ROUND TABLE
Arguments in favour of compulsory treatment of opioid dependence
Arguments en faveur du traitement obligatoire de la dépendance aux opioïdes
Argumentos a favor del tratamiento obligatorio de la dependencia de opiáceos
Zunyou Wu*
National Centre for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
ABSTRACT
Twelve agencies of the United Nations, including the World Health Organization, have issued a joint statement that calls on Member States to replace the compulsory detention of people who use opioids in treatment centres with voluntary, evidence-informed and rights-based health and social services. The arguments in favour of this position fall into three broad categories: Compulsory treatment centres infringe on an individual's liberty, they put human beings at risk of harm, and evidence of their effectiveness against opioid dependence has not been generated.
The United Nations statement underscores that although countries apply different criteria for sending individuals to compulsory treatment centres, detention often takes place without due process, legal safeguards or judicial review. This clearly violates internationally recognized human rights standards. Furthermore, people who are committed to these centres are often exposed to physical and sexual violence, forced labour and sub-standard living conditions. They are often denied health care, despite their heightened vulnerability to HIV infection and tuberculosis. Finally, there is no evidence, according to the statement, that these centres offer an environment that is conducive to recovery from opioid dependence or to the rehabilitation of commercial sex workers or of children who have suffered sexual exploitation, abuse or lack of care and protection.
The author of this paper sets forth several arguments that counter the position taken by the United Nations and argues in favour of compulsory treatment within a broader harm reduction strategy aimed at protecting society as well as the individual concerned.
RÉSUMÉ
Douze agences des Nations Unies, parmi elles l'Organisation mondiale de la Santé, ont émis une déclaration commune qui appelle les États membres à remplacer la détention obligatoire des consommateurs d'opioïdes dans des centres de traitement par des services sanitaires et sociaux volontaires qui s'appuient sur des données probantes et soient fondés sur le droit. Les arguments en faveur de cette position se répartissent en trois grandes catégories: les centres de traitement obligatoire empiètent sur la liberté de l'individu, ils exposent les êtres humains à des risques et la preuve de leur efficacité contre la dépendance aux opioïdes n'a pas été démontrée.
La déclaration des Nations Unies souligne que même si les pays appliquent des critères différents pour l'envoi des individus dans des centres de traitement obligatoire, leur détention survient souvent sans procédure régulière, protection légale ou contrôle juridictionnel. Cet état de fait contrevient clairement aux normes des droits de l'homme reconnues au niveau international. En outre, les personnes remises à ces centres sont souvent exposées à des sévices physiques et sexuels, à du travail forcé et à des conditions de vie inférieures aux normes. Ils se voient souvent refuser des soins de santé en dépit de leur vulnérabilité accrue à l'infection par le VIH et à la tuberculose. Enfin, il n'y a aucune preuve, selon cette déclaration, que ces centres offrent un climat propice à la récupération de la dépendance aux opioïdes ou à la réinsertion des professionnels du sexe ou des enfants victimes d'exploitation sexuelle, de maltraitance ou de manque de soins et de protection.
L'auteur de ce document de travail avance plusieurs arguments contraires à la position adoptée par les Nations Unies et milite en faveur d'un traitement obligatoire participant d'une stratégie élargie de réduction des risques visant à protéger la société, mais aussi l'individu concerné.
RESUMEN
Doce agencias de las Naciones Unidas, entre ellas la Organización Mundial de la Salud, han emitido una declaración conjunta que insta a los Estados miembros a reemplazar la retención obligatoria en centros de tratamiento de personas que hacen uso de opiáceos por servicios sociales y sanitarios voluntarios, basados en pruebas científicas y en sus derechos. Los argumentos a favor de esta postura se clasifican en tres amplias categorías: Los centros de tratamiento obligatorio atentan contra la libertad individual, ponen a las personas en riesgo y no existen pruebas de su eficacia contra la dependencia de opiáceos.
