Introduction

The recent confirmation of Robert F. Kennedy Jr. as the secretary of the Department of Health and Human Services has raised numerous concerns regarding the future shape of the United States’ medical and public health systems. Among his controversial opinions is support for involuntary commitment at abstinence- and faith-based “healing farms” for people struggling with addiction. Some of Kennedy’s beliefs stem from his own experience with addiction and recovery, which involved a variety of abstinence-based programs. He is far from the first politician to advocate for forced addiction treatment, which is growing in popularity as a central feature of the overdose crisis response. Upward of 25 states added new—or expanded existing—involuntary commitment statutes between 2015 and 2018 alone, a trend that invokes the United States’ grim history of institutionalization as a dominant approach to addiction and mental health problems.

While state-level laws allowing for forced addiction treatment are becoming commonplace, their implementation has been limited in most jurisdictions. Lack of funding, human rights concerns, and logistical constraints have thus far rendered existing legal mechanisms largely dormant. For example, California became one of the most recent adopters of forced addiction treatment through the passage of Senate Bill 43, which expanded the criteria for psychiatric involuntary commitment to include substance use disorder in isolation as a qualifying diagnosis. However, the use of this law is exceedingly rare because most patients fail to meet the criteria for involuntary commitment once they are no longer acutely intoxicated from substances, and those who do are unable to be placed because residential addiction treatment facilities do not have the infrastructural capacity to enact involuntary holds. One study from 2015 found that of the 33 states with laws permitting involuntary commitment for substance use disorder, fewer than half regularly adopted this approach.

As it stands, the United States is sitting on a sleeping giant where nearly every state has the capability to forcibly treat people for substance use disorders provided that the political climate allows for the expansion of funding to establish treatment facilities designated for this use. While the severity of the ongoing overdose crisis warrants swift and definitive intervention, we must be wary of the use of involuntary commitment for substance use disorder given the dearth of evidence supporting its use either domestically or abroad. Furthermore, the research that does exist on this subject is often not generalizable because ethical concerns limit the ability to conduct randomized controlled trials. One international review from 2009 synthesizing 30 years of research on coerced addiction treatments found that studies were generally inconsistent and of low quality. A more recent study from Sweden found that individuals released from compulsory addiction treatment had a threefold increased risk of dying immediately following their release.

The state of the research in the United States is even more abysmal: as noted by a 2015 study, of the twenty states implementing involuntary commitment for substance use disorder, only seven were able to consistently report utilization data. For years, compulsory treatment programs have functioned with little scrutiny—facilities providing care to those involuntarily committed for addiction release little information regarding the treatments they provide, and rarely (if ever) release data regarding patient outcomes.

Massachusetts as a cautionary tale

To illustrate the risks of wide involuntary commitment deployment, we need to look no further than the Commonwealth of Massachusetts, which, along with Florida and North Carolina, is one of the country’s highest utilizers of these laws. Each year, Massachusetts forces upward of 6,000 people into addiction treatment at great cost to its taxpayers. This system is promulgated under a law referred to as Section 35, which allows for the forceful detention and placement of individuals into dedicated involuntary addiction treatment facilities for up to 90 days at a time. Despite Section 35’s widespread deployment, and repeated efforts to increase transparency, the nature of its implementation and efficacy has remained shrouded in mystery. Until now, the most comprehensive reports on outcomes of involuntary commitment for substance use disorders in Massachusetts have been limited to data from 2011–2015.

Recently, however, the Massachusetts Department of Public Health (DPH) was forced to shed more light on this system. In late 2024, it released a statutorily mandated report comparing outcomes of voluntary versus involuntary addiction treatment. In this study, those subjected to involuntary commitment were younger (more than 80% were under the age of 45) and more often white (82%) compared to those receiving voluntary treatment. The vast majority of participants receiving any addiction treatment, voluntary or involuntary, were insured through Medicaid. To compare outcomes between different forms of addiction treatment, the report looked specifically at individuals who had both received voluntary treatment and undergone involuntary commitment between 2015 and 2021, comparing numerous health-related outcomes at 30 and 90 days after each treatment episode. Most notably, the report found that after release from involuntary treatment, individuals had a 1.4-fold increased risk of non-fatal overdose and possibly an increased risk of death from any cause.

While these findings may come as a surprise, they serve as further proof of the concerns that we and many others have raised for years and warrant a deeper dive to fully understand their significance. What happens to people subjected to involuntary commitment for substance use disorders? How might this lead to an increased risk of overdose and death? Moving forward, what should the United States do to ensure that involuntary commitment for substance use disorders does not continue to harm those it seeks to help?

Although the exact details of involuntary commitment for substance use disorders will vary state by state, it is worth examining the existing system in Massachusetts to better contextualize findings from this most recent DPH report. In Massachusetts, all involuntary commitment episodes start with a petition filed to a court requesting that an individual be forced into treatment for addiction. While many different people (e.g., health care providers, law enforcement officers, court officials, and so on) may submit these petitions, most are filed by an individual’s family member. In many cases, courts will then grant a warrant that allows the police to locate and physically detain the individual in question for a hearing to determine whether they qualify for involuntary commitment. It is important to note that an individual need not have been charged with or found guilty of a crime in order to be forcibly committed. Once sentenced to involuntary commitment, the individual is then sent to one of several treatment facilities across the state. Most facilities are run by the DPH or the Department of Mental Health, but the largest and most notorious is owned and operated by the Department of Corrections and staffed by prison guards. Although involuntary commitment for substance use disorders is branded as “treatment,” one can see how many parts of this process more closely approximate the process of incarceration than that of medical care.

