A look at treatment that is mandated — either by a drug court, or in a process similar a mental health hold, done by family members or friends petitioning the court. About 20 states permit involuntary treatment for addiction, dating back to a 1962 case heard by the Supreme Court that said addiction per se was not a crime, but treatment could be ordered by the court. And there is some evidence that it does work in many cases. At play is the continuing debate about whether addiction is a physical disease, or a series of poor judgements and lack of will power. And the recent increase in opioid addictions seems to be adding to the debate.
[Transcript Edited]
Howard: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. One of the stories that popped up in a number of places – New York Times and Time magazine has to do with forced treatment to addicts. And I thought it would be interesting to talk a little bit about that. There was an article recently in the New York Times written by a doctor and a corollary story in Time magazine on the same subject. What is your impression of forced treatment and are the chances success?
Darryl: Well, I was enlightened by the New York Times article because I didn’t realize that way back in 1962, a Supreme Court ruling in the Robinson v. California case prohibited the state from convicting somebody solely for being an addict,( the use of civil imprisonment as punishment solely for the misdemeanor crime of addiction to a controlled substance was a violation of the Eighth Amendment’s protection against cruel and unusual punishment) so the consciousness goes way back to 1962 that addiction per se is not illegal, and although you can’t convict somebody for being an addict, the states did have the power to coerce or force somebody with addiction to participate in a treatment process. So in a way, I guess the courts were really sensitive and aware of what addiction really was much more than the general public is even to this day – most of the general public views it as a moral issue.
Howard: Right we keep going back and forth about that one.
Darryl: And then there is the treatment issue. One thing we’ve known for awhile because of a number of studies done in California and other states, is that many times, coerced treatment is more effective than voluntary treatment. That has always been an enigma to me because I always thought someone would have to want to get better or want to deal with their addiction before they can actually do something about it that addiction required a self diagnosis or a self awareness that something had to change in order to get out of addiction. But the studies showed outcomes and those who were doing better after so many months of treatment were convicts or addicts who were in the criminal justice system – especially those in drug court systems. These people were forced into treatment and many of them didn’t really want to go to treatment. Many of the addicts sent to the Haight Ashbury Clinic in the 1980’s told us they didn’t care what the judge said, they “ain’t gonna participate in group – ain’t gonna do their homework – ain’t gonna do the treatment”. They would tell the judge, “yes, I’ve found God I want to go to treatment, my life is a mess” but then they come to us and hold their fists against our face and say “you ain’t going to make me do anything”. So there was a conflict right away – we merely dealt with it by not engaging the client, sort of a Gestalt therapy of flowing with the client saying you’re right. You can only do what you want to do. We’re not going to do anything more than provide the treatment and report to the judge whether or not you are participating in treatment. That information gave the drug courts the authority to get the sheriff’s department involved, probation involved, social workers involved and what they all did was round up the client and oftentimes brought him back and set him right in the chair and made him go through the groups.
Howard: Well, the alternative is going to jail, right?
Darryl: Yes, they go straight to jail and that’s what most judges do. Some judges are knowledgeable and have concern for the client and really know what addiction is and they want them in treatment. They don’t want to throw them back in jail, but by and large a majority
Howard: things don’t get much better there. In fact they get worse.
Darryl: The majority of drug court judges use the gavel, – “Okay, you aren’t going to treatment, you relapsed, your urine is dirty, whack! Another 6 months in jail”. And they use that as a hammer to get them back into treatment. But some other judges, and probation officers take a hands approach to make the person stick it out and those are called a treatment monitors and we know that the most effective treatment programs have effective treatment monitors, like the addiction programs for physicians and pilots. They oftentimes employ somebody outside the primary treatment program to monitor whether or not somebody is participating, if the urine tests are clean, and stuff like that. And an amazing thing happened, not only in our clinic, but across California – studies started showing that people who were in coerced treatment – by drug courts, probation, parole, criminal justice system, or by whatever else had leverage over the person . had better results than those in voluntary treatment. We were puzzled over that – it was hard to understand – then we realized that if someone comes in voluntarily for treatment – their life is a mess and they just lost another relationship or got another DUI and they were just tired of this and wanted to get off something – so they come in and spend a day in residential treatment or one week in outpatient treatment and then look around and start saying, “I’m not like these losers here. I’m not really an addict. I don’t need to be here” and they split. Okay they just leave because nothing is forcing them to participate in treatment. Well, that’s a treatment loss. We’ve lost that person, you know. We can only hope we had some impact on them and they’ll think about coming back in at another time. But if someone comes in through a drug court and they decide “I’m not going to participate, I’m not going to do this I’m going to leave” well they can’t do that because the judge is going to force them back into treatment. There is a belief we have in treatment that’s validated by the fact that if a person sits there long enough even if they are opposed to treatment, if they are exposed to the lesson plans, exposed to the medical interactions, exposed to other people who are in recovery, something amazing happens. We call it the miracle – we saw a number of people who were resistant to treatment but were there because of a DUI or their drug court situation who then embraced recovery, accepted the fact that they had a medical problem with drugs and were able to get into long term treatment. I’m sure there are a lot of issues some of them have to do with where is it legal and where is it not legal in terms of what the treatment must be comprised of. Here in Oregon, our drug court judges want to see one kind of treatment system, one provider, a single provider so they can control variables and have sanctioned only one evidence based treatment process and that’s the Matrix process. Which is a very good process.
