Civil Commitment and the Opioid Epidemic: A Call for Research

By Scott Burris, JD

There is a lot of interest in civil commitment these days, as a possible tool to fight two big health problems. As we continue to watch the rates of opioid-related deaths climb, and in the wake of an unfunded emergency declaration by President Trump, some policymakers are looking to involuntarily commit overdose survivors for drug treatment. On the gun violence side, experts like Jeffrey Swanson have argued for applying gun-access restrictions that now cover people subject to long-term civil commitment to those subjected to short-term civil commitment.

With those kinds of ideas in the air, it is important to recognize how little modern data we have on commitment and its effects. In a recent article in the Washington Post discussing commitment for opioid treatment, Michael Stein and Paul Christopher emphasize how little we know. I entirely agree on the need for more research, and offer a couple of things to help.

The first is the Policy Surveillance Program’s LawAtlas dataset that maps civil commitment laws across all 50 states and the District of Columbia. If we’re going to examine these laws and their impact, this is the place to start. We also put out the call to anyone interested in studying this to work with us not only to update this data through 2017, but also to make sure we’re mining these laws and their characteristics for the right information in these circumstances — Are we asking the right questions? Read More

The Opioid Crisis Requires Evidence-Based Solutions, Part II: How the President’s Commission on Combating Drug Addiction Ignored Promising Medical Treatments

By Mason Marks

Last year more than 64,000 Americans died of drug overdose, which is “now the leading cause of death” in people under 50. Opioids kill an estimated 91 Americans each day and are responsible for most drug-related deaths in the US. This public health crisis requires solutions that are supported by science and reason instead of emotion and political ideology. In Part I of this three-part series, I discuss how the President’s Commission on Combating Drug Addiction and the Opioid Crisis misinterpreted scientific studies and used data to support unfounded conclusions. In this second part of the series, I explore how the Opioid Commission ignored medical interventions that are used successfully in the U.S. and abroad. In Part III, I will discuss non-medical interventions such as drug checking and safe injection sites. The Commission’s failure to consider these options is likely driven by emotions such as fear and disgust rather than a careful review of scientific evidence.

Medical marijuana is currently accepted in 29 U.S. states and the District of Columbia. It is also permitted in at least 10 countries. However, the Opioid Commission outright rejected calls to consider the use of medical marijuana as an alternative to opioids for managing pain. Prior to the Commission’s first meeting, it solicited input from industry and members of the public on how to address the opioid crisis. In response, it received over 8,000 public comments. According to VICE News, which obtained the documents by submitting a Freedom of Information Act (FOIA) request, most comments were submitted by individuals urging the Commission to “consider medical marijuana as a solution to the opioid epidemic.” A spokesman for the Office of National Drug Control Policy, a body of the Executive Branch that provides administrative support to the Opioid Commission, reports receiving “more than 7,800 public comments relating to marijuana.” Despite these comments, in its final report, the Commission dismissed the notion that marijuana should play a role in treating chronic pain and opioid addiction. Its report cited a recent study from the American Journal of Psychiatry, which concluded that marijuana use was associated with an increased risk of opioid abuse. However, this study relied on data that was collected over twelve years ago. One of its authors, Columbia Medical School Professor Mark Olfson, told CNN that if the data were collected today, they could yield different results.

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The Opioid Crisis Requires Evidence-Based Solutions, Part I: How the President’s Commission on Combating Drug Addiction Misinterpreted Scientific Studies

By Mason Marks

The opioid crisis kills at least 91 Americans each day and has far-reaching social and economic consequences for us all. As lawmakers explore solutions to the problem, they should ensure that new regulations are based on scientific evidence and reason rather than emotion or political ideology. Though emotions should motivate the creation of policies and legislation, solutions to the opioid epidemic should be grounded in empirical observation rather than feelings of anger, fear, or disgust. Legislators must be unafraid to explore bold solutions to the crisis, and some measured risks should be taken. In this three-part series on evidence-backed solutions to the opioid crisis, I discuss proposals under consideration by the Trump Administration including recent recommendations of the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Though the Commission made some justifiable proposals, it misinterpreted the conclusions of scientific studies and failed to consider evidence-based solutions used in other countries. This first part of the series focuses on the misinterpretation of scientific data.