Once at a treatment facility, the patient is monitored while they undergo withdrawal—for patients with opioid use disorder, this process is excruciating and may last days, with only minimal relief provided from adjunctive medications. The exact details of treatment beyond this point are murky. One study investigating the experiences of individuals released from forced addiction treatment in Massachusetts found that fewer than one in five participants were offered medications for substance use disorder or scheduled for community-based follow-up, raising concerns about the standard of care in involuntary commitment facilities. The outcomes for these patients were perhaps even more worrisome—fewer than one in ten participants actually attended their scheduled follow-up, and more than one-third reported relapsing on the day of their release. While relapse is an expected part of the process for patients struggling with addiction, it becomes particularly dangerous for people whose tolerance for drugs has been reduced by being in an institutionalized setting. This is not simply a theoretical risk—this phenomenon has been studied extensively for people released from prisons, with studies showing a dramatically increased risk of overdose death, particularly in the first two weeks following release. We believe it is this same underlying process that may be driving the increased rates of overdose detected in the most recent data from the Massachusetts DPH.

Implications for the US response and beyond

With the shift in the federal administration, there is now a risk that dormant involuntary commitment mechanisms will become more actively deployed across the United States. Policy makers who support the expansion of involuntary commitment for substance use disorders as a solution to the ongoing overdose crisis must reconcile mounting evidence that this approach may increase the number of deaths among people who use drugs.

In Massachusetts and elsewhere, shutting the system down is not a realistic option in the short term—thousands of people receive treatment through involuntary commitment each year, and the practice remains politically popular. However, we must start the process of dramatically redistributing budgetary funds toward evidence-based voluntary treatment options and away from involuntary commitment. In 2023, the Massachusetts governor’s budget allocated more than US$22 million to the Massachusetts Alcohol and Substance Abuse Center, the involuntary treatment facility housed alongside a state prison, while providing less than US$7 million to harm reduction services across the state. This imbalance of resources has led to overreliance on involuntary commitment for substance use disorders as a first-line intervention. For instance, there have been numerous anecdotes from those treating addiction in the community that people are volunteering themselves for involuntary commitment because they are otherwise unable to access treatment. Additionally, the recent DPH report found that areas with access to more robust voluntary treatment services had proportionately lower rates of involuntary commitment for substance use disorders. Nationally, we must ensure that states seeking to implement involuntary commitment for substance use disorders have first taken care to allot sufficient resources to voluntary treatment options.

In cases where involuntary commitment is still needed, we must aim to use the least restrictive measures possible and guarantee the provision of evidence-based treatments to mitigate the risk of overdose. Courts evaluating patients for involuntary commitment for substance use disorders should consider alternative, less restrictive measures such as mandated outpatient or intensive outpatient programs, depending on the severity of an individual’s addiction. Those who do not meet the criteria for involuntary commitment should be directed to voluntary treatment options. We must also work to set treatment standards for involuntary commitment for substance use disorders, such as guaranteed provision of medications for substance use disorders for patients who are interested. The importance of these interventions cannot be understated—buprenorphine and methadone used in the treatment of opioid use disorder are the most effective treatments available for addiction, leading to a more than 50% reduction in all-cause mortality. Additionally, facilities must guarantee community-based follow-up for all individuals being discharged from treatment. Finally, we must ensure that treatment is provided in health care settings by trained medical and psychiatric providers. Although a Massachusetts bill passed in 2017 required that facilities for women be operated by the DPH or the Department of Mental Health, state house and senate bills providing the same protection for men have not been passed despite several attempts.

Given that drug overdose remains a leading cause of death for US residents under 45, we must do all that we can to protect the lives of those experiencing addiction. Although involuntary commitment for substance use disorders has been proposed as a desperate measure to prevent overdose, it has backfired. In Massachusetts, the magnitude of the system of involuntary commitment for substance use disorders will make change difficult. However, if we resort to this as the primary means of addressing the overdose crisis, we do so at the cost of the lives of those forced into treatment for addiction.

Introduction

The recent confirmation of an individual as secretary of the Department of Health and Human Services has generated discussion regarding the future direction of the United States' medical and public health systems. One notable perspective involves support for involuntary commitment to abstinence- and faith-based "healing farms" for individuals experiencing addiction. This position may be influenced by personal experiences with addiction and recovery, which involved various abstinence-based programs. Advocacy for forced addiction treatment is not new among political figures and is becoming a more common feature of responses to the overdose crisis. Between 2015 and 2018 alone, more than 25 states enacted new or expanded existing involuntary commitment statutes, a trend that recalls the history of institutionalization as a primary method for addressing addiction and mental health challenges in the United States.

While state-level laws permitting forced addiction treatment are increasingly common, their implementation has been limited across most jurisdictions. Factors such as insufficient funding, human rights considerations, and logistical obstacles have largely kept these legal mechanisms dormant. For example, California adopted forced addiction treatment through Senate Bill 43, which broadened criteria for psychiatric involuntary commitment to include substance use disorder as a sole qualifying diagnosis. However, utilization of this law remains rare because many patients do not meet the criteria for involuntary commitment once acute intoxication subsides. Furthermore, residential addiction treatment facilities often lack the infrastructure to accommodate involuntary holds. Research from 2015 indicated that among the 33 states with laws allowing involuntary commitment for substance use disorder, fewer than half regularly applied this approach.

