I was somewhat distressed by this post by Judge Glock at City Journal in support of incumbent New York City Mayor Eric Adams’s proposal for involuntary treatment for individuals addicted to drugs:
On Thursday, New York City mayor Eric Adams proposed the Compassionate Interventions Act, allowing doctors and judges to order involuntary treatment for people addicted to drugs or alcohol who pose a danger to themselves or others. “We must help those struggling finally get treatment, whether they recognize the need for it or not,” Adams said at a Manhattan Institute event. “Addiction doesn’t just harm individual users; it tears apart lives, families, and entire communities, and we must change the system to keep all New Yorkers safer.”
Adams’s plan is a welcome step. He understands that addiction, violence, and public disorder are closely linked, and that the city must address them together. Paired with more funding for rehabilitation, the measure could significantly reduce public drug use.
It’s not that I am pro-addiction or that I don’t think that people should be able to get treatment for drug addiction.
The sad reality is that involuntary treatment is rarely particularly effective. There’s truth in the dictum that admitting you have a problem is the first step on the road to recovery.
But that raises another very troubling question. The rate of relapse after an overdose is extremely high—maybe as much as 60%. There’s been quite a push for Naloxone for the last several years. Why? How do we reduce the likelihood that saving someone after an overdose is just maximizing the likelihood that they’ll continue to abuse?
While I support the objective, I keep thinking, “it seemed like a good idea at the time.”
I am more concerned that it will be abused. If the person had been medically diagnosed and it was documented, I might be more onboard.
Naloxone. According to personal contacts within the police and first responders community, Naloxone has the problematic effects of users being able to get higher on heavier doses of drugs as Naloxone will save them from death and they are more often furious and violent when first responders interrupt these wonderful highs by administering Naloxone.
Contacts within the police and first responders community have told me the addicts believe Naloxone allows them to get much higher as dying of overdose is prevented and that when administered Naloxone, the addicts are ofter violent and angry over having such a wonderful high disrupted.
I assume that NYC has a system for involuntary commitments already like other cities. If an overdose was done to try to commit suicide then the tools already exist to commit those people. Most of the narcotic overdoses are accidental. Forced treatment in that case has a very poor success rate.
Of note, even when you are using involuntary commitment for someone who is actively suicidal the results are mixed when studied. It has a positive short term effect but studies dont show a clear long term reduction. That appears to be mostly due to poor long term follow up. Some of that is due not being able to afford long term mental health care. However, a lot of it is very depressed people often feel hopeless and dont bother with follow up. So they kind of have to want to change as you note above but also need to think that they can change. (Before going to med school I worked in a emergency mental health centers and helped fill out involuntary commitment papers on hundreds of people. They were almost always approved by the city Judge/magistrate so its not that hard to get someone committed.)
I think there probably is a small group of addicts who think of using Naloxone but it’s very small. Addicts dont usually plan ahead that well and they would need a second person to give them the Naloxone.It also makes them feel like sh$t when it hits so I have a hard time seeing people doing it often. Also, if it’s a long term addict who is using high doses of fentanyl, or worse carfentanil, it may take quite a bit of naloxone.
Steve
I assume that you are citing that 60% of people who _survive_ an overdose will relapse. To reduce the number of relapses, simply reduce the number who survive. That’s what you are getting at, right?
That 40% who survive but don’t relapse, that number will shrink too.
Or maybe better treatment. We just need to come up with a program that will fill the pockets of whoever is running HHS these days…
Like steve, I’m a little confused about what this covers. Drug addiction can cause or contribute to mental illness, and mental illness can cause or contribute to drug addiction. It looks like New York law does not authorize commitment for drug addiction without mental illness. I suspect this might be a small group in the Venn diagram.
And the article seems to suggest the plan would work if there is “more funding for rehabilitation.” That seems like a problem if increasing the scope of coverage for commitment is not paired with added resources for a new class. It would just be taking resources from the mentally ill to the not mentally ill.
I have opinions on a lot of things, but this is one that I simply don’t know what the right course of action is. Addiction and overdose deaths are a massive problem affecting so many families of all socioeconomic levels. My nephew was one of them. More people die in one year from drug overdoses than died in the entire Vietnam War.
The problem extends beyond those who die to include other social ills including theft, joblessness, homelessness, and other crimes like DUI. This is part of a bigger problem known a deaths from despair: overdose, suicide, and alcohol related deaths. Why is the US worse than other countries on this?
I could try to blame it on our welfare system, our drug policies, or lack of working jobs for men. Each of these explanations come up short. I wish I knew.
