Note: This essay was originally published in TruthOut, November 19, 2015. I’ve reposted it today because calls for involuntary hospitalization are again popping up around the country in response to the perceived opioid “epidemic.” The bill that was eventually passed by the Massachusetts House and then sent to the Senate did not include Governor Baker’s proposal to allow involuntary hospitalization of drug users. Click here for the text of the enacted AN ACT RELATIVE TO SUBSTANCE USE, TREATMENT, EDUCATION AND PREVENTION, signed by the Governor on March 14, 2016.

 

November 2015: Massachusetts appears to be on the cusp of adopting legislation proposed by Governor Baker (Republican) that would allow doctors to hospitalize drug users, involuntarily and without a court order, for 72 hours (H.3817). Previously, the power to order involuntary commitment of drug or alcohol users lay exclusively in the hands of judges under a Massachusetts’ law known as Section 35. At this time, few states give judges similar power to take away the freedom of individuals not accused of a crime. (1)

The proposed bill also would limit doctors to prescribing a 72-hour supply of opiate painkillers to patients receiving a first-time prescription for acute pain. While the second part of the plan has received criticism – concern that patients needing painkillers may not be able to reach their doctors for a refill in a timely manner – the first part of the plan has received virtual cross-the-board support. According to press reports, the majority of Massachusetts’ sheriffs as well as the association representing Massachusetts’ district attorneys have come out in favor of the bill. Hampshire County Sheriff Robert Garvey’s comments represent the growing opinion that, “The governor’s bill changes the attitude that addiction is not a criminal offense as much as it is a medical problem.”

Sheriff Garvey’s remarks are echoed around the country. For a variety of reasons – including a shift in media portrayals of the race of drug users — – we currently are experiencing a cultural and judicial movement away from criminalization and towards medicalization of substance abuse. Massachusetts might well be the vanguard of this movement. Not only is Massachusetts a relatively “white” state at a time in which the new face of drug use is Caucasian, but it also is the first state to have passed the healthcare coverage reform (“Romneycare”) that later became the law of the land nationally (“Obamacare.”)

Addiction Treatment and the Role of Physicians

Having worked for the past decade with criminalized women, most of whom struggle or have struggled with addiction issues, I am far from convinced that the Governor, sheriffs and district attorneys have got it right. While re-categorizing addiction as a medical rather than a judicial issue certainly sounds like step in the right direction, giving doctors unchecked power to hospitalize people against their will opens the door for serious human rights violations. Our legal system, like that of other modern democracies, insists that an individual should not lose his or her freedom without the due process of law. A doctor, committing people without an opportunity for those people to be represented by counsel, will be asked to serve as both prosecutor and judge – a position that directly contradicts principles of American jurisprudence and places doctors in an uncomfortable and untenable position vis-à-vis their patients. Knowing that doctors have this power will, I fear, serve to discourage people who could benefit from immediate medical attention from seeking assistance.

More broadly, the proposed bill puts the onus on physicians to fix social problems.

I understand that the motives behind the proposed bill are benign. However, I assume that the image of the doctor – patient relationship in the minds of the governor, sheriffs and district attorneys is most likely the kind of relationship they have with their own family doctors – a doctor who knows their history and their families, who has a good grasp of their patients’ medical and social backgrounds. However, it is likely that the doctors who will be committing patients under Governor Baker’s plan are emergency room doctors or hospitalists; that is, doctors who meet the patient for the first time at the encounter that leads to the commitment. Asking doctors single-handedly to take away the freedom of patients whom they barely know is not a reasonable burden to place on doctors.

