Dr. Tom Warshawski is the medical director of Youth Recovery House. Grant Charles is an associate professor at the School of Social Work at the University of British Columbia.
The issue of how best to care for people with life-threatening substance-use disorders is emotionally charged. There is much at stake and the evidence to guide treatment is weak. In British Columbia alone, more than 2,500 people died of illicit drug overdoses in 2023. But there are some facts that should be kept in mind as we craft interventions, especially for children and youth.
Society has long recognized that many people think differently in their youth than they do as adults. Teens tend to seek immediate gratification, discount risks, and place more importance on peer acceptance than parental or societal advice. As a result, it is illegal for youth to buy cigarettes or alcohol due to health risks, and age restrictions are placed on driving cars. Youth do not voluntarily relinquish these privileges.
The evidence is clear that almost all teens with serious substance use disorders (SUD) have significant mental health challenges, and some have additional developmental disabilities. Individuals who have been chronically using illicit drugs have demonstrable cognitive impairment, which improves with sobriety. Most chronic users have had their brain reward systems hijacked by drugs and will continue to use them despite the accompanying risk of death. Persons who have had a life-threatening overdose have a 5-to-10-per-cent chance of dying within one year. Continuing in a dangerous pattern of chronic drug use is irrational and inconsistent with the assumption that the user is in full control of their decision-making process.
In B.C. this past August, 13-year-old Brianna MacDonald, after a series of near-fatal opioid overdoses, succumbed to the toxic drug supply. She had been discharged from a hospital in the spring despite her parents’ desperate pleas to hold her involuntarily. There are many similarly tragic stories. As a society, why do we not have more measures in place to stop a 13-year-old from dying of an overdose in a homeless encampment? It is reasonable to intervene when a minor is placing their life at risk – in fact, it is unethical not to do so.
Opponents of involuntary care most often cite a 2016 study by Dr. Daniel Werb et al, published in the International Journal on Drug Policy, which found that “evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches.” However, this paper is best regarded as a study of the effectiveness of incarceration in Asian prisons as a method for drug treatment, and is not relevant to Canadians. It is true, as the study also concluded, that persons treated for opioid-use disorders are at higher risk of death post-discharge if opioid-agonist therapy (which includes medications like methadone) is not provided, but this is no longer current practice.
Involuntary care may be life-saving for youth with a pattern of life-threatening drug abuse. A brief involuntary admission for such a teen provides a pause in a dangerous pattern of drug use. It allows for cognitive clearing to permit a mental health review, for a young person to capably consider treatment options, and for opioid-agonist therapy to be effectively initiated. Connections to community resources can be re-established. If treatment is refused, the adolescent can be counselled, equipped for harm reduction and discharged. A prolonged involuntary admission can be implemented if necessary.
The scope and details of involuntary care need to be carefully crafted and there is relevant evidence to support time-limited involuntary treatment when it incorporates opioid-agonist therapy and harm reduction. For example, in a 2016 Norwegian study of the efficacy of involuntary treatment, the authors concluded that while “voluntary treatment for SUD generally yielded better outcomes, nevertheless we also found improved outcomes for compulsory-admission patients.”
“It is important to keep in mind that in reality, the alternative to [compulsory] treatment is no treatment at all,” the study noted, and that the positive outcomes of compulsory treatment support the continuation of that treatment.
The use of involuntary treatment must be done so judiciously, and with medical and legal oversight. It may be more effective in youth than in adults who have long-standing, chronic addiction, but there is a role for compulsory treatment to play in this population as well. Involuntary care is resource-intensive, and not all communities will be able to provide it. It will not work for everyone, but certainly will work for some. It is not a substitute for prevention, but complementary to it.
Given the death toll of illicit drug overdoses in Canada, involuntary treatment should be a part of our treatment arsenal.