Tag Archives: medicalization

Involuntary Hospitalization of Drug Users Is Bad Policy

Note: This essay was originally published in TruthOut, November 19, 2015. I’ve reposted it today because calls for involuntary hospitalization are again popping up around the country in response to the perceived opioid “epidemic.” The bill that was eventually passed by the Massachusetts House and then sent to the Senate did not include Governor Baker’s proposal to allow involuntary hospitalization of drug users. Click here for the text of the enacted AN ACT RELATIVE TO SUBSTANCE USE, TREATMENT, EDUCATION AND PREVENTION, signed by the Governor on March 14, 2016.

 

November 2015: Massachusetts appears to be on the cusp of adopting legislation proposed by Governor Baker (Republican) that would allow doctors to hospitalize drug users, involuntarily and without a court order, for 72 hours (H.3817). Previously, the power to order involuntary commitment of drug or alcohol users lay exclusively in the hands of judges under a Massachusetts’ law known as Section 35. At this time, few states give judges similar power to take away the freedom of individuals not accused of a crime. (1)

The proposed bill also would limit doctors to prescribing a 72-hour supply of opiate painkillers to patients receiving a first-time prescription for acute pain. While the second part of the plan has received criticism – concern that patients needing painkillers may not be able to reach their doctors for a refill in a timely manner – the first part of the plan has received virtual cross-the-board support. According to press reports, the majority of Massachusetts’ sheriffs as well as the association representing Massachusetts’ district attorneys have come out in favor of the bill. Hampshire County Sheriff Robert Garvey’s comments represent the growing opinion that, “The governor’s bill changes the attitude that addiction is not a criminal offense as much as it is a medical problem.”

Sheriff Garvey’s remarks are echoed around the country. For a variety of reasons – including a shift in media portrayals of the race of drug users — – we currently are experiencing a cultural and judicial movement away from criminalization and towards medicalization of substance abuse. Massachusetts might well be the vanguard of this movement. Not only is Massachusetts a relatively “white” state at a time in which the new face of drug use is Caucasian, but it also is the first state to have passed the healthcare coverage reform (“Romneycare”) that later became the law of the land nationally (“Obamacare.”)

Addiction Treatment and the Role of Physicians

Having worked for the past decade with criminalized women, most of whom struggle or have struggled with addiction issues, I am far from convinced that the Governor, sheriffs and district attorneys have got it right. While re-categorizing addiction as a medical rather than a judicial issue certainly sounds like step in the right direction, giving doctors unchecked power to hospitalize people against their will opens the door for serious human rights violations. Our legal system, like that of other modern democracies, insists that an individual should not lose his or her freedom without the due process of law. A doctor, committing people without an opportunity for those people to be represented by counsel, will be asked to serve as both prosecutor and judge – a position that directly contradicts principles of American jurisprudence and places doctors in an uncomfortable and untenable position vis-à-vis their patients. Knowing that doctors have this power will, I fear, serve to discourage people who could benefit from immediate medical attention from seeking assistance.

More broadly, the proposed bill puts the onus on physicians to fix social problems.

I understand that the motives behind the proposed bill are benign. However, I assume that the image of the doctor – patient relationship in the minds of the governor, sheriffs and district attorneys is most likely the kind of relationship they have with their own family doctors – a doctor who knows their history and their families, who has a good grasp of their patients’ medical and social backgrounds. However, it is likely that the doctors who will be committing patients under Governor Baker’s plan are emergency room doctors or hospitalists; that is, doctors who meet the patient for the first time at the encounter that leads to the commitment. Asking doctors single-handedly to take away the freedom of patients whom they barely know is not a reasonable burden to place on doctors.

I have great respect for doctors and I understand their frustration at treating patients for overdoses, only to watch these same patients walk out the hospital door immediately following stabilization. However, the bottom line is that there is no evidence whatsoever to indicate that three days of treatment will have any impact upon drug users. (The three day proposal, I assume, is based on the three day commitment for psychiatric patients under Massachusetts General Law, Section 12, though, since no reason is articulated for the three day idea it might just as easily, although perhaps subconsciously, follow the three days between the crucifixion and resurrection of Christ). In any case, there is little to no evidence showing that coerced drug treatment is effective. (2)

When patients are released after their three-day involuntary commitment, there is no reason to think that they will not return to their former drug use. In fact, having abstained from opiates for several days may set them up to overdose when they return to their former level of drug use but with a reduced tolerance for the drugs. (3) If a plan were in place to provide long-term, multi-faceted support after the three days I might have a different take on the proposal. But I do not see that Governor Baker’s bill includes such a plan, or a way to fund it. As I’ve seen repeatedly among the women with whom I work, even the “good” – that is, three month or six month – rehab placements end with people going back out into poverty, unemployment, scarce community support and (often) homelessness. These are sure recipes for sending them back into the drug use / detox cycle.

