Clinical experience with civil commitment

The unstable motivation of the addicted person has represented a major problem in the treatment of opioid dependence. Only a minority of voluntary patients remained in the two PHS hospitals for treatment beyond withdrawal. Early followup studies at the two hospitals indicated that treatment under legal coercion, especially when combined with compulsory posthospital care, had better outcomes, but not markedly better, than did voluntary treatment. A large proportion, one-third to one-half, of the patients admitted to the hospitals for examination prior to civil commitment were found not suitable for treatment, mainly due to their disruptive or dangerous behavior. Due to attrition after examination and during 6 months of hospital treatment under commitment, only about one-third of the civil commitment patients admitted were discharged to aftercare. The high attrition rate may have been partly due to intensive psychosocial treatment. Patients who absconded from treatment were not prosecuted; consequently, civil commitment provided only a weak coercion to treatment. Two followup studies suggested that the short-term outcomes of the civil commitment patients were somewhat better than those of voluntary patients. Limited and inconclusive research exists on the relation of coercion to long-term stable abstinence. Methadone maintenance is accompanied by improved social adjustment, but it retains in treatment only a minority of opioid drug users. One study suggests that 16 to 30 percent of the population of chronic opioid users in the community is not in treatment. Civil commitment, as one of an array of social and legal coercions, can probably bring some opioid users into treatment who would not voluntarily enter. It has several limitations. Civil commitment cannot overcome deficits in treatment services. Civil commitment, or any other kind of external coercion, can bring drug users into treatment but cannot assure that patients will participate in treatment. Finally, civil commitment is restricted by constitutional guarantees of individual liberty.