Mandatory addiction treatment for people who use drugs: global health and human rights analysisBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2943 (Published 09 June 2016) Cite this as: BMJ 2016;353:i2943
- Karsten Lunze, assistant professor1,
- Bulat Idrisov, fellow1,
- Mikhail Golichenko, senior policy analyst2,
- Adeeba Kamarulzaman, professor3
- 1Boston University School of Medicine, Boston, MA, USA
- 2Canadian HIV/AIDS Legal Network, Toronto, ON, Canada
- 3University of Malaya, Kuala Lumpur, Malaysia
- Correspondence to: K Lunze
- Accepted 20 April 2016
During 2013 to 2015 the Russian Federation (Russia) amended its laws to enable courts to force people who use drugs to have treatment for addiction.1 2 3 4 The laws give courts the ability to mandate sentenced offenders with drug dependence to undergo dependence treatment in combination with non-custodial measures such as fines or coercive labour. Russian authorities have stated that the new laws were enacted as motivation for treatment. Our analysis globally examines the acceptability and efficacy of legislative approaches mandating treatment of drug dependence.
Increasing drug use in Russia led to parallel HIV epidemic
Drug use in Russia, consisting mostly of injectable heroin, increased after the break-up of the Soviet Union.5 There were over 540 000 drug users registered in Russia 6 but the United Nations Office on Drugs and Crime estimated that were about 1.8 million opiate users in the country in 2014.7 The prevalence of injecting drug use (2.29%) among 15-64 year olds is almost 10 times the global prevalence estimate of 0.27%.8
The deleterious effects of addiction on health are well recognised, including the risk of blood borne infections.9 Over the past decade, there have been few effective HIV prevention measures targeted at people who use drugs in Russia.10 HIV infection rates have been growing rapidly, and over half of all people with newly acquired HIV became infected through unsafe injecting of drugs.11 Over a million people living with HIV were registered in Russia at the beginning of 2016.12 Behind these numbers lies a substantial burden of ill health and stigma for affected people and their families.
Lack of evidence based treatment
Addiction treatment in Russia requires registration with authorities, relies heavily on antipsychotics and tranquilisers, and is largely limited to voluntary drug detoxification. and counselling. The new law presents several problems. The medical specialty of narcology, Russia’s addiction treatment system created during Soviet times, has insufficient facilities13 14 to accommodate patients for mandated addiction treatment, and agonist therapy with methadone or buprenorphine is banned in Russia15 despite evidence that it reduces craving for, and use of, heroin or other illicit opiates and drug related mortality.16 17 These drugs have also been shown to reduce risky injection behaviour and have improved adherence to antiretroviral therapy regimens among people with HIV infection.18 A meta-analysis of addiction treatment with methadone estimated that it reduced the risk of HIV infection by more than 50%.19 However, the Russian government argues that agonist treatment replaces one addiction with another. The reported relapse rate of opioid dependent people in Russia one year after treatment is over 90%.20
Harm reduction programmes involving provision of clean syringes and needles and distribution of the opioid antagonist naloxone have also been shown to reduce risk of HIV transmission, intensity of drug use,21 and overdose.22 The World Health Organization has emphasised that such programmes are highly cost effective,23 but a study in Russia found that more than half of all people who use drugs surveyed had been arrested for possession of needles and syringes (which is not illegal) or for drugs planted on them.24 These arrests were associated with adverse health outcomes such as overdose and risky drug use practices.24 Although pharmacies in Russia can legally sell needles and syringes, harm reduction programmes have met substantial resistance. The few programmes that have existed were insufficient,25 with temporary pilot programmes involving syringe exchange and counselling never being scaled up.26
Different approaches to mandatory treatment
Mandatory treatment refers to any form of drug treatment that is ordered, motivated, or supervised by the criminal justice system (table).27 Forms of mandatory treatment are being used in several EU countries, the United States, Latin America, New Zealand, and many Asian countries.28 Some types of mandatory treatment are compulsory, without informing and allowing the patient to give consent, and do not allow the individual to decline treatment or choose the type that they receive.29 It is often accompanied by detention in prison or other facilities and detoxification is often done without medical supervision or using evidence based methods.30 In contrast, quasicompulsory treatment is offered as a choice between incarceration and treatment with informed consent.31 32 Treatment under the threat of imprisonment if the person fails to comply represents an alternative to criminal justice sanctions and an opportunity for people with drug dependence to accept some form of help.33 Also referred to as drug courts, the system usually allows some choice of treatment, rehabilitation, education, and healthcare, and does not force offenders to be treated without consent.29
