Forced Rehab Isn't the Solution
Massachusetts wants to expand its civil commitment law for addiction, but it may make matters worse.
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What can family members do if a loved one is daily risking death, using street opioids that are frequently contaminated by super potent fentanyls? In some states, legislators are considering new legislation or reviving old laws to expand civil commitment—immediate removal to forced rehab, often under lockdown—to try to help. Massachusetts already uses the process aggressively, committing thousands every year. But if the Bay State’s experience is anything to go by, the approach may actually make matters worse.
In hard-hit Massachusetts, an estimated 6,500 people were involuntarily committed for addiction in fiscal year 2016 alone. Some 36 other states and the District of Columbia also have laws that permit involuntary detainment for addiction without any criminal charge or conviction, though in many places, they’re rarely used. Washington, Pennsylvania, and New Hampshire are considering expanding such programs—and Massachusetts Governor Charlie Baker wants to further extend the number of participants in his state by requiring commitment of hospitalized overdose patients who won’t accept voluntary care, according to the Wall Street Journal.
Massachusetts’s addiction commitment law is known as Section 35, after its legal title. Currently, parents, spouses, court officers, or medical professionals can petition a judge to “section” people with alcoholism or other addictions. After the concerned party fills out a one-page form, if a judge agrees, the addicted person is immediately arrested and taken to a state facility for up to 90 days.
“If the judge feels there’s sufficient information to assess the individual, a warrant for arrest is issued,” says Leo Beletsky, associate professor of law and health sciences at Northeastern University in Boston. “The cops arrest the person, take them into a holding cell and then they undergo an evaluation by a clinical professional.”
But whether the arrested person is then taken to an actual rehab—or just placed in a prison camp for cold-turkey withdrawal—depends on gender and luck. And most men seem to end up in prison. (Following a lawsuit, all women now get treated in state hospitals, though their quality can vary.)
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Previously, sectioned men were incarcerated at facility where they had contact with convicted sex offenders who’d completed their sentences but were considered too dangerous to release—but legal action also put a stop to that. Although the state agreed to make the change in 2016, they didn’t act until last year. The new center for men, however, does not appear to be a significant improvement. In it, there has been at least one rape, one suicide, and many suicide attempts.
Consider what happened to David McKinley. The 29-year-old had become addicted to heroin after his father died. For six years, he’d been through numerous rehabs, always relapsing not long afterwards. His mother had him sectioned twice.
Both times, he was locked in a prison camp known as the Massachusetts Alcohol and Substance Abuse Center (MASAC) surrounded by razor wire, without access to medical care for withdrawal; each time, his “treatment” was supervised by correction officers and he faced the possibility of solitary confinement if he made any complaints.
These facts are not in dispute: legal documents and interviews conducted by VICE, the Boston Globe, and other news organizations with people who’ve been sectioned report the same verbally abusive staff members, the same routinely overflowing toilets and disgusting food, the same lackluster and limited counseling, and the same ongoing failure to provide appropriate medical care for withdrawal. (The Massachusetts Department of Correction told the Globe that “it’s restrictive because it has to be” and that no drugs have ever been smuggled into the facility.)
Brian Straw, 51, has struggled with alcohol since enduring what he describes as a “very violent childhood” that left him with post-traumatic stress disorder (PTSD). Emergency room doctors in Massachusetts have sectioned him due to his alcohol use disorder at least 14 times.
“They don’t tell you you’re sectioned. You think you’re getting out [of the hospital] and next thing you know, the police are showing up,” he says. He describes being handcuffed, shackled and transported in a van without windows for several hours, kept “shoulder to shoulder with six to seven other men,” a claustrophobic experience he found traumatic in and of itself.
After arrival, he says, “You’re strip-searched and given a set of scrubs.” These orange uniforms are no longer stamped “Department of Corrections,” according to Straw, but the men still carry badges that say “inmate,” even though they’re supposedly being treated and haven’t been charged with crime.
The medical care at MASAC also seems shockingly lax: people in opioid withdrawal receive no addiction medication at all—the facility isn’t even licensed to prescribe it—while those whose alcohol problems might lead to potentially deadly seizures are only given meager doses of appropriate drugs. Straw says his dosage of Librium was “one-fifth” of what he was usually given in the hospital and that some men had seizures. He also says he wasn’t given his psychiatric medications—another practice not supported by evidence.
