A judge in Ohio has recently ordered an 18-year-old inmate to receive a series of injections of a controversial and under-researched medicine that blocks the effects of opioids, and that may be associated with a high risk of death.
The issue here is not just the treatment the judge ordered—but that he should feel comfortable prescribing treatment at all. Though we medical professionals recognize addiction as a chronic relapsing disease, the justice system continues to treat it as a moral disorder—which is often why those with experience on the bench, rather than in the clinic, feel entitled to determine what kind of treatment an addicted individual needs.
The treatment the judge has ordered in this case is nine to twelve injections of naltrexone—a drug that stops the body from getting high by blocking the brain’s opioid receptors. The drug was approved for treatment of heroin and other opioid dependence by the Food and Drug Administration in 2010, though the single study that was the basis for that approval was carried out in Russia under conditions that would have been highly ethically questionable in the U.S.
Furthermore, that study did not follow subjects after the injected medication wore off, even though the greatest risk of death after any treatment of addiction comes from relapse or overdose once treatment is discontinued. In fact, the oral form of naltrexone is highly associated with overdose rates for those who stop.
There are other issues with injectable naltrexone—including the fact that it is many times more expensive than other treatments for opioid dependence. However, that is not the main issue here. Rather, the big issue—and the one that the journalists covering this case seem to be ignoring—is the inappropriate use of judicial power. We’ve seen this before in drug courts, where judges either play doctor in deciding what kind of treatment patients should get, or imposing highly punitive sanctions on those who aren’t following a treatment plan they didn’t choose, and that may not meet their needs.
Judge Peeler, a past president of the Warren County Bar Association, may be a terrific judge. But a physician he is not, and he should resist the temptation, however well-intentioned, to act in that role.