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Opiate usage and resulting overdoses continue to grow.

 Although, medications can help curb cravings and prevent the misuse of narcotics,

 treatment adherence is limited by the incentives for diversion and the lack of motivation to change.

 Individuals’ inaccurate and unhelpful thoughts about themselves and about substances often interfere with positive change.

 Research shows that cognitive behavior therapy (CBT) is helpful when used together with medication-assisted treatment (MAT).

One of the problems individuals experience when misusing substances is the powerful immediate reinforcement they receive from taking the substance. Indeed, a primary reason individuals use substances is the immediate reinforcement that, in the moment, is much more compelling than the long-term negative consequences of continued use. By the time most individuals voluntarily talk to an addiction specialist, they have likely experienced negative consequences, including diminished pleasure, negative adverse effects, and negative social consequences.

Individuals who come to treatment are often conflicted. On one hand, they have experienced negative consequences; on the other hand, they are unable to imagine that their lives could be different or better. In 

, we work with individuals to help them change the trajectory of their lives by placing a renewed focus on the things they value. We help them imagine how their own lives could improve if they were to pursue aspirations that are aligned with their personal values. When individuals place a renewed focus on their values and personal aspirations, they can connect the short-term and long-term consequences of their actions. Individuals find motivation to change their old habits and participate in healthier activities.

With a newfound desire to make changes in their lives, individuals must make what are often difficult decisions. In CBT, we support individuals in making decisions by doing a cost-benefit analysis. The cost/benefit analysis helps elucidate the relative positive and negative elements of engaging and not engaging in a particular action. By conducting a cost-benefit analysis, individuals gain clarity about the things they value. Accordingly, individuals may make decisions about people with whom it is in their interests to associate, which places to frequent to further their goals, and what things they can do to help them move in a positive direction.

, individuals often lose their ability to manage their schedules. In CBT, we help individuals develop schedules with a focus on 2 types of activities. One type of activity increases their level of mastery of things they either need to do or want to do. These activities could include everything from basic hygiene to developing expertise in a profession. The second type of activity increases a person’s experience of pleasure, without engaging in substance use. Individuals who suffer from addiction have often lost their ability to experience pleasure when not using drugs. A CBT therapist will help individuals select activities that match their interests and include them on a master schedule designed to include all the different activities they need to do. Having scheduled activities allows less time for the individual to seek out and 

. The feelings of mastery and pleasure serve as positive reinforcement for engaging in the various activities.

When individuals are caught up in the dynamics of addiction, they often develop negative beliefs about themselves and their abilities. This can lead them to have negative expectations that become self-fulfilling prophesies when situations play out as they predicted. After a person engages in activities that increase their level of competence and pleasure, they gather evidence that contradicts their formerly held beliefs about themselves and about substances. The newly acquired evidence starts a cycle of reinforcement based upon positive assessment, statements, and feelings about themselves. Repeatedly engaging in activities that give them a sense of competence and/or pleasure, combined with positive experiences, lays the foundation for creating new beliefs about their capabilities and capacity for positive feelings.

The continuous use of substances over an extended period can cause a person to become numb to life’s events. Once an individual gives up using substances, the renewed experience of having feelings can be unnerving. Managing emotions can become an important target for therapy. Developing a routine 

, engaging in healthier eating, and moderating physical elements of emotions may all help an individual learn to better control their feelings. Relaxation techniques, 

, or other activities such as yoga, prayer, and meditation can be very effective ways of helping individuals tolerate and manage their experience of feeling emotions that they have not felt for a long time. These techniques can be used with individuals from all walks of life and with varying histories related to substance misuse.

