Opiod Plan, Part II — Coercion and Recovery

As outlined in Part I of this series, the legislature and the Governor are working on a number of measures to address the opioid epidemic. Much of what we are doing or proposing responds to the perception discussed in Part I of this series that prescription opioids have been much too available.

Another big theme in the discussion is treatment — making treatment for the disease of addiction more available in a host of ways. A particular issue that will be part of the conversation is expanding the ways in which people with addictions can be forced into treatment. This Part II offers background on the issue of coerced treatment and seeks feedback on the Governor’s proposal to allow physicians to hold people with addictions against their will for days or weeks or, after court approval, months for treatment.

Substance Abuse Treatment

Modern treatment for substance abuse disorders increasingly involves the use of medications to reduce the craving for and/or reduce the pleasure available from substances of abuse. Medications soften the powerful compulsion to relapse, but do not, in themselves, change the lifestyle and thought patterns associated with the habit of using substances. So, talk therapy — group or individual counseling — remains central to addiction treatment. In addition, as people try to change their lifestyle, they may need support in finding employment, housing and new peer groups.

Addiction treatment can occur in a variety of settings — from a website to a church basement to a therapist’s office to a residential house to a prison. Outpatient treatment has the advantage that one can actually practice drug-free living in a real life setting. Inpatient treatment allows more focus and reduces the risk of exposure to situations that will trigger relapse. People going through withdrawal may need a brief inpatient detoxification, but then may be able transition to outpatient treatment which is, of course, vastly less expensive.

Coercion of Treatment Participation — Theory

People often initiate treatment for substance abuse under pressure — a spouse, an employer, a school administrator or a judge brings down the hammer and threatens consequences if things don’t change. The person entering substance abuse treatment may or may not be at a point where they would seek treatment on their own.

Because people with addictions so often do not seek treatment voluntarily, a major public policy question is whether we can or should force more people into treatment through the expanded use of legal compulsion — physically holding them against their will or threatening them with incarceration if they do not begin and continue in treatment, following the rules of an inpatient facility if so ordered.

I was fortunate in the 90s to be part of an academic group that spent several years studying addiction and the role of coercion in recovery. There is a consensus literature that says, in summary, that coerced treatment often helps. Much of the research is government sponsored and supports the effectiveness of government programs. Some of it has an advocacy dimension to it. There is a critique of it which merits consideration.  But overall, I find it credible.

Even if the research is hard to evaluate, most of us can get a sense of the potential effectiveness of coerced treatment from our own experience: We have all been dragged to a meeting or entertainment venue and suddenly found that we are getting something out of it. Of course, if we are so angry about being there that we are incapable of paying attention, we may not benefit, but if forced to stay, windows in our anger may open from time to time that allow some learning to occur. And, in fact, we may get as much out of it as willing participants.

Coercion of Treatment Participation — Practice

At a certain point about 15 years ago, I got tired of talking about people with addiction in an academic setting and wanted to talk directly with people with addiction. I started working as an attorney in drug court. My clients taught me a lot about what coercion means and completely changed my perspective on the issue.

I knew from prior research that the quality of treatment is very uneven. But, when I started to work in drug court the meaning of that reality set in more clearly. If consumers of treatment have no choice about being in treatment or where they get treatment, then providers of treatment have less incentive to provide good quality treatment. And people who are committed to treatment cannot complain about quality issues — they risk having the committing judge hear the complaint as evidence of bad attitude or impending relapse.

In our current system, where a high percentage of the patients in many facilities are there under legal coercion  (1/3 on average nationally, or perhaps higher, certainly varying locally), the culture in some treatment facilities may suffer — the incentives to fake compliance and insight, simply to escape confinement, make necessary good faith conversations about recovery harder to have (although urine testing can help keep the process honest).

My appreciation of the delicacy of conversations about recovery was reinforced by the failure of a project I initiated in Dorchester Court ten years ago. We attempted to run a program of screening and brief intervention for substance abuse — judges were asked to make non-coercive referrals to the program. The results suggested that clients were afraid to be honest about their substance use after being sent from the courtroom to our little room in the court basement.

