By David M. Greenwald
Last week we presented a critique of DA Jeff Reisig’s homelessness proposal. One of his more controversial planks was: “Amend California law to mandate state-funded treatment for seriously addicted drug users, including involuntary residential treatment, when appropriate.”
But there are questions about whether this in fact represents an evidence-based approach. Critics point out that “involuntary and immediate” cessation of use often does not lead to lasting recovery, as it only deals with the chemical side of the equation and fails to address the underlying reasons why the person turned to drugs in the first place.
More troubling is evidence that mandatory drug treatment is not effective in reducing drug use to begin with.
Researchers in a 2016 Boston University Medical Center study looking at current global evidence found “mandatory treatment for people with substance use disorders is not effective in reducing their drug use.”
They found, “mandatory treatment, which is defined as treatment ordered, motivated or supervised under the criminal justice system, done without a patient’s informed consent violates their human 
rights and does more harm than benefit to the patient.”
Instead, Bulat Idrisov, MD, MSc, and Karsten Lunze, MD, MPH, DrPH, from the Clinical Addiction Research and Education Unit at BMC and Boston University School of Medicine argue “that in order to reach successfully reduced substance use disorder rates, countries should consider implementing approaches that have been shown to be effective in rigorous scientific studies.”
“These strategies include community-based opioid treatment, including methadone and buprenorphine. In addition, they suggest that offering harm-reduction programs like needle exchanges and providing education about overdose medications such as naloxone to people with substance use disorders, as well as to their friends and family members.”
“The evidence presented in this article provides additional argumentation supporting the position of all UN organizations that mandatory treatment settings do not represent a favorable or effective environment for the treatment of drug dependence,” said Fabienne Hariga, MD, MPH, senior adviser to the United Nations Office on Drugs and Crime during the recent meeting in New York.
The doctor added, “The United Nations therefore calls on States to transition from mandatory drug treatment and implement voluntary, evidence-informed and rights-based health and social services in the community.”
The 2016 study backs up evidence cited by a study publish by the NIH which found: “Despite widespread implementation of compulsory treatment modalities for drug dependence, there has been no systematic evaluation of the scientific evidence on the effectiveness of compulsory drug treatment.”
Their meta-study found, “Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.”
The mandatory component was the first of five proposals put forward by Yolo County DA Jeff Reisig as a plan to reduce homelessness.
“Homelessness is an exploding humanitarian crisis affecting almost every community in California. Too many people suffering from severe mental illness and crippling addiction are being allowed to languish in filth and perish on our streets from disease, overdose and violence,” Reisig writes. “They need help.”
He argues: “Meanwhile, the quality of life for all Californians has dramatically declined as the crime and despair associated with the crisis has seeped across our state. There are real potential solutions to this crisis. They are not easy and they are not cheap. But, if California ever hopes to turn the tide, dramatic action is required.”
The other four points are:
- Expand conservatorship laws – make it easier to allow the seriously mentally ill and addicted to be conserved by loved ones and health professionals.
- Establish permanent drug courts and mental health courts in every county, where judges can collaborate with health professionals and all the parties to oversee a comprehensive treatment and rehabilitation plan.
- Build addiction and mental health facilities that can serve as secure treatment focused sanctuaries, not jails or prisons.
- Develop a statewide chain of drop-in-centers to provide free ongoing support and Medication-Assisted Treatment (MAT) to those on the path to recovery.
Maya Schenwar and Victoria Law in their book, Prison by Any Other Name, express concern that drug courts and state-mandated treatment are expanding the scope of the criminal justice system to treat people who actually may not need to be treated.
“Most people are not debilitated by physical dependence on the substances they use, whether they be alcohol, caffeine or heroin.”
But more importantly the solutions to those who are, may not be effective.
They found, “Graduating” from a state-mandated treatment program does not necessarily equal real recovery and healing.”