Blind Faith

We Americans have great respect for physicians and we trust that their medical training is the best in the world. However, addiction treatment is not a substantial part of most medical school curricula, and even in instances where doctors took a course (typically an elective) in the subject, given the rapidity with which the field of addiction treatment is progressing, their knowledge in the field may well be outdated. (4) Anecdotally, I personally have spoken with physicians who know nearly nothing about Suboxone and have never administered a dose of Narcan. Few hospitals in Massachusetts, and even fewer in other parts of the country, have more than one or two addiction medicine specialists on staff, which means that non-specialists will be tasked with the responsibility of deciding whether or not to commit patients who, in many cases, are seen as a nuisance or “revolving door” patient group.

I also know from having spoken with doctors around the country that they, like politicians around the country, tend to believe that twelve step programs are effective for treating addiction when, in fact, there is no evidence showing that Narcotics Anonymous participation (and especially coerced NA participation) leads to long-term abstention from drug use. (5) Indeed, I suspect that lying behind the proposed legislation is the notion, propagated by twelve step organizations, that alcoholism and substance abuse are “diseases” that take over one’s life; that people living with alcohol or substance-abuse disorders lack the capacity to make sound decisions (which is why they must turn themselves over to a “Higher Power.”)

Race Matters

I do not doubt that the vast majority of doctors are thoughtful, fair and knowledgeable. But I do know that there is a sufficient history of medical abuses – including medical experiments on prisoners and on African American men (the infamous Tuskegee syphilis experiment) to require all medical research to undergo thorough vetting and oversight by ethics reviews boards (IRB). In the frenzied panic over opiate deaths in Massachusetts, Governor Baker’s bill lacks a requirement for any sort of oversight. Decades of research show that doctors may tend to treat patients differently depending on the gender or the race both of the patient and of the doctor. (6)

It certainly should raise eye-brows that the popular push to re-label addiction and send addicts to ‘treatment’ rather than prison is taking place at a time when public attention has shifted from Black crack users to White opiate users. At the same time, as I have argued before, redefining people as “sick addicts” rather than “criminal addicts” is not as significant a social shift as one may think. In both cases they are labeled as flawed individuals who have failed to take responsibility for their own lives. In both cases, the onus for “deviance” lies on the individual rather than on the society that creates and sustains social and economic conditions that lead far too many people to feel that mind-altering and mood-altering substances are the best – or the only – means of making it through the day, the week or their lives. And clearly, those people labeled as “addicts” or “drug abusers” are not all that deviant. Throughout the United States, the normative way for dealing with misery is through doctors’ prescriptions for attention challenges, for anxiety, for depression and even for low libido. (7)

And Class Matters

The “epidemic” of opiate related deaths is not spread evenly across White America. In fact, the new attention to white opiate users exposes an important and seldom discussed reality of American society: Class matters. The white opiate users in Massachusetts overwhelmingly come from poor and working-class white communities – mostly non-urban — where good jobs are scarce and where young people see little hope for ever attaining the American dream.

The criminalized women I have come to know over the past decade are, for the most part, poor and white, and I believe that they represent a tragic social trend. According to research published in 2014 by sociologist William Cockerham “For the first time in modern history, the life expectancy of a particular segment of the American population— non-Hispanic white women with low levels of education and income living in certain rural counties—is declining.” And the same decline is happening among white men. (8) Opiate abuse is one of the factors explaining declining life expectancies in these communities, but it is crucial that we understand that opiate abuse is a symptom of hopelessness, disaffection, powerlessness and marginalization. Unless we treat those social forces we are deceiving ourselves if we think that allowing physicians to commit drug users for three days is going to do anything other than intensify those forces.

