Editor’s note: The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team. As part of this project, editorial writer Alex Fryer has been examining issues related to behavioral health and substance use disorders.

Jeremy Roslie was living in a trailer on Whidbey Island when he started seeing things that weren’t there, images conjured by the methamphetamine he smoked, hit after hit.

One day, his landlady called the paramedics. In the hospital, staff summoned a mental health specialist who had the power to send Roslie to involuntary drug treatment, known as “secure detox.” Which is what happened, and Roslie transferred to Valley Cities Recovery Center — Kent, a 16-bed locked facility.

“I argued with them and they ordered me to go to Valley Cities,” said Roslie, 47, who now lives in a residential drug treatment house in Covington. “I was high and I was also upset. If the hospital had let me go home, I’d be dead.”

The Valley Cities secure facility opened in December 2019 and serves all of Western Washington. Despite an epidemic of methamphetamine, heroin and fentanyl use across the region, the problem hasn’t been lack of beds. Rather, it’s how to fill them.

Valley Cities has operated only at about half capacity, sometimes dropping as low as four people in treatment at any time.

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The pipeline of potential patients to involuntary drug treatment is full of kinks. These include lack of treatment nurses, police misunderstanding how to engage with people in crisis, and emergency room staff who either don’t know the laws or don’t want to use them.

For involuntary commitment to meet the needs of those with substance use disorders — and make the community healthier and safer — all these need to be fixed. Lives are in the balance.

People often arrive at the treatment center by ambulance, in restraints. They are high, or disoriented, or crashing, or angry. They are forced to remain against their will. For things to get to this point, there are few positive options. They are often chronically involved with the legal system, which usually offers only a pathway to jail. Anguished families and friends have nothing left to give.

Substance use disorder is a public health crisis, contributing to crime and chaos, fractured families, and avoidable and early death. It should be tackled with the same urgency and determination as any other disease outbreak. That means making secure detox an integral part of the state’s addiction recovery response instead of an underused option that makes little practical difference.

“We can have a profound impact on the patients who come through our system, but the number of patients who come through our system do not have a profound impact on the problem our region faces,” said Anne Mizuta, chair of the King County Prosecuting Attorney’s Office involuntary treatment unit.

It’s hard to estimate how many people could benefit from involuntary treatment if all systems worked perfectly, but experts say it could be in the thousands.

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Right now, there are 39 beds in Wenatchee, Chehalis and Spokane, in addition to the Kent facility’s. A 24-bed Spokane facility recently closed because it couldn’t hire enough nurses.

The state has funded organizations that plan to open involuntary treatment facilities in Vancouver, Bellingham and Walla Walla.

The legislation that created involuntary commitment for those with substance use disorder is called Ricky’s Law. Passed in 2016, it was conceived and championed by Lauren Davis to help people like her friend, Ricky Garcia, who had struggled with heroin. In 2018, Davis herself was elected to the state House representing Shoreline. Garcia has reportedly been clean and sober for many years.

“For people with severe substance use disorder, this notion that we are going to watch them self-destruct and wait idly by while they have some epiphany that they need care is just absolutely absurd,” said Davis.

“When there’s a forced pause, it provides people choice again. If you give people a little mustard seed of hope, they will cling to that with everything they have and they will choose recovery.”

The law works basically like this: community members — most often emergency room staff — call a county Designated Crisis Responder when a patient shows a likelihood of serious harm to themselves or others, other’s property, or is gravely disabled due to substance use disorder.

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The DCR can send a person to what’s called a Secure Withdrawal Management and Stabilization facility like Valley Cities for up to five days.

A public defender is assigned to represent the patient’s rights. In Western Washington, if the hospital believes the patient needs more time in treatment, King County prosecutors and defense attorneys go to Involuntary Treatment Act Court and make their case before a judge.

Going to court is a rarity for Ricky’s Law cases. Most are resolved with patients agreeing to receive help. When he was at Valley Cities, Roslie said he had a close relationship with his public defender, stayed for several months and never saw a judge.

