Correspondence
and fairness in progress toward other Sustainable Development Goals and targets, including universal health coverage (target 3.8), universal access to safe water (target 6.1), and sanitation (target 6.2).5 These tracers are essential to monitor equity precisely because NTD endemic populations are the least likely to have access to these services at present.6 I do not share the opinion that the main outcome for the inclusion of NTDs within the Sustainable Development Goals would be more money for NTDs.7 Inclusion of NTD indicators and tracers will, on the contrary, help to maximise returns on investment in a broad portfolio of Sustainable Development Goal targets. Inclusion will help to identify the communities that have the greatest need for attainment of these goals: the populations that are the furthest behind in terms of development. I declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Dirk Engels [email protected] Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva 27, Switzerland 1
2
3
4
5
224
Transforming our world: the 2030 agenda for Sustainable Development. United Nations. 2015. http://www.un.org/ga/search/view_doc. asp?symbol=A/70/L.1&Lang=E (accessed Nov 19, 2015). Second meeting of the Inter-Agency and Expert Group–Sustainable Development Goal. Bangkok: Oct 26–28, 2015. http://unstats. un.org/sdgs/meetings/iaeg-sdgs-meeting-02 (accessed Nov 18, 2015). Ban Ki-moon. Opening remarks to the media following the Summit for the Adoption of the Post-2015 Development Agenda. UN Headquarters, Sept 25, 2015. http://www. un.org/apps/news/infocus/sgspeeches/ statments_full.asp?statID=2751#.Vkx2fXYvfIU (accessed Nov 18, 2015). WHO. World Health Assembly (WHA) Resolutions on Neglected Tropical Diseases: 1948–2013. http://www.who.int/neglected_ diseases/mediacentre/resolutions/en (accessed Oct 20, 2015). Methodological note: proposed indicator framework for monitoring SDG targets on drinking water, sanitation, hygiene and wastewater. Geneva: World Health Organization and United Nations Children’s Fund. http://www. wssinfo.org/fileadmin/user_upload/resources/ Statistical-note-on-SDG-targets-for-WASH-andwastewater_WHO-UNICEF_21September2015_ Final.pdf (accessed Oct 6, 2015).
6
7
Water, sanitation, and hygiene for accelerating and sustaining progress on neglected tropical diseases: a global strategy 2015–2020. Geneva: World Health Organization, 2015 http://apps. who.int/iris/bitstream/10665/182735/1/ WHO_FWC_WSH_15.12_eng.pdf?ua=1 (accessed Oct 6, 2015). Horton R. Offline: The “chronic pandemic” that just won’t go away. Lancet 2015; 385: 758.
Methadone for prisoners Research by Josiah Rich and colleagues (July 25, p 350)1 shows that forced methadone withdrawal in prisons is associated with substantial individual and societal costs. These costs might be tolerable if a sound clinical or correctional rationale existed for forced withdrawal, but it does not. Retributivists might argue that criminal offenders should be punished for their wrongdoing, whereas providing methadone treatment rewards it.2 However, incarcerated offenders are already receiving punishment. Requiring prisoners to cease methadone treatment forces them to endure the physical and psychological burdens of opiate withdrawal in addition to those of imprisonment. This amounts to a double punishment and is inconsistent with the core principle of proportionate punishment that governs retributivism. Hardline anti-drug campaigners might argue that we should avoid treatments that seek to mitigate symptoms by replacing one addiction with another. 3 Instead, the goal should be abstinence from all drugs. However, evidence suggests that forced withdrawal rarely produces the long-term cure that such campaigners seek.4 For other medical disorders, clinicians and patients often opt for symptomatic relief when an attempted cure would be risky and unlikely to succeed; it is unclear why substance abuse should be treated differently. Withholding medical treatment from criminal offenders is not only detrimental to prisoner health and public safety, it is also inconsistent
with retributivism and with approaches to symptom management for other medical disorders. US federal and state authorities should work to ensure that addicts receive a reasonable standard of medical care, including, where appropriate, methadone treatment. We declare no competing interests.
