contingent on compliance with both the DEA's security regulations as well as treatment regulations jointly promulgated by the Food and Drug Administration and the National Institute on Drug Abuse.During the last decade, a number of events have occurred that persuaded NIDA that (...) it is time to reevaluate the current method by which the Department of Health and Human Services regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs. (shrink)

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration. Annual registration is contingent on compliance with both the DEA's security regulations as well as treatment regulations jointly promulgated by the Food and Drug Administration and the National Institute on Drug Abuse.During the last decade, a number of events have occurred that persuaded NIDA that (...) it is time to reevaluate the current method by which the Department of Health and Human Services regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs. (shrink)

In this issue of the Hastings Center Report, Joshua Rager and Peter Schwartz suggest using opioid treatment agreements as public health monitoring tools to inform patients about “the requirements entailed by undergoing opioid therapy,” rather than as contractual agreements to alter patients’ individual behavior or to benefit them directly. Because Rager and Schwartz's argument presents suspected OTA violations as a justification to stop providing opioids yet does not highlight the broader epistemic and systemic context within which clinicians prescribe (...) these medications, their proposal may perpetuate a climate of distrust and stigmatization without correcting systemic factors that may have placed patients and others at risk in the first place. Given the context of epistemic uncertainty regarding opioid safety and efficacy, insufficient training for opioid prescribers, and inadequate patient education, I propose replacing OTAs, which have a narrow focus on patient behaviors, with opioid treatment plans, which would promote mutual, collaborative, and shared decision-making on the most appropriate pain management program. An OTP can be ethically justified as a tool to prevent and treat iatrogenic addiction under a specific paradigm—one that adopts a default position of professional epistemic humility and holds all collaborative parties accountable in chronic pain management. (shrink)

In 2022, the Camden Coalition Medical-Legal Partnership began providing civil and criminal legal services to substance use disorder patients at Cooper University Health Care’s Center for Healing. This paper discusses early findings from the program’s first year on the efficacy of the provision of criminal-legal representation, which is uncommon among MLPs and critical for this patient population. The paper concludes with takeaways for other programs providing legal services in an addiction medicine setting.

The neuropsychoanalytic approach solves important aspects of how to use our understanding of the brain to treat patients. We describe the neurobiology underlying motivation for healthy behaviors and psychopathology. We have updated Freud’s original concepts of drive and instinct using neuropsychoanalysis in a way that conserves his insights while adding information that is of use in clinical treatment. Drive (Trieb) is a pressure to act on an internal stimulus. It has a motivational energic source, an aim, an object, and is (...) terminated by the satisfaction of a surge of serotonin. An instinct (Instinkt) is an inherited pattern of behavior that varies little from species to species. Drives are created by internal/ventral brain factors. Instincts require input from the outside that arrive through dorsal brain structures. In our model unpleasure is the experience of unsatisfied drives while pleasure if fueled by a propitious human environment. Motivational concepts can be used guide clinical work. Sometimes what had previously described psychoanalytically as, “Internal conflict,” can be characterized neurobiologically as conflicts between different motivational systems. These motivational systems inform treatment of anxiety and depression, addiction in general and specific problems of opioid use disorder. Our description of motivation in addictive illness shows that the term, “reward system,” is incorrect, eliminating a source of stigmatizing addiction by suggesting that it is hedonistic. Understanding that motivational systems that have both psychological and brain correlates can be a basis for treating various disorders. Over many papers the authors have described the biology of drives, instincts, unpleasure and pleasure. We will start with a summary of our work, then show its clinical application. (shrink)

While providing people with the same nicotine that forms the basis of their physical addiction, there is no available evidence that electronic nicotine delivery systems have carcinogenic eff...

