The issue of treating someone against their will for severe substance use disorder (SSUD) is arguably the most divisive issue in the treatment of SSUD. Those who are opposed often view involuntary treatment (IT) as an extension of prohibition/the failed war on drugs, a violation of the principles of harm reduction and never justifiable. Proponents view IT in the context of it being a solution where someone lacks capacity to make treatment decisions and/or is at serious risk of harm to themselves or others. With context and nuance, it is possible to reconcile opposing views on involuntary treatment (IT).
Sometimes people do lack capacity to make treatment decisions and sometimes people with untreated SSUD are at serious risk of harm to themselves or others and are not seeking treatment. This will be the case, likely to a lesser degree, even when we have a well-resourced voluntary system of care. Therefore, is not a question of if we need laws that allow us to intervene in these circumstances. Rather, the hard questions lie in determining to whom and when these laws should apply, and how to build an involuntary system of care that will maximize the benefits of intervening while minimizing the harms.
Involuntary treatment is not inconsistent with the principles of harm reduction. Done right, it allows an intervention where the harms of intervening are likely to be less than the harms of not intervening. In these circumstances, it is harm reduction.
Many opinion pieces have been published recently opposing involuntary treatment (IT) for people with severe substance use disorder’s (SSUD). There is skepticism and concern that political expediency is suddenly driving politicians to support IT when faced with a general public that has had enough of public disorder and encampments. But family caregivers have been advocating for a right to intervene for decades and until now their pleas have been ignored.
IT is intended to be a solution to a couple difficult problems, namely what to do if someone lacks capacity to make treatment decisions and what to do if someone is at serious risk of harm to themselves or others due to untreated addiction and they are not seeking treatment. This is what our health care consent and mental health acts are designed to do. While these acts are within provincial/territorial jurisdiction and are not identical across Canada, their purpose is to protect a person’s autonomy unless they lack capacity and to ensure the safety of everyone.
When framed this way, it becomes exceedingly difficult to argue against the need for IT. So, the questions become for those requiring IT, how do we protect their rights while maximizing the benefits and minimizing the harms of intervening?
In other words, the question isn’t whether the protections of our mental health acts should apply to SSUD, but rather, why we have not historically extended these protections to those with SSUD even where in many jurisdictions they clearly do apply. A Commentary in the Canadian Journal of Emergency Medicine by physicians and lawyers questions whether this is due to “therapeutic nihilism, or worse, stigma”.
Further, research conducted by the Centre for Addiction and Mental Health (CAMH) provides evidence that those with severe addiction are not being assessed to determine if they have capacity to make treatment decisions. It states, “Individuals may be unable to consent to life-saving OAT [Opioid Agonist Therapy for opioid addiction], and discontinuation of (or failure to start) OAT, particularly in a controlled hospital environment, may represent the greatest immediate threat to these patients’ morbidity and mortality with an extremely toxic unregulated drug supply.”
These findings are consistent with recent research conducted by Families for Addiction Recovery (FAR) in partnership with Toronto Metropolitan University. And when 12– and 13-year-olds are dying from overdoses after refusing treatment for previous overdoses, we should all be questioning if and how capacity is being assessed.
Opponents of IT argue that it is not effective. However, the most recent and thorough systematic review comparing the effectiveness of IT to voluntary treatment concluded that there is a lack of high-quality evidence to support or refute IT for addiction in comparison to voluntary treatment. But more importantly, no studies compared involuntary treatment to no treatment at all. To opine it is ineffective does not provide any solution to the problems that the health care consent and mental health acts are designed to solve in order to keep everyone safe.
Further, to say it is ineffective is to beg the question: “Compared to what?” The alternative to IT is not voluntary treatment, but untreated addiction and other mental health conditions. These alternatives are often human trafficking, sexual exploitation, incarceration, being unhoused, criminal activities, suicide, and other serious medical conditions including heart attacks, traumatic brain injuries, overdose, and death. This is the current reality for our most vulnerable, and the outcomes have been horrific with over 53,000 deaths since 2016. We can build an involuntary system of care that applies where the harms of IT are less than these alternative harms of untreated addiction.