Howard: Right, right.
Darryl: But I don’t think that’s a good way of approaching treatment because people are different. People come from different situations and we usually don’t try to shove a patient into a treatment system and make them stick it out regardless of how effective it is for them – we like to find a treatment that is acceptable to them. Again, this speaks to whether coerced treatment is good or not, but in that process, you know, what is the legality of that? Another legal issue is the use of medications. We use Antabuse for alcoholism or cocaine addiction, we use buprenorphine, and Suboxone but many of the drug courts don’t allow methadone. Many would like us to use Naltrexone, the blockers and Antabuse, but clients don’t want to take them because they know it’s going to interfere with their use of drugs and alcohol. So they often come in and tell us, “I’m allergic to that stuff. I’m allergic. You can’t give me no Naltrexone” – we challenge this and test them to find out if they’re really allergic to it or they just don’t want to take it, but it’s the best thing for them in terms of treatment. We just tell them it’s part of their your treatment plan – the medication will prevent them from using opiates and it’s going to block craving give them a chance to stay clean and sober. If the person says I’m not going to take it, we have to report to the drug court judge that they’re not compliant with their treatment plan. If they were in jail, I don’t think we could force them to take anything. You can’t force anybody in jail to take any medication no matter how bad they are, but someone in coerced treatment can be forced by the judges and the courts to take different medications because if they don’t – they are in violation. So, there are a lot of issues I think that come up that need to be teased out. But the fact is, coerced treatment has such a positive impact at reducing crime and reducing recidivism in the criminal justice system that it has caused another problem – in San Francisco anyway .the criminal justice system started monopolizing all the treatment. They had all the money and were able to buy up all the treatment slots so when they arrested or convicted someone they had a place to send them for treatment. These people didn’t have to go on a waiting list. The courts purchased and reserved and monopolized treatment slots, which then created the issue of, is that a fair situation for our society? If you have a law abiding addict if there’s such a thing, why should they have to go to the back of the line while someone who has committed a crime – got arrested and was forced into treatment gets to go ahead of them.
Howard: Well, the question that comes to mind is, are we making any steps forward in standardizing the treatment approaches? I know there is a focus on evidence based treatment but are there various associations around the country, coordinating the process as well as the training and credentialing of the counselors?
Darryl: I have a bit of an issue with that because due to the increased medicalization as well as the increase in coerced treatment and the need for accountability, the need to have outcomes verified things like that. We have an evidence based registry put out by the federal government and then each state seems to have their own evidence based acceptable registry of programs. In Oregon, you cannot provide treatment for addicts unless you use or are employing an evidence based treatment intervention. You can’t just go out there and use anything – the good thing is there are probably several dozen evidence based treatment interventions so you can use one or the other to address the individual needs of some of your clients. But the problem with that is that it totally ignores what I call “practice based treatment interventions”, things that have been used and been effective for maybe 100 years. For example, in Thailand they are still using puke therapy, it’s been used for many, many generations – they don’t “treat” your heroin addiction, they give you herbs and things that make you throw up a lot and that seems to be an effective way of treatment. Of course, it is not considered evidence based, so I don’t think that will fly here, but my issue with this is that there are some good evidence based treatment programs that can’t fund what it would take to validate the scientific process. It takes hundreds of thousands if not millions to do the statistical work and the research and the random assignments and the outcomes to make sure that you have solid scientific empirical evidence that this is an effective treatment. Only certain treatments can afford that and it is usually the packaged models, like the Matrix – which must be purchased.
Howard: Its always about the money.
