Involuntary drug treatment: ‘Compassionate intervention’ or policy dead end?

Angela Welz has a heart tattooed on her left wrist alongside her daughter’s name. “When I need to feel Zoe, I can feel my heart there. That’s how I feel her. Because the heart is on my pulse point.”

Welz can understand why the families of people using unregulated drugs would want to force their loved ones to get help. “You’re scared. You’re really scared, and you just want to keep them safe,” explains the Edmonton resident who twice sought court orders to send her youngest daughter, Zoe, to involuntary detoxification.

Zoe, who her mom described as bright, funny and smart, was never able to achieve the sobriety that she and her family fought so hard for. She died from fentanyl poisoning at age 18, only a few months after her last involuntary detention.

Zoe began experimenting with alcohol and prescription drugs at age 15. Following her grandmother’s death and her father’s terminal cancer diagnosis, her use escalated. “She started to self-medicate to treat the pain and anxiety that she was feeling,” Welz says. “Eventually, she ran away from home because she didn’t want to be a burden on us. She knew that she was getting deeper and deeper into it.”

After Zoe ran away, Welz began searching for any support she could find. “In 2014, nothing was available to us except for this program called PChAD.” Alberta’s PChAD, or Protection of Children Using Drugs (PChAD) Program, allows parents to petition a court for the involuntary detention of children under 18 for substance use “detoxification, stabilization and assessment.”

“I wasn’t really confident in the involuntary treatment route, but we just didn’t have any other options,” Welz says. “I did what I thought was best given what I knew at the time.”

Outside of the criminal justice system, youth-specific laws like PChAD are among the few existing examples of involuntary treatment solely for substance use in Canada. But with jurisdictions across the country considering more aggressive recovery-oriented policies, involuntary substance-use treatment may soon be legally enforceable for adults in Alberta as well.

Alberta’s proposed involuntary treatment legislation, the “Compassionate Intervention Act,” also known as the “Compassionate Care Act,” would be the first involuntary treatment law in Canada to target addiction specifically for adults, and would allow a family member, doctor or police officer to petition a family court for a treatment order when “someone is a danger to themselves or others.”

For Welz, what little is currently known about the proposed legislation is all too familiar and raises concerns that coercing people into treatment won’t do anything to slow drug poisoning deaths. Welz says forcibly sending her daughter into monitored 10-day detox on two separate occasions was “traumatic for the whole family,” and ultimately did more harm than good.

When Zoe tried to voluntarily secure a bed at a more comprehensive recovery centre, help wasn’t available. She was told she’d have to wait three months and travel to Calgary for a spot.

The wait proved to be too long. Welz’s family received a call shortly after Thanksgiving 2016 from the hospital, saying that Zoe was on life support after suffering from an opioid overdose.

“She was basically gone by the time they brought her in.”

The Alberta recovery model and involuntary treatment plan

For Welz, the proposals to expand involuntary treatment will be ineffective at best, and more lethal at worst. “It’s not going to make a difference at all. The increases in drug overdose deaths will continue.”

Reports on details of Alberta’s United Conservative Party’s (UCP) involuntary substance-use treatment policy thus far remain murky.

Over the past year, and following the dismantling of Alberta Health Services, the province has touted its intentions to use a “recovery-focused approach” to managing mental health and addictions. Premier Danielle Smith announced that the government will provide more than $1.13 billion to establish Recovery Alberta, the agency responsible for managing the mental health and addictions services pillar of the UCP’s new four-pillar approach to health care. Recovery Alberta is slated to begin operating this summer.

In April, the province also announced it would put forward $5 million for research into evidence-based approaches for its recovery-focused model. But few details have been released of its recovery plan that includes involuntary treatment for substance-use disorder. Though the legislation has yet to be formally introduced, Alberta’s Minister of Mental Health and Addictions, Dan Williams has renewed the province’s commitment to passing it.

