Baker would give hospitals the power to hold addicts
Opioid epidemic brings call for ‘coerced treatment’
Governor Charlie Baker, staring down a brutal opioid epidemic, wants to give hospitals new power to force treatment on substance abusers who pose a danger to themselves or others.
Administration officials say the governor plans to file legislation this week giving hospitals the authority to hold addicts against their will for three days, evaluate them, and decide whether to seek legal permission for substantially longer commitments.
The proposal, modeled after existing rules for mental illness commitments, revives longstanding concerns about the ethics and efficacy of what is known among medical specialists as “coerced treatment.” But officials say it is an appropriate response to a deadly problem.
“We have a crisis on our hands,” said Marylou Sudders, Baker’s health and human services secretary. “You need all of the tools in the toolbox.”
The plan, which is still in draft form and subject to revision, comes amid mounting concern on Beacon Hill over an opioid scourge that left more than 1,200 dead from overdoses in Massachusetts last year. Lawmakers have approved new funding for treatment programs and are weighing a proposal to screen high school students for drug use.
The Baker administration is expected to file its own legislative package in the coming days, including the proposed changes to the system of forced treatment.
Families, police officers, and doctors can already go to court to seek 90-day “civil commitments” for alcoholics or addicts who pose a serious risk of suicide, homicide, or physical harm to themselves or others. This year, as of mid-September, about 3,250 people had been committed to treatment under the state’s current law.
But clinicians do not often make use of the time-consuming, court-based process. Baker’s plan would get them much more deeply involved, evaluating substance abusers during an initial, three-day hold and building the case, if appropriate, for long-term commitment.
The move would, in effect, open up a second avenue for coerced treatment. Administration officials emphasize that due process would be preserved under the new system. Patients would have the right to legally challenge both the three-day hold and any subsequent effort to commit them for a longer period of time.
But the proposal, like others put forward by the Baker administration in response to the opioid crisis, is designed to shift the center of gravity away from the criminal justice system and toward the health care system.
Barbara Herbert, president of the Massachusetts chapter of the American Society of Addiction Medicine, calls the proposal “an extremely provocative idea that might actually bring some people into care.” Too often, she said, hospitals treat addicts for overdoses with antidotes like Narcan, only to watch them walk out the door and onto the street hours later.
“We’re saving more people [in Massachusetts] than anywhere else from death, from immediate overdose,” she said. “But we get these people, they come in — and then we lose them. The idea that we can hold them long enough to try to figure out what would be real care could be a really wonderful idea.”
But it could backfire, Herbert was quick to add. Overdose victims could grow afraid to seek treatment, she said, if they fear they will be held for three days and possibly shuttled into a longer-term commitment.
And if there are questions about the practical impacts of the policy, there are also ethical concerns about expanding a system that confines people against their will. Civil commitment, the Supreme Court declared in 1972, amounts to a “massive deprivation of liberty.”
Christine Griffin, executive director of the Boston-based Disability Law Center, said the state too often takes that liberty without offering adequate substance abuse recovery services in exchange. “That’s the part where we fall down,” she said. “Everyone pays attention to the process — yes, that’s important — but then, what ultimately happens to these folks?”
It is unclear what new treatment options Baker might offer in conjunction with the new policy. But broadly speaking, administration officials say they are acutely aware of the need to improve the system.
Baker proposed $27.8 million in new addiction-related funding in a budget bill now before the Legislature. And the administration is gearing up to move treatment beds for female addicts from a state prison in Framingham to what they say is a more appropriate venue: a psychiatric facility in Taunton.
But Jeffrey Eisen, a psychiatrist and medical director of community-based services for Lahey Health Behavioral Services in Danvers, said the research on the effectiveness of coerced care is mixed — leaving policymakers “in quite a bit of a gray area.”
He cited one review of 30 years of studies that found an “inconsistent and inconclusive pattern of results, calling into question the evidence-based claims made by numerous researchers that compulsory treatment is effective in the rehabilitation of substance users.”
Still, many in the substance abuse recovery movement say civil commitment — the 90-day process already on the books — is a vital bulwark for the most desperate families. Joanne Peterson, founder and executive director of parent support network Learn to Cope in Taunton, used the process twice to get her heroin-addicted son into treatment.
“No matter what we did, we weren’t able to reach him as a family, and we knew he was going to die,” she said. “You have to make the choice between buying a casket and a suit for him to wear in his casket, or standing in front of a judge and asking for help.”
Peterson’s son has been sober for nearly seven years now.
Government has wrestled with how to treat substance abuse for centuries, a challenge long wrapped up in the fraught debate about whether addiction is a malady, a failure of will — or, perhaps, both.
“Drunkenness is a disease as well as a sin,” Massachusetts governor John Andrew declared in an 1863 speech calling for an “inebriates” asylum. “We have long since legislated for its punishment; let us no longer neglect to legislate for its cure.”
Substance abuse commitment laws date back to the latter half of the 19th century. And the latest national tally, completed in 2012 and recently published in The Journal of the American Academy of Psychiatry and the Law, found 32 states and Washington had statutes on the books.
The states set out a wide range of criteria for commitment. And maximum periods of treatment fluctuate from less than a month to more than a year. Researchers chalk up the variance to ambivalence about the civil commitment process.
That ambivalence may be reflected in the decision, by some states, to rarely if ever use their statutes. And while the data on how much more active states utilize their laws is spotty, Massachusetts appears to be on the high end.
Lawyers and advocates say the number is driven, in part, by addicts committing themselves because they can’t find voluntary treatment.
Robert Fleischner, an attorney for the Northampton-based Center for Public Representation, which provides legal services for the disabled, adds that some judges use commitment as a sort of alternative to bail in drug cases.
Clearing a new path to long-term commitment, as the Baker administration is proposing,could draw more people into a taxed system. But Dr. Sarah Wakeman, medical director for Massachusetts General Hospital’s Substance Use Disorder Initiative, said she’s not convinced.
“I wonder if we might see even fewer,” said Wakeman, who served on Baker’s Opioid Working Group, a panel of experts that proposed the shift in commitment policies, among dozens of other ideas.
If the administration follows through on its pledge to introduce more treatment options, she said, clinicians could use the three-day confinement to find outpatient care that the patients might willingly accept, rather than push them into forced long-term care.
Easing addicts into voluntary treatment, Wakeman said, is always preferable. “With any other medical care, we give patients options for different types of treatment,” she said. “And often with addiction, it can be sort of an ultimatum: that you do this, or else.”