“Maria” was a 22-year-old college student when she was referred for treatment following her arrest for drug possession and distribution. Maria had excelled academically and in multiple sports during high school. She went to college on a softball scholarship and planned to become a physical therapist. Following her freshman year, Maria tore her rotator cuff. Initially, she thought it was a minor injury and continued to play and work out. The tear got worse and, despite surgery, ended her ability to play softball at the college level. The injury was devastating to Maria because not only could she no longer play sports, but she lost her scholarship, had continuous 

 and disrupted sleep, and became depressed as a result. She struggled to keep up with her studies. Her greatest relief from the physical pain and emotional upset was the oxycodone she was given following surgery. Her depression made it difficult for her to fully engage in treatment, and although her doctor recommended ibuprofen and alternative treatments, she continued to request the medication. After several months, her doctors discontinued the opiate medication.

Maria, in the meantime, had connected with others who were able to provide street drugs to fill her increasingly greater need for relief. When she was cut off by her doctors, she turned immediately to her friends. Eventually, she expanded her network of people from whom she could acquire and with whom she would share drugs. This eventually led to her arrest. Maria’s relationship with her parents and her old friends suffered along the way, and her parents became very concerned about her. They expressed a desire to help her find solutions. Maria’s attorney referred her for CBT treatment after her arrest and before any court appearances.

Initially, Maria was friendly and expressed a desire to participate in treatment. However, she was quite clear that she did not know how to get along in life without opioids. Maria felt responsible for getting herself into her current predicament and felt helpless; she thought her future was hopeless and that she had lost any measure of worth. Rather than reminding Maria of what she had lost or lecturing her about the consequences of her continued drug use, we started therapy by focusing on the things that were important to her before the injury. 

, academics, family, and friends were always important to Maria. They all seemed intricately linked to one another, and her injury seemed to take away everything she cared about.

Acknowledging the losses and the difficulties she had experienced, we talked about what her life could be like if she was able to reclaim the things she valued. Her family and academics were still important to her, and although she could not play softball, she was still capable of exercising. In session, we had her imagine that she finished school, renewed her relationship with her parents, and engaged in tolerable levels of exercise. She did not believe that she could be a physical therapist and switched her major to occupational therapy. Her vision of her aspiration served as a strong motivator to get her life back on track.

Still, Maria could not consistently resist her cravings for drugs. We taught her relaxation exercises that she found helpful for her emotional state and calming her urges, but they were not universally effective. We talked about the possibility of medication to help with her cravings. Both Maria and her parents had concerns about relying on medications to resolve medication issues, but after doing a cost-benefit analysis of the advantages and disadvantages of trying the medication versus the advantages and disadvantages of not trying the medication, Maria decided to give it a try. The medication had both agonist and antagonistic properties that worked well for controlling her urges and, to some extent, helped with her lingering pain. With those benefits, we then discussed other alternative treatments for pain that included ibuprofen and physical therapy. When Maria gained control of her urges with medication, she felt stronger.

After receiving relief from physical pain and urges to use, Maria was better able to concentrate on achieving her desired life. Initially, she found it challenging to manage her time. We worked together on an activity schedule to make time for her classes and homework. For Maria, it was important that she have a schedule that made time for her parents and other supportive friends, exercise, a routine sleep schedule, and 

. As she followed her schedule and became more active, she felt more confident and competent. She changed the way she thought about herself. Rather than thinking of herself as being helpless and worthless, she recognized the power she had to do many good things with her life and felt increasing more worthwhile as a person.

It had been 3 to 4 years after Maria’s rotator cuff injury when she was referred for CBT treatment. Simply stated, for a variety of reasons, she had deviated from her previously successful path in life. With about 12 months of CBT and medication, she was able to get her life back on course. At that point, she had been accepted into an accelerated rehabilitation disposition program of the court, had completed her bachelor’s degree, and was accepted into a master’s program in occupational therapy. She was still taking her medication, but did not want to have to take it forever. She exercised, but did not get the same level of pleasure as she did from playing high-level competitive sports and was working toward accepting that she could not do what she did before. She was making new, supportive friends whom she liked, although when she saw her old teammates, she experienced sadness that she could not be one of them. Maria maintained her values in life and took major steps toward achieving her aspirations. One thing she recognized was the need for her to continue using the tools she learned to stay on her path of recovery.