It is impossible to translate the consensus finding that says “coerced treatment works” into a conclusion about how well coerced treatment is working in any particular locality — there is no substitute for constant local monitoring of quality and outcomes. And all too often, we don’t have in place the trained personnel, robust information systems and contractual mechanisms to hold treatment providers accountable for results.

Given these realities, I feel we should coerce treatment only with great caution and only when we have very good quality monitoring in place.

Moving Civil Commitment out of the Department of Correction

The Governor’s Working Group on opioids made a number of constructive recommendations on how to expand access to and improve treatment, which the Governor has adopted and, in many cases, already implemented.

Among the working group’s findings, sensitive to the hazards of coerced treatment, was that:

It is important that treatment occur in a clinical environment, not a correctional setting, especially for patients committed civilly under section 35 of chapter 123 of the General Laws.

Section 35 is the mechanism through which people can be brought before a judge and committed to inpatient treatment against their will because of a “likelihood of serious harm.” The Supreme Judicial Court has recently reviewed this procedure and found that people can be committed for the relatively short and non-renewable periods allowed under Section 35 without proof beyond a reasonable doubt of necessity.

Currently, some of the facilities to which people are civilly committed are managed by the Department of Correction. Consistent with the finding above, the working group recommended that we should “transfer responsibility for civil commitments from the Department of Correction to the Executive Office of Health and Human Services.” In its action plan, the administration took a first step on this by planning to transfer facilities for women (241 were civilly committed to Framingham in 2014) and study the feasibility of transferring services for men (1,705 were civilly committed to Bridgewater in 2014).

As a result of this recommendation, more of the patients coerced into treatment under Section 35 would be in settings that are less coercive structurally. A collateral (unspoken) benefit would be that the Bureau of Substance Abuse Services would have a better handle on Section 35 referrals and be better able to manage them in the context of the public treatment system that it administers.

Expanding Civil Commitment through Hospitals

Among the working group’s recommendations was to “increase entry points to treatment”. That is a fundamentally sound recommendation and it can be translated to support many possible action steps, including both more coerced treatment and more access to voluntary treatment.

The administration has proposed a bold stroke on the issue of coerced treatment which goes beyond the specific recommendations of the working group. In Sections 11 to 15 of his opioid bill, the Governor proposes to create a completely new pathway to coerced treatment. Essentially, the bill would give physicians the power to “pink slip” persons with addictions and hold them for treatment as they now can hold people with major mental illness.

In many respects, it makes sense to try to shift treatment referrals out of the court system — judges using Section 35 do not all have the necessary expertise to evaluate treatment need; courts are not open 24/7 as emergency rooms are; treatment referrals should be more closely integrated with the public health treatment system; treatment should be as divorced as possible from the coercive setting of the courthouse. In this respect, the change parallels the proposed change in the management of Section 35 commitments.

But the legislation does more than encourage hospital referrals to treatment — it authorizes physicians to hold persons with addictions against their will. Based on a preliminary examination or based on the circumstances, a physician will be able to physically restrain or authorize the physical restraint of a person and send them to a treatment facility for 3 days of further examination. The facility will then be able to hold the person pending a court hearing and decision, a process that may last up to 15 days.  The decision timeline may be extended by the administrative justice for the district court.

While we already use procedures like this for people with major mental illness, expanding the procedures to cover substance abuse is not an incremental step. The threshold decision as to “likelihood of serious harm” may be more subjective. People with major mental illness who get pink-slipped are threatening suicide or homicide or obviously just not talking sense.  In contrast, people with addictions are generally neither suicidal nor homicidal nor disoriented.  It is unclear when they would meet the statutory standard for serious harm:

a very substantial risk of physical impairment or injury to the person himself as manifested by evidence that such person’s judgment is so affected that he is unable to protect himself in the community and that reasonable provision for his protection is not available in the community.

