Leslie Agans was desperate. Her teenage son, Michael, had once been a good student and terrific ice hockey player in Bucks County, Pennsylvania. But he’d become a deceitful, unmotivated, unpredictable and sometimes violent adolescent whose life was imploding thanks to his daily marijuana use. (U.S. News is identifying Agans by her maiden name and her son by his middle name to protect the family’s privacy.)
In 2016, when Michael was 15, Agans coaxed him into an outpatient drug rehabilitation program. He went to one session and refused to return. Agans lined up eight therapists for her son. One after the other, the boy would meet with a therapist, then refuse to see him or her again. Michael began routinely sneaking out of the house to smoke pot; then, he started using it in his bedroom.
In June, Agans spoke again with a local police chief with whom she’d confided in about Michael’s behavior. He reminded her about past conversations in which he had suggested she consider using Article 53, a Pennsylvania law that allows parents to petition a judge to place a minor child into drug treatment against his or her will. Initially, Agans recoiled from the idea of forcing her son into a program through a court order. But Michael’s upcoming 18th birthday caused her to reconsider. Once he was a legal adult, Agans thought, he could do whatever he wanted. Agans obtained the petition from the local courthouse and filled it out. “I had to stop him before he was 18, and that was my only recourse,” Agans says. “I did it with a very heavy heart.”
Having a judge order someone struggling with substance use disorder into treatment against his or her wishes is a controversial approach among addiction treatment clinicians. About three dozen states have laws allowing judges to order people into treatment for drug or alcohol addiction. These laws are similar to civil commitment statutes that allow judges to order individuals into a psychiatric facility if a physician determines he or she is a threat to the safety of him or herself or others.
[See: 4 Opioid Drugs Parents Should Have on Their Radar.]
Civil commitment for drug treatment is different from the programs offered in drug courts or mental health courts, in which someone who’s charged with a crime, often a low-level offense related to his or her substance use disorder or condition, is given a choice between treatment and jail. There’s no choice with civil commitment. Compulsory treatment laws for drug addiction vary by state; many allow a parent, guardian or law enforcement officer to file a petition for mandatory treatment. A judge can order the person into treatment, typically after an evaluation by a health care professional. The amount of time in treatment differs from state to state, from a few weeks to several months.
There’s no consensus among clinicians that mandatory treatment is an effective approach, and research suggests it’s not particularly effective. A 2016 meta-analysis of nine studies in the International Journal of Drug Policy found no evidence of improved outcomes with compulsory treatment. What’s more, a study by the Massachusetts Department of Public Health of clients served between 2011 and 2014 found that patients who received involuntary treatment died of an opioid-related overdose at more than twice the rate of people who had voluntary treatment. Researchers found that 0.63 percent of individuals who received voluntary treatment later died of an opioid-related overdose, while 1.4 percent of people who had compulsory treatment later died of an opioid-related overdose. The study did not analyze why those patients suffered a fatal overdose at a greater rate, says Elissa Snook, a spokeswoman for the Massachusetts Department of Health and Human Services. “Patients who are committed for treatment under Section 35 are appropriately among the sickest, most complex and at the greatest risk for an overdose,” Snook says. “It is inappropriate to directly compare the treatment outcomes of two different populations: one group that is actively seeking treatment and the other [that] is not.”
Though the Massachusetts study didn’t analyze why people ordered into treatment overdosed fatally at such a higher rate, it is nonetheless worrisome, says Dr. Sarah E. Wakeman, medical director of the substance use disorders initiative at Massachusetts General Hospital in Boston. Wakeman, one of the clinicians opposed to involuntary treatment, has other concerns. “You’re violating someone’s civil liberties and autonomy,” she says. “Many of the facilities providing compulsory treatment don’t offer evidence-based care.”
