Pubdate: Wed, 04 Nov 2015
Source: Boston Globe (MA)
Copyright: 2015 Globe Newspaper Company
Author: Sally Satel
Note: Dr. Sally Satel is a resident scholar at the American 
Enterprise Institute.


Spurred by an opiate problem that kills three people a day in 
Massachusetts, Governor Charlie Baker has proposed controversial 
legislation to give hospitals power to hold addicts against their 
will if they pose a grave danger to themselves.

Intruding on personal freedom is serious business. But in extreme 
situations it's necessary.

I remember the frantic parents of my 23-year-old patient, Susan. They 
tried to get her committed for "grave disability" due to addiction. 
Susan had dropped out of college three years earlier, chose to live 
on the streets of New Haven or crash on her friends' filthy couches. 
Two months before her parents sought forced treatment, their daughter 
had overdosed twice, suffered a near-rape, and was hospitalized for 
abscesses from infected injection sites.

The judge did commit Susan but soon after that I left New Haven so I 
never knew her fate. At the least, I know her imminent 
self-destruction was halted.

Senate President Stanley Rosenberg reacted to the governor's proposal 
with caution, giving it a "big yellow light." "You have to find the 
right balance point here," he said, "be[ing] really careful that we 
don't deny them their liberties." View Story

Editorial: Doctors should work with Baker on opioid plan

Governor Charlie Baker's proposal to limit prescriptions for opioid 
painkillers is worth a try. Editorial: Tackle the opioid crisis on 
your own street

The bill is indeed careful to give patients the right to legally 
challenge both the three-day detention and any subsequent effort to 
commit them for longer for 90 additional days. (There is already a 
substance abuse commitment law on the books, but it requires a 
judge's order. Under the governor's proposal, a doctor can trigger 
the three-day hold.)

As a psychiatrist who treats addicted patients, I know that voluntary 
help is sometimes not enough. The truth is that people immersed in 
heavy drug use are notoriously ambivalent about giving it up.

In fact many, if not most, patients come to treatment because someone 
- - a spouse, a boss, child, parent - mightily twisted their arms.

To be sure, voluntary treatment slots can be hard to come by. But 
even when patients enroll on their own, they drop out at high rates 
of 40 percent to 60 percent within days or weeks of admission.

Dropout typically means return to use. This is why leverage to keep 
patients in treatment is precious. Commitment provides leverage.

But can treatment really be helpful if a judge compels it? The answer 
is yes. Volumes of data from criminal justice programs lasting a year 
or more, such as drug courts and other probationary programs, attest 
to that fact.

Baker's civil commitment law, however, would max out at 90 days. 
That's a short period of time in which to gain a solid foothold in 
recovery, especially for a person whose addiction is so severe that 
he or she was committed.

So, how to get the most out of three months?

First, emphasize outpatient care. Coerced treatment should not 
reflexively mean institutionalization. Typically, a heavily addicted 
person needs a week or two as an inpatient to stabilize. This gets 
him through the worst of the opiate withdrawal, attend to any medical 
problems, and normalize eating and sleeping.

Beyond that, it's too easy to be an inpatient. While cocooned inside, 
protected from drugs, patients' craving tends to subside and 
over-confidence about being able to stay abstinent or to manage safe 
use grows. Discharge is often a rude awakening and a stimulus to relapse.

By starting to repair their lives in the real world - applying for 
jobs, preparing to re-enter school, establishing healthy social 
network and re-connecting with family - patients confront the stark 
reality of their vulnerability to relapse.

Outpatient care consists of counseling, family or couples' therapy, 
and employment or educational coaching. But the community is where 
patients put it all to work, especially the relapse prevention skills 
they've learned in counseling, such as identifying triggers for 
craving, coping with craving, and stress management.

The second way to help patients is for the treatment program to use 
incentives to shape their behavior and motivation to quit. A vast 
literature exists, for example, on the use of redeemable vouchers to 
extend retention and reduce drug use.

Such vouchers have monetary value that patients can exchange for food 
items, movie passes, or other goods or services that are consistent 
with a drug-free lifestyle. The voucher values are low at first, but 
increase as the number of consecutive drug-free urine samples 
increases. Positive urine samples reset the value of the vouchers to 
the initial low value.

In another model, psychologist Kenneth Silverman at Johns Hopkins and 
colleagues have offered $10 an hour to addicts to work in a 
"therapeutic workplace" if they submit clean urine. If the sample is 
positive or if the person refuses to give a sample, he or she cannot 
attend work and collect pay for that day. Workplace participants 
provided significantly more opiate-negative urine samples than 
controls; reported more days employed, higher employment income, and 
less money spent on drugs.

Third, add medication. For patients who have trouble refraining from 
opiates, physicians can prescribe naltrexone as a once-a-day pill or 
30-day injection to block the effects of opiates. Another option is 
buprenorphine (a combination opioid analog plus blocker sold as a 
sublingual film or tablet and prescribed by specially-licensed doctors).

Critics of the commitment proposal are understandably nervous that 
people won't come into drug treatment on their own for fear of being 
detained. But the opposite is likely true. People who present for 
treatment on their own are the least likely to be detained  after 
all, they've shown an interest in getting help.

A small fraction of heroin users are at imminent risk of serious harm 
or death. The option for commitment, like a very powerful medicine, 
should be used sparingly. But it can save lives.
- ---
MAP posted-by: Jay Bergstrom