After Civil Commitment, Medication and Sense of Fairness Help Prevent Relapse.

Civil commitment for substance use is a legal provision in 33 states, where a judge can order someone into treatment—usually inpatient—because their substance use poses a high risk of harm. Civil commitment is increasing in the face of the opioid epidemic, but research has been limited on whether it improves clinical and legal outcomes. No previous study has looked for factors that might be associated with longer periods of post-commitment abstinence.

Now, a new study co-authored by a School of Public Health researcher finds that individuals who feel the judicial process of their commitment was fair, and individuals who received medication treatment after commitment, stay off opioids longer.

The study, published in Drug and Alcohol Dependence, also found that individuals who have been committed for opioid use are an especially high-risk population, and that a third of individuals relapsed the day of their release.

“Civil commitment is happening 8,000 times a year in Massachusetts, at great cost, and we have very little sense who is being committed and whether commitment produces good results, such as introducing persons with opioid problems to long-term medication options or reducing overdose deaths,” says study co-author Michael Stein, professor and chair of health law, policy & management. “Our study offers a first peek at who’s committed and their attitudes toward commitment.”

The researchers used data from a survey of 292 people who sought inpatient opioid detoxification at a program in Fall River, Massachusetts, between October 2017 and May 2018.

A quarter of the survey participants reported they had experienced civil commitment one or more times. Participants with at least one prior commitment tended to be younger, and were more likely to be currently involved in the legal system, to have previously been incarcerated, to have used fentanyl, to have used heroin in the prior 30 days, to have a history of injection drug use, to have had a prior overdose, and to have received medication treatment for opioid use disorder.

The average time to relapse after being released was 72 days, but 39 percent of those who had been committed reported that they relapsed on the day of their release. Only 20 percent of participants who had been committed reported that they received medication treatment during their commitment, 18 percent had a scheduled appointment in the community for medication treatment at the time of release, and only 8 percent actually attended that post-commitment appointment and received medication treatment.

The survey participants generally reported feeling quite negative about being committed at the beginning of their commitment, but that their attitudes were more positive at the end of commitment. They also reported that their motivation for treatment increased after commitment. However, the majority of participants did not report feeling positive or motivated even after commitment, and just over half of participants said commitment was very or somewhat unhelpful, while 31 percent described commitment as somewhat or very helpful.

More positive attitudes after commitment, improvement in attitude during commitment, motivation after commitment, perceived helpfulness of commitment, and a greater sense of procedural justice were all significantly associated with longer periods of not using opioids after commitment. Keeping an appointment for medication treatment after commitment was also significantly associated with staying off opioids for longer.

The authors cautioned against taking the study findings to necessarily mean civil commitment is effective, because of the limits of the sample. Instead, they wrote, these findings point to the importance of medication treatment, and making sure individuals are treated fairly and respectfully in the civil commitment process.

The study was co-authored by Paul Christopher of the Brown University Warren Alpert Medical School, and Bradley Anderson of Butler Hospital in Providence, Rhode Island.

—Michelle Samuels