Addiction Disorders

Court-Mandated Substance Abuse Treatment: Exploring the Ethics and Efficacy

Avatar photoBatya Swift Yasgur, MA, LSW
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While many treatments for substance use disorder are not evidence based, several evidence-based approaches have shown effectiveness in court-mandated treatment settings.

Mandatory treatment is defined as “treatment ordered, motivated, or supervised under the criminal justice system.”1 Going beyond the more common drug court approaches that offer a person charged with a crime the choice of treatment instead of incarceration, several US states mandate that people with addiction enter treatment against their will, and that trend is expanding.2

Mandating addiction treatment is highly controversial, however, both ethically and practically. At a 2016 United Nations High Level Meeting on HIV in New York, Fabienne Hariga, MD, MPH, senior adviser to the United Nations Office on Drugs and Crime summarized the position of UN organizations that “mandatory treatment settings do not represent a favorable or effective environment for the treatment of drug dependence” and should be replaced by “voluntary, evidence-informed, and rights-based health and social services in the community.”3

The subject is highly complex, according to David Farabee, PhD, professor in residence at the Department of Psychiatry & Biobehavioral Sciences at the University of California, Los Angeles, and director of the Integrated Substance Abuse Programs (ISAP).

“Some people are opposed to coerced treatment on philosophical or constitutional grounds, or [believe] that little if any benefit can be derived if a drug user is forced by the criminal justice system to enter into treatment, while others suggest that this is a way for people who would not otherwise receive treatment to receive it,” he told Psychiatry Advisor.

Researching the role of mandatory drug treatment is essential because it has wide-reaching policy applications. Of the 2.3 million incarcerated individuals in the United States, 1.5 million meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition(DSM-IV) criteria for substance abuse disorder, and another 458,000 do not meet strict criteria but have histories of substance abuse, were under the influence of alcohol or another drug at the time of their crime, committed the offense to obtain money to buy drugs, or were incarcerated for an alcohol or drug law violation.4 Mental disorders related to substance abuse can lead to incarceration and affect as many as 83% of US inmates.5 The United States is not the only country affected — 69% of a sample of 104 countries had criminal laws allowing for compulsory drug treatment in 2009.6

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What is “Mandatory” or “Coercive” Treatment?

“The literature is sloppy in terminology, so that words such as ‘coerced,’ ‘mandated,’ ‘compulsory,’ and ‘criminal justice,’ ‘involuntary,’ and ‘legal pressure’ are used interchangeably, but they are actually not synonymous,” Dr Farabee said.

Coercion may describe a probation officer’s recommendation for the drug user to enter treatment, a judge’s offer of a choice between treatment or jail, a judge’s requirement that the offender enter treatment as a condition of probation, or a correctional policy of sending inmates involuntarily to a prison treatment program to fill beds.7 Even a treatment client’s involvement with the criminal justice system “is sufficient for him to be brought under the umbrella of coercion.”7

A more precise definition is offered in a recent literature review.8 Compulsory drug treatment can be defined as “the mandatory enrollment of individuals, who are often but not necessarily drug-dependent, in a drug treatment program.”8

Although compulsory drug treatment most frequently consists of “forced inpatient treatment,” it can nevertheless “be designed as outpatient treatment as well, either using an individualized treatment or group-based model that can include psychological assessment, medical consultation, and behavioral therapy to reduce the [substance use disorder].”8 There is a difference between “compulsory” and “coerced treatment,” which “provides the individual with a choice, however narrow, to avoid treatment.”8

Does Compulsory Treatment Work?

Results of trials of compulsory treatment in criminal justice settings are mixed. Farabee et al conducted a literature review of 11 studies and found that it “supported the use of the criminal justice system as an effective source of treatment referral, as well as a means for enhancing retention and compliance.”7 Another trial found that offenders who were mandated to community-based outpatient treatment had better completion rates compared with those who entered treatment voluntarily.9 However, coerced treatment findings based on offenders in the community cannot necessarily be generalized to incarcerated offenders.10

A recent review8 found only “limited scientific literature” evaluating compulsory drug treatment and that “evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms.” The authors concluded that, “given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.”

Similar global findings were obtained in a 2016 study.1 Further research is needed to determine the utility of this approach.

Types of Treatment

“The question isn’t only the pros and cons of coercing people into treatment, but what treatment they’re being coerced into, because the word ‘treatment’ in the substance abuse world is often a meaningless term,” Dr Farabee said.

“We all assume that treatment is a real thing, but it’s actually an inchoate array of services, which don’t necessarily have any effect and can consist of anything from [US Food and Drug Administration] (FDA)-approved interventions for substance abuse disorder to — literally — tarot card reading,” Dr Farabee said.

The disturbing lack of restrictions on who can start a rehabilitation center in the United States, what counts as treatment, and rehabilitation centers’ lack of data when reporting their supposed success rates are topics that were discussed recently by John Oliver on his HBO show, Last Week Tonight With John Oliver. Under current US laws (or lack thereof), equine therapy (in other words, petting and/or riding horses) counts as treatment for a substance use disorder.

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“I certainly feel comfortable saying that we should not coerce people into something of unknown efficacy, and much more emphasis should be placed on the effectiveness of what we are coercing people into, not only the mechanism through which we are getting them into treatment,” Dr Farabee said.

Several evidence-based approaches have shown effectiveness for the management of substance abuse disorders in court-mandated treatment settings.

