Canada Debates Expansion of Involuntary Addiction Treatment

Among Canadian politicians, there is a rising interest in the involuntary treatment of homeless patients with episodes of mental illness and substance abuse. Experts, however, say that the evidence to support the broader use of this approach is lacking.

New Brunswick Premier Blaine Higgs, a member of the Progressive Conservative Party, said that he will introduce legislation that would force a patient with severe addiction into treatment, CBC reported. The Ontario Big City Mayors caucus has discussed a motion seeking legislative changes to support mandatory community-based and residential mental health and addictions treatment, according to news reports.

Alberta Premier Danielle Smith, a member of the United Conservative Party, has been working on legislation to expand the use of involuntary treatment. The party did not respond to requests for comment, but its website says that its planned Compassionate Intervention Act would allow family members, physicians, and police officers to petition family court for treatment orders when a patient is considered a danger to themselves or others.

“It is the number-one job of a government to ensure that people are safe when they walk down the street,” Smith said in a statement. “Albertans shouldn’t have to look over their shoulders in their own communities. People have a right not to be randomly grabbed, punched, kicked, or spat upon. Or, heaven forbid, worse.”

Mental health professionals object to the emphasis on involuntary treatment. They see the growing promotion of this approach more as a response to public frustration about crime and homelessness than as an appropriate medical invention.

“A lot of people assume that the minute you start worrying about involuntary care, that somehow you aren’t compassionate. But I really worry about how that word has been used,” Ginetta Salvalaggio, MD, professor of family medicine at the University of Alberta in Edmonton, Alberta, Canada, told Medscape Medical News.

Salvalaggio has published research on harm reduction and illegal drugs. She holds a certificate of added competence in addiction medicine from the College of Family Physicians of Canada.

Evidence from published research, including a 2016 review of other studies, does not, on the whole, suggest that compulsory treatment is associated with improved outcomes, said Salvalaggio. While involuntary treatment has a limited role, physicians must focus more on approaches that will build trust with patients and offer the best chance for them to succeed, she said.

“If we’re going to be looking at strategies, we need to make sure that they’re rooted and grounded in evidence,” she said.

Aiding Those in Need?

Some physicians take a different tack, framing the debate as a question of providing appropriate care to people in need.

In a September interview with CBC, Daniel Vigo, MD, an adviser to British Columbia Premier David Eby, explained why he thinks the province must provide capacity for involuntary and voluntary treatment.

People with many medical conditions may not recognize that they need help, said Vigo, who is a psychiatrist. Vigo offered the example of someone with signs of a concussion after a car accident. Medical professionals would insist that that person needs help and they should care for those experiencing mental health crises in the same way, he said.

“A manic episode is the same. A suicidal episode is the same, and a psychotic episode with command hallucinations that may harm the person or others is the same,” said Vigo.

Ahead of this month’s election in British Columbia, Eby, a member of the New Democratic Party, and his challenger John Rustad, of the Conservative Party, have both advocated for more use of involuntary treatment.

Eby held a press conference about his plans in September. They include seeking more than 400 mental health beds at new and expanded hospitals. These beds will provide voluntary and involuntary care, as allowed under the province’s Mental Health Act. 

David Gratzer, MD, a psychiatrist at the Centre for Addiction and Mental Health, Canada’s largest mental health teaching hospital, noted in an interview with Medscape Medical News that similar discussions also are underway in the United States.

For example, California voters narrowly approved a ballot measure known as Proposition 1 in May. The measure, which had the support of the California Medical Association, doesn’t change existing legal authorities and rules about involuntary commitment, according to the state Department of Health Care Services.

Patient’s Attitude Is Critical

But critics, including the American Civil Liberties Union, contend that the ballot measure was intended to steer funding toward forced treatment and institutionalization and away from much-needed community-based mental health services and housing.

“Politicians across North America are talking about substance problems. I think that’s a step in the right direction,” said Gratzer. But he, too, is concerned about the approach favored in political discussions: Expanding the use of involuntary treatment.

The patient’s attitude and participation are key to successful treatment. This idea may not be well understood by people espousing forced treatment as a solution to the challenges many communities face, including encampments of homeless people with substance abuse and mental illness, said Gratzer.

“A locked door tends to be a poor motivator,” he added. “So, unfortunately, I don’t have a great sound bite” to offer as a solution.

It would be more productive in the long term if provincial leaders stuck with plans to get treatment for the many Canadians who want it, said Gratzer. For example, a patient in Ontario who is motivated to get help for a substance abuse disorder may have to wait for as long as 15 weeks to enter a residential care program.

But once people can connect with these kinds of programs, clinicians have many medications and approaches that can help address addiction, including therapies that can take away cravings, said Gratzer.

“I’m actually quite optimistic. I’m not in any way, shape, or form trying to minimize the opioid crisis that’s occurring across North America, but we have great tools in our toolkit” for helping patients, he said.

Like Salvalaggio, Gratzer stressed that the data gathered to date on involuntary treatment are not compelling. “Instead of saying, ‘Who can we force into treatment?’ I would say to anyone who’s interested in achieving sobriety, ‘We’re going to help in a timely way with evidence-based care,’” he said.

An Extraordinary Power

Many psychiatrists concur with Gratzer’s view about a lack of clear evidence supporting the broad use of involuntary psychiatric care. In a September statement, the British Columbia Division of the Canadian Mental Health Association raised concerns about Eby’s plan.

“We are already relying heavily on involuntary care without really examining whether it is effective,” the medical group concluded.

A 2022 paper in The Canadian Journal of Psychiatry showed a marked increase in involuntary psychiatric hospitalizations among British Columbians aged 15 years or older, while the number of voluntary hospitalizations remained stable.

Involuntary hospitalizations rose by 66% from 14,195 in 2008-2009 to 23,531 in 2017-2018. During the same period, voluntary admissions rose by less than 1% from 17,651 to 17,751.

The British Columbia Division of CMHA also raised known concerns with involuntary treatment in its statement. The inappropriate use of restraints and seclusion rooms and the coercive use of sedation have been reported, the group said.

The British Columbia Ombudsperson issued a report in 2019 highlighting failings in the processes used for involuntary psychiatric care. For example, in some cases, physicians did not explain why patients met the criteria for involuntary admission. In other cases, unintelligible entries were found in key documentation.

In 2022, the ombudsperson reported that while some progress had been made, more work was needed to protect patients forced into involuntary psychiatric treatment. Hospital staff must comply with the requirements of the Mental Health Act “all the time rather than only sometimes,” said Jay Chalke, the ombudsperson for British Columbia, in a statement.

“Involuntary detention is an extraordinary power in the healthcare system, and it must be done in a way that respects peoples’ rights and liberties,” Chalke said.

Neither Salvalaggio nor Gratzer reported relevant financial relationships.

Kerry Dooley Young is a freelance journalist based in Washington, DC. Follow her on LinkedIn and Threads.