Involuntary Treatment for Severe Substance Use Disorders – Issues,Evidence and Considerations for its Use

The proposition that persons with severe substance use disorders (SUDs) ¹ be given ‘involuntary treatment’ (InvTx) has recently been floated by protagonists across the political spectrum in Canada in response to the persistent toxic drug crisis which urgently requires more effective responses. In general, InvTx involves the compulsory treatment – sometimes in contexts of physical detention – of individuals with severe SUD for limited but possibly repeated periods of time irrespective of their will by force of designated (e.g. mental) health law. ¹ As such, it differs from coerced treatment of SUDs in criminal justice system contexts (e.g. through ‘drug treatment courts’). Discussions of InvTx for SUD, a sub-type of psychiatric condition in most nosological classification systems, are commonly framed by a ‘pro’ or ‘con’ nature, yet warrant careful consideration of some essential aspects.

InvTx provisions are already in place for severe mental health disorders – generally for individuals who represent a risk of acutely harming themselves or others – under (diversely scoped) provincial laws in Canada. Current discussions in different provinces focus on whether to apply these existing laws to severe SUD, or implement new legislation to do so.

Notably, InvTx for SUD is not a novel idea in Canada. ² As far back as 1927, the federal government proposed to establish detention centres to provide compulsory treatment for addiction. In 1955, a Special Senate Committee recommended segregation-based compulsory treatment of ‘addicted individuals’. The new federal Narcotics Control Act of 1961 included a provision for ‘indefinite detention for treatment in a special institution’, but this did not become law. British Columbia's 1978 Heroin Treatment Act provided for long-term compulsory treatment for drug-addicted individuals; this, however, faced major opposition – including from the federal government – and was declared unconstitutional by the BC Court of Appeal.

Many supporters of ‘InvTx’ believe that committing an individual with severe SUD to treatment will ensure that they receive effective and humane treatment that will put them on a path to recovery and a socially and economically productive life. While InvTx is generally motivated by the prospect of producing benefits for both the individual and society, it faces several fundamental caveats and challenges that arise from the nature of severe SUDs and available treatment options.

A first is that severe SUD, like many other severe psychiatric disorders, is typically not a curable disease; this is especially so in persons with the severe and chronic conditions who are the most likely candidates for compulsory treatment. ¹ In many instances, severe SUDs co-occur with other mental health conditions (e.g. depression, personality disorders) that not only worsen health status outcomes, but pose major challenges for effective treatment. ³ In addition, especially in contexts of current toxic drug use, many individuals involved feature forms of acquired brain disease and/or related adverse neuro-cognitive conditions that severely impair their behaviour. ⁴ In these cases, SUD is at best managed to varying degrees using different treatment modalities that depend on the drug used, but with outcomes that have substantive limitations.

For example, for opioid use disorder, opioid agonist therapy (OAT; e.g. with methadone or buprenorphine) is considered the ‘gold standard’ of treatment. However, substantial proportions or majorities of those entering soon exit OAT within short periods and more relapse while treatment-engaged, and face ongoing risks (e.g. overdose). ⁵ Outcomes are somewhat better in well-resourced special/high-intensity treatment options (e.g. injectable OAT) which, however, are offered only to small sub-groups. At the same time, outcomes can be worse in the highly problematic users, such as those using fentanyl and/or with co-occurring psycho-social instability or disorders – the most likely candidates for involuntary SUD treatment. ³ The treatment options for psychostimulant (e.g. methamphetamine)-related SUDs are even more limited. There are no approved pharmacotherapies and most of those who seek treatment, leave and relapse within short periods of time. ⁶ Many individuals with severe SUDs cycle in-and-out of treatment for much of their lives. But even for those who are treatment-engaged, their addiction will not be ‘cured’ by a time-limited treatment regimen (unlike, for example, pneumonia effectively treated by a course of antibiotics). In addition, evidence shows that individuals discharged from InvTx can be at elevated risk for harm (e.g. overdose, including deaths) in contexts of acute relapse and reduced drug tolerance. ⁷

How would InvTx practically address these challenges and what would be considered a successful outcome for those committed? We realistically should not expect for the SUD-related problems to be resolved. At best, we could see the person's SUD-related problems temporarily stabilized or managed with adequate, state-of-the-art treatment provided, while knowing that there was a high risk for relapse on release that requires comprehensive and effective post-commitment care provisions. Yet we also need to have reasonable expectations on a time-limit or realistic clinical benchmarks that define an end to InvTx in individual cases if we are to avoid repeated commitments as a common but undesirable outcome.