The United States possesses the widespread capacity to forcibly treat individuals for substance use disorders, contingent on a political climate that supports expanded funding for designated treatment facilities. Although the severity of the ongoing overdose crisis necessitates prompt and decisive action, caution is warranted regarding the use of involuntary commitment for substance use disorder, given the limited evidence supporting its efficacy both domestically and internationally. Existing research on this topic is often not generalizable due to ethical constraints that limit the feasibility of conducting randomized controlled trials. An international review synthesizing 30 years of research on coerced addiction treatments found that studies were generally inconsistent and of low quality. A more recent study from Sweden indicated that individuals discharged from compulsory addiction treatment faced a threefold increased risk of mortality immediately following their release.

The state of research in the United States is even more constrained. A 2015 study noted that among the twenty states implementing involuntary commitment for substance use disorder, only seven consistently reported utilization data. For many years, compulsory treatment programs have operated with minimal oversight; facilities providing care to those involuntarily committed for addiction disclose little information about the treatments offered and rarely, if ever, release data concerning patient outcomes.

Massachusetts as a Cautionary Tale

To illustrate the risks associated with broad deployment of involuntary commitment, the Commonwealth of Massachusetts serves as a pertinent example. Alongside Florida and North Carolina, Massachusetts is among the states with the highest utilization of these laws. Annually, Massachusetts compels over 6,000 individuals into addiction treatment, incurring significant costs for taxpayers. This system operates under Section 35, a law that permits the forceful detention and placement of individuals into dedicated involuntary addiction treatment facilities for periods of up to 90 days. Despite the extensive use of Section 35 and repeated efforts to enhance transparency, the nature of its implementation and effectiveness has largely remained opaque. Until recently, comprehensive reports on outcomes of involuntary commitment for substance use disorders in Massachusetts were limited to data from 2011–2015.

The Massachusetts Department of Public Health (DPH) recently provided greater insight into this system. In late 2024, a statutorily mandated report was released, comparing outcomes of voluntary versus involuntary addiction treatment. The study found that individuals subjected to involuntary commitment were typically younger (over 80% under 45) and more frequently white (82%) compared to those receiving voluntary treatment. The majority of participants in both voluntary and involuntary treatment groups were insured through Medicaid. To compare outcomes, the report specifically analyzed individuals who had received both voluntary treatment and involuntary commitment between 2015 and 2021, examining various health-related outcomes 30 and 90 days after each treatment episode. Notably, the report indicated that after release from involuntary treatment, individuals experienced a 1.4-fold increased risk of non-fatal overdose and potentially an increased risk of death from any cause.

These findings, while potentially surprising, underscore long-standing concerns and warrant thorough examination to fully comprehend their implications. Further investigation is needed to understand the experiences of individuals subjected to involuntary commitment for substance use disorders and how these experiences might contribute to an increased risk of overdose and mortality. Moving forward, the United States must determine strategies to ensure that involuntary commitment for substance use disorders does not inadvertently harm those it intends to assist.

While the specific details of involuntary commitment for substance use disorders vary by state, an examination of Massachusetts's existing system provides valuable context for the recent DPH report's findings. In Massachusetts, all involuntary commitment episodes begin with a petition filed in court, requesting that an individual be compelled into addiction treatment. Although various individuals, including healthcare providers, law enforcement officers, and court officials, can submit these petitions, most are filed by family members. In many instances, courts issue a warrant, enabling police to locate and physically detain the individual for a hearing to determine eligibility for involuntary commitment. It is important to note that an individual does not need to have been charged with or convicted of a crime to be forcibly committed. Once sentenced, the individual is transferred to one of several treatment facilities statewide. Most facilities are managed by the DPH or the Department of Mental Health, but the largest and most prominent is operated by the Department of Corrections and staffed by prison guards. Although involuntary commitment for substance use disorders is framed as "treatment," aspects of this process bear a closer resemblance to incarceration than to medical care.

Upon arrival at a treatment facility, patients are monitored during withdrawal. For patients with opioid use disorder, this process can be severe and last for days, with only minimal symptom relief provided by adjunctive medications. The specifics of treatment beyond this initial phase are often unclear. A study investigating the experiences of individuals released from forced addiction treatment in Massachusetts revealed that fewer than one in five participants were offered medications for substance use disorder or scheduled for community-based follow-up, raising questions about the standard of care in involuntary commitment facilities. Patient outcomes were perhaps even more concerning: fewer than one in ten participants actually attended their scheduled follow-up appointments, and over one-third reported relapsing on the day of their release. While relapse is an anticipated aspect of recovery from addiction, it becomes particularly hazardous for individuals whose drug tolerance has decreased due to institutionalization. This is not merely a theoretical risk; this phenomenon has been extensively studied in people released from prisons, with research demonstrating a significantly increased risk of overdose death, particularly within the first two weeks post-release. This underlying process may contribute to the increased rates of overdose observed in the most recent data from the Massachusetts DPH.

Implications for the US Response and Beyond

With changes in the federal administration, there is a potential for dormant involuntary commitment mechanisms to be more actively deployed across the United States. Policymakers who advocate for expanding involuntary commitment for substance use disorders as a solution to the ongoing overdose crisis must reconcile this approach with mounting evidence indicating that it may increase fatalities among individuals who use drugs.

