Spurred by an opiate problem that kills three people a day in Massachusetts, Governor Charlie Baker has proposed controversial legislation to give hospitals power to hold addicts against their will if they pose a grave danger to themselves.
Intruding on personal freedom is serious business. But in extreme situations it’s necessary.
I remember the frantic parents of my 23-year-old patient, Susan. They tried to get her committed for “grave disability” due to addiction. Susan had dropped out of college three years earlier, chose to live on the streets of New Haven or crash on her friends’ filthy couches. Two months before her parents sought forced treatment, their daughter had overdosed twice, suffered a near-rape, and was hospitalized for abscesses from infected injection sites.
The judge did commit Susan but soon after that I left New Haven so I never knew her fate. At the least, I know her imminent self-destruction was halted.
Senate President Stanley Rosenberg reacted to the governor’s proposal with caution, giving it a “big yellow light.” “You have to find the right balance point here,” he said, “be[ing] really careful that we don’t deny them their liberties.”
The bill is indeed careful to give patients the right to legally challenge both the three-day detention and any subsequent effort to commit them for longer for 90 additional days. (There is already a substance abuse commitment law on the books, but it requires a judge’s order. Under the governor’s proposal, a doctor can trigger the three-day hold.)
As a psychiatrist who treats addicted patients, I know that voluntary help is sometimes not enough. The truth is that people immersed in heavy drug use are notoriously ambivalent about giving it up.
In fact many, if not most, patients come to treatment because someone — a spouse, a boss, child, parent — mightily twisted their arms.
To be sure, voluntary treatment slots can be hard to come by. But even when patients enroll on their own, they drop out at high rates of 40 percent to 60 percent within days or weeks of admission.
Dropout typically means return to use. This is why leverage to keep patients in treatment is precious. Commitment provides leverage.
But can treatment really be helpful if a judge compels it? The answer is yes. Volumes of data from criminal justice programs lasting a year or more, such as drug courts and other probationary programs, attest to that fact.
Baker’s civil commitment law, however, would max out at 90 days. That’s a short period of time in which to gain a solid foothold in recovery, especially for a person whose addiction is so severe that he or she was committed.
So, how to get the most out of three months?
First, emphasize outpatient care. Coerced treatment should not reflexively mean institutionalization. Typically, a heavily addicted person needs a week or two as an inpatient to stabilize. This gets him through the worst of the opiate withdrawal, attend to any medical problems, and normalize eating and sleeping.
Beyond that, it’s too easy to be an inpatient. While cocooned inside, protected from drugs, patients’ craving tends to subside and over-confidence about being able to stay abstinent or to manage safe use grows. Discharge is often a rude awakening and a stimulus to relapse.
By starting to repair their lives in the real world — applying for jobs, preparing to re-enter school, establishing healthy social network and re-connecting with family — patients confront the stark reality of their vulnerability to relapse.
Outpatient care consists of counseling, family or couples’ therapy, and employment or educational coaching. But the community is where patients put it all to work, especially the relapse prevention skills they’ve learned in counseling, such as identifying triggers for craving, coping with craving, and stress management.
The second way to help patients is for the treatment program to use incentives to shape their behavior and motivation to quit. A vast literature exists, for example, on the use of redeemable vouchers to extend retention and reduce drug use.
Such vouchers have monetary value that patients can exchange for food items, movie passes, or other goods or services that are consistent with a drug-free lifestyle. The voucher values are low at first, but increase as the number of consecutive drug-free urine samples increases. Positive urine samples reset the value of the vouchers to the initial low value.
In another model, psychologist Kenneth Silverman at Johns Hopkins and colleagues have offered $10 an hour to addicts to work in a “therapeutic workplace” if they submit clean urine. If the sample is positive or if the person refuses to give a sample, he or she cannot attend work and collect pay for that day. Workplace participants provided significantly more opiate-negative urine samples than controls; reported more days employed, higher employment income, and less money spent on drugs.
Third, add medication. For patients who have trouble refraining from opiates, physicians can prescribe naltrexone as a once-a-day pill or 30-day injection to block the effects of opiates. Another option is buprenorphine (a combination opioid analog plus blocker sold as a sublingual film or tablet and prescribed by specially-licensed doctors).
Critics of the commitment proposal are understandably nervous that people won’t come into drug treatment on their own for fear of being detained. But the opposite is likely true. People who present for treatment on their own are the least likely to be detained – after all, they’ve shown an interest in getting help.
A small fraction of heroin users are at imminent risk of serious harm or death. The option for commitment, like a very powerful medicine, should be used sparingly. But it can save lives.Dr. Sally Satel is a resident scholar at the American Enterprise Institute.