Notes

  1. Testa, Megan and Sara G. West. 2010. “Civil Commitment in the United States.” Psychiatry (Edgmont). 7(10): 30–40.
  2. Urbanoski, Karen. 2010. Coerced Addiction Treatment: Client Perspectives and the Implications of Their Neglect.” Harm Reduction Journal. 7(13).
  3. Strang, John, Jim McCambridge, David Best, Tracy Beswick, Jenny Bearn, Sian Rees and Michael Gossop. 2003. “Loss of Tolerance and Overdose Mortality after Inpatient Opiate Detoxification: Follow Up Study.” BMJ (British Medical Journal). 326(7396): 959–960.
  4. Rasyidi, E, JN Wilkins and I Danovitch. 2012. “Training the Next Generation of Providers in Addiction Medicine. Psychiatr Clin North Am. 35(2):461-80.
  5. Dodes, Lance and Zachary Dodes. 2014. The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Boston: Beacon Press
  6. Staton, LJ et al. 2007. “When Race Matters: Disagreement in Pain Perception between Patients and Their Physicians in Primary Care.” Journal of the National Medical Association. 99(5):532-8; Weisse, Carol S., Paul C Sorum, Kafi N Sanders and Beth L Syat. 2001. “Do Gender and Race Affect Decisions About Pain Management?” Journal of General Internal Medicine. 16(4): 211–217.
  7. Greenberg, Gary. 2013. The Book of Woe: The DSM and the Unmaking of Psychiatry. NY: Plume.
  8. Cockerham, William. 2014. “The Emerging Crisis in American Female Longevity.” Social Currents. 1(3): 220-227.

 

Acknowledgments: I wish to thank Barak Sered, MD for his expert advice and input into this paper. All opinions and errors are solely my own.

Why Brain Science Won’t Cure Poverty

This article was first published by The Conversation.

Recently I’ve seen news reports with headlines like this one: “Can Brain Science Help Lift People Out Of Poverty?

This particular article described the near miraculous recovery of a woman who grew up surrounded by violence in the housing projects, became a “single mom on welfare” who wasted her money and damaged her health with a pack-a-day smoking habit, and was stuck in an abusive relationship. Then, with the help of “a novel program that uses the latest neuroscience research to help women dig themselves out of poverty” by making better choices, she quit smoking, got rid of the bad boyfriend, earned a business management degree and landed a job as an administrative assistant. It’s not the only article I’ve seen recently that is looking at brain science as a way to cure poverty.

The enchantment with neuroscience to explain social misery has spread among individuals and organizations with longstanding commitments to progressive social change. “What the new brain science says is that the stresses created by living in poverty often work against us, make it harder for our brains to find the best solutions to our problems. This is a part of the reason why poverty is so ‘sticky,’” explained Elisabeth Babcock, chief executive of the nonprofit Crittenton Women’s Union. Recent research from Princeton University has suggested that living in poverty can have an impact on concentration. Other research has found a similar correlation between poverty and neuroscience.

There is growing public discourse invoking neuroscience to re-emphasize that poverty really is bad, that bullying and abuse really hurt children, and that someone who has experienced rape or torture really is suffering. But uncritically invoking neuroscience is a risky propositionContinue reading Why Brain Science Won’t Cure Poverty

White Women, Opiates and Prison

Author’s note: Race is hard to write about; so is class; so is gender. I struggle with articulating — especially in a short essay —  two truths. Broad social forces and inequalities impact life experiences. And, each individual has her own unique life experiences framed by the particular ways in which class, race, gender, sexual orientation, ethnicity, nationality, citizenship status and other social categories intersect for her. I thank Robin Yang and Lois Ahrens for helping me try to get it right here. I accept sole responsibility for bits where I’ve missed the mark.

Black men have been the face of incarceration in America for decades, and black men continue to be locked up at rates far exceeding those of other gender and racial demographic groups. But, over the past few years, just as the pace of incarceration finally began to decline for men and for black women, incarceration rates have risen by 47.1% for white women. Opiate use seems to be driving much of that increase.

CDC Director Tom Frieden, in a 2013 briefing, announced that rates of opiate use, abuse, overdose and death are rapidly increasing among women. Aside from age (those in the 45-54 year age group have the highest rate of opiate related death), Frieden did not offer demographic details beyond the rather meaningless “mothers, wives, sisters, and daughters.”

Research published last week by the Boston Globe found that the number of babies born in Massachusetts with opiates in their system is more than triple the national rate, and that the numbers in Maine and Vermont are even worse. This research did not track race, but we do know that Maine and Vermont are two of the whitest states in the county – 95% white, Massachusetts is 84% white, and that many of the opiate hot spots in these states are poor, white communities. In Fall River, for instance, approximately 72% of residents have received a prescription for opiates, a rate well above the state average of 40 percent.

