Considerations in civil commitment of individuals with substance use disorders

The impact of civil commitment laws for substance use disorder on opioid overdose deaths

Objective

Our study analyzed the impact of civil commitment (CC) laws for substance use disorder (SUD) on opioid overdose death rates (OODR) in the U.S. from 2010-21.

Methods

We used a retrospective study design using the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) dataset to analyze overdose death rates from any opioid during 2010-21 using ICD-10 codes. We used t-tests and two-way ANOVA to compare the OODR between the U.S. states with the law as compared to those without by using GraphPad Prism 10.0.

Results

We found no significant difference in the annual mean age-adjusted OODR from 2010-21 between U.S. states with and without CC SUD laws. During the pre-COVID era (2010-19), the presence or absence of CC SUD law had no difference in age-adjusted OODR. However, in the post-COVID era (2020-21), there was a significant increase in OODR in states with a CC SUD law compared to states without the law (p = 0.032). We also found that OODR increased at a faster rate post-COVID among both the states with CC SUD laws (p < 0.001) and the states without the law (p = 0.019).

Conclusion

We found higher age-adjusted OODR in states with a CC SUD law which could be due to the laws being enacted in response to the opioid crisis or physicians' opposition to or unawareness of the law's existence leading to underutilization. Recent enactment of CC SUD law(s), a lack of a central database for recording relapse rates, and disparities in opioid overdose rate reductions uncovers multiple variables potentially influencing OODR. Thus, further investigation is needed to analyze the factors influencing OODRs and long-term effects of the CC SUD laws.

Gender Differences in Civil Commitment Hearing Experience for Persons Who Use Opioids

OBJECTIVES

Civil commitment has increasingly served as a court-based legal intervention for severe opioid use, but little research has examined the civil commitment (CC) hearing process from the perspective of the person who is committed. Despite documented gender differences in opioid use and experiences within the legal system, past research has also not investigated gender differences in perceptions of the CC process for persons who use opioids.

METHODS

Participants were 121 persons (43% female) with opioid use who were interviewed upon arrival at the CC facility about their experience of the CC hearing process in Massachusetts.

RESULTS

Two thirds of participants were taken to the commitment hearing by police, and 59.5% shared a cell with others while waiting. Overall, the commitment intake process at the courthouse took over 5 hours. Participants spent, on average, less than 15 minutes with their lawyer before the hearing, and a majority of CC hearings lasted less than 15 minutes. Once transferred to a CC facility, opioid withdrawal management began within 4 hours. Compared with women, men reported longer wait times between the hearing and transfer, as well as longer wait times for withdrawal management at the facility ( P < 0.05). Women perceived worse interactions with the judge and greater dissatisfaction with the commitment process compared with men ( P < 0.05).

CONCLUSIONS

There were few gender differences in the experience of CC. However, overall, participants reported a lengthy court process and low levels of perceived procedural justice.

Opioid relapse and MOUD outcomes following civil commitment for opioid use

INTRODUCTION

Opioid use disorder (OUD) continues to present a major public health problem in the United States. Civil commitment for substance use is one mandatory form of treatment for severe opioid use that has become increasingly available in recent years, but empirical data on this approach are lacking. This study examines clinical outcomes of civil commitment in a sample of adults with severe opioid use.

METHODS

Participants were 121 persons with opioid use who were interviewed at the point of entry into civil commitment, then followed for 12 weeks after their release.

RESULTS

Prior to civil commitment, this sample exhibited serious substance use characteristics (including high rates of illicit opioid use, other substance use, and injection drug use), as well as mental health problems (diagnoses of depression and anxiety disorders). During follow-up, approximately 41 % of the sample reported at least one illicit opioid use day. More than 64 % of the sample reported at least one day of medication for opioid use disorder (MOUD) receipt, and participants were significantly less likely to use illicit opioids on days that they received MOUDs. No participants died during the follow-up period.

CONCLUSIONS

In this sample of persons with severe opioid use, clinical outcomes of civil commitment included illicit opioid relapse as well as varying levels of MOUD uptake. Civil commitment may be a viable method for short-term prevention of overdose for a subset of this vulnerable patient population.

