Nothing new here: Why involuntary care for substance abuse has a role in addictions medicine

In response to Dr. Bonnie Larson’s article, entitled, ‘New is not always better,’ I would like to point out that involuntary treatment is not new at all. We have been using it for other mental illnesses for hundreds of years. And despite multiple expert professional agencies insisting that it doesn’t work for substance-use disorder (SUD), or increases overdose rates after discharge, we need an alternative to criminalization and death for our loved ones afflicted by SUD. The alternative to involuntary treatment is no treatment, because that is what the patient chooses.I participated in the most recent literature review regarding involuntary treatment.1 I can confidently say that the review did NOT find that involuntary treatment doesn’t work. It found that we do not really know if it works or not. First of all, comparing involuntary and voluntary treatment is comparing apples and oranges. Patients who choose treatment have recognized their affliction and their own inability to simply quit using. The DSM 5 includes several criteria based on an inability to modify one’s own drug use despite suffering extreme adverse consequences and despite multiple attempts. Patients who need involuntary treatment are more severely involved in their addiction than those who are able to choose treatment. Yes we need voluntary treatment, but we also need involuntary treatment for the more severely affected. By definition, the alternative to involuntary treatment is no treatment, because that is what the patient chooses. So we are in effect abandoning the severely affected SUD patients.Second of all, the review included many so-called “treatment programs” which did not include evidence based treatment such as OAT. In those cases, involuntary treatment consisted of incarceration and forced abstinence. Of course, the overdose rates are higher after this punishment disguised as treatment. We know that tolerance is easily lost and abstinence creates the highest risk of overdose death when the patient resumes using.Dr. Larson refers to involuntary treatment as “criminalization under the guise of care.” In reality, involuntary treatment attempts to avoid the inevitable criminalization of patients with addiction to illegal drugs. These patients are forced to steal, deal drugs and prostitute themselves to pay for the highly priced illegal drugs. They can be homeless, malnourished and seriously ill with complications of drug use.In Dr. Larson’s words, Alberta’s bill 53 will allow “people to be detained and confined based on nothing more than a history of substance use and risk of harm. They don’t even need a mental health diagnosis.” Really? Severe SUD is not a mental health diagnosis? Substance use that destroys health, lives and families is a valid choice?As for Indigenous patients, let’s ask their friends and families, their communities. And if they feel that their loved ones who are homeless, malnourished, ill and living lives of despair need treatment, no matter what, then Indigenous-led facilities can provide it with the help of federal funding.The worst is the children. Severe SUD is more likely in patients who started using the drug of choice in adolescence.2 And adolescents are more likely to refuse treatment. It takes decades of wisdom to learn that you cannot control your own behaviour. The most common cause of death in young people ages 15-to-25 in Canada is drug overdose!As for the implementation, I agree there is a serious risk of doing this wrong, just as decriminalization of drugs for personal use has gone seriously wrong in B.C. We followed the lead of Portugal with decriminalization but we failed to add in the Drug Dissuasion Committee, treatment program and the multiple needed social supports. Portugal has a complete program, and they have enough resources dedicated to all the various aspects of the program to make it accessible to anyone who needs it. Imagine! Treatment on demand!!Dr. Larson approves of mental health legislation that allows involuntary detention and treatment of mentally ill patients with severe psychiatric illness who lack capacity and would otherwise suffer grave harm. How is this different? Severe SUD by definition, takes away the patient’s capacity to make health decisions for themselves and certainly they suffer grave harm. Death is grave harm. Having to live with a criminal record is grave harm. Malnutrition and serious illness such as endocarditis are grave harm. Homelessness is grave harm.In the end it is very simple, our youth are dying. That is why we need involuntary treatment.References: “ Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review”, published in the Canadian Journal of Addiction in December of 2023. Bahji, Anees BSc(H), MD, CISAM, CCSAM, DABPN1,2,3,4; Leger, Philip MD5; Nidumolu, Aditya MD6; Watts, Barbara MD7,8; Dama, Sumeet MD9,10; Hamilton, Angela LLB8; Tanguay, Robert MD1,3,1Adolescent Substance Use Disorder Treatment: An Update on Evidence-Based Strategies Curr Psychiatry Rep. 2019 Sep 14;21(10):9 Matthew C Fadus 1, Lindsay M Squeglia 1, Emilio A Valadez 1, Rachel L Tomko 1, Brittany E Bryant 1, Kevin M Gray 1

Nothing new here: Why involuntary care for substance abuse has a role in addictions medicine

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