Cognitive and behavioral strategies can be useful in treating opioid use disorder, either on their own or in conjunction with medication. Alone, or with medication, CBT can improve motivation, aid in important decision-making, jumpstart behavioral activation, and facilitate the development of new beliefs about drugs, oneself, and the future. Medication can help patients control their urges so they can better focus on the work of therapy.

is an experienced clinician, trainer, and administrator who provides oversight to the training and clinical services at Beck Institute as the CBT program director. For more than 25 years, he held leadership positions in a large integrated health system, including roles as director of behavioral health at WellSpan Behavioral Health, as chair of psychology for a 580-bed acute care hospital, and as chief psychologist for an APA-approved internship in clinical psychology that he founded. As a clinician, Dr Miller has used CBT to help individuals of all ages with a myriad of presenting problems coming from forensic, community, educational, and medical settings. He has conducted workshops, written professional articles, and published several resource books for lay readers about personality, depression, anxiety, and stress.

1. Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. Press release. November 17, 2021. Accessed March 24, 2022. 

https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm

2. Substance abuse and addiction statistics. National Center for Drug Abuse Statistics. February 19, 2022. Accessed March 24, 2022. 

3. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Medication-Assisted Treatment for Opioid Use Disorder. The effectiveness of medication-based treatment for opioid use disorder. In: 

Medications for Opioid Use Disorder Save Lives

. Mancher M, Leshner AI, eds. National Academies Press; 2019.

4. Alfonsson S, Johansson K, Uddling J, Hursti T. 

Differences in motivation and adherence to a prescribed assignment after face-to-face and online psychoeducation: an experimental study.

Effectiveness of the cognitive restructuring approach on irrational beliefs and hopelessness in individuals with a substance abuse disorder: a randomized controlled trial.

7. Ray LA, Meredith LR, Kiluk BD, et al. 

Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: a systematic review and meta-analysis.

8. Moore BA, Fiellin DA, Cutter CJ, et al. 

Cognitive behavioral therapy improves treatment outcomes for prescription opioid users in primary care buprenorphine treatment.

Cognitive behavioral therapy for substance use disorders.

Alleviating Opioid Use Disorder With Cognitive Behavior Therapy and Medication-Assisted Treatment

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this activity is to review the clinical, legal, and ethical aspects of the civil commitment for substance use disorders.

1. Identify the legal basis of civil commitment for substance use disorders.

2. Formulate the ethical arguments for and against civil commitment for substance use disorders.

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals seeking to improve the care of patients with mental health disorders.

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource®, LLC, and Psychiatric Times™. Physicians’ Education Resource®, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource®, LLC. No commercial support was received.

This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

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None of the staff of Physicians’ Education Resource®, LLC, or Psychiatric Times™, or the planners of this educational activity, have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

For content-related questions, email us at 

. For questions concerning the accreditation of this CE activity or how to claim credit, please contact 

 and include “Civil Commitment for Substance Use Disorders: Coercion or Compassion?” in the subject line.

Once you have read the article, please use the following URL to evaluate and request credit: 

https://education.gotoper.com/activity/ptcme22june

. If you do not already have an account with Physicians’ Education Resource®, LLC, you will be prompted to create one. You must have an account to evaluate and request credit for this activity.

If he will not go voluntary into the special surroundings necessary for health, it is the duty of his friends and society to force him to do so.

The United States of America has entered the third year under siege from not just 1, but 2 epidemics: COVID-19 and addiction. Each scourge has multiplied the victims and magnified the death toll of the other; together, they have caused immeasurable suffering and loss.

 On November 17, 2021, the Centers for Disease Control and Prevention (CDC) made the grim announcement that annual overdoses passed the 100,000 mark. The 100,306 tragic deaths represent a nearly 30% increase from the prior year. Fatalities from synthetic and semisynthetic opioids, especially 

, along with methamphetamine and cocaine were all higher in the past 12 months than in the period before.

 The vast majority of those who overdosed would meet criteria for a substance use disorder (SUD).

