Forcing people into drug treatment is on the political agenda. Here’s what the evidence says

As the toxic drug crisis continues to claim thousands of lives each year and fuel perceptions that existing policies are failing, the concept of involuntary treatment is gaining political significance.

Across Canada, there are a growing number of political leaders who are proposing forcing people into treatment for drug addiction, although a recent research study found no conclusive evidence on whether this is effective.

Some addiction doctors warn against using compulsory treatment as a simple answer to a complex health and social problem.

“It’s a reaction to seeing pain and suffering in front of you and saying, ‘I don’t want to have to see that, so let’s just make sure that doesn’t get in the way,'” Dr. Anita Srivastava, medical director of addiction medicine at Unity Health in Toronto.

“I think it’s a frustrated reaction to a problem [people] I don’t think it will work, but I can see where it might come from.”

Others believe that given the urgency of the crisis, involuntary treatment must be one of the available options. More than 47,000 Canadians have died from toxic opioids since 2016, according to the latest federal figures released in September.

REGARD | Can forcing people into addiction treatment help solve Canada’s drug crisis?

“More research is needed”

A working group set up by the Canadian Society of Addiction Medicine recently reviewed global research on the effectiveness of involuntary treatment. The task force examined 42 studies from around the world and published its report in the Canadian Journal of Addiction in 2023.

Of the 22 studies comparing involuntary versus voluntary treatments, ten reported negative outcomes of involuntary treatments, five found no significant differences, and seven found improvements, primarily in treatment retention. Only one of these seven patients experienced a decrease in substance use after treatment, but this was not sustained long-term.

“There is a lack of high-quality evidence to support or refute compulsory treatment [substance use disorders]“, the report concludes. “More research is needed to inform health policy.”

The review also noted that it is difficult to draw conclusions about what worked because the quality and type of treatments offered varied widely – particularly in the US, China and Canada.

Despite this lack of evidence and calls for more research, there is no shortage of politicians proposing compulsory treatment as a policy option.

In recent election campaigns in the provinces of British Columbia and New Brunswick, various parties have proposed forcing people into addiction treatment.

In Ontario, Brampton Mayor Patrick Brown is calling on the provincial government to launch a pilot project that would provide involuntary treatment for drug addicts in his community.

Dr. Anita Srivastava is the medical director of addictions at Unity Health in Toronto and an associate professor in the Department of Family and Community Medicine at the University of Toronto. (Unit Health)

The province closest to compulsory treatment is Alberta, where Premier Danielle Smith’s government has promised legislation.

Requires a change in the law

Under the Criminal Code, courts cannot force anyone to undergo drug treatment, but in certain cases they can offer it as an alternative to prison and threaten a prison sentence if the person cannot complete treatment.

Provincial mental health laws across Canada generally allow involuntary psychiatric treatment if a doctor believes a person poses a danger to themselves or others. To force people into addiction treatment, a province would have to change its health care consent legislation.

Keith Humphreys, a professor of psychiatry at Stanford University in Palo Alto, California, who chaired the Alberta Expert Panel on Addiction Recovery, believes involuntary treatment must be part of the arsenal to respond to the drug crisis.

“We have to be realistic that addiction is a chronic disease,” Humphreys said in an interview.

“When we talk [about] When we force people into treatment, we should remember that there aren’t really that many people who will spontaneously wake up in a tent and say, ‘I never want to use fentanyl again.'”

Alberta Premier Danielle Smith has promised legislation that would allow people to be forced into treatment for drug addiction. Your government has also dramatically increased the number of voluntary treatment and detoxification rooms in the province. (Trevor Wilson/CBC)

Calls for compulsory treatment are increasing in part because of perceptions that the current harm reduction approach to the drug crisis is failing.

There are not enough voluntary treatments available

But opponents of compulsory treatment argue that the real blame lies with the increasing potency and toxicity of the illegal drug supply – the drugs have become stronger, more addictive and more deadly than when heroin dominated the street trade.

Dan Werb, executive director of the Center on Drug Policy Evaluation at St. Michael’s Hospital in Toronto, says those who advocate for compulsory treatment assume the blame lies with the addicted person.

“The scientific evidence to support [involuntary treatment] “There is simply no effective approach,” he said in an interview.

Werb was the lead author of a 2015 review of the effectiveness of compulsory drug treatment published in the International Journal of Drug Policy. Of the nine studies reviewed at the time, only two showed that compulsory treatment had a positive effect on crime recidivism and drug use.

Werb and his co-authors concluded that policymakers should prioritize investments in voluntary treatment programs. But he says Canadian governments are not putting enough resources into such programs.

Dr. Katie Dorman is a family physician at Sumac Creek Health Center in Toronto. (Turgut Yeter/CBC)

“We have this huge disconnect between the number of people being referred for treatment and the capacity of the treatment system to meet that need,” he said.

Dr. Katie Dorman, a family doctor at Sumac Creek Health Center in Toronto who has worked in addiction medicine for much of her career, says there are far too many barriers to voluntary treatment, including long wait times and restrictive criteria.

“I think it’s absurd that we’re talking about involuntary care when there are so many people who want care but don’t have access to it,” Dorman said in an interview.

Wait times in Alberta are much shorter than in Ontario

Statistics from the Ontario Ministry of Health show that for intensive residential treatment programs designed for people with chronic substance use, the average waiting time is 16 days for assessment and then another 72 days for admission.

In Alberta, the comparable wait time to begin residential treatment is between 20 and 37 days, according to the province’s Ministry of Mental Health and Addictions

The Government of Alberta has dramatically expanded its publicly funded drug treatment program since 2019, adding 7,700 detox rooms and more than 2,700 residential treatment and recovery beds, representing a total capacity increase of more than 55 per cent.

Marshall Smith, former chief of staff to Alberta Premier Danielle Smith, is pictured at Lakeview Recovery Community, a recently opened addiction treatment facility in Gunn, Alta., about 90 kilometers northwest of Edmonton. (Trevor Wilson/CBC)

“Everything about the Alberta model is really focused on getting people off drugs,” said Marshall Smith, a former chief of staff (but no relation) to the prime minister, in an October interview at a newly opened recovery facility in Gunn, Alta. , about 90 kilometers northwest of Edmonton.

While Smith says making voluntary drug treatment easily accessible is crucial, he also believes forcing people into treatment plays a role.

“Is it better to receive involuntary care or let someone languish in a tent, shooting fentanyl down their throat under an overpass at the risk of death?,” Smith said. “I would say it’s more effective any day of the week.”

His perspective is shaped by personal experiences. Smith has spoken publicly about how he spent four years homeless in Vancouver and addicted to methamphetamines. He attributes his recovery to a police ultimatum.

“They basically told me, ‘Go to treatment or go to prison,'” he said in his interview with CBC News. “I decided to have treatment and haven’t looked back since.”