Risk behaviors among persons civilly committed for opioid use

Despite the growth in civil commitment for persons who use opioids, we know little about the kinds of risk behaviors among those committed. This study examined the behaviors that a judge might use to determine if there is sufficient evidence that an individual's opioid use poses a risk for serious harm. The study recruited participants (n = 121) from three Massachusetts Department of Public Health civil commitment facilities in 2018. We used a list of risk behaviors that courts consider supportive of opioid-related civil commitment. Participants averaged 28 years of age, 56% were male, and 91% met criteria for severe opioid use disorder. Participants endorsed an average of 9 of the 27 risk behaviors. On average, participants endorsed three of the six drug use behaviors representing a danger to themselves, four of eleven behaviors representing an inability to care for or protect themselves (home safety, weight loss), and two of ten behaviors representing a danger to others (driving high or drunk). Participants who reported they were "not at all pleased" to have been civilly committed endorsed significantly (p = .009) fewer behaviors representing a danger to themselves than those who said they were at least "a little pleased." We conclude that the majority of individuals civilly committed for opioid use are engaging in multiple high-risk behaviors that pose a serious risk of harm to themselves.

Meanings constructed by family members about coerced treatment for alcohol and drug use in Brazil

BACKGROUND

In Brazil, regarding drug and alcohol treatment, there is an emphasis on financing long-term residential treatment and a lack of community-based approaches, leading to a burden on families. Therefore, family members increasingly seek coerced treatment even though there are reports of human rights violations in this context. This study aims to describe the meanings constructed by family members regarding coerced treatment of people who use alcohol and other drugs.

METHODS

We conducted 15 interviews with the family members of people who use alcohol and other drugs and had requested coerced treatment. The interviews were recorded, transcribed and analyzed using reflexive thematic analysis.

RESULTS

Through analysis, five major themes regarding the use of coerced treatment were constructed: (1) as protection for people from the dangers related to the use of alcohol and other drugs; (2) as punishment, aiming to prevent the return to drug use; (3) as a guarantee of abstinence; (4) as a consequence of the loss of autonomy to decide what was best for themselves; and (5) as time for the reorganization of the family members' lives. The lack of emotional support in relation to their concerns regarding the health and safety of the person using drugs, the prohibitionist discourse and the emphasis on abstinence shared in the decision to seek coerced treatment, and the lack of knowledge about voluntary treatments contributed to family members requesting coerced treatment more than once.

CONCLUSION

This study highlights the importance of the need for public policies that expand evidence-based voluntary approaches, especially community-based services, and promote the disclosure of these services to eliminate coerced treatment. Health care providers should support the feelings of family members and provide guidelines related to other treatment options, making families feel genuinely included as partners in the care of people who use drugs.

Civil Commitment for Substance Use Disorders: A National Survey of Addiction Medicine Physicians

BACKGROUND

Civil commitment (CC) for substance use disorders (SUDs) is a legal mechanism, initiated by family members, healthcare professionals, or others, that compels individuals with substance use problems into involuntary treatment. With the recent rise of US overdose deaths, more states are considering these laws. Yet little is known about physicians' perspectives regarding CC in treating patients with SUDs.

METHODS

We conducted a web-based survey of American Society of Addiction Medicine (ASAM) physician members regarding their awareness of, attitudes towards, and experiences with CC for adults with SUDs.

RESULTS

One hundred sixty-five addiction physicians completed the survey; 60.7% favored, 21.5% opposed, and 17.8% were unsure regarding CC for SUDs. More than a third (38.4%) were unfamiliar with these laws and more than a quarter (28.8%) were unsure if CC for SUDs was permitted in their state. Support for CC was strongest for SUDs involving heroin (79.0%), alcohol (74.7%), and nonheroin opioids (74.7%). Those opposing CC were more likely to believe it would jeopardize patient rapport (P < 0.001), would be ineffective for unmotivated individuals (P < 0.001), and should only be permitted for certain substances (P = 0.007). A majority of respondents endorsed the need for more clinician education (91.5%) and research (87.1%) on this topic.