In Massachusetts and other jurisdictions, dismantling the existing system is not a feasible short-term option, as thousands of individuals receive treatment through involuntary commitment annually, and the practice maintains political popularity. However, a significant redistribution of budgetary funds is necessary, moving resources toward evidence-based voluntary treatment options and away from involuntary commitment. In 2023, the Massachusetts governor's budget allocated over US$22 million to the Massachusetts Alcohol and Substance Use Center, an involuntary treatment facility located alongside a state prison, while providing less than US$7 million for harm reduction services statewide. This resource imbalance has led to an overreliance on involuntary commitment for substance use disorders as a primary intervention. Reports from addiction treatment providers suggest that individuals sometimes volunteer for involuntary commitment because they are otherwise unable to access treatment. Additionally, the recent DPH report found that areas with access to more robust voluntary treatment services had proportionally lower rates of involuntary commitment for substance use disorders. Nationally, states seeking to implement involuntary commitment for substance use disorders must first ensure sufficient resources are allocated to voluntary treatment options.

In situations where involuntary commitment remains necessary, the least restrictive measures possible should be employed, and the provision of evidence-based treatments must be guaranteed to mitigate overdose risk. Courts evaluating patients for involuntary commitment for substance use disorders should consider alternative, less restrictive measures, such as mandated outpatient or intensive outpatient programs, based on the severity of an individual’s addiction. Those who do not meet the criteria for involuntary commitment should be directed to voluntary treatment options. Furthermore, treatment standards for involuntary commitment for substance use disorders must be established, including the guaranteed provision of medications for substance use disorders for interested patients. The importance of these interventions is significant; buprenorphine and methadone, used in the treatment of opioid use disorder, are the most effective treatments available for addiction, leading to a reduction of over 50% in all-cause mortality. Facilities must also guarantee community-based follow-up for all individuals discharged from treatment. Finally, it is crucial that treatment be provided in healthcare settings by trained medical and psychiatric professionals. Although a Massachusetts bill passed in 2017 mandated that facilities for women be operated by the DPH or the Department of Mental Health, similar protections for men have not been enacted despite multiple legislative attempts.

Given that drug overdose remains a leading cause of death for U.S. residents under 45, every effort must be made to protect the lives of individuals experiencing addiction. Although involuntary commitment for substance use disorders has been proposed as an urgent measure to prevent overdose, it has yielded counterproductive results. In Massachusetts, the extensive scale of the involuntary commitment system for substance use disorders will make change challenging. However, relying on this approach as the primary means of addressing the overdose crisis comes at the cost of the lives of those compelled into addiction treatment.

Introduction

The recent confirmation of Robert F. Kennedy Jr. as the secretary of the Department of Health and Human Services has raised concerns about the future of medical and public health systems in the United States. Among his controversial views is support for involuntary commitment to abstinence- and faith-based "healing farms" for individuals struggling with addiction. Some of Mr. Kennedy's beliefs come from his own experiences with addiction and recovery, which included various abstinence-based programs. He is not the first politician to support forced addiction treatment, which is becoming a more common part of the response to the overdose crisis. Between 2015 and 2018 alone, over 25 states added new or expanded existing laws for involuntary commitment, a trend that brings to mind the history of institutionalization for addiction and mental health issues in the United States.

Although state laws allowing forced addiction treatment are becoming common, their actual use has been limited in most areas. A lack of funding, human rights concerns, and logistical challenges have largely kept these legal mechanisms inactive. For example, California recently adopted forced addiction treatment through Senate Bill 43, which expanded the reasons for psychiatric involuntary commitment to include substance use disorder alone. However, this law is very rarely used because most patients do not meet the criteria for involuntary commitment once they are no longer acutely intoxicated. Those who do meet the criteria often cannot be placed because residential addiction treatment facilities lack the infrastructure to hold people involuntarily. A 2015 study found that fewer than half of the 33 states with laws permitting involuntary commitment for substance use disorder regularly used this approach.

Most states have the legal authority to forcibly treat people for substance use disorders, but this power remains largely unused. Its expansion would require a political climate that allows for increased funding to establish specific treatment facilities. The serious nature of the ongoing overdose crisis requires quick and clear action. However, a cautious approach is necessary regarding the use of involuntary commitment for substance use disorder, especially given the limited evidence supporting its effectiveness in the United States or elsewhere.

The research that does exist on this topic often cannot be broadly applied because ethical concerns limit the ability to conduct randomized controlled trials. A 2009 international review, which looked at 30 years of research on forced addiction treatments, found that studies were generally inconsistent and of low quality. A more recent study from Sweden found that individuals released from compulsory addiction treatment had a threefold increased risk of dying immediately after their release.

The state of research in the United States is even more limited. A 2015 study noted that among the twenty states implementing involuntary commitment for substance use disorder, only seven consistently reported data on its use. For years, compulsory treatment programs have operated with little examination. Facilities providing care to those involuntarily committed for addiction release little information about the treatments they provide and rarely, if ever, release data on patient outcomes.

Massachusetts as a Cautionary Tale

To understand the risks of widespread involuntary commitment, one can examine the Commonwealth of Massachusetts. Along with Florida and North Carolina, Massachusetts is one of the highest users of these laws in the country. Each year, Massachusetts forces over 6,000 people into addiction treatment at a significant cost to taxpayers. This system operates under a law called Section 35, which allows for the forceful detention and placement of individuals into dedicated involuntary addiction treatment facilities for up to 90 days at a time. Despite Section 35's frequent use and repeated efforts to increase transparency, the nature of its implementation and effectiveness has remained unclear. Until recently, the most comprehensive reports on outcomes of involuntary commitment for substance use disorders in Massachusetts were limited to data from 2011–2015.