When people are committed by a court using the same standard pursuant to Section 35, the court often has testimony of family members and others available about the extreme situation that the person is in.  In the emergency room setting, all the physician will necessarily know is the fact of an overdose and whatever the person chooses to share in their typically agitated state after having been revived with Narcan.  Should the fact of an overdose be evidence enough to restrain a person?

Another fundamental difference from the mental illness context is that often a few days of medication will stabilize a mental health patient. By contrast, we know that people with addictions are not cured by medication and often stabilize only after months of treatment.  They will remain at high risk of relapse (and overdose, especially if their tolerance is down) when released after 3 days or even the full 90 days available after a court order under the new law.   Both the loss of liberty and the likelihood that the commitment will be contested may be much greater than in the mental illness context.

Attempting to identify secure treatment referral destinations and restraining involuntary patients until they can be transported to them could pose a significant new burden on emergency rooms. While they may therefore not really use the new powers, the proposal has the potential to lead to an unmanageable increase in referrals for secure treatment. There are approximately 50,000 emergency room visits per year involving substance abuse in the Boston area alone, while there are only roughly 5,000 Section 35 commitments per year statewide. It seems likely that there is a subpopulation of persons with addictions who have family members who are concerned enough and able to force them in to a Section 35 process.  But there may be a much larger group who would get swept in through the new process.

As another comparison, annually statewide, approximately 50,000 patients are transported to mental health hospitals for mental health care and approximately 10,000 are admitted for additional care after the initial 3 day hold.   It is unclear that we have the capacity to absorb the new coerced referrals — we lack reliable measurement of treatment demand, but it appears that acute detox services are often difficult to locate.  Many existing facilities may not be secure enough to be inappropriate for involuntary commitments.

In addition to these concerns and the broader concerns about coerced treatment voiced above, the special concern that I have about this proposal is that it may transform hospitals into places that most persons with addictions will want to stay away from. If persons with addictions know that they may end up held for a few days or a few weeks, they may tell their “running” buddies not to bring them to the hospital if they appear to be overdosing. By also authorizing police to pink slip people in “emergency situations”, the bill may give persons with addictions more reasons not to involve first responders in overdose situations. It may undermine police efforts to serve as agents of voluntary treatment access. It may also undermine efforts to implement voluntary screening and brief intervention in the emergency room setting where it appears to be effective.

The proposal has provoked some interesting discussions on the web at Salon and the New York Times Room for Debate.

I certainly understand the motivation of the Governor’s proposal.  One wants to wrap one’s arms around young people with addictions and just make them stop.  But I do have concerns about the proposal.  I’d very much appreciate your local insights into the quality of treatment and the pros and cons of greatly expanding coerced participation in treatment through hospitals.

Please go to the next post in this series to make additional comments.

I’m really grateful for all those who have taken the time to respond to this post.  I especially thank those who have offered personal perspectives — as family members or as patients: I congratulate those who achieved good outcomes and wish strength to those still struggling.  I salute your courage in speaking out.  I have read all the comments through today, January 11.

I’ve closed this thread, but we can continue the conversation — the legislative process is moving forward to a different, and I think better, place.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

63 replies on “Opiod Plan, Part II — Coercion and Recovery”

  1. I think mandatory treatment is unconstitutional.

    I do think that treatment — not just for opioids but all drugs — is preferable to incarceration. Addiction is a disease, whether it’s alcohol or drugs.

  2. I don’t have time to read it all right now (politics). But we’ve lived/live this and I’m absolutely for forced treatment, I’m a proponent of an alternate incarceration model. Hit it with “chemo” very aggressively before it metastasizes.

  3. I read with interest that coerced treatment can help and I am hopeful that the research is accurate.

    However, in my experience if a person is not ready to acknowledge their problem then they are not ready to deal with it and the treatment would not help.

    Also, for a number of years I worked with primary care physician practices who saw a lot of medicare patients. They always said there weren’t enough acute detox beds in the system.

