When Free Will Fails People With Opioid Use Disorders

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.

The University of Florida has offered a professional health provider program for substance abusers over 30 years. The university's research on impaired health professionals, 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, outcomes 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.”

Scott Teitelbaum, MD

Source: University of Florida

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.

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.

Phases of the Marchman Act

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 psychiatric 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.

Some Roadblocks

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 not 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.

Recent Developments

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.

Teitelbaum told me that the Act is crucial to harm reduction-focused addiction medicine in Florida. “I know we have saved lives with the Marchman Act. We often find drug-use-related depression or extreme anhedonia 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 gratitude come, but much later.”

Psychiatrist Michael Lesser, former medical services director of the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services and medical director of the New York State Office of Mental Health, has a long history as a pioneer and thought leader 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.”

Michael Lesser, MD

Source: Permission from RANE

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, people who have to use drugs and are not capable of looking after themselves. Unfortunately, civil commitment is unavailable everywhere but should be left to doctors, patients, and families.”

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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.

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 now, rather than wait for the addict to suffer and hit bottom, which may mean death.

Harms to the General Public by Substance Abusers, Avoided with Civil Commitment

Substance abuse 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 crime 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 free will—to fend for themselves, knowing they are incapable of understanding the risks and consequences of their use or actions?”

Research on Loss of Control Over Drug Intake

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 executive functions like self-control 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 compulsive behavior. Disruption of the PFC in addiction underlies not only compulsive drug taking but also erosion of free will.

Similar to how society intervenes in cases of suicidality 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.