I have great respect for doctors and I understand their frustration at treating patients for overdoses, only to watch these same patients walk out the hospital door immediately following stabilization. However, the bottom line is that there is no evidence whatsoever to indicate that three days of treatment will have any impact upon drug users. (The three day proposal, I assume, is based on the three day commitment for psychiatric patients under Massachusetts General Law, Section 12, though, since no reason is articulated for the three day idea it might just as easily, although perhaps subconsciously, follow the three days between the crucifixion and resurrection of Christ). In any case, there is little to no evidence showing that coerced drug treatment is effective. (2)

When patients are released after their three-day involuntary commitment, there is no reason to think that they will not return to their former drug use. In fact, having abstained from opiates for several days may set them up to overdose when they return to their former level of drug use but with a reduced tolerance for the drugs. (3) If a plan were in place to provide long-term, multi-faceted support after the three days I might have a different take on the proposal. But I do not see that Governor Baker’s bill includes such a plan, or a way to fund it. As I’ve seen repeatedly among the women with whom I work, even the “good” – that is, three month or six month – rehab placements end with people going back out into poverty, unemployment, scarce community support and (often) homelessness. These are sure recipes for sending them back into the drug use / detox cycle.

Blind Faith

We Americans have great respect for physicians and we trust that their medical training is the best in the world. However, addiction treatment is not a substantial part of most medical school curricula, and even in instances where doctors took a course (typically an elective) in the subject, given the rapidity with which the field of addiction treatment is progressing, their knowledge in the field may well be outdated. (4) Anecdotally, I personally have spoken with physicians who know nearly nothing about Suboxone and have never administered a dose of Narcan. Few hospitals in Massachusetts, and even fewer in other parts of the country, have more than one or two addiction medicine specialists on staff, which means that non-specialists will be tasked with the responsibility of deciding whether or not to commit patients who, in many cases, are seen as a nuisance or “revolving door” patient group.

I also know from having spoken with doctors around the country that they, like politicians around the country, tend to believe that twelve step programs are effective for treating addiction when, in fact, there is no evidence showing that Narcotics Anonymous participation (and especially coerced NA participation) leads to long-term abstention from drug use. (5) Indeed, I suspect that lying behind the proposed legislation is the notion, propagated by twelve step organizations, that alcoholism and substance abuse are “diseases” that take over one’s life; that people living with alcohol or substance-abuse disorders lack the capacity to make sound decisions (which is why they must turn themselves over to a “Higher Power.”)

Race Matters

I do not doubt that the vast majority of doctors are thoughtful, fair and knowledgeable. But I do know that there is a sufficient history of medical abuses – including medical experiments on prisoners and on African American men (the infamous Tuskegee syphilis experiment) to require all medical research to undergo thorough vetting and oversight by ethics reviews boards (IRB). In the frenzied panic over opiate deaths in Massachusetts, Governor Baker’s bill lacks a requirement for any sort of oversight. Decades of research show that doctors may tend to treat patients differently depending on the gender or the race both of the patient and of the doctor. (6)

It certainly should raise eye-brows that the popular push to re-label addiction and send addicts to ‘treatment’ rather than prison is taking place at a time when public attention has shifted from Black crack users to White opiate users. At the same time, as I have argued before, redefining people as “sick addicts” rather than “criminal addicts” is not as significant a social shift as one may think. In both cases they are labeled as flawed individuals who have failed to take responsibility for their own lives. In both cases, the onus for “deviance” lies on the individual rather than on the society that creates and sustains social and economic conditions that lead far too many people to feel that mind-altering and mood-altering substances are the best – or the only – means of making it through the day, the week or their lives. And clearly, those people labeled as “addicts” or “drug abusers” are not all that deviant. Throughout the United States, the normative way for dealing with misery is through doctors’ prescriptions for attention challenges, for anxiety, for depression and even for low libido. (7)

And Class Matters

The “epidemic” of opiate related deaths is not spread evenly across White America. In fact, the new attention to white opiate users exposes an important and seldom discussed reality of American society: Class matters. The white opiate users in Massachusetts overwhelmingly come from poor and working-class white communities – mostly non-urban — where good jobs are scarce and where young people see little hope for ever attaining the American dream.

