As politicians grapple with strategies to fight the national opioid epidemic, we must reckon with a valuable lesson based on decades of drug treatment: compassionate coercion to forceseverely disordered drug addicts into comprehensive treatment.
Coercion may worry some civil libertarians who argue it deprives people of their civil rights.
But the sad fact is that for most drug addicts the thrill of the high outweighs the obvious risks, even after multiple overdoses. An addict who is revived but is unwilling to voluntarily accept treatment usually enters a revolving door of drug use, overdose and rescue that all too often ends in the morgue.
That was the tragedy last year for many of the 64,000 Americans who died from drug overdoses.
To stop drug use several states are now turning to coercion in the form of limited mandatory treatment or strong legal incentives, such as drug courts and civil commitment. Research shows that people who at first are coerced into drug treatment have outcomes very similar to those who enter treatment voluntarily.
Mandatory treatment is not a new idea: More than 30 states already have laws allowinginvoluntary commitment under specific circumstances.
But because these laws usually involve the time consuming process of obtaining a judge’s approval, they can be ineffective. In this unrelenting opioid epidemic, we administer overdose reversal drugs to save addicts’ lives but then are powerless to get them immediate evaluation and treatment.
A number of states including Kentucky, Indiana and New Hampshire are considering revising laws or adopting new ones to force addicts into assessment. Massachusetts Governor Charlie Baker proposes empowering medical professionals and first responders to send a revived addict to a specialized addiction facility for up to 72 hours for evaluation.
Once off drugs, detoxed, sober and in treatment they have time to think clearly and make rational choices about seeking a drug-free future. They receive drugs that reduce craving. And the imminent danger of an overdose is avoided.
Florida has had an involuntary commitment law since 1993. Last year more than 400 people in the Tampa area were sent to addiction treatment assessment – and in very encouraging results more than two-thirds of them completed their court-ordered programs.
Findings from federal studies of more than 70,000 people in drug treatment starting in the 1970s found that addicts who were compelled to enter treatment stayed in treatment longer. And the longer they remained the more likely they were to remain drug-free. In other words, coerced treatments worked at least as well as voluntary treatment and sometimes better.
One successful program in Hawaii called HOPE – Hawaii Opportunity Probation with Enforcement – operates under the theory that judicial punishment for violations should be “swift, certain and proportionate.” That means a few days of jail time for offenders who miss a probation appointment or fail a drug test.
As a result, HOPE participants were less likely to be arrested for a new crime, have their probation revoked or use drugs. And they served fewer days of incarceration.
But when coercion is removed from the equation, the success rate falters. After New York City’s criminal justice system reformed sentencing guidelines in 2006 and reduced the length of prison time for drug-related crimes, most arrested drug users no longer opted for treatment.The incentive to avoid incarceration was gone.
That’s why the Massachusetts proposal to detain addicts for three days makes a lot of sense, particularly in the battlefield conditions of today’s opioid epidemic. Extending that period for up to 30 days is essential to improve effectiveness and prevent many more fatal overdoses.
Coercion is not a violation of civil rights and liberties. To tell an addict who has just been resuscitated from an overdose that, no, you may not return to the streets for at least a reasonable time to find more drugs, is an act of humanity and compassion – and a matter of life and death.