Wide Variation in Commitment Laws for Substance Abuse

Legal statutes governing involuntary commitment for substance abuse vary widely from state to state in the United States, new research presented at the American Psychiatric Association (APA) Annual Meeting suggests.

“We found that most states, about 38 jurisdictions, permit some form of involuntary substance abuse treatment separate from any kind of criminal issues under their civil statutes,” lead author Debra A. Pinals, MD, associate professor of psychiatry in the Law and Psychiatry Program at the University of Massachusetts Medical School in Worcester and assistant commissioner of Forensic Mental Health Services at the Massachusetts Department of Mental Health, told Medscape Medical News.

She noted that although statutes for civil commitments related to mental illness tend to have some variation, “the large themes” tend to be consistent among the states.

However, she said, in the involuntary substance abuse treatment world, the themes “vary tremendously.”

“Some states have no statutes at all, while others allow various forms of involuntary treatment. Also, the criteria under which somebody could be involuntarily forced into some period of treatment are extremely varied in length of time,” explained Dr. Pinals.

In some states statutory criteria for commitment include dangerousness to self or grave disability, while other states require a combination of criteria.

“Our thoughts are that the statutes tend to reflect how lawmakers and society may balance competing interests in different jurisdictions. So, clinicians who are unfamiliar with their statute should consult with colleagues to understand how it actually gets practiced and operationalized in their jurisdiction,” said Dr. Pinals.

Few Seek Treatment

According to the study, less than 10% of patients with substance use disorders (SUDs) seek treatment, and most of these individuals do so because of external, coercive influences.

“We were interested in the issue of involuntary commitment for substance abuse because it felt like an area that had not been fully explored in the psychiatric and addictions world,” explained Dr. Pinals.

“The issue of coercion and substance abuse treatment has been written about before but often those are in the context of criminal matters. There’s a growing literature related to drug courts, for example, where people under the terms of probation from a drug offense charge appear before the court as part of a treatment plan to treat their substance abuse problem. But what we were interested in was the civil end of coerced care for addiction.”

The investigators evaluated “involuntary detentions and hospitalization of persons with SUDs-related conditions” within the legal statutes of all 50 states plus the District of Columbia.

Results showed that in general, police pickup, emergency hospitalization, and civil commitment were the 3 forms of involuntary treatment most used by the states with legal statutes in place.

All but 4 states (Alabama, Wyoming, Pennsylvania, and Virginia) currently allow police pickup or emergency hospitalization, whereas 38 permit outpatient or inpatient civil commitment.

Lack of Consensus

In the states permitting civil commitment, criteria included some form of the following (alone or in combination): dangerousness to self or others, grave disability, lack of decisional capacity, incapacitation, failure to manage personal affairs, or addiction/loss of control.

“The variability in statutory criteria reflects a lack of consensus among lawmakers and society on how to best balance the responsibility to offer protection and honor personal freedoms for those with SUDs,” note the investigators.

Although the maximum periods of involuntary treatment varied, the median time was 24 hours for police pickup (range, 7 to 120 hours), 3 days for emergency hospitalization (range, 1 to 15 days), and 3 months for civil commitment (range, 1 month to indefinite).

“There’s just a great deal of variability. So we recommend that clinicians go to their state’s statutes directly to look at what the exact provisions are,” said Dr. Pinals.

“Also, it’s important to know that what’s written in the statute may not be exactly how the statute is operationalized in practice. There can be variability across and within jurisdictions even if the language of the statute is written in a certain way. How it gets practiced and how it gets emphasized may differ.”

Dr. Pinals noted that substance abuse statutes “also reflect societal values on whether substance abuse or substance dependence is something that’s more of an illness versus more of a behavior that somebody is able to control. So I don’t think it’s likely that the states would ever develop 1 uniform statute across the country.”

Overall, “our findings raise questions about how these statutes are used in real world settings and the justifiability of costs associated with compulsory SUDs treatment given the limited evidence for their long-term effectiveness,” write the researchers. “Further research on this topic is needed.”

Uncommon but Necessary Research

“When a psychiatrist is licensed in a state, he or she has a pretty good idea of the status of these things, particularly if they do legal or inpatient work,” APA Scientific Program Committee co-chair Don Hilty, MD, professor of psychiatry and behavioral sciences at the University of California, Davis, in Sacramento, told Medscape Medical News.

“However, some psychiatrists are licensed in multiple states because they practice in one but trained in another or they live in another state. And that makes it hard for them to keep track. So this is very helpful for them,” said Dr. Hilty, who was not involved with this study.

He noted that this information is also helpful for those who practice telemedicine or videoconferencing.

“It’s important to realize that when people consult on a patient and give an opinion, that is not actually managing care unless you have a license in the state of the patient. And if you consult for many states, you really have to be aware of this. Also, if you work in the Veterans Affairs system, you would have to have this information available,” said Dr. Hilty.”The one thing we’ll probably never quite see is similar licensing across states and similar statutes across states. That can’t be unless this information is forwarded to policy people and they actually take it up. Maybe that’ll happen at some point but it goes against the trend of a lot of other legal issues nationally.”

Overall, Dr. Hilty called the study “well done” and a nice summary.

“I think this kind of research is not that common but needs to be done. And I think the APA and other organizations can think about this and see whether or not anything can be standardized and whether there’s anything their members, as well as allied mental health workers, should know,” he said.

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