Coercion Into Addiction Treatment Is Ubiquitous: Five Ways It Happens

    The range and intensity of coercion in addiction treatment isn’t well recognized. Yet coercion through Alcoholics Anonymous is long-established in America, and is now expanding to fight the opioid-involved death crisis. Both of these existential intrusions are built on the disease theory of addiction.

    The Drug Policy Alliance is holding a crucial conference and workshop series—“Coercive Treatment: Moving Beyond ‘For Your Own Good’”—in San Francisco this week, including Filter contributors Maia Szalavitz and Dinah Ortiz, leading harm reduction clinician Patt Denning, and many other notable speakers. DPA announces:

    Harmful and coercive drug addiction treatment interventionssuch as forced detox, civil commitment, and drug and other treatment courts—are proliferating with wide public and government support, despite a myriad of negative  consequences for both individuals and society.

    This coercive cast to addiction treatment is built on the NIDA-led idea that people are incapable of making substance-related decisions for themselves, since their wills are controlled by addictive disease. As we’ll see, this vision has long been the primary recruitment tool for America’s dominant 12-step treatment paradigm.

    No form of treatment is universally applicable.

    It’s important to establish that forced treatment is always wrong. It is a tool for controlling people that tramples human rights by ignoring the individual’s own values and preferences. And it is ineffective since it eliminates the most essential element in genuine recovery—human agency in the form of people’s investment in their own well being. Such human agency is an increasingly depleted resource in our society.

    No form of treatment is universally applicable. The miscalculation that everyone should be treated the same way includes a phenomenon seen more recently: coercion into medication-assisted treatment. MAT, as noted in Filter, is an effective tool for reducing our seemingly uncontrollable drugs deaths epidemic. But MAT is dangerously misused when it is presented as a “cure” for a “brain disease” and made compulsory.

    Both NIDA’s chronic brain disease version of addiction and the 12-step version reinforce the idea that drug users are unable to control their drug use and therefore must be forced into treatment “for their own good.”

    I have been fighting this notion for decades with the argument that mindless disease treatment, built on the idea that drug use is inherently uncontrollable, will only feed back into more addiction and more treatmentnot greater freedom and well being for drug users. Per DPA:

    Calls for more treatment funding, or “treatment instead of incarceration,” are common in the drug policy, mental health, recovery, criminal justice, and disability spaces. The same indignities and negative consequences commonly associated with criminalization, however, can also be reproduced by public health and treatment interventions that fail to prioritize consent.

    This trend is more apparent today than ever, as Zach Rhoads and I detail in our new book, Outgrowing Addiction.  


    AA’s Coercive Template

    Alcoholics Anonymous, contrary to its image, is by and large not a voluntary organization. AA’s own North American membership survey indicates that “referrals”with greater and lesser degrees of coercion—supply the bulk of the fellowship’s participants. Coercion into the 12 Steps comes from five main sources: criminal courts; family courts and family services; healthcare systems; families; and employers.

    The most critical venue for coerced treatment is the criminal justice system, where forced 12-step participation has been the rule for a half century.

    Now, the same agencies are coercing treatment based on MAT in ways that have yet to be tallied, but which, as DPA notes with appropriate alarm, are proliferating. Writing at my Life Process Program website, Rebecca describes her treatment by her physician when, on a prescription for hydrocodone, she unexpectedly became pregnant:

    I was in an accident a few years ago and was prescribed hydrocodone, 10mg up to three times a day. I’ve never taken that many a day—usually only 1 or 2. I talked to my doctor about how to slowly wean off them. Concerned for my unborn baby, my goal is to be off completely by my fifth month of pregnancy. My OB and pain doctor agree that was a good plan and expressed how happy they were that I wanted to get off them.

    That takes us to my appointment yesterday. My OB said that he feels I should switch and start taking methadone. That confused me because my goal was to get off the ones I was on, not start taking something new. I said I wasn’t sure if I was comfortable with that and he was upset. I just don’t understand why I would switch to that one when my goal is to get off them completely. [My emphasis.]