Last year more than 64,000 Americans died of drug overdose, which is “now the leading cause of death” in people under 50. Opioids are responsible for most of these deaths. By comparison, the National Safety Council estimates about 40,000 Americans died in auto crashes last year, and the Centers for Disease Control reports that 38,000 people were killed by firearms. Unlike deaths due to cars and firearms, which have remained relatively stable over the past few years, opioid deaths have spiked abruptly. Between 2002 and 2015, U.S. opioid-related deaths nearly tripled (from about 12,000 deaths in 2002 to over 33,000 in 2015). Last year, synthetic opioids such as fentanyl contributed to over 20,000 deaths and accounted for the sharpest increase in opioid fatalities (See blue line in Fig. 1 below). Read More

Reflecting on Dementia and Democracy: America’s Aging Judges and Politicians

By Gali Katznelson

This month, the Petrie-Flom Center collaborated with the Center for Law, Brain & Behavior  to host a panel entitled Dementia and Democracy: America’s Aging Judges and Politicians.” The panelists, Bruce Price, MD, Francis X. Shen, JD, PhD, and Rebecca Brendel, JD, MD, elucidated the problems, as well as potential solutions, to the challenges of America’s judiciary and elected politicians getting older. Reconciling dementia with democracy is a pressing matter. As Dr. Price explained, age is the single largest risk factor for dementia, a risk that doubles every five years after the age of 65, and America is a country with five of the nine Supreme Court Justices over the age of 67, a 71-year-old president, a 75-year-old Senate Majority Leader, and a 77-year-old House Minority Leader.

In his talk “Dementia in Judges and Elected Officials: Challenges and Solutions,” Dr. Shen defined the complex problem. While most other jobs are not retaining workers into old age, many judges and elected officials continue to serve well into their 80s. To complicate matters further, without widespread regulations or metrics to identify how dementia impedes one’s work, the media assumes the position of speculating the cognitive statuses and fates of judges and elected officials. Dr. Shen’s key point was, “Surely we can do better than speculation.”

Dr. Shen proposed several solutions to address dementia in elected officials and judges. Currently, we leave the open market and colleagues to regulate individuals, which remains a valid approach as we consider other options. Another default position is to diagnose based on publicly available data, a solution that introduces the specific ethical concerns that Dr. Brendel addressed in her talk (discussed below). There are, however, novel solutions. We could consider requiring cognitive testing and disclosure (which could be overseen by an internal review board), or we could simply impose an age limit for service. For judges, if such an age limit were imposed, we could create a rebuttable presumption in which a judge can continue to serve by completing an evaluation. Alternatively, perhaps judges can be limited to adjudicating specific cases based on their cognitive status.

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Dementia and Democracy: America’s Aging Judges and Politicians

Dementia and Democracy: America’s Aging Judges and Politicians
November 15, 2017 12:00 PM
Pound Hall, Room 102
Harvard Law School, 1563 Massachusetts Ave., Cambridge, MA

Our judiciary and our elected officials are getting old. Five of the nine Supreme Court Justices are 67 or older, with two over age 80. The President is 71, the Senate Majority Leader is 75, and the House Minority Leader is 77. Does the public have a right to know whether these officials have been screened for dementia? If the individuals don’t self-report their dementia status, should experts continue to adhere to the “Goldwater Rule” and refrain from offering an armchair diagnosis? As the nation reflects on its midterm elections, and prepares for the 2020 election cycle, these questions are timely and challenging.

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Dementia and Democracy: America’s Aging Judges and Politicians

Dementia and Democracy: America’s Aging Judges and Politicians
November 15, 2017 12:00 PM
Pound Hall, Room 102
Harvard Law School, 1563 Massachusetts Ave., Cambridge, MA

Our judiciary and our elected officials are getting old. Five of the nine Supreme Court Justices are 67 or older, with two over age 80. The President is 71, the Senate Majority Leader is 75, and the House Minority Leader is 77. Does the public have a right to know whether these officials have been screened for dementia? If the individuals don’t self-report their dementia status, should experts continue to adhere to the “Goldwater Rule” and refrain from offering an armchair diagnosis? As the nation reflects on its midterm elections, and prepares for the 2020 election cycle, these questions are timely and challenging.

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Instagram and the Regulation of Eating Disorder Communities

By Clíodhna Ní Chéileachair

I’m sure not how much time the average health law enthusiast spends on Instagram, but as a rare opportunity to see health regulation in real-time, I’d encourage logging onto the site, which curates content based on user profiles and by tags, and searching for the following tags; #thinspo, #thighgap, and #eatingdisorder. The site will either return no results, or will present the searcher with a warning message that “Posts with words or tags you’re searching for often encourage behavior that can cause harm and even lead to death” and encouraging the user to reach out for help, though the flagged content is still accessible if the user clicks-through. #thinspo (short for another neologism, ‘thinspiration’) is exactly what it sounds like – images designed to inspire an individual to restrict their diet, and exercise to attain what will generally be an underweight physique. Many social media sites have enacted similar bans on content as a reaction to the role that online communities can play in promoting eating disorders.

