Alecia Gordon is quick to admit that forced drug treatment was a good thing for her son. He was 19 years old when he entered a court-mandated program for the first time. She believes it saved his life.
“If it wasn’t court-ordered, he really might not have survived,” Gordon said.
Mandatory rehab turned out to be a good thing for Gordon’s son, whose only other option was jail time with no treatment at all.
However, many researchers suspect that forcing people into short-term drug treatment programs may not be enough to help them stay sober long term.
This hasn’t stopped U.S. states from expanding the use of involuntary commitments for drug and alcohol addiction. Nor has it slowed the growing number of private rehab programs in the country.
Court-ordered drug treatment on the rise
According to the National Alliance for Model State Drug Laws, currently 37 states and the District of Columbia allow families and medical professionals to petition to have a person ordered into treatment.
Generally, a person can only be civilly committed if they’re deemed a danger to the health or safety of themselves or others.
Emergency commitment varies from 24 hours to 15 days. In some states, families, medical professionals, and law enforcement officers can petition the treatment facility directly, without a judge’s order.
Supporters of these programs argue that short-term commitments provide a critical stopgap for when courts are closed, such as on weekends and during the night.
However, some healthcare providers are concerned that allowing doctors to involuntarily detain people with substance use disorders will burden emergency rooms, reports the Associated Press.
The AP cites data showing that involuntary commitments for drug addiction are on the rise in some states.
In Florida, requests for commitment topped 10,000 in both 2016 and 2015, much higher than in 2000 when it was more than 4,000. In Massachusetts, requests doubled from fewer than 3,000 in fiscal year 2006 to more than 6,000 in both fiscal years 2016 and 2017.
In most states, longer involuntary commitments require a court order. Stays can last for up to a year, but many states have lower durations. And these may not be enough to really make a difference.
“When someone’s brain is hijacked by an addiction, six weeks isn’t long enough — two months isn’t even long enough — for their brain to stop craving the drug,” said Lisa, a mother from Arizona whose daughter has been cycling in and out of addiction for several years.
Does forced drug treatment work?
The rise in involuntary commitments may be a sign of the severity of the opioid epidemic. According to the National Institute on Drug Abuse (NIDA), more than 115 people in the United States die each day after overdosing on opioids.
However, there’s little research showing that forcing someone into drug treatment helps them in the long run.
Many states don’t track whether civil commitments help people with a substance use disorder stay in recovery, or how many times they enter forced treatment.
But there are studies showing that these programs don’t help and may actually be harming people instead.
A 2016 report by the Massachusetts Department of Public Health found that people who were involuntarily committed were more than twice as likely to die of an opioid-related overdose than those who chose to go into treatment.
Another 2016 study published in the International Journal of Drug Policy found little evidence that mandatory drug treatment helps people stop using drugs or reduces criminal recidivism.
“There appears to be as much evidence that [compulsory treatment] is ineffective, or in fact harmful, as there is evidence that it is effective,” said study author Dan Werb, PhD, who’s also an epidemiologist and policy analyst at the University of California at San Diego (UCSD).
Most of the studies reviewed by Werb and his colleagues looked at involuntary drug treatment centers outside the United States, many of which are rife with human rights violations.
“What we’ve seen across the world — in Mexico and Southeast Asia and China — is that ‘treatment centers’ that are mandated can effectively turn into internment camps,” Werb said.
A 2018 study done in Tijuana, Mexico, by Claudia Rafful, a doctoral student in public health at UCSD, found that involuntary drug treatment is also associated with an increased risk of nonfatal drug overdoses.
Part of this may be due to loss of tolerance to the drugs when someone suddenly stops using them. This happens not just with mandatory treatment, but also when people end up in jail.
However, Rafful says that interviews with people taken involuntarily into the treatment centers in Tijuana showed that most of them weren’t ready to stop using drugs. This may be another contributing cause of drug overdose after involuntarily committed individuals are released.
Many of these centers also didn’t use evidence-based treatments. This is also a problem in the United States.