  4. I am very leery of government-coerced participation, especially given the great push by conservatives to have the federal government mandate what choices women can or must make concerning their own bodies.
    On the other hand, as epidemics — whether of disease or drug use– affect
    and cost society as a whole, we should
    be able to apply government sanctions
    to alleviate problems that affect the common good.

  5. I am very concerned about this and am NOT in favor of forcing treatment. While I belive his intentions are good, and something must be done about this growing drug problem, the Governor is wrong here. He is assuming a “doctor know’s best” and all hospital and medical professionals are the same. Medicine is part art and part science. Not all doctors make the right decisions, or are in procession of the fact. Many do not understand the side effects of the medicines they prescribe. Often when told by patients of these side effects they are dismissive. I do not have experience dealing with addicts but in my dealings with ill relatives, I have seen many, many errors by well meaning hospital staff. To take away an individual’s power and give it to an institution is a dangerous path to travel down.

  6. Senator, you clearly have a deep domain knowledge on this issue. I trust your judgement. All I would ask is that we consider also keeping firearms out of the hands of those with a record of drug abuse and/or domestic violence. Would like to hear more about whether our laws currently completely cover this.

  7. At this point in history, I am staunchly against forced treatment. It is putting the cart a mile before the horse.

    Due to an embryonic state of data management regarding long-term individual effectiveness of our taxpayer-funded treatment sector, we literally don’t know what we’re doing. If we still lack clear measures of comparative success or failure among various treatment facilities, then forced treatment acts as a multiplier for already wasted resources. If relapse after TSS or CSS treatment programs are still at 70-80%, then why multiply the flow of clients when we haven’t seriously scrutinized and optimized the quality of treatment they are getting? There is so much work to do in regards to data-platforms through which we can track addicts long-term to determine objectively which treatment facilities are working best, or worst, and why. We should get our treatment house in order before flooding it with more vulnerable people who may fall deeper into their addiction with self-hatred, because they “failed” to kick the habit while in a low-quality treatment program that was already stacked against them.

    As always, thank you for the in-depth, careful analysis Sen. Brownsberger.

    1. Excellent point! Though even with better evidence of treatment efficacy, I still oppose civil commitment.

  8. I sincerely worry about the State giving a way for doctors to coerce treatment. This has all the same individual liberty issues as the commitment of people declared insane. If a mandate for treatment is to be passed then it should at least depend on the permission of family members, but I’d rather forced treatment not be put into law.

    People should go into treatment voluntarily. I’d like there to be more treatment places and for there to be far more effort to get addicts into treatment voluntarily before they end up in hospital.

  9. Having dealt with the system for pink slipping people for mental health reasons, I believe that system has high standards for demonstrating that an individual needs to be held against their will (which is what we are talking about here). And the individual can only be held for 72 hours, not some indefinite period of time while waiting for a hearing. I think the proposed system is open to abuse. In addition, there is no indication of where these people would be held for that indefinite period, and who would pay for it. It put medical personnel in a bad light, just when their help might be needed.
    This needs to be very carefully crafted.

  10. This was an eye-opening article. My first impulse was to be opposed to forced treatment, and I think I still feel that way unless more resources and organization are in place for these folks.
    Thank you for your email.

  11. Sorry, couldn’t read all of your comments due to lack of time. But, I will say that I’m opposed to any form of FORCED treatment, even though it might be the only saving factor for saving the patient’s life. I think that the addictee should find the appropriate care through his doctor, who should be the influential factor as to what the patient requires in order to work through his/her drug problem.

  12. Thanks for this very clear explanation of the situation and the proposal. After considering the various aspects, I find that I am highly opposed to allowing the proposed expansion of coercive treatment. To name just one of my concerns, the idea that one person (a physician) could order another person to be forced into medical treatment against their will is disturbing. Courts of law, not individual professionals, are rightly the only authority under which persons in a democracy can be forced into obligations against their will. The various other negative institutional implications are also important, as is the likelihood that a full-scale system of coerced treatment will not be as effective as anticipated.