Opioid withdrawal symptoms include copious vomiting and diarrhea—and Straw says he saw feces all over the bathroom floor. “The bathrooms were horrifically unsanitary,” he adds, reporting a several-week period where no soap of any type was available.
McKinley had been about to start a new life once he completed detox in these conditions in September: a friend had a job waiting for him and his mother was looking for a place for him in a sober house. But after just three days in the facility, he hung himself on a bunk bed, using a sheet. Straw was not in the same unit as McKinley, but he was there at the same time and says he heard from others about the death.
Incredibly, even though he knew how awful withdrawal would be at MASAC, McKinley had asked his mother to petition the court to lock him up: he saw it as the only way he could get treatment so he could start his new job. Indeed, at least 20 percent of people who are sectioned in the state are not actually being forced to go—they’ve asked to be committed.
And that reality underlies a key problem with civil commitment: even liberal Massachusetts, which is supposed to have universal access to health insurance that covers addiction care, creates such high barriers to treatment that families see involuntary commitment as the best path to treatment.
“The reason is that the process of petitioning is very simple,” Beletsky says. “It’s totally free and you don’t pay a cent.” There are no waiting lists, no co-pays, no confusing multi-page forms—and the police actually come to you to take the person away.
“We’re seeing more and more people who want treatment using Section 35 because it is the only way they can get it,” says Bonnie Tenneriello, a staff attorney with Prisoners’ Legal Services, one of the groups that successfully sued the state to close the women’s “treatment” facility and the one where men with addictions were kept alongside sex offenders. “These are not people who need to be forced. They want it because there are no resources in the community.”
There’s another, even more dangerous risk associated with treatment at MASAC and even in some community programs used for Section 35. When people with opioid addiction are made to undergo withdrawal—rather than being treated long-term with medications like buprenorphine or methadone that maintain their tolerance—their risk of death from a relapse actually increases.
“We know we have to be incredibly careful about who we choose to detox because we can accidentally increase the risk of overdose death,” says Jessica Hulsey Nickel, president and CEO of the Addiction Policy Forum, who supports allowing civil commitment for addiction, but only when it involves genuine evidence-based care. “Just locking someone up is not the proper way to handle this illness,” she says. “I think we are stuck in a place where we don’t see this as a health issue and even if [people] say that they do, we don’t treat it like a health issue.”
Sarah Wakeman is medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School. She says, “The sad thing is that we know from research that a lot of people would be willing to accept treatment if it were presented in a different form. We’re offering ineffective treatment that doesn’t meet the needs of patients and when they’re not interested in that form of treatment, we turn to coercion.”
Wakeman notes that many families and even patients themselves are misinformed about what works and what doesn’t, often stating that medication-assisted treatment (MAT) isn’t “really” recovery or just substitutes one addiction for another. Few know that the only treatment proven to cut the death rate by half or more—and the one that reduces the risk of relapse the most—is not a bed in a rehab facility, but long-term outpatient treatment with either methadone or buprenorphine.
In her work at Mass General, Wakeman has never used Section 35. “Trust is at the core of this work and the bar is incredibly high for me to think about violating that trust and the relationship with the patient,” Wakefield says.
“The thing that is so heartbreaking is that families are so desperate and so misinformed about what effective care looks like that this is the intervention they’re turning to,” she adds. “At the center of all of this is the fixation with ‘beds’ and Section 35 is a pathway to a bed.”
But the saddest irony of Massachusetts’ civil commitment policy may be this: The state’s own data show that people who are civilly committed or otherwise forced into treatment are twice as likely to die from overdose, compared to those who seek care voluntarily. “We’d get more bang for the buck investing in low-barrier treatment that is proven by science and it would have a far higher yield,” Wakeman says.
Governor Baker’s latest proposal to expand civil commitment would allow doctors to commit people to some type of treatment facility for up to three days—without the court order that Section 35 requires. For example, if someone is hospitalized for an overdose and a doctor believes they are a danger to themselves, the doctor can have them committed. Unfortunately, this would not only pose the same problems that involuntary care does in general, it might also deter people from seeking emergency medical care for overdose because they don’t want to lose their freedom.
While there may be some circumstances in which a humane system of civil commitment to evidence-based care might make sense, they don’t exist in most of the US. Until we stop thinking that coercion is the best way to help people with addiction, we may be doomed to spend more and more money doing harm.
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