A related caveat is that there is very limited scientific evidence on the relative therapeutic benefits of InvTx approaches for SUD, for example, on substance use or recidivism outcomes. While individual studies produced mixed results, seminal evidence reviews report equivocal results when comparing InvTx outcomes with alternative treatment paths.^8,9 Bahji et al.'s recent systematic review found that only 7-of-42 studies on InvTx for SUD reported comparatively improved outcomes compared to voluntary treatment. ⁸ However, most of these studies assessed treatment retention and only one showed an actual reduction in substance use, informing the conclusion that there was ‘a lack of high-quality evidence to support or refute InvTx’ which consequently requires more research to inform policy decisions. But while most candidates for InvTx are unlikely to consider voluntary treatment, comparative support for outcomes with no treatment is also limited, and the overall evidence base appears as insufficient to guide decisions for InvTx intervention strategies.^8,9

InvTx has other potential disadvantages. It is often resource-intensive in terms of staffing and expensive to provide treatment to the usually relatively small numbers of persons who receive it. The treatment often requires some form of (quasi-)judicial oversight to protect patient rights. These costs can be difficult to justify when there is generally insufficient (e.g. community-based) treatment available for people with severe SUDs who seek care. It may practically be impossible to implement InvTx when there is insufficient capacity in the system.

One argument in favour of InvTx is that it might connect more people with severe SUD with treatment services towards exiting the cycle of use-related harm and regaining some control over their situation for some therapeutic benefits. However, this perspective conflicts with fundamental principles of protecting the individual liberties of adults. Adults can generally not be forced to undergo medical interventions against their will, even when this is likely to protect their health (or even prevent death), unless there is good evidence that they lack autonomous capacity for decision-making. Such lack of capacity justifies existing InvTx provisions for other severe psychiatric disorders. While SUD is generally characterized by loss of behavioural control, and many SUD afflicted individuals are burdened by other severe (e.g. psychiatric and/or neuro-cognitive) disorders that compromise capacity for autonomous decision-making, this is not categorically the case and difficult to assess. Overall, better evidence and protective mechanisms are required to ensure that the benefits of InvTx for SUD outweigh its collateral costs, including the suspension of fundamental individual rights. ¹

Finally, we recognize that the adverse consequences of severe SUD are not limited to the individual. Severe SUDs can impose a substantial burden of harm on other individuals and/or communities that deserve consideration in decision-making. Specifically, the toxic drug crisis in Canada has resulted in extensive public expenditures, disorder and compromised community safety, including from select instances of random violence. These adverse impacts represent legitimate societal interests to consider when developing and weighing the utility of possible interventions to reduce these harms.

InvTx for severe SUD is a complex and contentious concept that requires careful in-depth consideration before its adoption. It surely does not offer a panacea or superior solution for severe SUD-related problems, including the ones acutely produced by the toxic drug crisis. It may be warranted for limited sub-groups of individuals with severe SUD and related mental health/cognitive disorders who have lost control over their lives and who are at high risk of harming themselves or others. Even in these cases, InvTx requires rigorous weighing, safeguarding and monitoring for benefits and collateral costs, the latter including the suspension of individual freedoms and the risk of repeated commitment cycles because of SUDs’ chronicity and the limitations of treatment. While severe SUDs’ harms commonly extend beyond the affected individual, InvTx ought not to be used as a strategy to mainly remove difficult human beings from social life in the guise of care. Principally, it should only be carefully considered for development and use as a ‘last resort’ intervention when other, less liberty-infringing measures to help individuals manage their severe SUD-related problems and protect community welfare have been widely implemented and their benefit potential demonstrably exhausted.