Mayor Eric Adams’s recent proposal to force addicted New Yorkers into treatment if they pose a risk to themselves or others is “horrific,” one activist said. Another said the plan “sends a chill up my spine.”
But mandated treatment, if properly carried out, can help addicted people and the communities where they live.
It is well established that the government can provide care to seriously mentally ill people even if they refuse. The standards required to do so — typically, showing that the individual is gravely disabled or poses a threat to the community — can vary, but the underlying principle is the same.
Such civil commitment has existed for a century in the United States, and all 50 states have laws governing the practice. But New York is among the minority that does not consider addiction alone a sufficient legal foundation to mandate care.
It should. Because the alternative to mandated treatment in places like New York City is usually not voluntary treatment but no treatment at all — life on the street with the most lethal illicit drug supply in U.S. history.
Besides, one of the largest and longest-term studies on this followed 2,095 addicted patients and found that one year after treatment, those whose care was mandated were somewhat more likely to avoid drug use than were those who entered treatment voluntarily. Further, compared with their peers who had voluntarily sought treatment within the justice system, the patients whose care was mandated were less likely to be rearrested. Other studies found that mandated patients do somewhat worse or the same as voluntary patients. A new review of 22 studies found “a lack of high-quality evidence” in favor of or against involuntary treatment for addiction.
But none of those studies compared the results of involuntary treatment with the results of getting no treatment, the most pertinent comparison.
That patients can benefit from mandatory addiction treatment is surprising only if you assume that typical treatment seekers spontaneously and with strong internal motivation wake up one day and decide to change their lives. In reality, such patients are rare.
In a national sample of 476 individuals who had sought treatment for an alcohol problem, more than nine in 10 reported being pressured to quit or change their drinking by their family, spouse or partner, friends or others. People under legal pressure to seek care can thus be in a situation similar to others in the same treatment program.
Why do people so often need to be pressured to seek treatment when addictive substances are destroying their lives? Quite simply, drug use feels good, at least in the short term, making many people ambivalent about giving it up. And treatment requires hard work in the short term to overcome the visceral pull of addiction, before it brings long-term relief.
Continuing to prioritize substance use in the face of harm is the sine qua non of addiction. Addiction reduces people’s ability to exercise self-control, to accurately weigh long-term versus short-term consequences and to make decisions that benefit them. Critics of mandated treatment who assert that intervention undermines an individual’s autonomy forget that addiction itself saps that autonomy. Mandatory treatment that gives people their good judgment back is a restoration of their autonomy, not a violation of it.
The other main reason to mandate treatment is that addicted people are not the only ones affected by their behavior. Many of the burdens of addiction fall on others — loved ones who wait up at night by the phone scared it will ring and scared it won’t, people exposed to the aggressiveness caused by some drugs (particularly alcohol and stimulants like meth) and the communities and businesses that are overrun by public drug use. Those bearing such burdens have every right to pressure addicted individuals to change, including by engaging the criminal justice system where necessary.
For decades, public health officials worried about the impact of addiction on users’ children, co-workers, neighbors and communities, as well as the users themselves. One reason the public health field supported laws restricting smoking and advertising campaigns against tobacco, even when smokers objected, was that they reduced the damage of secondhand smoke and helped persuade nonsmokers not to start smoking.
But many drug policy activists in recent years have adopted a stance akin to that associated with gun rights activists or those who resist vaccines, namely that individual desires to use drugs should outweigh community consequences.
In San Francisco, harm reduction activists and public health officials collaborated to put up billboards portraying opioid users as young, attractive, successful people, on the theory that this would be destigmatizing and encourage them to do it with friends who might rescue someone who overdosed. This was a slap in the face to parents who did not want their children to be persuaded that fentanyl use was a desirable activity and to the many people who were having difficult interactions with street fentanyl users who were not of the friendly, healthy and harmless variety portrayed on the billboards.
As the police chief turned public health researcher Brandon Del Pozo recently put it, “If there has been one blind spot among drug policy reformers, harm reduction activists and their allies in the halls of government, it is the need to compassionately — but effectively — address the highly disruptive consequences of public drug use and to take heed of how resentful a community gets when problems are left to fester.”
If advocates will not consider the value of mandatory treatment for the community on the merits, they might do so as an exercise in realpolitik. The decriminalization and harm reduction wave that swept the Pacific Northwest beginning in 2020 went from popular to unpopular not just because it failed to reduce overdoses but also because property and violent crime went up, even as they fell nationally. Ignoring how drug use and associated disorders can harm people who don’t use drugs is a good way to undermine popular support for your entire reform agenda.
All that said, mandated treatment programs can work only if they are well resourced and thoughtfully carried out. In decades of working with policymakers, I have heard many enthusiastic proposals to force legions of people into programs that didn’t even meet current demand. And mandatory initiatives depend not just on an adequate quantity of treatment but also on the right quality. Treatment programs should be guided by the best evidence, and should be clean, safe and respectful. Judges, whether they are evaluating requests for involuntary commitment from health professionals or overseeing addicted patients in a drug court, must be well versed in the best scientific evidence on the nature of addiction and its treatment.
Establishing a mandatory treatment program in a thoughtful, careful way may seem a lot to ask of an already overstretched bureaucracy. But the degrading and dangerous reality on the streets makes the status quo unacceptable. If New York can build a well-resourced and well-designed mandatory treatment initiative, addicted people, their loved ones and the broader community will all benefit enormously.
Keith Humphreys is a professor of psychiatry at Stanford University and served as senior drug policy adviser in the Obama administration.
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