Despite shifts in rhetoric and some positive movement, Americans with the disease of addiction are still often stigmatized, criminalized, and denied access to evidencebased care. Dramatically reducing the number of lives unnecessarily lost to overdose requires an evidence-based, equity-focused, well-funded, and coordinated response. We present in this brief article evidence-based and promising practices for improving and refocusing the response to this simmering public health crisis. Topics covered include improving clinical decision-making, improving access to non-judgmental evidence-based treatment, investing in comprehensive (...) public health approaches to problematic drug use, and changing the way law enforcement actors interact with people who use drugs. (shrink)

An emerging ethical dilemma in light of the opioid crisis, repeat cardiac valve replacements for patients diagnosed with endocarditis from intravenous drug use presents specific challenges to Catholic health care organizations. While secular health care is tasked with the allocation of scarce resources, Catholic institutions must address additional considerations when balancing stewardship of scarce resources, human dignity, and patient accountability. A recent ethics consultation illustrates the issues involved in multiple valve replacements for substance-addicted patients from a Catholic ethical perspective. (...) The discussion includes policy recommendations and ethical reflections. (shrink)

In recent years, public discourse has largely embraced the idea that persons with addictions have a “brain disease,” and ought to be treated medically rather than judicially. This article first argues that this social shift is mostly the result of middle- and upper-class whites being among the addicted. The medical language is deployed so that such persons avoid the stigma of “deviance” commonly linked to addiction. Second, this article argues for a Christian “holy deviance,” whereby Christians become deviant by (...) going out to those who are already marked by society as deviant, letting the latter know in word and deed that they are loved. (shrink)

Intravenous drug abusers may incur bloodstream infections, in particular those involving the heart valves, that often require extended courses of antibiotics, commonly on the order of six weeks.Conventional wisdom has dictated that even when patients are sufficiently well to not need ongoing hospitalization, it is unsafe to complete their antibiotic course in any setting other than in a closely supervised facility, even if this is contrary to their wishes. The assumption has been that such patients would be at risk of (...) using their indwelling intravenous catheter for illicit purposes. Recent advances in the care of patients who suffer from addiction disorders suggest that when patients receive state-of-the-art addiction treatment, many may be able to continue their intravenous antibiotic course unsupervised, at home. This represents a departure from the parentalistic model of care of impaired patients who are prone to self-harm, moving towards a model that respects autonomy and trusts patients who are in recovery to continue their care in a manner that is self-beneficial. (shrink)

As the rates of intravenous opioid use have increased, so have its associated medical complications, such as endocarditis, and known interventions, such as heart‐valve replacements. For many patients, including Jacob, whose case was brought to my psychiatric consult service and to my colleagues in the clinical ethics service, relapse increases the risk of repeat endocarditis and the need for repeat surgical interventions. Previous works have posed the bioethical quandary regarding the responsibilities of a surgeon in these repeat procedures and (...) whether a surgeon may ethically refuse to perform a repeat intervention in a patient who has relapsed. Notions of futility are commonly used to navigate this complex terrain, and they were the focus of the ethics consideration given to Jacob's case, in which surgeons were reluctant to perform valve replacements. In this narrative essay, I interrogate the concept of futility by appealing to its history and variable meanings, and I argue against its relevance in cases like Jacob's. I propose that a more suitable bioethical approach in such cases would consider resource allocation, the sociocultural stigma of addiction, and the interpersonal and narrative factors that make each case unique. (shrink)

According to Marshall et al. (2024), some of the patients who refuse to stay in observation after being resuscitated following an opioid overdose are likely not making an autonomous choice. While I do not intend to dispute this claim, it merits discussion what is the concept of autonomy at play in making this assessment. I contend that the concept at work is more substantive than Marshall et al. acknowledge—and more substantive, too, than the form of autonomy usually thought to (...) underpin the moral justification of the requirement of informed consent . (shrink)

Buprenorphine is a form of opioid agonist treatment that has been demonstrated to be an effective medication for opioid addiction. It is available in different formulations and marketed under various trade names, including commonly as a buprenorphine/naloxone combination. This paper provides an overview of existing literature on the supply of buprenorphine treatment, the ability of people to access treatment with buprenorphine, and the quality of treatment received. We argue that better data for each of these aspects of (...) treatment could inform policy to expand effective treatment with buprenorphine, and we suggest steps to obtain and act on such data. (shrink)

