Considerations for Policy Makers
With fatal drug overdoses nearly tripling in the United States between 1999 and 2014,1policymakers and others are urgently striving to implement new solutions to contain this crisis. Various forms of tort laws have been implemented to protect people with a mental health disorder from harming themselves or another person. These laws allow for the involuntary commitment of an individual by the courts, subject to the presentation of substantial and credible evidence of potential harm. For people with severe substance use disorder, several states are now considering involuntary commitment laws for the first time or proposing changes to existing laws that would remove barriers to make involuntary commitment less difficult.2-5In at least two of those states, the new involuntary commitment policies apply specifically to opioid use.6,7
The treatment gap (the gap between the need for and utilization of treatment) for substance use disorder in the United States stems from stigma, the lack of effective treatment services available, and the inability of some people with substance use disorder. of substances to seek treatment voluntarily. Family members and loved ones of a person with a substance use disorder often feel helpless and helpless when that person is unable, due to brain damage, to make the rational decision to undergo and complete addiction treatment. Situations can escalate to the point where family members and loved ones feel unsafe or fear that the person with substance use disorder is at great risk of overdose and/or death. Involuntary commitment laws for substance use disorder may be a way to initiate the treatment these individuals need to prevent death and ultimately restore a productive and healthy life. This point of view is balanced, according to some, with the need to protect the privacy and freedoms of people with a substance use disorder. For those who emphasize this point, unless a crime has been committed, treatment should always be an option, even if the ability to choose is compromised.
This report outlines the current state of involuntary commitment laws in the United States to the best of our knowledge and, more importantly, sheds light on various considerations for legislators and others regarding these laws. Few research studies have been conducted to systematically collect stakeholder views on these laws or to assess their short- and long-term impacts. This is certainly a fertile area for future research, but while we hope these studies will reveal an evidence base, we need to think carefully and sensibly about how these laws can protect liberties while promoting health and safety.
The current state of involuntary commitment laws
To the best of our knowledge, 37 states and the District of Columbia (DC) have laws in place that allow for the involuntary commitment of people with a "substance use disorder," "alcoholism," or both.8However, in most states these laws are rarely used and many families, doctors, and local judges are unaware of this option. A 2015 analysis showed that about 40% of states with substance use liability provisions rarely or never use these laws.9A judge may be reluctant to submit an individual to treatment without a strong precedent established by decisions in previous cases. Involuntary commitment laws also vary widely in terms of who can petition the court to involuntarily commit a person undergoing treatment (for example, a relative, treating physician, psychologist), how difficult it is to get a petition approved, how long a person can be admitted (from one day to one year) and what type of treatment is required (eg inpatient, outpatient, unspecified).8,9
As shown in Figure 1, five of the 38 states (including DC) specifically include "substance abuse" and "alcoholism" in the legal definition of a mental illness or disorder, making the impairment of people with mental health problems of substance use is the same as the impairment of persons with psychiatric disorders. The other 33 states have separate provisions for the involuntary commitment of people with substance use disorders and alcoholism. This latest policy strategy is intended to prevent criminal defendants who committed a crime under the influence from claiming an insanity defense. Thirteen states do not allow the involuntary commitment of people with substance use disorders.
Important Issues to Consider
What evidence of potential harm is needed to inadvertently commit a person with a substance use disorder?
States vary on the requirements to involuntarily commit a person with a substance use disorder.8An evaluation of the person by a physician or medical director of the treatment center prior to admission and a statement from the physician accompanying the request indicating that the person is in need of intensive care are commonly required. Some states accept testimony from psychologists, psychiatrists, physician assistants, or addiction counselors instead of a doctor. Some states require documentation that the person had previously refused admission to an accessible and affordable voluntary treatment program or that the person was recently admitted for emergency care.
State laws also vary widely regarding who can petition the court to involuntarily place a person in drug and alcohol addiction treatment. Most states allow a spouse, guardian, relative, medical professional, or treatment center administrator to petition the court for involuntary commitment. However, some states will allow a friend or any responsible person to file a petition and, in at least one state, law enforcement officers are allowed to do so.
Many believe that involuntary commitment should be an option only for those with a severe substance use disorder who pose a serious risk to themselves or others. However, Charlotte Wethington, a mother who lost her son to an overdose and went on to lead Kentucky's involuntary commitment law known as Casey's Law, says such stipulations are not necessary. She said the reality is that a civil compromise requires a concerted effort on the part of the person filing the petition with the court, and is generally only pursued as a last resort, after the disorder and danger have clearly subsided. become stern and serious.
"Families who have filed a Casey's Law petition have only done so in desperate situations, after multiple overdoses and the loss of home, job, children, car, insurance, self-esteem and hope," Wethington said. "The only thing left to lose is the life of your loved one. That is the right the family is trying to protect: your loved one's right to live."
