When Free Will Fails People With Opioid Use Disorders

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Gold M.D.</a> </div> <div class="profile_card__blog-title"> <a href="/gb/blog/addiction-outlook" hreflang="en">Addiction Outlook</a> </div> </div> </div> </div> <div class="blog-entry--header-second"> <h6 class="blog-entry__topic--full text-uppercase-primary-large"> <a href="/gb/basics/addiction" hreflang="en-gb">Addiction</a> </h6> <h1 class="blog-entry__title--full"> When Free Will Fails People With Opioid Use Disorders </h1> <h2 class="blog-entry__subtitle--full"> Why experts believe that civil commitment could save lives. </h2> <p class="blog-entry__date--full fine-print"> Updated <span class="blog_entry--date">November 22, 2024</span> <span class="blog_entry--full__review-info"> <span class="blog_entry--full__review-info-bar">|</span> <a href="/gb/docs/editorial-process" class="blog_entry--full__review-info-link"> <span class="blog_entry--full__review-info-icon"></span> <span class="blog_entry--full__review-info-text">Reviewed by Gary Drevitch</span> </a> </span> </p> <div 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href="mailto:?subject=Psychology%20Today%3A%20When%20Free%20Will%20Fails%20People%20With%20Opioid%20Use%20Disorders&body=Hi%2C%0D%0A%0D%0AI%20thought%20you%27d%20be%20interested%20in%20this%20article%20on%20Psychology%20Today%3A%0D%0A%0D%0A%20When%20Free%20Will%20Fails%20People%20With%20Opioid%20Use%20Disorders%0D%0Ahttps%3A//www.psychologytoday.com/gb/blog/addiction-outlook/202411/when-free-will-fails-people-with-opioid-use-disorders%3Feml%0D%0A%0D%0A%0D%0A---%0D%0AFind%20Counselling%3A%20https%3A//www.psychologytoday.com/gb&destination=node/5027343"> <div><img border="0" src="https://cdn2.psychologytoday.com/theme-assets/icons/icon-share-round-email-md.svg" alt="Share via Email" width="37" height="37" /><span class="visually-hidden">Email</span></div> </a> </div> </li> </ul> </div> </div> </div> <div class="blog-entry--body"> <div class="blog-entry--body-first"> <div class="d-none d-xl-block"> <div class="pathways_card" > <div class="pathways_card__header"> <span class="pathways_card__title_verified"></span> <div class="h3 pathways_card__title">THE BASICS</div> </div> <ul> <li class="swatch-primary"> <a href="/gb/basics/addiction" class="swatch-primary font-semi-bold" hreflang="en">What Is Addiction?</a> </li> <li class="swatch-primary"> <a href="https://www.psychologytoday.com/gb/counselling?category=addiction" class="swatch-primary font-semi-bold">Find counselling to overcome addiction</a> </li> </ul> </div> </div> </div> <div class="blog-entry--body-second"> <div class="blog_entry__key-points"> <h3 class="blog_entry__key-points-title">Key points</h3> <ul class="blog_entry__key-points-item-list"> <li class="blog_entry__key-points-item">People addicted to opioids often deny their problems, and delay and refuse treatment.</li> <li class="blog_entry__key-points-item">Coerced treatment may help addicts break the cycle of addiction, overdose, and relapse. </li> <li class="blog_entry__key-points-item">The Marchman Act in Florida allows involuntary treatment of people with severe substance use disorders. </li> <li class="blog_entry__key-points-item">Prefrontal cortex compromise in SUDs can impair executive functions like self-control, free will and awareness</li> </ul> </div> <div class="field-name-body"> <p>Many U.S. states have laws allowing for “civil commitment" (involuntary commitment) and treatment of individuals with substance use disorders (SUDs). These laws, like those psychiatrists use to treat patients with severe mental illness, are intended to help someone posing a threat to themselves or others.</p> <div class="markup-replacement-slot markup-replacement-slot-0" data-slot-position="0"></div> <p>The University of Florida has offered a professional health provider program for substance abusers over 30 years. The university's <a href="https://pubmed.ncbi.nlm.nih.gov/26971079/">research on impaired health professionals</a>, their addictions, and outcomes have been reported; an astonishing 80% were still substance-free five years after treatment. According to U.F. Chief of Addiction Medicine Professor Scott Teitelbaum, MD, <a href="https://pubmed.ncbi.nlm.nih.gov/19161896/">outcomes</a> were "identical regardless of whether the professional came to treatment after hitting bottom, after an intervention, walked in asking for help, [was] coerced, or through involuntary treatment.” </p> <div class="markup-replacement-slot markup-replacement-slot-1" data-slot-position="1"></div> <div class="insertArea"> <div class="image-article-inline-half"> <div class="insert-inner"> <div class="insert-image"><img alt="University of Florida" class="image-article_inline_half_caption" data-insert-type="image" height="480" src="https://cdn2.psychologytoday.com/assets/styles/article_inline_half_caption/public/field_blog_entry_images/2024-11/ScottATeitelbaum-86425090-portrait.jpg%20UFCOM.jpg?itok=LDKCEdsk" title="University