There’s something a bit strange going on in Canada. The citizens do not want to treat drug addiction as criminal, but they don’t want to be exposed to drug addicts living on the street. Rather than incarcerate them — an expensive and often futile solution — they want to force them into treatment programs against their will. This solution is also expensive and ineffective.

It began in June 2023, when The Canadian Journal of Addiction published a review entitled, “Involuntary Treatment for Adult Nonoffenders With Substance Use Disorders?” The review was conducted by a trio of researchers in Calgary, Alberta, with very different backgrounds. Dr. Emily Cooley is with the Department of Psychiatry at the University of Calgary; Dr. Anees Bahji is at the Hotchkiss Brain Institute at the University of Calgary, and Dr. David Crockford is with the Foothills Medical Centre in Calgary, which services Calgary’s impoverished, homeless and drug-addicted populations.

The researchers found 10 studies involving involuntary treatment for non-criminal substance use disorder, none of them from Canada. Based on this slim review, the researchers concluded that involuntary treatment is not a great idea except in a few special cases:

Patients entering treatment voluntarily did better overall than those admitted involuntarily. However, some studies showed some improvements in those involuntarily treated, with benefits extending beyond acute therapy.

The review recommends that, due to the ineffectiveness, the cost, the legal and ethical issues raised, that voluntary treatment incentives be expanded rather than pursuing involuntary treatment. A summary of the review does not mention anything about contingency management, the most effective addiction treatment in America, which involves paying patients to take their medications, stay clean, and pass drug tests.

The bell was rung a second time in Canada when, six months later, The Canadian Journal of Addiction published a systematic review entitled, “Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders.” This could not be a clearer message to the provinces, such as Alberta, considering involuntary treatment for substance use disorders. The researchers this time included Dr. Bahji at the Hotchkiss Brain Institute, plus doctors affiliated with educational institutions and treatment facilities in Vancouver, Montreal, Halifax, Toronto, and Thunder Bay, Ontario.

The much broader systematic review looked at all outcomes in the treatment of substance use disorder compared with involuntary treatment. It involved 42 studies and 342,000 patients in the United States, Canada and China. The findings were that in seven of 42 studies, involuntary treatment resulted in improved outcomes. Unfortunately, six of those seven studies involved people in detention. The authors cite a grim report from the Massachusetts Department of Public Health:

[…] which found involuntary treatment resulted in a greater than double rate of opioid-overdose deaths compared with voluntary treatment.

Involuntary treatment of children under 18 years of age is a particularly difficult situation because “such practices would undermine trust and result in fewer youth seeking help out of fear of being hospitalized against their will,” according to studies cited in the review. Still, in the end, the task force assembled by the Policy Committee of the Canadian Society of Addiction Medicine found that “the overall data neither supports nor is against involuntary treatment, and more research needs to be done.”

That brings us to Round Three, a report in Medscape Medical News from October with the sobering title, “Canada Debates Expansion of Involuntary Addiction Treatment.” Written by veteran medical journalist Kerry Dooley Young who has an eye for expensive, unproven therapies, she sets the scene:

New Brunswick Premier Blaine Higgs, a member of the Progressive Conservative Party, said that he will introduce legislation that would force a patient with severe addiction into treatment.

No doubt encouraged by the Canadian Society for Addiction Medicine‘s weak call for “more research,” Alberta Premier Danielle Smith and several mayors in Ontario are also calling for an expansion of involuntary treatment for drug addiction and mental illness. Young cites Calgary Dr. Ginetta Salvalaggio that research, “does not, on the whole, suggest that compulsory treatment is associated with improved outcomes.”

Young suggests that in Ontario, where the wait to be accepted into a drug treatment program is 15 weeks, perhaps expanding the available facilities and staff involved in recovery care would assist those who know they need help. As for those who do not want help and have it imposed upon them, a study in British Columbia found that the documented reasons for involuntary treatment were often missing or sketchy.

We’ll continue to watch for the deterioration of a commitment to voluntary treatment for substance use disorders, here in the United States and around the world.

Written by Steve O’Keefe. First published November 4, 2024.

Sources:

“Involuntary Treatment for Adult Nonoffenders With Substance Use Disorders?,” The Canadian Journal of Addiction, June 2023.

“Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review,” The Canadian Journal of Addiction, December 2023.

“Canada Debates Expansion of Involuntary Addiction Treatment,” Medscape Medical News, October 22, 2024.

Image Copyright: Andrew Litton, used under Creative Commons license.