Why involuntary treatment for addiction is a dangerous idea

“When I first started out in addiction medicine to now, I thought that this made sense as a last-ditch approach [involuntary commitment]. 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. [..]

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 [a law instituted in the 1970’s that allows people deemed at imminent risk of harm from their substance use to be sent against their will to “treatment”] 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 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.”

Full editorial, SE Wakeman, 2023.4.25