of Florida" width="320"></div> <div class="caption">Scott Teitelbaum, MD</div> <div class="insertArea--origin subtext">Source: University of Florida</div> </div> </div> </div> <p>While not frequently utilized, the Marchman Act, enacted in Florida in 1993, covers the involuntary civil commitment used today for SUDs. Named after Rev. Hal S. Marchman, a Methodist minister known for advocating addiction recovery, the Act allows family members, medical professionals, or law enforcement officers to petition the court for an order of involuntary treatment when someone is unwilling or unable to seek help independently.</p> <div class="markup-replacement-slot markup-replacement-slot-2" data-slot-position="2"></div> <p>The legislation is modeled after Florida’s Baker Act, allowing involuntary commitment of individuals with severe mental illnesses posing a risk to themselves or others. While the Baker Act pertains to mental health crises, the Marchman Act specifically addresses addiction/substance-related crises, recognizing addiction as a significant public health and safety issue.</p> <div class="markup-replacement-slot markup-replacement-slot-3" data-slot-position="3"></div> <h2>Phases of the Marchman Act</h2> <p>The Marchman Act allows several phases, such as an initial assessment and stabilization. Typically lasting up to five days, this phase involves a medical and <a href="https://www.psychologytoday.com/gb/basics/psychiatry" title="Psychology Today looks at psychiatric" class="basics-link" hreflang="en-GB">psychiatric</a> assessment to determine the level of care the person needs. During this period, the individual is evaluated for substance use and co-occurring conditions. If the assessment shows the need for ongoing care, a court can order involuntary treatment, generally up to 60 days.</p> <div class="markup-replacement-slot markup-replacement-slot-4" data-slot-position="4"></div> <h2>Some Roadblocks</h2> <p>By the time the Marchman Act is considered, addicts may have lost their jobs, health, insurance, and savings. While the law mandates treatment, it does <em>not</em> guarantee funding or access to crowded programs. Some families are reluctant to use the Act, knowing the addict may become very angry since often they don’t think they are ill. Consequently, impaired individuals confronted with involuntary Marchman Act treatment may resist or appeal commitment, prolonging the legal process. However, others recognize that treatment can save their lives and switch to voluntary status.</p> <div class="markup-replacement-slot markup-replacement-slot-5" data-slot-position="5"></div> <h2>Recent Developments</h2> <p>The Marchman Act has been updated to improve accessibility and effectiveness and streamline the process, making it more accessible and responsive to immediate needs, particularly as overdose and addiction rates remain high across the state.</p> <p>Teitelbaum told me that the Act is crucial to <a href="https://www.psychologytoday.com/gb/basics/harm-reduction" title="Psychology Today looks at harm reduction" class="basics-link" hreflang="en-GB">harm reduction</a>-focused addiction medicine in Florida. “I know we have saved lives with the Marchman Act. We often find drug-use-related <a href="https://www.psychologytoday.com/gb/basics/depression" title="Psychology Today looks at depression" class="basics-link" hreflang="en-GB">depression</a> or extreme <a href="https://www.psychologytoday.com/gb/basics/anhedonia" title="Psychology Today looks at anhedonia" class="basics-link" hreflang="en-GB">anhedonia</a> in some of our patients. Suicidal or wishing they would just die and get it over with, they continually and nihilistically refuse treatment. We have also seen patients so far along their alcohol, opioid, cocaine, methamphetamine, or speedball addictions, they cannot imagine life without drugs and actively choose continued use over treatment despite fulminant illness and abject ruination of their family and professional lives. The bottom line is the Marchman Act has been a great tool in helping people receive the appropriate level of treatment they need, providing them the opportunity to access psychiatric addiction evaluation, evidence-based detox, recovery, and MAT services when they are incapable of recognizing their need for help. Intervention and effective use of this act as leverage has saved lives and is saving lives right now. Patient awareness and <a href="https://www.psychologytoday.com/gb/basics/gratitude" title="Psychology Today looks at gratitude" class="basics-link" hreflang="en-GB">gratitude</a> come, but much later.”