Does forced drug treatment actually work?

A judge's gavel

Note: We are pleased to announce CARBC scientist Dr. Karen Urbanoski’s appointment as the Canada Research Chair in Substance Use, Addictions and Health Services Research. This blog post offers a look at some of her research on treatment services in Canada.

Why can’t we just make people go to addiction treatment? This is a question some may be asking in light of recent overdose deaths and other drug-related problems in Victoria. Is forcing people to get help an effective response to the problems caused by addiction? It turns out the evidence is murky—and the research may not even be asking the right questions.

Compulsory addiction treatment does exist in Canada in a number of different forms. People can be formally mandated to a treatment program as an alternative to going to jail or as a condition of parole or probation. People can also be compelled to get help in order to keep their jobs, their children, their social assistance benefits, and so on. Where the data are available in Canada, the statistics show that around 1 in 5 people attending services for addiction are required to be there.

Advocates of compulsory treatment argue that providing services and supports for addiction is more humane, economical, and effective than putting people in jail, firing them, or letting them hit “rock bottom.” These arguments have (quite reasonably) led to a large number of studies aimed at determining whether or not forcing someone to attend treatment “works.” After decades of research, why is this still such a controversial topic?

At this point, it has become apparent that the right question is not whether or not mandated treatment works, but under what circumstances might it work and how? And under what circumstances does it become yet another negative experience with the system, leading to further marginalization and drug-related harms? Here’s why.

The majority of studies have focused on mandates from the legal system (e.g., through the courts). Findings differ across studies, but most show that people who are court-mandated seem to do just as well in treatment as others. However, people who are court-mandated tend to be different from those who are not. Specifically, they tend to be younger and less severely addicted. Comparing groups of people who are different to begin with, finding that they differ (or not) at the end of a study, and chalking that finding up to treatment is not good science.

Another important issue is that personal motivation and other life circumstances play a role in recovery, and this is true whether or not the person is required to be there. Many people who are court-mandated report low motivation to attend treatment, but not all. Many of those who are not court-mandated report low motivation and would not describe themselves as “voluntary.”  Comparing people who do and do not have a court mandate is opportunistic research, but it misses the point if we are interested in knowing whether addiction services are effective when they are forced versus voluntary.

Current policies on compulsory treatment implicitly assume that people who do not initially want to be there will “come around” with time. However, this has never actually been studied. If the point of compulsory treatment is to help people make steps toward recovery, then this is exactly the kind of research that needs to be conducted. We need to figure out the best ways to support and increase people’s motivation and their capacity for decision-making.

Of course it is preferable (and likely more effective) if we can help someone early on, before their problems get really bad. But it is not at all clear that the people who are being diverted from the legal system to addiction treatment are ones who are most in need, or the ones who will end up being most in need down the road. If we aren’t careful, there is ample opportunity for inequities to arise in terms of who is even offered the choice of going to treatment. There is some evidence that this may already be happening. A recent review of Canada’s Drug Treatment Courts found that the majority of those diverted from prison via the program are middle-aged white men. This means women, youth, and indigenous peoples—among the prime target groups of the program—are not being served.

There is no doubt that some people mandated to treatment have been helped. But it is far from a panacea. Even with a variety of strategies in place to compel people into programs, the most severely affected people are still falling through the cracks.

The bottom line is that no society will ever treat its way out of addiction. Yes, addiction treatment can help people. A continuum of services should be accessible to everyone.  At the same time, the impacts of poverty, homelessness, colonialism, racism, and mental illness are not solved by a short stint in a treatment program. Such complex problems will require systemic policy changes that extend far beyond what addiction services are able to provide.

Dr Karen Urbanoski

Author: Dr Karen Urbanoski, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.