Visions Journal

Involuntary addiction treatment for drug dependence

Kora DeBeck, PhD and Perry Kendall, CM, OBC, MBBS, FRCPC, MHSC LLD(HON)

Reprinted from the Involuntary Treatment: Tensions and choices issue of Visions Journal, 2025, 21 (2), pp. 34-36

As BC contends with the tenth year of a toxic drug public health emergency, policy makers, alongside community and the public, continue to search for solutions.

Rates of death have dropped slightly, but in 2024 they were still twice as high as when the public health emergency was declared in 2016.¹ Throughout the crisis, many policy ideas have been brought forward to prevent fatal drug poisonings. Compulsory addiction treatment is one policy idea that various segments of society have advocated for as a way to separate people from toxic street drugs.²

In the fall of 2024, the Government of BC announced plans to expand involuntary treatment through the Mental Health Act for individuals struggling with mental health disorders, addictions, and brain injuries.³ This announcement sparked more debate about the risks and benefits of using involuntary addiction treatment for substance dependence.

The stated reason for expanding involuntary addiction treatment is that it could safeguard vulnerable individuals struggling with substance use. Yet some media largely characterized the announcement as a "public safety pitch."⁴ This suggests that street disorder and random violence are driving political support for this intervention, especially concerns about the trio of acquired brain injury, serious untreated mental illness, and substance use.

Unclear evidence Regardless of why people support more involuntary treatment, we have significant concerns with implementing this approach in BC. A primary concern, based on our decades of research and public health experience, is the lack of evidence supporting the effectiveness of involuntary addiction treatment, particularly among structurally marginalized populations (people disadvantaged by social structures of power, like racial categories and poverty).⁵ This is particularly troubling given the large increase, over the past two decades, in use of BC's Mental Health Act on youth with problematic substance use.

Vulnerability for people who use drugs Involuntary treatment forces people to restrict their drug intake. This poses risks of serious unintended consequences. That's because a period of drug abstinence lowers people's drug tolerance. When individuals leave addiction treatment, or other locations like hospitals and jails, they face significantly increased risk of fatal overdose.⁷

Despite noble intentions, involuntary treatment forcibly induces a state of low drug tolerance (where people cannot take the amount they might have been used to before without overdosing). This is a highly vulnerable and potentially life-threatening position, given the frequency of drug relapse.

Historically, what many consider to be the best way to support abstinence from street opioids has been opioid agonist therapy, like methadone and suboxone. To be effective, individuals must take their medications consistently. Yet evidence across multiple settings is showing that people are not keeping up with methadone and suboxone treatment in the era of fentanyl.⁸ When individuals do not stay on opioid agonist therapy, the risk of drug relapse and subsequent fatal overdose increases even more.⁹ This underscores the very real dangers of forcing drug abstinence on people who are not ready or willing to stop using drugs altogether.

Lack of trauma-informed support

Another concern with involuntary addiction treatment is that many people who are dependent on substances have histories of trauma and institutionalization.¹⁰ Being forced into a treatment setting can be traumatic. It also risks undermining connection and trust in therapeutic systems, the very factors known to be important for long-term recovery.⁶

This may not only undermine the success of initial treatment but may also inadvertently deter people from voluntarily seeking help in the future. A related worry with involuntary addiction treatment is that the voluntary addiction treatment system is under-resourced and inadequate. In our view, there is a fundamental flaw with forcing some people into addiction treatment when many others who want and need treatment can't access it because there aren't enough treatment beds and other services.

Potential misuse

We are encouraged to see that, despite pressure from some advocates to implement involuntary addiction treatment for drug dependence, the BC government appears to have listened to public health advice. In March 2025, they issued guidance to clarify that substance dependence itself should not be treated on an involuntary basis.¹¹

The document, called General Guidance for Physicians on the Use of the Mental Health Act when Treating Substance Use Disorders, says: "the Act should not be invoked or relied upon for the purpose of treating substance abuse or addiction in and of itself."¹¹

While this is good news, substance use disorders continue to be classified as a subtype of mental health disorders by government advisors.¹¹ This creates the possibility of confusion and potential misuse of the Mental Health Act. Close monitoring and regular reporting are critical to ensure the Act is not extended to involuntary addiction treatment.

Sadly, we believe there's a high threat of scope creep with the Mental Health Act, meaning using the legislation to cover more people, for more reasons. We observe a growing movement of magical thinking in the public and among some political actors about addiction treatment and its potential to meaningfully address the overdose crisis and reduce public street disorder.¹².

Improvements to the addiction treatment system are urgently needed, and we welcome initiatives that bring much needed additional funding and support for the voluntary addiction treatment system. However, given that substance dependence is a chronic relapsing condition, ongoing substance use is inevitable in society. Thinking that we can "treat" our way out of this crisis is not only misguided, it risks issuing a literal death warrant for many people struggling with substance dependence. People who use drugs and all British Columbians deserve more than wishful thinking and politically convenient actions that are not suited to the complex problems of substance use.