Why Forced Addiction Treatment Fails

By Maia Szalavitz of The NY Times. Excerpts:

"But voluntary rehab has a better track record and is less likely to harm the people it is intended to help. Criminalization and coercion have helped create a patchwork of addiction programs that is harsh, low quality, underfunded, understaffed and too often fraudulent. Since legally mandated care is often the only way to get immediate and free treatment, a damaging cycle continues. 

To do better, the United States needs more evidence-based treatment. And since the data shows that the best treatment is compassionate and inviting, coercion should be the last resort, not the first."

"A 2016 research review shows why. Of the nine studies included, five found no significant reductions in drug use or crime among people who underwent required treatment, and two studies found that mandated therapy made those measures worse. Only two studies found a small benefit in short-term recovery. This is in contrast with the strong literature on voluntary medication use for opioid addiction, which shows that it can reduce mortality by 50 percent or more.

Massachusetts has one of the most frequently used civil commitment systems for addiction, and the results are grim. Much of the treatment takes place in prisons, and lawsuits and reporting has described filthy conditions and lack of access to addiction medications proven to save lives. The state’s statistics show that people who have been committed are twice as likely to die of opioid-related overdose as those who seek help voluntarily. A meta-analysis looking at studies in the United States and around the world of involuntary treatment and H.I.V. and overdose-related risk found similar results."

"Legal coercion undermines many aspects of effective addiction therapy. It can be difficult to trust providers whose job involves reporting on you to a court. Since relapse is common and often leads to legal consequences, this can discourage disclosure. Coercion can also smother the internal desire to change, which is known to be critical for long-term success."

"One of the most successful addiction treatments, motivational enhancement therapy, focuses on helping people build relationship and career goals. Proponents of this approach say it allows people to see for themselves that their drug use is an obstacle, creating desire to change.

Another therapy, called Community Reinforcement and Family Therapy (CRAFT), teaches families to lovingly motivate people with addiction and is more effective than other treatments. A third highly effective approach, known as contingency management, uses rewards like free movie tickets instead of punishment. But these therapies are, unsurprisingly, rarely available in mandated treatment."

"Research finds that 86 percent of people with long histories of frequent emergency room visits and arrests who have diagnoses of substance use and severe mental illness will accept and persist in housing with supportive care. This includes being guided by advocates through the bureaucracy and welcomed without the rigid rules requiring perfect abstinence that are typical in rehabs and housing programs."

"spending more on reducing barriers to care and housing, and improving the quality of treatment so that people with addiction actually want to participate will be far more effective than adding yet more money for courts and cops."

"reducing compulsory treatment will improve the quality. Currently, more than a quarter of people in rehab are legally mandated."

"But if fewer people were forced to simply accept what’s offered, programs would have to become friendlier. It’s basic capitalism: Customer service is better when businesses compete than when consumers have no choice."