As a suite of illnesses, eating disorders have severe, and sometimes life-threatening medical complications. Anorexia nervosa has the highest death rate of all psychiatric illnesses; bulimia carries severe medical complications associated with starvation and purging including bone disease, heart complications, digestive tract distress, and even infertility, and EDNOS (eating disorder not otherwise specified) while carrying subclinical status in DMS-IV, carries similar levels of eating pathology and general psychopathology to anorexia nervosa and binge eating disorder, and a similar degree of danger to physical health to anorexia. Instagram had been criticised for its inaction in the face of an explosion of pro-eating disorder community activity on its site after Tumblr and Pinterest enacted bans on ‘thinspiration’ content, at which point many users migrated to Instagram’s platform. Five years on from the initial ban, some terms, like #starve and #purge will display the above warning message; other obvious tags for the pro-eating disorder community, like #skinnyinspiration and #thinspire attract no warning message and display images of emaciated women, romanticizations of eating disorders, images of individuals destroying food, and in line with clinical understandings of how eating disorders manifest themselves, images of self harm.

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“Siri, Should Robots Give Care?”

By Gali Katznelson

Having finally watched the movie Her, I may very well be committing the “Hollywood Scenarios” deadly sin by embarking on this post. This is one of the seven deadly sins of people who sensationalize artificial intelligence (AI), proposed by Rodney Brooks, former director of the Computer Science and Artificial Intelligence Laboratory at MIT. Alas, without spoiling the movie Her (you should watch it), it’s easy for me to conceptualize a world in which machines can be trained to mimic a caring relationship and provide emotional support. This is because, in some ways, it’s already happening.

There are the familiar voice assistants, such as Apple’s Siri, to which people may be turning for health support. A study published in JAMA Internal Medicine in 2016 found that that the responses of smartphone assistants such as Apple’s Siri or Samsung’s S Voice to mental and physical health concerns were often inadequate. Telling Siri about sexual abuse elicited the response, “I don’t know what you mean by ‘I was raped.’” Telling Samsung’s S Voice you wanted to commit suicide led to the perhaps not-so-sensitive response, “Don’t you dare hurt yourself.” This technology proved far from perfect in providing salient guidance. However, since this study came out over a year ago, programmers behind Siri and S Voice have remedied these issues by providing more appropriate responses, such as counseling hotline information.

An AI specifically trained to provide helpful responses to mental health issues is Tess, “a psychological AI that administers highly personalized psychotherapy, psycho-education, and health-related reminders, on-demand, when and where the mental health professional isn’t.” X2AI, the company behind Tess, is in the process of finalizing an official Board of Ethics, and for good reason. The ethical considerations of an artificially intelligent therapist are rampant, from privacy and security issues to the potential for delivering misguided information that could cost lives. Read More

The State of Care in Mental Health Services in England 2014-2017

By John Tingle

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. They have recently published a report of inspections on specialist mental health services. The  report is very thorough and detailed and reveals both good and bad practices. When reading the report however the poor practices identified eclipse the good ones.

Patient safety concerns

Concerns about patient safety are a constant and overarching theme in the report. The CQC biggest concern in this care area is patient safety:

“For both NHS and independent mental health services overall, and for eight of the 11 core services, safe was the key question that we most often rated as requires improvement or inadequate. At 31 May 2017, 36% of NHS core services and 34% of independent core services were rated as requires improvement for safe; a further 4% of NHS core services and 5% of independent core services were rated as inadequate for safe “(29).

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Vicarious Traumatization in the Wake of Community Violence: Healing the Helpers

This post is part of a series “Healing in the Wake of Community Violence: Lessons from Newtown and Beyond,” based on an event of the same name hosted at Harvard Law School in April 2017. Background on the series and links to other blog posts are here.

By Michelle Bosquet Enlow, PhD

depression_slideWhen a horrific violent event occurs, the community’s thoughts and efforts to help naturally extend out to the injured and traumatized survivors and the loved ones of those killed. However, the effects of such traumatic events ripple out beyond those so directly impacted. According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), the definition of trauma includes not only direct exposure to actual or threatened death or serious injury, but also witnessing such an event or experiencing repeated or extreme exposure to aversive details of such an event. Under this more comprehensive definition, the circle of affected individuals in the wake of community violence widens to include professionals and community leaders who are tasked with tending to the safety, medical, emotional, instrumental, and spiritual needs of those wounded. These “helpers” include first responders (e.g., police officers, emergency medical technicians), medical and mental health professionals, case workers, and religious leaders. Read More