Mental health disorders and suicidal ideation also increased during this dire period in our nation’s history. The CDC surveyed 5470 US adults at the end of June and found that 40% of respondents reported symptoms of anxiety, depression, or other trauma- or stress-related disorder related to the pandemic. Of that cohort, 26% indicated they had either started or increased substance use to help manage their distress.

 The latest National Survey on Drug Use and Health (2019-2020) (NSDUH) found that in the period of study, 25.9 million individuals who had previously used alcohol and 10.9 million prior users of drugs endorsed the statement that they were “using substances a little more or much more” than they did before. In addition to these alarming statistics, 2020 data show that 97.5% of those aged more than 12 years who needed SUD treatment and did not receive it at a specialty facility in the last year did not believe treatment was necessary.

In the face of such an enormous social, economic, and public health crisis, fearful and frustrated policy makers, demoralized health care professionals, and desperate family members of individuals struggling with SUDs have sought out potential solutions. It is no wonder that there has been growing interest in laws authorizing civil (involuntary) commitment for SUDs. Much of the scholarly attention has understandably been focused on the use of these statutes to curb the 

 However, most state laws also apply to serious alcohol, cannabis, and stimulant use disorders that many clinicians more commonly see in their practices.

This continuing education article is written for mental health care clinicians who, given the formerly mentioned data, are likely already caring for individuals with 

 in a variety of nonspecialty settings. Legal considerations, including state criteria and processes for civil commitment for SUD, will be outlined. These are the basis for the clinical ethics arguments for and against civil commitment: They are the central concern of the continuing education offered here. A case study and a review of recent literature will illustrate the values perspectives of the various parties involved in civil commitment for SUD. Civil commitment for SUD potentially pits compassion against coercion, requires a caregiver to choose paternalism over autonomy, and may compromise respect for individuals in discharging the duty of nonmaleficence. Overarching all these conflicts is the principle of justice and how civil commitment will impact the health disparities that the pandemic has both exposed and exacerbated.

Hall and Appelbaum’s detailed review of the history of commitment for SUD clearly demonstrates that it is not a new practice in the United States.

 Many of the luminaries of 19th-century American psychiatry advocated for legislation to permit the commitment of individuals (primarily with 

) to newly established inebriate asylums.

In response to social and political forces, the ethical and medical pendulum swings between the 2 legal bases of civil commitment: Parens patriae is in general the more clinical standard based on beneficence, while police powers is a more legal standard grounded in nonmaleficence.

 Parens patriae is the legal doctrine that the state is responsible for safeguarding the interests and welfare of those unable to protect themselves, even if that protection requires a corresponding restriction of self-determination. Police powers give the state the authority to limit autonomy to the extent that it is necessary to protect the health and life of citizens from harm and ensure public safety. Civil commitment for mental illness, and even more for SUD, places these 2 legal perspectives and the clinical practices that implement them in ethical tension, as the following case study illustrates.

“Jeff” is a divorced man, aged 28 years, and a graduate of a technical school. He was fired from his job for the fourth time in 2 years when he repeatedly arrived late and hungover for work as a computer technician. Jeff has been admitted to the local academic medical center’s intensive care and medical units for alcohol intoxication and 

, and gastrointestinal bleeding, 5 times in the last year. He has failed multiple residential and outpatient programs that provided both psychotherapy and medication-assisted treatment. Even several stints in jail for public intoxication, as well as the loss of his driver’s license after a crash occurred when he was driving drunk, have not motivated him to stop drinking.

Jeff has not been diagnosed with any other mental illness and has never been psychotic, suicidal, or homicidal. Upon his most recent admission, he is diagnosed with cirrhosis, and the gastrointestinal physician informs Jeff and the treatment team that complete alcohol cessation is critical if Jeff is to have any chance to survive. Jeff does not fully appreciate the gravity of his prognosis and remains ambivalent at best about stopping drinking. The hospital consultation-liaison psychiatrist has evaluated Jeff several times and has determined that when the patient is not intoxicated or in withdrawal, he retains decisional capacity.