</p> <div class="d-xl-none pathways_card" > <div class="pathways_card__header"> <span class="pathways_card__title_verified"></span> <div class="h3 pathways_card__title">THE BASICS</div> </div> <ul> <li class="swatch-primary"> <a href="/gb/basics/addiction" class="swatch-primary font-semi-bold" hreflang="en">What Is Addiction?</a> </li> <li class="swatch-primary"> <a href="https://www.psychologytoday.com/gb/counselling?category=addiction" class="swatch-primary font-semi-bold">Find counselling to overcome addiction</a> </li> </ul> </div> <p>Psychiatrist Michael Lesser, former medical services director of the New York City Department of Mental Health, Mental Retardation, and <a href="https://www.psychologytoday.com/gb/basics/alcohol" title="Psychology Today looks at Alcoholism" class="basics-link" hreflang="en-GB">Alcoholism</a> Services and medical director of the New York State Office of Mental Health, has a long history as a pioneer and thought <a href="https://www.psychologytoday.com/gb/basics/leadership" title="Psychology Today looks at leader" class="basics-link" hreflang="en-GB">leader</a> in civil commitment. Lesser says laws like the Marchman Act have far too long been overlooked and dismissed: “An involuntary commitment must be viewed on a relative scale and judged as to what is better for the individual in the near- and long-term and also society.”</p> <div class="markup-replacement-slot markup-replacement-slot-7" data-slot-position="7"></div> <div class="insertArea"> <div class="image-article-inline-half"> <div class="insert-inner"> <div class="insert-image"><img alt="Permission from RANE" class="image-article_inline_half_caption" data-insert-type="image" height="309" src="https://cdn2.psychologytoday.com/assets/styles/article_inline_half_caption/public/field_blog_entry_images/2024-11/Michael%20Lesser,%20M.D.%20RANE%20Network.jpg?itok=6Pe7Lzld" title="Permission from RANE" width="320"></div> <div class="caption">Michael Lesser, MD</div> <div class="insertArea--origin subtext">Source: Permission from RANE</div> </div> </div> </div> <p>Lesser says that family needs should also be considered. “I have met many families driven to mental and physical exhaustion as they suffer powerlessly to try to get help for their loved ones. They are expected to watch the painful deterioration and death of loved ones, <em>people who have to use drugs</em> and are not capable of looking after themselves. Unfortunately, civil commitment is unavailable everywhere but should be left to doctors, patients, and families.” </p> <div class="card-group card-group--condensed card-group--border-bottom d-lg-none"> <div class="h2 card-group__title">Addiction Essential Reads</div> <div class="card-group__body"> <article data-history-node-id="5030246"> <div class="media"> <div class="media--image"> <a href="/gb/blog/some-assembly-required/202502/new-weight-loss-medications-may-help-treat-addiction"> <img loading="lazy" src="https://cdn2.psychologytoday.com/assets/styles/manual_crop_1_1_75x75/public/teaser_image/blog_entry/2025-02/pexels-tara-winstead-7722970_0.jpg?itok=funBo-sY" width="75" height="75" alt="" title="Tara Winstead/Pexels" /> </a> </div> <div class="h3 media--title"> <a href="/gb/blog/some-assembly-required/202502/new-weight-loss-medications-may-help-treat-addiction" rel="bookmark">New Weight Loss Medications May Help Treat Addiction </a> </div> </div> </article> <article data-history-node-id="5030163"> <div class="media"> <div class="media--image"> <a href="/gb/blog/the-digital-self/202501/treating-pain-avoiding-the-brain"> <img loading="lazy" src="https://cdn2.psychologytoday.com/assets/styles/manual_crop_1_1_75x75/public/field_blog_entry_images/2025-01/Screen%20Shot%202025-01-31%20at%209.58.12%20AM.png.jpg?itok=bTqoVHDH" width="75" height="75" alt="" title="ChatGPT/OpenAI" /> </a> </div> <div class="h3 media--title"> <a href="/gb/blog/the-digital-self/202501/treating-pain-avoiding-the-brain" rel="bookmark">Treating Pain—Avoiding the Brain</a> </div> </div> </article> </div> </div> <p>The American Society of Addiction Medicine (ASAM) supports involuntary treatment as a last resort when someone at imminent risk of harm refuses treatment. This reflects a commitment to balancing individual autonomy with public and personal safety.</p> <p>The Marchman Act remains an essential, albeit imperfect, tool for civil commitment in cases of severe addiction in Florida. Proponents argue that it saves lives like other harm reduction approaches utilized in addiction medicine. It can prevent overdoses or other catastrophic outcomes, including traumatizing families and harming others. Civil commitment allows families to act <em>now</em>, rather than wait for the addict to suffer and hit bottom, which may mean death.