Civil commitment refers to legally sanctioned, involuntary hospital treatment of drug dependence for those unwilling or unable to obtain services on their own, who pose an imminent risk to their own or others’ safety.34 It aims to protect both the individual and society from danger and as such is both an ethical and acutely effective form of mandatory treatment.35 Such emergency, involuntary detention or treatment needs to be limited to a few days and rely on evidence based methods such as detoxification with methadone.36
When patients consent or even select to have treatment, legally mandated inpatient or outpatient therapies under supervision of the justice system can be effective in reducing drug use.27 An evaluation of US drug courts found that non-violent offenders who chose court supervised dependence treatment over sentences in the regular criminal systems were much less likely to use drugs than the comparison group in regular prisons.37
Poor record of compulsory treatment
Mandatory treatment and detention for treatment occurs in many countries.29 30 Official accounts state that more than 400 000 people are detained for periods ranging from several months to several years in over 1000 compulsory drug rehabilitation centres as means of both punishment and treatment in parts of Asia.38 Such centres are usually administered and operated by the police or military, rarely have any trained health or medical staff, and do not provide evidence based treatment.30 Criteria for detention of people in these centres and their “treatment” forms vary among countries, and have been reported to involve detoxification and abstinence without medical assistance, forced labour, physical and sexual violence, and religious or moral instruction.39 There is no evidence that these centres are effective in treating drug dependence.40 Rather, detention in such centres often leads to the denial or inadequate provision of medical care.39 41
In China and Vietnam, compulsory drug detention centres are historically grounded in a system of “re-education through labour” that has detained dissidents and activists. In other countries, such as Cambodia and Laos, people who use drugs have been detained with other people deemed “socially undesirable,” including sex workers, homeless people, people with mental illness, and those with alcohol dependence or gambling problems.42 Detainees have been subject to human rights abuses, including extrajudicial and indefinite detention, physical abuse, and torture.30 33 43 For example, in Cambodia, children with drug dependence were detained against their will, routinely beaten (sometimes with electrical cables), forced to work, and were subject to other abuses, including sexual abuse.44
Evidence from compulsory drug detention centres is sparse but has supported concerns about the efficacy of mandatory treatment techniques.40 In a study in Malaysia, 86% of detainees reported cravings for opioids and other drugs even after months of incarceration, and 87% reported that they expected to resume drug use after release.41 High relapse rates after release have also been reported in China and Cambodia.42 45 High rates of drug overdose and crime recidivism are also reported after release from compulsory treatment.45
In the absence of effective treatment and harm reduction, drug detention centres represent a high risk environment for other health harms, primarily transmission of HIV and hepatitis C. In Malaysia, HIV prevalence among people in compulsory drug detention centres is estimated to be 10%, nearly twice as high as that in prison populations and 20 times higher than in the general population.41 And a study from south China found the odds of being infected with HIV was positively associated with the number of compulsory treatments for drug abstinence a person had undergone.46 The United Nations has therefore called for such centres to be closed and for voluntary, evidence and rights based health and social services to be implemented in the community.47
Compulsory treatment conflicts with human rights and evidence
Drug dependence is a chronic, relapsing medical condition, and treatment of criminal offenders or non-offenders for addiction is considered medical care.48 Mandating treatment conflicts with human rights principles as stated in the International Covenant on Economic, Social and Cultural Rights, a legally binding UN treaty signed by over 160 member states, including Russia.49 These principles include informed consent, the ability to withdraw from treatment, the right to confidentiality, non-discrimination in healthcare, and freedom from interference. The Committee on Economic, Social and Cultural Rights, the UN body monitoring compliance with the covenant, has emphasised the state’s obligation to refrain “from applying coercive medical treatments, unless on an exceptional basis for the treatment of mental illness or the prevention and control of communicable diseases. Such exceptional cases should be subject to specific and restrictive conditions, respecting best practices and applicable international standards, including the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care.”50
There is limited evidence to justify mandatory treatment. Clinical experience has shown that treatment does not need to be self initiated to be effective. Sanctions or incentives from family, employers, or the criminal justice system can increase rates of entering treatment and retention.48 However, global evidence raises concerns around compulsory drug treatment regimens, both with respect to injecting drug users’ human rights and their effectiveness in tackling drug dependence (box).
