Wednesday, 8 Apr 2020

Opinion | Jails Rebranded as ‘Treatment Facilities’ Are Still Jails

Imagine your aunt has developed diabetes and you want her to get better. Medical science suggests that medicine might help, but you decide that the better strategy is to lock your aunt in a room and force her to eat only lettuce — even though she hates vegetables. No medication, no discussion of other options.

Does this seem absurd? Illegal? It’s both of those, and no medical professional would advise it. But we are doing more or less the same to people who use drugs.

Laws in many states authorize family members, health care providers or police officers to ask courts to send someone who has not been convicted of any crime to be detained for involuntary addiction treatment; in many cases this means being locked in a jail or prison.

In places like Massachusetts, where the overdose crisis has been particularly destructive, these jails and prisons are being rebranded as “treatment facilities.”

As we continue to hear the mantra that we can’t arrest our way out of this crisis, policymakers are facing more pressure to expand treatment. Involuntary treatment has become an attractive response because it allows them to keep the punitive status quo, while also boasting they’re shifting toward a public health response.

There are many ways this approach falls short. For one, people are held in jail cells under lock and key. The facilities typically offer only one approach to treating addiction — abstinence. Medicines proved to effectively address addiction to heroin or other opioids are typically unavailable.

Troublingly, involuntary treatment is becoming increasingly popular, spurred by the overdose crisis. At least 38 states allow civil commitment for substance use, up from 18 in 1991.

And while politicians, families and others view involuntary commitment as a good solution, research suggests that involuntary treatment is actually less effective in terms of long-term substance use, and more dangerous in terms of overdose risk.

A study by the Massachusetts Department of Public Health found that people who were involuntarily committed were more than twice as likely to experience a fatal overdose as those who completed voluntary treatment. Just as with other forms of incarceration, people with addiction who are forced into withdrawal behind bars are very likely to relapse upon release. Lower levels of tolerance makes the risk of fatal re-entry astronomically high.

Changing a name without a change in approach is dangerous. Jails masquerading as “treatment centers” make clear how harmful it is for the health of patients — and public discourse — to describe detention in correctional facilities as “treatment.” In a Massachusetts treatment center, for example, patients are required to wear orange uniforms, carry a badge with the word “inmate” and are monitored by corrections officers, without having committed a criminal offense. Patients can’t even have visitors.

Moreover, unlike at treatment centers not tied to the judicial system, judges can override clinicians’ recommendations in making medical decisions in involuntary commitment cases. Would we want family members with cancer or diabetes to have their course of treatment mandated by a judge?

We have the evidence that voluntary treatment can drastically reduce overdose, cutting risks from 50 to 80 percent. The World Health Organization recommends that anyone likely to be a lay “first responder” — a relative, friend, fellow drug user — should have access to naloxone, which reverses opioid overdose. It has saved lives in the United States and across the world. The medicines buprenorphine and methadone also reduce injection of illegal drugs. Safe injection facilities, which provide an environment for the most vulnerable to consume drugs under medical supervision and without fear of arrest, help reduce overdose. Syringe service programs, though under constant threat in the United States, have helped people who inject drugs control H.I.V. infection effectively.

We need a more profound cultural shift to embrace solutions that are both scientific and ethical. Encouraging people to be active participants in their care and recovery improves the impact of treatment, while empowering people to take control of their lives. Reams of evidence on the success of harm-reduction programs refute the idea that people who use drugs cannot make healthy or rational choices.

Making meaningful changes is more than mere rebranding — it’s about dismantling outdated systems and reinvesting in alternatives that are more effective and humane.

People entering addiction treatment deserve ethical and effective care. While some may find the idea of involuntary treatment alluring, a suspension of civil rights is not just unnecessary — it hijacks efforts to solve our overdose crisis. Civil rights violations in the name of “treatment” are still violations. And jails called “treatment facilities” are still jail.

Leo Beletsky (@LeoBeletsky) is an associate professor of law and health sciences at Northeastern University, and the faculty director of the Health in Justice Action Lab. Denise Tomasini-Joshi (@DMTJoshi) is a division director at the Public Health Program of the Open Society Foundations.

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