Over the past few years, we have been asked by various colleagues, community members and journalists about our Center’s stance on “coerced,” “mandatory,” or “involuntary treatment” and its evidence base. These requests have become more frequent as mainstream and social media have picked up lay assertions that involuntary treatment could/should be used to treat people who are not ready, wiling or able to stop using substances. There is an implication this approach is an effective way to impose recovery.
However, the topic of coerced treatment and its efficacy, including involuntary civil commitment, has been hotly debated for decades (Klag et al 2005). Nonetheless, the topic entails new twists and consequences, especially considering the COVID-19 pandemic and explosion of both fentanyl contamination and overdose. This is not a comprehensive or systematic review of the literature, but provides some basic information about the topic and its challenges. It will walk you through our own considerations of the scientific literature that informed our Center’s position that that involuntary civil commitment is a ethically fraught approach of last resort, not an effective treatment solution for broader implementation. Our review of this work also fueled our commitment to developing harm-reduction treatment solutions for people who are not ready, willing or able to stop using.
Definitions
When it comes to understanding research on this topic of involuntary civil commitment, we first have to address the definitional issues: What does “coerced” or “involuntary” treatment even mean? Studies show even physicians are often confused about these definitions (Jain et al, 2021). In fact, informal forms of coercion, like family or employment pressure, are very common in substance use treatment referrals and self-referrals. Formal forms of coercion (e.g., treatment mandated by children and family services, legal/criminal justice system) are likewise very common. When it comes to the research, which is sparse on any kind of coercion, it’s also important to note that many studies take only one form of coercion into account at a time (Klag et al., 2005). However, there are often multiple points of coercion, which makes it challenging to know what exactly contributes to outcomes (Klag et al 2005). Third, there are a lot of methodological challenges with a lot of these studies. For some, there’s no control group, for others, they are not measuring outcomes in an optimal way.
With all that said, let’s take the currently widely discussed example of “involuntary civil commitment” as a means of intervention for people with severe opioid use disorder. Civil commitment is when a person is hospitalized for a psychiatric disorder (sometimes including SUD) after a (typically) 72-hour hold for evaluation and then treated involuntarily for a physician- or court-determined amount of time. At last report, 35 states, including DC, have some form of civil commitment for substance use disorder. However, many of these statutes are not active for various reasons, including not having facilities that are adequate to support civil commitment.
What is the reasoning for and hypothesized benefit of civil commitment? The reasoning behind civil commitment stems from the state’s “parens patriae,” which refers to its broad powers to protect citizens who demonstrate that need. The argument is that the state is called to avoid the risk of extreme harm to its citizens due to its own inaction and that short-term involuntary civil commitment can save lives when individuals with severe substance use disorder are at acute and high risk of harming themselves or others. Thus, civil commitment is also meant to use the least restrictive means necessary (although this varies by state) and to be restorative. It is meant to be a means of averting grave harm in the short term as well as an entry point for longer-term recovery when individuals are believed to be unable/not have the capacity to avert harm to themselves or others due (in this case) to their substance use (Messinger et al 2021).
Even as it is well-intentioned, civil commitment carries extreme risk and thus requires strong evidence to tip the risk-to-benefit ratio. Civil commitment requires balancing the known harm of stripping civil liberties from an individual with the potential benefit protecting their own and the community’s safety. Where is that line? Even if we find the line, we need to be able to provide treatment that is effective to ethically and legally justify stripping of civil liberties. Even those who are most in favor of coerced or civil commitment for treatment note this. However, we don’t have that adequately defined.
And, as well-intentioned as civil commitment can be, it is not uniformly so. Internationally, the UN has called for involuntary civil commitment-type facilities be closed due to their lack of effectiveness (one study conducted in Malaysia showed that 87% of people say they will continue using substances when they get out), their human rights abuses, lack of evidence-based practices (medications) in the facilities, and their ability to spread illness among detainees (Lunze et al, 2016).
