Leap of Faith

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein
Across America today, people are worried. 

Newsclip montage

Dan Gorenstein
And for every person that fatally overdoses, there are many more who overdose and survive. Research shows those people are more likely to overdose again. And again. 

Merredith Cunniff
Do you know how difficult it is to not use heroin?

Dan Gorenstein
Other research shows that the vast majority, around 90%, of people who could benefit from treatment for opioid use disorder, don’t think they need it. 

News clip
In many instances the first time a substance user gets treatment is in the criminal justice system.

Dan Gorenstein
We’ve seen a rise in drug courts as an alternative to incarceration and Jails and prisons are becoming de facto treatment centers.

But the problem isn’t going away. So increasingly states are trying to get people help before they commit a crime. 

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.

Today, we look at the effectiveness of forcing people into treatment, what’s often called civil commitment or involuntary treatment. 

Dr. Abhishek Jain is a psychiatrist who has studied these laws in recent years.

Dr. Abhishek Jain
This is something that permits family members, loved ones, law enforcement, even medical providers, to petition the courts to allow individuals who may not be interested in substance use treatment on their own to get them into treatment.

Dan Gorenstein
These laws have come in and out of favor since the late 1800s, and have seen a resurgence in just the last few years. 

Today, 37 states plus DC have some kind of compelled treatment law on the books. More telling, most of them have amended or created their laws since 2015. 

Dr. Abhishek Jain
There’s about 20 states that use it with some degree of frequency. Florida and Massachusetts use it the most frequently. Massachusetts committed more than 5000 people last year. And Florida, the annual estimate from a recent study was about 9000. And then other states that do use it might be a few hundred in each state. So we’re talking about less than twenty thousand people that are probably committed under these laws each year. 

Dan Gorenstein
Most of these states require a court to rule that a person is a “danger to themselves or others” because of their substance use in order to be committed. 

But from there, the specifics of these laws vary a lot. In a place like Missouri, a person can only be held for a few days. In West Virginia, it could be up to two years. In Kentucky and Ohio, families have to pay for the treatment they’re forcing on their loved ones.

The ACLU and other organizations have opposed these laws, arguing they violate people’s due process and could cause serious harm. 

Supporters say these laws prevent harm by getting people into treatment and point to anecdotal success stories that are easy to find online.  

Testimonial #1
When I was first sent to treatment I did feel my rights were violated, but sitting here 3 1/2 years sober, I have more gratitude because it saved my life.

Testimonial #2
I have hope today, I don’t feel like I need drugs and alcohol to cope with things in life. 

Testimonial #3
I have my daughter today, and if it were not for Casey’s Law, I don’t believe my daughter would be here.

Dan Gorenstein
But Dr. Jain says the evidence is in question. 

Dr. Abhishek Jain
We have very limited evidence on whether or not these laws are effective. We have family stories about how there was a positive outcome. And then we also have evidence that could be harmful. For example, there was one recent paper that looked at individuals who are in civil commitment in Massachusetts. And they found that a third of those individuals relapsed on the opioids immediately after the commitment was over. These are individuals who are now being set up for potential overdoses because once the body has been detoxed from the substances, and they go back to using the same amount, we may have set them up for an overdose.

Dan Gorenstein
What’s it going to take to get good evidence in this space? 

Dr. Abhishek Jain
I think this starts with collecting accurate data: How many people have been committed, How long were they committed for? Were medications offered in the treatment programs? So once we have the data that will allow us to look at the quality outcomes a lot easier.

Dan Gorenstein
What are the implications of having so many different laws out there with such little evidence?

Dr. Abhishek Jain
We are dealing essentially with a risk versus risk situation. As we’re dealing with this urgent crisis, people are looking to potential solutions. And these laws that are being passed, sometimes there just a leap of faith, you know, and hoping for the best they can be.

Dan Gorenstein
A leap of faith. Hoping for the best. It’s clear states are grasping for answers. It’s what you do when more than 100 people die a day from opioid overdoses.

What we know is that some of the people forced into these programs will pick up where they left off as soon as they can, putting them at greater risk of a fatal overdose. 

To Merredith Cunniff, that threat is great enough that states should reserve this approach for just the most extreme cases.

Merredith Cunniff
People that are psychiatrically impaired, that are unable to make decisions for themselves, that are using drugs and alcohol. That’s it. 

Dan Gorenstein
Merredith lives in Quincy, Massachusetts, and is an advocate for people like her who have struggled with opioid use. 

Today she’s 45, a nurse, a daughter, a mother, and she’s one of the thousands of people who have been forced into treatment in Massachusetts through its Section 35 law.

