Compulsory detention, forced detoxification and enforced labour are not ethically acceptable or effective ways to treat addiction

Authors


Compulsory detention of drug users without trial is neither an ethical nor an effective way of addressing addiction.

During the past century, a number of countries have passed laws that provide for the compulsory detention of addicted individuals, usually under the description of compulsory treatment for their addiction. A number of Australian [1] and US states [2] legislated for the involuntary treatment of ‘inebriates’ in the late 19th and early 20th centuries. US Federal courts sent heroin-addicted individuals for 6 months’ compulsory treatment in Public Health Hospitals at Lexington, Kentucky and Fort Worth, Texas from 1934 to 1971 [3]. In these detention centres treatment (usually detoxification and 12-Step psychotherapy) was mandatory. That is, detainees were not offered the choice of conventional addiction treatment in the community as an alternative to imprisonment, an approach for which there is some evidence of effectiveness [4].

Compulsory detention of addicted individuals has either been abandoned or fallen into disuse in most developed countries for two main reasons. First, it failed to treat addiction effectively, with most people detained returning to drug use after release [1,3,4]. Secondly, this approach has been criticized for violating the human rights of drug users (e.g. [5]). The few developed countries that still detain addicted people compulsorily—such as Russia [6] and Sweden [7]—do so in the absence of rigorous evaluations of the efficacy or safety of this approach.

Compulsory detention of drug users has been implemented recently in a number of developing countries with serious drug use problems, e.g. Cambodia, China, Myanmar, Thailand and Vietnam [8,9]. In these countries, large numbers of drug users (more than 300 000 in China, more than 60 000 in Vietnam and more than 40 000 in Thailand) have been sent to ‘drug detention centres’ for as long as 2–4 years [10]. These centres have been criticized as violating basic human rights by human rights advocates (e.g. [5,8]), and UN Agencies such as the World Health Organization (WHO) [10] and the UN Office on Drugs and Crime (UNODC) [11].

Authorities in these developing countries do not usually allow independent inspections of the centres or evaluations of their inmates’ experiences, so critics have relied upon interviews with former residents and staff members (e.g. [12,13]). These studies reveal major concerns about the way in which these centres are allowed to operate under law. There is no independent review or appeal process on entry; centres are run by the military, security or police officers; and such ‘treatment’, as is provided, usually consists of unmedicated detoxification, hard physical labour, physical and psychological abuse and withholding of food as punishment for non-compliance. There is little, if any, medical oversight of treatment, conditions are often overcrowded and unsanitary and release is usually after a fixed term rather than based on clinical outcomes [5,9,10]. These centres are, in short, prisons by another name.

What occurs in these compulsory detention centres cannot be dignified by the term of ‘compulsory treatment’. It does not, for example, meet minimum criteria for ethically acceptable forms of legally coerced addiction treatment as an alternative to imprisonment [4]. In these centres drug users: are detained without legal due process or review; have no choice about the treatment offered; and do not receive humane and effective treatment of addiction [14]. A recent WHO and UNODC [10] discussion paper concluded very reasonably that detention centres in many developing countries violated the human rights of drug users.

Detention centres in these developing countries do nothing to reduce, and may well amplify, the substantial public health and order problems that drug use causes in these countries [8,9]. In the absence of effective addiction treatment, there are high rates of relapse to drug use after release and high rates of human immunodeficiency virus (HIV) infection among participants in these centres. The resources devoted to running these centres are not available to provide more effective public health interventions to prevent blood-borne viruses (BBV) transmission among injecting drug users [9].

There are some signs that these policies are beginning to change for the better in some developing countries. The governments of Vietnam [15] and China [16], for example, have recently introduced needle and syringe programmes and opioid substitution for heroin dependence. These changes are welcome, but drug users continue to be detained compulsorily in these countries.

We urge governments that are afflicted by serious illicit drug problems to replace unethical and inhumane detention of drug users with effective forms of addiction treatment that are provided humanely, where appropriate, in the community, on a voluntary basis and by appropriately trained staff. We also urge all members of the international community of addiction treatment providers, scientific researchers, people in recovery and public health professionals to advocate vigorously for better reporting and monitoring of drug treatment in these countries to ensure that evidence-based addiction treatment is provided in compliance with basic human rights.

Declarations of interest

In the past 5 years W.H. has not received fees or funding of any kind from alcohol, pharmaceutical or tobacco companies. His research funding has been from the following public funding sources: the Australia Research Council, the Australian Alcohol Education and Research Fund, the National Health and Medical Research Council of Australia and the National Prescribing Service (a government-funded service that advises prescribers on evidence from clinical prescribing). T.B. has, over the past 5 years, conducted research projects whose funding sources have derived from federal, state or non-profit organizations, and from JBS International, Inc., a subcontractor to the federal Center for Substance Abuse Treatment. He has received travel expenses and subsistence from the Society for the Study of Addiction, World Health Organization, US National Institutes of Health (NIAAA) and other professional organizations. T.B. receives salary support not covered by grants from a PHS Endowed Chair in Community Medicine and Public Health. PHS (Physicians Health Service) is a for-profit Health Maintenance Organization that donated funding for five endowed chairs to the University of Connecticut School of Medicine. He has received no direct or indirect support from industry sources such as pharmaceutical, alcohol and tobacco companies and holds no personal stock. G.E. has for many years received fees for medico-legal consultancy. He received a fee for preparing a briefing document for the British Crown Prosecution Service and has advised the Metropolitan Police. Travel expenses have been paid by WHO (Europe), the Society for the Study of Addiction and university sources. A number of academic publishers have paid him for advice and he receives book royalties. G.E. has no institutional affiliations or society memberships which he believes could reasonably be construed as potentially constituting conflicts of interest. R.L. has no conflicts of interest to report. J.M. works within an integrated university and National Health Service (NHS) academic health sciences centre (King's Health Partners) and declares the following financial relationships: he has part-time employment as Senior Academic Adviser for the National Treatment Agency for Substance Misuse (NTA); consultation to Reckitt Benckiser Pharmaceuticals (RBP) in 2011; untied educational grant funding at KCL from RBP for a pharmacogenetic study of opioid substitution treatment (OST) in 2010, and a 3-year adaptive maintenance study of OST and behaviour therapy (the latter via Action on Addiction) from 2012. P.M. has no affiliations which he believes constitute a conflict of interest. In the past 5 years he has been funded by charitable foundations, government departments and a pharmaceutical company via an intermediary charity. Travel expenses have been paid by charities, the Society for the Study of Addiction and university sources. He holds no stocks in any related companies. I.O. has received travel support from the World Health Organization on several occasions and the Centre for Research and Information on Substance Abuse (CRISA) has been funded by two international development non-governmental organizations (NGOs) [International Organization of Good Templars (IOGT) and Campaign for Development and Solidarity (FORUT-NTO)], and conference support provided by the Open Society Institute. None of these, she believes, constitute any relevant conflict of interest to declare. N.P. has no affiliations which she believes constitute a conflict of interest. In the past 5 years, she has received fees for medico-legal consultancy, book royalties, grant reviews and delivering trainings. Her research funding sources have derived from federal and non-profit organizations. She holds no stocks in any related companies. T.T. has no conflicts of interest to report. R.W. has received travel funds and hospitality from, and undertaken research and consultancy for, pharmaceutical companies that manufacture or research products aimed at helping smokers to stop. These products include nicotine replacement therapies and Zyban (bupropion). This has led to payments to him personally and to his institution. He undertakes lectures and training in smoking cessation methods which have led to payments to him personally and to his institution. He has received research grants from medical charities and government departments.

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