Compulsory detention, forced detoxification andenforced labour are not ethically acceptable oreffective ways to treat addictionadd_3888 1..3

Compulsory detention of drug users without trial isneither an ethical nor an effective way of addressingaddiction.

During the past century, a number of countries havepassed laws that provide for the compulsory detentionof addicted individuals, usually under the description ofcompulsory treatment for their addiction. A number ofAustralian [1] and US states [2] legislated for the invol-untary treatment of ‘inebriates’ in the late 19th and early20th centuries. US Federal courts sent heroin-addictedindividuals for 6 months’ compulsory treatment inPublic Health Hospitals at Lexington, Kentucky and FortWorth, Texas from 1934 to 1971 [3]. In these detentioncentres treatment (usually detoxification and 12-Steppsychotherapy) was mandatory. That is, detainees werenot offered the choice of conventional addiction treat-ment in the community as an alternative to imprison-ment, an approach for which there is some evidence ofeffectiveness [4].

Compulsory detention of addicted individuals haseither been abandoned or fallen into disuse in mostdeveloped countries for two main reasons. First, it failedto treat addiction effectively, with most people detainedreturning to drug use after release [1,3,4]. Secondly, thisapproach has been criticized for violating the humanrights of drug users (e.g. [5]). The few developed coun-tries that still detain addicted people compulsorily—suchas Russia [6] and Sweden [7]—do so in the absenceof rigorous evaluations of the efficacy or safety of thisapproach.

Compulsory detention of drug users has been imple-mented recently in a number of developing countrieswith serious drug use problems, e.g. Cambodia, China,Myanmar, Thailand and Vietnam [8,9]. In these coun-tries, large numbers of drug users (more than 300 000 inChina, more than 60 000 in Vietnam and more than40 000 in Thailand) have been sent to ‘drug detentioncentres’ for as long as 2–4 years [10]. These centres havebeen criticized as violating basic human rights by humanrights advocates (e.g. [5,8]), and UN Agencies such as theWorld Health Organization (WHO) [10] and the UN Officeon Drugs and Crime (UNODC) [11].

Authorities in these developing countries do notusually allow independent inspections of the centres orevaluations of their inmates’ experiences, so critics have

relied upon interviews with former residents and staffmembers (e.g. [12,13]). These studies reveal major con-cerns about the way in which these centres are allowed tooperate under law. There is no independent review orappeal process on entry; centres are run by the military,security or police officers; and such ‘treatment’, as isprovided, usually consists of unmedicated detoxifica-tion, hard physical labour, physical and psychologicalabuse and withholding of food as punishment for non-compliance. There is little, if any, medical oversight oftreatment, conditions are often overcrowded and unsani-tary and release is usually after a fixed term rather thanbased on clinical outcomes [5,9,10]. These centres are, inshort, prisons by another name.

What occurs in these compulsory detention centrescannot be dignified by the term of ‘compulsory treat-ment’. It does not, for example, meet minimum criteriafor ethically acceptable forms of legally coerced addic-tion treatment as an alternative to imprisonment [4]. Inthese centres drug users: are detained without legal dueprocess or review; have no choice about the treatmentoffered; and do not receive humane and effective treat-ment of addiction [14]. A recent WHO and UNODC [10]discussion paper concluded very reasonably that deten-tion centres in many developing countries violated thehuman rights of drug users.

Detention centres in these developing countries donothing to reduce, and may well amplify, the substantialpublic health and order problems that drug use causes inthese countries [8,9]. In the absence of effective addictiontreatment, there are high rates of relapse to drug use afterrelease and high rates of human immunodeficiency virus(HIV) infection among participants in these centres. Theresources devoted to running these centres are not avail-able to provide more effective public health interventionsto prevent blood-borne viruses (BBV) transmissionamong injecting drug users [9].

There are some signs that these policies are beginningto change for the better in some developing countries.The governments of Vietnam [15] and China [16], forexample, have recently introduced needle and syringeprogrammes and opioid substitution for heroin depen-dence. These changes are welcome, but drug users con-tinue to be detained compulsorily in these countries.

We urge governments that are afflicted by seriousillicit drug problems to replace unethical and inhumane

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EDITORIAL doi:10.1111/j.1360-0443.2012.03888.x

© 2012 The Authors. Addiction © 2012 Society for the Study of Addiction Addiction

detention of drug users with effective forms of addictiontreatment that are provided humanely, where appropri-ate, in the community, on a voluntary basis and by appro-priately trained staff. We also urge all members of theinternational community of addiction treatment provid-ers, scientific researchers, people in recovery and publichealth professionals to advocate vigorously for betterreporting and monitoring of drug treatment in thesecountries to ensure that evidence-based addiction treat-ment is provided in compliance with basic human rights.