Potential conflicts of mandatory treatment approaches with aspects of drug treatment60
Acute intoxication or withdrawal potential—Requires medical assessment for intoxication or withdrawal management; detoxification care and preparation for continued addiction services usually not available in mandated settings
Biomedical conditions and complications—Treatment of coexisting physical health conditions or complications may not be provided in mandated settings and coordination with physical health services is usually not available
Emotional, behavioural, or cognitive conditions and complications—Medical assessment and treatment of coexisting mental health conditions or complications in mandated settings or through coordination with mental health services usually not available
Readiness to change—Requires assessment of readiness to change and, if not ready to commit to full recovery, motivational enhancement strategies, which are not offered in mandated settings
Potential for relapse, continued use, or continued problems—Relapse prevention and continued services usually not linked to in mandatory settings
Recovery environment—Requires assessment of individualised family situation; housing, financial, vocational, educational, legal, transportation, childcare services usually not linked to in mandatory settings
Mandatory treatment—from detention to cooperation
There is some indication that mandatory treatment reduces drug use when provided under the supervision of specialised criminal justice systems such as drug courts rather than in prison.51 However, when people are ready to change and perceive a medical necessity, and effective therapies are accessible, they see a stronger incentive to engage and remain in treatment than through legal pressure.52 Efficient coordination between treatment providers and police or courts can facilitate better access to treatment and improve outcomes.53
In recent years, several Asian countries have begun moving to voluntary centres providing comprehensive evidence based treatment and support services. China has reportedly banned physical punishments during mandatory treatment, in recognition of high drug relapse rates. In addition, it has established minimum standards of medical care in detention centres and injecting drug users who voluntarily seek treatment are exempted from punishment.42 Malaysia has implemented harm reduction and methadone treatment centres across the country, which has resulted in reduced criminal activity, increased employment prospects, and reduced substance use and related HIV risks in those who have had treatment.54
Russia’s balancing act to reconcile treatment needs and human rights
The global evidence suggests that a substantial challenge for mandatory treatment in Russia is to balance the goals of improving the health of people who use drugs with their human rights. Some Russian providers support a return to the Soviet system of compulsory treatment, under which drug users discharged from inpatient care were legally required to see a narcologist once a month—this had little effect on reducing drug use.55 More than 60% of Russian addiction care providers surveyed supported mandatory treatment of injecting drug users.56 Others oppose registration of people with addiction and are concerned that mandatory treatment might prompt affected people to avoid healthcare.57
WHO emphasises that treatment should be mandated for a limited period only if drug users risk immediate harm to themselves or others, lack mental capacity to consent to treatment, and there are no other reasonably available, appropriate, and less restrictive responses.58 Whenever possible, drug users should be free to choose whether to participate in treatment and be able to provide and withdraw informed consent. WHO maintains that if people who use drugs are convicted of crimes related to their opioid use, they should be offered treatment for opioid dependence as an alternative to imprisonment.59
Laws on mandatory treatment ignore evidence that much of the treatment currently delivered is not effective. Mandating ineffective treatment will not increase its effectiveness. Instead, states should offer evidence based, high quality treatment with patients’ consent as an alternative to penalties. People who use drugs need equitable access to effective care. By creating additional capacity for treatment, revising treatment and rehabilitation practices to the best international standards, and reconsidering their position on agonist therapy and harm reduction, countries like Russia can hugely aid the fight against the burden of drug related disease.
Mandatory treatment without consent conflicts with human rights principles and is not effective in treating drug addiction
Evidence shows that compulsory treatment is associated with high rates of relapse
The focus should instead be on voluntary treatment using methods that are evidence based
Policies to tackle drug dependence should be linked with interventions to reduce HIV infection
Contributors and sources: The authors are members of academia and civil society organisations with clinical and policy expertise on addiction treatment. KL is a paediatrician and board certified addiction medicine physician, health adviser for various UN organisations, and public health researcher supported by NIDA grant K99DA041245. BI is a physician, health policy researcher, and NIDA INVEST fellow. MG is a licensed Russian lawyer. AK is physician, professor, and expert on mandatory treatment; she receives funding from the Ministry of Higher Education-University of Malaya High Impact Research Grant (HIRGA E000001-20001). KL is the guarantor.
Competing interests: We have read the BMJ’s competing interests policy and declare that we have no conflict of interest to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.