Should drug addicts be forced into treatment against their will?
In the face of skyrocketing overdose deaths resulting from an opioid epidemic that has been called the “greatest drug crisis in American history”, communities throughout the country are scrambling to come up with effective solutions. The cost to society – both economically and in human terms – is becoming too great to bear.
In response, the idea of involuntary commitment for drug addiction is gaining traction.
Let’s take a closer look at the positives and negatives of compulsory drug rehab.
First Things First – What Is Forced Treatment?
“Forced” treatment is exactly what it sounds like – compulsory participation in a substance abuse rehabilitation program. In most cases, it is Court-ordered by the judge during a criminal case involving drugs. Family members and/or medical professionals may also petition the Court to intervene.
In some US States, either medical personnel or law enforcement officers also have the authority to remand someone for involuntary psychiatric commitment and evaluation, although the stay will be very brief, typically no more than 72 hours. Every state allows for short-term psychiatric holds in emergency situations.
Because Substance Use Disorder is classified as a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, it is governed by such statutes.
After the initial evaluation and hold, the physician and the treatment team will make recommendations to the Court as to whether the commitment period should be extended and if involuntary treatment—including the use of approved medications— should commence. Currently, 37 states allow for Court-ordered treatment.
Balancing Patients’ Rights versus Patient Safety
Both the United Nations and the US Supreme Court consider involuntary treatment and hospitalization of an otherwise-competent patient to be a violation of that person’s civil rights. In fact, for a person to be even temporarily committed, the most common standard is “substantial risk of serious harm to the person or to others unless the person is immediately restrained.”
Landmark court decisions have determined patients’ rights:
- 1975: The Supreme Court ruled that involuntary treatment and/or hospitalization constitutes a civil rights violation.
- 1977: The US District Court for the District of New Jersey ruled that involuntary-committed patients who have not been ruled incompetent have the right to refuse psychotropic medications, barring an emergency.
- 1979: The US Court Of Appeals for the First Circuit ruled that competent patients have the right to make decisions about their care, including the right to refuse treatment in a non-emergency situation.
Opponents of forced treatment include the Church of Scientology and the New York Civil Liberties Union.
On the other hand, supporters of what they call “assisted treatment” include the American Psychiatric Association, the National Alliance on Mental Illness, and the Treatment Advocacy Center.
A 2015 study found that forced treatment not only saves lives but also reduces the economic burden that untreated mental illness forces upon the community:
- Law enforcement
- Court costs
- Crisis intervention
- Homeless shelters
- Long-term hospitalization
How significant are the savings? Some counties in New York were able to realize net cost savings as great as 67%.
The Executive Director of the Treatment Advocacy Center, Doris Fuller, says that a court order “… improves what is assisted outpatient treatment? Quality of life for the individual and safety for the community – all while being far less restrictive than the jails or hospitals where this population too often lands… (assisted treatment) is a cost-effective alternative for promoting the stability they need to begin recovery.”
What Is the Difference between Involuntary Commitment and Forced Treatment?
Although they are related terms, there is a difference between “involuntary commitment” and “forced/involuntary treatment”.
“Commitment” is usually an emergency measure aimed at preventing a person with mental illness from harming themselves or others. It can also be thought of as a stabilization period where the patient is observed to determine if they should be released, evaluated further, or be given additional treatment.
Most initial commitments last no longer than three days before a hearing is held where the judge listens to recommendations and makes a ruling as to what happens next.
“Forced treatment” is when the patient has been evaluated and is directed to check into a rehab program, whether they want to or not. It can be ordered after the initial 72-hour evaluation, when the family of an addict successfully petitions the Court, or as an alternative to jail during a drug-related criminal case.
A Few Words about Drug Court
First used in Miami-Dade County in 1989 as a response to the area’s crack cocaine problem, Drug Courts provide an alternative to nonproductive incarceration for people who are struggling with severe mental health or addictive disorders.
Rather than punishment, Drug Courts look to lessen the individual and societal damage caused by addiction. Every involved official entity works together to help the participating defendant achieve and maintain successful long-term recovery.
- The presiding judge
- Defense attorneys
- Probation officers
- Law enforcement
- Mental health services
- Social service providers
- Rehab programs
Nonviolent offenders are allowed to participate in a rehabilitation and monitoring program that keeps out of jail if they meet several requirements, including:
- Successful completion of an approved substance abuse treatment program
- Complete abstinence from drugs and alcohol, as verified by random screenings and/or ankle bracelet monitoring
- Attendance at 12-Step meetings such as Alcoholics Anonymous or Narcotics Anonymous
- Gainful employment or school attendance
- Payment of any fines and restitution
- Community service
- No additional criminal charges
Here’s the best part – in most cases, the person will have the charge removed from their record upon successful “graduation” from Drug Court.
How Effective Are Drug Courts?
Decades of ineffective efforts such as the “War on Drugs” shows that single-mindedly focusing on the illegality of drug use to take a punitive approach just doesn’t work. For example, 70% of drug offenders resume use after being released from prison.
A solely-punitive approach to the drug crisis means that there may be as many as 1.5 million people with SUD – a legitimate medical disorder – currently in jail or prison. This equates to $80 billion annually spent on correctional costs.