</p> <div class="markup-replacement-slot markup-replacement-slot-9" data-slot-position="9"></div> <h2>Harms to the General Public by Substance Abusers, Avoided with Civil Commitment</h2> <p><a href="https://www.psychologytoday.com/gb/basics/addiction" title="Psychology Today looks at Substance abuse" class="basics-link" hreflang="en-GB">Substance abuse</a> is harmful to the general public. For example, it often contributes to the spread of infectious diseases (HIV, hepatitis) and overdoses, creating public health concerns. Addiction may also lead to theft, assault, prostitution, and drug trafficking, as individuals turn to <a href="https://www.psychologytoday.com/gb/basics/law-and-crime" title="Psychology Today looks at crime" class="basics-link" hreflang="en-GB">crime</a> to support their substance use. Civil commitment to treatment could reduce harm, recidivism, and associated criminal justice costs by addressing the underlying addiction. Opponents argue that involuntary treatment can be stigmatizing and may violate individual rights. Lesser asks, “Is it better to help and act or leave the person who has to use drugs—lost control over both drugs and <a href="https://www.psychologytoday.com/gb/basics/free-will" title="Psychology Today looks at free will" class="basics-link" hreflang="en-GB">free will</a>—to fend for themselves, knowing they are incapable of understanding the risks and consequences of their use or actions?”</p> <div class="markup-replacement-slot markup-replacement-slot-10" data-slot-position="10"></div> <h2>Research on Loss of Control Over Drug Intake</h2> <p>The loss of control over drug intake is a key and essential feature separating people who use drugs from people with SUDs who have to use drugs. This is due to the compromise of the prefrontal cortex (PFC), regulating limbic reward regions, and involvement in higher-order <a href="https://www.psychologytoday.com/gb/basics/executive-function" title="Psychology Today looks at executive functions" class="basics-link" hreflang="en-GB">executive functions</a> like <a href="https://www.psychologytoday.com/gb/basics/self-control" title="Psychology Today looks at self-control" class="basics-link" hreflang="en-GB">self-control</a> and awareness. Although initial experimentation with a drug of abuse is largely voluntary, continued drug use eventually impairs neuronal circuits in the brain involved in free will, turning drug use into automatic, repetitive, self-destructive, and <a href="https://www.psychologytoday.com/gb/basics/compulsive-behaviors" title="Psychology Today looks at compulsive behavior" class="basics-link" hreflang="en-GB">compulsive behavior</a>. Disruption of the PFC in addiction underlies not only compulsive drug taking but also erosion of free will.</p> <div class="markup-replacement-slot markup-replacement-slot-11" data-slot-position="11"></div> <p>Similar to how society intervenes in cases of <a href="https://www.psychologytoday.com/gb/basics/suicide" title="Psychology Today looks at suicidality" class="basics-link" hreflang="en-GB">suicidality</a> or severe mental illness, it should also intervene in cases of severe substance use. The ethical principle of beneficence (the obligation to help others) supports intervention when individuals are at risk of harm, unable to protect themselves. </p> <div class="markup-replacement-slot markup-replacement-slot-last" data-slot-position="last"></div> </div> <div class="blog-entry-references" data-hide-large-count-items="true"> <p class="blog-entry-references-label">References</p> <div class="blog-entry-references-content-items"> <div class="blog-entry-references-content"> <p>Ho JJ, Jones KF, Sager Z, Wakeman S, Merlin JS. De-Stigmatizing the Language of Addiction #429. J Palliat Med. 2022 Jan;25(1):155-157. doi: 10.1089/jpm.2021.0478. PMID: 34978913; PMCID: PMC9022126.</p> </div> <div class="blog-entry-references-content"> <p>McLaren N, Jones CM, Noonan R, Idaikkadar N, Sumner SA. Trends in stigmatizing language about addiction: A longitudinal analysis of multiple public communication channels. Drug Alcohol Depend. 2023 Apr 1;245:109807. doi: 10.1016/j.drugalcdep.2023.109807. Epub 2023 Feb 13. PMID: 36801706; PMCID: PMC10901231.</p> </div> <div class="blog-entry-references-content"> <p>Goldstein RZ, Volkow ND. Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci. 2011 Oct 20;12(11):652-69. doi: 10.1038/nrn3119. PMID: 22011681; PMCID: PMC3462342.</p> </div> <div class="blog-entry-references-content"> <p>Merlo LJ, Campbell MD, Shea C, White W, Skipper GE, Sutton JA, DuPont RL. Essential components of physician health program monitoring for substance use disorder: A survey of participants 5 years post successful program completion. Am J Addict. 2022 Mar;31(2):115-122. doi: 10.1111/ajad.13257. Epub 2022 Jan 17. PMID: 35037334; PMCID: PMC9303734</p> </div> <div class="blog-entry-references-content"> <p>DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: Physicians' Health Programs. J Subst Abuse Treat. 2009 Mar;36(2):159-71. doi: 10.1016/j.jsat.2008.01.004. 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