Recently, however, the Massachusetts Department of Public Health (DPH) was required to provide more information about this system. In late 2024, it released a report, mandated by law, comparing outcomes of voluntary versus involuntary addiction treatment. In this study, those subjected to involuntary commitment were younger (over 80% were under 45) and more often white (82%) compared to those receiving voluntary treatment. The vast majority of participants receiving any addiction treatment, whether voluntary or involuntary, had health insurance through Medicaid. To compare outcomes between different forms of addiction treatment, the report specifically looked at individuals who had both received voluntary treatment and undergone involuntary commitment between 2015 and 2021. It compared numerous health-related outcomes at 30 and 90 days after each treatment episode. Most notably, the report found that after release from involuntary treatment, individuals had a 1.4 times higher risk of non-fatal overdose and possibly an increased risk of death from any cause.

While these findings may be surprising, they support long-standing concerns and require closer examination to fully understand their significance. Understanding what happens to individuals subjected to involuntary commitment for substance use disorders is important. This includes exploring how the process might increase the risk of overdose and death, and what steps the United States should take to prevent harm for those it aims to help.

Although the exact details of involuntary commitment for substance use disorders vary by state, examining the existing system in Massachusetts helps to put the findings from the recent DPH report into context. In Massachusetts, all involuntary commitment episodes begin with a petition filed in court requesting that an individual be forced into addiction treatment. While many different people (e.g., healthcare providers, law enforcement officers, court officials) may submit these petitions, most are filed by a family member. In many cases, courts then grant a warrant allowing the police to locate and physically detain the individual for a hearing to determine if they qualify for involuntary commitment. An important point is that an individual does not need to have been charged with or convicted of a crime to be forcibly committed. Once sentenced to involuntary commitment, the individual is then sent to one of several treatment facilities across the state. Most facilities are run by the DPH or the Department of Mental Health, but the largest and most well-known is owned and operated by the Department of Corrections and staffed by prison guards. Although involuntary commitment for substance use disorders is called "treatment," many parts of this process resemble incarceration more closely than medical care.

Once at a treatment facility, the patient is monitored while undergoing withdrawal. For patients with opioid use disorder, this process is very difficult and can last for days, with only limited medication to ease symptoms. The exact details of treatment beyond this point are unclear. One study investigating the experiences of individuals released from forced addiction treatment in Massachusetts found that less than 20% of participants were offered medications for substance use disorder or scheduled for follow-up care in the community. This raises concerns about the standard of care in involuntary commitment facilities. The outcomes for these patients were perhaps even more concerning: less than 10% of participants actually attended their scheduled follow-up, and over one-third reported relapsing on the day of their release. While relapse is an expected part of the process for patients struggling with addiction, it becomes particularly dangerous for people whose tolerance for drugs has been reduced by being in an institutionalized setting. This is not just a theoretical concern; this phenomenon has been studied extensively for people released from prisons, with studies showing a dramatically increased risk of overdose death, especially in the first two weeks following release. This same process is believed to be a factor in the increased overdose rates detected in the most recent data from the Massachusetts DPH.

Implications for the US Response and Beyond

With changes in the federal administration, there is a risk that unused involuntary commitment systems will be used more often across the United States. Policymakers who support expanding involuntary commitment for substance use disorders as a solution to the ongoing overdose crisis must consider the growing evidence that this approach may increase deaths among people who use drugs.

In Massachusetts and elsewhere, closing the system is not a realistic short-term option. Thousands of people receive treatment through involuntary commitment each year, and the practice remains politically popular. However, it is essential to begin the process of reallocating funds toward voluntary, evidence-based treatment options and away from involuntary commitment. In 2023, the Massachusetts governor's budget allocated over US$22 million to the Massachusetts Alcohol and Substance Use Center, an involuntary treatment facility located alongside a state prison, while providing less than US$7 million to harm reduction services across the state. This uneven distribution of resources has resulted in an overreliance on involuntary commitment for substance use disorders as a primary intervention. For instance, reports from addiction treatment providers indicate that individuals sometimes seek involuntary commitment because they cannot otherwise access treatment. Additionally, the recent DPH report found that areas with access to more robust voluntary treatment services had proportionally lower rates of involuntary commitment for substance use disorders. Nationally, states seeking to implement involuntary commitment for substance use disorders must first ensure they have allotted sufficient resources to voluntary treatment options.

In cases where involuntary commitment is still necessary, the least restrictive measures possible should be used, and the provision of evidence-based treatments must be guaranteed to reduce the risk of overdose. Courts evaluating patients for involuntary commitment for substance use disorders should consider alternative, less restrictive measures such as required outpatient or intensive outpatient programs, depending on the severity of an individual's addiction. Those who do not meet the criteria for involuntary commitment should be directed to voluntary treatment options. It is also important to set treatment standards for involuntary commitment for substance use disorders, such as guaranteed provision of medications for substance use disorders for patients who are interested. The significance of these interventions is considerable; buprenorphine and methadone used in the treatment of opioid use disorder are the most effective treatments available for addiction, leading to a reduction of over 50% in deaths from all causes. Additionally, facilities must guarantee community-based follow-up for all individuals being discharged from treatment. Finally, treatment must be provided in healthcare settings by trained medical and psychiatric providers. Although a Massachusetts bill passed in 2017 required that facilities for women be operated by the DPH or the Department of Mental Health, state bills offering the same protection for men have not passed despite multiple attempts.

Given that drug overdose remains a leading cause of death for US residents under 45, every effort must be made to protect the lives of those experiencing addiction. Although involuntary commitment for substance use disorders has been proposed as a desperate measure to prevent overdose, it has had negative consequences. In Massachusetts, the magnitude of the system of involuntary commitment for substance use disorders will make change difficult. However, if this becomes the main approach to addressing the overdose crisis, it will be at the expense of the lives of those forced into treatment for addiction.