    We don’t yet know how commonplace such experiences are. But Rebecca can hardly be exceptional. And the trend will only, as DPA notes, expand “with wide public and government support.”

    The most critical venue for coerced treatment is the criminal justice system, where forced 12-step participation has been the rule for a half century. This despite an uninterrupted stream of court decisions ruling that such coercion violates the First Amendment’s religious freedom clause.

    But MAT escapes the court-ordered 12-step flaw of the government telling you how to live your spiritual life. As such, it stands a good chance of becoming the established law of the land. In the most famous such case to date, Julie Eldred was jailed in Massachusetts while on probation for theft. Unlike Rebecca, Eldred could be considered addicted to opioids, and she was ordered by the court into intensive outpatient (IOP) treatment, supplemented with Suboxone. IOPs are invariably 12-step based.

    While receiving MAT, Eldred tested positive for her drug of choice, fentanyl, and she was jailed. She was then sent by the court to residential treatment and, then again, back into MAT. In a case brought before the Massachusetts Supreme Judicial Court in 2017, long after these events, Eldred’s attorney, Lisa Newman-Polk, and medical experts argued that since she had a brain disease, Eldred shouldn’t have been jailed for using.

    I agree wholeheartedly that no one should be jailed for using drugs. But Newman-Polk and the experts had no objection to Eldred’s being forced into treatment with the implicit threat of a prison alternative when they were interviewed in an article about the case in The Atlantic:

    Even among those who strongly believe in the brain-disease model, there are some who think incarceration shouldn’t be entirely taken off the table as punishment. John Kelly, a Harvard Medical School psychiatry professor who teaches addiction medicine. . . [argues]:  “You can require someone to remain drug-free, but instead of the threat of jail you can have the threat of more treatment.” [My emphasis.]

    Rather than showing the effectiveness of a new kind of treatment, Eldred—in being bounced between standard 12-step therapy, MAT, and jail—embodies the modern imposition of coercive addiction therapy.

    Here is an overview of the five main sources of such coercion.


    1. Criminal Courts

    Throughout the US, people are routinely forced to go to AA, 12-step rehab, MAT, or other forms of treatment in order to avoid prison, to get out of prison, or to maintain or to restore their driver’s licenses.

    While it is impossible to compare precisely the prevalence of each form of coercion, DUI and other criminal and administrative court orders that people attend AA are ubiquitous.

    According to AA’s figures (which don’t include NA), of 1,383,848 US and Canada members in January 2016, 12 percent were introduced by the judicial system, and 2 percent within a correctional facility. But these figures vastly understate the extent to which courts—including drug and municipal courts—routinely require AA and or treatment attendance.

    According to SAMHSA’s now quite dated DASIS report*—well before the present heyday of drug courts—the criminal justice system was the principal source of referral for 36 percent of all treatment admissions in 2002 (655,000 referrals out of a total of 1.9 million admissions). Along with this number, per AA’s figures, 32 percent of its membership was directed to AA by treatment facilities.

    Even by these conservative estimates, hundreds of thousands of Americans per year are forced into AA and 12-step-oriented treatment. This occurs even though a steady stream of legal decisionsas I described with Charles Bufe and Archie Brodsky in Resisting 12-Step Coercionaffirms that such court-ordered treatment is illegal. Every state Supreme Court and federal appeals court that has heard such cases has declared that the 12 Steps are religious in nature, and that requiring parolees or probationers to attend 12-step programs when these oppose people’s belief systems violates their First Amendment rights.

    The Ninth Circuit (federal appeals) Court upped the ante on such government coercion in the case of Ricky Inouye after the Hawaiian parole board and Inouye’s parole officer required Inouye to attend AA. Inouye, a Buddhist, had objected to participating in AA in prison. Both the Hawaiian Paroling Authority and Inouye’s parole officer were held liable in 2007 for violating Inouye’s civil rights, even though government actors ordinarily have legal immunity.

