Substance Abuse and Involuntary Commitment: Will it Work?

Mental health professionals seem to support, but questions remain.

AUSTIN, Texas — A majority of mental health professionals supported adult civil commitment for substance use disorder, according to a researcher here.

In a sample of 165 psychologists, psychiatrists, and mental health specialists, 61% of survey respondents said they were in favor of establishing adult civil commitment centers for opioid and other substance abuse, 21% were opposed, and 18% were unsure, reported Abhishek Jain, MD, of Columbia University in New York City.

Generally, respondents who spent more time with substance abuse patients were more supportive of civil commitment than those who were not, and the strongest support tended to be for opioid and alcohol use as opposed to other drugs like cocaine and heroin, he said at the American Academy of Psychiatry and the Law (AAPL) annual meeting.

However, the majority of physicians also reported that they were concerned with the amount of resources and facilities needed to impose this treatment, and said medication-assisted treatment (MAT) would be essential if these facilities were implemented.

“[The data] suggests that people oppose civil commitment for substance use more based on the lack of resources and the ability to pay for the commitment rather than other concerns such as losing rapport with patients, or that you would need motivation for people to have successful civil commitment treatment,” Jain said.

Civil commitment allows family members, or others, to seek court-ordered treatment for individuals with substance abuse on the basis that they pose a substantial threat of harm to themselves or others. However, unlike being processed through a drug court, civil commitment does not require substance abusers to go through the criminal justice system, Jain explained. As of 2015, 32 states had laws permitting civil commitment in these cases.

But he said the literature regarding civil confinement is often extrapolated from other international studies, and that U.S. studies in this field tend to have small sample sizes and insufficient treatment details, making it difficult to generalize. For example, some of the most comprehensive data is from a 2007 American Psychiatric Association (APA) survey where just 22% of respondents supported alcohol or drug civil commitment, Jain added.

Those against the implementation of these programs argued that taking patients in against their will was a violation of a civil liberty, and that treatment imposed involuntarily may not be effective. Jain cited a 2017 vignette-based report, six of seven patients relapsed immediately after discharge.

For the current study, surveys were sent to active American Society of Addiction Medicine (ASAM) members. In addition to yes or no questions, the survey also asked respondents to submit their thoughts on adult civil confinement for substance abuse disorder. One provider said involuntary treatment “treats addiction like a crime rather than a disease” and that, instead, “voluntary, low threshold treatment” should be made available. In contrast, another respondent reported, “I think all 50 states should have it.”

Part of the issue is that these institutions very across states and jurisdictions, Jain said. Within some states with civil commitment legislation, for example, only healthcare providers are legally allowed to petition. In others, family members must submit a guarantee of payment stating they claim responsibility for the payment of treatment. Additionally, in some jurisdictions, civil commitment may only be offered for alcohol use but not other drugs.

Debra Pinals, MD, of the University of Michigan in Ann Arbor, developed the Women’s Recovery from Addictions Program in Massachusetts to provide women with substance use disorders an alternative to the prison system. Although she acknowledged that there is not yet data supporting the success of this program, she said it has been used as a model for similar developing institutions.

Pinals, who was not involved in the study, said many of these patients tend to have comorbid mental health disorders like suicidality, depression, and bipolar disorder that need to be addressed. Additionally, since substance use treatment typically tends toward coercion, personal interviewing, and helping patients own their recovery in a personal way. In the civil commitment setting, patients are there involuntarily so it’s important for mental health professionals to share administrative authority, she stated.

“I… don’t know what I believe in terms of what the right direction of any of this is, and I think we really do need a lot more research,” Pinals said.

Pinals said that several paradigms need to be established before civil commitment institutions are officially established. For example, when a patient states their desire to leave the institution, what measures should be taken? Pinals said she generally tries to avoid restraining patients, but it might be necessary if patients get violent during substance withdrawal.

She also noted that licensure and funding for these facilities need to be considered. Some AAPL attendees stated that these programs may be of particular importance for pregnant women with substance abuse disorders, pointing out that these women, as well as other vulnerable populations, tend to require more complex treatment.

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