Recent developments regarding the pharmacology of psychoactive substances are significant for treating depressions or opioid addictions. Current theories, hypotheses, and models of drug effects assume a cause–effect narrative, which is based on a stimulus/response mechanism. These narratives prioritize effects rather than conscious experiences. In this sense, drug experiences are quickly subsumed into common categories and codes of biological determinism. If subjective experiences are in the focus of the research, it quickly becomes a link to mystical, spiritual, or transcendental narratives. (...) These classifications lead to epistemological doublets (Gadamer). In this article, psychedelic experiences of drug users are analyzed in the frame of the pharmaco-analysis by Deleuze/Guattari. These framed psychedelic experiences are interpreted by means of a non-philosophical approach through philo-fictions (Laruelle), i.e., contradictory assumptions and hyperspeculations. In this respect, the aim of this article is to bring philo-fictions in relation to psychedelic experiences and to discuss them with models of information science, quantum mechanics, new materialism, and the philosophy of immanence. The result will be an open synthesis, with the assumption of further reflections on the agency, immanence, and the wholeness of matter. (shrink)

Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and citizenship of (...) the participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

In this essay, I offer some reflections on how the topics were identified and approached by the Presidential Commission for the Study of Bioethical Issues, on which I had the honor to serve, in the hope that the reflections may be useful to future national bioethics commissions. In the executive order that established the bioethics commission, President Obama explicitly recognized the ethical imperative to responsibly pursue science, innovation, and advances in biomedical research and health care, and the importance of national (...) attention to these issues. The bioethics commission prioritized practicable, actionable, targeted recommendations. Like most earlier U.S. national bioethics commissions, President Obama's commission did not undertake projects on significant and troublesome issues related to health and health care that were not associated with new science or technology. Issues such as health care access, health care delivery, opioid addiction, end‐of‐life care, and physician‐aid‐in‐dying are topical and ethically complex areas of significance to bioethics, and they are also being discussed and debated by the public, the media, and policy‐makers. In my view, there are good reasons to select and prioritize projects as well as a justification for confining commission efforts to issues related to novel science and emerging technologies, when there is only one national‐level bioethics commission that has been established by the Office of the President. (shrink)

This paper is a study about Philadelphia’s comprehensive user engagement sites (CUESs) as the authors address and examine issues related to the upcoming implementation of a CUES while seeking solutions for its disputed questions and plans. Beginning with the federal drug schedules, the authors visit some of the medical and public health issues vis-à-vis safe injection facilities (SIFs). Insite, a successful Canadian SIF, has been thoroughly researched as it represents a paradigm for which a Philadelphia CUES can expand upon. Also, (...) the existing criticisms against SIFs are revisited while critically unpackaged and responded to in favor of the establishment. In the main section, the authors propose the layout and services of the upcoming CUES, much of which would be in congruent to Vancouver’s Insite. On the other hand, the CUES would be distinct from Insite, as the authors emphasize, in that it will offer an information center run by individuals in recovery and place additional emphasis on early education for young healthcare professionals by providing them a platform to work at the site. The paper will also briefly investigate the implementation of a CUES site under an ethical scope of the Harm Reduction Theory. Lastly, the authors recommend some strategic plans that the Philadelphia City government may consider employing at this crucial stage. (shrink)

Background: Psychopathy and substance use disorders are highly co-morbid and their co-occurrence is associated with higher severity of addictive behavior and increased risk of violent offending. Both substance use disorders and psychopathy are related to prominent impairments in emotion processing, which are also central features of alexithymia. The nature of the relationship between psychopathy and alexithymia is not well understood and has been particularly understudied among substance dependent individuals. Aims: Our goal was to evaluate the levels of psychopathy and alexithymia (...) in a relatively homogeneous sample of heroin dependent individuals and healthy controls and to examine group differences in the pattern of associations between these constructs. Methods: We examined 62 participants (31 heroin dependent individuals and 31 healthy controls) with the Psychopathy Checklist: Screening version (PCL:SV, Hart et al., 1995) and the Toronto Alexithymia Scale-20 (TAS-20, Bagby et al., 1994). Results: Heroin dependent individuals were characterized by higher levels of both psychopathy and alexithymia as compared to the control group. In addition, heroin dependent individuals with higher levels of psychopathy reported more difficulties in identifying and verbalizing emotional states. In the heroin group, alexithymia was more strongly associated with the impulsive/antisocial characteristics (impulsivity, irresponsibility, antisocial behavior) than with the interpersonal/affective features of psychopathy (grandiosity, manipulativeness, lack of empathy and remorse). Conclusions: Our findings suggest that alexithymia may be one potential mechanism linking psychopathy with opioid use disorders. The development of interventions targeting alexithymia could have significant applications in relapse prevention programs and psychotherapy of substance use disorders with concurrent psychopathy. (shrink)