Drug Court, on the other hand, saves money, returning $2.21 in benefits to society for every $1 spent on treatment and monitoring.
Nationally, 60% of Drug Court participants successfully complete their ordered program. To put that number in perspective, that is more than twice the success rate of addicted offenders who were merely given probation.
Finally, Drug Court graduates are far less likely to commit new crimes. While the recidivism rate among nonparticipants is 48%, while those who complete drug court reoffend at rates as low as 4%.
This “problem-solving” judicial model has been an unprecedented success. Today, there are well over 3000 drug courts operating in every state, the District of Columbia, and US territories – Puerto Rico, Guam, and the Northern Mariana Islands.
Every year, approximately 120,000 people in the United States are treated through drug courts. In fact, more people participate in a rehab program because of drug court than through any other kind of intervention.
What Is Assisted Outpatient Treatment?
Also called “outpatient commitment”, this is when individuals suffering from severe mental health or addictive issues are ordered by the Court to adhere to a strict outpatient treatment program. Distinct from involuntary commitment or inpatient treatment, AOT allows patients to live at home, work or go to school, and maintain family involvement.
Currently, there are 45 states that allow for compulsory outpatient treatment.
The requirements for AOT can be exacting:
- Taking of prescribed medications
- Attendance and participation in an outpatient rehab program
- Mental health counseling
- Group therapy
- 12-Step meetings
- Anger management classes
- Abstaining from alcohol or drug use
- Avoiding certain people and places
- Random drug screening
- Breathalyzer on vehicles
- Lawful behavior
- Good attendance at work and/or school
The success rate of AOT is inarguable:
- 90% of participants report that AOT made them more likely to keep therapy appointments and take their medications.
- 88% said they agreed with their case manager about treatment goals.
- 87% expressed confidence in their case manager.
- 87% fewer experienced incarceration.
- 83% fewer were arrested.
- 81% believe that AOT helped them get and stay sober.
- 77% suffered less psychiatric hospitalization.
- 75% say that AOT helped them regain control over their everyday lives.
- 56% shorter hospital stays
- 49% fewer abused alcohol.
- 48% fewer abused drugs.
If the requirements of the program are not met, participants risk involuntary hospitalization or incarceration.
What Is Coerced Abstinence?
This is a somewhat controversial kind of forced rehab that focuses exclusively on abstinence, rather than treatment. Because drug court is not usually an option offered to serious offenders, a coerced abstinence program allows them to stay out of jail while strongly motivating them to stay clean and sober, no matter what.
Adherence to the program is enforced by regular drug testing with predictable consequences. Failed tests will immediately result in a short jail sentence – no exceptions.
There is psychological science behind the promise of coerced abstinence programs – the “prospect theory”. According to this concept, people are more likely to attempt to avoid lesser harms that are certain than more severe harms that are merely probable.
In other words, coerced abstinence can get people off drugs because they know for sure that they WILL be tested, just as they know that if they fail, they WILL go to jail, even if it is only for a few days. Punishment is swift and sure.
This is completely different from other illegal activities where the penalties are higher, but the chances of getting caught and punished are less.
In Hawaii, a coerced abstinence program known as “H.O.P.E.” – Hawaii’s Opportunity Probation with Enforcement – is showing some promise. Participants spend an average of 130 fewer days incarcerated than those who participate in other traditional supervision programs. Already, it is inspiring pilot programs throughout the rest of the country.
What’s the Bottom Line about Forced Treatment?
There’s a long-held philosophy in recovery that an addict must want to get better before they will accept help. That has been a hard-and-fast concept for decades.
But there is one inherent flaw with that idea.
The concept that a substance abuser has to choose help predates the widespread acceptance of the disease concept of addiction. The prevailing sense of wisdom today supposes that “choice” is not an accurate way to describe an active addict’s actions.
If we now know that chronic substance abuse triggers neurochemical changes within the areas of the brain associated with moral reasoning, decision-making, learning, and motivation, how can we cling to the antiquated idea that successful recovery completely depends on an active addict’s ability to make a good choice for their future?
Because there is another old recovery slogan – “Fake it until you make it.”
The original writer of this slogan understood that, in early recovery, it isn’t necessary to completely buy into all the messages and lessons being presented. In the beginning, just continuing to show up is a triumphant step forward. Understanding and acceptance can come later.
As evidence of this, consider a 2006 review of involuntary hospitalization. At the time they were hospitalized, 48% of patients did not initially agree with their treatment. However, up to 81% later agreed that their involuntary admission had been justified and that they had benefited from the treatment.
And what about the criticism that forced treatment is a violation of the patient’s human rights and far too restrictive to be effective?
A compelling argument can be made that for those patients for whom forced/assisted treatment is necessary—the most severely ill and addicted—compulsory rehab is much LESS restrictive than the chaotic cycle of legal entanglements, hospitalizations, and personal dysfunction caused by untreated SUD.
To be clear—involuntary drug and alcohol rehab is not a needed option for the vast majority of people with SUD. But in a current reality where only about 10% of those who need help are getting it, maybe this is an option that should be explored further.