British Columbia Premier David Eby recently announced that his government plans to open highly secure facilities where people struggling with mental health, serious brain injuries and severe addictions will receive involuntary care.
The B.C. government describes the move as a new phase of its response to the addiction crisis that includes a promise to change the law to “ensure that people, including youth, can and should receive care when they are unable to seek it themselves.”
Unregulated drugs kill an average of six British Columbians every day. Since a public health emergency was declared in 2016, more than 15,000 people in B.C. have died from consuming unregulated drugs.
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Interventions and services
Policymakers along with affected communities are struggling to identify, implement and scale up necessary interventions and services. Many highlight that we need all the tools in our toolkit to respond to this unprecedented crisis.
Currently, involuntary admissions to care facilities are possible for people with a “disorder of the mind” through B.C.’s Mental Health Act. Between 2011-12 and 2020-21, the number of voluntary admissions in B.C. remained relatively stable (10,000 to 12,000) but involuntary admissions increased from 11,000 to more than 17,000 during this time period.
Expanding involuntary care to people with addictions is intuitively appealing to some. Supporters of the idea position it as compassionate intervention that keeps the most vulnerable safe. But drug addiction and treatment are complex.
While parents, policymakers and others rightfully want to do everything they can to protect young people from harmful drugs, in the long run, involuntary treatment will cause more harm than good.
Involuntary treatment is dangerous
Scientific evidence is lacking that supports involuntary addiction treatment as an effective approach for reducing substance use and related harms among vulnerable populations. A 2020 study of more than 3,000 people who use drugs in Vancouver found no significant improvements in substance use outcomes among those who were coerced into addiction treatment compared to people who received no treatment.
We also know that substance dependence is a complex chronic condition and relapse is common. Relapse after a period of abstinence is a particularly dangerous time due to reduced tolerance. Indeed, the risk of overdose death has been found to be highest immediately after discharge from compulsory care, voluntary treatment and hospitals, as well as upon release from prison.
A lack of effectiveness paired with serious increased risk of a fatal overdose, particularly in the era of illicit fentanyl, are not the only weaknesses of involuntary treatment for people with addictions.
Involuntary treatment can undermine trust
Accounts from young people who have experienced being coerced into treatment highlight that involuntary care can be counterproductive and risks pushing vulnerable young people away from the very services they need most.
After consulting with young people who use drugs, the B.C. Representative for Children and Youth in 2021 cautioned that involuntary care “may create distress in young people to the extent that they may come to distrust the health-care system and be less inclined to seek support when it is needed.”
Research scientist Danya Fast, who has more than a decade of experience working with young people who use drugs, has described seeing “the lengths that some young people would go to in order to evade or escape from [institutional] places, often with devastating effects. I knew that even the threat of involuntary hospitalization could lead some to avoid calling 911 if someone was overdosing and needed help.”
Furthermore, a 2023 qualitative study with parents who resorted to involuntary treatment in Alberta describes how for some, forcing their child into treatment harmed their relationship, and for many, did not result in improvements in their children’s risky substance use behaviours.
Addiction treatment in the era of fentanyl
In the context of forced addiction treatment, it’s important to recognize that the effectiveness of current medications for opioid dependence (typically methadone and suboxone) is limited, particularly for young people.
In a study among young people who used opioids in Vancouver between 2005-2018, initiating an opioid agonist therapy (primarily methadone or suboxone) was not found to be protective for non-fatal overdose. In addition, 60 per cent of young people who initiated methadone prematurely discontinue their treatment.
This is consistent with emerging evidence from B.C. indicating that retention on methadone and suboxone have both been consistently declining over the last decade, which corresponds to the emergence of illicitly manufactured fentanyl in the province.
Given the volatility of street drugs and increasing exposure to and dependence on highly potent fentanyl, the clinical management of opioid dependence is increasingly complex. This reality makes forcing people into addiction treatment against their will particularly concerning.
There is also widespread evidence that the existing voluntary addiction treatment system is inadequate and fails to provide appropriate care. It is our view that resources are better directed towards improving the existing voluntary treatment system and ensuring there are comprehensive supports available throughout the continuum of care.
Alternatives to involuntary treatment
The safety of our children and communities would be enhanced if governments strengthened and expanded the voluntary treatment system and evidence-based prevention programs. Substance dependence is a chronic relapsing condition. Therefore, accessible harm reduction programs and addressing the toxic supply of drugs are critical steps to prevent overdose deaths and other drug related harms.
B.C.’s provincial health officer issued a report in July 2024 outlining how a public health approach could be leveraged to provide alternatives to the toxic drug supply.
While some may think we have already tried drug regulation, current prescribed “safe” supply programs include less than five per cent of the estimated 115,000 people in B.C. with an opioid use disorder.
Analyses of overdose fatalities also indicate that the majority of people who died from drug poisonings did not have a diagnosed opioid use disorder or use opioids on a daily basis. These individuals would not have been eligible for existing prescribed safe supply.
This underscores that current initiatives are not reaching the vast majority of the population at risk of a toxic drug poisoning. There are also many different approaches and models that could be considered for drug regulation.
As we have outlined previously, innovation and transformational policy action to strictly regulate the production, distribution and consumption of currently illegal drugs is a promising way forward.
Read more:
Drug prohibition is fuelling the overdose crisis: Regulating drugs is the way out
We empathize and relate to parents and caregivers who want to do everything possible to protect their children. However, we cannot “treat” our way out of our current crisis and involuntary treatment is a particularly risky and harmful tool.
Evidence-based interventions across the pillars of early prevention, voluntary treatment and harm reduction, along with rigorous drug regulation that tightly controls the production, distribution and consumption of currently illegal drugs, will give us the most control over the toxic drug supply. This mix of foundational and innovative public health tools will be best positioned to reduce risky substance use and related health and social harms.
Kora DeBeck receives funding from the Canadian Institutes of Health Research, the US National Institutes of Health and the National Killam Program. She is also a Research Scientist with the BC Centre on Substance Use.
Perry Kendall was a cofounder of Fair Price Pharma, a not-for-profit dedicated to providing low-cost Canadian access to diacetylmorphine morphine as a treatment option for individuals whose treatment needs are not met by first-line available medications for opioid substance use disorder. He is no longer on the board, but remains a vocal advocate for the expansion of evidence-based therapeutics for opioid substance use disorder.