This commitment was further affirmed with the release of the 2024-2027 Alberta Fiscal Plan, which states that “the Ministry (of Justice) will continue to work with Mental Health and Addiction, to develop compassionate intervention legislation, and support facilities and legal processes to protect those in danger to themselves or others.” The plan allocates $10 million to “Compassionate Intervention Implementation intake and assessment centres.”

A LinkedIn announcement from early May also revealed that former senior policy analyst in Alberta’s Ministry of Mental Health and Addiction, Robert Murdoch, has been named the newly hired “Manager of Compassionate Intervention Implementation.”

Marshall Smith, chief of staff to Premier Danielle Smith, recently told the Globe and Mail that he hopes to build 11 additional “therapeutic communities” across the province mirroring an existing site in Red Deer. The sites would offer “long-term programs” that include addictions treatment as well as “job training” and “communal living” to a mix of patients who are there, presumably both voluntarily and involuntarily.

Under the existing Mental Health Act, involuntary detainment is only allowed in extreme cases, and people designated under the act who are using substances have the right to refuse treatment if they have the capacity to understand the risks of drug use.

However, according to records obtained by the Globe, “drug users could be forced into treatment after committing non-violent criminal or statutory offences ‘primarily as a result of a substance-use disorder.’ ”

Critics have highlighted issues ranging from limited space and long waits for existing voluntary treatment centres, limited safeguards against abuse and mistreatment at centres, human right violations and limited evidence to prove the effectiveness of compulsory treatment.

Because no official plans have been released thus far, details of what exactly Alberta’s protocol for an involuntary treatment program would include aren’t yet available but psychiatrist Robert Tanguay, who sits on the Alberta Recovery Expert Advisory Panel that advises the ministry of mental health and addictions, supports involuntary treatment as a policy approach.

Though there is little evidence for the effectiveness of involuntary treatment, Tanguay says the absence of conclusive data, particularly when comparing its effectiveness against no intervention at all, seems to suggest more potential than problems.

However, he emphasizes that “any mandated treatment that doesn’t include long-term protocols, that doesn’t include medications for opioid use disorder, and that is not evidence-based is probably disastrous.”

If it resembles the PChAD program, Tanguay says the evidence wouldn’t support it. “The PChAD program continues to this day, and I don’t know if it’s ever been evaluated. You can’t just mandate detox. That is not treatment. We have to be very clear there are three levels of treatment for addiction, and detox is just level one.”

What does addiction medicine have to say about treating addiction?

Tanguay says that when it comes to treating opioid use disorders specifically, the evidence overwhelmingly shows that combining psychosocial treatments like therapy, along with opioid agonist treatments (OATs), provide the best outcomes. OATs are medications, usually methadone or oral or injectable buprenorphine, used to treat opioid use disorders. Tanguay notes that the longer that someone is in a treatment facility, the better the outcome. Typically, this is anywhere between 45 and 90 days.

Tanguay points to a Boston study showing that longer in-patient treatment stays are significantly more effective than detox alone. “The data showed that the all-cause mortality rate for those who received no treatment after detox was high, at 2 per cent per year, with overdose being the primary cause.” Those who received both residential treatment and pharmacotherapy like OATs saw their mortality rate reduced by nearly 90 per cent compared to those who received no treatment at all.

But while these outcomes were significant and show promising results, the Boston study author confirmed with Healthy Debate that all the patients assessed in the study were in treatment programs voluntarily. The evidence for the effectiveness of interventions when administered without patient consent is scant.

Overwhelmingly, most involuntary treatment programs that have been assessed have relied on abstinence-only methods, like 12-step programs, which researcher and director of the Centre on Drug Policy Evaluation Dan Werb says haven’t been effective.

A 2020 Connecticut study shows abstinence-only treatment modalities were actually worse for patients than not intervening at all. While treatment with buprenorphine or methadone was associated with a 32 per cent reduction in serious opioid-related acute care use at three months, Werb highlights that the study also found that “the relative risk of non-medication treatment, so recovery-based and abstinence-based treatment … was equal to or worse than no treatment at all.”