Generic generalisations like ‘Opioids are highly addictive’ are very useful in scientific communication, but they can often be interpreted in many different ways. Although this is not a problem when all interpretations provide the same answer to the question under discussion, a problem arises when a generic generalisation is used to answer a question other than that originally intended. In such cases, some interpretations of the generalisation might answer the question in a way that the original speaker would not endorse. (...) Rather than excising generic generalisations from scientific communication, I recommend that scientific communicators carefully consider the kinds of questions their words might be taken to answer and try to avoid phrasing that might be taken to provide unintended answers. (shrink)

ABSTRACT Defining a nonpaternalistic yet achievable form of trust in medicine in an era of simultaneous patient empowerment and institutional control has been and remains an important task of bioethics. The ‘crisis of trust’ in medicine has been viewed mainly as the problem of getting patients to trust their health care providers, especially physicians. However, since paradigmatic cases of trust are mutual, bioethicists must pay more attention to physician trust in patients. A physician’s view of the reasonableness of trust in (...) a particular patient is affected not just by his or her relationship with that patient, but also by what is going on institutionally, professionally, legally, and politically with regard to a given treatment or intervention. Since general moral principles are insufficient in determining the moral value and reasonableness of trust in particular instances, I discuss in detail the role of trust and distrust in the specific case of treating patients with medications implicated in drug abuse. I conclude that it is important to become aware, first, of the clinical significance of physician trust and distrust in patients, and second, of the many factors which inform both of these moral attitudes. These two claims together suggest that a central, but overlooked, virtue of medical practice is reflective, context‐responsive trust in patients. (shrink)

The argument from inductive risk claims that judgments about the moral severity of errors are relevant to decisions about what should count as sufficient evidence for accepting claims. While this idea has been explored in connection with evidence required for the approval of pharmaceuticals, the role of inductive risk in the post-approval process has been largely neglected. In this article, we examine the ethics of inductive risk in connection with revisions to the product monograph for OxyContin in Canada, which understates (...) the risks of addiction and abuse associated with this drug. Using the concept of inductive risk, we consider what evidence should have been sufficient for Health Canada to revise the product monograph for OxyContin. Given the stakes involved, we argue that a less strict standard of evidence would have been appropriate, yet HC in fact took the opposite course, insisting upon a higher standard of evidence than it normally requires. In addition to providing a novel perspective on the opioid crisis in Canada, this article contributes to existing philosophical work by demonstrating that inductive risks in the post-approval stage are important and linked to pre-approval inductive risks. (shrink)

While pain is common among seniors, it is not adequately treated or managed. In particular, pain in seniors with dementia is often undertreated and undermanaged. Although the undertreatment of pain among persons with cognitive impairments represents a serious ethical concern for pain clinicians, most writers in the area explain the undertreatment of pain by focusing on issues related to liability, fears of addiction to opioids, and erroneous beliefs that pain is a normal part of the ageing process. We argue (...) that the philosophical notion of personhood must also be given careful attention when considering the problem of pain undermanagement. In this paper, we consider the undertreatment of pain among seniors with dementia, while focusing on the ontology of relationships and on existential philosophy. Moreover, we outline a series of recommendations to help minimize the probability of pain undertreatment in this population and to encourage considerations relating to personhood when treating people with dementia. (shrink)