Involuntary Civil Commitment Laws

Research SummaryPublished Dec 20, 2023

Allow family members, health care practitioners, or other persons to seek court-mandated treatment for an individual who poses a substantial threat of harm to self (e.g., by overdose) or others as a result of their substance use. This policy does not require a concomitant criminal justice case and does not include laws that apply only to serious mental illness (with a definition of mental illness that does not include substance use).

A panel of experts rated how they expect this type of policy to affect four outcomes: opioid use disorder (OUD) treatment engagement, OUD treatment retention, OUD remission, and OUD 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
Yes
No
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
Yes
No
Feasibility
No
Yes
No
Affordability
Yes
No
No
Equitability
Yes
No
No

Summary of Expert Comments

  • Experts expect the policy to have minimal effects: It is too narrowly focused to influence population-level outcomes.
  • Public acceptability would depend on how the policy is framed and communicated, the degree of stigma toward individuals with OUD, community acceptance of paternalistic measures for that population, and the social positioning of members of the public (e.g., law enforcement versus advocate).
  • Involuntary civil commitment laws are difficult to implement fairly with effective care and without abuses. They require considerable resources and administrative oversight, with little-to-no population health benefit (i.e., little-to-no cost-effectiveness).
  • This excessively harsh and severe policy criminalizes people who use drugs and is likely to have significant disparate negative impacts on marginalized communities.

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 By definition improves treatment initiation (though not meaningful engagement). “Forcing people into treatment probably does result in more treatment initiation for those who are forced to do it”
Little-to-no
(selected)
 Involuntary civil commitment laws make no impact on treatment engagement, apply to too few people to influence population-level treatment engagement, and lead some people into treatment but deter others. “I wish I could be more enthusiastic but dragging people into treatment is not ... terribly effective”
Harmful Involuntary civil commitment does not improve treatment engagement. “Outcomes do not seem to improve after involuntary commitment”

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 Slight increase in treatment engagement could yield slight increases in retention. “To the extent that more people enter treatment, there will be an increase in the number retained”
Little-to-no
(selected)
 Nature and length of involuntary commitment is not likely to be sufficient to lead to changes in retention. “Involuntary commitment is unlikely to last for 6 months, and coercive treatment is counterproductive to long term retention in treatment”
Harmful Treatment retention is likely to be lower compared with those who voluntarily engage with treatment. “I believe, compared to people who voluntarily enter treatment, there will be a decrease in retention among those forced into treatment”

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 Slight increase in treatment engagement and retention could yield slight increases in remission. “A few folks who enter treatment due to this might achieve remission, increasing the overall rate. Should be rather small increase”
Little-to-no
(selected)
 Unlikely to impact long-term patient health outcomes. “It is unlikely that involuntary commitment will have lasting impacts on long-term client outcomes”
Harmful Forced treatment leads to relapse, takes resources away from other potential patients, and often involves care that is not evidence-based. “People who have been forced to receive treatment have experienced a traumatic event, and many times they do not wish to remain in treatment once they have a choice. Additionally, many of these programs do not use proven treatment methods”

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 Could decrease mortality among high-risk populations who otherwise might not enter treatment. “With this policy, persons at high-risk of overdose are being identified and treated, which should have a net positive effect on overdose (despite drawbacks and ethical considerations)”
Little-to-no
(selected)
 Unlikely to impact long-term patient health outcomes, especially given the limited number of people targeted by the policy. “While it may be highly effective, because civil commitment is applied to such a small segment of the OUD population, it’s not likely to have a large impact on per capita rates of overdose”
Harmful Concerns about increased risk of overdose if patients are released or discontinue treatment without access to medication for OUD, mandated treatment does not facilitate access to harm reduction services, or mandated treatment takes resources away from voluntary patients. “I believe the research is clear that a large percentage of people who are forced into treatment relapse and experience a higher chance of death”

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 Public is generally receptive to these policies and sees them as an appropriate approach to addressing substance use disorder. “Very acceptable to most of the general public because of a prevailing belief that people with SUD [substance use disorder]/OUD are unable to make sound decisions (‘brains have been hijacked by drug use,’ etc).”
Moderate
(selected)
 Depends on framing of policy, degree of stigma toward and public acceptability of paternalistic measures for people with opioid use disorder, and social positioning (e.g., law enforcement versus advocate). “On the one hand, people do not like the idea of involuntary commitment. On the other hand, many people do like a ‘tough’ (punitive) approach to SUD treatment”
Low The public has a negative view of these types of laws that take freedom from people (violation of civil/human rights). “These have generally been viewed negatively in states where there have been discussions”

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 Feasible with current resources, and already implemented in some places. “Based on how ubiquitous these policies are, I think they are relatively easy to implement”
Moderate
(selected)
 Difficult to implement fairly, with effective care, and without abuses. Requires considerable resources and administrative oversight, hindered by legal bureaucracy and treatment availability. “There are well-formed policies for involuntary commitments for psych when a person lacks capacity and presents an acute danger, but those systems are currently widely overwhelmed and overcapacity. We may not have the physical plants in place for involuntary hospitalizations for OUD. There is currently insufficient capacity to provide maintenance medication treatment—the core element of evidence-based treatment for OUD—even among those who seek it”
Low Yields significant resistance and requires significant resources (e.g., to track and monitor involuntary commitments). “This will be difficult—there will be a great deal of resistance and you will need significant resources”

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 Feasible with existing resources. “Seems feasible with existing resources”
Moderate Depends on the health care and criminal legal systems in a state. “This seems highly variable depending on the system and state. Unsure at face value who covers cost of commitment, length of commitment, if programs are already in place with clear protocol, and data systems are in place for oversight”
Low
(selected)
 Implementing involuntary commitment policies through the criminal legal system requires a significant amount of resources with little-to-no population health benefit (i.e., little-to-no cost-effectiveness). “To provide high-quality treatment is particularly expensive and difficult, if impossible, to pull off when the treatment is coercive. More commonly, these programs funnel money to the criminal legal system with resulting low quality/no treatment and hinge on locking people up more than treating them”

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 N/A N/A
Moderate Depends on how it will be implemented. “Two factors have to be considered. Will there be bias in who gets access to these resources, and will there be bias in who is getting committed”
Low
(selected)
 Excessively harsh and severe policy that criminalizes people who use drugs. Likely to have significant disparate negative impacts on historically and continuously marginalizes communities, such as people of color and people with fewer socioeconomic resources. “Involuntary civil commitment is burdened with the historical legacy and the current practice of criminalizing drug use and people who use drugs, which treats people who use drugs like they are criminals and/or less valued. So it exacerbates the underlying health disparity that results in worse and different treatment for people who use drugs compared to people with other health conditions. Furthermore, it is particularly inequitable for groups that have been historically and are currently excluded from the benefits of high-quality health care, like Black, Latinx, and Native American people and have been over-policed and targeted for incarceration by the War on Drugs”
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Involuntary Civil Commitment Laws. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-20.html.
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