La declaración de las Naciones Unidas enfatiza que, aunque cada país aplica criterios distintos a la hora de enviar a los individuos a los centros de tratamiento obligatorio, es frecuente que la retención se lleve a cabo sin el debido proceso, la seguridad jurídica ni el examen judicial correspondiente, lo que viola claramente las normas de los derechos humanos reconocidas a nivel internacional. Además, las personas internadas en dichos centros se ven expuestas, con frecuencia, a violencia física o sexual, trabajos forzados y condiciones precarias de vida, y es frecuente que se les niegue la atención sanitaria a pesar de ser más vulnerables a la infección por VIH y a la tuberculosis. Por último, no hay ninguna evidencia, de acuerdo con la declaración, de que dichos centros ofrezcan un ambiente propicio para la recuperación de la dependencia a los opiáceos o para la rehabilitación de trabajadores sexuales o de niños que han sufrido explotación sexual, abusos o falta de cuidado y atención.
El autor del presente artículo describe numerosos argumentos que rebaten la posición adoptada por las Naciones Unidas a favor de un tratamiento obligatorio en el ámbito de una estrategia más amplia enfocada a la reducción del daño y cuyo objetivo es proteger tanto a la sociedad como al individuo afectado.
Twelve United Nations agencies, including the World Health Organization, have issued a joint statement that calls on Member States to "close compulsory drug detention and rehabilitation centers and implement voluntary, evidence-informed and rights-based health and social services in the community".1 In this paper I refute each of the claims made in support of this petition and argue in favour of compulsory treatment as one component within a broader harm reduction strategy aimed at protecting and reintegrating into society individuals who are opioid-dependent while ensuring the safety of the broader community.
First, opioid dependence should not be viewed solely as a medical issue affecting the individual, but rather, as a complex social problem that affects entire communities. Opioid dependence harms not only the users themselves, but also their families and neighbours and even strangers far beyond their immediate circle of acquaintances. Therefore, a comprehensive response to opioid dependence must take into account both the human rights of the opioid-dependent individuals and those of the people who live in their communities.2 In fact, compulsory treatment centres provide not only short-term opioid substitution therapy for the treatment of withdrawal symptoms, but also educational programmes, job skills training programmes and physical exercise routines in a safe, isolated environment. Some even offer opportunities for manual work. Hence, these centres increase the personal safety of both the individuals who have opioid dependence and the members of the communities in which they live. Besides reducing the use of opioids, they protect opioid-dependent individuals from death and suicide, opioid-related criminal activity and the physical harm that might befall them in a general prison. In addition, they protect the individual's community through reductions in illicit opioid dealing, theft, vandalism, sexual assault and murder, and by mitigating the health risks associated with needle sharing and high-risk sexual behaviour.
The benefits of compulsory treatment centres for opioid dependence are substantial, albeit at the temporary expense of the opioid-dependent individual's autonomy. However, this terrain is admittedly fraught with ethical dilemmas. Efforts to protect the rights of individuals and efforts to protect the broader community need not conflict, but where is the ideal balance? Although an individual's human rights are generally upheld as universal and of paramount value and much has been written in their defence, are they more valuable than the rights of entire communities? In my view, what is regarded as the ideal balance in this context is rooted in cultural norms. In general, Western societies defend and protect individual rights over the rights of the broader community, while the opposite is true of Eastern societies.3 An example may serve to illustrate the point. Are people who have been dependent on opioids for years and who, in many cases, have severe psychological problems, able to make rational decisions, provide informed consent for treatment or participate competently in their own due process? At what point does the broader community have a responsibility to intervene? Some experts argue, as I do, that mental illness itself deprives an individual of their autonomy by rendering them unable to make free choices. Under some circumstances, the individual's autonomy must be overridden for the sake of the community as a whole.4,5
Second, although physical violence and high-risk sexual behaviour sometimes occur in compulsory treatment centres, no scientific evidence so far supports the notion that in these centres such problems are more common than elsewhere, or that the opioid-dependent individuals who live in them are at higher risk of opioid-related medical complications, infectious diseases or death than those not living in compulsory treatment centres. In fact, a research report jointly authored by officials from China's Center for Disease Control and Prevention and Australian public health researchers shows quite the opposite. According to the report, about 50% of the interviewees, who were detained in a camp for re-education through labour, described their general health as good, very good or excellent.6 Furthermore, testing for the detection of communicable diseases (including HIV infection, syphilis, hepatitis C, tuberculosis, etc.) is expanding in many compulsory treatment centres. This will make it possible to detect new cases of infectious disease earlier in this high-risk population, which is otherwise very difficult to access.
