Voluntary treatment, not detention, in the management of opioid dependence.

Zunyou Wu, the author of this round table,1 attempts to rebut the United Nation’s recent criticism of compulsory treatment centres for opioid dependence by arguing that: (i) illicit opioid dependence is not simply a health problem, since the dependent person’s behaviour can adversely affect other community members through drug-related crime, use of illicit opioids in public, and transmission of blood-borne viral infection when the opioids are injected; (ii) the rights of people who are dependent on illicit opioids need to be balanced against the rights of the community that is adversely affected by their use of these drugs; (iii) compulsory treatment for opioid dependence is justifiable because it reduces the harms caused to both the dependent person and the community; and (iv) since voluntary treatment is not completely effective in reducing the harms associated with illicit opioid dependence, compulsory treatment must also be provided. We accept the first and second premises but do not believe that they suffice to justify compulsory treatment for dependence on illicit opioids. Such treatment requires evidence that opioid-dependent individuals are unable to control their habit unless compelled to undergo treatment. As for the third and fourth claims, the evidence is either insufficient or misinterpreted. The author seems to place the burden of proving that such treatment is ineffective and unsafe on the critics of compulsory treatment, rather than assuming the responsibility of demonstrating that it is ethically acceptable, safe and effective. He can do so safe in the knowledge that critics cannot present evidence to the contrary because the governments that operate compulsory treatment centres do not allow their independent and rigorous evaluation. The author puts forth only one argument in defence of the effectiveness of compulsory treatment for dependence on illicit opioids: that the use of these drugs is likely to be much lower in compulsory treatment centres than in the community. By the same logic, it could be argued that imprisonment qualifies as treatment because the use of injected opioids is less common in prisons, although much riskier when it does occur than it is in the community.2 The author’s support of compulsory treatment for dependence on illicit opioids is at odds with the consistent failure of this type of treatment over the past century in Australia,3 China4 and the United States of America.4 He also ignores the fact that no evidence of the efficacy and safety of contemporary programmes for compulsory treatment has been generated in the Russian Federation, Sweden or the Australian treatment programme that he cites in support.3,5,6 We applaud the fact that China is offering more effective forms of treatment for opioid dependence, including methadone maintenance treatment. It would be better still if compulsory treatment centres no longer formed a part of China’s response to the real public health and social problems caused by opioid dependence in its population. ■