Werb notes that, particularly when dealing with patients who have the mental capacity to provide consent, forcing someone onto an OAT quickly becomes a hairy ethical issue.

“There are restrictions in North America around forced pharmacotherapies,” he says. “In Canada, there’s a big difference between treatment and conservatorship, or when someone’s mental health is so compromised that they can no longer make medical decisions for themselves, and the state is able to force them to take medications. You can’t legally force someone to take, for example, methadone if they don’t want to.”

Werb says he’s concerned about the risks in moving ahead with a policy that hasn’t yet been supported by the evidence.

“The combination of a lack of evidence that involuntary treatment is effective – particularly compared to the level of known effectiveness for voluntary-based treatments – along with the potential for abuses in compulsory and involuntary treatment settings, [raises questions regarding] the potential for harm. That can be a lot harder to quantify,” says Werb.

Both Werb and Tanguay have co-authored separate studies analyzing the research on compulsory drug treatment, Werb in 2016 and Tanguay in 2023. Both systematic reviews came to more or less the same conclusion: That there is no solid evidence for the effectiveness of involuntary treatment.

Yet, what we should take away from this varies significantly for each of these researchers.

“In [the other research group’s] systematic review from last year, they similarly found just an absolute dearth of scientific evidence,” says Werb. “But I think this [research group] is potentially less philosophically concerned about the negative aspects of involuntary treatment.”

“This research group is potentially less philosophically concerned about the negative aspects of involuntary treatment.”

Says Tanguay: “Our conclusion was there was a lack of evidence to support or refute involuntary treatment for substance-use disorders. What’s most important of all those studies – 42 studies, 350,000 participants – not one study compared involuntary treatment to no treatment at all.”

For Tanguay, the implication is that involuntary treatment, especially if using methods approved by addiction medicine experts, could still be better than doing nothing.

What does the international evidence say about involuntary treatment?

Though the context for involuntary treatment varies from study to study, Werb says international examples can still shed light on its effectiveness.

Massachusetts, for example, is one of the few examples in North America where there is a legal mandate for involuntary treatment for adults who are not otherwise connected with the criminal justice system. Under the state’s Section 35, people can be detained if their substance use is deemed to “put them at immediate risk of harm” and can be sent against their will to “treatment.” Under Section 35, offenders are sent to a treatment facility, if available. Others however, are sent to correctional facilities where they can be held for up to 90 days and often live under the same conditions as those convicted of criminal charges.

However traumatic the treatment (or lack thereof) may be in these cases, they are also demonstrably ineffective. Observational data from the Massachusetts public health department found that the risk of fatal overdose was twice as likely after Section 35 compared to voluntary treatment.

Werb’s 2016 systematic review found that although compulsory drug treatment approaches have been implemented in southeast Asia, Russia, North America, Latin America, Europe and Australia, the “evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms.”

“Just because involuntary treatment is put in place in a certain region doesn’t mean that abuses will certainly follow,” says Werb. “But we can tell from just the international literature that there has been evidence of ongoing concerns around human rights abuses in various involuntary treatment sites.”

One study looked at drug detoxification facilities in China, which have been criticized for human rights abuses, and include mandatory treatment, “re-education-through-labor rehabilitation” and “compulsory isolated detoxification.” Though treatment modalities varied by facility, 46 per cent of 177 respondents reported using illicit drugs within a month to six months following release from mandatory treatment, with an additional 10 per cent relapsing within a year.

In a 2020 joint statement, UNAIDS, the World Health Organization (WHO) Regional Office for South-East Asia, WHO Regional Office for Western Pacific and other United Nations entities in the region called on member states to close compulsory drug detention and rehabilitation centres and implement voluntary, evidence-informed and rights-based health and social services.

Despite previous investments in compulsory treatment infrastructure, China, Vietnam and Malaysia are all increasingly moving toward voluntary methadone maintenance programs and harm reduction programs such as clean needle exchanges.

