Why involuntary treatment for addiction is a dangerous idea

By Sarah E. Wakeman

April 25, 2023

As the overdose crisis rages on and the pandemic-fatigued public runs low on empathy, there have been increasing calls for expanded involuntary commitment for people with substance use disorder. Some of the advocacy for more coercive treatment seems rooted in a disdain for people who use drugs, most especially when their drug use occurs visibly and in close geographic proximity to affluence, for example in San Francisco or in the Massachusetts Avenue and Melnea Cass area of Boston which borders the wealthy South End neighborhood.

However, many others’ support for involuntary treatment is rooted in compassion, love, and sheer desperation. In these instances, the supporters are often parents, loved ones, or beleaguered clinicians who care deeply for the well-being of individuals who use drugs and grasp at the idea of civil commitment as a necessary evil to save a life. A powerful description of this perspective, and the love behind it, was recently written by a father and published in the New York Times.

The problem is, forced treatment likely does more to harm than to help.

When I first started out in addiction medicine to now, I thought that this made sense as a last-ditch approach. But my thinking has changed as I’ve seen the clear evidence of its lack of benefit and heard stories and observed data indicating its harm. I also know intimately the feeling of powerlessness that comes with being a close family member to someone dealing with addiction. When I see medical professionals and loved ones reaching to involuntary treatment as a solution, I know it is out of a desperate wish to do something, anything, to respond to the human suffering of watching someone you care for struggle with addiction in a broader system and context that is fragmented seemingly beyond repair. But rather than lean into broken strategies, we can put that compassion and urgency into effective, bold, and brave solutions to finally bend the arc of the overdose epidemic and save lives.

Before diving into the evidence, it is helpful to understand what involuntary treatment or civil commitment for substance use disorder looks like. In Massachusetts, “Section 35” allows for people deemed at imminent risk of harm from their substance use to be sent against their will to “treatment.” Section 35 in Massachusetts was enacted back in the ’70s and was initially used predominantly for people with longstanding, severe alcohol use disorder. The onset of the overdose crisis resulted in an increase in its use. Between 2011 and 2018, 42,853 people in Massachusetts were sent to involuntary treatment. The process begins when a family member or doctor or police officer petitions a judge to issue a warrant — yes, a warrant — for the individual. Then, the person is picked up by police and detained to come before a judge, much like being arrested for an alleged criminal offense.

If the judge agrees with pursuing a civil commitment for a man in Massachusetts, he may then be taken to a correctional facility and held against his will for up to 90 days, often wearing an orange prisoner jumpsuit and submitted to the same dismal conditions that people criminally convicted are.

Now, Massachusetts has made progress over the years to bring more actual treatment to people going through this process, instead of just confinement, and moving women who are committed outside the correctional system. Nevertheless, men may still be sent to correctional facilities which massively underutilize the most effective treatments for addiction, most notably medications for opioid use disorder, the only treatment proven to reduce mortality.

Even under ideal care, though, the very experience of Section 35 is traumatic, particularly for the many people with substance use disorder who have already experienced the trauma of incarceration.

It is simply impossible to deliver what is supposed to be person-centered treatment in a correctional facility. As one of my patients explained it to me, during his time under Section 35, he wore an orange jumpsuit, was locked in a cell, and ate crappy food. But the worst part was the hours upon hours of low-quality group meetings. He said he actually preferred being in prison.

Sometimes people are even encouraged to “section themselves” as a way to ensure placement in a treatment facility. Another patient of mine, desperate for care, ended up going through the process, which he later told me was utterly traumatic. Instead of the care he needed, he was thrust into a carceral experience and described being demeaned by the guards. Feeling ashamed and stigmatized, he was scared off from voluntarily seeking treatment again.

Despite all of this, involuntary treatment might be worth it if it worked — but evidence strongly suggests that it doesn’t. Data from other countries comparing compulsory treatment to voluntary medication treatment shows rapid recurrence of opioid use after release from these centers. A systematic review of involuntary treatment found no evidence of benefit and a suggestion of potential harm. Here in Massachusetts, observational data from the public health department found that the risk of fatal overdose was twice as high after Section 35 as opposed to voluntary treatment. In addition, the risk of fatal overdose is 120 times higher among people recently released from correctional settings, largely due reduced tolerance to opioids and a failure to initiate effective medication treatment.

Studies used as evidence of mandated treatment’s success often look to drug courts, which are a frequently proposed model for mandating treatment. However, drug courts are also problematic in their design. Indeed, Physicians for Human Rights published a sobering report in 2017 titled “Neither Justice Nor Treatment: Drug Courts in the United States,” which found that drug courts often mandate treatment to people who don’t actually have substance use disorder who are arrested on drug-related charges and then fail to provide high quality addiction care to the individuals who do need it.

Other studies have attempted to compare outcomes between people who report they were mandated by probation or parole to treatment — often to 21- or 28-day residential programs which themselves have limited evidence of benefit — with those there voluntarily. But these studies have a foundational problem: The group there under coercion is often different, with fewer consequences from drug use and lower rates of drug use disorder. Regardless of how the data is analyzed, the fatal flaw here is the idea of forcing residential “rehab” on individuals with minimal substance-use related consequences under threat of imprisonment.

The fact that the data doesn’t support involuntary treatment may be a surprise given how it is often covered in a favorable way by news media, usually with anecdotes of how being imprisoned saved someone’s life. There’s even a catchy term — “arrescued.” The idea of forcibly sending someone to a less than pleasant environment where they may be treated poorly also may not sound like such a bad idea if you have been inundated with the false tropes about drug use and addiction that abound. Notions of “tough love,” “hitting bottom,” and “enabling” all send a not-so-subtle message that the best way to help someone suffering with addiction is to be hard on them. Only then will they realize how terrible their drug use is and pull themselves up by their bootstraps, this line of reasoning suggests.

Yet the definition of addiction is compulsively using a substance despite bad things happening to you. And substance use is a powerful coping mechanism for when things are going terribly. So why would making someone’s life worse, making them feel even more beaten down, help someone get well? Putting addiction aside, think about the last time you made a big change, like starting an exercise routine or making a relationship decision. Did you have the wherewithal to do that on a day when you were feeling exhausted and stressed and hopeless? Probably not. Now magnify that by a thousand. If someone is using chaotically because of trauma and their use has worsened in the context of homelessness, forcibly removing the drug use is not the solution. Giving that person hope, treating them with kindness and compassion, hearing what they need, and partnering with them on whatever they think might make their life better is what actually helps.

The other problem with focusing on and funding expansion of involuntary commitment for substance use disorder is that we have huge numbers of people who want treatment and aren’t able to access it.

The evidence is quite clear that addiction is a treatable health condition, and what works is voluntary, welcoming, low-barrier treatment that includes a range of options based on science, delivered with compassion, and centered on and driven by patients. Before pouring money into filling prison cells reformed as “treatment beds,” why not fund and expand models that have decades of evidence? Rather than spend money to renovate and staff departments of correction, let’s invest in supportive housing, low-threshold bridge clinics, hospital-based addiction consult teams, expanded harm reduction services, and training programs for physicians and other healthcare providers to become addiction specialists. Rather than put more people in carceral settings, why not invest in community revitalization projects, economic opportunity, building resilience in youth, and addressing neighborhood blight?

At the end of the day the seemingly opposed viewpoints on involuntary treatment are more aligned than they might seem, rooted in a wish to respond to the overdose crisis and to the individual humans at greatest risk of harm. For most, this is a disagreement of compassion.

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