The criminalized women I have come to know over the past decade are, for the most part, poor and white, and I believe that they represent a tragic social trend. According to research published in 2014 by sociologist William Cockerham “For the first time in modern history, the life expectancy of a particular segment of the American population— non-Hispanic white women with low levels of education and income living in certain rural counties—is declining.” And the same decline is happening among white men. (8) Opiate abuse is one of the factors explaining declining life expectancies in these communities, but it is crucial that we understand that opiate abuse is a symptom of hopelessness, disaffection, powerlessness and marginalization. Unless we treat those social forces we are deceiving ourselves if we think that allowing physicians to commit drug users for three days is going to do anything other than intensify those forces.

Notes

  1. Testa, Megan and Sara G. West. 2010. “Civil Commitment in the United States.” Psychiatry (Edgmont). 7(10): 30–40.
  2. Urbanoski, Karen. 2010. Coerced Addiction Treatment: Client Perspectives and the Implications of Their Neglect.” Harm Reduction Journal. 7(13).
  3. Strang, John, Jim McCambridge, David Best, Tracy Beswick, Jenny Bearn, Sian Rees and Michael Gossop. 2003. “Loss of Tolerance and Overdose Mortality after Inpatient Opiate Detoxification: Follow Up Study.” BMJ (British Medical Journal). 326(7396): 959–960.
  4. Rasyidi, E, JN Wilkins and I Danovitch. 2012. “Training the Next Generation of Providers in Addiction Medicine. Psychiatr Clin North Am. 35(2):461-80.
  5. Dodes, Lance and Zachary Dodes. 2014. The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Boston: Beacon Press
  6. Staton, LJ et al. 2007. “When Race Matters: Disagreement in Pain Perception between Patients and Their Physicians in Primary Care.” Journal of the National Medical Association. 99(5):532-8; Weisse, Carol S., Paul C Sorum, Kafi N Sanders and Beth L Syat. 2001. “Do Gender and Race Affect Decisions About Pain Management?” Journal of General Internal Medicine. 16(4): 211–217.
  7. Greenberg, Gary. 2013. The Book of Woe: The DSM and the Unmaking of Psychiatry. NY: Plume.
  8. Cockerham, William. 2014. “The Emerging Crisis in American Female Longevity.” Social Currents. 1(3): 220-227.

 

Acknowledgments: I wish to thank Barak Sered, MD for his expert advice and input into this paper. All opinions and errors are solely my own.

This article was originally published on April 13, 2016 by The Influence.

Kahtia “acted out” from a young age. At least that’s what the counselors involved in her case said. The reality, Kahtia recounts, is that she wanted to get away from the horrific sexual abuse in her home. By age 12 she was in residence at a juvenile treatment institution. By age 13 she was tired of being locked up.

After running away she had a few good years, during which she was adopted by a New York City gang whose leader had heard impressive stories about “the girl who hides a razor blade in her mouth to protect herself.” Later on she contributed to the gang through some high-priced prostitution and exotic dancing at upscale clubs. “Then,” she explains, “I was dealing drugs and became my own best customer.” The high-end sex work descended to street work, and Kahtia spent the next 15 years or so in and out of prisons and jails.

By the time I met her in 2008 (I have come to know her as part of an ongoing project with formerly incarcerated Boston-area women) she was spending far more time in treatment programs than in jail. Over the years, Kahtia has been sent by the courts, social workers, child welfare workers and doctors to residential treatment both in and out of jail, to outpatient multi-service clinics, gender-sensitive therapeutic groups, methadone treatment and ubiquitous 12-step programs.

What Should “Alternatives to Incarceration” Mean?

As a national consensus seems to be building around the idea that people who use drugs problematically are mentally ill and need treatment rather than incarceration, Kahtia’s experiences shed needed light on the concept as well as the practicalities of the “alternatives to incarceration,” which are garnering more enthusiasm than critical examination around the country.

