Involuntary Hospitalization of Drug Users Is Bad Policy

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Massachusetts appears to be on the cusp of adopting legislation proposed by Republican Gov. Charlie Baker that would allow doctors to hospitalize drug users, involuntarily and without a court order, for 72 hours. Previously, the power to order involuntary commitment of drug or alcohol users lay exclusively in the hands of judges under a Massachusetts law known as Section 35. At this time, few states give judges similar power to take away the freedom of individuals not accused of a crime. (1)

The plan to allow the involuntary commitment of drug users has received virtual across-the-board support. According to press reports, the majority of Massachusetts’ sheriffs and the association representing Massachusetts’ district attorneys have come out in favor of the bill (H.3817). Hampshire County Sheriff Robert Garvey’s comments represent the growing opinion that, “The governor’s bill changes the attitude that addiction is not a criminal offense as much as it is a medical problem.”

Garvey’s remarks are echoed around the country. For a variety of reasons – including a shift in media portrayals of the race of drug users – we are currently experiencing a cultural and judicial movement away from criminalization and toward medicalization of substance abuse. Massachusetts might well be the vanguard of this movement. Not only is Massachusetts a relatively “white” state at a time in which the new face of drug use is white, but also it is the first state to have passed the health-care coverage reform (“Romneycare”) that later became the law of the land nationally (“Obamacare”).

However, does allowing people to be forcibly confined in any space – whether it is a jail or a hospital – really serve the interests of the addicted person? And should the onus to fix social problems really be placed on physicians?

Addiction Treatment and the Role of Physicians

Having worked for the past decade with criminalized women, most of whom struggle or have struggled with addiction issues, I am far from convinced that the governor, sheriffs and district attorneys have got it right. While recategorizing addiction as a medical rather than a judicial issue certainly sounds like a step in the right direction, giving doctors unchecked power to hospitalize people against their will opens the door for serious human rights violations.

Our legal system, like that of other modern democracies, insists that an individual should not lose his or her freedom without the due process of law. A doctor, committing people without an opportunity for those people to be represented by counsel, will be asked to serve as both prosecutor and judge – a position that directly contradicts principles of US jurisprudence and places doctors in an uncomfortable and untenable position vis-à-vis their patients. Knowing that doctors have this power will, I fear, serve to discourage people who could benefit from immediate medical attention from seeking assistance.

More broadly, the proposed bill puts the onus on physicians to fix social problems.

I understand that the motives behind the proposed bill are benign. However, I assume that the image of the doctor-patient relationship in the minds of the governor, sheriffs and district attorneys is most likely the kind of relationship they have with their own family doctors: a relationship in which the doctor knows each patient’s history and family and has a good grasp of each patient’s medical and social background. However, it is likely that the doctors who will be committing patients under Governor Baker’s plan are emergency room doctors or hospitalists; that is, doctors who meet the patient for the first time at the encounter that leads to the commitment. Asking doctors to singlehandedly take away the freedom of patients they barely know is not a reasonable burden to place on doctors.

I have great respect for doctors and I understand their frustration at treating patients for overdoses, only to watch these same patients walk out the hospital door immediately following stabilization. However, the bottom line is that there is no evidence whatsoever to indicate that three days of treatment will have lasting positive effects upon drug users. The three-day proposal, I assume, is based on the three-day commitment for psychiatric patients under Massachusetts General Law, Section 12, though, since no reason is articulated for the three-day idea it might just as easily (although perhaps subconsciously) follow the three days between the crucifixion and resurrection of Christ. In any case, there is little to no evidence showing that coerced drug treatment is effective. (2)

When patients are released after their three-day involuntary commitment, there is no reason to think that they will not return to their former drug use. In fact, having abstained from opiates for several days may set them up to overdose when they return to their former level of drug use, with a reduced tolerance for the drugs. (3)

If a plan were in place to provide long-term, multifaceted support after the three days, I might have a different take on the proposal. But I do not see that Governor Baker’s bill includes such a plan, or a way to fund it. As I’ve seen repeatedly among the women with whom I work, even the “good” rehab placements – that is, ones that last three or six months – usually end with people going back out into poverty, unemployment, scarce community support and often homelessness. These are sure recipes for sending them back into the drug use/detox cycle.

A Gap in Standard US Medical Training

We in the United States have great respect for physicians and we trust that their medical training is among the best in the world. However, addiction treatment is not a substantial part of most medical school curricula, and even in instances where doctors took a course (typically an elective) in the subject, given the rapidity with which the field of addiction treatment is progressing, their knowledge in the field may well be outdated. (4)

I personally have spoken with physicians who know nearly nothing about Suboxone (a drug used to assist people recovering from heroin addiction) and have never administered a dose of Narcan (a drug used to treat heroin overdoses). Few hospitals in Massachusetts, and even fewer in other parts of the country, have more than one or two addiction medicine specialists on staff, which means that non-specialists will be tasked with the responsibility of deciding whether or not to commit patients who, in many cases, are seen as a nuisance or part of a “revolving-door” patient group.

