How does drugs affect you ethically

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When a legal or medical obligation exists for obstetrician—gynecologists to test patients for substance use disorder, there is an ethical responsibility to notify patients of this testing and make a reasonable effort to obtain informed consent. Obstetrician—gynecologists have an ethical responsibility to follow current best prescribing practices for controlled medications in order to avoid inadequate or inappropriate treatment of pain and patient misuse or diversion ie, redistribution of prescription medications.

Obstetrician—gynecologists should protect patient autonomy, confidentiality, and the integrity of the patient—physician relationship to the extent allowable by laws regarding disclosure of substance use disorder. Physicians should be aware that reporting mandates vary widely and be familiar with the legal requirements within their state or community. Obstetrician—gynecologists should, when possible, advocate evidence-based and consensual interventions related to substance use disorder.

Obstetrician—gynecologists have an ethical responsibility to their pregnant and parenting patients with substance use disorder to discourage the separation of parents from their children solely based on substance use disorder, either suspected or confirmed. It is unethical for obstetrician—gynecologists to practice medicine with diminished capacity resulting from the use of alcohol or licit or illicit substances because it may put patients at risk of harm.

If obstetrician—gynecologists identify substance use disorder in themselves or their colleagues, they have an ethical responsibility to safeguard patients by modifying their own practice and by seeking guidance from professional organizations to assist with resources for support and intervention. This Committee Opinion proposes an ethical rationale for routine screening, brief intervention, and referral to treatment for substance use disorder in obstetric and gynecologic practice.

Support for this protocol is derived from the following four basic principles of medical ethics: 1 beneficence, 2 nonmaleficence, 3 justice, and 4 respect for autonomy.

Therapeutic intent, or beneficence, is the foundation of medical knowledge, training, and practice. Positive behavior change arises from the trust implicit in the patient—physician relationship, the respect that patients have for physician knowledge, and the ability of physicians to help patients see the links between physiologic dysfunction and behavior and their physical and psychologic consequences. The Centers for Disease Control and Prevention suggests that all patients be asked about alcohol and substance use regularly and in plain language 7.

There are several examples of evidence-based screening tools that can be used in the evaluation of alcohol and substance use disorder 4 5 6 7. It may be most efficient and effective to screen using a team approach, in which nonphysician members of the health care team are educated about screening and how to assist women who have positive screening results. The core ethical purpose of routine screening for substance use disorder is the beneficent provision of timely and effective care, rather than stigmatization or punishment.

Physicians who identify alcohol use disorder, for example, may offer their patients alternatives to their continued drinking, including stopping drinking, cutting down on use, and seeking help. Brief intervention by physicians or peer educators has been shown to be as effective as conventional treatment for alcohol and substance use disorder and can produce dramatic reductions in use, improved health status for the patient, and reduced costs to society 8 9 10 11 12 13 The obligation to prevent, or not to impose, harms nonmaleficence , including harms of omission, also is relevant to care for patients with substance use disorder.

Patients also may be harmed when substance use disorder is viewed as a moral failing rather than a medical issue Women with substance use disorder particularly are likely to be stigmatized and labeled as hopeless Humiliation as a tool to force change is ethically and professionally inappropriate, engenders resistance, and acts as a barrier to successful treatment and recovery As leaders of the health care team, it is important for physicians to model empathy and support rather than criticism when caring for patients with substance use disorder.

The principle of justice in medicine governs equitable access to care, fair distribution of resources, and nondiscriminatory medical practices. This principle requires that routine screening for substance use disorder should be applied equally to all people, regardless of age, sex, race, ethnicity, or socioeconomic status.

Physicians may fail to apply principles of universal routine screening. When women are less likely to be screened or referred for treatment for substance use disorder, their burden of disability is increased and health status decreased. Another source of injustice is that punitive measures related to substance use disorder are not applied evenly across sex, race, and socioeconomic status.

For example, in a landmark study among pregnant women who were anonymously tested for drug use, the prevalence of use was found to be similar between African American women and Caucasian women but African American women were 10 times more likely to be reported to law enforcement as a result of positive screening results Universal application of substance use disorder screening questions, brief intervention, and referral to treatment eliminates these disparities.

Justice also requires that preventive education and treatment referral should be provided for all patients in whom substance use disorder is identified.