Daniel D’Hotman, Jonathan Pugh, *Thomas Douglas [email protected] Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK (DD’H, JP, TD); and Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia (DD’H) 1
2 3 4
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Kershnar S. A defense of retributivism. Int J Appl Philos 2000; 14: 97–117. Gewirtz P. Methadone maintenance for heroin addicts. New Haven: Yale Law School, 1989. Liu H, Grusky O, Zhu Y, Li X. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug Alcohol Depend 2006; 84: 114–21.
The Article by Josiah Rich and colleagues1 impressively shows that methadone continuation has major advantages over forced withdrawal in prisoners, a vulnerable population. It is helpful from a psychiatric standpoint to put this issue on solid ground because it is normally dealt with in moral and emotional terms instead of in terms of scientific evidence. Although prisons differ structurally and in terms of the types of prisoners between countries, these results should also encourage methadone continuation in prisons outside the USA. In this context, I would like to know whether illicit drug use was also monitored during imprisonment, and if so, what the findings were in the different study groups. Another important question is how psychiatric treatment and care was organised in those institutions, especially if psychotherapy was also offered. Substance abuse is a very www.thelancet.com Vol 387 January 16, 2016
Correspondence
I declare no competing interests.
Ion Anghelescu [email protected] Clinic Dr Fontheim, Psychiatry, Lindenstrasse 15, 38704 Liebenburg, Germany 1
2
3
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Rowell TL, Wu E, Hart CL, Haile R, El-Bassel N. Predictors of drug use in prison among incarcerated Black men. Am J Drug Alcohol Abuse 2012; 38: 593–97. Reed E, Raj A, Falbo G, et al. The prevalence of violence and relation to depression and illicit drug use among incarcerated women in Recife, Brazil. Int J Law Psychiatry 2009; 32: 323–28.
Authors’ reply Daniel D’Hotman and colleagues make important points that forced withdrawal from methadone causes predictable pain and suffering, is a disproportionate double punishment, and does not cure the addiction, and question why substance dependence is treated differently to other medical disorders. We suggest that addiction is treated differently owing to the stigma associated with the disease and its treatment. Addiction is fundamentally misunderstood to be a moral failing rather than a chronic relapsing brain disease. This stigma has enabled society’s major approach to be incarceration rather than treatment. It is time for us to pay attention to the www.thelancet.com Vol 387 January 16, 2016
overwhelmingly positive outcomes associated with opioid substitution therapy, which starkly contrast with the poor outcomes and high relapse rates associated with incarceration. Ion Anghelescu encourages a scientific rather than an emotional or moral approach to addiction and also asks whether illicit drug use was monitored during incarceration in our study.1 We did not monitor illicit drug use because of the complexities of required reporting of illegal behaviour in this setting. However, especially for correctional institutions where substantial illicit opioid use occurs, treatment with methadone or other effective medication for opioid dependence can reduce use and associated problems, including overdose, violence, and corruption of correctional staff. Anghelescu also inquires about racial disparities; our study reflected the population enrolled in methadone on entry to custody, which is predominantly white in Rhode Island, USA.2 Our study population, like most incarcerated people,3 had a substantial burden of mental illness, with 83% reporting history of depression, 65% having been prescribed psychiatric medications, and 39% previously being admitted to hospital for psychiatric reasons. Similar to most correctional institutions in the USA, psychiatric care was scarce. Finally, our study included only patients on methadone treatment at the time of incarceration. We, and others, have shown the feasibility and benefits of initiating methadone4,5 or buprenorphine6 before release. Since prevalence of opioid dependence is 12–15% among prisoners,5 and the root cause of behaviour leading to incarceration is often opioid dependence in this population, efforts should be made to screen all entrants to the criminal justice system for opioid dependence, and offer individually tailored, evidence-based opioid substitution therapy with continuation in the community after release.
Our work was supported by the National Institute on Drug Abuse, the US National Institutes of Health funded Lifespan/Tufts/Brown Center for AIDS Research, and SL is funded by the National Health and Medical Research Council Early Career Fellowship. The content is solely that of the authors and does not necessarily reflect the views of the funders.