Declarations of interest

In the past 5 years W.H. has not received fees or funding ofany kind from alcohol, pharmaceutical or tobacco com-panies. His research funding has been from the followingpublic funding sources: the Australia Research Council,the Australian Alcohol Education and Research Fund,the National Health and Medical Research Council ofAustralia and the National Prescribing Service (agovernment-funded service that advises prescribers onevidence from clinical prescribing). T.B. has, over the past5 years, conducted research projects whose fundingsources have derived from federal, state or non-profitorganizations, and from JBS International, Inc., a sub-contractor to the federal Center for Substance AbuseTreatment. He has received travel expenses and subsis-tence from the Society for the Study of Addiction, WorldHealth Organization, US National Institutes of Health(NIAAA) and other professional organizations. T.B.receives salary support not covered by grants from aPHS Endowed Chair in Community Medicine and PublicHealth. PHS (Physicians Health Service) is a for-profitHealth Maintenance Organization that donated fundingfor five endowed chairs to the University of ConnecticutSchool of Medicine. He has received no direct or indirectsupport from industry sources such as pharmaceutical,alcohol and tobacco companies and holds no personalstock. G.E. has for many years received fees for medico-legal consultancy. He received a fee for preparing abriefing document for the British Crown ProsecutionService and has advised the Metropolitan Police. Travelexpenses have been paid by WHO (Europe), the Society forthe Study of Addiction and university sources. A numberof academic publishers have paid him for advice and hereceives book royalties. G.E. has no institutional affilia-tions or society memberships which he believes could rea-sonably be construed as potentially constituting conflictsof interest. R.L. has no conflicts of interest to report.J.M. works within an integrated university and NationalHealth Service (NHS) academic health sciences centre(King’s Health Partners) and declares the followingfinancial relationships: he has part-time employment asSenior Academic Adviser for the National Treatment

Agency for Substance Misuse (NTA); consultation toReckitt Benckiser Pharmaceuticals (RBP) in 2011; untiededucational grant funding at KCL from RBP for a phar-macogenetic study of opioid substitution treatment (OST)in 2010, and a 3-year adaptive maintenance study ofOST and behaviour therapy (the latter via Action onAddiction) from 2012. P.M. has no affiliations which hebelieves constitute a conflict of interest. In the past 5years he has been funded by charitable foundations, gov-ernment departments and a pharmaceutical companyvia an intermediary charity. Travel expenses have beenpaid by charities, the Society for the Study of Addictionand university sources. He holds no stocks in any relatedcompanies. I.O. has received travel support from theWorld Health Organization on several occasions and theCentre for Research and Information on SubstanceAbuse (CRISA) has been funded by two internationaldevelopment non-governmental organizations (NGOs)[International Organization of Good Templars (IOGT)and Campaign for Development and Solidarity (FORUT-NTO)], and conference support provided by the OpenSociety Institute. None of these, she believes, constituteany relevant conflict of interest to declare. N.P. has noaffiliations which she believes constitute a conflict ofinterest. In the past 5 years, she has received fees formedico-legal consultancy, book royalties, grant reviewsand delivering trainings. Her research funding sourceshave derived from federal and non-profit organizations.She holds no stocks in any related companies. T.T. has noconflicts of interest to report. R.W. has received travelfunds and hospitality from, and undertaken research andconsultancy for, pharmaceutical companies that manu-facture or research products aimed at helping smokers tostop. These products include nicotine replacement thera-pies and Zyban (bupropion). This has led to payments tohim personally and to his institution. He undertakeslectures and training in smoking cessation methodswhich have led to payments to him personally and to hisinstitution. He has received research grants from medicalcharities and government departments.

Keywords Addiction, compulsory detention, ethics,evidence based policy, human rights, involuntarytreatment.

WAYNE HALL1, THOMAS BABOR2,

GRIFFITH EDWARDS3, RONALDO LARANJEIRA4,

JOHN MARSDEN5, PETER MILLER6, ISIDORE OBOT7,

NANCY PETRY8, THAKSAPHON THAMARANGSI9 &

ROBERT WEST10

The University of Queensland, UQ Centre for ClinicalResearch, Royal Brisbane and Women’s Hospital Site,Herston, QLD, Australia,1 Department of Community

Medicine & Health Care, University of Connecticut School

2 Editorial

© 2012 The Authors. Addiction © 2012 Society for the Study of Addiction Addiction

of Medicine, 263 Farmington Avenue, Farmington, CT06030-6325, USA,2 Addictions Department, Institute of

Psychiatry, King’s College London, London SE5 8AF, UK,3

Psychiatry Department, Federal University of Sao Paulo,Brazil,4 Addictions Department, Institute of Psychiatry,King’s College London, London SE5 8AF, UK,5 School of

