Comment: Involuntary treatment qualifies addiction as a moral failure

By Peg O’Connor / For the herald

Calls to invoke civil involuntary commitment laws for people with substance use disorders (SUDs) are growing louder in communities with a marked increase in overdose deaths. Preliminary data suggests that nearly 108,000 people died from drug overdoses in 2021. Currently, 35 states, including Washington State, have laws that allow an individual’s civil recognizance for a SOUTH.

Commitment is a legal mechanism that allows family members, medical professionals, police, or others to go to court to seek legally mandated drug treatment for a person who represents a significant threat to themselves or others. The process often involves an assessment by professionals of the harm caused by an individual. These assessments may result in orders for hospitalization, inpatient or outpatient treatment, or participation in other community resources for specified periods.

While SUDs are included in the fifth edition of the “Diagnostic and Statistical Manual of Mental Disorders”, some of these states’ laws exclude SUDs from their legal definition of mental illness or disorder. The exclusion of SUDs from this category in legal statutes may be a consequence of the intertwining of two considerations.

The first is the remnants of the idea that addiction is on some level a moral failure. Moral failings in general are not considered the sort of thing that absolves a person of responsibility. On the contrary, people tend to think that we are primarily responsible for our moral failures and the acts that result from them.

Moral failings can most certainly lead to illegal activities, which is the second consideration. Some addictions are to illicit substances or to legal substances used illegally, such as prescription drugs used off-label or alcohol consumption by minors, for example). In other words, these laws enshrine the view that mental illnesses can involve diminished capacity that is different in nature from the diminished capacity of a TUS. The former may mitigate legal liability, but the latter does not.

There are few studies on the effectiveness of mandatory treatment for SUD. One reason for this is the significant variation between states in what can be mandated or even what is possible to mandate. Rural areas, for example, are treatment deserts for inpatient and outpatient services. Some areas do not have inpatient treatment facilities, but may be richer in other community programs. How does one compare an experience where medication-assisted therapies are available to those that are not, for example? How does mandatory treatment in an unused building of a correctional facility affect outcomes, as it does in Massachusetts? This brings us to the deeper and even more troubling issue of efficiency. There is no shared standard or benchmark for successful treatment in general.

Treatment centers that primarily use the 12-step model view abstinence as success. But how long after the end of treatment do you have to stay clean to count as a success? It is never specified. Treatment centers that use drug therapies aim to reduce harm by using drugs that can reduce cravings or replace an illegal drug with a medically prescribed drug like methadone or naltrexone. While a more rigid 12 step might say it’s not true abstinence, someone who drastically reduces their cravings reduces the chances of overdosing, which drastically reduces the harm. Should harm reduction versus abstinence be the guiding consideration in judging efficacy?

The rise of civil engagement laws perpetuates a long-established practice of holding individuals accountable for issues that have systemic or structural dimensions. Addiction is a condition of an individual most surely; it is the individuals who are dependent. But that’s not all; addiction has social, political and economic dimensions. The production and aggressive marketing of oxycontin to targeted communities, for example, shows some of these dimensions.

Communities that had high disability claims were singled out; they were people in physical and psychological distress. These considerations made people particularly vulnerable to developing addictions. This is especially true in the state of West Virginia, which has the highest overdose rate of 81.4 deaths per 100,000 people. This vulnerability is linked to the lack of accessible and affordable health care, treatment options, other forms of social services and viable employment opportunities. Pharmaceutical companies were apex predators.

The sharp increase in overdose deaths is due to a multitude of causal factors; some are deeply personal and others are social, political and economic. No focus on the personal will ever be enough to thwart the power of larger considerations. Involuntary commitment laws focus on people seen as desperate, intractable, or outright rebellious. To reduce the major harms of addiction, we need better health care, treatment options, social services and employment options.

Peg O’Connor, Doctor of Philosophy, has been a recovering alcoholic for 34 years and was a professor of philosophy at Gustavus Adolphus College in St. Peter, Minnesota, for 27 years. She is the author of “Higher and Friendly Powers: Transforming Addiction and Suffering”. (Wildhouse Publications, 2022) and “Life on the Rocks: Finding Meaning in Addiction and Recovery” (Central Recovery Press, 2016).