Conceptually, the term “alternatives to incarceration” takes for granted that we are talking about ways to handle criminals who otherwise would need to be incarcerated—that incarceration is a reasonable baseline against which to measure “alternatives.” In light of the over-representation of Americans of color and low-income Americans in jails and prisons, however, it’s necessary to be careful about any sort of presumption of correlation between criminality and incarceration. In fact, about a third of people locked up in the US are awaiting trial; that is, they have not been convicted of a crime. Another third are locked up because they violated the terms of probation or parole; that is, the “criminal” act was not sufficiently egregious to require imprisonment but a subsequent action—often simply not showing up for a meeting with a parole or probation officer, or failing to keep up restitution payments or money owed in court fees—was the reason for incarceration. And 97 percent of federal and state criminal prosecutions are resolved by plea bargain—often accepted by defendants out of fear that if they don’t accept the deal they will be locked up even longer—rather than by trial.

Logistically, most alternatives to incarceration involve various sorts of intensive monitoring. This includes electronic bracelets, probation, parole and drug courts. Kahtia, like many other women I know, explains that all of these are a “set up” to be sent to prison. The terms of the supervision tend to be so extensive and rigid that, in her experience, everyone is bound to violate the terms. In her case, her last incarceration—four years ago—was triggered by the parole violation of having a “dirty urine.” When she added up the jail time and the time she was on parole, the total came to more months than she would have served if she’d been sent to jail to begin with.

Criminalization and Medicalization: Two Sides of the Same Coin

For the past 40 years, the cultural logic behind the mass incarceration of drug users rested on framing drug use as a personal choice, with the implication that it is appropriate to punish drug users who could have “just said no” to drugs. A similar logic still lies behind nearly all treatment alternatives to incarceration.

The individualistic understanding of addiction that is the bedrock both of prisons and of most treatment programs has important consequences in terms of social policies. In both medical and correctional settings Kahtia has been told—repeatedly—that her problems are the result of the bad choices she has made: the wrong men, wrong friends, wrong ways of getting money and wrong drugs. Correctional staff and therapeutic staff alike have drilled her in the idea that her problem lies within herself, her flaws, her disease, her female propensity to be “too nice,” and her proclivity for “denial.” Neither while incarcerated nor in any treatment programs has she ever been told that her problems may be the consequence of the failure of the collective to address economic inequality, racism, or sexual violence.

Sociologist Peter Conrad explains that, “[S]ince the medical profession’s mandate to treat addiction is dependent on (and accomplished at the determination of) the state, medicine functions as a social control agent in the former’s behalf. The uneasy alliance between law-enforcement and medical systems has created a hybrid criminal-medical designation of addiction” (Conrad p. 144). For women like Kahtia medicalization and criminalization are two sides of the same coin. She has been treated by doctors and psychiatrists for the very same conditions (pain and fear) and with the same or similar psychotropic and pain medications for which she has been sent to prison.

The murky line between punishment and treatment has not been lost on some of the corporations involved in the prison industry. Correctional Healthcare Companies, for example, has expanded beyond providing medical services to prisons and now offers services for the “full spectrum” of “offenders” lives: “pre-custody, in custody, and post-custody,” a timeline that perhaps says more than the company intended about American understandings of criminality.

What Is Treatment?

Typically, treatment begins with a short (five- or seven-day) detox. Ideally, people are sent from detox to residential facilities. However, in Massachusetts, like in much of the country, that transition often does not happen because there are no appropriate long-term placements available. Kahtia has been through dozens, perhaps even hundreds, of detoxes. Francesca, a friend of Kahtia’s, describes detox as “spin dry”—people come in, dry out, and are spat out afterwards. Spinning dry is particularly problematic because tolerance for heroin or pain medication is lower right after detox, making post-detox a period of danger for overdosing.

