(PO-019) (PO-019) Mandatory Substance Use Treatment: What Should C-L Psychiatrists Know?

Background: C-L psychiatrists are often asked to comment on the appropriateness of referral to involuntary psychiatric treatment based on a patient’s inability to care for themselves due to severe addiction. 38 states allow for court-mandated substance use treatment in various settings, though data regarding its efficacy is both limited and inconsistent (Udwadia, 2020).




Case: Patient JAC is a 59 year old male with a history of alcohol use disorder with Wernicke-Korsakoff encephalopathy resulting in repeat admissions who was admitted for management of beer potomania and electrolyte imbalances complicated by alcohol withdrawal requiring phenobarbital taper. Primary team had concerns about his continued alcohol use after discharge and inquired into the indications for court-mandated substance use treatment. This led to a larger discussion into what the process entails, its implications and the role of the hospital provider.



Discussion: A sense of helplessness in the setting of severe addiction or repeat admissions drives primary teams and family members to attempt to “rescue” the patient from their addiction and to inquire about involuntary psychiatric commitment. Legally mandated substance use treatment, however, is distinct from primary psychiatric hospitalization and varies between states in rate of utilization, structure, and implementation (Jain, 2018). The decision to refer to involuntary treatment is based primarily on availability of services and patients retain little autonomy. Moreover, medication-assisted treatment is not offered in all mandated programs and some even house patients in prisons. Notably absent are consistent data supporting long-term efficacy of compulsory programs. Although mandated patients are more likely to complete treatment than voluntary patients (Coviello, 2013), referral to involuntary substance use disorder programs are not without risks as these patients are twice as likely to overdose upon discharge (Udwadia, 2020).




Conclusion: Considering involuntary addiction treatment for a patient on the C-L service can be complex, controversial, and of unclear value. The increasing number of patients with sequelae from severe addiction engenders powerlessness in primary teams, not recognizing that successful treatment of substance use disorders requires sufficient internal motivation which is negated with compulsory treatment. The educated C-L psychiatrist must appreciate the ethical complexities, acknowledge limited evidence for efficacy, and recognize the risks of mandated substance use treatment to support the primary team in their medical decision making.




References:

1. 
   Udwadia FR, Illes J. An Ethicolegal Analysis of Involuntary Treatment for Opioid Use Disorders. J Law Med Ethics. 2020 Dec;48(4):735-740.
   
   

1. 
   Jain A, Christopher P, Appelbaum PS. Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work? Psychiatr Serv. 2018 Apr 1;69(4):374-376.
   
   

1. 
   Coviello DM, Zanis DA, Wesnoski SA, Palman N, Gur A, Lynch KG, McKay JR. Does mandating offenders to treatment improve completion rates? J Subst Abuse Treat. 2013 Apr;44(4):417-25.
   
   

Learning Objectives:

• Review what court-mandated substance use treatment may involve in the US
• Outline medicolegal complexities of court-mandated substance use treatment
• Discuss the role of C-L psychiatrists in framing the discussion with our medical colleagues regarding consideration of involuntary substance use treatment