Third, the evidence on the relative effectiveness of compulsory treatment and of voluntary, community-based treatment for opioid dependence is still mixed. Opioid-dependent individuals, whether remanded to a compulsory treatment centre or voluntarily enrolled in a community-based treatment programme, often continue to use opioids and relapse immediately after their release or after treatment is completed or discontinued. They also frequently re-engage in criminal activity linked to their opioid dependence. Thus, it is becoming increasingly clear that neither option is a "magic bullet" for the complete and permanent rehabilitation of all opioid-dependent people. Opioid dependence is now widely recognized as a mental disorder and has been shown to permanently alter brain function. The effects of opioid dependence are lifelong and sometimes involve debilitating psychological co-morbidity.7 Further research on this complex problem is required before the evidence surrounding the effectiveness of any single rehabilitation or treatment strategy for people with opioid dependence is deemed conclusive. More than likely, strategies will have to be tailored to different segments of the opioid-dependent population.
Compulsory treatment centres for opioid dependence play an important role within a broader harm reduction strategy. Voluntary treatment for opioid dependence is no longer unobtainable in some Asian countries. China has the largest methadone maintenance treatment network in the world.8 Since 2004, the network has served more than 350 000 opioid-dependent individuals, cumulatively, in nearly 750 methadone maintenance treatment clinics across the mainland. Similar programmes are being piloted or scaled up in Cambodia, the Lao People's Democratic Republic, Malaysia and Viet Nam, and many Asian countries are taking aggressive steps towards broader, more comprehensive harm reduction strategies comprising educational campaigns, peer outreach, needle exchange programmes, voluntary counselling and testing programmes and expansion of treatment coverage for HIV infection.9 Thus, opioid-dependent individuals in some Asian countries now have more opportunities than ever to choose treatment over continued opioid dependence.
Despite the wide availability of voluntary treatment options, however, a certain proportion of opioid-dependent individuals persistently refuse treatment and engage in offences related to their opioid dependence, including violent crimes.2,10,11 In China, this proportion is thought to range from 60 to 90% (unpublished findings). Furthermore, a recent international study of the effects of methadone maintenance treatment programmes showed that they do reduce heroin dependence, but not opioid-related crime.12 Rather, an expanding body of research suggests that community-based voluntary methadone maintenance treatment programmes are simply not enough to keep some opioid-dependent individuals from engaging in criminal activity2 and that offenders' perceptions of legal pressure or coercion are very important in reducing rates of rearrest.10,11 These studies have prompted some high-income countries to re-examine the idea of compulsory treatment and even open new compulsory treatment centres for opioid-dependent people.2
Although compulsory treatment centres vary widely in terms of management, prevailing conditions and the treatments offered, much room for improvement clearly exists. However, closing these facilities all at once and releasing their inmates into the community is not the answer. A more prudent course would be to gradually move towards embracing the recommendations in the United Nations' joint statement: not remanding people to compulsory treatment centres arbitrarily; establishing adequate oversight and reporting mechanisms in the centres, and reviewing the conditions within them.1 Most the Asian countries cited in the joint statement are already actively engaged with various United Nations agencies and other international organizations in trying to learn and implement best practices in harm reduction strategies for opioid-dependent people.9 Studies on the problems affecting Asia's compulsory treatment centres for opioid-dependent individuals are already under way. For example, a study from China explored ways to effectively transition opioid users in such centres to community-based methadone maintenance treatment clinics upon their release. The study provides evidence that administering methadone within compulsory treatment centres is beneficial not just for opioid substitution therapy or detoxification, which is the current practice, but also for methadone maintenance treatment.13 Continued efforts to improve and expand on existing options for the rehabilitation of opioid-dependent people and to leverage a broad range of harm reduction strategies are the only way to effectively address the problem of opioid dependence.