They argue: “Even if a treatment sentence doesn’t end in incarceration, there’s no guarantee it will transform a person’s life. In fact, if the underlying causes behind the drug use – poverty, trauma, the enduring impacts of racism and other oppressions, and so forth – aren’t address, the recovery may not last.”
Our chief criticism of the DA’s plan last week is that while they put forth a large number of enforcement-based remedies, there is no provision for rebuilding their lives, job training, counseling and affordable housing. Without those kinds of programs, they may remove the drug-component or potentially the mental health component without allowing them to move forward.
And this research suggests that these approaches are not evidence-based, with no firm research to suggest that such treatment actually works.
—David M. Greenwald reporting
To sign up for our new newsletter – Everyday Injustice – https://tinyurl.com/yyultcf9
Support our work – to become a sustaining at $5 – $10- $25 per month hit the link:
“a 2016 Boston University Medical Center study found…“Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.”
Reisig writes: ““Meanwhile, the quality of life for all Californians has dramatically declined as the crime and despair associated with the crisis has seeped across our state.”
I suspect the key is a marked difference in emphasis. Reisig sees the effects on those of us who are not afflicted by drug addiction or homelessness as the priority, whereas the MDs and homeless advocates see a holistic approach to the individual’s health and reintegration into society as the priority. Both goals are laudable, but a full evidence-based approach is what is needed and that will indeed be very difficult, long-lasting, and costly.
I agree that mandatory rehab doesn’t work. What is needed are programs for those that are ready to recover, leading to getting back on their feet. Most will never reach this point and take a slow path to death. I agree with Resig on coservatorship for the severely mentally ill, but not for drug addiction. This is of course complicated for those who suffer from both, and for them there is no easy call as each case is different.
True the underlying issues must be addressed. Government doesn’t have the power to ‘address’ each individual’s trauma – that is the lifetime job of the individual if they survive. Not that the trauma, especially early trauma, is the person’s fault.
I have never believed drug use or possession itself should be illegal. However, the effects of the collective use by many individuals harms families and society. Crimes committed in the pursuit of drug use should not be minimized or forgiven, such as how a crash from intoxicated driving is not forgiven because one is an alcoholic. Behavior must have consequences, lest society becomes the enabler of the addict slowly or quickly destroying their lives.
Society should, however, always have sufficient resources available to those who are ready and ask for a helping help and give them a chance to find their recovery from addicition.
95% agree, Alan… but am aware of at least 2 folk, where an “intervention”, initially involuntary, quickly lead to voluntary treatment, and a ‘recovery’ (including future “abstinence”) was achieved… (and successful lives, careers)… but the individual had to “make the choice, and act on it”…
There may be a ‘place’ for both, but 100% mandatory?… once the ‘mandate’ ends, often so does the ‘compliance’…l
Interventions can work. They don’t have a high-success rate, but neither does drug addiction 🙁 I recommend to people with a family member addicted to give intervention one shot – really read up on it so you have the greatest chance of success – don’t expect results – and realize you may have planted a seed that takes root later. What is rarely successful is a second try at an intervention – they can see it coming a mile down Main Street.
Now, we’re in 99.44% agreement, Alan. One of the two folk I know of, needed a second ‘intervention’… but, it “took”…
But you are 100% correct, when you say,
Like some rules in softball… two strikes, and you’re out… first strike could happen when the family/friends haven’t really informed themselves, and had the cahones to come from a “tough love” view in the first try… your main point, bolded, is ‘spot on’…
Alan M
What I’m reading into your message is a claim that there’s no solution so we shouldn’t do anything. Do you have empirical evidence beyond your own personal experience that backs this claim? We cannot make general policy based on anecdotal personal experience because it is by its nature quite limited and is largely unable to explore alternative solutions.
Addiction is a bear. If you know of a way to shoot the bear, I’m all ears.
https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
Examples of private programs that basically use CBT or REBT include SMART Recovery, Rational Recovery (for-profit), Women For Sobriety, Secular Organization for Sobriety, LifeRing, etc.