  13. This is a very complicated issue. Firstly, it addresses civil rights to government intervention. Coercion doesn’t work. We still have the right to Freedom to choose our lives.
    Do it in the name of drug addicts
    On the other hand, the addictions are impeding on other peoples lives. I hear that the heroine addiction on the cape is so bad, that addicts will walk into peoples homes, while they are watching TV, point the gun, say stay where you are and you won’t get hurt. Steal what they can and just walk out. So, who is right. The one that is addicted and can’t stop, and will go to any length? So we throw them in jail, where they are able to get more drugs?

    Where is the incentive to stop? Where is the money to care for these individuals? Where is the money to pay for those who are the caregivers?
    In truth, this all about the money.

    Drug lords in our own community, Drs who overprescribe, mentally ill who try to manage their own illness. When and where does it end?
    It is the tax payer, the normal citizen who pays for it one way or another. It is a complicated issue.

    It is delusional to think that this can change. It would have to stop with drug gangs, and the availability of hard drugs on the street. Law enforcement needs to do more to go after… manufacturing, distribution and contraband into the country. Break that up, and, limit supply and see how people will be willing to get help. As long as drugs are available, what is the incentive to stop?

    Thank you for being inclusive to allow us to share our thoughts.

  14. I just want to second Adam Friedman’s comment. I treat people who use and abuse substances and the one thing that is clear is that one size does not fit all and that we have very little sophistication in our treatment approaches. More research.

  15. IT’S A WASTE OF MONEY. YOU CAN’T FORCE SOMEONE TO GIVE UP DRUGS. THERE ARE EVEN DRUGS IN PRISONS. SAVE TREATMENT RESOURCES FOR THOSE THAT WANT THEM.

  16. IT’S A WASTE OF MONEY. YOU CAN’T FORCE SOMEONE TO GIVE UP DRUGS. THERE ARE EVEN DRUGS IN PRISONS. SAVE TREATMENT RESOURCES FOR THOSE THAT WANT THEM. MANDATE THERAPY TO HEAL THE TRAUMA OF ADDICTS WHILE THEY COME TO THE DECISION TO STOP BY THEMSELVES. ADDRESS THE UNDERLYING REASONS WHY ESCAPING FROM REALITY SEEMS LIKE THE ONLY OPTION FOR GETTING THROUGH LIFE.

  17. I have personal and professional experience with this issue. The enormity of this problem requires drastic and immediate attention by government and substance abuse partners. This period in our history will be looked back on with disbelief. What will be remarkablewill be the numbers of young lives lost, families devastated and the “too little too late” response of government and the substance abuse/criminal justice systems charged with addressing this crisis. We hold people against their will for mental health reasons, I think it should be the same for drug treatment. Of course we have to have the treatment for someone to use it….the huge problem with treatment is the lack of de-tox, and quality de-tox. If someone hasn’t “used” for a couple of days and then they want to de-rox instead of scoring more drugs, they have to use again to qualify for treatment. It makes no sense. Our nephew has struggled with heroin addiction and mental health issues over the past 8 months…it is a daily struggle but the hardest thing is knowing that he is “using” and feeling powerless to get him into treatment. At times we felt like we would do ANYTHING to keep him ALIVE…there are no second chances if you die of a lethal overdose.

  18. I am against coercion. Even if a doctor were to judge correctly that a person is an addict and that a forced treatment regime would “cure” the “disease,” I am against giving that doctor the power to compel treatment. If a judge or jury convicts the person of illegal behavior and includes treatment as a part of the sentence, I still have reservations but at least due process is preserved.

  19. I’d like to see a proposal or suggestions offered by the medical community! I think government should stick to their scope of practice and let the medical industry stick to theirs!