Merredith Cunniff
I lost a lot. You know, I was like a country song. I lost my house. I lost my car. I lost my son. I lost my soul.

Dan Gorenstein
It was a hot August morning in the summer of 2012. Her boyfriend had just been arrested, and she couldn’t get any of her stuff.

Merredith Cunniff
I was thinking, “What am I going to do? Where am I going to go?” I was getting sick. I needed to get high. I was just a mess.

Dan Gorenstein
With just 1% charge left on her phone, she called her father and asked if she could take a nap at his house.

Merredith Cunniff
When I lay down in my bed, he pulled up a chair and he looked at me and he said, “Merri, you can’t leave. You stay here, and you’re not leaving. You’re done, Merri.” And I said, “OK, Dad, let me sleep. Just let me sleep.” And I fell asleep. And around 11 in the morning, two police officers were at the end of my bed with handcuffs.

Dan Gorenstein
Merredith didn’t realize what had happened until a judge explained it.

Merredith Cunniff
She said your father was granted a Section 35, which means you’re going to be held, and you’re going to state prison for women. And I remember looking over at my dad, and he just looked gray and old and and sad.

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Dan Gorenstein
Merredith’s father hoped this extreme step would finally get his daughter sober.

Massachusetts is the only state that sends some people to prison for their treatment.  

So when Merredith was sent to MCI Framingham, neither she nor her dad had any idea what kind of treatment she’d be getting. 

Merredith Cunniff
It was just awful. 

Dan Gorenstein
Vomiting, diarrhea, hallucinations. That’s how Merredith describes her first three weeks in the hospital unit. 

Massachusetts prisons only began offering medication assisted treatment, now widely considered the best treatment option, in 2014.

Merredith says the only medicine she got was Pepto Bismol and Tylenol. 

Merredith Cunniff
I remember I asked for a shower and two COs came in and they handcuffed my right hand to the pole because I was so sick, I couldn’t stand up straight. And I just remember sitting there crying.

It was archaic. I was 87 pounds. 

The nurse said drink more water. So I would sit in the bathroom and just cup water shaking, like my heart rate was pounding in my chest. And I just would sit there and, like, hold my head up with one hand and cup water from the sink into my mouth.

Dan Gorenstein
Sitting in prison…  

Merredith Cunniff
I’m alone, I’m scared. I’m stuck here. 

Dan Gorenstein
Merredith made a choice. 

Merredith Cunniff
I needed to stop, and I knew I was done. And I didn’t want to live that way anymore.

Dan Gorenstein
If the point of being forced into treatment was to quit heroin, it worked — for Merredith.

But if she had wanted to keep using in prison, it would have been easy.

Merredith Cunniff
There were girls across the hall from me shooting heroin, needles and everything. I don’t know how the hell they got it in, but they did.

Dan Gorenstein
That scene — and honestly her entire time in prison — helped her come to a simple conclusion. 

Merredith Cunniff
You can’t tell someone you’re done. You know, I decided I was done. Yes. My father sectioned me. But it was me that said, “I’m done, I can’t do this anymore.”

Dan Gorenstein
Prison officials declined to comment specifically on Merredith’s case but said that it is against regulations to use restraints in a shower.  

The state stopped sending women to prison for treatment after a 2014 lawsuit alleged they were being mistreated. Men have filed a similar suit. 

As for Merredith, after her 60-day stay in prison, she spent seven months at an inpatient treatment center.

Today she is seven years sober

Dan Gorenstein
Merredith’s experience is arguably at the extreme end of what compelled treatment looks like. 

But men in Massachusetts are still being sent to prison for their addiction, and across the country people who are civilly committed are not guaranteed medication-assisted treatment.

Even among people who support these laws, there’s no agreement on how people should be treated — what medicine they receive, how long they should stay, who should pay for it.

Washington state believes its policy addresses many of the concerns critics raise.

News clip
Ricky’s Law is named after a suicide survivor who is now four years sober. Ricky Garcia hopes the bill bearing his name will help save lives.

Dan Gorenstein
Lawmakers committed to spending $60 million a year and building nine new treatment facilities by 2026. The newest one opened just last month just outside Seattle.

Washington has forced fewer than a thousand people into treatment in the two years the law has been in effect. 

Rep. Lauren Davis
I very much believe it should be a last resort, that you should offer a person the moon before you ever look at a civil commitment.

Dan Gorenstein
Lauren Davis is the Washington state representative who pushed for the law, which allows certain mental health professionals to commit someone for 72 hours and then ask a judge to keep people for up to two weeks.

Rep. Lauren Davis
The process itself involves denial of a person’s civil liberties, which we should only do in an emergency situation.

