Coerced Drug Treatment Policies

Research Brief

Legally compel an individual to participate in and comply with treatment for opioid use disorder (OUD) as an alternative to another form of sanction (e.g., incarceration, loss of child or custody, loss of employment or benefits).

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and opioid overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
Yes
No
No

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
No
Yes
OUD Treatment Retention
No
Yes
No
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
Yes
No
Affordability
No
Yes
No
Equitability
Yes
No
No

Summary of Expert Comments

  • Despite small increases in OUD treatment engagement and retention, experts anticipate no effects on remission and overdose mortality.
  • The general public may find the policy acceptable (due to stigma around OUD), but numerous panel members strongly disapprove of the coercive and punitive nature of the policy on ethical grounds.
  • Experts believe the policy will exacerbate health disparities among low-income communities and people of color, reflecting oppressive practices by the criminal-legal system regarding substance use in these groups.
  • The policy would be feasible to implement in the current criminal-legal system; potential barriers could include community norms, political context, legal environment, and limited implementation resources.
  • The policy could be potentially cost-effective in the long term (compared with incarceration) but has large resource requirements in the short term and high continuing costs.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial

(selected)
Coercion will lead to more initial treatment engagement compared with alternative sanctions. Evidence on physician health programs, court mandates, Veterans Court, and drug courts indicates positive impacts on treatment engagement. “While I believe coerced treatment is not good, I agree that it [is] better than the current situation…. If the choice was between coerced and not coerced, we should choose not coerced. But the choice is really between coerced and incarceration unfortunately”
Little-to-no Coercion could help some individuals seek treatment who otherwise might not. These individuals will likely receive services within 34 days (but may not fully participate). “It might help some individuals who might not otherwise seek treatment”
Harmful Forcing people into treatment does not help; rather, it is counterproductive for client engagement. “Forcing people with OUD into treatment is never a helpful solution”

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increased initial engagement from coercion will translate to more treatment retention compared with alternative sanctions, especially if treatment is (1) mandated for at least 6 months and (2) high-quality and therefore becomes valued by patients over time. “Coercion is counterproductive for client engagement and retention in treatment and is wrong. But sometimes people will remain in treatment due to coercion if there is a strong incentive like getting one’s children back”
Little-to-no

(selected)
While some may benefit, initial treatment engagement generally will not translate into sustained, long-term retention in treatment, especially if mandates are short term. “There is likely to be increased initiation in treatment if a court mandates this for an individual, but he/she may not remain engaged for the long term, especially since the person may not be ‘choosing’ this option”
Harmful Forces people into treatment instead of supporting them to make the decision to start treatment on their own. Abstinence-only and punitive approaches have longer-term collateral consequences. “Forcing people with OUD into treatment instead of protecting them while they make the decision to start treatment on their own is never the answer”

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increased engagement and retention will translate into increased remission for some patients. “Increased retention leads to decreased relapse”
Little-to-no

(selected)
Will not impact symptom remission after 1 year if mandated treatment ends before then. “Folks would leave treatment after they are no longer mandated to be in it since it was not their decision”
Harmful Coerced treatment will not lead to improved OUD outcomes, especially after mandate ends. “Coercion is wrong and unlikely to result in lasting client outcomes without the client’s buy-in”

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increased treatment engagement and retention will translate into some decreased overdose mortality. “Getting people into treatment, no matter the path, I believe, is better than the consequences”
Little-to-no

(selected)
Too few people will be mandated to treatment to see meaningful changes in population-level overdose mortality, and the negative impact of discontinuing treatment after mandate ends could counteract any positive impact on mortality during active treatment. “Most overdoses are among folks who have not been in treatment. I don’t think that a large enough percentage of the population could be mandated to treatment such that it moves the needle very far by way of mortality from overdose”
Harmful Punitive nature of coerced treatment could lead to unintended negative consequences, especially when the mandated period ends. “Once court mandates end, especially if a person then discontinues medication, risk of overdose may actually increase”

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Public accepts punitive measures (like mandated treatment) for people who use drugs due to stigma and perceived diminished autonomy. “General acceptance of punitive measures against people who use drugs and people with substance use disorders persists”
Moderate Some pushback against coercion, though acceptability (as an alternative to incarceration) is increasing with increasing overdose mortality. “There is consistent pushback from the standpoint of intrusiveness. This perspective, though not measured to my knowledge, is decreasing in its strength due to increasing overdose death in the general public”
Low Forcing treatment violates civil rights. “It is not acceptable to force people against their will into treatment as it removes their civil rights”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Already common practice. “Many local jurisdictions already do this through probation, parole, and drug court/problems solving court”
Moderate

(selected)
Likely feasible within the current criminal-legal system, though it depends on community norms, political context and will, and legal environment. Increasingly scrutinized due to costliness and contributions to re-incarceration. Facilitators (e.g., availability of OUD treatment providers) may not exist for some (e.g., rural populations). Compulsory treatment via the justice system seems to be an increasingly common pathway to care. However, the extent to which such treatment is evidence-based is unclear, indicating the potential challenges of linking the justice and medical systems
Low To assess cases and enforce mandates will be complex. Insufficient (MOUD) resources to implement high-quality care and evidence-based treatment. Lack of expertise in OUD among actors in criminal-legal system could influence treatment plans “It takes a lot of resources to set these up then follow through to make them work”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Affordable policy long term compared with costs of incarceration. “Dependent on the method of administration and competence of evaluation, this is an extremely affordable policy—in the long run”
Moderate

(selected)
Potentially cost-effective in long term, but high short-term and continuing costs (setting up complicated systems, training, coordination, treatment costs). Depends on staffing, existing treatment infrastructure, and who pays. “They are cost effective … but short-term costs include setting up new systems, training, coordination, etc.”
Low Coerced treatment is both expensive and ineffective. Requires additional resources or stressing existing ones. High costs to administer (reviewing cases, assessment, locating treatment, reliance on residential [versus outpatient or office-based] treatment, enforcement). Funnels resources into criminal-legal system with low likelihood of reducing overdoses and recidivism. “Coerced treatment probably counterproductive and expensive, therefore using resources with little benefit”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Could reduce disparities when the alternative is incarceration. “In the cases when someone would otherwise be going to jail AND the offered treatment is evidence-based and high quality then this probably improves equity”
Moderate Might lead some to have greater access to OUD treatment. Depends on how it is implemented (which judge, who is coerced, who pays for treatment, if evidence-based MOUD is covered, if treatment providers are available). “It’s possible some people who otherwise would not have access to treatment might benefit”
Low

(selected)
Negative history of coerced treatment and criminal-legal approaches among low-income communities and people of color (e.g., War on Drugs). Coercive mandates will exacerbate existing health disparities in treatment outcomes due to structural racism and racial bias in the criminal-legal system (e.g., over-policing, racialized arrest rates for drug use and possession, selective and inequitable use with people of color), low-quality evidence for coerced treatment, and criminalization of substance use disorders (compared with other health issues). “The current state of enforcement mechanisms across systems (e.g., criminal justice, health care, child welfare) shows gross inequities in populations that are targeted, surveilled, and treated, with [communities of color] being most surveilled and targeted. Having less access to effective, evidence-based treatment (e.g. MOUD) and having higher likelihood of facing sanctions for non-compliance”

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