While one might argue that this simply points to the need for more long-term residential facilities, it is far from clear that such facilities offer much of a solution. If residence is voluntary, many people will leave because like Kahtia, they have families whom they do not wish to abandon or because they are fed up with the many rules about making beds, eating times, dress codes, etc. that residential programs typically see as necessary to “recovery.” If residence is coerced, then we as a society are at risk of a mass return to the cuckoo’s nest.

Recently there has been more interest in opioid agonist therapies such as methadone and buprenorphine. To be clear, these drugs do not “cure” addiction but rather are used like insulin or other on-going treatments for chronic diseases. While many people find these therapies useful, others feel that they simply substitute one drug for another (Kahtia told me that she found detoxing from buprenorphine even worse than detoxing from heroin), put money into the coffers of pharmaceutical companies, and too easily are misused when people sell or trade their doses.

Kahtia currently is in an outpatient program that provides group and individual therapy, psychiatric medication and methadone. Unfortunately, the combination of psychiatric medication and methadone made her so groggy that the director of the day camp to which she sent her kids last summer reported her to child welfare services (DCF) for being on drugs. Eight months later her kids are still in foster care; in order to get them back Kahtia is required to attend a full-time program of therapy and classes.

While not all treatment programs prescribe psychotropic medication, virtually all incorporate—explicitly or implicitly—12-step ideology and practices. Treatment facilities tend to be plastered with 12-step slogans such as “Let Go and Let God” and “Cultivate an attitude of gratitude,” and formal AA/NA meetings typically are part of the treatment regime. With emphasis on admitting one’s powerlessness (Step One) and making moral inventories of one’s faults (Step Four), these programs do not seem to offer people like Kahtia a meaningful script for re-organizing their lives. Having been at the receiving end of physical, emotional and sexual abuse both as a child and as an adult, she already is quite familiar with her powerlessness. And having spent much of her life in correctional facilities, her faults have been inventoried more times than she cares to think about.

Most treatment programs in Massachusetts also include some sort of psychotherapy. Kahtia has been treated by multiple therapists in both conventional and gender-sensitive programs over the years. While Kahtia typically enjoys talking about her history and her problems, she is frustrated by the rapid turnover in therapists at community mental health centers, by the fact that therapy has been required by parole officer and caseworkers, and most of all by the fact that therapy addresses her attitude to life’s challenges but can’t address the challenges themselves.

But Does It Work?

Politicians, advocates and just plain folks tout treatment as if there is clear evidence that treatment for addiction works. Indeed, “work it til it works” is a popular 12-step slogan. But by the standards commonly accepted for medical and scientific research there simply is no substantial evidence that this is the case. Studies showing positive outcomes to treatment typically look only at participants who completed the program, do not track program participants for long enough time to establish meaningful rates of success, fail to control for confounding variables, or look at very small numbers of participants from the start. Indeed, a recent meta-analytic review of the effectiveness of continuing care for substance use disorders (the need for ongoing treatment is one of the few things that virtually everyone in the field seems to agree upon), the researchers concluded, “Limited by [the] small number of [methodologically sound] studies, analyses did not identify any significant moderators of overall effects.”

Studies of addiction treatment tend to focus on retention rate in programs rather than on how the program impacted participants after they finished. The notion of treatment being measured by sticking with the program rather than by actually being cured seems bizarre. In cancer treatment we wouldn’t consider long-term treatment to be good. Yet, in the world of addiction research we find studies like this one that conclude that “Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles.” Despite the researchers’ use of the word “benefit,” all that their study showed is that there is some correlation between attendance and abstinence. Their data do not show that one causes the other. (In other words, it could just as well be that people who are not using drugs—for whatever reason—are more likely to continue attending 12-step meetings.)

Every Statistics 101 student learns that correlation does not prove causation, that two phenomena can be related with one causing the other. Yet studies like this one on “engagement” in treatment seem to remember that wisdom only in the “Limitations” section at the end of the article.  After pages of numbers showing that people who remain engaged in treatment are also less likely to be arrested, the authors acknowledge that “clients with stronger motivation at entrance to treatment may have both higher engagement and better outcomes.”

