States Consider Mandatory Treatment for Opioid Abusers

Alicia Ault

March 28, 2017

Lawmakers in several states are advancing proposals to force individuals who abuse opioids into treatment via involuntary commitment statutes as a means of coping with the rapid rise in overdose rates. Some experts say that the proposals, while commendable, so far are not perfect.

Bills have been offered in New Hampshire, Pennsylvania, and the state of Washington. The simplest proposal — Senate Bill 220-FN, in New Hampshire — would modify state involuntary commitment laws to change the definition of mental illness to include "ingestion of opioid substances."

Andrew J. Saxon, MD, professor, Department of Psychiatry and Behavioral Sciences, University of Washington, in Seattle, told Medscape Medical News that adding substance use disorder to the mental illness statute is "a positive step in most ways," because experts in the field already view such disorders as a mental illness.

Individuals who are dangerous to themselves or others – whether it's because of a mental disorder or a severe substance use disorder – should be treated the same, agreed Andrew Kolodny, MD, codirector of opioid policy research at the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. "The courts should handle it the same way," he told Medscape Medical News.

But proposals should not single out a particular drug, said Dr Kolodny, who is also executive director of Physicians for Responsible Opioid Prescribing. Involuntary commitment proposals "should be for severe substance use disorder, regardless of the drug."

The New Hampshire law's language is flawed, said Dr Kolodny. "Simply ingesting an opioid doesn't mean you have a use disorder," he said.

Proposals also should ensure that people with opioid use disorder get the specialized treatment they require, said Dr Saxon, who is a member of the American Psychiatric Association's Council on Addiction Psychiatry.

Someone with an opioid use disorder may not be ready to be discharged after 72 hours — a common time frame for involuntary commitment laws — he said, noting that after acute withdrawal, the resulting lower tolerance puts them at higher risk for an opioid overdose. Follow-up treatment is crucial.

New Hampshire is one of 24 states that has excluded substance use disorders and alcoholism from its statutory definition of mental illness, and it is one of eight that do not have any involuntary commitment provisions for substance use disorders, according to the National Alliance for Model State Drug Laws, a congressionally funded organization that drafts model drug and alcohol laws, policies, and regulations with the White House Office of National Drug Control Policy.

Treatment Demand Outstripping Capacity

New Hampshire has been hard hit by opioid use and drug overdoses. The state saw a 31% increase in drug overdose deaths from 2014 to 2015, according to the Centers for Disease Control and Prevention.

The New Hampshire Drug Monitoring Initiative is predicting an 8.6% increase in drug overdose deaths from 2015 to 2016.

An estimated 385 people died from overdoses in 2015 — 183 from fentanyl, and another 107 from fentanyl combined with heroin or another drug. An additional 85 overdoses are still being investigated, so the toll will likely increase.

Treatment admissions in January 2017 were at the highest level in the past year for heroin and fentanyl, at 20.2 per 100,000 residents. Admissions for prescription opioids had declined to 1.95 per 100,000, down from a high of 4.4 per 100,000 in November 2016.

The New Hampshire bill reportedly has bipartisan support, but questions are being raised about the ability to treat an influx of opioid addicts.

In an analysis attached to the bill, the state's Department of Health and Human Services said it is not clear how many people would "meet the standards for involuntary emergency admissions under the proposed legislation," and added, "designated receiving facilities currently lack the capacity and staff skills to care for opioid users."

Similar discussions about capacity and skills should be held in Washington and Pennsylvania, said Dr Saxon. "It's premature for states to make these new laws without the resources in place to deal with it," he said.

The Washington state proposal, Senate Bill 5811, lays out specific criteria ― some taken from the DSM-5 — for involuntarily commitment, but it's still "a very poorly crafted, unrealistic piece of legislation," Dr Saxon added.

On the one hand, it casts a very narrow net and sets a high bar, limiting who might be eligible for commitment; on the other hand, for those who do meet those criteria, the proposal does not address opioid-specific treatment, he said. Under the bill, "opioid use disorder" is characterized as "active use of heroin," but it does not include the use of prescription opioids, fentanyl, or other opioids, he noted.

"I view it as the legislators wanting to make a statement," said Dr Saxon.

Need to Protect Civil Liberties

Dr Kolodny took issue with the Washington bill's premise. Establishing a diagnosis is not as relevant for involuntary commitment as the individual's actions as a result of the disease, said Dr Kolodny.

"The question is whether or not that condition, that brain disease, is making you dangerous to yourself and others," he said. "If so, the family members or courts or medical personnel should be able to hold you for a brief period of time to stabilize that condition," he said.

Dr Kolodny added that appropriate safeguards still need to be in place, because the state would be denying the individual's civil liberties.

Pennsylvania lawmakers have advanced two proposals that would address involuntary commitment and opioid use.

In the Senate, Bill 391 would let families petition for treatment. The individual with the disorder would have to appear at a healthcare facility for a hearing conducted by a mental health review officer, and the attending physician would determine the necessary length of stay.

The House proposal, House Bill 677, targets those who have overdosed on heroin or other opioids. According to this proposal, it is in the public interest to ensure that those users "are not immediately released, and to ensure that assessment is completed to protect them, their children who are minors, other members of their family, and their communities."

If someone has overdosed and requires immediate intervention to prevent death or serious bodily injury, a hospital or healthcare provider can commit the individual for involuntary emergency treatment of not more than 48 hours, during which they will also be assessed to determine what caused the overdose, according to the bill.

Dr Saxon said that he is not completely opposed to involuntary treatment, noting that some users "respond to external contingencies." The "idea is good in theory, but what would make a lot of sense if this is a big problem is, let's make treatment more available," he said.

Dr Saxon and Dr Kolodny have disclosed no relevant financial relationships.

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