Jeff’s father, “Dr Frank,” is a general surgeon, and, with Jeff’s permission, he asks to speak to the psychiatrist, as he does not agree that his son has decisional capacity. Jeff’s parents have found him passed out in a filthy apartment with no food, often covered in his own body fluids, more times than they can count. Dr Frank asks the psychiatrist, “How can you say someone who is drinking himself to death is in his right mind?” Frustrated, Dr Frank asks the psychiatrist, “Can Jeff be committed, as he is surely a danger to himself?”

As of May 2021, if Jeff is a resident of 34 states or DC, the psychiatrist will be able to tell Dr F that civil commitment is a possibility. The Prescription Drug Abuse Policy System (PDAPS) defines substance use laws for involuntary commitment as follows: “Involuntary commitment is a legal process through which an individual who is deemed by a qualified agent to have symptoms of substance use disorder is ordered by a court into treatment in an inpatient setting.” The PDAPS identified the jurisdictions where SUDs may meet criteria for civil commitment (

 In other states, like Arizona and Arkansas, substance use is specifically excluded from the definition of mental illness utilized in the involuntary commitment statute.

Civil commitment for SUD is distinct from involuntary commitment for mental illness and from legally mandated treatment in a criminal justice context, such as through drug courts. Psychiatrists know well that many involuntarily committed patients have cooccurring addiction and mental illness. In 2020, the NSDUH found that 17 million individuals had comorbid mental illness and SUD.

 A common example is the patient with posttraumatic stress and alcohol use disorders who becomes suicidal when intoxicated. In contrast, in states with civil commitment for SUD, a patient like Jeff may be involuntarily committed solely for severe, chronic alcohol use disorder. Numerous legal and psychiatric scholars have drawn attention to the heterogeneity of state laws on several key provisions,

States also differ in the actual process of civil commitment for SUD. The general steps found in most statutes are illustrated in 

. Similar to commitment proceedings for mental illness, the petitioner is required to present facts to support their case; a health care professional with addiction expertise must evaluate the evidence to determine if it meets the specific criteria for commitment in the respective jurisdiction; and an attorney represents the patient in a hearing before a judge.

 The court officer must use a clear and convincing standard in their deliberations. Commitment is usually to an inpatient unit, although in some jurisdictions, an individual can be committed to a residential or outpatient setting. The duration of commitment may be from 1 day to more than a year, with an option for renewal of the court order.

A crucial aspect of public health policy is to solicit the diverse perspectives of stakeholders involved in an issue under consideration.

 We are fortunate to have limited yet valuable data on the opinions of the various parties involved in the civil commitment for SUD process. It should be noted that many of those surveyed, especially individuals who have been committed, are from Massachusetts—a state with among the highest rates of civil commitment for SUD. The civil commitment process for SUD in that state has been critically scrutinized in academic and media reports alike.

Clinicians. A 2021 survey of 165 addiction medicine physicians found that nearly 3 times as many doctors favored civil commitment for SUD (60.7%) than either opposed it (21.4%) or were unsure of their position on the question (17.8%). A concerning finding is that nearly 30% of the respondents, despite being addiction experts, did not know if SUD was grounds for civil commitment in their state and indicated the need for more education and research on the practice.

 This study found almost 3 times as much support for civil commitment for SUD than did a similar study conducted more than a decade earlier.

 This relative change in opinion mirrors the steady growth in civil commitment laws for SUD, with 25 states in the last 4 years authorizing or amending legislation.

Christopher et al surveyed clinicians who performed court-ordered evaluations of individuals with SUD as part of commitment proceedings.

 Of the 33 participants who completed the survey, the overwhelming majority (76.7%) opined that civil commitment constituted an effective and appropriate intervention to minimize risks associated with SUD. A similar number (73.3%) believed that civil commitment for SUD resulted in more overall good than harm.