In summary, I believe that compulsory treatment for opioid dependence should be retained as one component within a broader harm reduction strategy comprising voluntary treatment, needle exchange programmes, voluntary counselling and testing, expanded infectious disease treatment coverage, peer outreach and intensive educational campaigns. Compulsory treatment centres serve to protect the safety of both opioid-dependent individuals and their communities and offer a particularly important means of reaching the segments of the opioid-dependent population that repeatedly refuse outpatient treatment and engage in crime. 
Competing interests: None declared.
References
1. Joint statement: compulsory drug detention and rehabilitation centres. New York: International Labour Organization; Office of the High Commissioner for Human Rights; United Nations Development Programme; United Nations Educational, Scientific and Cultural Organization; United Nations Population Fund; United Nations High Commissioner for Refugees; United Nations Children's Fund; United Nations Office on Drugs and Crime; United Nations Entity for Gender Equality and the Empowerment of Women; World Food Programme; World Health Organization & Joint United Nations Programme on HIV/AIDS; 2012. Available from: http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint%20Statement6March12FINAL_en.pdf [accessed 19 November 2012] .
2. Birgden A, Grant L. Establishing a compulsory drug treatment prison: therapeutic policy, principles, and practices in addressing offender rights and rehabilitation. Int J Law Psychiatry 2010;33:3419. doi:10.1016/j.ijlp.2010.09.006 PMID:20923717
3. Kausikan B. Asia's different standard. Foreign Policy 1993;92:2441. doi:10.2307/1149143
4. Williamson T. Ethics of assertive outreach (assertive community treatment teams). Curr Opin Psychiatry 2002;15:5437. doi:10.1097/00001504-200209000-00013 PMID:15264342
5. Charland LC. Cynthia's dilemma: consenting to heroin prescription. Am J Bioeth 2002;2:3747. doi:10.1162/152651602317533686 PMID:12189075
6. Wu Z, Liu W, Chen Y, Yap L, Reekie J, Butler T. Health and wellbeing of re-education-through-labour camp (laojiaosuo) detainees in south-western China region. Summary report. Sydney: University of New South Wales; 2012.
7. Volkow ND, Wang GJ, Fowler JS, Tomasi D. Addiction circuitry in the human brain. Annu Rev Pharmacol Toxicol 2012;52:32136. doi:10.1146/annurev-pharmtox-010611-134625 PMID:21961707
8. Metzger DS, Zhang Y. Drug treatment as HIV prevention: expanding treatment options. Curr HIV/AIDS Rep 2010;7:2205. doi:10.1007/s11904-010-0059-z PMID:20803321
9. Mesquita F, Jacka D, Ricard D, Shaw G, Tieru H, Hu Y et al. Accelerating harm reduction interventions to confront the HIV epidemic in the Western Pacific and Asia: the role of WHO (WPRO). Harm Reduct J 2008;5:26. doi:10.1186/1477-7517-5-26 PMID:18680604
10. Young D, Fluellen R, Belenko S. Criminal recidivism in three models of mandatory drug treatment. J Subst Abuse Treat 2004;27:31323. doi:10.1016/j.jsat.2004.08.007 PMID:15610833
11. Somers JM, Currie L, Moniruzzaman A, Eiboff F, Patterson M. Drug treatment court of Vancouver: an empirical evaluation of recidivism. Int J Drug Policy 2012;23:393400.
12. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009;3:CD002209. PMID:19588333
13. Yan L. A pilot study to refer drug users from detoxification centres to community-based HIV prevention services [thesis]. Beijing: Peking Union Medical College; 2010. Chinese
(Submitted: 14 June 2012 Revised version received: 30 October 2012 Accepted: 12 November 2012)
* Correspondence to Zunyou Wu (e-mail: wuzunyou@chinaaids.cn).