Leap of Faith
Season 1: Episode 6
January 2, 2020
Photo by Ryan Levi
As the opioid crisis continues to ravage the country, some states are turning to controversial laws that force people into treatment. Are they part of the solution or could they make things worse?
Listen to the full episode below, read the transcript or scroll down for more information.
NOTE: This page has been corrected to include the most updated number of states with compelled treatment laws.
By The Numbers: The Opioid Overdose Crisis
Source: Centers for Disease Control and (2019) Adults who misuse opioids: Substance abuse treatment use and perceived treatment need, Substance Abuse, 40:2, 247-255
A Response: Involuntary Treatment Laws
Many states have turned to controversial laws that allow family members and physicians to ask a judge to force someone into treatment if they have a severe substance use disorder and present an imminent danger to themselves or others.
If granted, the holds can last anywhere from a few days to two years depending on the state. Data is hard to come by, but experts estimate between 10,000-20,000 people a year are civilly committed for substance use disorder.
The Evidence
There is very limited evidence on the effectiveness of compelled treatment laws for substance use disorders. The few studies that exist show mixed results, often include small sample sizes, examine compelled treatment outside the U.S. or extrapolate data from criminal justice settings. Supporters of compelled treatment often point to anecdotal success stories, while opponents point to the potential for increased overdose risk if someone relapses after detoxing.
Performing high-quality research that compares voluntary and involuntary treatment is a challenge because those receiving involuntary treatment are typically a much higher-risk population. Experts say it’s important for states with these laws to collect data and track outcomes, which has not been a common practice.
Merredith's Story
Merredith Cunniff was involuntarily committed for 60 days in Massachusetts in 2012 at the age of 37 while suffering opioid use disorder.
Cunniff’s father used Massachusetts’ Section 35 law to send her to MCI Framingham, the oldest women’s prison in the country.
She says she received little medical care and was mistreated while she suffered through three weeks of painful detox in a small cell.
(Prison officials couldn’t comment on Cunniff’s case, but a 2014 lawsuit alleging mistreatment of women committed to prison led to a law change ending the practice in 2016).
She did stop using heroin after her commitment, but she says it was only because she was “ready to quit.”
“You can’t tell someone you’re done,” she says. “I decided I was done. Yes, my father sectioned me. But it was me that said I’m done.”
Cunniff has been sober for seven years and believes that only people with severe psychiatric and substance use disorders should be compelled into treatment.
The Tradeoffs: Involuntary Treatment Laws
Policymakers and families who support civil commitment laws see them as a last resort to get people at risk of dying from opioid use disorder into treatment. They point to data showing most people struggling with addiction don’t think they need treatment, as well as research suggesting addiction impairs a person’s ability to make good choices.
But there is a lack of evidence on the effectiveness of these laws, and forcing people into treatment before they’re ready could increase their risk of fatal overdose and make them less likely to seek treatment in the future. There’s also no consistent standard of treatment, so patients in some states do not receive evidence-based care. Involuntary commitments also curtail people’s liberties, presenting legal and ethical challenges.
A State-by-State Snapshot
While 34 states and the District of Columbia allow for civil commitment for substance use as of March 2019, only about half those states use those laws with any regularity. The laws vary greatly from state to state, as illustrated in the side-by-side comparison below of four select states’ laws. (Click on the outline of each state for additional information.)
Massachusetts
Massachusetts' Section 35 is one of the oldest and broadest substance use civil commitment laws in the country.
More than 6,000 people were committed using Section 35 in 2018.
A police officer, physician, spouse, blood relative, guardian or court official may petition the court to commit someone.
Up to 3 months
Men in Massachusetts are the only people in the country that are regularly committed to prisons and jails. More than 75% of treatment beds for men are in correctional facilities. All Section 35 facilities offer medication-assisted treatment during and after detox.
Patients develop individualized care plans before discharge and can receive referrals to community-based treatment.
Florida
Involuntary commitment in Florida is governed by the Marchman Act, which was passed in 1993.
Data is not well tracked, but Florida reported an annual average of around 9,000 commitments in 2015.
Any “adult who has direct personal knowledge of the respondent’s substance” use
Up to 3 months
Treatment must be by a “licensed service provider,” usually a hospital, detox or addiction treatment facility.
A patient is discharged unless an extension is requested.
California
A new California law allows San Francisco, Los Angeles and San Diego counties to set up civil commitment pilot programs. Only San Francisco has done so.
San Francisco has yet to commit anyone, but only people who have had at least eight involuntary psychiatric commitments in the last year and have a substance use disorder are eligible. Officials estimate this applies to just 50-100 people.
Sheriff, medical professional or social service provider
Up to 6 months (may be renewed)
Treatment can occur in residential treatment facilities or locked subacute facilities. Patients detox and are offered treatment, including medication-assisted treatment for opioid use disorder.
Individuals are offered a range of ongoing services including housing, case management, psychiatric medication and therapy.
Washington
"Ricky's Law" was passed in 2016 and is named after Ricky Garcia, who pushed for the law after struggling with substance use disorder.
Around 700 people have been committed in the law’s first two years.
Certain mental health professionals known as “designated crisis responders”
Initial 3-day hold can be extended up to 2 weeks.
Legislation funded the building of up to nine new treatment facilities by 2026. Patients have access to medication-assisted treatment during and after detox.
Treatment facility staff estimate 90% of patients have continued with voluntary treatment after discharge.
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Episode Resources
Select Research on Compelled Treatment
Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work? (Jain, Christopher, & Appelbaum, Psychiatric Services, 2018)
The Effectiveness of Compulsory Drug Treatment: A Systematic Review (Werb et. al, 2016, International Journal of Drug Policy)
Nature and Utilization of Civil Commitment for Substance Abuse in the United States (Christopher et. al, Journal of the American Academy of Psychiatry and the Law, 2015)
Integrated Crisis Response Pilots: Long-Term Outcomes of Clients Admitted to Secure Detox (Washington State Institute for Public Policy, 2011)
Additional Information
Laws Authorizing Involuntary Commitment for Substance Use (Health In Justice Action Lab and Prescription Drug Abuse Policy System, 2019)
Report on Section 35 in Massachusetts (Section 35 Commission, 2019)
Understanding the Opioid Overdose Epidemic (Centers for Disease Control and Prevention)
Episode Credits
Guests: Dr. Abhishek Jain, forensic psychiatrist
Rep. Lauren Davis, Washington state
Merredith Cunniff, nurse, advocate and former civil commitment patient
Original music composed by Ty Citerman; additional music by Blue Dot Sessions, Whitewolf, Moscardo and Moby
This episode was reported and produced by Ryan Levi and Victoria Stern. It was mixed by Ryan Levi and Andrew Parrella.
Additional thanks to:
Keith Humphreys, Evan Anderson, Kelly Clark, Angelica Almeida, Erin Mundy, Paul Christopher, Paul Appelbaum, Heather Klusaritz, Leo Beletsky, the Tradeoffs Advisory Board…
…and our stellar staff!