Arguments in favour of compulsory treatment of opioid dependence

Abstract

Twelve agencies of the United Nations, including the World Health Organization, have issued a joint statement that calls on Member States to replace the compulsory detention of people who use opioids in treatment centres with voluntary, evidence-informed and rights-based health and social services. The arguments in favour of this position fall into three broad categories: Compulsory treatment centres infringe on an individual’s liberty, they put human beings at risk of harm, and evidence of their effectiveness against opioid dependence has not been generated.

The United Nations statement underscores that although countries apply different criteria for sending individuals to compulsory treatment centres, detention often takes place without due process, legal safeguards or judicial review. This clearly violates internationally recognized human rights standards. Furthermore, people who are committed to these centres are often exposed to physical and sexual violence, forced labour and sub-standard living conditions. They are often denied health care, despite their heightened vulnerability to HIV infection and tuberculosis. Finally, there is no evidence, according to the statement, that these centres offer an environment that is conducive to recovery from opioid dependence or to the rehabilitation of commercial sex workers or of children who have suffered sexual exploitation, abuse or lack of care and protection.

The author of this paper sets forth several arguments that counter the position taken by the United Nations and argues in favour of compulsory treatment within a broader harm reduction strategy aimed at protecting society as well as the individual concerned.

Twelve United Nations agencies, including the World Health Organization, have issued a joint statement that calls on Member States to “close compulsory drug detention and rehabilitation centers and implement voluntary, evidence-informed and rights-based health and social services in the community”.¹ In this paper I refute each of the claims made in support of this petition and argue in favour of compulsory treatment as one component within a broader harm reduction strategy aimed at protecting and reintegrating into society individuals who are opioid-dependent while ensuring the safety of the broader community.

First, opioid dependence should not be viewed solely as a medical issue affecting the individual, but rather, as a complex social problem that affects entire communities. Opioid dependence harms not only the users themselves, but also their families and neighbours and even strangers far beyond their immediate circle of acquaintances. Therefore, a comprehensive response to opioid dependence must take into account both the human rights of the opioid-dependent individuals and those of the people who live in their communities.² In fact, compulsory treatment centres provide not only short-term opioid substitution therapy for the treatment of withdrawal symptoms, but also educational programmes, job skills training programmes and physical exercise routines in a safe, isolated environment. Some even offer opportunities for manual work. Hence, these centres increase the personal safety of both the individuals who have opioid dependence and the members of the communities in which they live. Besides reducing the use of opioids, they protect opioid-dependent individuals from death and suicide, opioid-related criminal activity and the physical harm that might befall them in a general prison. In addition, they protect the individual’s community through reductions in illicit opioid dealing, theft, vandalism, sexual assault and murder, and by mitigating the health risks associated with needle sharing and high-risk sexual behaviour.

The benefits of compulsory treatment centres for opioid dependence are substantial, albeit at the temporary expense of the opioid-dependent individual’s autonomy. However, this terrain is admittedly fraught with ethical dilemmas. Efforts to protect the rights of individuals and efforts to protect the broader community need not conflict, but where is the ideal balance? Although an individual’s human rights are generally upheld as universal and of paramount value and much has been written in their defence, are they more valuable than the rights of entire communities? In my view, what is regarded as the ideal balance in this context is rooted in cultural norms. In general, Western societies defend and protect individual rights over the rights of the broader community, while the opposite is true of Eastern societies.³ An example may serve to illustrate the point. Are people who have been dependent on opioids for years and who, in many cases, have severe psychological problems, able to make rational decisions, provide informed consent for treatment or participate competently in their own due process? At what point does the broader community have a responsibility to intervene? Some experts argue, as I do, that mental illness itself deprives an individual of their autonomy by rendering them unable to make free choices. Under some circumstances, the individual’s autonomy must be overridden for the sake of the community as a whole.^4,5

Second, although physical violence and high-risk sexual behaviour sometimes occur in compulsory treatment centres, no scientific evidence so far supports the notion that in these centres such problems are more common than elsewhere, or that the opioid-dependent individuals who live in them are at higher risk of opioid-related medical complications, infectious diseases or death than those not living in compulsory treatment centres. In fact, a research report jointly authored by officials from China’s Center for Disease Control and Prevention and Australian public health researchers shows quite the opposite. According to the report, about 50% of the interviewees, who were detained in a camp for re-education through labour, described their general health as good, very good or excellent.⁶ Furthermore, testing for the detection of communicable diseases (including HIV infection, syphilis, hepatitis C, tuberculosis, etc.) is expanding in many compulsory treatment centres. This will make it possible to detect new cases of infectious disease earlier in this high-risk population, which is otherwise very difficult to access.