Introduction

The recent appointment of Robert F. Kennedy Jr. as the head of the Department of Health and Human Services has raised many concerns about the future of medical and public health care in the United States. One of his debated ideas is supporting forced treatment at abstinence- and faith-based "healing farms" for people dealing with addiction. Some of Kennedy's views come from his own struggles with addiction and recovery, which involved various abstinence-focused programs. He is not the first politician to support forced addiction treatment, which is becoming a popular way to respond to the overdose crisis. Between 2015 and 2018 alone, over 25 states either created new laws or expanded existing ones to allow forced commitment. This trend brings to mind the country's difficult past of using institutions as the main way to deal with addiction and mental health problems.

While state laws allowing forced addiction treatment are becoming common, they are rarely put into practice in most areas. A lack of money, worries about human rights, and practical problems have largely kept these laws from being used. For example, California recently adopted forced addiction treatment by passing Senate Bill 43. This law broadened the reasons for forced mental health commitment to include substance use disorder as a stand-alone diagnosis. However, this law is used very little because most patients no longer meet the requirements for forced commitment once the immediate effects of substances wear off. Those who do qualify often cannot find a placement because residential addiction treatment centers do not have the facilities to hold people against their will. A 2015 study found that out of 33 states with laws permitting forced commitment for substance use disorder, fewer than half regularly used this approach.

The United States currently has the ability to forcibly treat people for substance use disorders in almost every state. This could change if the political climate allows for more funding to create treatment facilities specifically for this purpose. The serious overdose crisis needs quick and clear action, but careful thought is required when considering forced commitment for substance use disorder. There is little evidence from the U.S. or other countries to support its use. Also, existing research on this topic is often not widely applicable because ethical concerns limit the ability to conduct fair comparison studies. An international review from 2009, which looked at 30 years of research on forced addiction treatments, found that studies were generally inconsistent and of poor quality. A more recent study from Sweden showed that individuals released from forced addiction treatment had three times the risk of dying soon after their release.

Research within the United States on this issue is even worse. A 2015 study noted that out of the twenty states that use forced commitment for substance use disorder, only seven were able to regularly report data on how often it was used. For years, mandatory treatment programs have operated with little public review. Facilities that provide care to those forcibly committed for addiction release little information about the treatments they offer and rarely, if ever, share data about patient results.

Massachusetts as a Cautionary Tale

To understand the dangers of widespread forced commitment, one only needs to look at Massachusetts. Along with Florida and North Carolina, Massachusetts uses these laws more than most other states. Each year, Massachusetts forces over 6,000 people into addiction treatment, costing taxpayers a great deal. This system is put into effect under a law called Section 35. It allows individuals to be held against their will and placed in specific forced addiction treatment facilities for up to 90 days at a time. Despite Section 35 being used extensively and repeated attempts to make its workings more open, how it is put into practice and its effectiveness have remained unclear. Until recently, the most complete reports on the results of forced commitment for substance use disorders in Massachusetts were limited to data from 2011 to 2015.

However, the Massachusetts Department of Public Health (DPH) was recently required to provide more information about this system. In late 2024, it released a report, required by law, that compared the results of voluntary versus forced addiction treatment. The study found that those who underwent forced commitment were younger (more than 80% were under 45) and more often white (82%) compared to those who received voluntary treatment. Most people getting any addiction treatment, whether voluntary or forced, had health insurance through Medicaid. To compare results between different types of addiction treatment, the report specifically looked at individuals who had both received voluntary treatment and undergone forced commitment between 2015 and 2021. It compared various health outcomes 30 and 90 days after each treatment period. Most importantly, the report found that after being released from forced treatment, individuals had a 1.4 times higher risk of non-fatal overdose and possibly an increased risk of death from any cause.

While these findings might be surprising, they further confirm concerns that have been raised for years. A deeper look is needed to fully understand their meaning. What happens to people who are forced into treatment for substance use disorders? How might this lead to a higher risk of overdose and death? Looking ahead, what should the United States do to make sure that forced commitment for substance use disorders does not continue to harm those it aims to help?

While the exact details of forced commitment for substance use disorders vary by state, it is helpful to examine the current system in Massachusetts to better understand the findings from this recent DPH report. In Massachusetts, all forced commitment begins with a petition filed in court, asking that a person be made to enter addiction treatment. While many different people (such as health care providers, police officers, and court officials) can submit these petitions, most are filed by a family member of the individual. In many cases, courts then issue an order that allows the police to find and physically detain the person for a hearing. This hearing determines if they meet the criteria for forced commitment. It is important to know that a person does not need to have been charged with or found guilty of a crime to be forcibly committed. Once ordered into forced commitment, the person is then sent to one of several treatment facilities across the state. Most facilities are run by the DPH or the Department of Mental Health, but the largest and most well-known is owned and operated by the Department of Corrections and staffed by prison guards. Although forced commitment for substance use disorders is called "treatment," one can see how many parts of this process are more like being jailed than receiving medical care.