Another study on involuntary treatment in Tijuana, Mexico, points to the dangers that drug users faced following release from facilities. People who had been taken into drug treatment involuntarily were more likely to report a recent overdose event. The study explains this in part by saying that “most of the [people who use drugs] in our sample are not prepared to stop using when they are taken into involuntary drug treatment. This, in addition to loss of tolerance related to abstinence periods, probably puts them at higher risk of overdose.”

What we can learn about involuntary treatment from Iran

But what if generally well-evidenced treatment approaches, like OATs in combination with counselling, are involuntarily administered to people who use drugs?

A study published earlier this year examining compulsory treatment centres in Iran may shed light on the effectiveness of these approaches on long-term abstinence.

In 2010, Iran included a provision for compulsory drug treatment in lieu of criminal prosecution in its anti-narcotics law. At these “compulsory drug detention and rehabilitation centres,” individuals are kept for three months with the possibility of extension for up to six months. They are put on a methadone maintenance program, have psychologists and physicians available for daily visits and counselling, and are offered referrals to further treatment at various publicly funded care centres upon discharge.

Of the more than 1,000 individuals court-mandated to undergo compulsory treatment, nearly 97  per cent relapsed by the two-month post-discharge follow-up appointment. The effectiveness of the program at getting people to stay off drugs at the 12-month follow up was only 2.6 per cent.

The study ultimately concluded that “this observed low effectiveness contradicts the primary objective of these interventions in Iran but is consistent with an international body of evidence suggesting that compulsory treatment fails to result in improved treatment outcomes.”

Study co-author Mohammed Karamouzian says this research highlights a few key takeaways. First, at the 12-month follow up, more than 40 per cent of those who were admitted had been detained a second time or more for public drug use.  “It really shows that these interventions aren’t effective, particularly if you’re dealing with people living in poverty.”

Karamouzian says that when discharging people who are unhoused from a several months-long treatment facility, the environment that contributed to their drug use will not have changed upon their release. Further, they will also have reduced tolerance to whatever drugs they were taking, increasing their risk of overdose, and will have lost the ability to generate income while in treatment. For Karamouzian, housing and social supports must be a priority in any effective drug policy. “You need to ensure that there is a safe and stable environment post rehabilitation. Otherwise, you’ll just see more relapse and overdose.”

“We used to think that treatment doesn’t have to be voluntary to be effective. But that’s not really the case.”

Karamouzian also says it’s important to look at the goal of any intervention. This study only looked at abstinence. “When you look at these programs, like in Iran, they have a very medicalized notion of addiction and substance-use disorders,” Karamouzian says. “That’s why they offer things like MMT upon release.” He says we should question both forced treatment as well as the expectation that abstinence be the ultimate aim of treatment.

“We used to think that everyone needs to recover, and if they aren’t ready for that, we should force it on them,” says Karamouzian. “Not long ago, the U.S. National Institute on Drug Abuse used to say that treatment doesn’t have to be voluntary to be effective. But even they have seen that it’s not really the case.”

Karamouzian says involuntary treatment from a policy standpoint is not worth the risk. “Though there is no evidence to suggest that involuntary treatment isn’t worse than no treatment at all, it’s still not justified because there are human rights abuses involved,” he adds, “So how do you justify that? If you only focus on substance use-related outcomes, that’s an incredibly superficial lens because it’s not just about substance use. You’re putting people in situations that can traumatize them for life.”

Broader drug policy approaches: What works?

Despite its limited efficacy, involuntary substance-use treatment has been gaining traction as a policy proposal. In British Columbia, the Mental Health Act only allows for detention for a substance-use disorder when there is a concurrent psychiatric condition requiring care. However, B.C. Premier David Eby has said he is considering expanding involuntary medical treatment, which could include addiction treatment.

New Brunswick recently announced that it would delay its own forced treatment bill until it has “more time to get this right,” says Sherry Wilson, the province’s Mental Health and Addictions Minister.

In 2020, B.C. proposed mandatory treatment for youth who repeatedly overdose – a proposal it withdrew following significant criticism; in March this year, it reintroduced this legislation for a third time. The bill is currently in its first reading, though it is likewise expected to fail.