    Compulsory AA attendance remains standard practice in courts’ dealings with alcohol, and often drug, problems.

    I have been tracking these cases for some time. In 2001, Archie Brodsky and I reviewed coerced 12-step treatment for Reason, based on the original Southern District of New York Federal Court’s decision in the case of Robert Warner, an atheist who was ”sentenced” to AA for his DUIs.

    That court—like every court that has assessed the AA program since—declared that AA and the 12 Steps are essentially religious, no matter how loudly AA advocates proclaim that their “higher power” is a door knob. “God” or an equivalent pronoun appears in a majority of the steps.  

    Nonetheless, there can be no doubt that in states outside the Ninth Circuit, parolees and probationers are still regularly sentenced or obligated to attend AA. Even for California, which is in that circuit, I see no reference to the case or protocols for handling AA referrals at the California Department of Corrections website. It seems that California’s regulations restricting coercion into 12-step programs, if they really do exist, are extraordinarily difficult to access.

    Here is an example from another state, Texas, which a woman posted on my Facebook page in 2016:

    I’m halfway through a year-long drug court in Dallas, TX. I’m court-ordered to attend four AA meetings a week, and I am also mandated to actively have a sponsor and “work” the 12 steps.  There is an AA meeting close to where I live, hence my attending AA, even though I have a heroin charge. Drug court has taught me to not ask questions, and to shove my opinions and feelings somewhere deep inside—and to smile and do whatever it takes to get through this.

    Compulsory AA attendance remains standard practice in courts’ dealings with alcohol, and often drug, problems. As noted, compulsory MAT has the potential to expand this form of coercion on a huge scale.

    And while women are not as often diagnosed with alcohol and drug use disorders as men, it is notable that so many of these stories of being shunted off to unwanted treatment involve women. This could be, as DPA points out, because “coercive drug addiction treatment, fueled by racism, stigmatization, paternalism, ableism, and profit, is on the upswing.”


    2. Family Courts and Family Services Agencies

    Another major source of AA and treatment referrals are state family courts and family service divisions. I once worked as a public defender in the Morris County, NJ, family court, where the state regularly forced parents into AA to maintain or regain child custody. (Alarmingly, teens also were regularly sent to AA through drug and traffic courts.)

    I also represented parents like Eloise in divorce proceedings. As a young woman Eloise had worked in bars, where she usually drank all night. She was put in treatment in her early 20s, went to AA, and lived in a sober house. She then went back to college, earned an MBA, and got a high-powered job in the financial industry.

    Meanwhile, she married her older AA boyfriend and they had a child. Eloise quit AA and started going out for drinks with her coworkers. This caused a split in her marriage, with her husband seeking custody of their child.

    The Morris County district court family division judge wanted Eloise to have treatment, which her husband demanded involve AA and the county’s intensive 12-step outpatient program. I Instead gained the court’s acceptance for alternative treatment by harm reduction psychotherapist Andrew Tatarsky in New York, where Eloise worked, and she retained joint custody of her son.

    No one keeps track of AA referrals like the one Eloise would have received. Such referrals are so customary that they rarely raise an eyebrow. Although I can’t offer a number, the family court where I practiced was an extremely active court division. And, in one of the wealthiest counties in the nation, these referrals were commonplace.


    3. & 4. Healthcare Systems and Families

    I received this email several years ago:

    I have a sister who has cirrhosis with Hep C and needs a liver transplant. I have another sister who is an AA fanatic. [Sister 1] is a patient at the —– Liver Transplant Center. Her team includes an alcohol/drug counselor. This counselor informed [Sis. 1] she must attend 3-5 AA meetings a week as a condition for a liver transplant.

    After she got out of the hospital last year, she went to 12-step rehab and outpatient AA meetings. She was never informed of other types of support groups. She stated she did not like the meetings, felt like it was a cult and that it made her want to drink afterwards. She is also an atheist. Since she found out about her liver cirrhosis one year ago, she has never had a drink or an urge to drink. Despite this she is being coerced into AA.