Our overdose rate is probably the highest in the world. We are at 35 (per 100,000) for men and 20 for women. That’s twice the rate of the next closest countries (Finland and Sweden) per some studies. Mexico is at about 0.1 per 100,000. Of note, in the 90s-early 2000s our rates were much lower and Sweden and Finland were higher. A lot of this right now is due to fentanyl. Its a much more potent drug than heroin and most other narcotics so its easier to overdose with. It also has a faster onset than most narcotics, especially the respiratory depressive effects which makes it more of a risk. Also, since its a lot more potent it’s easier to transport.
So there are plenty of countries with poor people, with lots of people on welfare, with men not working who have much lower rates of overdose deaths. It is also not clear to me why this is unique (n severity) for the US. It looks like starting last year that fentanyl deaths are dropping so I think there is a faddish issue with a lot of drugs so I expect this to continue to drop some.
(As an aside, I think a lot of the credit to the narcotic overdoses becoming such an issue traces back to the drug company push, especially Purdue, to increase the usage of narcotics. Having read pretty extensively Purdue et al engaged in a genius and comprehensive marketing strategy. Many in the medical profession gave them outright aid and many were complicit in just accepting their claims at face value. For a slightly sensationalized version watch Painkiller on Netflix though since the series is only 6 or so hours long they couldn’t cover all of the ways that Purdue et al worked to cover the market with false or misleading info. Matthew Broderick does a nice job as Sackler.)
Steve
We have all spoken sympathetically to this issue which history has proven to be a pointless exercise. Drug addiction, like stupidity and mental illness, can not be rehabilitated or “cured”. The more we have tried for the past sixty years, the worse addiction has gotten. What we see on the streets now a days is the result. The only beneficiaries of the policies of treatment/rehab are a vast army of experts, administrators,
and paramedic types. I suggest it is time we now serve society and take the addicts off the streets; let the experts do their short term magic then release them and re admit after a few weeks when they relapse.
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Very sadly, I think William is correct.
I am reminded of the Soviet Union’s use of psychiatric hospitals to detain and demonize opponents.
Also did we not shut down most psychiatric hospitals decades ago? A large part of our homeless and street violence problems are due to former inmates or people who would be inmates under the old rules.
The problem is what justifies involuntary confinement, and who makes the decision. The criminal justice system evolved to solve those problems, defining how, why, and who makes the decisions, and who suffers the consequences.
The main problem with confinement for psychiatric reasons is the person to be confined has little or no recourse to counsel, nor to a well-defined due process.
By the way, in the Netherlands, once one of Hitler’s happy gang, and willing so, euthanasia is once again has become a reality, and the people to be killed and their families have only minimal say in the matter.
We should add numbers to the discussion rather than base it on feelings. Our overdose death numbers were relatively stable for quite a while and we were only a bit of an outlier compared with other countries instead of number 1. What we had was a big rise due to fentanyl, which as I said above was largely self inflicted due to the marketing efforts of a few pharmaceutical companies companies and negligence/ignorance on the part of providers.
We saw a 3% drop in 2023 in deaths and a 27% drop in 2024 and so far it looks like numbers are continuing to drop this year. I expect overdose to drop back closer to the levels before this surge. Illegal drug use probably wont change much.
https://www.cdc.gov/nchs/products/databriefs/db522.htm
Steve
I’m afraid that’s less meaningful than you may think.
The statistics on overdose deaths are probably pretty good but they tell us very little about the total number of overdoses about which we know relatively little. What may be happening is that there are more overdoses, possibly many more overdoses, but more people are surviving them because of naloxone. If there are more overdoses and people are surviving them that’s not necessarily a good thing. And we certainly cannot make reasonable speculations about trends based on such lousy information.
The decrease has been fairly uniform across states. Naloxone has been available for quite a while in a number of states but only recently in others. In the states where it was long available they also saw an increase in opioid deaths, just at a smaller 10%-15% decreased rate. The actual literature looking specifically at naloxone is a bit mixed with some claiming it encouraged more drug use.
So people who study this think that naloxone may be playing a part in the reduction but it’s only a part. Which makes sense as most addicts arent really good at planning ahead. To a non-addict it would make sense to have some naloxone around. To an addict it’s not much of a consideration for most of them. Part of that is when you do use naloxone it works pretty fast and the effects feel pretty awful. Addicts dont like it. It also means that you need to have a second person around and a lot of addicts, probably most use their drug alone all of the time or at least occasionally.
Steve