While the media seems shocked to “discover” that white women make illicit use of drugs, we really should not be surprised. Indeed, over the same years in which black men were the face of incarceration, white women were the face of medicine. White women take more prescription and over-the-counter medication, are prescribed more pain medication, undergo more cosmetic surgery, and make more doctor visits than any other major demographic group. White women are the greatest users of commercial holistic healing (alternative and complementary medicine). And white women are over-represented on pharmaceutical commercials and in high profile “war on illness” campaigns such as the pink ribbon breast cancer extravaganzas.

Just as higher incarceration rates do not necessarily mean that black men are especially wicked, higher medication rates do not necessarily mean that white women are especially sick. They do mean that white women tend to be portrayed as particularly in need of — and deserving of — expert medical care, and that the health challenges of white women are treated with more attention than the health challenges of other groups. Think, for instance, of how the natural aging process becomes seen as a medical problem (medicalized) when millions of prescriptions are written for hormone replacement therapy (HRT) for women who do not have any disease other than not being young. And think of the racial implications of these findings from a large government study released in the 1990s: HRT use among white women was 89% higher than among black women and white women were 54% more likely than black women to receive HRT counseling from their doctors.

Women – and especially white women – are prescribed more psychiatric medication (especially for depression and anxiety) than men. Jonathan Metzl, in Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs, traced advertisements for psychiatric medication in the American Journal of Psychiatry over a period of decades. He found that marketing to doctors disproportionately addressed women’s problems. Advertisements for Milltown and then Valium featured women’s unhappiness with their husbands, family responsibilities and sex, and offered medication as a way to make them more compliant with expected gender roles. Overwhelmingly, the pictures in these advertisements were of white women benefiting from treatment provided by white male doctors.

…..

What does all of this mean for white women’s experiences of opiates today? Continue reading White Women, Opiates and Prison

Medicalization of the Death and Other Penalties

Executions of three men in Oklahoma and Ohio have been postponed recently in the wake of controversy regarding the botched administration of lethal injections.

Lethal injection table. (Photo: <a href=" https://www.flickr.com/photos/kenpiorkowski/11501354666/in/photolist-iwks3o-7T8bhE-nvjDfh-BFeFH-atNfvj-j1SMiz-dfe8c-57C3i3-5YEDVk-dCh1ad-8ViGsY-8ViGgs-4jjfVB-bwwHQ7-5YJSFo-ediZUT-LtcQL-nuZBTq-nQS5KZ-nvjDjA-nvjDjf-9Q5HY1-apoiVi-nvjDiU-5961SS-cp4c1Q-8VmRzW-drAGpU-ofdXe-4CMpR2-ectFEr-8ViHjY-8ViHdm-8ViHgG-8ViHaq-bo99Lg-8ViGQL-8ViGWJ-7wY18P-8VfCgk-8VfCdH-5nuZnD-7pkB92-4HYrVk-4FNumb-nuq6pB-8PssQT-bM7Gs6-gwXrCE-a2gjpo" target="_blank">Ken Piorkowski / Flickr</a>)Lethal injection table. (Photo: Ken Piorkowski / Flickr)

Capital punishment is by nature controversial. Can the state ever be 100 percent sure that the person sentenced to execution really committed the crime? Is there no possibility that evidence was overlooked or misinterpreted, that confessions were coerced or that there were mitigating circumstances? Looking at the photos of the three Oklahoma and Ohio men raises additional questions: Is it truly coincidental that all three are African-American? Can anyone truly believe that racism did not contribute to their death sentences when we know that African-Americans are incarcerated at nearly six times the rate of white Americans; that African-Americans are 14.2 percent of the total US population, but 34 percent of defendants executed since 1976; that the victims of nearly all lynchings throughout US history have been African-American? And ultimately, from a human rights angle, is it ever morally justified to sentence a person to death?

But the recent controversy is not about these ideological, ethical or sociological issues. The current controversy focuses on a single question: Is death by lethal injection “too painful” and therefore inconsistent with the Eighth Amendment, which prohibits cruel and unusual punishment? That question is, at heart, a medical question.