Psychology, Deakin University, Geelong, Vic, 3217,Australia,6 Department of Psychology, University of Uyo,

PO Box 423, Uyo 520003, Nigeria.7

E-mail: obotis@gmail.comCalhoun Cardiology Center, University of Connecticut

School of Medicine, 263 Farmington Avenue, Farmington,CT 06030-3944, USA,8 Center for Alcohol Studies (CAS),

International Health Policy Program (IHPP), Muang,Nonthaburi, Thailand9 and CRUK Health Behaviour

Research Centre, Department of Epidemiology and PublicHealth, University College London,London, UK.10

E-mail: w.hall@uq.edu.au

References

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2. Baumohl J. Inebriate institutions in North America, 1840–1920. Br J Addict 1990; 85: 1187–204.

3. Leukefeld C., Tims F. Compulsory treatment: a reviewof findings. In: Leukefeld C., Tims F., editors. CompulsoryTreatment of Drug Abuse: Research and Clinical Practice.Rockville, MD: National Institute on Drug Abuse; 1988,p. 236–51.

4. Hall W., Lucke J. Legally Coerced Treatment for Drug UsingOffenders: Ethical and Policy Issues. Crime and JusticeBulletin. Sydney: Bureau of Crime Statistics and Research;2010. Available at: http://www.lawlink.nsw.gov.au/lawlink/bocsar/ll_bocsar.nsf/vwFiles/CJB144.pdf/$file/CJB144.pdf (accessed 27 January 2011; archived byWebCite® at http://www.webcitation.org/66prjqF0O).

5. Wolfe D., Saucier R. In rehabilitation’s name? Ending insti-tutionalised cruelty and degrading treatment of people whouse drugs. Int J Drug Policy 2010; 21: 145–8.

6. Anokhina I. P., Pelipas V. E., Tsetlin M. G. Compulsory treat-ment: the Russian Federation’s approach. In: Ethical Eye:Drug Addiction. Strasbourg: Council of Europe Publishing;2005, p. 65–73.

7. Svedburg E. Compulsory treatment: the Swedish approach.In: Ethical Eye: Drug Addiction. Strasbourg: Council ofEurope Publishing; 2005, p. 75–90.

8. Jurgens R., Csete J., Amon J. J., Baral S., Beyrer C. Peoplewho use drugs, HIV, and human rights. Lancet 2010; 376:475–85.

9. Mathers B. M., Degenhardt L., Ali H., Wiessing L., HickmanM., Mattick R. P. et al. HIV prevention, treatment, and careservices for people who inject drugs: a systematic review ofglobal, regional, and national coverage. Lancet 2010; 375:1014–28.

10. World Health Organization (WHO) Western PacificRegional Office (WPRO). Assessment of Compulsory Treat-ment of People Who Use Drugs in Cambodia, China, Malaysiaand Viet Nam: Application of Selected Human Rights Principles.Manila: WHO WPRO; 2009. Available at: http://www.who.int/hiv/topics/idu/drug_dependence/compulsory_treatment_wpro.pdf (accessed 31 January 2012; archivedby WebCite® at http://www.webcitation.org/66pux8GoY).

11. United Nations Office on Drugs and Crime (UNODC).From Coercion to Cohesion: Treating Drug Dependence throughHealthcare, Not Punishment. Discussion paper. Vienna:UNODC; 2010. Available at: http://www.idpc.net/publications/unodc-from-coercion-to-cohesion-treatment(accessed 7 July 2010; archived by WebCite® at http://www.webcitation.org/66puikQLf).

12. Cohen J. E., Amon J. J. Health and human rights concerns ofdrug users in detention in Guangxi Province, China. PLoSMed 2008; 5: e234.

13. Csete J., Kaplan K., Hayashi K., Fairbairn N., SuwannawongP., Zhang R. et al. Compulsory drug detention center expe-riences among a community-based sample of injection drugusers in Bangkok, Thailand. BMC Int Health Hum Rights2011; 11: 12.

14. Porter L., Arif A., Curran W. The Law and the Treatment ofDrug-and Alcohol-Dependent Persons a Comparative Study ofExisting Legislation. Geneva: World Health Organization;1986. Available at: http://whqlibdoc.who.int/publications/1986/9241560932_eng.pdf (accessed 7 July 2010;archived by WebCite® at http://www.webcitation.org/66puEFgiD).

15. Vuong T., Ali R., Baldwin S., Mills S. Drug policy in Vietnam:a decade of change? Int J Drug Policy 2011; Epub ahead ofprint 27 December.

16. Yin W., Hao Y., Sun X., Gong X., Li F., Li J. et al. Scaling upthe national methadone maintenance treatment programin China: achievements and challenges. Int J Epidemiol2010; 39: ii29–37.

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