Is Involuntary Drug Treatment Ethical or Even Effective?
The first time Deirdre Sampson (name changed) ever tried to have her younger sister, Kelly, involuntarily committed to drug treatment was after police found Kelly standing on an overpass threatening to jump. Kelly’s opioid use, once manageable enough to allow her to work as a veterinarian, had spiraled out of control. Kelly was threatening suicide, using drugs chaotically, and involved in violent, abusive relationships.
Deirdre and her parents brought Kelly to a local hospital in Baltimore where she was placed on involuntary hold for the suicide attempt. But under Maryland law, which makes it difficult to hold someone against their will, Kelly was allowed to check herself out a few hours later. Over the next five years, Deirdre and her family tried twice more to have Kelly involuntarily committed to a hospital or drug treatment center, but each time Kelly was permitted to leave without completing the treatment. In May 2017, after a five-month period during which Kelly had stopped using drugs on her own, she relapsed and died of an opioid overdose.
For Deirdre and many families with a loved one whose drug use has turned chaotic, the stress and fear of potentially losing a loved one are daily companions. That’s why in recent years, several states, including New York, Kentucky, Ohio, Indiana, and Florida, have changed their laws to make it easier for someone who uses drugs to be involuntarily committed by a family member or caregiver. Some family members welcome these new statutes to help navigate situations that are otherwise frustratingly out of their control. But others are not so sure that these laws help more than they harm.
“I have mixed feelings about these types of laws,” says Maria “Alex” Alexander, of Rosita, California, who has a daughter who struggles with addiction. “I admit there have been times I have wanted to commit my daughter to treatment. One time when I was really desperate I even dragged her to the police station and begged them to do something – like, I don’t know, scare her away from the drugs. But I would also be concerned that these involuntary commitment laws could be abused by family members or by unethical treatment centers who could try to convince family members to commit their kids so they make money.”
Involuntary commitment laws do raise concerns about the potential for abuse and unethical behavior, not to mention civil liberties violations, but there are also other issues at play, such as increased risk of overdose death. One comprehensive analysis of opioid-related deaths in Massachusetts showed that people involuntarily committed to treatment were twice as likely to die of an overdose after release than those who went voluntarily. There are overdose risks for people while in treatment as well. For Louise Vincent, a mother in Greensboro, North Carolina, that risk became reality in March 2017 when she lost her 19-year-old daughter, Selena, to an overdose while Selena was still enrolled in treatment.
“Most parents believe that if their kids are in rehab they are safer than when actively using, but that’s not always true,” says Louise. “Rehab presents many risks. Some people use dangerously right before going to treatment as a ‘last hurrah.’ Others use while in treatment – you can definitely get drugs into treatment centers and jails – and many people use drugs right after they get out, and are at higher risk of overdose because their body’s tolerance for the drugs went down while they were abstinent.”
Louise is an advocate for a harm reduction approach to drug use and has dedicated her life to improving wellness and fighting stigma against people who use drugs. Harm reduction is a philosophy that accepts where people are on the change continuum and encourages any step in a positive direction, whether or not it involves stopping drug use. Louise helps people who are using drugs feel connected to the community again by getting them involved in overdose prevention programs, syringe exchange programs, or hepatitis C testing programs to reach out to their fellow users. She has seen that often, when otherwise marginalized people feel a sense of purpose and are able to give back, they slow or even stop drug use. She works with people to come up with plans to improve their lives that involve small, manageable steps in the right direction.
“I’ve seen too many people go through treatment, have a bad experience, relapse when they get out, and be too frustrated to try again, especially if the treatment was forced,” she says. “They think – because society tells them - that total, immediate abstinence from all drugs is the only definition of success. People don’t even realize that there are other ways to move in a positive direction. I think we do a great disservice to the many people struggling with chaotic drug use by not even offering them other options.”
Louise believes that the tendency for many family members to place all their hope into getting a loved one into a traditional drug treatment center can be misguided and even dangerous.
“Parents going through these situations are terrified their children are going to die,” she says. “I get it. I’ve been there. But the conversation shouldn’t be just about getting a person into treatment, as if that were a golden ticket to make people well. We need to talk about real solutions. Listen to our loved ones. What do they actually want and need? Often people using drugs chaotically have much deeper problems that need to be addressed. Grief. Joblessness. Homelessness. No sense of purpose. They are using to cope with those things. Taking away their coping mechanism – the drugs – won’t help them get better.”
It is easy to understand how a concerned family member watching a loved one struggle with drug use would seek a solution, or even just respite and a bit of hope, in the form of drug treatment. But hanging all hope on the chance that treatment alone will fix the problem is to misunderstand addiction, where it comes from, and how to live with it. As Louise points out, it is common to think that drugs cause chaos in a person’s life, so if we get rid of the drugs, other issues will fix themselves. But often it’s the other way around. The outside chaos (relationship issues, lack of purpose, socioeconomic struggles) is driving people to manage their pain with drugs. Those other issues need to be addressed before the person can turn their attention to the impact of drugs on their lives.
Harm reductionists believe that people who use drugs can make rational decisions for themselves (even when it might not seem like it), and therefore, do not support involuntary commitment laws. However, even without the involuntary commitment option, there are ways in which family members can help their loved one stay safe. First they can seek guidance and education on the nature of addiction from science-based behavioral therapy groups, harm reduction organizations and peer-lead recovery centers. Addiction is complicated. It can be really hard to understand why someone whose life appears to be falling apart wouldn’t just stop using drugs. But learning about the chemical changes that take place in a person who has been using drugs for a long time is useful in helping families understand addiction and how to work with it.
For many family members, it is helpful to seek out a harm reduction organization to learn about ways to reduce risks while using or to explore alternatives to traditional treatment models. People using drugs and their family members can learn about overdose prevention, risk of relapse, safer use techniques and more to reduce the risk of death, disease and chaotic lifestyle even while the person is still using. Medication-assisted treatment for opioid users, which has higher success rates than most traditional treatment models and reduces the risk of overdose death, is also an option.
Listening to a loved one and having conversations about issues besides drugs can provide clarity on some of the root causes of negative behavior. What other issues are they struggling with besides drug use? How can those be addressed? Do they feel a sense of purpose in their lives? Are there any realistic, manageable goals that they can set and sustain that at least move in a positive direction?
Lastly, self-support for family members is critical. The day-to-day strain and fear of living with a loved one in chaotic drug use can wear families down. It’s important to find a supportive environment where one can learn about self-care and form relationships with other people who are living through similar struggles so that the stress doesn’t lead to desperate decisions.
Amidst the frustration of trying to help a loved one with a substance use issue, it can become easy to pin hopes on one solution. If that solution seems out of reach because a loved one refuses traditional drug treatment, it may appear that all hope is lost. But accepting that traditional treatment may not be an option in the short-term can open up other possibilities. There are different roads to recovery and wellness for families to explore. Instead of one source of hope, there can be many.
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