Cordelia Molloy/Science Photo Library
common feature in incarcerated people2 and might also be associated with other psychiatric disorders. 3 Therefore, the frequency of comorbid psychiatric disorders in the study population would be interesting to know. Additionally, I would like to know whether Rich and colleagues recommend initiation of methadone in opiate-dependent prisoners if they did not receive it before incarceration. Remarkably, most opiate-dependent prisoners in this study were white people, although this ethnic group is a minority in the overall population in prisons. I would like to know whether Rich and colleagues have a hypothesis about where this mismatch stems from.
*Josiah D Rich, Michelle McKenzie, Sarah Larney, Amanda Noska, Jennifer Clark [email protected] Brown University, Providence, RI, USA (JDR, MM, SL, AN, JC); The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA (JDR, MM, SL, AN, JC); National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia (SL); and Memorial Hospital, Pawtucket, RI, USA (JC) 1
2
3
4
5
6
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Zaller N, Bazazi A, Velazquez L, Rich JD. Attitudes toward methadone among out-oftreatment minority injection drug users: implications for health disparities. Int J Environ Res Public Health 2009; 6: 787–97. Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. N Engl J Med 2011; 364: 2081–83. McKenzie M, Zaller N, Dickman S, et al. A randomized trial of methadone initiation prior to release from incarceration. Subst Abus 2012; 33: 19–29. Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction 2008; 103: 1333–42. Zaller N, McKenzie M, Friedmann P, Green T, McGowan S, Rich J. Initiation of buprenorphine during incarceration and retention in treatment upon release. J Subst Abuse Treat 2013; 45: 222–26.
Ixekizumab for psoriasis Christopher Griffiths and colleagues (Aug 8, p 541) 1 reported that ixekizumab, a high-affinity antibody targeting interleukin 17A, given to patients with moderate-to-severe psoriasis for 12 weeks had greater efficacy than etanercept and placebo. However, the dermatology life-quality index used in the studies might have been insufficient to assess adverse effects because it only assesses dermatological symptom-associated mental status. Patients with psoriasis are known to have an increased risk of depression in 225
and fairness in progress toward other Sustainable Development Goals and targets, including universal health coverage (target 3.8), universal access to safe water (target 6.1), and sanitation (target 6.2).5 These tracers are essential to monitor equity precisely because NTD endemic populations are the least likely to have access to these services at present.6 I do not share the opinion that the main outcome for the inclusion of NTDs within the Sustainable Development Goals would be more money for NTDs.7 Inclusion of NTD indicators and tracers will, on the contrary, help to maximise returns on investment in a broad portfolio of Sustainable Development Goal targets. Inclusion will help to identify the communities that have the greatest need for attainment of these goals: the populations that are the furthest behind in terms of development. I declare no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Dirk Engels [email protected] Department of Control of Neglected Tropical Diseases, World Health Organization, 1211 Geneva 27, Switzerland 1
2
3
4
5
224
Transforming our world: the 2030 agenda for Sustainable Development. United Nations. 2015. http://www.un.org/ga/search/view_doc. asp?symbol=A/70/L.1&Lang=E (accessed Nov 19, 2015). Second meeting of the Inter-Agency and Expert Group–Sustainable Development Goal. Bangkok: Oct 26–28, 2015. http://unstats. un.org/sdgs/meetings/iaeg-sdgs-meeting-02 (accessed Nov 18, 2015). Ban Ki-moon. Opening remarks to the media following the Summit for the Adoption of the Post-2015 Development Agenda. UN Headquarters, Sept 25, 2015. http://www. un.org/apps/news/infocus/sgspeeches/ statments_full.asp?statID=2751#.Vkx2fXYvfIU (accessed Nov 18, 2015). WHO. World Health Assembly (WHA) Resolutions on Neglected Tropical Diseases: 1948–2013. http://www.who.int/neglected_ diseases/mediacentre/resolutions/en (accessed Oct 20, 2015). Methodological note: proposed indicator framework for monitoring SDG targets on drinking water, sanitation, hygiene and wastewater. Geneva: World Health Organization and United Nations Children’s Fund. http://www. wssinfo.org/fileadmin/user_upload/resources/ Statistical-note-on-SDG-targets-for-WASH-andwastewater_WHO-UNICEF_21September2015_ Final.pdf (accessed Oct 6, 2015).