Third, the evidence on the relative effectiveness of compulsory treatment and of voluntary, community-based treatment for opioid dependence is still mixed. Opioid-dependent individuals, whether remanded to a compulsory treatment centre or voluntarily enrolled in a community-based treatment programme, often continue to use opioids and relapse immediately after their release or after treatment is completed or discontinued. They also frequently re-engage in criminal activity linked to their opioid dependence. Thus, it is becoming increasingly clear that neither option is a “magic bullet” for the complete and permanent rehabilitation of all opioid-dependent people. Opioid dependence is now widely recognized as a mental disorder and has been shown to permanently alter brain function. The effects of opioid dependence are lifelong and sometimes involve debilitating psychological co-morbidity.⁷ Further research on this complex problem is required before the evidence surrounding the effectiveness of any single rehabilitation or treatment strategy for people with opioid dependence is deemed conclusive. More than likely, strategies will have to be tailored to different segments of the opioid-dependent population.

Compulsory treatment centres for opioid dependence play an important role within a broader harm reduction strategy. Voluntary treatment for opioid dependence is no longer unobtainable in some Asian countries. China has the largest methadone maintenance treatment network in the world.⁸ Since 2004, the network has served more than 350 000 opioid-dependent individuals, cumulatively, in nearly 750 methadone maintenance treatment clinics across the mainland. Similar programmes are being piloted or scaled up in Cambodia, the Lao People's Democratic Republic, Malaysia and Viet Nam, and many Asian countries are taking aggressive steps towards broader, more comprehensive harm reduction strategies comprising educational campaigns, peer outreach, needle exchange programmes, voluntary counselling and testing programmes and expansion of treatment coverage for HIV infection.⁹ Thus, opioid-dependent individuals in some Asian countries now have more opportunities than ever to choose treatment over continued opioid dependence.

Despite the wide availability of voluntary treatment options, however, a certain proportion of opioid-dependent individuals persistently refuse treatment and engage in offences related to their opioid dependence, including violent crimes.^2,10,11 In China, this proportion is thought to range from 60 to 90% (unpublished findings). Furthermore, a recent international study of the effects of methadone maintenance treatment programmes showed that they do reduce heroin dependence, but not opioid-related crime.¹² Rather, an expanding body of research suggests that community-based voluntary methadone maintenance treatment programmes are simply not enough to keep some opioid-dependent individuals from engaging in criminal activity² and that offenders’ perceptions of legal pressure or coercion are very important in reducing rates of rearrest.^10,11 These studies have prompted some high-income countries to re-examine the idea of compulsory treatment and even open new compulsory treatment centres for opioid-dependent people.²

Although compulsory treatment centres vary widely in terms of management, prevailing conditions and the treatments offered, much room for improvement clearly exists. However, closing these facilities all at once and releasing their inmates into the community is not the answer. A more prudent course would be to gradually move towards embracing the recommendations in the United Nations’ joint statement: not remanding people to compulsory treatment centres arbitrarily; establishing adequate oversight and reporting mechanisms in the centres, and reviewing the conditions within them.¹ Most the Asian countries cited in the joint statement are already actively engaged with various United Nations agencies and other international organizations in trying to learn and implement best practices in harm reduction strategies for opioid-dependent people.⁹ Studies on the problems affecting Asia’s compulsory treatment centres for opioid-dependent individuals are already under way. For example, a study from China explored ways to effectively transition opioid users in such centres to community-based methadone maintenance treatment clinics upon their release. The study provides evidence that administering methadone within compulsory treatment centres is beneficial not just for opioid substitution therapy or detoxification, which is the current practice, but also for methadone maintenance treatment.¹³ Continued efforts to improve and expand on existing options for the rehabilitation of opioid-dependent people and to leverage a broad range of harm reduction strategies are the only way to effectively address the problem of opioid dependence.

In summary, I believe that compulsory treatment for opioid dependence should be retained as one component within a broader harm reduction strategy comprising voluntary treatment, needle exchange programmes, voluntary counselling and testing, expanded infectious disease treatment coverage, peer outreach and intensive educational campaigns. Compulsory treatment centres serve to protect the safety of both opioid-dependent individuals and their communities and offer a particularly important means of reaching the segments of the opioid-dependent population that repeatedly refuse outpatient treatment and engage in crime.