Individuals with SUDs and those who care for them. Evans et al offered nuanced and contextualized qualitative data from interviews about pros and cons of commitment with individuals who had been committed for OUD, along with their allies and clinicians involved in the process. Respondents identified positive themes: that the intervention was lifesaving; that it protected vulnerable patients who were out of control or a danger to themselves or others; that it gave families options; that it was preferable to dying or going to jail; that it provided treatment access that could not otherwise be obtained; that the experience could be a life-changing event; and that it promoted public health and safety. Among the negative motifs that participants cited were feeling coerced and as if they were incarcerated; that the ordeal divided their family; that they endured withdrawal without medications to treat OUD; that it potentially increased risks over the long term; and that the practice was not evidence-based.

The viewpoints of individuals with addiction, their families and caregivers, as well as the addiction health care professionals who treat them should inform— although not determine—the ethical analysis and recommendations about civil commitment for SUD. Good clinical ethics are based on good medical facts, and perhaps the most crucial empirical ethics concern is the lack of data about the efficacy and outcome of civil commitment.

 Even from a utilitarian orientation, this information is necessary to calculate the overall utility or benefits of the intervention as weighed against the harms.

 Most of what is known about the effectiveness of civil commitment for SUD is drawn from a 2005 review of research on legal coercion in 

Regrettably, 3 decades of research into the effectiveness of compulsory treatment have yielded a mixed, inconsistent, and inconclusive pattern of results, calling into question the evidence-based claims made by numerous researchers that compulsory treatment is effective in the rehabilitation of substance users.

This empirical lacuna is so significant because the strongest argument made by proponents of civil commitment is that it saves lives. Opponents of the statutes would argue that, even if civil commitment reduces overdoses in the short term, studies in criminal justice cohorts show that it may actually increase the risk of death from overdose once the patient is discharged.

 This risk is amplified in the many programs that do not provide evidence-based treatment of OUD.

 Not using opioids decreases tolerance, and the traumatizing experience of commitment may alienate the individual from voluntarily seeking further care. Psychiatrists are quite familiar with serious and imminent danger to self and others being an acceptable basis for involuntary commitment for patients, and even with grave passive neglect in many jurisdictions. However, as seen in 

, the civil commitment statutes for SUD stretch the latter best interest standard beyond that utilized in involuntary commitment for mental illness.

There is a deontological imperative that human beings have an innate dignity and should be regarded with the utmost respect and empathy, even—and perhaps especially—during the process of civil commitment. There is also a more pragmatic and communitarian rationale for this approach: As with mental illness, research has found that experiencing the process of commitment as humane and compassionate improves the likelihood that the individual will not relapse to substance use and will follow up with care.

Christopher, Appelbaum, and Stein have called upon state authorities to end the criminalizing and stigmatizing of civil commitment that has been the most frequent objection of those committed under dehumanizing conditions and their advocates.

 The implementation of current statutes does not provide sufficient due process to protect the rights and liberties of individuals with addiction. In addition, the vague, broad provisions of the laws may allow too much latitude for clinical examiners, judges, and petitioners acting upon complex motivations. Christopher found that evaluators most frequently cited danger to self (ie, a suicide attempt or repeated overdoses) or threats toward others (like interpersonal violence). These are established grounds for involuntary commitment that organized psychiatry has long endorsed. What is more concerning is that examiners expanded the interpretation of serious and imminent at-risk behaviors, even at times beyond the law, and judges generally ruled in accordance with their recommendations.

Whether civil commitment for SUD is in most cases beneficence-based or a coercive breach of autonomy turns on the question Dr Frank asked the psychiatrist: “How can you say someone who is drinking himself to death is in his right mind?” The issue of decisional capacity as grounds for civil commitment for SUD has not received sufficient attention. Most mental health professionals would likely agree that individuals in the throes of acute intoxication with stimulants or in florid withdrawal from alcohol are incapacitated. Yet far fewer might concur that individuals with chronic and severe addiction lack decision-making capacity outside those 2 medically compromised states. This is true even if intense craving for the substance diminishes their ability to make what we as professionals or as a society would consider life-affirming choices. The divergent assessments of the capacity of individuals and the rationales for those judgments recapitulate among the oldest conceptual debates in addiction: Is it a moral flaw, a learned behavior, or a disease?