Just as with any chronic medical condition, physicians should counsel their patients with substance use disorder and refer them to an appropriate treatment resource when available, even if there might be a low likelihood of response to treatment. Respect for autonomy directs that patients have the right to full information about their health and health care and the power to make their own health care decisions.

A climate of respect and trust within the patient—physician relationship promotes patient autonomy and enables effective intervention for women with substance use disorder by increasing motivation to change, sup-porting self-efficacy, and offering hope and resources 21 Patients who fear sensitive information may be disclosed to others will be inhibited from honest reporting to their physicians If a patient has the capacity to make her own decisions and declines to discuss alcohol and substance use, the physician should respect her decision.

A significant ethical dilemma is created by state laws that require physicians to report the nonmedical use of controlled substances drugs or other chemicals that are potentially addictive or habit forming by a pregnant woman and laws that require toxicology tests of the woman, her newborn, or both after delivery when there is clinical suspicion for fetal exposure to potentially harmful controlled substances.

Such laws may unwittingly result in pregnant women concealing substance use from their obstetricians or even forgoing prenatal care entirely. State lawmakers are encouraged to look to science-based guidelines, medical evidence, and ethical principles to guide appropriate public health interventions.

Obstetrician—gynecologists have a responsibility to respond in a medically and ethically appropriate manner, within legal requirements, to patient-care issues involving substance use disorder. Cornerstones of an ethical approach to the management of substance use disorder include patient education and safe prescribing practices; care and advocacy for patients with substance use disorder who are parents, pregnant, or seeking pregnancy; and protection of patient autonomy, confidentiality, and the integrity of the patient—physician relationship to the extent allowable by law.

Patient education is central to the prevention of intentional and unintentional therapeutic drug diversion, with a trusting relationship between physicians and their patients at the core of this education process. This relationship is especially vital when patients ask their physicians to prescribe medications that are not indicated. In partnership with local pharmacies, physicians also should be a resource for their patients regarding proper use, storage, and disposal of medications 4.

When treating patients with acute or chronic pain, obstetrician—gynecologists have an ethical responsibility to follow current best prescribing practices for controlled medications in order to avoid inadequate or inappropriate treatment of pain and patient misuse or diversion ie, redistribution of prescription medications such as opioids. It is inappropriate to avoid treating acute pain because of concerns for opioid addiction, although alternative and complementary pain relief modalities also should be considered.

Obstetrician—gynecologists can be proactive in developing careful postoperative care plans for patients with a history of opioid use disorder. Consultation with pain specialists often is appropriate for patients at risk of opioid withdrawal and for patients with chronic pain syndromes who may be at risk of opioid dependence.

On the one hand, the physician may be concerned about nonmaleficence. Because medical records may not be safe from inappropriate or state-mandated disclosures of a positive drug test result or a diagnosis of substance use disorder, the patient may experience real harms—including job loss unrelated to workplace performance issues, eviction from public housing, loss of public assistance benefits, termination of insurance, arrest and incarceration, and removal of child custody.

On the other hand, the principles of beneficence and nonmaleficence require that physicians ensure the accuracy of the medical record to optimize collaborative care with other clinicians. Pertinent medical information obtained by obstetrician—gynecologists may be vital for other clinicians to provide appropriate patient care and avoid harm. Concerns about breaching confidentiality and causing harms through disclosure can be appropriately addressed by including only accurate and medically necessary information in the medical record and informing the patient why and how this information will be included.

Published evidence should guide physician concern for the fetal effects of any substance exposure. Although a full description of the multiple possible effects of alcohol on offspring cognition and behavior is beyond the scope of this document, the effect of alcohol use in pregnancy remains the best studied among prenatal substance exposures.

Although stimulants such as cocaine and methamphetamine have not been clearly linked to neonatal abstinence syndrome, intrauterine exposure to these agents has been associated with fetal growth restriction and adverse effects on infant neurobehavior 28 It is important to consider carefully whether biologic testing is needed when there is clinical suspicion of fetal exposure to potentially harmful substances.

Although several maternal biologic specimens, neonatal biologic specimens, or both can be used to test for drug exposure, each has its limitations, and it is more likely that fetal exposure will be identified through a structured interview.

Second, intoxication and addiction impair the capacity of individuals to exert self-control, make decisions, and express their preferences. Third, harmful AOD use often leads to conditions of social disadvantage and marginalization Room, , which can reduce the ability of individuals to sustain themselves financially and to maintain valued social connections.