How long must a person with substance use disorder involuntarily undergo treatment?
One criticism of some current civil detention laws is that the length of detention for people with a substance use disorder is insufficient. Some say that effective treatment for severe substance use disorder must last at least 90 days.10States vary on how long an individual must be civilly committed. The most recent data available shows that about a third of involuntary commitment states allow a maximum period of 30 days or less. Several states allow a person to stay in the hospital beyond the maximum period if the court orders that additional treatment is required. Only one state, Kentucky, allows a person to involuntarily undergo treatment for up to a year.8
What type of treatment would be most effective in situations where a person is involuntarily hospitalized?
The National Institute on Drug Abuse advises that the type of treatment administered should be tailored to the individual.10Most opioid and other drug users abuse multiple substances11-15and also have co-occurring mental health conditions.sixteenFor these reasons, treatment must be comprehensive and not rely solely on medications or any therapy.
At the Hazelden Betty Ford Foundation, widely considered a leader in addiction treatment, the emphasis is on evidence-based treatments that encourage long-term commitment, especially for those with a severe substance use disorder. For example, the Foundation for Opioid Addiction's influential treatment framework, the Comprehensive Twelve-Step Opioid Response, or COR-12®, uses certain medications in combination with other evidence-based practices, such as twelve-step facilitation. , cognitive therapy, behavioral and motivational interviews. .
Medications are used to decrease cravings and stabilize patients so that they participate in treatment long enough to establish long-term recovery. Treatment is also individualized to address substance use and mental health issues.
Generally speaking, addiction is like other chronic illnesses in that the sooner it is recognized and the longer it is treated, the better the chances of recovery.
Individuals with severe substance use disorder often receive recommended residential treatment that may ultimately transition or forgo outpatient treatment and other lower levels of care. These determinations are made by professionals based on the criteria established by the American Society of Addiction Medicine.17
Quality addiction treatment can be difficult to find in rural areas and difficult to finance for some who are constrained by financial considerations. However, as of this writing, public and private insurance coverage for substance use disorder has expanded in recent years, greatly improving access.18
What happens after the treatment?
Continuation of treatment after release from mandatory detention is not required under current civil detention laws. After the maximum period of "detention" has elapsed, and if the court does not order further treatment, people are released. For example, without further judicial intervention, a person who has been civilly admitted for treatment in California can leave two weeks after her arrival.8Decreases in drug tolerance can occur during the period when people are in treatment and abstinent from all drug use. This loss of tolerance can increase the risk of overdose if people start using upon returning to their previous living environment. The ideal situation would be to maintain a connection to long-term care, including Twelve Step programs, to ensure ongoing support and monitoring of the individual's health and risk of relapse. It should be noted that this question is not specific to the topic of tort law, but more general to addiction treatment.
Do parents already have the right to involuntarily hospitalize their minor children undergoing treatment for chemical dependents?
In the United States, parents and legal guardians can involuntarily commit their children under the age of 18 to a drug treatment program without a court order. However, when young people who are in treatment against their will turn 18, they can leave. In the eyes of the law, seniors can make their own treatment decisions, although most parents do not consider their responsibility for their child's welfare to end when the child turns 18. For parents, the ability to petition the court and submit an adult to treatment can be a way to continue a treatment process that began when the child was still a minor.
Will involuntary commitment to treatment result in different results than if the person voluntarily submitted to treatment?
There are many situations in which an individual may experience legal pressure to seek substance use treatment. National data on substance use treatment admissions for 2014 show that one-third of all people admitted were referred for treatment by the criminal/judicial justice system.12Civil commitment is only one type of compulsory treatment, in which the individual is compelled to receive treatment by lawful order rather than voluntarily elect treatment, possibly as an alternative to incarceration.
Little research exists on the effectiveness of civil commitment laws for substance abuse. However, many researchers have studied the efficacy of general coercive treatment or compulsory treatment for substance-using offenders. Unfortunately, the results of studies on the effectiveness of compulsory treatment are inconsistent. Two systematic reviews of the scientific literature revealed that studies of compulsory treatment are plagued with methodological problems.19,20However, research-based guidance published by the National Institute on Drug Abuse states that people forced into treatment stay in treatment longer and do as well or better than their non-treatment peers. legal pressure.10
The effectiveness of addiction treatment depends on many factors in addition to whether or not it is required, including, but not limited to, severity of illness, number of prior treatment episodes, presence of comorbid psychiatric conditions, length of stay and Therapeutic Alliance. Many have argued that conceptualizing addiction treatment as a one-time event is misleading because the chronic, relapsing nature of addiction requires a system of care to address the long-term nature and complexity of the disorder.21
brilliant and martyr19they suggest that policymakers proposing and implementing any kind of coercive treatment have an obligation to provide evidence of its effectiveness. Existing involuntary commitment laws must be evaluated using a sound methodology to determine if they are an effective tool in the effort to address America's addiction crisis.