Recently, well-known progressive drug policy laws internationally have been rolling back. Oregon has reinstituted criminal penalties for possession of hard drugs, effectively ending its three-year decriminalization policy. Possession of small quantities of drugs would lead to jail time, with drug treatment offered as an alternative to criminal penalties.

Treatment as an alternative to criminal penalties effectively replicates a “drug court” system. Drug courts differ by jurisdiction, but they are specialized court docket programs that primarily serve to offer typically non-violent drug offenders alternative sentencing conditional on sobriety and treatment requirements. They’ve had mixed results but overwhelmingly fail to reduce the burden on corrections facilities, as one study notes the majority of those enrolled in drug courts will fail their programs.

The repeal of decriminalization and the implementation of drug courts still doesn’t meaningfully address the central failure of Measure 110, says Portland Mayor Ted Wheeler. He told the New York Times that ultimately the “state botched the implementation.”

He says that the overdose deaths across North America skyrocketed after the pandemic and overdoses rates in Oregon were not directly attributable to the passing of the law. He points to bad timing as well as the state’s failure to build up behavioural health services infrastructure before moving ahead with decriminalization. “It shouldn’t have gone the other way around.”

A similar issue has been highlighted with some calling the famous Portugal Model – the archetype for Oregon’s Measure 110 – a failure. While some pointed to what they say is the failure of decriminalization efforts in their entirety, others say the reality is much more complicated.

By all accounts, the initial results of Portugal’s decriminalization framework were a success. Addiction and prison population rates fell, the country had the lowest drug-related death rates in Western Europe, and HIV infections from drug injection declined by 90 per cent.

Where the program began to unravel, several sources highlight, is a decrease in funding. Following years of economic crisis, Portugal decentralized its drug oversight operation in 2012, with funding falling from 76 million euros to 16 million euros. Portugal in many ways demonstrated the fate that would later befall Portland: without robust and sustained social service infrastructure (housing supports, rehab facilities and harm reduction programs), decriminalization on its own won’t end overdose deaths.

What Werb says has had the best and most consistent outcomes is the Swiss Model. Faced with high HIV transmission rates and a rise in public injection of drug use, in 1994 Switzerland passed one of the most progressive drug policies in the world, which included the dispensing of heroin.

“The Swiss are pretty conservative people at the end of the day, but they’re pragmatic.”

“The Swiss are pretty conservative people at the end of the day, but they’re pragmatic,” says Werb. “They wanted to address these twin issues so they scaled up heroin-assisted treatment and supervised consumption sites.”

Over three years, the number of people who reported newly starting to use drugs dropped by half. Within seven years, rates of drug use dropped from 19 per cent to 3 per cent. “And these results have been sustained,” says Werb.

The number of opioid-related deaths in Switzerland has declined over the past 20 years. For Werb, these results are because the Swiss assessed the primary issue and then rigorously funded those solutions. “They really went hard on the public health and treatment side of things.”

Under the Swiss model, treatment is well-funded and widely available. However, treatment is also voluntary and while its opioid-substitution program includes traditional OATs, it also supplies slow-release morphine and medical-grade heroin to patients interested in getting off the street supply.

Where does Canada go from here?

While discourse around the best policy approaches becomes increasingly politicized, the nationwide crisis continues to worsen. One of every four deaths in Canada for those aged 20 to 39 is now due to toxic drug poisoning. In Alberta, that number is one in every two. Although B.C. saw a decrease this year in overdose rates among young people aged 19 to 29, overall overdoses still rose to an all-time high, up 5 per cent from last year.

Overwhelmingly, researchers interviewed for this article agree that we need an all-hands-on-deck approach. “We need all services coordinated together,” says Tanguay. “Unfortunately, there is no one magic bullet here.”

In Alberta, where the UCP has focused on its “recovery model” of care and in 2019 committed over $140 million to “strengthen recovery-oriented systems of care”, drug deaths rose 17 per cent in 2023, the highest per capita increase of any province in the past five years, despite adding more than 2,700 publicly funded treatment beds in 2022 alone, a 55 per cent increase.

