Patients with substance use disorders need care, not coercion

Above: Emergency responders reach out to a person sleeping on a bench in the Manhattan subway system. In New York City’s latest effort to address a mental health crisis on its streets and subways, Mayor Eric Adams announced in November 2022 that authorities would more aggressively intervene to help people, even if it means providing care to those who don’t ask for it. (John Minchillo / AP Photo, File)

Cities across the country are grappling with the intersecting, pandemic-exacerbated crises of housing, mental illness, and substance abuse. Pressured to act swiftly, policymakers this year jumped to pass new laws and regulations lowering the threshold for emergency intervention, even if it means forcing people into treatment for mental illness or substance use disorders.

It’s tempting to see forced treatment, also known as involuntary commitment, as in the best interest of everyone involved—but we are health care providers who treat involuntarily committed patients in Boston, Massachusetts. We’ve rarely seen the practice achieve good outcomes for patients.

Instead, policymakers and public health professionals should be asking themselves whether the investment in involuntary commitment might be better spent on housing, case management, and expanding availability of voluntary treatment for substance use disorders. All of that is difficult, but relying on involuntary commitment is a dangerous and convenient distraction from real solutions.

Politicians often bill involuntary commitment as a measure of last resort, but in fact it’s been used for years, and much more often than we like to admit. In Boston, it’s even been weaponized to clear encampments of people living on the streets as part of police “clean sweep” operations.

Massachusetts involuntarily commits more than 6,000 individuals each year for substance use disorders under Section 35, a statute allowing family members, medical providers, and law enforcement to forcibly detain individuals for up to 90 days when they pose “a clear and convincing risk of harm” to themselves or others as the result of a substance use disorder. These statutes have expanded in recent years, and now 38 states have similar laws on their books.

In Boston, involuntary commitment has only gotten easier. In 2017, the Boston municipal court launched a pilot program allowing health care providers to fax their Section 35 affidavits instead of physically appearing in court. Emergency departments could send patients directly from the hospital to involuntary treatment. As a result, the number of petitions in Boston exploded—increasing by 272% from 2016 to 2018.

To be fair, hospitals are ill-equipped to provide comprehensive care for patients with substance use disorders, and placement in residential or outpatient treatment programs can take days or weeks, if it happens at all. Section 35 petitions almost always result in patients being prioritized for a treatment bed, sometimes in just a few hours.

For example, we treated an elderly man (we’ll call him Richard) and regular visitor to our emergency department. Richard, a former construction worker injured on the job, struggled with severe alcohol use disorder, and had recently lost a loved one. We saw Richard more than 100 times in a single year, mostly because of complications from alcohol use. He almost always came to the hospital intoxicated, with injuries from falling while impaired. Although we encouraged him to consider treatments for his alcohol use, he frequently left the hospital against medical advice. Eventually, we used Section 35 to involuntarily commit him.

The police escorted him to a treatment facility and we lost contact with him. Because Section 35 programs operate independently (and are often located in correctional facilities), they rarely share information about patient treatment with other providers. We received no details of Richard’s stay. Less than two months after he was committed, we saw him in our emergency department again, intoxicated.

We used Section 35 to commit Richard to inpatient treatment no fewer than nine times over three years. Every time treatment failed, and Richard’s health continued to deteriorate.  Eventually, Richard began to leave the hospital before courts opened for the day, because he knew the staff would file a Section 35 petition against him.

Clearly, forcing Richard into treatment failed him. Richard is just one of the 22 patients we followed as part of a new study published in Community Health Journal. We found that every single one of those patients relapsed within a year of being released from involuntary commitment, and continued to have serious medical complications. Two patients died.

The evidence on whether involuntary commitment works to solve persistent public health problems like housing instability and substance use disorders is, put simply, inconsistent and inconclusive. While standards of care in facilities where patients are committed seem to be improving, studies from as recent as 2018 found that fewer than 20 percent of patients committed for opioid use disorder received medication as part of their treatment, an evidence-based practice that should be followed.

Experts have also raised concerns about the ethics of involuntary commitment. In Massachusetts, detainees are often treated as though commitment is a criminal proceeding. To be clear, it is not; it is a civil procedure. But individuals are frequently held with criminal defendants prior to involuntary commitment hearings, handcuffed during courtroom proceedings, and provided little to no medical attention for potentially fatal withdrawal symptoms.  Some of the treatment centers for men are even operated by the Department of Corrections alongside prisons. In fact, Massachusetts is the only state that allows for involuntary treatment to occur in carceral settings. The punitive nature of this process is particularly worrisome as many people who use drugs have negative, even traumatic experiences with the carceral system. Involuntary commitment has the potential to re-traumatize patients, and affect their trust in treatment providers.

While the institutional burden of managing patients with intense health needs can be overwhelming, it is important for health providers and public health officials to recognize the realities of coercive treatment for patients, which more often than not resembles arrest and incarceration.

However, this does not mean that we can simply abandon these patients, or leave emergency departments without resources. Instead of temporarily commiting people to forced treatment over and over again, we must invest in reducing housing instability, given that homelessness is a key predictor of repeated emergency visits. In 2017, Boston Medical Center joined a growing number of hospitals across the country when it announced its plan to invest $6.5 million in housing for its patients with the goal of improving community health and patient outcomes. Early studies of this program have shown promising results.

We must also expand access to voluntary treatment for substance use disorders. One potential solution is the expansion of low-barrier bridge clinics. These treatment models offer a flexible, patient-centered approach, which typically includes walk-in or same day appointments for patients struggling with addiction and serve as a transition to longer-term care.

Let’s invest in a system that doesn’t perpetuate harm—and relies on care, not coercion, to treat the most vulnerable among us.

Additional contributions by: Lisa Vercollone, Scott G Weiner, William Bromstedt, Carol Garner, Joshua W Joseph, Leon D Sanchez, Dana Im, Alice K Bukhman