I’ll check it out (the link), and head on over to Big 5 to purchase a bear rifle.
No surprise that when criminal justice professionals are the ones establishing policies, you’ll get criminal justice solutions. Those solutions inevitably focus on involuntary interventions and incarceration.
Drug addiction and treatment entail medical, psychological, behavioral, and civil liberties issues. We should rely primarily on those with expertise in those disciplines in formulating treatment approaches, not on law enforcement professionals.
Yet, getting agreement between those disciplines as to a “solution”, would be somewhat like getting an armadllo to successfuly mate with a mango, and expect offspring…
I see Resig as not setting policy on addiction in general, but setting policy for when people reach his system.
No?
Not how I read it, except, perhaps for the drug courts. If that were the intent, I would think the proposal would be framed more as an expanded diversion program.
Seems that a primary “purpose” of involuntary treatment (holding) is misunderstood here, as usual.
A primary reason is to get people off the street (for others’ benefit). Much like incarceration of prisoners, which removes those who’ve committed problems for others, and presumably are at high risk for continuing to do so.
And given that there would always be those who refuse voluntary treatment, involuntary treatment is ultimately the only way to get everyone off the street.
that point was not missed at all. In fact it’s basis of the book Prison by other Means.
I believe people should be held for crimes, not drug use itself. As part of incarceration, they should be given the option of drug treatment.
It “used to be” a crime to live on, block sidewalks and entrances to buildings, collect garbage thereupon, and urinate and defecate on the street. 😉
As it should be again.
That’s the problem: compassion doesn’t equal public feces.
By the way, there appeared to be a significant homeless presence over by the Park-and-Ride lot, near Ikedas. A lot of garbage/belongings that can be seen when walking over the overpass. I suspect that this isn’t the “only” semi-remote area like that.
In general, I wonder if we’re seeing the decline of Western civilization at times.
But I believe that there may be a hotel being used to house the homeless, on the other side of I-80 in that area. Unrelated to the garbage, I assume.
That has been there for years, and the garbage is horrific. That encampment extends under the Mace overpass and behind the businesses on the SE side of the 2nd street curve towards Mace (across from target) as well. I would have much higher tolerance for so-called homeless if these encampments weren’t accompanied by what seems like an impossible-to-ever-cleanup amount of trash. I’m not really sure why the neuvo-homeless are so attracted to trash and so good at creating more and more of it. If someone could study the cause of this and find a solution, that would go a long way towards solving one of the major issues.
I have noticed that along the bike path on the north side of the railroad from Olive to Mace, the inhabitants have not piled up so much trash. I’ve seen garbage bags there – like waiting to be picked up, and heard indirectly the City works with some of the so-called homeless to collect their garbage and leave it for a City crew to pickup. Perhaps that is what is happening here – and if so – maybe could be expanded?
Some notes from a seminar I attended several years ago. The presenter’s background was CBT.
In the general population, it has been shown that cognitive behavioral approaches are somewhat effective in reducing substance abuse. There is some evidence for that in prison populations as well. [Note: whether it translates to effective treatment for the homeless population is not evident so far as I know.]
Unfortunately, even cognitive approaches are not highly effective. In fact, no program has been shown to be highly effective at achieving abstinence, though there are better outcomes if your goal is harm reduction. Of the more common treatments, 12-step has very low proven efficacy although it has been shown to be somewhat effective for people who use it very long-term. The fact that many individuals consider it very effective based on their own experiences should not be discounted. But it’s not sufficiently effective to be considered a reasonable program for our criminal system to adopt, or for physicians to recommend as being evidence-based. 12-step rates of abstinence are on par with, or lower than, simple self-remission.
Brief interventions and motivational enhancement have generally been shown to be the most effective methods for achieving abstinence.