Is there a way to make involuntary commitment laws less of a threat to civil rights?
As with psychiatric civil commitments, there are privacy issues to consider with involuntary commitment for substance use treatment. For example, documentation indicating that an individual was committed involuntarily may appear on permanent records in some states. These types of records can make it difficult for people in recovery to find employment, continue their education, or access health care.
All involuntary detention laws guarantee certain rights to the detained person, such as the right to a lawyer and the right to request a habeas corpus (evidence of the reason for the detention).8Many laws also guarantee involuntary detainees a copy of the petition, the right to be present during the hearing, and the right to continue to communicate with family and friends. However, tort laws are not consistent about who can ask the court to imprison people against their will. Laws should ensure that those who judge whether a person is a danger to themselves or others are addiction experts or have extensive knowledge of the person, their substance use, and any related health problems.
How can we better emphasize that there are privacy protections for addiction treatment, just like any other health care service?
It's worth noting that addiction treatment providers are required, like all healthcare providers, to protect their clients' medical information under the provisions of the Health Insurance Portability and Accountability Act (HIPAA).22As of this writing, they must also comply with the patient privacy requirements of a regulation known as 42 CFR Part 2.23
Would it be possible to obtain a person's formal consent for involuntary commitment that may be required at a later date?
The severity of a substance use disorder can wax and wane over time, even in the absence of formal treatment. Although drug use can alter a person's mental state, people with substance use disorder experience long periods of sobriety and autonomy. It is possible that during these periods, the individual realizes that a commitment to drug treatment may be necessary at some point in the future, perhaps after a relapse. To the best of our knowledge, this possibility has not been discussed in the tort law literature. To resolve the ethical ambiguity surrounding involuntary commitment to substance use, lawmakers may consider implementing mechanisms that allow an individual to formally consent to "involuntary commitment" during these periods, similar to power of attorney documents.
Is the current addiction treatment system adequate to deal with the influx of inadvertently compromised individuals?
Substance use treatment centers, hospitals, and detoxification facilities in the United States may not have the resources or capacity to handle the additional patients that may result from the increased use of involuntary commitment laws. In some states, when private treatment centers are full, civil commitees are referred to more basic prison-housed programs. Imprisoning people against their will is not justifiable if the treatment they receive is ineffective and lacks evidence-based strategies.
Ultimately, America's substance use problem will not be solved without more resources being dedicated to the treatment infrastructure. For involuntary commitment laws to be implemented as intended, it is necessary to expand the availability of effective and affordable treatment programs with qualified professionals.
Perspectives and Prospects
Nick Motu, ex vicepresidente de Hazelden Betty Ford Institute for Recovery Advocacy
"More study is needed on this important topic. Our involuntary commitment laws are inconsistent and lacking in established best practice and solid research. It makes sense to consider it in the most serious cases of addiction, but I would like to see this reasoned and studied much more." ". We sort of moved forward, as vigorously as we fund and study drug courts, for example."
Charlotte Wethington, reclamation advocate and originator of Casey's Law, a model involuntary commitment law in Kentucky
"With substance use disorder, especially opioid use disorder, people are a danger to themselves because each use could be their last. It's a matter of playing Russian roulette. Time is of the essence. This is not like waiting for a person to go from stage one to stage four of addiction. With opioids, the danger is now!"
"People who are severely addicted to opioids will do anything to get the drug their brain demands. When they come off the drug, they are in a state of withdrawal, as if they are starving."
"A person must be alive to recover. We must do whatever it takes to ensure that recovery remains possible."
"Involuntary commitment laws not only help initiate the care some people need to stay alive. They also help people maintain care. Some voluntarily enter treatment in a moment of clarity, but those same people can also leave voluntarily, and many times they do. This is one of the reasons we see some end up going into treatment multiple times before they can sustain recovery. Recovery is NOT a matter of 'making it'. It is a matter of heal the brain, which takes time. Involuntary commitment laws can help us keep people in treatment for as long as necessary."
"If a person with a substance use disorder thought with a healthy brain, there would be no question about their choice of treatment. Rational decisions about their illness. The fact, based on decades of brain research, is that they are not. It is because This is why so many people are already forced into treatment, whether by the criminal justice system, by employers, or by their loved ones.Involuntary commitment laws simply provide another tool to help us reach those who cannot be reached. By other means".
"People are often upset at first by an involuntary commitment order, but many of the people I spoke to after treatment are grateful that someone stepped in before it was too late. They often say, '...of Otherwise, I'd be dead.'"