April 12, 2023 – He insisted he was fine and said he could stop using on his own if he wanted to, but he didn’t want to. Once he was 18, I couldn’t force him. He had to decide for himself — and yet he was in no condition to do so. “I was completely out of my mind, unable to make rational decisions,” he says now.
Most people who are seriously ill want to get better and, if given the opportunity, will choose to be treated. However, addiction can defy logic.
“You can only understand what it’s like to be addicted if you imagine being deprived of air,” a boy addicted to opioids once told me when I visited an adolescent treatment program for book research. “You’ll do anything in order to breathe. You’ll kick, punch, knock down walls. I didn’t want drugs; I needed them — that’s how it felt — and I did whatever it took to get them. I lied, cheated and stole. I would do anything for drugs.”
This is why substance use disorders, if untreated, can lead to criminal behavior, debilitation and — all too often — death. The number of overdose deaths in the United States is higher than ever.
Ideally, people with addiction would seek care. But waiting for a person to choose treatment for a disease that affects rational thought can be catastrophic, now more than ever. The ubiquity and lethality of street drugs such as fentanyl and fentanyl mixed with xylazine, a veterinary tranquilizer, mean that many people with substance use disorders are in grave and imminent danger, and most cannot simply quit on their own.
This is excruciating for people with loved ones addicted to drugs. I spent years in abject terror waiting for the phone to ring in the middle of the night, afraid of being told, “Mr. Sheff, we have your son. He didn’t make it.”
In November 2022, when Mayor Eric Adams of New York announced that the city would begin sending people with untreated mental illnesses to hospitals, even against their will, the controversial decision resonated with me. He said the city had a “moral obligation” to help them. I believe that moral obligation extends to people with substance use disorders. I would have wanted someone to intervene with my child on the street using potentially lethal drugs and admit him to a hospital. As unpopular as that decision may be, I would have supported it even if I knew my son had been taken into care against his will.
There’s a common view that people with addiction can’t be helped unless they choose to go into treatment. But the data on voluntary versus coerced and court-mandated treatment is not so clear-cut. Some studies show people don’t need to choose treatment for it to be effective, even though it may be more effective if they choose it willingly.
“The fashionable rhetoric is that mandating people doesn’t work, but evidence points the other way,” says Keith Humphreys, a professor of psychiatry at Stanford University and an expert in addiction medicine.
One study he cites, published in The Journal of Substance Abuse Treatment in 2005, followed patients one and five years after voluntary and court-mandated treatment. It concluded that “contrary to popular belief,” when drug users mandated to treatment are compared with people who sought treatment themselves, those who were mandated had similar results related to drug use outcomes and reductions in crime “or sometimes better than those achieved by voluntary patients.” The study also indicated that recognizing they have a problem and being motivated to stop using “may not be necessary for salutary changes to occur, either in the short or longer term.”
Not every expert agrees, and there are also studies questioning the long-term efficacy of compulsory treatment and the risk of potential harms, especially in programs that fall short of standard of care. The data can be difficult to parse because there are many different levels of coercion and ways that people can be pushed into treatment programs — and different treatment protocols when they get there.
The National Institute on Drug Abuse says the evidence for compulsory treatment is mixed. “Creating a climate that encourages and supports people to seek treatment voluntarily and provides access to evidence-based treatment methods is critical,” the group said in a statement. “When that fails to happen, systems and organizations may begin to look to coerced treatment as an alternative.”
To understand whether compulsory treatment works, the institute says, “one must first ask if that treatment is evidence-based and also consider both short-term outcomes like halting drug use and long-term outcomes like staying in recovery.”