Dan Gorenstein
The treatment facilities in Washington are called Secure Withdrawal Management and Stabilization Facilities.

Rep. Lauren Davis
Or SWMS, S-W-M-S, is the acronym.

Dan Gorenstein
Who ends up in these SWMs? What sorts of issues are these folks struggling with?

Rep. Lauren Davis
So these are people who have a primary substance use disorder, people who might be experiencing psychosis because of methamphetamine. They might be passed out from alcohol in the middle of the street. They might be individuals who have experienced a heroin overdose, and been narcanned and brought back to life. So people who are at really significant risk of serious harm or death because of their addiction.

Dan Gorenstein
And so when somebody walks into a SWM are they often alert? Are they unconscious?

Rep. Lauren Davis
So people are generally alert when they enter. They’re typically coming from an emergency department and they’re medically stabilized at the emergency department. In fact, they can’t be admitted to a SWMs facility if they’re not medically stable. And so they’re greeted warmly, they are offered food. And they are given any medications they need at that moment to stabilize any withdrawal symptoms. That’s really their first several days, and the staff tell them like, “You’re not in trouble. We’re here to help you. You’re not going to jail. There’s no law enforcement involvement.” And typically, people are significantly relieved at that point.

Dan Gorenstein
Skeptics of these laws would argue that instead of forcing people into treatment, and I’m sure you’ve gotten this question a bunch, we should be putting as much money as possible into voluntary treatment. Why not do that, representative?

Rep. Lauren Davis
We actually for a whole host of reasons have scores of empty voluntary beds in our state at this juncture. And so this is really a “yes and” answer. We need to provide ample capacity for treatment on demand for people who are electing voluntarily to go to inpatient treatment. And we also need to provide crisis services for individuals who have really lost their volition and ability to choose because they’re so so far down in their disease progression. If you can do what we call arresting the disease, if you can stop it and stabilize them physically, stabilize them psychologically, it gives people that choice back, and they can still choose to continue in their active addiction, that’s a choice, but at least they have a choice at that point. 

Dan Gorenstein: So it’s really trying to hit the pause button for folks who’ve ceased to be able to hit the pause button for themselves.

Rep. Lauren Davis
That’s exactly right. And the fact that 90% of the people coming out of these facilities are choosing to go to voluntary continued inpatient treatment indicates that they do want to get better. They either stopped seeing a way out at all, or they didn’t know how to stop or couldn’t stop on their own.

Dan Gorenstein
Can you tell me more about that? You say 90% of people who go through SWMs then go on to seek voluntary treatment?

Rep. Lauren Davis
So right now it’s staff reports in terms of where clients are discharging to. Staff at the facilities estimate that 90% of those individuals are choosing continued care in an inpatient facility, a voluntary inpatient facility. Part of the enacting legislation actually requires a study by the Washington State Institute of Public Policy to look at the efficacy of Ricky’s Law, but that study is still in its early stages. And so we don’t have the comprehensive long-term data yet.

Dan Gorenstein
One of the people we spoke to for this story is a woman named Meredith. She was compelled into treatment as a 37 year old by her father in Massachusetts, and she’s got a horror story that she tells us. And she thinks that really the only people who should be compelled are the people who are suffering from addiction, but also have such mental illness that they really are incapacitated, they cannot make a choice for themselves. So it’s a narrower slice of people than the group of people you’re imagining. What do you think about that idea?

Rep. Lauren Davis
I disagree. All of the neuroscience, everything we know about the brain and the way the brain works and the parts of the brain that are complicit in the addiction process, indicate that a person at a certain point in their disease progression loses the ability to choose every part of the brain that regulates impulsivity, that regulates decision making is complicit in the brain disease of addiction. How can we then say that this individual has a choice and we have to wait until this person hits rock bottom, we have to wait until this person wakes up one day and chooses recovery when all the neuroscience suggests that they cannot and their behavior suggests that they cannot?

Dan Gorenstein
The science may not be as clear cut as Representative Davis makes it sound. 

Yes, the latest research suggests addiction changes the brain and compromises a person’s ability to choose, but that’s different than saying they lose all ability to choose. 

And that’s really what this entire debate is about: When is it okay for a parent, a doctor, a friend to decide when someone else can no longer be trusted to make this decision for themselves?

More data from states like Washington and Massachusetts may help inform the debate, but numbers alone likely won’t settle it.

When life and liberty are on the line, there are rarely easy, clear cut answers.

But with many people still dying every day from opioids, states cannot afford to shy away from these hard questions.

I’m Dan Gorenstein, and this is Tradeoffs.