Once at a treatment facility, the patient is watched while going through withdrawal. For patients with opioid use disorder, this process is very painful and can last for days, with only minimal relief from other medications. The exact details of treatment beyond this point are not clear. One study that looked at the experiences of people released from forced addiction treatment in Massachusetts found that fewer than one in five participants were offered medications for substance use disorder or scheduled for follow-up care in the community. This raises concerns about the quality of care in forced commitment facilities. The results for these patients were perhaps even more troubling: fewer than one in ten participants actually attended their scheduled follow-up, and more than one-third reported using drugs again on the day they were released. While using drugs again is an expected part of the process for people dealing with addiction, it becomes especially dangerous for those whose tolerance for drugs has decreased after being in an institutional setting. This is not just a theoretical risk. This situation has been studied widely for people released from prisons, with studies showing a greatly increased risk of overdose death, especially in the first two weeks after release. It is believed that this same basic process may be causing the increased rates of overdose found in the most recent data from the Massachusetts DPH.

Implications for the U.S. Response and Beyond

With changes in the federal government, there is now a risk that inactive forced commitment laws will be used more often across the United States. Policymakers who support expanding forced commitment for substance use disorders as a way to solve the ongoing overdose crisis must face the growing evidence that this approach may increase the number of deaths among people who use drugs.

In Massachusetts and elsewhere, shutting down the system is not a realistic option in the short term. Thousands of people receive treatment through forced commitment each year, and the practice remains popular with politicians. However, the process of significantly shifting funds away from forced commitment and towards voluntary, evidence-based treatment options must begin. In 2023, the Massachusetts governor's budget allocated over US$22 million to the Massachusetts Alcohol and Substance Use Center, the forced treatment facility located next to a state prison. Meanwhile, less than US$7 million was provided for harm reduction services across the state. This imbalance of resources has led to an overuse of forced commitment for substance use disorders as a primary approach. For example, there have been many stories from addiction treatment providers in the community about people voluntarily seeking forced commitment because they cannot otherwise access treatment. Additionally, the recent DPH report found that areas with access to stronger voluntary treatment services had proportionally lower rates of forced commitment for substance use disorders. Across the country, states that want to use forced commitment for substance use disorders must first ensure they have dedicated enough resources to voluntary treatment options.

In cases where forced commitment is still deemed necessary, the goal must be to use the least restrictive methods possible and guarantee that evidence-based treatments are provided to lower the risk of overdose. Courts evaluating patients for forced commitment for substance use disorders should consider other, less restrictive options, such as required outpatient or intensive outpatient programs, depending on how severe a person's addiction is. Those who do not meet the criteria for forced commitment should be directed to voluntary treatment options. Efforts must also be made to establish treatment standards for forced commitment for substance use disorders, such as guaranteeing the provision of medications for substance use disorders for patients who want them. The importance of these interventions cannot be overstated. Buprenorphine and methadone, used in the treatment of opioid use disorder, are the most effective treatments available for addiction, leading to a more than 50% reduction in all causes of death. Additionally, facilities must guarantee follow-up care in the community for all individuals released from treatment. Finally, it must be ensured that treatment is provided in health care settings by trained medical and psychiatric providers. Although a Massachusetts bill passed in 2017 required that facilities for women be run by the DPH or the Department of Mental Health, state bills offering the same protection for men have not passed despite several attempts.

Since drug overdose remains a leading cause of death for U.S. residents under 45, every effort must be made to protect the lives of those experiencing addiction. Although forced commitment for substance use disorders has been suggested as a desperate measure to prevent overdose, it has unfortunately caused more harm than good. In Massachusetts, the large scale of the forced commitment system for substance use disorders will make change difficult. However, if this approach becomes the main way to address the overdose crisis, it will come at the cost of the lives of those forced into addiction treatment.

Introduction

Robert F. Kennedy Jr. has been named a main leader in health for the country. This has caused many people to worry about how health care and public health will work in the future. One of his ideas is to force people with drug problems into special "healing farms" that focus on not using drugs and on faith. This is a very debated idea.

Mr. Kennedy has faced addiction himself and used programs that focused on not using drugs. He is not the first leader to say that people should be forced into drug treatment. This idea is becoming more common as a way to deal with the overdose problem. Between 2015 and 2018, more than 25 states made new laws, or made older laws stronger, to allow people to be forced into treatment. This reminds some people of a difficult past when the US often put people with drug and mental health problems in institutions.

While many states now have laws for forced drug treatment, they are not used much in most places. This is because there is not enough money, people worry about human rights, and it's hard to make it happen. For example, California recently passed a law to allow forced treatment just for drug use. But this law is rarely used. This is often because people don't meet the rules once they are no longer high from drugs. Also, places that treat addiction do not have enough space to hold people who are forced to be there. A study from 2015 found that out of 33 states with laws for forced drug treatment, fewer than half actually used this method often.

The United States has laws in almost every state that could force people into treatment for drug problems. These laws could be used more if there was enough money to build special treatment centers. The current overdose problem is very serious and needs quick action. However, leaders must be careful about forcing people into treatment for drug use. There is little proof that it works well, both in the US and in other countries. Also, the studies that do exist are often not fair to compare. This is because rules about doing studies on people can limit how they are done. A world review from 2009 looked at 30 years of research on forced addiction treatments. It found that the studies were often not clear and not very good. A more recent study in Sweden found that people who were forced into treatment had a three times higher chance of dying right after they were released.

In the US, the research is even weaker. A 2015 study noted that out of twenty states that used forced treatment for drug problems, only seven could regularly share numbers about how often it was used. For many years, forced treatment programs have not been checked closely. The places that give care to people forced into treatment share little information about the treatments they provide. They also rarely share numbers about how patients do after leaving treatment.