CONCLUSIONS

Although most addiction physicians in this study approve of CC for SUDs, enthusiasm for this compulsory intervention is mixed with strongest support for patients with opioid and alcohol use disorders. At the same time, many respondents are unfamiliar with these laws and most believe more education and research are needed.

Comparing views on civil commitment for drug misuse and for mental illness among persons with opioid use disorder

Despite the growing use of civil commitment for drug use disorders, little is known about attitudes among individuals who might be subject to civil commitment. This study examined attitudes of persons with opioid use disorder toward civil commitment for drug misuse and for psychiatric illness. Consecutive persons entering a brief, inpatient opioid detoxification (n = 254) were surveyed regarding their attitudes about civil commitment for mental illness and for drug use, and responses were compared by commitment type and by individual history of being civilly committed for opioid misuse. Participants endorsed high support for civil commitment (both psychiatric and drug misuse-related) when used to address risk of harm to self, to others, and of criminal activity. Respondents were more likely to support civil commitment for psychiatric disorders than for drug misuse, expressing higher support for civil commitment in general, higher agreement with the criteria used to justify civil commitment, and greater perceived efficacy of commitment. Individuals previously committed for opioid misuse were less likely to support drug misuse-related commitment on the basis of its perceived efficacy. These results suggest individuals with opioid use disorder hold more favorable views toward civil commitment for mental health disorders than for drug misuse, and reinforce the need for more research on the procedures and outcomes related to civil commitment for drug misuse.

Retention and Treatment Outcome of Youth with Cannabis Use Disorder Referred By the Legal System

Background

Youth with Substance Use Disorders (SUDs) referred to treatment from the Juvenile Justice System (JJS) account for approximately half of the treatment admissions nationwide. The objective of this paper is to report a comparison of retention and outcomes for JJS referrals to those from the general community.

Methods

A total of 172 adolescents, 13-18 years of age, 83% males, 70% JJS referrals, diagnosed with DSM-IV Cannabis Use Disorder (CUD), enrolled in this outpatient, randomized, continued care study. Following a 7-session weekly motivational enhancement and cognitive behavioral therapy intervention (MET/CBT-7), only poor responders were randomized into a 10-week second phase of either an individualized enhanced CBT or an Adolescent Community Reinforcement Approach (ACRA) intervention.

Results

JJS referrals' retention rates were significantly higher than those of non-JJS referrals (X ² (1) = 11.21, p < .01) at the end of Phase I (i.e. week 7). However, there was no difference in abstinence rates between the groups at the end of phase I or II and any of the quarterly additional follow-up assessments up to one year from treatment onset.

Conclusions

Additional research examining how to capitalize on improved retention rates among youth JJS referrals is necessary in order to advance abstinence.

Civil commitment experiences among opioid users

INTRODUCTION

Civil commitment is an increasingly used policy intervention to combat the opioid epidemic. Yet little is known about persons who get committed and outcomes following commitment for opioid use. In the current cross-sectional study, we compared the characteristics of persons with and without a history of civil commitment, and the correlates of post-commitment abstinence.

METHODS

Between October 2017 and May 2018, we surveyed consecutive persons entering a brief, inpatient opioid detoxification (n = 292) regarding their lifetime experiences with civil commitment for opioid use.

RESULTS

Participants averaged 34.6 years of age, 27.1% were female, and 78.1% were White. Seventy-eight (26.7%) experienced civil commitment for opioid use at least once in their lifetime. Committed individuals had significantly higher rates of fentanyl, heroin, and injection drug use, drug overdoses, past incarceration, current criminal justice involvement, and past medication treatment for opioid use (p < .05). The average time to relapse following commitment was 72 days, although 33.8% relapsed on the same day of their release. Longer post-commitment abstinence was significantly associated with post-commitment medication treatment, higher perceived procedural justice (i.e., fairness) during the commitment hearing, positive attitude and higher motivation at the end of commitment, and improvement in attitude during commitment (p < .05).

CONCLUSION

Opioid users who experience civil commitment constitute an especially high risk group. A positive commitment experience and post-commitment medication treatment are associated with longer post-commitment abstinence.