Paul Christopher, M.D. of The New York Times, wrote a compelling article about the struggle facing an addict, a potential patient of his. Prescription drug abuse is America’s fastest-growing drug problem. Every 19 minutes, someone dies from a prescription drug overdose in the United States, triple the rate in 1990. And according to the Centers for Disease Control and Prevention, prescription painkillers (like oxycodone) are largely to blame. More people die from ingesting these drugs than from cocaine and heroin combined.
The requirements for involuntary substance treatment vary widely across the nation, from posing a serious danger to oneself, others or property, to impaired decision-making or even something as vague as losing control of oneself. States approach compulsory treatment for mental illness with far greater uniformity. All allow it, and almost all restrict it to instances in which a patient poses an immediate danger to himself or another.
This common standard stems from a series of federal court cases that set procedural and substantive requirements for mental health commitments. But involuntary commitment for addiction treatment, while certainly not new, has received considerably less judicial attention. In a 1962 case, Robinson v. California, the Supreme Court held that while conviction solely for drug addiction was unconstitutional, “a state might establish a program of compulsory treatment for those addicted to narcotics.” Many did, others didn’t. The high court has yet to revisit the issue.
Another complicating factor is society’s disagreement about what addiction really is: a disease, a moral failing or something in between. Many (often patients themselves) see drug abuse as purely a choice. Under this view, justifying the lost autonomy and expense to taxpayers that accompany mandated treatment becomes a hard sell. Yet a large and ever-growing body of research paints a far more complicated picture of addiction.
The cognitive concepts that we typically associate with “willpower” — motivation, resolve and an ability to delay gratification, resist impulses and consider and choose among alternatives — arise from distinct neural pathways in the brain. The characteristic elements of drug abuse — craving, intoxication, dependency and withdrawal — correspond with disruptions in these circuits. A host of genetic or environmental factors serve to reinforce or mitigate these effects. These data underscore the powerful ways in which addiction constrains one’s ability to resist.
The spotty existence of commitment laws for addiction has created something odd in medicine: a landscape where the standard of care differs dramatically from one place to the next. But change seems to be afoot. In March, Ohio passed a law authorizing substance-related commitments. Pennsylvania is considering a similar bill. In July, Massachusetts extended its maximum period of addiction commitment from 30 days to 90 days, a move driven by the state’s growing opioid abuse epidemic. In the same month, however, California terminated its commitment program for drug abuse.
These shifts come at a time when private insurers increasingly refuse to cover even brief inpatient stays for treatment of opioid abuse and as states grapple with dwindling resources. Still, while short periods of involuntary custody make intuitive sense — to provide protection until the effects of intoxication or withdrawal subside — surprisingly little evidence exists to suggest that a longer period of commitment will lead to abstinence or prevent the behavior that justified commitment in the first place. Science must guide the crafting of these laws, but for now the empirical jury is decidedly out.
A version of this article appeared in print on 10/02/2012, on page D5 of the NewYork edition with the headline: When a Drug Addict Isn’t Ready to Accept Help.
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