The American Behavioral Health Systems Chehalis facility reports that 93% of patients convert to voluntary treatment, and about half continue with substance-abuse treatment after they leave. Meanwhile, Valley Cities reported that about 90% of its patients voluntarily continue treatment, and 90% enroll in residential treatment afterward. “We are very proud of that,” said Richard Geiger, chief of patient and inpatient services at Valley Cities.

There is a great deal of overlap between people with substance use disorder and other behavioral health disorders. But the involuntary commitment laws are currently very different.

With mental health patients, state law mandates that hospitals take care of the person until a bed opens up. With Ricky’s Law cases, if there are no services available, the individual can walk away. This provision was inserted into legislation by lawmakers concerned that emergency rooms would fill up with Ricky’s Law patients waiting for treatment beds. It sunsets in 2026, when additional facilities are scheduled to open.

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So why are so many secure detox beds currently empty when so many people in the region struggle with substance use disorders?

Mizuta, the prosecutor, said Valley Cities has the ability to refuse patients if they are violent or unruly, or have medical conditions.

If you know someone in substance use crisis

Call 911 for police assistance if the situation is life threatening or if it looks like someone may get hurt.

If there is no immediate physical danger, call King County Crisis Connections Public Line at 206-263-9200. This is an answering service and they will forward the contact to the Crisis and Commitment office and place it on the call log. The Designated Crisis Responders will respond to the calls in the order that they are received.

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“When you have private facilities able to decide which patients to accept, they really do get to pick, I don’t want to say the cream of the crop, but they have a lot of decision-making about who they are treating and who they are not,” she said. “So some of our most impaired individuals are being denied treatment because their illness is so severe.”

King County filed 40 reports notifying the state when a DCR wanted to involuntarily commit someone for drug treatment but Valley Cities was not willing to take them. Geiger said the underlying issue was not having enough staff. “When we first started Valley Cities, we had a lot of episodes of staff being hurt, and so they were much more exclusionary. As we’ve trained up our staff and have some history under our belt, we’ve been able to open our admission criteria a bit more.”

For her part, Davis, the lawmaker, said the problem lies with hospital staffs who don’t call for an involuntary treatment evaluation when a patient with substance use disorder shows up in their emergency department.

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“The biggest choke point by far is the hospital,” said Davis. “They have zero interest in having that patient population taking up a bed in their emergency department for one second longer than is required. There are some hospitals who figured it out and use it (Ricky’s Law) with great efficacy, but the vast majority of the state’s hospitals are not using it at all.”

Geiger, the treatment provider, said part of the problem is law enforcement reforms that changed when officers can use force to detain someone. Last year, when the laws went into effect, cops suddenly stopped engaging with people in crisis. According to King County, Ricky’s Law referrals from police dropped by more than 50% from 2020 to 2021.

On March 4, Gov. Jay Inslee signed a bill that makes clear officers may use force to help detain or transport people in crisis. It takes effect immediately.

Another big issue for Valley Cities and a lot of other providers of behavioral health services is being able to hire enough staff to meet patient needs.

With Ricky’s Law, we have an example of a good idea — implemented across the state — that has so far failed to meet expectations due to myriad issues. As Davis observed: “Ricky’s Law is wildly successful for the people who receive services, but the population for whom it was intended are largely not being served.”

To be sure, making services available like paying meth users to stop and other techniques should be brought to bear before addiction reaches the stage where involuntary treatment is the best option. But it has proven an important last resort. Bottom line: When the destructive behavior stops, people get better.

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Police, hospitals, crisis responders and treatment providers must continue to share experiences, collaborate and work out their respective problems. The complexities and challenges of Ricky’s Law should not deter or discourage those committed to helping people debilitated by substance use disorder.

Given the number of empty treatment beds, it’s too early to call for the Legislature to fund more Secure Withdrawal Management and Stabilization facilities. But lawmakers should closely monitor the early successes and shortcomings of Ricky’s Law, and be prepared to take advantage of lessons learned to expand when the time is right.

Taking away someone’s freedom so they can receive care is an extreme step, but involuntary treatment can offer the best way for someone with substance use disorder to rewire their thinking and behavior. For friends and families, it provides an alternative to watching a loved one die. It should be used to its full potential.