Forced chemotherapy in a teen: Exploring the ethics

By Ruth Macklin
Dr. Kevin MD blog
Originally posted January 16, 2015

Here is an excerpt:

Exploring the ethics

The legal barrier to respecting Cassandra’s autonomy remains, but the ethics of the case are murky. If this were a one-shot treatment — perhaps painful or uncomfortable, but over quickly — it would be easy to conclude that forced medical treatment would do more good than harm. But that is not clearly the case when the patient has to endure for as long as six months the discomforts of chemotherapy.

In December Cassandra first underwent surgery to install in her chest a port through which the drugs would be administered. State officials took custody of Cassandra and confined her in the hospital, Connecticut Children’s Medical Center, where she has received the forced treatments. Her cell phone was taken away (for a teen, this may be worse than the nausea and vomiting), and the phone in her hospital room was also removed. Her mother has been allowed to visit her in her hospital room, but only with a child welfare worker present. Mother and daughter are not allowed to have contact by phone.

The entire article is here.

Forced medication of Jared Lee Loughner OK'd by court

By Carol J. Williams

Los Angeles Times

Originally published March 5, 2012

Jared Lee Loughner

Reporting from Los Angeles — Tucson shooting suspect Jared Lee Loughner can be forcibly medicated with antipsychotic drugs, a federal appeals court ruled Monday.

In a 2-1 ruling, the U.S. 9th Circuit Court of Appeals said prison authorities have the right to treat an inmate who would otherwise be a danger to himself or others around him.

Loughner, 23, has been charged with 49 felony counts in the Jan. 8, 2011, shooting rampage outside of a Tucson supermarket in which six people were killed and 13 others injured, including U.S. Rep. Gabrielle Giffords. The congresswoman was holding a meet-the-public event when the shooter attacked.

Loughner’s defense attorneys had objected to his being forcibly treated with antipsychotic drugs. They argued that because he is a pretrial detainee who has not been convicted of any crime that he has the right to refuse medication that he believes could harm or kill him.

The entire article is here.

Amicus Curiae Brief on Forced Medication of Loughner

ARLINGTON, Va. (Aug 4, 2011) - The American Psychiatric Association (APA) and the American Academy of Psychiatry and the Law (AAPL) have submitted an amicus curiae brief on the issue of forcibly administering antipsychotic medication in the case of the United States v. Jared Lee Loughner.

The brief was submitted August 3 to the U.S. Court of Appeals for the Ninth Circuit.

Loughner has pleaded not guilty in the Tucson, Arizona shootings that killed 6 people and injured 13 others, including Rep. Gabrielle Giffords.

He has been diagnosed with schizophrenia, was found incompetent to stand trial and is being held in a federal prison hospital in Springfield, Mo.

The APA/AAPL brief argues that under existing standards the government may administer involuntary medication to a pre-trial detainee who is a danger to himself or others if appropriate administrative procedures are followed.

It was also argued that such decisions should be made by those having custody of the defendant and should not require a judicial hearing.

"We have two interests in this case," said Paul S. Appelbaum, M.D., chair of APA's Committee on Judicial Action.

"When the courts address issues concerning psychiatric disorders, we want them to have accurate data on the nature and consequences of those illnesses and on appropriate treatments.

In addition, we believe psychiatrists working in correctional facilities need the flexibility to deal with dangerous persons without the delay involved in lengthy court proceedings. Those are the issues that we focus on in the brief."

The defense in the Tucson shootings case has opposed the defendant's being treated with antipsychotic medication, and the 9 th Circuit Court of Appeals halted further treatment with antipsychotics until a hearing before that court at the end of August.

Since then, the psychiatrists treating Loughner concluded he was rapidly deteriorating and represented a danger to himself, and antipsychotic medication was restarted on an emergency basis.

The brief submitted by APA and AAPL did not side with either party, but seeks to clarify issues regarding managing violent, including self-injurious, inmates and about the use of antipsychotic medications.

The brief addresses the scientific evidence of the benefits and risks associated with antipsychotic medications, likely side effects, the medical reasons for involuntary administration in certain circumstances, and the inappropriateness of using other medications (i.e., sedatives) in the place of antipsychotics.