Massachusetts as a Warning

To see the dangers of using forced treatment widely, one can look at Massachusetts. This state, along with Florida and North Carolina, uses these laws more than most others. Each year, Massachusetts forces over 6,000 people into drug treatment. This costs the state's taxpayers a lot of money. This system works under a law called Section 35. It allows people to be held and placed in special forced treatment centers for up to 90 days at a time. Even though Section 35 is used a lot, it has been hard to know how it works or if it helps. Until recently, the most complete reports on what happens after forced treatment in Massachusetts were from 2011 to 2015.

Recently, the Massachusetts Department of Public Health (DPH) had to share more details about this system. In late 2024, it released a report that compared what happened to people who chose treatment to those who were forced into it. This report was required by law. The study showed that people who were forced into treatment were younger (more than 80% were under 45) and more often white (82%). Most people who received any addiction treatment, whether they chose it or were forced, had health insurance through a program called Medicaid. To compare what happened after treatment, the report looked at people who had both chosen treatment and been forced into treatment between 2015 and 2021. It compared many health results 30 and 90 days after each treatment. The most important finding was that after leaving forced treatment, people had a 1.4 times higher chance of a non-fatal overdose. They also possibly had a higher chance of dying from any cause.

These findings might seem surprising. However, they show what many people have worried about for years. It is important to look deeper to fully understand what they mean. What happens to people who are forced into treatment for drug use? How might this lead to a higher risk of overdose and death? Moving forward, what should the United States do to make sure that forced treatment for drug use does not keep harming those it is meant to help?

The exact details of forced treatment for drug use are different in each state. But it is helpful to look at the system in Massachusetts to better understand the findings from this new DPH report. In Massachusetts, all forced treatment starts when someone asks a court to make a person get treatment for addiction. Many different people, such as health workers, police, and court officials, can make these requests. But most are filed by a family member. In many cases, courts will then give an order that allows the police to find and hold the person for a court meeting. This meeting decides if they should be forced into treatment. It is important to know that a person does not have to be charged with a crime or found guilty of one to be forced into treatment. Once ordered to forced treatment, the person is sent to one of several treatment centers in the state. Most centers are run by the DPH or the Department of Mental Health. However, the largest and most well-known center is owned and run by the prison system and has prison guards working there. While forced treatment for drug use is called "treatment," many parts of this process feel more like being in prison than getting medical care.

Once at a treatment center, the patient is watched while they go through withdrawal from drugs. For people with opioid problems, this process is very painful and can last for days. They receive only a small amount of relief from some medicines. What happens after this is not very clear. A study that looked at what happened to people released from forced treatment in Massachusetts found that less than one out of five people were offered medicines for their drug problem. Also, they were not set up for follow-up care in their community. This raises concerns about the quality of care in forced treatment centers. The results for these patients were perhaps even more concerning. Less than one out of ten people actually went to their planned follow-up appointments. More than one out of three said they used drugs again on the day they were released. Relapse, or using drugs again, is a normal part of recovery for people with addiction. But it becomes very dangerous for people whose bodies have lost their ability to handle drugs because they have been in an institution. This is not just an idea. This problem has been studied a lot for people released from prisons. Studies show a much higher risk of overdose death, especially in the first two weeks after release. It is believed that this same basic problem may be causing the higher rates of overdose seen in the newest information from the Massachusetts DPH.

What This Means for the US and Beyond

With changes in the federal government, there is now a chance that states will use forced treatment methods more often. Leaders who want to expand forced treatment for drug problems as a way to solve the overdose crisis must think about the growing proof. This proof suggests that this method may cause more deaths among people who use drugs.

In Massachusetts and other places, stopping the forced treatment system right away is not a real option. Thousands of people get treatment through forced means each year, and many people still support it. However, the process of greatly changing how money is spent must start. More money needs to go to voluntary treatment choices that are proven to work, and less to forced treatment. In 2023, the Massachusetts governor's budget put over $22 million toward a forced treatment center located next to a state prison. At the same time, it provided less than $7 million for services that help people use drugs more safely across the state. This uneven spending of money has led to forced treatment for drug use being used too much as a first step. For example, there have been many stories from people who help those with addiction that people are choosing forced treatment because they cannot find other help. Also, the recent DPH report found that areas with more strong voluntary treatment services had fewer cases of forced treatment for drug problems. Across the country, states must make sure they have put enough money into voluntary treatment choices before they try to use forced treatment for drug use.

If forced treatment is still needed, the state must aim to use the least strict methods possible. It must also promise to provide treatments that are proven to work to lower the risk of overdose. Courts that decide if patients need forced treatment for drug use should consider other, less strict options. These could be programs where people go to treatment during the day but live at home, depending on how severe their addiction is. Those who do not meet the rules for forced treatment should be sent to voluntary treatment choices. Rules for forced treatment for drug use must also be set. For example, patients should be guaranteed medicines for their drug problem if they want them. These medicines, such as buprenorphine and methadone used for opioid use disorder, are the best treatments available for addiction. They lead to a more than 50% drop in deaths from all causes. Also, treatment centers must promise that all people leaving treatment will have follow-up care in their community. Finally, treatment must be given in health care places by trained medical and mental health workers. A Massachusetts law passed in 2017 required that centers for women be run by the DPH or the Department of Mental Health. But state laws that would give the same protection for men have not passed, even after several tries.

Drug overdose remains a main reason why people under 45 die in the US. Because of this, everything possible must be done to keep the lives of those facing addiction safe. Forced treatment for drug use has been suggested as a last effort to stop overdoses. But it has caused more harm than good. In Massachusetts, the size of the forced treatment system for drug use will make change difficult. However, if this is used as the main way to deal with the overdose problem, it will cost the lives of those forced into treatment for addiction.