In the US, involuntary civil commitment has not been rigorously evaluated in practice, which we delve into a bit more below. However, there is a strong suggestion that the long-term harms could outweigh the short-term gains (abstinence) when inpatient (Messinger et al 2021). Of particular note, institutions who provide civil commitment are rarely set up to provide state-of-the-science care for people with opioid or other substance use disorder (e.g., opioid agonist therapy; Evans et al., 2021). This has resulted in overdose when people leave civil commitment (Rafful et al., 2018), and is especially salient when considering that one study showed 34% of people relapse the day they are released (Christopher et al., 2018). With fentanyl out there – which was not the case when a lot of this prior work was done– the risk for overdose after a period of forced abstinence in civil commitment is even higher.
Civil commitment has not been rigorously evaluated, which is necessary to disseminate this more broadly as an intervention. OK, so there’s the issue of severe harm (e.g., loss of civil liberties, potential for abuses, high potential for overdose upon release), but let’s get boringly wonky for a second. Recommending this as a viable intervention for people with OUD or other substance use disorder is also just not in line with our basic standards for determining evidence-based care. When you really move a treatment or policy into practice in the US these days, you need to be sure it is evidence-based. That means that multiple rigorous, large-scale randomized controlled trials or at least nonrandomized controlled studies find it is effective and not iatrogenic (i.e., not having harmful effects). The fact is, there is no rigorous science on civil commitment for OUD, and because it does violate civil liberties and raises the risk for overdose, we need to be sure this is an evidence-based practice before it is a recommended treatment or intervention for people who use substances. If citizens would like to see involuntary civil commitment as a more widely available intervention practice, they should demand funding an effort to have states collect data on their current programs and/or submit existing data for rigorous analysis. To date, this has not been systematically done.
In the absence of adequate data on civil commitment, let’s briefly consider findings for compulsory treatment for SUD more generally. Because there are no adequate data for involuntary civil commitment in the US specifically, let’s take a step down and look at tx that is coerced with varying levels of intensity through the criminal justice system (not civil commitment). There is some evidence that abstinence-based interventions ensconced in the legal system, like drug court, have modest effects on recidivism (e.g., rearrest; Trood et al., 2021). But one review of the literature that actually took into account other important outcomes as well –namely actual drug use — indicated either poor or no changes outcomes in response to compulsory treatment in 7 of 9 studies, with clear iatrogenic effects in 2 of them (Werb et al 2016). This is a low bar considering that substance use treatment researchers typically consider interventions acceptable for dissemination if they show consistent positive findings, not mixed and even iatrogenic findings. This means even with coerced treatment more generally, which is a step down or two from the intensity of involuntary civil commitment, we are regularly submitting the most vulnerable and severely impacted people to treatment in such a way that is often ineffective and even harmful.
Conclusions
Civil commitment for substance use disorder entails involuntary hospitalization deemed necessary by the state to manage the risk for acute harm to self or others due to substance use. While meant to be restorative, it is widely acknowledged to be the most restrictive, last-resort intervention in our system because it requires stripping individuals of their civil liberties. It also carries significant risk for physical harm due to inadequate facilities and resources for providing evidence-based care (e.g., opioid agonist therapy). Because a significant minority of those civilly committed relapse the day of their release, which puts them at high risk of overdose and death after a period of abstinence.
Because involuntary civil commitment has always been an extreme measure that carries high risk for harm, it requires rigorous evaluation and compelling evidence to support a strong benefit-to-risk ratio. To date, however, there is no adequate evaluation that has established its shorter- and longer-term outcomes. This is a bit of an anomalous and challenging situation: Before even minimal risk treatments are widely disseminated and state-supported, various government agencies and the scientific field often require rigorous research trials. Given the restrictive and high-risk nature of this intervention, we recommend states systematically collect and manage their data on civil commitment and submit it for large-scale analysis by qualified statisticians. Before a clear evidence-base, strong benefit-to-risk ratio, and well-considered guidelines for its recommendation can be established, it is our Center’s position that this treatment cannot be recommended for broader or routine use.