  20. I’m surprised by the many categorical statements against coercion. We easily accept coercion if our lives are endangered by others. It’s fine–desirable–for govt to force a quarantine to deal with an Ebola epidemic when it arises, for example. So the difference here seems to be that there is no apparent danger to others? I wonder … I am working through with my extended family the painful reality of a mid-20-something relative’s apparent addiction and his vociferous denial of it. I feel that my entire family is sickened by this addiction, and I worry about the irrevocable harm that a death would cause. I fantasize about having him swooped up unawares, evaluated, and diagnosed … so that we could have a true reckoning, find the best treatment program, and support him in his effort to recover. It is so tempting to think that we could help if we had a few more tools in our belt… but who is to decide when it’s okay to be coercive and when not? You have a lot to weigh … I don’t think there is a simple answer.

  21. Addiction is disturbing to parents, the addict and the community. There is too much to say. However, on big note: we need affordable professional quality treatment facilities and residential sober living. Let’s make a difference in 2016. Please prioritize addiction in our hovetnment.

    1. Addiction is disturbing to parents, the addict and the community. There is too much to say. However, on big note: we need affordable professional quality treatment facilities and residential sober living. Let’s make a difference in 2016. Please prioritize addiction in our municipalities. Boston needs addiction services. I also advocate AA and NA.
      Worked in the field for 22 yrs.

  22. I wish I could add constructive dialogue to what you wrote. It is ever so complex that I do not know what truly is the best approach. The Governors has some merit but they come with some complicating factors. I think on this, I would say go with your gut.

  23. It seems to me that the proposed legislation is aiming for progress in effectively preventing death from and addiction to opiods, not for perfection, which would be eliminating addiction in one fell swoop. The reasons for rejecting this legislation as imperfect are many, but in my opinion, not enough to throw it out. We will have to keep working on other parts of this to get it right. When family members and friends ask a physician to commit a loved one, it is because they know how seriously ill the person has become. Recovery has to start somewhere – preferably in a clinical setting, not in jail or prison.

    I haven’t lost faith in the ability of most people practicing medicine to assess an illness. Petitioning the court is not the same as the court committing someone. Being able to buy drugs once in prison is not the same as having effective clinical services once “committed”.

    The pertinent part of the proposed legislation reads: “This act will provide medical professionals with the ability to clinically asses a patient for 72-hours and work to engage the patient in voluntary treatment. Acknowledging that voluntary treatment is the best avenue for therapeutic success, this new statute requires clinicians to try to engage the individual in voluntary treatment before pursuing involuntary treatment. However, if after 72-hours the individual is not able to consent to treatment and the individual poses an imminent risk to himself/herself by reason of his/her substance use disorder, then the clinician may petition the court to commit the person to treatment involuntarily. “

  24. We used to have hospitals/ institutions for retarded or people who could not otherwise take care themselves (for lack of a correct phrase) Maybe it is time the Commonwealth put those lands back to use as hopspitals like Fernald School in Waltham ? Medfield State hospital. people with addiction do not need to be with criminal , they need a different safe enviorment

  25. This is a terrible idea! Don’t take my word for it. I urge Governor Baker and your constituents to read “Anatomy of an Epidemic” by Robert Whitaker.

  26. While I think that forced treatment is a good thing in many cases, we already have forced treatment. I was in outpatient treatment for drug addiction for 10 months during 2011-2012 (this was in Wisconsin not Massachusetts) and found the treatment to be stellar. But as you said in this post, “talk therapy … remains central to addiction treatment.” If people who aren’t serious about getting clean enter the group, they can be poisonous. Whenever we had a group member who was faking it (you could always tell when they were faking it), It brought down the morale of the entire group and hurt recovery. It seems like the current setup we have places individuals who wish to improve themselves into treatment and those who don’t into prison. While I don’t want more people in prison, I want those who have a chance to recover to be given that chance and filling treatment facilities with individuals who have no intention of getting clean will only lower the chances of those who with to recover.

  27. I would say that I am not is favor of coercion for drug treatment, and certainly think it should not be done in a correction facility. I don’t think mental illness and drug addiction should be treated the same.