Darryl: and that locks you into only one system. I think the DSM 5 is going to look at addiction and related disorders as a spectrum disorder. There’s not just one type of addict, but many different types and many different interventions need to be available in order to meet the needs of the specific type of addict you’re dealing with. Here in the Rogue Valley the court mandated programs require the use of the Matrix model just one model and there is only one counseling center that offers it – and their substance abuse workers must meet the state guidelines. So things are becoming codified. My gosh, you can force a person into treatment and actually get good results with it.
Now the other thing you mentioned, Howard, is the need for certification – that counselors are trained and have knowledge of the different evidence based programs. Every state has a credentialing process and they are becoming more stringent. In Oregon..
Howard: Not necessarily mandatory in all the states, right?
Darryl: It’s always mandatory, but because some are fairly new, there are ways to circumventing the requirements. For instance, in Oregon, once a person is working in a treatment program they have to apply within 6 months or so to get credentialed and the process takes 2 years, but during that time they can work as long as they are under the supervision of a credentialed counselor. And so a lot of programs take advantage of this very affordable labor during the credential process and sometimes don’t keep them on staff once they have earned their credentials.
To be an effective addiction counselor for somebody who has a dual diagnosis or co-occurring disorder, you have to have knowledge of mental health conditions. Oregon is expanding certifications . You have to be a gambler counselor in order to work with gamblers, a pain specialist to work with pain, a registered mental health person as well as an addiction counselor to treat those patients. In the state of Washington, I think just to be able to sit down and work with addicts, although there might be a honeymoon period when you’re working on your degree you have to have a Bachelor’s degree. In Oregon an Associate’s degree or certificate is all you need to start as a level 1 and level 2 requires Bachelor or Master level work and allows a person to supervise. Level 3 requires PhD work and qualifies you to teach at a city college or state college or at the university level. Not all states are structured that way – some are more advanced than others. I think the state of Washington is really up there because they’re requiring a Bachelor’s and then Masters .maybe PhD degree to be able to work with addicts. The sad part is the wages – it’s the opposite of following the money if you’re a drug abuse worker! The money does not reflect the credentialing that’s required and the schooling that’s required.
Howard: Right, right. Well, this was an interesting topic and thanks for the update on treatment in general. We’re about out of time. You’ve got one more thing?
Darryl: Well, I did want to mention the DSM 5 that’s coming out in May, it will have many changes and it’s good that they’re going to include internet addiction for further consideration. There’s a lot of brain studies and imaging under review now that shows that the brains of people who are nomophobic, I guess, is a word
Howard: Nomophobic is what we talked about, yes,fear of being out of mobile phone contact.
Darryl: Yes, mobility. Using your mobile phone
Howard: No mobo phone.
Darryl: That’s the derivation of nomophobia I guess, but as researchers looked at brains they found differences in people that validated the condition – there is a true anomaly between a normal user of a cell phone and versus a pathological user. As to the DSM 5 though, my understanding is that only gambling will be included as a true addiction related disorder. It is news that internet addiction and possibly nomophobia is up for further consideration. And maybe sexual and other disorders – so it’s an expanding field. I was talking to some folks I work with at the University of Utah where we have the school on alcohol. When I first started, it was a school on alcoholism and then as more and more drugs polydrug use became recognized, we had to change the name to the school on alcoholism and other chemical dependencies. With these recently recognized conditions I think we have to consider renaming it to School of Addictions period because it encompasses a lot of different things. The other story that I thought was funny and I wanted to mention involved research on the process of craving and the brain and the ability to image the brain to predict relapse based upon brain activity. Some researchers and some professionals believe it’s medically unethical yet we include expensive brain scans in our treatment processes so addicts can gauge how their brain is healing and what they need to do. Interesting research just came out of China where they are associating cholesterol levels total cholesterol levels and low density lipoprotein, the beneficial cholesterol in our system, as an indicator of craving and of relapse. If those numbers get too high, the person may relapse. If they stay low, it’s a good thing. I think that’s how I read it. Now the research is very confusing on this, but that’s the thing I’m looking for – more practical ways to evaluate the physical differences associated with addiction. Can we find markers? Can we find biological markers that are practical and cheap enough to measure so that we have an effective tool to help addicts know where they are in terms of their risk of relapse and addiction.
Howard: I think that would be very valuable. Okay, well, that’s all the time for this week. Thanks to our listeners for tuning in – we welcome your comments, suggestions and questions. Stop by the website, cnsproductions.com and leave us a note. Thanks, Darryl.
Darryl: Thank you, Howard.
Howard: That wraps our pod for today. Please check back soon for the next in the series and visit our website, www.cnsproductions.com