Emergency Holds Not The Answer for Reducing Opioid Deaths

Ricki Lewis, PhD

November 06, 2019

Use of emergency hold laws to protect people with severe substance use disorder from overdose deaths is not based on evidence of efficacy and may inappropriately allocate resources, according to a Perspective article published online today in the New England Journal of Medicine.

Court-ordered 72-hour holds to force inpatient observation and possibly treat opioid overdoses are already on the books in two states — Minnesota and Washington — and are being considered in other states. The goal is to hold an individual who "presents a danger or threat of danger to self, family, or others, if not treated." The intervention is modeled after mental health hold laws, which apply in every state and require demonstration of danger or decisional incapacity, or both.

Elizabeth A. Samuels, MD, MPH, MHS, from the Department of Emergency Medicine at Brown University in Providence, Rhode Island, and colleagues point out distinctions between mental health holds and substance use disorder holds, specifically addressing opioid overdoses.

Sacrificing patient autonomy for perceived beneficence of a forced hold doesn't hold water, they argue, because efficacy has not been demonstrated. "The limited research evaluating involuntary treatment for substance use disorders is inconclusive, and no data exist in support of emergency holds," according to the authors.

Another bioethical issue is social justice: medications for opioid use disorder are less available to marginalized groups. These include people with low incomes, prisoners, those who live in rural areas, and people of color, they explain. "Involuntary holds may exacerbate existing inequities by disproportionately affecting people in communities with poor access to voluntary services."

In addition, the situations of mental illness and opioid use disorder differ. Whereas a hold for mental illness may intend to address suicide risk, most overdoses are unintentional, the authors point out, and involuntary holds would not reduce the risk for unintentional overdose.

Practically speaking, people with substance use disorders who are suicidal would be covered by the mental health hold laws. And because substance use disorders are chronic, forced 3-day stays "are unlikely to fully restore competent decision making," the authors write. They wouldn't provide the long-term therapies that are the mainstay of addiction control: monitored medication use, harm-reduction services, recovery support, and behavioral counseling.

A physical risk of forced holds is that short-term abstinence may set the stage for overdose after release.

Practical issues emerge too, such as finances. Most states lack sufficient resources for voluntary inpatient treatment of opioid use disorder. Would emergency holds, which would be prioritized, take from existing inpatient programs and services?

"We believe that addressing the substantial challenges associated with obtaining access to voluntary treatment for opioid use disorder, particularly medications, should instead be the priority and that harm-reduction services, including easy access to naloxone, syringe-services programs, supervised consumption spaces, and fentanyl test strips, should also be aggressively pursued," the researchers conclude.

Coauthor Otis Warren, MD, reports that he provided testimony in opposition to the Rhode Island state bill in support of 72-hour holds mentioned in the article. The other writers have disclosed no relevant financial relationships.

NEJM. Published online November 6, 2019. Abstract

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