Attempts have been made to determine if there are variable outcomes based on how people feel about agency for change (internal vs external locus of control). The theory is this could be used to determine whether group (12-step) or cognitive approaches would be a better ‘fit’ for an individual who has been remanded, or chosen, to enter a treatment program.
The evolving definition of addiction (there is no clearly accepted definition of the term ‘alcoholism’, for example) into a spectrum approach rather than a binary definition could help direct people to the right kinds of treatment. Some people literally need medical supervision (about one in six can suffer seizures if they quit alcohol cold turkey, for example). Others may only need some individual or group counseling, with scheduled followups (IOP).
Many people who commit crimes and are using substances don’t actually require substance abuse treatment. Their issues are primarily criminal behavior and should be treated as such.
Important data point is that most people age out of substance abuse.
My opinion: substance abuse is not primarily a criminal issue. But reliance on treatment programs is unlikely to succeed in achieving abstinence because no programs have high rates of efficacy. Harm reduction may be achievable.
The consequences of implementing housing programs based on harm reduction approaches may not be desirable in traditional residential neighborhoods. The threat of incarceration may well be what it takes to get some people into programs and keep them there. If there are no consequences for failing to continue the programs, outcomes are likely to be even worse.
One of the most important things is for people who graduate from these programs to not fall back into their previous associations and neighborhoods. Housing vouchers and jobs programs may be helpful in that aspect of re-entry. I am not aware of any data about the efficacy of these programs, other than anecdotal. We all want to believe it works, and it’s probably better than doing nothing.
Good points…
… yet, a homeless person, unemployed, addicted, may get free from their addiction(s), and still be homeless/shelterless, jobless… particularly in today’s ‘pandemic’ economy… they might just be more ‘aware’ of that reality…
Gets to “pallative treatment”…
My experience with the homeless is that they have a “constellation” of issues… homelessness, poverty, drugs/alcohol, MH issues, etc. … the hydra does not die if you cut off one head…
DS, a lot of what you said is ‘true’ from the point of view that you are taking, which is probably how most people would view it. Addiction, however, falls into a completely different paradigm for those afflicted. It is basically a death sentence because the desire for the intense internal pleasure escape becomes impossible to ignore, and the pursuit of this “high” becomes an obsession from which one cannot escape – but for whatever reason – a small percentage do. For those, a 12-step program can be 100% effective if actually practiced. But there is no way to measure this, as the question isn’t – are 12-step programs effective? . . . but rather – do they work for those that seek recovery? Put another way, would the millions that have found recovery have been able to achieve long-term freedom from addiction if 12-step didn’t exist? I will venture to say, though it is impossible to quantify, most of those millions would be lost with nothing to moor themselves to.
True, courts cannot rely on 12-step programs, because they are not a ‘cure’. Rather, they are there for those that need them. Nor will I say they are the only way – I have known people who recovered through their religion – but as 12-step is basically a distillation of universal spiritual principals along with fellowship of those similarly afflicted, we are really talking about the same thing.
You mention “self-remission” and “aging out of substance abuse”, which are basically the same thing. I totally agree this is the most common outcome for substances users and abusers with many substances. I would argue, however, that these are not true addicts for which those concepts are impossible. I have known hundreds who followed those very paths – most from my college years. When they realized getting wasted wasn’t going to work for a career or raising a family, their brains worked well enough that they ceased the abuse and turned a corner in their lives.
You also mentioned ‘graduation’. One may graduate from a rehab center, but an addict never graduates from being an addict. Addiction is a death sentence, and to relapse, even after years of abstinence, is return right back to where you were. There are of course exceptions, and for some drugs the term “death sentence” may be too strong, but generally it is on target. True, I have known several addicts who simply found a softer drug that didn’t destroy their lives and their bodies so completely and has allowed them to live functional lives. I don’t know that this is truly ‘recovery’ from addiction, but it is certainly preferable to death, devastation and prison.
Bottom line: the idea success in recovering from addiction isn’t defined by treatment methods and programs, so much as it is by the devastating nature of addiction itself.