Additionally, people going through drug courts can face many barriers to receiving evidence-based diagnoses and treatments, according to a 2017 report by Physicians for Human Rights.
Interventions shown to be most effective for helping people with substance use disorders were often not available, or not available to everyone — including support for stable housing and employment and medication-assisted treatment.
When those interventions were available, people weren’t always able to afford them. Or their insurance — including Medicaid — may not have covered them.
Gordon’s son spent some time in jail before a bed finally opened in the treatment program. Until then, his addiction was left untreated.
Some researchers see drug courts as coerced, rather than mandatory treatment, because people are still given a choice: go to jail or enter drug treatment.
The first time Gordon’s son went to court-ordered treatment, it was part of his incarceration, though it was held at a different location.
“Even though you were still not free,” Gordon said, “it was much different than if you were in the county jail.”
Gordon’s son was initially given a two-year sentence. He was able to get it reduced by doing well in the treatment program.
Unregulated rehab industry
As many families of people with a drug or alcohol addiction know, relapse is a common detour on the road to recovery.
Gordon’s son went to several treatment programs after the first court-ordered treatment, another court-ordered, one “mom-ordered,” and a program at a private rehabilitation center that he attended voluntarily.
But tough love doled out by families is another form of coerced treatment.
Rafful says there’s a very thin line between coerced and mandatory drug treatments.
What’s missing in both is a person with a drug or alcohol addiction embracing treatment voluntarily.
“If forced treatment worked, I think we’d all do it,” Lisa says. “Ideally, they do better when they’re asking for it. But you can’t always wait for that.”
A multibillion dollar rehab industry has grown up around families desperate to help their loved ones overcome addiction.
There are more than 14,500 specialized drug treatment facilities in the United States, according to the NIDA. But this industry is largely unregulated, and many programs offer treatments that aren’t based on research. There are also no federal standards for rehab programs or counseling practices.
Residential rehabs can cost tens of thousands of dollars for one month of treatment. In some cases, insurance may cover treatment. But families often end up paying out of their own pocket.
There’s no requirement that rehab programs offer medication-assisted treatments. Some may opt for other types of interventions, including unproven ones like equine or other forms of pet therapy.
Rehab programs may sell families a quick fix. But addiction is a chronic disease, not one that can be treated with a few weeks of intensive treatment.
What drug treatments work?
One common thread among successful opioid treatment programs in particular is the use of pharmacological treatments.
“We have decades of evidence suggesting that methadone and similar opioid-based medications can be really effective in helping people to manage their opioid use,” Werb said.
Other options are buprenorphine and injectable naltrexone.
Transitions are also important. If a person is forced into drug treatment, either through a court order or family coercion, they’ll still eventually need to take control of their own treatment.
Voluntary treatment ensures that “patients can have a voice in the care that they’re provided, and that they can take control of their own health,” Werb said.
Rafful adds that treatment programs also need to address a person’s environment, which may have contributed to the drug problem. “If we are not helping to fix the problems that are related to their drug use — such as housing, employment, or stigmatization — chances are the person will go back and use drugs,” she said.
This doesn’t mean forced treatment or rehab won’t help some people with addiction. But families need to be careful about choosing the right treatment for their loved ones.
The first step is getting help from a qualified medical professional, such as your doctor or a mental health provider with experience treating addiction.
The American Board of Preventive Medicine has a directory of doctors in the United States who are board-certified in addiction medicine.
When choosing treatment for a loved one, look for interventions that are supported by research.
Residential treatment is also not the only option. A 2014 study found that outpatient substance use disorder treatment programs can be just as effective as inpatient programs.
It’s also important to remember that relapse isn’t a failure. People with an opioid use disorder will often relapse along the road to recovery.
Gordon credits the program at the private rehabilitation center with helping her son stay sober for the past 18 months. But not because it was voluntary. The program included both a six-month inpatient treatment program and a three-month transition to sober living program.
This made all the difference.
“Although my son’s last treatment was court-ordered — and I’m thankful it was court-ordered — I think mandatory programs would be much more successful, with much lower recidivism, if people had longer-term court-ordered treatment.”