AOD use not only affects those using the substance. A pedestrian may be fatally struck by a drunk driver. Family members are harmed when a family breadwinner loses his or her employment due to addiction. Widely diffused harms include medical spending and losses in economic activity due to reduced productivity. Efforts to avert harms from AODs include preventing people from initiating harmful use, treating harmful use once it arises, enforcing laws that keep others safe, and creating a legal environment that supports public health goals.

Arguments framed in terms of personal responsibility contend that harmful AOD use is to some extent voluntary, and that this voluntariness limits individual claims to social assistance. Others argue that while society should not entirely abandon those suffering from addiction, it may take personal choice into account when deciding how to confront addiction or prioritize scarce public health resources Satel and Lilienfeld, In a classic argument, Richard J.

If the luck egalitarian position argues that assistance is limited for diseases or injuries that occur because of lifestyle free choice Roemer, , , this raises into question the degree to which AOD use is voluntary and to which individuals can control whether their use will harm themselves or others.

Related, even if initiating AOD use is voluntary, becoming addicted surely limits free choice and, on some accounts, calls into question whether this limited choice also limits personal responsibility. Low-resource neighborhoods and poverty increase risk factors for harmful AOD use and increase the stakes of harmful use such as incarceration or job loss Caton et al. Much of the variance in risk of addiction can also be explained by genetic factors; in studies of twins adopted into different family environments, shared genetics accounted for as much as 60 percent of the risk of developing alcoholism Kendler et al.

Finally, as mentioned earlier, addiction is an illness characterized by a loss of personal control. Thus, even if it were determined that there is some element of personal choice in initiating AOD use, people who have addictions may have diminished control over when, and how much, they use. Fully withholding assistance to those harmed by AOD through their own choices may seem overly harsh, or indeed counter to principles of justice such as social solidarity. Following Shlomi Segall , some luck egalitarians may adopt a pluralistic view that does not entirely withdraw support from those with AOD-related disadvantage, but rather assumes that personal responsibility is one of several bases that can be used to determine resource allocation, and could therefore assign less but at least some priority to people who are harmed through their own choices.

Preventing harmful AOD use can take many forms—including taxation, broad-based social programs, and other drug control policies described further in subsequent sections —but the focus in this section is on prevention through educational and p. For an intervention to be ethically justified, it should be among other things effective Childress et al. Many prevention campaigns, however, have been shown to be ineffective.

By contrast, other prevention strategies have shown effectiveness, including programs to build psychological skills such as resilience to resist harmful use Griffin and Botvin, Screening, often used as a means of identifying individuals to receive education or other prevention programs, poses its own ethical challenges. One challenge is that screening—outside of the doctor-patient relationship—can intrude into individual privacy. For example, workplace screening may involve collecting information on illegal behaviors that could raise concerns of bodily privacy to obtain urine or blood samples or informational privacy.

In some cases, such screening can result in dismissal from a job. Finding ways to implement screening in settings where individuals may benefit while assuring necessary privacy is a critical challenge.

Relatedly, there are challenges to making participation in prevention programs confidential, especially when these programs occur in workplaces or schools. While these concerns may be mitigated in practice, concerns about privacy and stigma could constrain how policymakers target high-risk populations. However, treatment programs are difficult for many people to access and are largely disconnected from the medical system, a legacy of the historical marginalization of treatment.

Outside of medically oriented programs, many people access treatment through self-help programs or the criminal justice system Smith and Strashny, Many individuals in treatment are legally required to participate, which also raises ethical concerns. First, individuals in court-ordered programs have constrained treatment choices compared to other medical patients.

Receiving treatment in an outpatient program is less disruptive, and ultimately more productive, than the alternative of incarceration.

Physicians must ordinarily obtain patient consent to cooperate with law enforcement before initiating care, but the ability to obtain truly free consent can be limited since that consent is obtained under coerced conditions i. In extraordinary circumstances, where obtaining consent may be impossible e. There are also deep philosophical disagreements about how best to help individuals with harmful AOD use. These disagreements concern not only scientific debates about which treatments are effective, but also about whether it is appropriate to focus on the character of a person in recovery.

These ideas are not grounded in the medical understanding of addiction, but they may nevertheless be valuable to some people Humphreys et al. On the other end of the spectrum, methadone maintenance for opioid use disorder—which has very strong medical evidence—is rejected by many in the self-help community as an addiction by other means Stancliff et al.

