This summer, the Hazelden Betty Ford Foundation released a research paper embracing the concept of civil commitment for substance use disorders (SUDs). The driving force is similar to that for suicidality: saving the life of a possible overdose victim. In issuing this paper, called “Involuntary Commitment for Substance Use Disorders,” Hazelden Betty Ford has opened a national dialogue among treatment providers on this controversial issue.
It’s controversial because some say that if addiction is indeed a disease, treatment should not be coerced, any more than treatment for cancer would be coerced. But according to the National Institute on Drug Abuse (NIDA), “treatment does not need to be voluntary to be effective.” In Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA states, “Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.”
In addition, civil commitment is used for mental illness when a patient is a danger to himself or others, and that is how it is being positioned for substance use disorders — or, more specifically, for opioid use disorders.
Related to the issue of patient control are efforts to do away with 42 CFR Part 2, the regulations protecting the confidentiality of SUD treatment records. Hazelden Betty Ford was also on the cusp of this controversy in aligning itself with the American Society of Addiction Medicine and others in removing this regulation, which requires that patients give written consent for their treatment records to be released (see ADAW, August 7).
Civil commitment laws in general provide only for residential, not ambulatory treatment. There are already laws in place allowing the commitment of someone with a mental disorder who is at risk of causing harm to himself or someone else. Now, some states are considering laws that would make commitment in some cases for opioid use disorders easier.
“Relatives and loved ones of an individual with a substance use disorder often feel helpless and disempowered when that individual is unable, due to an impaired brain, to make the rational decision to undergo and complete addiction treatment,” the report states. “Involuntary commitment laws for substance use disorder might be a way to initiate the treatment these individuals need to avoid death and ultimately re-establish productive and healthy lives.” The report goes on to say that “according to some,” there is a need to protect privacy and freedom of people with SUDs, and that treatment should always remain a choice, “even if the ability to choose is compromised.”
“We have no official position either pro or con” on civil commitment, said Jeremiah Gardner, spokesman for the treatment chain. “The laws on this matter vary greatly. They are inconsistent and lack established best practices and robust research.” But because so many people are dying from overdoses, it’s time to discuss options. “Our only position is that, in light of the opioid crisis, there ought to be a national dialogue around this issue so that such questions can be discussed and studied.”
Faces & Voices of Recovery also is not ready to make a statement on civil commitment. “Our Public Policy Committee has mixed views on it right now,” Executive Director Patty McCarthy Metcalf told ADAW last week. “We hope to have a consensus statement after our next meeting later this month.”
In addition to the concerns about privacy and self-determination for patients, there are practical questions, such as who pays for treatment under civil commitment? What if the patient has no insurance? Does insurance even have to abide by a court ruling that a patient needs, say, 30, 60 or even 90 days in residential treatment? “Good questions,” said Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), which is currently reviewing the civil commitment issue.
In fact, the opioid epidemic puts the residential treatment field in a painful dilemma. Science says that the best treatment for opioid use disorders is with medication. Three are approved — methadone and buprenorphine, both opioids themselves, and naltrexone, an opioid blocker — but most residential programs have a bias against opioids, considering treatment with them not to be true abstinence. Still, they see the potential to help many patients who need treatment. And some see nothing but the potential to fill beds, giving rise to some of the seamy scenarios in the addiction treatment field that have filled the headlines — and which NAATP and respected facilities like Hazelden Betty Ford are seeking to distance themselves from.
There are laws that allow for involuntary commitment of people with an SUD, alcoholism or both in 37 states and the District of Columbia, but the laws are rarely used, according to the report. In five of these locales, mental illness specifically includes substance abuse and alcoholism, making commitment the same as for individuals with psychiatric disorders. The other 33 states have separate statutes for substance use, to prevent criminal defendants from pleading an insanity defense if they committed a crime while under the influence. In 13 states, involuntary commitment for SUDs is not allowed.
States require an evaluation by a physician prior to commitment. Some states require proof that the person previously refused voluntary treatment, or was recently admitted on an emergency basis.
Most states allow a family member, medical professional or the treatment program to petition the court to get the patient committed to SUD treatment. In some states, even police officers can do this.
Parents who lost children to overdoses are a driving force behind these laws. In Kentucky, Casey’s Law, which took effect in 2004, was spearheaded by Charlotte Wethington, whose son died in 2002 from an overdose.
More questions than answers
How long should a civil commitment last? Some say it must be at least 90 days, but about a third of the states allow for only 30 days or less. Only in Kentucky can an individual be committed to treatment for up to a year.
Asserting that most people with SUDs also have co-occurring mental disorder, the Hazelden Betty Ford paper states that “treatment must be comprehensive and not rely solely on medications or any one therapy.”
The Hazelden Betty Ford Foundation has a program that combines medication — either buprenorphine or naltrexone — with the 12 Steps, which utilizes evidence-based practices, including 12-Step facilitation, cognitive behavioral therapy, and motivational interviewing. Residential treatment can help patients step down to outpatient treatment, the report states.
Section 35 in Massachusetts
One state does have a civil commitment law that is sending people to treatment. In Massachusetts, the treatment providers must contract with the state to be Section 35 facilities. High Point provides treatment for women in its New Bedford complex, and for men at its Brockton campus. Both facilities are unlocked. Treatment starts with detoxification.
“We have a very robust civil commitment process in Massachusetts,” said Vicker V. DiGravio III, president and CEO of the Association for Behavioral Healthcare. A combination of the state, Medicaid and commercial insurers pay for treatment under Section 35, as the civil commitment statute is called. The statute allows treatment up to 90 days, but “only allows patients to be detained as long as they are deemed to be a risk to themselves or others,” he told ADAW. “If the presentation warrants it, you start in a 24-hour detox, then a 24-hour stepdown and then you go into residential,” he said. Even if they are not deemed a risk, many patients then choose to continue in treatment voluntarily, he said.
Section 35 is not the same as Section 12, a Massachusetts law under which patients with mental illness (not an SUD) can be held for 72 hours against their will based on a medical professional’s determination. In most cases, this involves suicidality. There doesn’t need to be court involvement for Section 12. A court order is required for Section 35. Gov. Charlie Baker proposed two years ago that Section 12 be extended to SUDs (see ADAW, Nov. 16, 2015).
If a patient wants to leave a Section 35 program, he can, said DiGravio. “The program can’t physically restrain someone from leaving,” he said.
For the Hazelden Betty Ford report, go to http://www.hazeldenbettyford.org/education/bcr/addiction-research/involuntary-commitment-edt-717.
Hazelden Betty Ford has started a national dialogue about civil commitment for opioid use disorders.