In a Massachusetts courtroom, a man strains to hear the proceedings of his case from behind a glass window. Escorted by security, his hands cuffed–he looks like every other criminal defendant. But this man has committed no crime. His family is sitting in the gallery praying the judge will commit him to treatment for his opioid use. After years of watching his substance use escalate, fearing for his safety, and pleading with him to receive treatment, they pulled the only lever they had left to get him help. They turned to the courts.
Civil commitment is a legal process to compel people with substance use disorders to receive treatment. Commonly called “Section 35,” civil commitment in Massachusetts begins when a family member, law enforcement officer, or medical professional petitions the court—which means completing a short document describing an individual’s substance use problem that is putting that user’s life, or others’ lives, at risk—to evaluate a person’s need for forced treatment. After receiving and reviewing this petition, the judge typically issues a warrant for that person’s arrest.
Often people with severe substance use disorders do not recognize their need for treatment or they utilize voluntary services. With overdose deaths rising steeply in America, more states are considering if and how to expand civil commitment for substance use, particularly for persons who abuse opioids. Massachusetts has one of the highest number of civil commitments for drug use in the country with over 10,000 cases filed in 2018. Surprisingly, little is known about how individuals who are subject to commitment proceedings and treatment experience this process despite the growing interest in using civil commitment to respond to the opioid epidemic.
Brought to the courthouse by local police, the respondent is placed in a holding cell until their case is heard. No opioid withdrawal management is provided and many persons experience drug withdrawal symptoms such as cramping or vomiting while they wait, often hours, for their courtroom hearing.
A judge holds the final authority over whether to “commit” (or force treatment for) someone under Section 35. That decision, however, often hinges on family testimony, a court clinician’s assessment of the person’s risk (done while they are in the holding cell), and the person’s severity of substance use. The person who is committed will be treated for up to 90 days at an inpatient facility, operated either by the Department of Public Health (DPH) or the Department of Correction, if the judge determines the person poses a serious danger to themselves or others as a result of substance use. After the commitment hearing, persons often return to their holding areas for hours while awaiting transport to these facilities. Committed individuals are shackled in the back of a transport van along with other committed persons, and often prisoners being taken to jail.
The opioid epidemic threatens the health, safety, and welfare of both individuals and society.
At the DPH facilities, including Men’s Addiction Treatment Center in Brockton and Women’s Addiction Treatment Center in New Bedford, “sectioned” people are assessed and treated for opioid withdrawal in the Acute Treatment Services (ATS) unit for approximately six days. While in ATS, individuals are offered medication to address their symptoms and meet with counselors and a psychiatrist. After ATS, patients are “stepped-down” to another unit where they receive group therapy, additional medical treatment, and planning for discharge. This includes referrals to healthcare providers and longer-term residential treatment if needed. If a bed at a residential program is not available, the facility will typically allow an individual to stay until one opens, a policy rarely offered to patients in other substance use treatment settings Although the law allows commitments for up to 90 days, individuals stay in commitment facilities for an average of 21 days.
Civil commitment overrides the liberty of people with substance use disorders; there is also no evidence that this costly policy changes outcomes for people with substance use disorders. For many individuals, the court-mandated intervention is also profoundly unwanted, humiliating, and painful. Yet not everyone subject to civil commitment identifies the experience this way. Some report positive attitudes about the treatment they received while committed. Some individuals even describe their commitment as voluntary. Although the law does not allow individuals to “self-petition,” many ask someone else to petition them, either because they cannot adequately access treatment services or because they fear they would leave a voluntary program prematurely, while court-imposed commitment enforces days to weeks of inpatient treatment.
The opioid epidemic threatens the health, safety, and welfare of both individuals and society. Massachusetts provides a well-intentioned but imperfect example of how civil commitment policy can be implemented. Improvements are needed in implementation, particularly in the early phases of the commitment process, where individuals are held in a courthouse unequipped to treat their withdrawal. Moreover, important questions about Section 35 treatment remain unanswered. We know very little about post-commitment outcomes. Careful evaluations would help to inform how existing civil commitment policies can be improved and identify best practices for states considering new civil commitment legislation.