There have been four suggested alternatives to IT by those who oppose it. The first is prevention, which is definitely important but too late for those to whom the health care consent and mental health acts apply. The second is voluntary treatment, but this is not an option when the person’s illness is so severe that there is a lack of capacity to accept or refuse treatment. The third is harm reduction, an imperative public health response to the crisis, but harm reduction cannot protect those who are unwilling or incapable of practicing harm reduction. About 80% of those dying from overdoses are dying indoors and using alone, while not using overdose prevention apps, phonelines, or other protective harm reduction services. The fourth is regulating illegal substances. There is potential here, but our governments struggle to stand up to the legal recreational drug industry to effectively minimize the harms of legal substances as discussed at the end of the Positions section of this website on alcohol, cannabis and the regulation of illegal drugs.
Is IT a violation of autonomy/rights or unethical? It is evident from the definition of addiction that it involves, to a greater or lesser extent depending on the severity, a lack of autonomy. It is continued use despite unwanted harms. The four C’s of addiction includes cravings leading to a lack of control due to a compulsion to use despite the consequences. This lack of autonomy is recognized in human rights codes where it is viewed as a disability which entitles, for example, health care workers who have used pain medication intended for their patients to be accommodated in the workplace. To argue that those with severe addition have complete autonomy is to say that they desire, intend, and chose the harms they cause to themselves and others including their loved ones. These harms are evidence of a lack of autonomy. This is also an incredibly stigmatizing view that addiction is a choice, something we have worked to reduce with education on the neurobiology of addiction.
With respect to rights, rights come with responsibilities. People do not have the right to harm others. Further, an individual can have competing rights. When someone with SSUD refuses treatment and they do not want to die or go to jail, but those are the likely outcomes, should we prioritize their autonomy, which is compromised, or their right to life and health? To say we should not intervene when someone is at serious risk of harm to themselves or others is to say that they have a right to harm themselves to death when they don’t want to die, or to harm others when they don’t want to do that either.
From The Final Report of the Select Committee on Mental Health and Addiction (Ontario, 2010):
“The Select Committee believes, however, that the right to autonomy must be balanced with the right to be well. The Select Committee also believes that our present laws tie the hands of health professionals and families and have contributed to the criminalization of mental illness, where individuals need to be arrested in order to receive care. While Ontario undoubtedly needs better access to community supports and hospital beds, some people will not avail themselves of such services because it is the nature of their condition to deny that they are ill.”
With respect to ethics, why is there so much concern over intervening and so little concern over not intervening? Is it ethical to do nothing when someone lacks capacity or in circumstances where the mental health acts apply, particularly for minors? Is it ethical to let people who are suffering die from a treatable illness when that treatable illness prevents them from seeking treatment?
What about the argument that people who want help can’t get it? Shouldn’t we hold off on IT until we have voluntary treatment on-demand? Without question we should be urgently building systems of care providing compassionate, evidence-based treatment on-demand. So why has this not happened? It is important to know that the Canada Health Act only covers hospitals and doctors, and not evidence-based treatment for our most vulnerable with complex chronic illnesses, leaving this to the provinces and leading to the politicization and divisiveness seen today. While national groups have just started to advocate for reform of the Canada Health Act, we can’t wait. The need to create a system with treatment on-demand is a must and should be the number one priority of our policy makers today.
The need for IT would be greatly reduced if people suffering with addiction could get into treatment when they are ready. And, in many ways, it is simply not possible to implement IT with current resources available to most Canadians. Regardless, those who are at risk to themselves or others should not be left to die or harm others.
Will IT prevent people from reaching out for voluntary treatment? The most severely ill are not seeking help now and there is good evidence that for adults and youth one of the primary reasons is that they feel they are not ready and/or do not think that they need treatment, not that they will be apprehended under the mental health acts.
With regards to IT adversely affecting relationships and trust in the healthcare system, much will depend on ensuring that the system is compassionate, therapeutic, and evidence-based. Reviews have shown that the development of a therapeutic bond with clinicians is a key factor influencing positive experiences for involuntary mental health care. It is also important to acknowledge that healthcare providers come and go in the lives of the people they serve. It is thus important to also focus on the relationships of those in active addiction with their families and friends who are there before and after intervention by healthcare providers. Healing those relationships should also be prioritized and it is difficult and sometimes impossible to do so when addiction and concurrent conditions remain untreated.
People do not choose to suffer with SSUD, our society has chosen to allow it. For our most ill, who lack capacity and/or have become a harm to themselves or others, an involuntary system of care can be built that respects their rights, gives them back their autonomy and maximizes the benefits while minimizing the harms of intervening.
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