Walton and Hall rightly suggest that the philosophical underpinnings of civil commitment for SUD are implicitly grounded in the brain disease model that predominates in American psychiatry, medicine, and law.

 Loss of control, rationality, and even eventually capacity due to prolonged heavy use of substances of abuse, are core assertions of the brain disease model.

 If this supposition is accurate, the scientific basis of that model needs to be more explicitly articulated as the meta-ethical justification for the deprivation of civil liberty. Those who think addiction is a choice or a habitual behavior

 may dispute the contention that, except when in acute states of intoxication or withdrawal, individuals with SUDs lack the capacity, control, or reasoning cited as a primary ethical validation of civil commitment.

The most common and compelling argument of those opposing civil commitment for SUD is that it violates the legal and ethical doctrine of the least restrictive alternative. It is manifestly unjust, critics say, to involuntarily treat patients who cannot access evidence-based treatment for addiction due to lack of funding, availability, and a host of other social determinants of health. Independent of the side of the question of civil commitment for SUD they are on, many constituents agree that if individuals have their rights curtailed, evidence-based addiction treatment, including medication-assisted therapy, and concurrent treatment for cooccurring mental illness, as well as follow-up care, should be mandatory. Fairness and our fiduciary duty as health care professionals also demand that treatment not end with the commitment. Addiction experts know well that serious addiction is most often a chronic disease that requires continuing recovery services.

 Currently, under most state laws, there is no such mandate, in part due to a lack of appropriate resources.

Coercion has always been a significant force in addiction treatment, operating through family dynamics, employment, career pressures, and threat of legal sanctions, among others.

 Civil commitment for SUD may be seen as a legitimate and more formalized extension of prosocial influences, or as a coercive recourse to a legal solution for what is the complicated social, economic, cultural, and human problem of addiction.

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is the lead ethicist for the western region and director of education, Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College. She serves as the ethics editor for

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Neurobiologic advances from the brain disease model of addiction.

Brain change in addiction as learning, not disease.

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In this CME, review the clinical, legal, and ethical aspects of the civil commitment for substance use disorders.

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Special Report Chairperson: Tony P. George, MD, FRCPC

 has become a pervasive topic in discussions around mental health and addictions because of its complexities and high impact. When diagnosed with a mental illness or 

 (SUD), individuals experience barriers directly related to their disorder that can affect their personal and professional life (eg, depression and anxiety) and overall health and well-being. Stigma further perpetuates these consequences through internalized, public, and institutionalized discrimination based on being labeled as having a mental illness or SUD. It is important to understand the additive effects of stigma when one experiences a comorbid SUD in order to more effectively address the consequences that ensue. This article highlights the literature around stigma in those with both a mental illness and SUD, specifically addressing the characteristics and consequences of stigma that result within dual diagnosis.

"Jim" is a 29-year-old man with major depression who has been treated for 2 years by his family doctor. He is a successful junior advertising executive and has been encouraged to apply for the job of regional manager, which would be a huge promotion. He joins several colleagues at a restaurant bar for an after-work function. He realizes he forgot to take the new medication prescribed by the addiction specialist his family doctor asked him to see for his drinking, which has been ongoing since college. He takes the bottle from his briefcase and drops it on the floor. His colleague picks it up and asks, “Naltrexone? Isn’t that the drug for alcoholics?” Jim takes the bottle back and changes the subject. At the interview later that week, Jim’s boss and a few senior executives tell him he is a great candidate for the regional manager job, but new information has come to their attention. “Have you been straight with us Jim? Depression is bad enough, but this other thing? Well, that is a deal breaker.” Jim attempts to apply for alternate jobs but is rejected several times and eventually gives up after deciding “there is no point.”

Stigma has been defined as involving components of knowledge (ie, ignorance), attitudes (ie, prejudice), and behavior (ie, discrimination)

, all of which can be observed at the individual level through internalized or self-stigma, between individuals through interpersonal stigma, and at the institutional level through structural stigma. In addition, there is experienced and anticipated stigma in those who are stigmatized, as well as intersectional influences, such as gender, race, and socioeconomic class, that further contribute to the complexities of stigma.

