The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids.

Anna Buadze,Michael Liebrenz,Eveline Aeberhard,Stephanie Baggio,Andres Schneeberger,Roman Schleifer,Hans Wolff

doi:10.3389/fpsyt.2020.00395

Abstract

BackgroundOpioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.AimsThe present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.MethodsUsing a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.ResultsDefenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.

Highlights

Modern opioid agonist treatment (OAT) with methadone, buprenorphine or other prescribed opioids such as morphine is an important strategy in the treatment of patients with an opioid use disorder [1,2,3,4]
Our study revealed that perceived difficulties with non-opioid agonist medication like benzodiazepines used to mitigate withdrawal symptoms are discussed and debated among defense lawyers and clients, but that these discussions are constrained by the fact that defenders assess their influence on prison staff as being extremely low
Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT, and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis and a reduction in recidivism

Summary

Introduction

Modern opioid agonist treatment (OAT) with methadone, buprenorphine or other prescribed opioids such as morphine is an important strategy in the treatment of patients with an opioid use disorder [1,2,3,4] This form of therapy is associated with an improvement in the individual's health and leads, among other things, to a reduction in the incidence of HIV and drugrelated crime [5,6,7,8,9]. OAT is an important pillar in the treatment of opioid addiction in jails and prisons, and various professional medical associations recommend the continuation of therapy during imprisonment [12,13,14] In this context, it should be emphasized that the overdose-related mortality rate of people with heroin addiction is high after withdrawal under detention conditions and following release without established aftercare [15,16,17]. It can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention

Methods

Results

Discussion

Conclusion