I know from having spoken with doctors around the country that they, like many politicians, tend to believe that 12-step programs like Narcotics Anonymous (NA) are effective in treating addiction when, in fact, there is no evidence showing that NA participation (and especially coerced participation) leads to long-term abstention from drug use. (5) Indeed, I suspect that lying behind the proposed legislation is the notion, propagated by 12-step organizations, that alcoholism and substance abuse are “diseases” that take over one’s life, independent of social and structural conditions – and that people living with alcohol- or substance-abuse disorders lack the capacity to make sound decisions. (This is why they must turn themselves over to a “higher power.”)

How Race and Class Shape the Treatment of Drug Users

I do not doubt that many doctors are thoughtful, fair and knowledgeable. But I do know that there is a sufficient history of medical abuses – including medical experiments on prisoners and on Black men (e.g. the infamous Tuskegee syphilis experiment) – which warrants that all medical research undergoes thorough vetting and oversight by ethics reviews boards such as the institutional review boards. Crafted in the frenzied panic over opiate deaths in Massachusetts, Governor Baker’s bill lacks a requirement for any sort of oversight. Decades of research show that doctors tend to treat patients differently depending on the gender or race or both of the patient and of the doctor. (6) Particularly when doctors are being granted full discretion in whether or not to subject individuals to confinement, this lack of oversight is troublesome.

It certainly should raise eyebrows that the popular push to relabel addiction and send addicts to “treatment” rather than prison is taking place at a time when public attention has shifted from Black crack users to white opiate users. Still, redefining people as “sick addicts” rather than “criminal addicts” is not as significant a social shift as one may think. In both cases, they are labeled as flawed individuals who have failed to take responsibility for their own lives. In both cases, the onus for “deviance” lies on the individual rather than on the society that creates and sustains social and economic conditions that lead far too many people to feel that mind-altering and mood-altering substances are the best – or the only – means of making it through the day, the week or their lives.

Of course, those people labeled as “addicts” or “drug abusers” are not all that deviant. Throughout the United States, the normative way for dealing with misery is through doctors’ prescriptions for attention challenges, for anxiety, for depression and even for low libido. (7)

The “epidemic” of opiate-related deaths is not spread evenly across white communities in the United States. In fact, the new attention to white opiate users exposes an important and seldom discussed reality of US society: class matters. The white opiate users in Massachusetts overwhelmingly come from poor and working-class communities – mostly non-urban – where good jobs are scarce and where young people see little hope of ever attaining the American dream.

The criminalized women I have come to know over the past decade are, for the most part, poor and white, and they represent a tragic social trend. According to research published in 2014 by sociologist William Cockerham, “For the first time in modern history, the life expectancy of a particular segment of the American population – non-Hispanic white women with low levels of education and income living in certain rural counties – is declining.” And the same decline is happening among white men. (8)

Opiate use is one of the factors explaining declining life expectancies in impoverished white communities, but it is crucial that we understand that opiate use is a symptom of hopelessness, disaffection, powerlessness and marginalization. Unless we treat those social forces, we are deceiving ourselves if we think that allowing physicians to commit drug users for three days is going to do anything other than intensify those forces.

Acknowledgments: I wish to thank Barak Sered M.D. for his expert advice and input into this paper. All opinions and errors are solely my own.

Footnotes

1. Testa, Megan and Sara G. West. 2010. “Civil Commitment in the United States.” Psychiatry (Edgmont). 7(10): 30-40.

2. Urbanoski, Karen. 2010. Coerced Addiction Treatment: Client Perspectives and the Implications of Their Neglect.” Harm Reduction Journal. 7(13).

3. Strang, John, Jim McCambridge, David Best, Tracy Beswick, Jenny Bearn, Sian Rees and Michael Gossop. 2003. “Loss of Tolerance and Overdose Mortality after Inpatient Opiate Detoxification: Follow Up Study.” BMJ (British Medical Journal). 326(7396): 959-960.

4. Rasyidi, E, JN Wilkins and I Danovitch. 2012. “Training the Next Generation of Providers in Addiction Medicine. Psychiatr Clin North Am. 35(2):461-80.

5. Dodes, Lance and Zachary Dodes. 2014. The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Boston: Beacon Press.

6. Staton, LJ et al. 2007. “When Race Matters: Disagreement in Pain Perception between Patients and Their Physicians in Primary Care.” Journal of the National Medical Association. 99(5):532-8; Weisse, Carol S., Paul C Sorum, Kafi N Sanders and Beth L Syat. 2001. “Do Gender and Race Affect Decisions About Pain Management?” Journal of General Internal Medicine. 16(4): 211-217.

7. Greenberg, Gary. 2013. The Book of Woe: The DSM and the Unmaking of Psychiatry. NY: Plume.

8. Cockerham, William. 2014. “The Emerging Crisis in American Female Longevity.” Social Currents. 1(3): 220-227.