Contingency Management

Contingency management uses rewards to “positively reinforce abstinence from or reduced use of drugs during treatment for opiate addiction.”11 Unlike other psychological interventions such as motivational interviewing, which focus on an introspective analysis of discrepancies between goals or cognitive behavioral therapy (CBT), which focuses on behavioral modification of flawed cognitive processing, contingency management influences the reinforcement mechanisms involved in addiction directly.11 A recent meta-analysis found it to be efficacious for treating most drug use during treatment for opiate addiction.11 It has also been used successfully for alcohol and other drug disorders.12

“Contingency management is by far the most powerful behavioral treatment for substance use disorders,” Dr Farabee remarked. “However, the problem is that once the contingency or reward is removed, the effects weaken and people typically go back to where they were before treatment.”

Cognitive Behavioral Therapy

CBT is well established as an evidence-based approach to substance use disorders, Dr Farabee observed.

Although CBT for substance abuse is “characterized by heterogeneous treatment elements [across protocols], such as operant learning strategies, cognitive and motivational elements, and skills-building interventions … several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances.”13 CBT has “demonstrated efficacy in controlled trials and may be combined with each other or with pharmacotherapy to provide more robust outcomes.”13

“CBT seems to have a sleeper effect, meaning that the benefits are sustained for longer,” Dr Farabee said. “But in general, the gains are still difficult to sustain on a long-term basis.”

Motivational Interviewing

Motivational interviewing “has been widely validated as a stand-alone treatment, as a precursor to more extensive treatment, or integrated with other components, such as tailored feedback.”14 Motivational interviewing has shown good outcomes in criminal justice settings and is a “tool for promoting evidence-based practice in the criminal justice system.”14

“The effects of motivational interviewing seem obvious because it is a way to increase people’s desire for treatment and change, and findings have been promising,” Dr Farabee observed.

Pharmacotherapy

Evidence-based pharmacotherapies for substance use disorders are underused in criminal justice settings.15 However, research suggests their efficacy in settings of incarceration. For example, one study found naltrexone prior to discharge from prison to be an effective approach to reduce relapse to opioids.16 A major trial currently underway (Studies of Medication for Addiction Treatment in Correctional Settings [SOMATICS]) is investigating the role of extended-release naltrexone opioid treatment at jail re-entry.17,18 Another study conducted under SOMATICS focuses on methadone initiated in incarcerated people.19

No Assumptions

What comes to mind when hearing the term “coerced” or “compulsory” treatment is typically “the kind of person who’s thinking, ‘I don’t want to do this,’ but is forced into a program anyway,” Dr Farabee observed.

In fact, “our research has demonstrated many offenders actually want treatment, even if they are court mandated to go,” he said.10,20

Creating a therapeutic environment, as treatment involves a certain degree of vulnerability, and “if you are sitting in a group but the 2 guys next to you are rolling their eyes and making fun of you, it’s not a therapeutic environment,” Dr Farabee emphasized.

He noted that more research is needed to investigate the effectiveness of court-ordered treatment and the best settings and methodologies.

References

  1. Lunze K, Idrisov B, Golichenko M, Kamarulzaman A. Mandatory addiction treatment for people who use drugs: global health and human rights analysis. BMJ. 2016;353:i2943.
  2. Fisher CE. People Struggling with Addiction Need Help. Does Forcing Them into Treatment Work? Slate. https://slate.com/technology/2018/01/coerced-treatment-for-addiction-can-work-if-you-coerce-correctly.html. January 18, 2018. Accessed April 20, 2018.
  3. Study: Mandatory Treatment Not Effective at Reducing Drug Use, Violates Human Rights [news release]. Boston Medical Center. https://www.bmc.org/about-us/news/2016/06/21/study-mandatory-treatment-not-effective-reducing-drug-use-violates-human. June 21, 2016. Accessed April 21, 2018.
  4. Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets. CASAColumbia. https://www.centeronaddiction.org/addiction-research/reports/shoveling-ii-impact-substance-abuse-federal-state-and-local-budgets. May 2009. Accessed April 19, 2018.
  5. Wu P-C, Chou Y-C, Yeh H-W, et al. Offenders with substance abuse who receive mandatory psychiatric treatment. J Am Acad Psychiatry Law. 2017;45(3):316-324.
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  8. Werb D, Kamarulzaman A, Meacham M, et al. The effectiveness of compulsory drug treatment: a systematic review. Int J Drug Policy. 2016;28:1-9.
  9. Coviello DM, Zanis DA, Wesnoski SA, et al. Does mandating offenders to treatment improve completion rates? J Subst Abuse Treat. 2013;44(4):417-425.
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  12. Davis DR, Kurti AN, Skelly JM, Redner R, White TJ, Higgins ST. A review of the literature on contingency management in the treatment of substance use disorders, 2009–2014. Prev Med. 2016;92:36-46.
  13. McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33(3):511-525.
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  16. Friedmann PD, Wilson D, Hoskinson R Jr, Poshkus M, Clarke JG. Initiation of extended release naltrexone (XR-NTX) for opioid use disorder prior to release from prison. J Subst Abuse Treat. 2018;85:45-48.
  17. Extended-Release Naltrexone Opioid Treatment at Jail Re-Entry. Centerwatch. http://www.centerwatch.com/clinical-trials/listings/173624/heroin-dependence-extended-release-naltrexone-opioid-treatment/?&radius=50. Updated April 2018. Accessed April 22, 2018.
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  19. A Randomized Trial of Interim Methadone and Patient Navigation Initiated in Jail (SOMATICS FRI). ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT02334215. Updated March 9, 2017. Accessed: May 1, 2018.
  20. Prendergast M, Greenwell L, Farabee D, Hser Y-I. Influence of perceived coercion and motivation on treatment completion and re-arrest among substance-abusing offenders. J Behav Health Serv Res. 2009;36(2):159-176.