Opinion: Mandated care ensures that people remain in treatment and don’t drop out, which is consistently shown to be one of the best predictors of a successful outcome
In a remarkable turn of events, B.C. Premier David Eby announced last month that the government will support 400 or more beds — the term $1 billion was even mentioned — for mandatory, involuntary care for the severely addicted and mentally ill. Vancouver Mayor Ken Sim followed this up by calling on the federal government to commit to assist the city, and cities across the province and country, to advance mandatory care.
This discussion comes at a time when violence seems to be getting more severe, and the problems in the Downtown Eastside are not shrinking. Overdose deaths in B.C. are still 50 per cent higher than in the U.S., and deadly drugs such as methamphetamine and fentanyl continue to be used with record intensity.
It wasn’t supposed to be like this.
In 2001, then-Mayor Philip Owen released Vancouver’s Four Pillars Strategy to deal with addiction. This strategy, in theory, was meant to equally emphasize prevention, treatment, harm reduction and enforcement. Looking back almost 25 years later, harm reduction — and extreme versions of it — has been the dominant, sometimes only, pillar the city and province have adopted. The introduction of things such as “safe supply”— government-sponsored distribution of powerful pharma-grade hydromorphone — and the encouragement of “safer” ways to use drugs, have made our problems worse. The consequences we are seeing now should force us to recalibrate our drug policy to one that emphasizes prevention and recovery.
Part of this means mandatory care for some. Such care is in line with some of even the most progressive states in the U.S., including California, Massachusetts and Washington. In Washington, roughly 700 people a year are admitted to treatment under what’s called Ricky’s Law — that’s 700 souls who are given a new chance. There’s no reason we can’t do the same here.
One of the earliest demonstrations of the value of compelled treatment comes from the California Civil Addict program, established in the 1960s. The program included an average of 18 months in residential treatment. Patients received drug treatment, job training and education with transition services. Upon release, they were to spend up to five additional years being closely monitored and undergoing weekly urine toxicology tests. During the program’s first two years, however, about half of patients were mistakenly released from mandatory treatment after only minimal exposure to the initial, residential part of the program. A natural experiment was born, allowing researchers to compare people who finished treatment with those who were inadvertently released. After reviewing records and interviewing almost 1,000 heroin-addicted participants, the researchers found that, seven years after admission to the program, participants who were prematurely released went back to using heroin at more than twice the rate of those who completed 18 months of compulsory residential care.
Studies show that people who are mandated to undergo addiction treatment fare at least as well as those who volunteer. In the 2000s, a group of Stanford researchers compared a group of patients who attended court-imposed drug treatment with others who entered care voluntarily. At one year and five years following enrolment, the mandated and voluntary patients made similar improvements in areas such as drug use, criminal activity and employment status. Notably, the groups were equally satisfied with their treatment experience.
Compulsory treatment offers a chance to rescue people earlier in their drug addiction. Mandated care ensures that people remain in treatment and don’t drop out, which is consistently shown to be one of the best predictors of a successful outcome. The longer participants stay in care, the more likely they are to internalize the values and goals of recovery. Some critics say that compelling treatment for addiction is unethical because addiction is a disease. But it is not a classic, involuntary illness; it is a behaviour that entails choice and responds to consequences. A successful approach known as “contingency management” offers people undergoing drug treatment a positive incentive by offering small rewards for meeting expectations; for instance, a negative drug test might earn movie tickets or a gift cards.
Vancouver and British Columbia are at a breaking point: This is the worst drug crisis in our history, and it’s time we move away from rhetoric emphasizing “safe” ways to use drugs and toward compassionate care.
Too often our policies are underpinned by the assumption that it’s too late. But we know the reality is most people have not gone past the point of no return. People can and will recover. Yes, some people will start to use again, but we cannot give up hope on them. Addiction is the only disease where you are a better person after you get into recovery than before you had the disease. That’s why we have to move people toward recovery.
Of course, we can’t just snap our fingers and assume things will be fine. Major investments into treatment are required so that people have somewhere to go. We also need to intervene earlier — mandated care is a last resort because ideally we will have identified people who are using and on the path to addiction. But for people far down this path, we cannot simply wait for them to tell us when they want to get better. Their brains are changed; they are not making rational decisions. That’s where mandatory care comes in. And since the vast majority of the crime and disorder comes from a small number of our overall neighbours, this has the potential to make a real impact. Governments must act.
The old harm reduction adage taught us to “meet people where they are at”. We should be sure we don’t leave them there.
Kevin Sabet, PhD, is a Vancouver resident who helped introduce Vancouver Mayor Ken Sim’s call on Sept. 16 for additional action by the federal government to address B.C.’s mental health and addiction crisis. He is a former Obama administration drug policy adviser and the co-founder of B.C.’s PROSPER, the Policy Roundtable on Substance Prevention Education and Recovery.