  28. I believe we should err on the side of individual liberty. Relatives may not always have the best interests of the patient in mind- a knew-jerk reaction to forced treatment may seem the best to them, when it is really violating medical ethics of consent. I go along with your concerns about this difficult aspect of the legislation.

  29. Hi Will,
    Thank you for your attention to this and many other tough issues. We appreciate you seeking outside opinions.
    In almost all cases, drug addiction is not victimless. The addict may think so, but loved one’s of the addict are hurt in many ways. Drug addiction is expensive, causing many addicts to steal from family and the public. The addicts are rarely in the right state of mind to seek treatment, the result being their very high fatality rate. The addicts don’t know what is best for them, as in mental illness, but loved one’s, physicians, and the courts do, therefore they should have a legal avenue to compel or coerce an addict into whatever treatment a legal professional deems necessary. This is a plan the loving survivors of the deceased addicts needed in place, and want in place to help save others. Get over offending the addict and start thinking “tough love” resolutions. Because society is also a victim in this, they should be able to dictate rules and laws of prevention.
    Easing penalties of predatory drug dealers sure isn’t helping this situation.
    Sincerely,
    David Benoit

  30. Thank you, Will, for your thoughtful approach to the issue and for the sincere comments others have posted. My feeling is that the state should not coerce treatment.

  31. This is a very delicate situation. Eventhough the drug addicted is completely out of mental balance, the treatment must be chosen, accepted and permitted by the patient. Respect to the individual sovereignity must be always practiced.
    Forced detoxication will result in reincidence of the addiction and this program will be created just to make more jobs and bring more money to the hospitals and to the people involved with the business.

  32. Oh my goodness I can’t imagine that forced rehab is being considered. From what I’ve seen and heard addicts cannot truly be rehabilitated unless they want to be. It’s a long road for them and without a real commitment to being clean and sober and a strong support system it’s unlikely they will remain in recovery for long.

  33. Taking addiction treatment out of Corrections is an excellent idea. However, given the numbers involved it is would be impractical and impossible to have every addict subject to involuntary commitment. And while it may sound brutal, probably a couple of overdoses leading to emergency room visits (assuming survival of the victim) should not lead to immediate commitment, especially if the addict is managing to function in the world without harming others. But maybe if the person hasn’t gotten the message after the third overdose it should be considered. This of course means that medical privacy should be overruled when people show up at different hospitals, which in turn requires some kind of privacy-invading database. But even after determining that a person is in need of intervention, ensuring availability and quality of treatment is a major issue. Certainly there will be a NIMBY factor in locating any such facilities. And given the Commonwealth’s aversion to new financial resources (normally called taxes) I’m not sure how quality would be assured and measured. Would there be enough people trained in addiction treatment to staff any commitment centers that might be established? And would there be enough information available to flag doctors who are maybe overprescribing without realizing it? Is there enough experience yet from the Gloucester outreach program to make some judgements? Would some sort of pilot programs in a few addiction hot spots be of any help – assuming that there are people capable of designing them? I realize that these are more questions than opinions, pretty much off the top of my head. But what’s really important is to start some kind of rational discussion and thought process about what could be accomplished.

  34. You have made some excellent points about involuntary commitment lm impressed with your knowledge and thoughtfulness.
    I would like to see the focus be strongly on having quality treatment available including peer mentors who can support people post treatment.

  35. As a sister of an older brother who is currently in treatment for alcohol/drug addiction, I would advocate against forced treatment. Someone struggling with addiction will only be able to fully recover and come to terms with the disease when they are willing and able. Coercion is counterproductive and I firmly believe will do more harm than good. It will lead to distrust and resentment of treatment which has the capacity to be an amazing saving grace.

  36. I have seen cases where people have overdosed, received NARCAN and leave the hospital right away like nothing has happened. At least if they are required to get some assistance in a civil public or private facility regarding their addiction, it might prevent a return trip. I have seen some people willing to go to treatment but be sent home instead because there were no beds anywhere. At least if the law requires for them to stay then they would not be sent home. Just my two cents. Keep up the good work!