    The practices the e-mail writer describes are standard for liver transplants around the country, where frightened family members are brought in to reinforce the agencies’ demands. The belief is: How else could the providers make sure that people stay off alcohol?

    And, as Rebecca’s case above shows, healthcare is an infinitely pliable avenue for applying disease notions of drugs and MAT.

    Once again, AA and the 12 Steps are the template. According to the AA survey, 27 percent of North American members were introduced by family, and 17 percent by medical or mental health professionals. That again would add up to hundreds of thousands of “referrals.”


    5. Employers

    Workplace Employee Assistance Programs are nearly always staffed by “recovering alcoholics“ who direct their fellow employees strictly to AA and 12-step treatment.  According to AA’s survey, 4 percent of AA members were referred there by an “employer or fellow worker.” This is surely a gross underestimate.

    As a private attorney, I was involved in a series of such cases with impaired physician programs, where doctors were sent for a variety of reasons (DUIs, self-medication, complaints by a divorcing spouse of heavy drinking), after which they were sent to an approved rehab. In my experience, these were always 12-step-based. The doctors were then forced to sign a contract with their medical board to abstain from alcohol and drugs and to attend AA and work with a sponsor for a number of years. They had to comply in order to continue to practice medicine.

    Since she refused to declare she was an alcoholic, the supervisors never certified her as successfully completing the program.

    I worked with other employers including New York’s Metropolitan Transportation Authority (MTA). At the MTA, my client was a woman who showed a 0.2 BAL at a random test after drinking a beer at lunch (she was a small woman). This is well short of intoxication, but is a prohibited level for transportation workers. (Doug Husak and I traced how the US Supreme Court relied on fear-mongering to justify random testing of transportation workers.)

    My client was sent to 12-step treatment, then required to report to the MTA’s EAP program to be tested weekly. Since she refused to declare she was an alcoholic, the recovering EAP supervisors never certified her as successfully completing the program. She thus operated under their regime for six years, until she maxed out her “sentence.”

    I argued her case before a three-judge panel in the Federal Second Circuit Court of Appeals in New York. I couldn’t make the judges, who were laughing, understand that the woman wasn’t an “alcoholic.” When the justices asked the MTA attorney how long the woman had been out of work, they were brought up short. She had never stopped working as a train router, the most safety-sensitive job in the system, and had never tested anything but 0.0 BAL for six years.

    No one considered her an “alcoholic” but the EAP recovery nuts, who unfortunately controlled her life. Now, we might have people who consider themselves very forward-looking drug treatment advocates recapitulating this process with opioid-using employees and MAT.


    The Coercive Monolith

    AA and the 12-step rehab industry certainly also have many voluntary participants. Nonetheless, rather than the treatment deficit we are constantly told we have, the current bloated American treatment system is maintained by force-feeding it unwilling clients. The American Addictive Disease monolith could not continue without constant threats to deprive people of their legal freedom, custody of children, licensure or employment, medical care, or family support.  

    Extrapolating the figures over many years suggests that hundreds of thousands of Americans, perhaps millions, have lost their autonomy in this way.

    In short, flying below nearly everyone’s radar, conducted under the beneficent aegis of medical care, ostensibly “for your own good,” alcohol and drug treatment comprises the largest, most pervasive organized violation of people’s civil rights in the United States.

    While working to dismantle this massive offensive against human rights, we must confront the reality that other forms of addiction-disease treatment are rising to join AA and the 12 steps in the industrial-scale coercion of Americans who use drugs. This is the opposite of a path to freedom and dignity for them, and current results indicate it has likewise failed to stem addiction and drug deaths.

    The Drug Policy Alliance has its work cut out.

    * The DASIS Report: Substance Abuse Treatment Admissions Referred by the Criminal Justice System: 2002. Washington, DC: Office of Applied Studies, SAMHSA, July 30, 2004.

    Photo via Wikimedia Commons

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