For example, the facilities in Massachusetts that provide treatment to patients forced into a program by a court don’t provide buprenorphine or methadone, medications that studies show are helpful in treating opioid addiction, Wakeman says. One of the main providers for compulsory treatment in Massachusetts is the Department of Correction. The department is in charge of a 250-bed facility, the Massachusetts Alcohol and Substance Abuse Center at Plymouth, to provide services for men ordered by a judge into compulsory treatment. The vast majority of the 250-bed facility is used to treat patients ordered into substance misuse treatment, and the 20 or so prison inmates housed there are kept in a different section of the facility, says Jason Dobson, a spokesman for the Department of Correction. Clinicians at the facility provide comfort medication for patients undergoing detoxification; opioid withdrawal can produce an array of symptoms such as sweating, gastrointestinal pain, anxiety and vomiting. After the detoxification process, clinicians also provide patients with naltrexone, a medication approved by the Food and Drug Administration to treat opioid use disorders and alcohol use disorders, according the Substance Abuse and Mental Health Services Administration. Treatment methods aside, Wakeman says she’s not a fan of placing having patients ordered by a judge into treatment in a prison setting. “That risks retraumatizing people who may have already been incarcerated, and can damage [clinicians’] trust with the patient,” Wakeman says. Dr. Patrice A. Harris, chair of the American Medical Association’s opioid task force and president-elect of the AMA, shares Wakeman’s concerns, and also worries that mental health counseling may be in short supply in involuntary treatment programs.
Understandably, Wakeman says, mandatory treatment is supported by many family members desperate to help a loved one with substance use disorder get off drugs.
[See: 11 Strategies for Staying Sober While Traveling.]
Charlotte Wethington, of Kenton County, Kentucky, is one of those family members who supports compulsory treatment. After Wethington’s son, Casey, 23, died of a heroin overdose in 2002, she successfully lobbied Kentucky lawmakers to pass mandatory treatment legislation. The statute, known as Casey’s Law, took effect in 2004. Since then, hundreds of people have received treatment through Casey’s Law, she says. Recently, 10 people who’d been through compulsory treatment through Casey’s Law participated in a video, telling their stories. These individuals — five men and five women — may have died if they hadn’t been forced into treatment, she says. “Casey’s Law is an intervention tool, not a guarantee,” Wethington says. “It would have given us the opportunity to intervene and give Casey a chance at recovery.”
In light of the terrible toll the opioid epidemic is exacting, some clinicians agree with Wethington that mandatory treatment is worth a shot. In 2016, 42,249 people in the U.S. died of overdoses linked to opioids, according to the Centers for Disease Control and Prevention. That accounted for almost 66 percent of the nearly 63,600 overdose fatalities that year. The emergence of the synthetic opioid fentanyl as a readily available street drug is a key driver of the uptick in overdose deaths. Fentanyl is 50 to 100 times stronger than morphine and up to 50 times more potent than heroin. More than 20,000 of the overdose deaths in 2016 involved fentanyl or fentanyl analogs, according to the National Institute on Drug Abuse. Between 2015 and 2016, the drug overdose death rate for young adults people in the 24 to 35 age group rose by more than 10 percent, according to the CDC.
The advent of fentanyl as a popular street drug means that with each injection or snort, people who misuse opioids risk taking a fatal dose. In that context, every method of getting people into treatment should be tried, says Howard Samuels, a licensed therapist and founder and chief executive officer of The Hills Treatment Center in Los Angeles. “I believe that addicts, at this particular point, because of the fentanyl and the mass amounts of people dying from using heroin, it is suicide. It’s a cry that you are going to kill yourself because you’re so depressed. Because it is such a suicidal risk now, it is justification not to give addicts a choice.”
Agans, the mother from Pennsylvania, says she now feels comfortable not giving her son Michael a choice about drug treatment. Michael learned she’d petitioned a judge to place him into drug treatment when two sheriff’s deputies went to the family’s home and handed him a subpoena, she says. Initially, Michael was angry, but later that night he hugged her and said he knew how much she loved him and that he understood she was trying to help him. A substance abuse counselor is working with Michael, who has had an initial assessment about his marijuana use and will meet soon for a second time with a therapist, who will recommend to the judge on his case whether he should be treated on an inpatient or outpatient basis.
[See: 7 Health Risks of Binge Drinking You Can’t Ignore.]
Agans realizes she has no guarantees, but she does have hope. “I don’t know what to expect, and I’m scared, but I’m so relieved because he’s finally going to get the help he needs,” she says. “I felt it was the only choice I had left. I’ll do anything I can to save my son from himself.”
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Is Forcing People With Substance Use Disorder Into Drug Treatment a Good Idea? originally appeared on usnews.com