In our society, doctors function as the primary and often sole legitimate judges of pain. Doctors decide what constitutes “real” pain, who “really” is in pain and how pain should be treated. The monopoly of doctors over the treatment of pain is made clear by the anti-drug laws that have filled our courts and prisons with the many people incarcerated for “illicit” use of the very same medicines that doctors routinely prescribe. With the power to determine who is a drug seeker and who is a “legitimate” pain patient, physicians function as arbiters of the moral order. Of course, a great deal of the hands-on work of treating pain is delegated to nurses, paramedics and pharmacists. But only doctors hold the authority to make formal decisions regarding pain.

This has not always been the case. At other times in history and in other cultures, pain has been the province of shamans and priests, mothers and grandmothers. In other words, pain has been addressed as a moral, spiritual, relational or domestic challenge rather than (or in addition to) a medical one.

The medical monopoly over pain treatment is part of a much broader social process of characterizing problems or conditions in medical terms and adopting medical approaches to address those problems or conditions. This process, known as medicalization, is a hallmark of contemporary Western societies. Over the past century, more and more, phenomena, sensations and experiences have been drawn into the medical sphere. Pregnancy, childbirth, infant feeding, menopause, weight (too much or too little), sex drive (too much or too little), gender identity (think of gender reassignment surgery), anxiety, anger, depression, alcohol and drug dependence – and all sorts of physical “imperfections” from nose to breast size – are handled medically.

In medicalized cultures, physicians are employed to supervise, control and – when possible – correct those who are deemed “deviant.” Invoking an aura of scientific impartiality that other social institutions cannot easily claim, physicians determine eligibility for disability insurance (SSI and SSDI), justify – or not – insanity defenses, and write the prescriptions for the psychiatric medications so heavily used within the penal and welfare systems. While public acceptance of physicians as gatekeepers to social services, pain treatment and other desired goods is premised on the objectivity of science, there are, in fact, significant differences among physicians in how they rule regarding SSI and SSDI, what pain medications they prescribe, and how likely they are to support insanity defenses. Indeed, while we tend to assume that doctors’ first and only loyalty is to their patients, in the current health care reality, doctors generally are paid and employed by insurance companies, hospitals and government agencies (including prisons).

The transformation of capital punishment into a medical event is part of this broad cultural landscape. While the American Medical Association has ruled that physicians should not administer lethal injections, the fact remains that physicians helped design the lethal injection protocol. Lethal injections utilize standard medical materials such as intravenous lines, EKG machines and drugs obtained from pharmacies (barbiturates, pancuronium bromide and potassium chloride). Seventeen death penalty states require physician involvement and all practicing jurisdictions employ medical personnel, though not always doctors. Physicians monitor vital signs, declare death and sign death certificates. And doctors declare incarcerated people sufficiently “competent” for execution.

I want to be clear that only a tiny number of physicians actively participate in administering lethal injections. I also want to be clear that many doctors dedicate their lives to caring for those who are poor, afflicted and underserved. In the current climate of growing alliances between medical and penal institutions, my concerns are structural rather than personal. That does not, however, detract from what I see as a problematic cultural trend of defining and treating “deviance” in medical terms. Los Angeles County – the county with the largest number of incarcerated people in the country – has approved a plan to replace a jail with a correctional center designed to provide care for prisoners suffering from mental illnesses and substance abuse. In New Hampshire, the Department of Corrections is planning a new “gender sensitive” 224-bed prison designed for the particular needs of incarcerated women, most of whom have been identified as suffering from post-traumatic stress disorder as a result of sexual violence. The new prison intends to meet needs for “personal healing”: there is no discussion of the need for freedom or autonomy.

“Treatment” certainly sounds more benevolent than “punishment.” And it certainly is the case that the overwhelming majority of people serving time in US jails and prisons suffer from physical and mental health challenges. Yet the receipt of a psychiatric evaluation reduces a defendant’s chances of having his or her charges dropped. It also increases the likelihood of a conviction, a prison sentence, and a lengthier sentence at that. Given the gross overrepresentation of people of color in US jails and prisons, I worry that the medicalization of the penal system risks adding “insane” to the long list of incurable flaws assigned to black and brown Americans by white America. I worry that rebranding from “offender” to “sick” – instead of seeking new models that get at why people really are caught up in the system – encourages the proliferation of psychiatric medication to be used as chemical restraints (less visible but no less repressive than physical restraints.)

And I worry that utilizing standard medical equipment, procedures, materials and terminology to carry out executions sends the message that capital punishment is, if not therapeutic, at least okay.

Copyright, Truthout.org. Reprinted with permission

http://www.truth-out.org/opinion/item/24251-medicalization-of-the-death-and-other-penalties