Since restoring normal functioning is a key goal of treatment, this trade-off should be viewed as more than acceptable. Incarceration has serious and wide-reaching negative health consequences. African Americans in particular are at substantially greater risk of imprisonment Western and Pettit, The racial disparities resulting from mass incarceration, on their own, raise questions about the fairness of criminal justice policies Alexander, The many health harms of incarceration raise questions about whether there is any public health justification for incarcerating people for low-level AOD offenses as distinct from those who distribute drugs.

Renewed calls for decriminalizing drug possession p. It is important to note that decriminalization—reducing or eliminating criminal sanctions for drug possession—is different from legalization discussed further below. For example, marijuana has been decriminalized in twenty-one US states as of NCSL, , but it is illegal to possess marijuana in most of these states.

Countries such as Portugal have decriminalized harder drugs. Keeping people out of correctional settings and mitigating the harmful effects of a criminal record are positive effects of decriminalization. However, there are legitimate concerns about increasing the scope of decriminalization—including normalizing the use of illegal drugs and reducing deterrence. Decriminalization also may eliminate the legal enforcement that leads many people to receive treatment.

Many AOD users on their own will not be motivated to seek treatment for their harmful drug use, and individuals in coerced treatment are more likely than others to complete treatment Saloner and Cook, That said, coerced treatment involves deprivations of liberty and may not be cost-effective when delivered in a broad, untargeted manner Kleiman, Caulkins, and Hawken, One promising model for coerced treatment involves programs that place offenders into programs with swift and certain criminal sanctions for violating drug-testing requirements, but that limit jail time to short periods such as weekends for violators.

Those successfully meeting sobriety benchmarks can receive reduced judicial supervision, until they are finally released from the program. Harm reduction encompasses a broad range of approaches to reducing the harmful effects of AOD use and may overlap with the goals of treatment. The most visible and controversial strategies include needle exchange programs, safe consumption sites, and supervised administration of clinical-grade heroin now provided on a limited basis in Switzerland, Canada, and other countries.

Other programs that permit AOD use among people participating in employment or housing programs are also controversial. Many of these approaches have been shown to be effective Lurie et al. On the other end of the continuum, Amsterdam has a program that employs individuals with alcohol use disorders to work as street sweepers and pays them in beer Holligan, Such a program is ostensibly justified in that it reduces idleness in this group, provides them with a sense of self-worth, and may substitute p.

In whatever form they take, harm reduction efforts can be justified on straightforward consequentialist terms—providing these programs increases the well-being of AOD-using individuals, and society more broadly, by preventing the bad health outcomes that accompany AOD use without necessarily reducing substance use. These programs, it is argued, have little downside, since they improve the well-being of people who are not otherwise willing or able to fully abstain from use.

If someone is not prepared to stop injecting heroin, their health trajectory can still be improved by ensuring that they have access to safe needles and to naloxone, the medication to reverse an overdose. Nonetheless, making commitments to quitting is not a requirement of harm reduction. Moreover, harm reduction programs can have secondary benefits through reduced disease transmission and prevention of other harms to others, and thus may advance other justice-based concerns.

By reducing the health costs of using drugs—such as blood-borne infections or the risk of overdose—one concern about harm reduction is that it neutralizes risks that otherwise encourage quitting MacCoun, Harm reduction could also reduce the perceived harms of initiating drug use for children and adolescents to the extent that harm reduction normalizes the behavior. Moreover, harm reduction as provided in public health interventions generally includes counseling and referral to treatment programs.

Even if concerns about normalization were well founded, the government—and affected individuals themselves—arguably has a strong interest in reducing the harmful social ills related to illegal drugs, especially in reducing the transmission of human immunodeficiency virus HIV , hepatitis C virus, and other costly infectious diseases, and harm reduction could be integrated with treatment to foster long-term health improvement.

Some people may object that harm reduction is problematic despite its potential to improve health. On this view, social programs especially those funded with government resources have a duty not only to promote health, but also to represent the values of a good society, including respect for the law and concern for individual dignity.

This public role is incompatible with harm reduction programs, which, it is argued, do not go far enough in rejecting behaviors that diminish individual dignity or condone criminality.

In response, it might be argued that public sentiment is contaminated by prejudices that make it unreliable—for example, p.