6
7
Water, sanitation, and hygiene for accelerating and sustaining progress on neglected tropical diseases: a global strategy 2015–2020. Geneva: World Health Organization, 2015 http://apps. who.int/iris/bitstream/10665/182735/1/ WHO_FWC_WSH_15.12_eng.pdf?ua=1 (accessed Oct 6, 2015). Horton R. Offline: The “chronic pandemic” that just won’t go away. Lancet 2015; 385: 758.
Methadone for prisoners Research by Josiah Rich and colleagues (July 25, p 350)1 shows that forced methadone withdrawal in prisons is associated with substantial individual and societal costs. These costs might be tolerable if a sound clinical or correctional rationale existed for forced withdrawal, but it does not. Retributivists might argue that criminal offenders should be punished for their wrongdoing, whereas providing methadone treatment rewards it.2 However, incarcerated offenders are already receiving punishment. Requiring prisoners to cease methadone treatment forces them to endure the physical and psychological burdens of opiate withdrawal in addition to those of imprisonment. This amounts to a double punishment and is inconsistent with the core principle of proportionate punishment that governs retributivism. Hardline anti-drug campaigners might argue that we should avoid treatments that seek to mitigate symptoms by replacing one addiction with another. 3 Instead, the goal should be abstinence from all drugs. However, evidence suggests that forced withdrawal rarely produces the long-term cure that such campaigners seek.4 For other medical disorders, clinicians and patients often opt for symptomatic relief when an attempted cure would be risky and unlikely to succeed; it is unclear why substance abuse should be treated differently. Withholding medical treatment from criminal offenders is not only detrimental to prisoner health and public safety, it is also inconsistent
with retributivism and with approaches to symptom management for other medical disorders. US federal and state authorities should work to ensure that addicts receive a reasonable standard of medical care, including, where appropriate, methadone treatment. We declare no competing interests.
Daniel D’Hotman, Jonathan Pugh, *Thomas Douglas [email protected] Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK (DD’H, JP, TD); and Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia (DD’H) 1
2 3 4
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Kershnar S. A defense of retributivism. Int J Appl Philos 2000; 14: 97–117. Gewirtz P. Methadone maintenance for heroin addicts. New Haven: Yale Law School, 1989. Liu H, Grusky O, Zhu Y, Li X. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug Alcohol Depend 2006; 84: 114–21.
The Article by Josiah Rich and colleagues1 impressively shows that methadone continuation has major advantages over forced withdrawal in prisoners, a vulnerable population. It is helpful from a psychiatric standpoint to put this issue on solid ground because it is normally dealt with in moral and emotional terms instead of in terms of scientific evidence. Although prisons differ structurally and in terms of the types of prisoners between countries, these results should also encourage methadone continuation in prisons outside the USA. In this context, I would like to know whether illicit drug use was also monitored during imprisonment, and if so, what the findings were in the different study groups. Another important question is how psychiatric treatment and care was organised in those institutions, especially if psychotherapy was also offered. Substance abuse is a very www.thelancet.com Vol 387 January 16, 2016
Correspondence
I declare no competing interests.
Ion Anghelescu [email protected] Clinic Dr Fontheim, Psychiatry, Lindenstrasse 15, 38704 Liebenburg, Germany 1
2
3
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Rowell TL, Wu E, Hart CL, Haile R, El-Bassel N. Predictors of drug use in prison among incarcerated Black men. Am J Drug Alcohol Abuse 2012; 38: 593–97. Reed E, Raj A, Falbo G, et al. The prevalence of violence and relation to depression and illicit drug use among incarcerated women in Recife, Brazil. Int J Law Psychiatry 2009; 32: 323–28.