Very few studies follow the people who have left the treatment program, though in many studies more than half of the initial participants have left before the end. And even the best studies, the ones that make efforts to follow-up with all participants, typically cannot find half or more of the participants thus have no idea what has happened to them or whether the half (or less) they have managed to find are in any way representative of the full participant cohort.

For example, an otherwise strong study that compared methadone with buprenorphine (Suboxone) looked at 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive buprenorphine or methadone for 24 weeks. But perhaps the most important finding is that the treatment completion rate was 74 percent for methadone versus 46 percent for buprenorphine. The researchers have no idea what happened to the half of the participants who dropped out. In short, while the study ostensibly found better patient retention with methadone but lower continued use of illicit opioids with buprenorphine, it’s difficult to conclude anything meaningful about the efficacy of treatment.

Even the best studies, the ones that that make efforts to follow-up with everyone who started the study, typically limit the follow-up to three months, six months, or at the most a year or 18 months post-program. However, as in Kahtia’s case, it is common for people who use drugs to have periods in which they use heavily, periods in which they use occasionally, and periods in which they don’t use at all. And while I suspect it is likely that many forms of treatment do have a short-term positive impact on participants, without a double-blind random study in which some people are treated and some are not and then everyone is followed-up for a substantial period of time, we really cannot know which, if any, treatment modalities actually work.

The absence of evidence for the success of treatment programs is especially glaring when the treatment is coerced or carried out in a coercive situation. It may be tempting to believe that even if treatment doesn’t help everyone, at least it doesn’t hurt. Yet, as we’ve learned from past efforts to “cure” homosexuality, treatment that is ostensibly for the patient’s own good may be used to bring the “deviant” individual back into line when their ideas or behaviors challenge social hierarchies of race, gender, sexual orientation or class. Those of us old enough to remember Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest can attest to the reality that therapeutic interventions aimed at “getting inside” the patient’s head can carry heavy costs indeed.

A Real Alternative

As the treatment-industrial complex gathers steam, there is need for critical thinking regarding not only the effectiveness but also the goal of treatment. Is the goal necessarily abstinence (an ideology promoted by the 12-step movement), as opposed to temperance or moderate drug use? More broadly, is abstinence or even temperance really the ultimate aim, or is the true goal a life of purpose, meaning and dignity? In Kahtia’s case the absurdity is that she would now be considered a “success” by treatment researchers because she has not had a dirty urine in many months. But the reality of her life is that she spends all of her weekdays in various classes and groups, she is not able to work, she is always broke, and her kids are still in foster care with no set date for her getting them back. Is that a success story?

Last month President Obama gave a strong speech about drugs. Yet even this thoughtful man, a president who has demonstrated his ability to hold onto competing ideas and live with ambiguity, offered the same uncritical promotion of treatment that has started to replace the uncritical promotion of mass incarceration. There was, however, an intriguing kernel of insight in his allusion to his own drug use in his younger days and his implicit acknowledgment that not everyone who uses drugs becomes addicted. I would have liked him to examine his own experiences a bit more and move beyond his uncharacteristically superficial analysis that, “I was lucky because, for whatever reason, addiction didn’t get its claws into me.” Could it be that his strong political and social views and commitments—his deep belief that the world can be made better and that he can be part of that process—made drug use less appealing?

If so (and I think it’s pretty likely that this is so) then we should be talking about social factors in addition to medical ones.

If, as President Obama has articulated many times, reckless use of violence by the United States cannot cure the violence that plagues the Middle East, then surely he can recognize that uncritically escalating our use of medical treatment cannot cure the problem of America’s massive overuse of drugs. Just like we need to put more thought and resources into understanding why people become suicide-bombers and into preventing disaffected young people from joining terrorist organizations, we need to put more thought and resources into understanding why so many Americans feel the need to use large amounts of mood-altering and sense-numbing substances. At this point we barely know what prevention of problematic drug use would entail.