In Loughner's appeal the court will address whether, in a case involving a pre-trial detainee, the Washington v. Harper standard may be applied in a prison administrative process or whether the greater protection of a judicial proceeding is required.

Washington v. Harper holds that the government may treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will if he is dangerous to himself or others and if the treatment is in his medical interest.

In that case - which involved a convicted prisoner - the court also held that an administrative hearing was adequate to satisfy procedural due process.

Loughner's lawyers have raised additional substantive and procedural arguments.

The APA's position in the brief, approved by the APA Board of Trustees, is consistent with the organization's ongoing support of adequate mental health care for individuals in the criminal justice system.

Please see our prior blog post that details a history of this case.

Thanks to Ken Pope for this information.

Prescription pain medication addiction prevalent among chronic pain patients

News Release

A new study by Geisinger Health System researchers finds a high prevalence of prescription pain medication addiction among chronic pain patients. In addition, researchers found that the American Psychiatric Association’s (APA) new definition of addiction, which was expected to reduce the number of people considered addicts who take these medicines, actually resulted in the same percentage of people meeting the criteria of addiction.

Published in the Journal of Addictive Diseases, the study found that 35 percent of patients undergoing long-term pain therapy with opioids like morphine, OxyContin, Percocet and Vicodin, meet the criteria for addiction.

“Most patients will not know if they carry the genetic risk factors for addiction,” said study lead Joseph Boscarino, senior investigator II, Geisinger Health System. “Improper or illegal use of prescription pain medication can become a lifelong problem with serious repercussions for users and their families.”
Boscarino added that “genetic predisposition to addiction further exacerbates the risks associated with misuse of prescription pain medication.”

Using electronic health records, a random sample of outpatients undergoing long-term opioid therapy for non-cancer pain was identified and 705 participants completed telephone interviews from August 2007 through November 2008.

When comparing the APA’s newly revised criteria for addiction with the old criteria, researchers were surprised to find the prevalence of and risk factors for addiction to be virtually the same. It was determined that different symptoms now qualify the same patients for inclusion who would have been excluded under the previous classification system.

The study states that pain medication addiction often happens in people under 65, with a history of opioid abuse, withdrawal symptoms and substance abuse treatment. Risk factors for severe pain medication addiction also include a history of anti-social personality disorder.

“Ultimately, we hope our research will aid the development of newer classes of medications that don’t negatively impact the brain and therefore avoid addiction entirely,” Boscarino said.

Researchers from New York University also contributed to the study.

Loughner forced medication OKd by judge

From the San Francisco Chronicle

A judge ruled Wednesday that prison officials can forcibly give the man accused of the Tucson shooting rampage antipsychotic drugs in a bid to make him mentally fit for trial.

U.S. District Judge Larry Burns' decision came after Jared Lee Loughner's attorneys filed an emergency request last week to prevent any forced medication of their client without approval from a judge. The judge said he did not want to second guess doctors at the federal prison in Springfield, Mo., who determined that Loughner was a danger.

"I have no reason to disagree with the doctors here," Burns said. "They labor in this vineyard every day."

Loughner, who was not at the hearing in San Diego, has been at the Missouri facility since May 28 after the judge concluded he was mentally unfit to stand trial and help in his legal defense.

Mental health experts had determined the 22-year-old college dropout suffers from schizophrenia and will try to make him psychologically fit to stand trial. He will spend up to four months at the facility.

Prosecutors have argued that Loughner should be given antipsychotic drugs because he has been diagnosed as schizophrenic and poses a danger to others.

"This is a person who is a ticking time bomb," prosecutor Wallace Kleindienst said Wednesday.

In a filing Tuesday, prosecutors cited an April 4 incident where Loughner spit on his own attorney, lunged at her and had to be restrained by prison staff. They also cited an outburst during a March 28 interview with a mental health expert in which Loughner became enraged, cursed at her and threw a plastic chair at her twice.

Loughner has pleaded not guilty to 49 charges stemming from the Jan. 8 shooting that injured Rep. Gabrielle Giffords and 12 others and killed six people, including John Roll, the chief federal judge for Arizona.

If Loughner is later determined to be competent enough to understand the case against him and assist his lawyers, the court proceedings will resume.