HD75 - Final Report on the Study of Commitment Options for Persons with Primary Substance Abuse Problems


Executive Summary:
This document is the final report of a study mandated by the 1994 Session of the General Assembly. This report presents background information concerning estimated costs of serving persons with primary substance abuse admitted to state mental health facilities; empirical data concerning the clinical needs of persons with primary substance abuse admitted to state mental health facilities during a two year period, actual costs of providing the care, and estimated costs of providing more appropriate care in the community; data collected from a survey of sheriffs concerning the proportion of transportation resources absorbed by persons with primary substance abuse in the civil commitment process; and data about the cost to the court system of the current civil commitment process related to primary substance abuse collected by the Joint Legislative Audit and Review Commission (JLARC) for its own study of the involuntary commitment process. A review and discussion of legal issues pertinent to amending the Code to develop a separate civil commitment process for primary substance abuse is also included. The report concludes with a summary of findings and recommendations.

The study of clinical needs of persons with primary substance abuse admitted to state mental health facilities determined that more appropriate and cost-effective care could be provided in the community to persons with primary substance abuse who are now admitted to state mental health facilities, contingent upon the availability of appropriate capacity. Anecdotal data, utilization data, and the Department's own study of community capacity indicate that residential substance abuse treatment capacity, which encompasses the types of treatment most needed by persons with primary substance abuse entering state mental health facilities, is in short supply. The survey of sheriffs and review of court data from JLARC both indicate that more than one-third of civil commitment procedures involve persons with primary substance abuse.

The review of legal issues raised complex questions. First, fundamental constitutional questions concerning the reason and purpose for commitment need to be resolved. Issues related to protecting the confidentiality of persons committed for primary substance abuse, in the context of specific federal statutes and regulations in this regard, must be addressed. Since the criminal laws of Virginia already contain provisions for criminal commitment of offenders with substance abuse, the legal relationship between the Code sections would need to be specified. The current Code requires that the least restrictive alternative be utilized prior to civil commitment, yet practical barriers related to lack of community incentives and lack of community capacity often prevent this protection from being fully implemented. Finally, given that persons who seek care for primary substance abuse from state mental health facilities, either involuntarily or voluntarily, may present special medical and psychiatric needs, special attention must be given to facility design, program implementation, case management, and training.

The report concludes with four recommendations for action by the Department:

1. Census Reduction Emphasis - Future census management projects should place a special emphasis on diverting persons with primary substance abuse from admission to state mental health facilities. The Department has successfully undertaken several projects which provided incentives to community services boards to reduce admissions to state mental health facilities. All of these efforts have focused on persons with serious mental illness. The clinical data in this study clearly indicate that many persons now admitted to state mental health facilities with primary substance abuse could have received services in the community which would have been more clinically appropriate and more cost-effective than admission to a state mental health facility, assuming that capacity for the appropriate community program is adequate.

2. Expanded Community-Based Residential Capacity - Data from the Department's own study of community capacity indicates that residential substance abuse treatment services for adults are in high demand and short supply. The Department must explore methods of developing and expanding residential treatment capacity, including design and construction of appropriate facilities, program development and implementation, and development of human resources, to address the needs of persons now admitted to state mental health facilities with primary substance abuse. This effort should include detailed regional assessment of need and capacity, and should address the special safety issues, both personal and public, that some persons with primary substance abuse present.

3. Civil Commitment for Primary Substance Abuse - The Department, in conjunction with the Office of the Attorney General, should continue to explore the development of a civil commitment process for primary substance abuse which is separate and distinct from the process currently used for mental illness.

4. Funding - Since Virginia ranks above the mean in per capita expenditures for community-based substance abuse treatment, it should be possible to fund new substance abuse treatment services by reinvesting funds currently used for facility care or for substance abuse programs that are not proven to be effective.