ROUND TABLE
DISCUSSION
Voluntary treatment, not detention, in the management of opioid dependence
Nicolas Clark; Anja Busse; Gilberto Gerra
The compulsory treatment of opioid dependence is an approach to the management of opioid use based on detention in locked facilities resembling low security prisons where the main activities are drug education, military style drills and manual labour.17 These centres are not part of the criminal justice system or subject to judicial oversight and their detainees have not necessarily been convicted of any crime. Staffed by security personnel, they do not provide the kind of evidence-based treatment that is described elsewhere in this theme issue and are probably more aptly named "extrajudicial drug detention centres" than "compulsory treatment centres".
In his defence of the use of drug detention facilities in China,8 Wu argues that the concerns indicated in a recent United Nations statement9 are based on a "western" sense of ethics and that in more communitarian societies drug detention centres play a role in a spectrum of responses. He also argues that such centres pose little risk of maltreatment and poor health to detainees and that detention in them is practically as effective as voluntary, community-based treatment.
Societies undoubtedly vary in their perspectives on the appropriate balance between the rights of the individual and those of the community. More communitarian societies might be expected to justify the practice of social exclusion through confinement in compulsory drug detention facilities on the grounds that it is for the common good. On the other hand, there are some "western" countries without drug detention facilities but with high rates of imprisonment of people who use drugs. In a third group of countries there are neither drug detention centres nor high rates of imprisonment for people who use drugs. The difference between these three groups of countries lies not so much in their preference for individual versus community rights, but rather in their preference for policies of social inclusion versus social exclusion for dealing with people who use illicit drugs, and perhaps in their capacity to implement such policies.
On the issue of the relative effectiveness of treatment and compulsory detention, we disagree with Wu's assertion that the evidence for the effectiveness of treatment approaches is mixed. Methadone maintenance treatment is one of the most effective and cost-effective treatments for a chronic, non-communicable disease known to modern medicine. It reduces heroin use, transmission of the human immunodeficiency virus (HIV), criminal activity and the risk of death in the treated individual, each by approximately two thirds.10 On the other hand, there is no evidence provided that compulsory detention for opioid dependence is rehabilitative. Maximizing the proportion of people with drug use disorders who receive effective treatment is widely thought to benefit both the community at large and people who use illicit drugs. This can be done by ensuring that quality treatment is available, accessible and affordable.11
Treatment rates can be further improved by optimizing the interaction between the health-care system and the criminal justice system.12 If, for example, someone with heroin dependence is arrested for stealing and faces imprisonment, he will be more motivated to start drug treatment if it reduces his chances of going to prison. Since successful treatment reduces the risk to the community, is generally cheaper for the state, and better for the individual, it is a "win-win" solution.
Many countries around the world are now developing such mechanisms of interaction between the criminal justice system and the health-care system.13 Such arrangements can usually be made without any change in legislation, but several countries have introduced special legislation to facilitate this process. Voluntary treatment can also be offered in prison and on leaving prison. Many countries have a system whereby people are released from prison early on certain conditions, which may include treatment, and must return to prison if these are no longer being met. The interaction between the criminal justice system and the drug treatment system is one of the areas of focus of a recent initiative, the Joint UNODC/WHO Programme on Drug Dependence Treatment and Care,14 now active in 15 countries.
The general experience with such methods of interaction between the criminal justice system and the health-care system has been positive, and most countries that are initiating collaboration between these systems are looking to expand them.13 The threat of detention alone appears to be already more effective than detention itself in encouraging people to get treated. More often than not, the barrier is a lack of treatment places, not a lack of volunteers.
With the full use of effective, voluntary treatment, fewer people with opioid dependence would be committing the kind of crimes that would render them a danger to their communities. For the small group of people who commit serious crimes despite the opportunity to receive treatment, the criminal justice system is best placed to determine if social exclusion via detention is necessary, and to oversee that detention. Recent world history is full of examples of abuses committed in settings of extrajudicial detention. Similar stories are emerging from drug detention facilities, and the figures quoted by Wu8 that half the detainees in compulsory drug detention centres were in good health are hardly encouraging for the other half. It is for good reason that the United Nations considers "the deprivation of liberty without due process [...] an unacceptable violation of internationally recognized human rights standards".9 
Acknowledgements
The views of the authors do not necessarily represent the views of WHO or UNODC.
Competing interests: None declared.
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