Robert Tanguay is an addiction psychiatrist and clinical assistant professor at the University of Calgary. Angie Hamilton is the co-founder and executive director of Families for Addiction Recovery.
Involuntary treatment (IT) for people with severe substance use disorder (addiction) is a hotly debated topic. There is skepticism that political expediency is suddenly driving elected officials to support IT when faced with a general public that has had enough of public disorder. But family caregivers have been advocating for a right to intervene for decades, and until now, their pleas have been ignored.
Our health laws are intended to include solutions to difficult problems, including what to do when someone lacks the capacity to make their own treatment decisions, and/or is at serious risk of harm to themselves or others due to untreated mental disorders. These laws protect individual autonomy, unless an individual lacks capacity, while also ensuring everyone’s safety. When framed this way, it becomes difficult to argue against the need for IT for those struggling with addiction.
There is good evidence to show that one of the primary reasons that both adults and youth struggling with addiction do not seek help is that they are not ready and/or do not think that they need treatment. Recent research conducted by the Centre for Addiction and Mental Health (CAMH) found that those facing addiction are rarely being assessed to determine if they have the capacity to make treatment decisions. “Individuals may be unable to consent to life-saving OAT (Opioid Agonist Therapy),” the report states, adding that this “may represent the greatest immediate threat to these patients’ morbidity and mortality with an extremely toxic unregulated drug supply.” When 12- and 13-year-olds in Canada are dying from overdoses after refusing treatment, we should all be questioning if and how capacity is being assessed.
Further, the protections of our IT laws for those who are at serious risk of harm to themselves or others have not historically been applied to those with addiction. One article co-authored by a group of respected physicians and lawyers in the Canadian Journal of Emergency Medicine questions whether this is due to “therapeutic nihilism, or worse, stigma.” In other words, this may well be due to discrimination in the health care system.
Many Canadians believe that IT is ineffective for addiction, but a recent systematic review found that quality research is inconclusive. In any event, to say IT is ineffective is to beg the question: Compared to what? The alternative to IT is untreated addiction. Those with severe addiction are far more likely to face sexual exploitation, incarceration, homelessness and serious medical complications, including death. There have been over 47,000 toxic drug deaths in Canada since 2016. Surely, we can ensure that IT is less harmful and traumatic than these alternatives?
When we consider IT, the potential for violations of individual autonomy is a primary concern. But this fails to recognize that addiction itself involves, to varying degrees depending on the severity, a lack of autonomy. Addiction is the continued use of a harmful substance despite the individual not wanting to be harmed by it; its “four Cs” include 1) cravings, which lead to 2) lack of control, and 3) compulsion to use, despite 4) the consequences. To argue that those with severe addiction have complete autonomy is to say that they desired, intended for, and chose the harms they caused to themselves and others. But in reality, these harms are evidence of a lack of autonomy.
Why do we seem to have so much concern over intervening, and so little concern over not? Is it ethical to let people who are suffering die from a treatable illness when they don’t want to die and their illness affects their capacity and decision-making?
Concerns that IT will adversely affect relationships and trust in the health care system can be addressed by ensuring that the system is compassionate, therapeutic, and evidence-based. Scientific reviews have shown that the development of a therapeutic bond with clinicians is a key factor influencing positive experiences for involuntary mental health care. Equally important are the relationships of those in active addiction with their families and friends, who are there before and after intervention by health care providers. Healing those relationships is difficult when addiction remains untreated.
While IT will be needed as part of a system of care for those suffering from addiction, building that system with on-demand access to detox services, addiction medicine, outpatient services, in-patient services, and mental health services is a must. For most individuals with addiction in Canada, there is little treatment available. People do not choose to suffer with addiction – our society has chosen to allow it. For our most ill, who lack capacity and/or are at serious risk of harm to themselves or others, IT will help them far more than doing nothing.