Authors’ reply Daniel D’Hotman and colleagues make important points that forced withdrawal from methadone causes predictable pain and suffering, is a disproportionate double punishment, and does not cure the addiction, and question why substance dependence is treated differently to other medical disorders. We suggest that addiction is treated differently owing to the stigma associated with the disease and its treatment. Addiction is fundamentally misunderstood to be a moral failing rather than a chronic relapsing brain disease. This stigma has enabled society’s major approach to be incarceration rather than treatment. It is time for us to pay attention to the www.thelancet.com Vol 387 January 16, 2016
overwhelmingly positive outcomes associated with opioid substitution therapy, which starkly contrast with the poor outcomes and high relapse rates associated with incarceration. Ion Anghelescu encourages a scientific rather than an emotional or moral approach to addiction and also asks whether illicit drug use was monitored during incarceration in our study.1 We did not monitor illicit drug use because of the complexities of required reporting of illegal behaviour in this setting. However, especially for correctional institutions where substantial illicit opioid use occurs, treatment with methadone or other effective medication for opioid dependence can reduce use and associated problems, including overdose, violence, and corruption of correctional staff. Anghelescu also inquires about racial disparities; our study reflected the population enrolled in methadone on entry to custody, which is predominantly white in Rhode Island, USA.2 Our study population, like most incarcerated people,3 had a substantial burden of mental illness, with 83% reporting history of depression, 65% having been prescribed psychiatric medications, and 39% previously being admitted to hospital for psychiatric reasons. Similar to most correctional institutions in the USA, psychiatric care was scarce. Finally, our study included only patients on methadone treatment at the time of incarceration. We, and others, have shown the feasibility and benefits of initiating methadone4,5 or buprenorphine6 before release. Since prevalence of opioid dependence is 12–15% among prisoners,5 and the root cause of behaviour leading to incarceration is often opioid dependence in this population, efforts should be made to screen all entrants to the criminal justice system for opioid dependence, and offer individually tailored, evidence-based opioid substitution therapy with continuation in the community after release.
Our work was supported by the National Institute on Drug Abuse, the US National Institutes of Health funded Lifespan/Tufts/Brown Center for AIDS Research, and SL is funded by the National Health and Medical Research Council Early Career Fellowship. The content is solely that of the authors and does not necessarily reflect the views of the funders.
Cordelia Molloy/Science Photo Library
common feature in incarcerated people2 and might also be associated with other psychiatric disorders. 3 Therefore, the frequency of comorbid psychiatric disorders in the study population would be interesting to know. Additionally, I would like to know whether Rich and colleagues recommend initiation of methadone in opiate-dependent prisoners if they did not receive it before incarceration. Remarkably, most opiate-dependent prisoners in this study were white people, although this ethnic group is a minority in the overall population in prisons. I would like to know whether Rich and colleagues have a hypothesis about where this mismatch stems from.
*Josiah D Rich, Michelle McKenzie, Sarah Larney, Amanda Noska, Jennifer Clark [email protected] Brown University, Providence, RI, USA (JDR, MM, SL, AN, JC); The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA (JDR, MM, SL, AN, JC); National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia (SL); and Memorial Hospital, Pawtucket, RI, USA (JC) 1
2
3
4
5
6
Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. Zaller N, Bazazi A, Velazquez L, Rich JD. Attitudes toward methadone among out-oftreatment minority injection drug users: implications for health disparities. Int J Environ Res Public Health 2009; 6: 787–97. Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. N Engl J Med 2011; 364: 2081–83. McKenzie M, Zaller N, Dickman S, et al. A randomized trial of methadone initiation prior to release from incarceration. Subst Abus 2012; 33: 19–29. Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction 2008; 103: 1333–42. Zaller N, McKenzie M, Friedmann P, Green T, McGowan S, Rich J. Initiation of buprenorphine during incarceration and retention in treatment upon release. J Subst Abuse Treat 2013; 45: 222–26.
Ixekizumab for psoriasis Christopher Griffiths and colleagues (Aug 8, p 541) 1 reported that ixekizumab, a high-affinity antibody targeting interleukin 17A, given to patients with moderate-to-severe psoriasis for 12 weeks had greater efficacy than etanercept and placebo. However, the dermatology life-quality index used in the studies might have been insufficient to assess adverse effects because it only assesses dermatological symptom-associated mental status. Patients with psoriasis are known to have an increased risk of depression in 225
