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Addiction Treatment Can Work Even When It’s Not Voluntary

As Oregon reconsiders its decision to decriminalize hard drugs like fentanyl, research shows that mandating treatment programs for drug addicts can benefit them and the public.

In 2020 Oregon voters approved Measure 110, the nation’s first law decriminalizing possession of small amounts of drugs, including fentanyl, heroin and methamphetamines. Under Measure 110, people cited for drug possession had the option of paying a $100 fine or calling a hotline for treatment. Oregon committed marijuana tax revenue to addiction and recovery services, but in the first year after decriminalization, only 136 people in the state chose to enter treatment. Instead, the state saw a proliferation of open-air drug markets and a rise in crime, homelessness and overdoses.

A public backlash ensued, and last summer a poll of 1,000 registered voters found that two-thirds wanted a major change in the law. A campaign to “fix and improve” Measure 110 has proposed to recriminalize the possession of fentanyl, methamphetamine and cocaine, prohibit the use of these drugs in public, and make drug treatment mandatory.

Popular opinion holds that an addict cannot be helped until he or she wants to quit, and there is overwhelming agreement among experts that it is preferable for people to choose to enter care rather than be forced into it. But research has borne out the conclusion of a 1990 Institute of Medicine report that “criminal justice pressure does not seem to vitiate treatment effectiveness, and it probably improves retention.”

Most people who are addicted do not want to enter a treatment program. Data from the federal Substance Abuse and Mental Health Services Administration show that in 2022, a staggering 94.8% of people with a drug or alcohol use disorder within the past year “did not seek treatment and did not think they should get treatment.” Those who do voluntarily enter treatment usually don’t complete it. About one-third of voluntary patients drop out of treatment before completion, according to government data. Other studies show that up to 80% leave by the end of the first year. Among dropouts, relapse within a year is the rule.

One of the earliest demonstrations of the value of compelled treatment comes from the California Civil Addict program, established in the 1960s for both criminal and non-criminal drug addicts. The program included an average of 18 months in residential treatment. Patients received drug treatment, job training and education with transition services. Upon release, they were to spend up to five additional years being closely monitored and undergoing weekly urine toxicology tests. During the program’s first two years, however, judges and other officials mistakenly released about half the patients from mandatory treatment after only minimal exposure to the initial, residential part of the program.

A natural experiment was born, allowing researchers to compare people who finished treatment with those who were inadvertently released. After reviewing records and interviewing almost 1,000 “out of control” heroin-addicted participants, the researchers found that, seven years after admission to the program, participants who were prematurely released went back to using heroin at more than twice the rate of those who completed 18 months of compulsory residential care.

Today the U.S. has about 4,000 drug courts that offer an alternative to incarceration for addicts who commit nonviolent crimes. Defendants who choose drug court remain in treatment for one to two years under close supervision, including routine urine testing. Once participants complete the treatment program, their record is expunged—a big dangling carrot. A 2002 study in the Journal of Research in Crime and Delinquency looked at 235 arrestees in Baltimore who were randomly assigned to either drug court or typical community supervision, which might include regular meetings with probation officers and referral to drug treatment services. The study found that those in drug court were one-third as likely to be rearrested after a year.

These and other studies show that people who are mandated to undergo addiction treatment fare at least as well as those who volunteer. In the 2000s, a group of Stanford researchers compared a group of patients required by a court attend drug treatment with others who entered care voluntarily. At one year and five years following enrollment, the mandated and voluntary patients made similar improvements in areas such as drug use, criminal activity and employment status. Notably, the groups were equally satisfied with their treatment experience.

Compulsory treatment offers a chance to rescue people earlier in their “careers” of drug addiction, when intervention can produce greater lifetime benefits. And mandated care can ensure that people remain in treatment and don’t drop out, which is consistently shown to be one of the best predictors of a successful outcome. The longer participants stay in care, the more likely they are to internalize the values and goals of recovery.

Some critics say that compelling treatment for addiction is unethical because addiction is a disease. But it is not a classic, involuntary illness; it is a behavior that entails choice and responds to consequences. An approach known as “contingency management” offers people undergoing drug treatment a positive incentive by offering small rewards for meeting expectations; for instance, a negative drug test might earn movie tickets or a gift cards.

As for negative incentives, almost everyone who enrolls in Dr. Satel’s methadone clinic arrives under pressure, whether from a fed-up spouse, an angry boss or a probation officer. And mandatory treatment is far less restrictive than jail, where many addicts end up when they commit drug-related crimes such as theft, child neglect or threatening public safety.

For people who are so chronically intoxicated that they can’t meet their own basic needs, there is also the alternative of civil commitment. In October, California Gov. Gavin Newsom signed a law reforming the state’s conservatorship system to make it easier to compel treatment for people suffering from mental illness or drug addiction.

Critics are correct, however, to point to the inconsistent quality of addiction treatment programs. Until relatively recently, many drug courts were reluctant to allow participants to use proven medications such as methadone or buprenorphine for opioid addiction. In Oregon, the effort to expand treatment under Measure 110 failed in part because the infrastructure was not put in place quickly enough. If mandated treatment becomes more common nationwide, services will need to ramp up quickly.

Oregon may no longer incarcerate people solely for possessing a small amount of drugs, but there is still a need for accountability when someone with a substance use disorder threatens public safety. By mandating high-quality treatment programs for offenders, and providing care for those who can’t otherwise maintain their own safety, the state could turn its failed experiment into a valuable lesson.

Dr. Sally Satel is a senior fellow at the American Enterprise Institute and medical director of a methadone clinic in Washington, D.C. Kevin Sabet, Ph.D., is a former White House adviser and President and CEO of the Foundation for Drug Policy Solutions.

By Sally Satel and Kevin Sabet


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