Stigma is consistently observed in the space of mental health and addiction and is associated with a multitude of negative consequences, such as treatment avoidance, lower employment rates, and social discrimination.

 For example, each form of stigma can be observed throughout the case vignette, as Jim experiences stigma at the interpersonal level (when his colleagues stigmatize him by calling him an “alcoholic” at the bar), at the institutional level (when he is discounted as an attractive job applicant because of his SUD), and at the individual level (when he internalizes the stigma of his diagnoses and anticipates the forthcoming barriers, losing the will to seek employment).

 There is sufficient evidence that describes stigma when addressing various presentations of both mental illness and SUD.

 However, there is less prominent information around the specific differences in stigma when assessing mental illness or SUD alone in comparison to dual diagnosis (ie, comorbid MI and SUD), despite the high prevalence of this comorbidity.

To generalize those with comorbid mental illness and SUD as having 1 shared experience is flawed, as different mental illness type, as well as intersectionality of external factors (eg, homelessness), can facilitate completely different characteristics of, and outcomes from, stigma.

 However, for the purposes of this paper, we will focus on the concurrent diagnosis of both a mental illness and SUD to provide an understanding of the current literature around stigma in dual diagnosis to make future research suggestions and understand how this may translate to actionable change.

Stigma is perpetuated toward those experiencing mental illness and SUD at the individual, interpersonal, and institutional levels, all of which are associated with negative consequences toward one’s mental health and well-being (eg, societal and structural discrimination, worsened treatment outcomes, and lowered self-esteem).

 Research has further indicated differences in stigma when addressing individuals with a mental illness diagnosis in comparison to a SUD diagnosis. Evidence describes more negative attitudes surrounding those with SUDs in comparison to those with a mental illness.

 Some of these attitudes include the perception of those with SUDs as being more dangerous and less competent in navigating treatment, as well as the association of SUDs with personal or moral “shortcomings” rather than the underpinnings of a medical illness.

Considering the prominence of, as well as differences between, stigma in those with mental illness and those with SUDs, it is important to address the characteristics of stigma among those with a diagnosis of both disorders. This population experiences distinct barriers to treatment and worsened outcomes, with only 72% of this population receiving treatment.

 In addition to the inaccessibility of treatment, there is low recognition of and support toward dual diagnosis by health care professionals.

 However, despite the high prevalence and vulnerable nature of dual diagnosis, there has been incongruous research addressing stigma within this population.

Of the research that has been conducted, stigma remains pervasive and has been associated with worsened symptomatology and heightened substance misuse.

 However, the uniqueness of this stigma is yet to be fully understood.

There has been some research to suggest that those with dual diagnosis experience more stigma and, therefore, more treatment barriers in comparison to those with a single diagnosis of either mental illness or SUD.

 Some research has suggested that this stronger stigma is due to the presence of a SUD, which has been proposed to be more heavily stigmatized in comparison to mental illness.

With this conceptualization, there is literature to support how stigma can possibly act as a mediating factor toward dual diagnosis, perpetuating substance use in those experiencing stigma toward their mental illness.

 For example, 1 theory proposes that a lack of self-esteem, identity, and social engagement due to the stigmatization of one’s mental illness may trigger substance use, which leads to meaning and identity within a community of substance users.

 This association falls in line with data around higher posttreatment stigma correlating to higher substance use.

Clearly, there is a need for further research on stigma in individuals with dual diagnoses in comparison to either mental illness or SUDs alone. Which mental illness diagnoses and SUDs are associated with the most stigma, and which combinations are the most impacted by stigma? How can we best address the dual stigma faced by these individuals? We hope this brief article provokes further interest and action toward understanding and managing stigma in the lives of individuals with dual diagnoses.

is a research consultant at the Centre for Complex Interventions, Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada. 

 is a research nurse in the Addictions Division at CAMH. 

Understanding the additive effects of stigma surrounding dual diagnosis with both substance use disorder and a mental illness.

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