Civil commitment for substance use disorder treatment—what do addiction medicine specialists think?

Amid the rising toll of opioid overdoses and deaths in the U.S., several states are considering laws enabling civil commitment for involuntary treatment of patients with substance use disorders (SUDs). Most addiction medicine physicians support civil commitment for SUD treatment—but others strongly oppose this approach, reports a survey study in Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM).

"Civil commitment has emerged as a sometimes compelling yet controversial policy option," according to the new study, led by Abhishek Jain, MD. At the time of the study, Dr. Jain was at Columbia University and New York State Psychiatric Institute. The report is accompanied by a pair of expert commentaries: one discussing the idea of civil commitment in a historical context and another highlighting the dangers of coercive treatment and patient harm.

Physician specialists agree: more education and research needed on civil commitment for SUDs

Most states already have legislation providing for civil commitment of patients with SUDs. "These laws create a mechanism for family members, healthcare practitioners, or select others to seek involuntary court-mandated treatment for individuals suffering from addiction," according to the authors. The opioid crisis has spurred many states to adopt new or expand existing laws, or to implement them more widely.

However, there is little evidence for either beneficial or harmful effects of civil commitment for SUD treatment. To assess the views of addiction medicine physician specialists, Dr. Jain and coauthors sent an online survey to 1,451 members of the ASAM. The analysis included responses from 165 physicians, a rate of 11.4 percent.

Overall, 60.7 percent of the addiction medicine specialists favored civil commitment with involuntary treatment of SUDs. Another 21.5 percent of physicians were opposed to civil commitment for SUDs, while 17.8 percent were unsure. About half of respondents said they would likely consider using civil commitment laws if available in their state, while more than one-third said they were not familiar with such laws.

Nearly 80 percent of respondents believed civil commitment should be permitted for patients who used heroin, while about 75 percent thought it would be appropriate for those who used alcohol or opioids other than heroin. Sixteen percent opposed civil commitment for any type of SUD.

Most respondents believed that medications and behavioral therapies—as well as resources to pay for treatment—would be essential for civil commitment laws to be effective. By large majorities, the specialists agreed on the need for more education and research.

Those who opposed civil commitment were more likely to say it would "jeopardize patient rapport" and would be ineffective for unmotivated patients. Whether they favored or opposed civil commitment, addiction medicine specialists agreed on the need for an efficient legal system, available secure treatment facilities, clear consequences for patients who don't follow treatment plans, and ongoing aftercare.

A commentary by William F. Haning III, MD, of the University of Hawai'i at Manoa, Honolulu, discusses reasons for the diverging views of addiction medicine specialists and highlights critical questions for further research, particularly the criteria for civil commitment and the effectiveness of compulsory treatment. He emphasizes the need for "a wider range of supervisory and custodial changes," based on evidence-based approaches.

In another commentary, John C. Messinger, BS, of Harvard Medical School and Leo Beletsky, JD, MPH, of Northeastern University, Boston, call on addiction care providers to "challenge the use of state power to coerce people into treatment settings—especially when such settings often diverge from best clinical practices." They conclude, "Addiction professionals must reject perpetuating punitive structures that harm the individuals we are hoping to serve."