Canada debates expansion of involuntary addiction treatment

Among Canadian politicians, there is growing interest in the involuntary treatment of homeless patients with episodes of mental illness and substance abuse. Experts, however, say there is no evidence to support wider use of this approach.

New Brunswick Premier Blaine Higgs, a member of the Progressive Conservative Party, said he will introduce legislation that would force a patient with severe addiction into treatment, CBC reported. Ontario’s big city mayors’ caucus has debated a motion seeking legislative changes to support mandatory community and residential mental health and addiction 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 its planned Compassionate Intervention Act would allow family members, doctors and police officers to apply for treatment orders in family court when a patient is considered a danger to themselves or others.

“It’s a government’s number one job to make sure 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, hit, kicked or spat on. Or, God 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 with crime and homelessness than as a proper medical invention.

“A lot of people assume that the moment you start worrying about involuntary care, you’re somehow not compassionate. But I’m very concerned about how that word has been used,” said Ginetta Salvalaggio, MD, a professor of family medicine at the University of Alberta in Edmonton, Alberta, Canada. Medscape Medical News.

Salvalaggio has published research on harm reduction and illegal drugs. He holds a Certificate of Additional Competency in Addiction Medicine from the College of Family Physicians of Canada.

Evidence from published research, including a 2016 review of other studies, does not generally suggest that mandatory treatment is associated with better outcomes, Salvalaggio said. While involuntary treatment has a limited role, doctors need to focus more on approaches that build trust with patients and give them the best chance for success, he said.

“If we’re going to analyze strategies, we need to make sure they’re rooted and grounded in evidence,” he said.

Help those in need?

Some doctors take a different tack, framing the debate as a matter of providing adequate care to people who need it.

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

People with many medical conditions may not recognize 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 this person needs help and should treat 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 hallucinations of order that can harm the person or others is the same,” Vigo said.

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

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

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

For example, California voters narrowly approved a ballot measure known as Proposition 1 in May. The measure, which was supported by the California Medical Association, does not change existing legal authorities and rules on involuntary commitment, according to the state’s Department of Health Care Services.

The patient’s attitude is critical

But critics, including the American Civil Liberties Union, say the ballot measure was aimed at directing funding toward forced treatment and institutionalization and away from community-based mental health services and housing very necessary

“Politicians in North America are talking about substance problems. I think it’s a step in the right direction,” Gratzer said. But he, too, worries about the favored focus in policy discussions: expanding the use of treatment involuntary

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

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

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

But once people can connect with these types of programs, doctors have many medications and approaches that can help address addiction, including therapies that can eliminate cravings, Gratzer said.

“I’m actually quite optimistic. I’m in no way, shape, or form trying to minimize the opioid crisis that’s happening in North America, but we have great tools in our toolkit” to help patients, he said.

Like Salvalaggio, Gratzer stressed that the data collected so far on involuntary treatment is inconclusive. “Instead of saying, ‘Who can we force into treatment?’ He would say to anyone who is interested in achieving sobriety, “We will help in a timely manner with evidence-based care,” he said.

An extraordinary power

Many psychiatrists agree with Gratzer’s opinion about the lack of clear evidence to support the widespread use of involuntary psychiatric care. In a September statement, the British Columbia Division of the Canadian Mental Health Association expressed concern about Eby’s plan.

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

A document from 2022 a The Canadian Journal of Psychiatry showed a marked increase in involuntary psychiatric hospitalizations among British Columbians aged 15 and over, while the number of voluntary hospitalizations remained stable.

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

CMHA’s British Columbia Division also raised known concerns about involuntary treatment in its statement. Inappropriate use of restraint and seclusion rooms and coercive use of sedation have been reported, the group said.

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

In 2022, the ombudsman reported that while some progress had been made, more work needed to be done to protect patients forced into involuntary psychiatric treatment. Hospital staff must comply with the requirements of the Mental Health Act “all the time and not just sometimes,” Jay Chalke, British Columbia’s ombudsman, said in a statement.

“Involuntary detention is an extraordinary power in the health care system and must be done in a way that respects people’s rights and freedoms,” Chalke said.

Neither Salvalaggio nor Gratzer reported any relevant financial relationships.

Kerry Dooley Young is a freelance journalist based in Washington, DC. follow her LinkedIn i threads.