  37. My motivation for believing in forced recovery is more about re-orienting funding of treatment efforts toward long term care. Honestly, even with really good private health insurance and an addict willing to seek treatment the odds are bad, and honestly, in my opinion, a lot has to do with the hospitals operating the detoxes as profit centers and starving out downstream funding.

    Also, the distribution for methadone (works) and Suboxone (doesn’t work), are outdated and appear to be more oriented to making money for a small licensed set of providers that solving the problem.

    Not to mention that law enforcement is getting creamed by the distribution networks.

    Maybe in committee you should reflect on how far an 18/19 year old needs to go before they reach where they need to be and also reflect where you are with respect to how you can help them get there:

    “God, Grant me the serenity to accept the things I cannot change, the courage to change the things I can; And the wisdom to know the difference.”

  38. I have concerns.

    Providers must be properly trained. facilities and Treatment must be carefully monitored.

    Treatment facilities in the past for mentally ill were never monitored properly nor were the staff trained properly.

    Oversight of these facilities must be closely monitored and report of progress or failure must be monitored.

  39. Thank you for your email. Given the points presented, I oppose greatly expanding coerced participation in treatment through hospitals.

  40. I have had some experience with alcohol and drug addiction through the City of Cambridge’s “Support Team”. A program to help employees with problems that were interfering with their job performance. Substance abuse problems were among the concern of this team. The threat of being fired did help many subsistence abuses accept treatment that resulted in their rehabilitation.

  41. First of all, thank you for asking for input from the public.

    I believe that treatment should be available for anyone who has the desire and will to ask for help with drug addiction, but I’m very against the idea of forced intervention and treatment. The money we need for treatment will never be enough, so we must allocate the funds to those with the highest chance of success. There are hundreds of NA and AA meetings in just about every community here in Massachusetts. The addict needs to fist admit they are powerless over the drug and ask for help for any chance of success.

    A standard 30-day residential addiction treatment can cost between $10,000 – $20,000. This money can not be wasted on those who are not ready and willing to receive treatment.

  42. As a heroin addict in Recovery and a retired Substance Use Disorder Counselor, I’d say a good idea is to have Treatment On Demand. In other words, when an addict is seeking a bed in detox there is a good chance that their “window of opportunity” is open. If you force an addict into treatment when they are not ready, then it will make them more determined to use when they get out. Harm Reduction, Needle Exchange, Narcane Distribution and education are the best answers. During the time I was using there were many times my “window of opportunity” was open but I couldn’t get a bed. Thank God I managed to survive the devastation of active addiction and found help when I was ready. The first time I became abstinent was 1994. Since then, I have had a few relapses but at this time, and with the help of support groups, a LISW therapist and a psychopharmacologist who specializes in medication that is a psych drug for addicts, I have been in continuous Recovery for over 10 years. I am 70 years old.

  43. It seems to me that whether coerced treatment is effective or not is moot. It’s unethical for the government to force a citizen to do something against their will which so greatly impacts their freedom – unless they are given a fair trial first.

  44. As you suggested above, coercion may prompt victims to be dishonest when answering questions from a physician, and honest answers may lead to better diagnoses and more effective treatments.
    Also, treatment could be more effective if victims are willing participants rather than having it forced on them.
    I do not believe that “forced treatment” is the answer.

  45. If someone is an immediate threat to him/herself or others for any reason, s/he should be taken into protective custody. If immediate danger exists, it should be addressed as a temporary measure. If someone has committed a crime, such as a break-in to steal for drugs, s/he should be dealt with for that crime. For the overall picture, I think we need to focus more on mental health services, which are sorely underfunded. Services should be available for individuals of all ages, and learning about drugs should start as early as kindergarten. People who are locked up or forced to stop taking drugs will not necessarily recover. They could relapse. Ongoing support is what’s needed, so they can make the right choices for themselves.
    Thanks for asking.

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