Voices: Utah’s plan to expand forced substance use treatment is lacking in ethics — and supporting evidence

Utah has been at the center of a national controversy surrounding its proposed homeless campus. Models of the 1,300 bed facility, isolated away from the city near the Great Salt Lake, have drawn comparisons to a jail and a concentration camp. These comparisons are based in part on Gov. Spencer Cox’s stated plan to forcibly relocate individuals experiencing chronic homelessness and/or who have severe substance use disorders there for involuntary mental health and addiction treatment.

Involuntary addiction treatment has historically been reserved for only the most severe cases in which people are gravely disabled or imminently pose a danger to themselves or others, but Utah has been at the vanguard of a national movement to exercise expanded state authority to displace and sequester unsheltered people away from urban areas in the name of medical care.

In addition to the violation of civil liberties inherent in this approach, there is another problem with involuntary addiction treatment — there isn’t evidence that it works.

The most recent data examining the effects of involuntary addiction treatment in the United States comes from Massachusetts, which forces approximately 6,000 people into treatment annually. Massachusett’s 2024 report compared outcomes for people subjected to involuntary treatment vs. those who voluntarily enrolled in drug treatment programs. Rates of treatment continuation were low in both groups — less than 40% were still receiving medications to treat addiction (e.g., methadone, naltrexone) a month after program completion. Importantly, people in involuntary treatment had a 41% higher odds of overdose and a 51% higher odds of dying within 30 days of release compared to people who willingly enrolled in treatment programs.

These results mirror those of other studies of individuals forced into addiction treatment. The high rates of post-release overdose are the product of a perfect storm of factors including poor community treatment access, ambivalence about addiction treatment and increased susceptibility to overdose (i.e., lower opioid tolerance) stemming from a forced period of abstinence. These harms, compounded by the risk of mistreatment and traumatization during detainment, have led the World Health Organization to call for the elimination of involuntary treatment facilities.

As Utah peers down a path that risks the safety and assaults the rights of our fellow citizens, it is important to remember that our state was once part of a different vanguard — the Housing First movement. Housing First rapidly provides housing to unsheltered individuals without requiring them to jump through hoops or meet stringent eligibility requirements; then it brings services to them. Housing First reduced chronic homelessness by 91% in Utah between 2005-2015. However, housing costs, homelessness and addiction have all changed drastically since that time, and updated approaches are necessary.

States such as Oregon, who face similar issues with urban homelessness and public drug use, have shown what is possible through evolving the Housing First model. The central dogma of this movement is that “Housing First” doesn’t mean “Housing Only,” and Central City Concern has been one its primary architects. They offer rapid entry into housing for those in need and then proactively provide access to often co-located medical care, mental health care, vocational training and more. But the magic of Central City Concern lies in building and celebrating community. Incoming residents are paired with a peer who lives in the building for support, common spaces with community gardens and social activities abound, residents are frequently engaged in community service and employed through the organization doing property maintenance and program facilitation, and the faces and stories of the people who live there are celebrated. Their model is voluntary — operating on the principle that if you work with your community to build appealing housing that meets their needs, readily offers crucial services and nurtures social engagement, they will come and stay. Public financial data are limited but suggest that the model is likely cheaper, too.

Innovative housing models must also be paired with investment in low-barrier access to community addiction treatment, overdose prevention resources, peer support, vocational training, compassionate outreach and health care. In rare cases where short-term involuntary treatment is pursued, it is essential that appropriate safeguards such as embedded patient advocates and “least-restrictive environment” policies are required and that an airtight continuity plan is in place to maintain longitudinal support after release.

Gov. Cox frequently refers to the “Utah Way”, an approach to policymaking that is collaborative, compassionate and civil. Unfortunately, his proposed model for addiction treatment and homeless services betrays this ethos, opting for a more convenient “fix” of displacement, internment and forcing an unproven style of treatment on vulnerable citizens.

What I know of the core values of our state and its people make me believe that the harder path — partnering with community members to design housing and community services that foster connection, preserve freedom and nurture self-determination — is not only incumbent upon us, but also within our reach.

Michael Incze is a Board-certified internal medicine and addiction medicine physician and researcher at the University of Utah whose work focuses on care transitions for people with substance use disorders. His views are his own and do not represent the University of Utah or any professional society with which he is affiliated.

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