B.C. has likewise expanded its recovery infrastructure. The province now has 3,633 publicly funded adult and youth substance-use treatment beds, up nearly 400 beds from 2022. Yet as of 2023, B.C.’s rate of death from drug poisoning was 45.7 per 100,000; Alberta’s was 44.

While B.C. has tried some of the most progressive harm reduction-oriented policy approaches like decriminalization for simple possession and prescriber-based safe supply, some experts say these measures haven’t gone far enough to be more widely effective.

“We need to intervene on the drugs themselves.”

B.C.’s provincial health officer, Bonnie Henry, has said the medical safe supply model needs to be expanded to include more options and reach more people. According to a recent report, 4,331 people in B.C. were given prescribed opioid alternatives, less than four per cent of the estimated 150,000 people with a substance-use disorder. Lisa Lapointe, B.C.’s chief coroner, has gone a step further and called for a non-prescription safe supply option to slow deaths in the province.

Meanwhile, critics of safer supply models, particularly members of the B.C United party and the federal Conservatives, have argued that these interventions are ineffective and cause more harm to communities, despite recent reports showing a 61 per cent reduced risk of mortality for those with access.

Under rising political pressure, B.C. has begun rolling back some measures, re-criminalizing drug use in public spaces. This decision is now being challenged in federal courts by a coalition of community organizations.

Even well-evinced public health interventions, such as supervised consumption sites, are increasingly facing pressure to shutter their operations. “Everybody is frustrated,” says Werb. “Harm reduction is not the only component of overdose response, but it is the most visible.”

A recent study co-authored by Werb shows that overdose rates significantly decrease in communities where supervised consumption sites are opened. But he says that as the overdose crisis worsens, the sites become easy targets despite the positive evidence. “It’s easy to pick on them as the problem rather than the solution. Whereas if a treatment system isn’t working, it’s not nearly as visible as a target.”

Amid the chaotic clash of policies nationwide, the experts we spoke with agreed with the need for improved social supports, in particular access to affordable and supportive housing. They also agree that harm reduction interventions like safe consumption sites need to be widely accessible and able to connect people to a network of services. They acknowledge the need for evidence-based and accessible recovery and treatment options when people need them.

But where they ultimately differ is on where efforts need to be focused and what the limits of these interventions should be. “If somebody was going to jump off a bridge because they were suicidal, [emergency medical services] would stop them and take them to a hospital,” Tanguay says. “But if somebody were to inject a lethal dose of fentanyl, we would watch them do it.”

Werb and Karamouzian, however, say they are deeply concerned about the lack of evidence for interventions like involuntary treatment and say the emphasis on recovery in Alberta is misplaced. Overwhelmingly, they say that the government needs to take control of the illicit drug market.

“This is only going to continue unless we focus our aim on the actual target here, which is the toxic drug supply. Everything else is secondary,” says Werb. “If you’re a reasonable person, regardless of your political affiliation, you recognize that the reason people are dying more than they were 10 years ago is because the drugs are more dangerous.

“We need to intervene on the drugs themselves.”

At a time when desperation is at an all-time high, the question of whether involuntary treatment is better than doing nothing at all is a compelling one for many. But for Karamouzian and Werb, there simply is not enough evidence to justify imposing on the human rights of people who use drugs.

“People should be extremely cautious when they’re seeking to disenfranchise people. If the evidence was amazing, that might be a different argument, but it’s just not there,” says Werb.

While policymakers argue over what interventions may or may not put a dent in the worst public health emergency facing the country, it’s families on the ground who continue to pay the price. “The coroners can’t even keep up with the families experiencing more and more losses,” says Welz, who adds that while putting people into involuntary care might help keep them safe in that moment, they’re still going to be dealing with the same poisonous and unpredictable drug supply when they come out.

“Unless we can start regulating the supply that’s out there, we won’t get any respite from people dying. If people have access to safer drugs, we can keep them alive. And then we at least still have the opportunity to help them.”