‘A plan to make a plan’: Experts speak out on B.C.’s involuntary care proposal

We still don’t know exactly what is being proposed, so this was in essence a plan to make a plan. To the extent that it brings new funding and new services, those are all good things.

But where I have concerns is that it appears that the government is proposing to use tools that we apply for mental health crises to people with substance-use disorders. While there is considerable overlap between mental health and substance dependence, they are not the same condition, and it is not wise to expand tools for addressing mental health crises to substance dependence.

A primary concern I have with involuntarily “stabilizing” and trying to push people who use drugs into addiction treatment is that we’re setting them up for a high risk of fatal overdose afterwards. We know how common relapse is in the journey of addiction treatment and when people are abstinent from substance use their tolerance to opioids declines significantly. The danger with relapse in the context of fentanyl is that it’s deadly.

“The unfortunate reality is that forced treatment has many unintended risks.”

When it comes specifically to forced addiction treatment for young people, I’m also really concerned that it undermines therapeutic connections and trust that are critical for supporting people who use drugs. As a parent, I know I’d want to do everything I could to keep my kids safe, and I understand why people would want to seek forced treatment. But the unfortunate reality is that forced treatment has many unintended risks and there is no compelling scientific evidence that it is effective in reducing risky substance use in the long run.

Along with increased risk for overdose upon release from addiction treatment or periods of ‘stabilization’, we’ve heard from young people in other settings who’ve been forced into addiction treatment that it was an incredibly traumatic event for them. I also think it is important to recognize that we are not going to be able to “treat” our way out of the overdose crisis. Because illegally manufactured fentanyl, which is what is driving fatal overdoses, is so pervasive in the toxic drug supply, peoples’ tolerance for opiates is much higher than in previous eras. This is complicating how we respond to and medically manage opioid dependence.

We definitely need addiction treatment to be available when people seek it voluntarily, but it’s not going to address the toxic drug crisis that we’re facing. Success in treating addiction takes a long time and it’s not a linear journey. We need to enhance services and care that are lacking in the voluntary treatment system. Many people can’t access treatment when they need it and many aren’t connected with necessary supports such as housing, meaningful employment and social connection. To create an involuntary treatment system when we don’t have an adequate voluntary system is misguided.

My first reaction was, “It’s about time.” This has been an issue that’s been going on for many, many, many years and it keeps getting hung up in ideological arguments.

My second reaction was, “There’s not much detail yet.” We still don’t know how it’s actually going to work but in general, it’s a good announcement.

Third, when they say they’re going to do involuntary care for youth, I think what youth need in these circumstances is often different than what adults need. If we look at experiences in different provinces, in Alberta they have short-term stabilization care. It’s roughly 30 days. It’s not meant to be a treatment. It’s meant to be an intervention. You’re not looking for long-term change, but you’re looking for stabilization. That young person is getting sleep, they’re getting fed, they’re getting their health needs addressed and they’re having time to go through that process of reestablishing contact with themselves and their families.

“We’re part of a larger community and there has to be a balance.”

My fourth response is that there’s a big difference between someone who is experiencing issues because of brain damage and someone who’s experiencing issues because of addiction. So, this work is really going to have to be based on not just clumping people together, but really looking at individual needs and developing programming around that.

In B.C., we tend to set up programs that make sense, but they’re not necessarily connected with one another. The most effective way to intervene with adults or young people is integrated service networks and that means having programs that are on a continuum. An example would be going into a recovery centre but then a person is released and there’s nowhere for them to live. That’s a huge gap.

There’s a lot of arguments that are going on against this type of programming based on human rights issues. We should focus on human rights issues, but we have to have a more in-depth discussion about what individual rights mean versus collective rights and family rights. We’re part of a larger community and there has to be a balance there.

We’re in an election period in British Columbia, so just about every politician in the province is throwing out ideas they think will pander to voters.

The opposition party, as well as the governing party, have both gotten behind this idea of involuntary treatment. This means they’ve decided on certain criteria that means you can lock people up and force them to have medical treatment for mental health or addictions.

The problem is that we don’t have a voluntary treatment system in British Columbia. It seems very premature to build an involuntary treatment system. People who want to get help are not reliably able to do so. Mental health is not covered under the Canada Health Act – subsidized medical care in Canada only goes from the neck down: Your teeth, your eyes and your brain are not covered. Most people just don’t have access to any kind of mental health or drug use help. Therefore, this proposal is just a sort of an idea for voters.

“It’ll make drug users scared to reach out and get help. “

We’ve tried this before in British Columbia in the ’60s and the ’70s. We’ve debated it several times and the research shows it doesn’t work. Even people in Narcotics Anonymous will say you’ve got to want to quit drugs for any kind of treatment to work. Force doesn’t work.

What it will do is people like me are going to get scared to go to the doctor. If my methadone doctor, for example, is turned into some kind of narc for the state where she has to report if I take other drugs and could lead me on a path to involuntary care, that will make me reticent to seek health care.

It’ll make drug users scared to reach out and get help. If someone’s overdosing, their friend might not want to call 911 for an ambulance because they are worried their friend will be incarcerated in a treatment program. It has lots of negatives that have been very well studied and haven’t produced many good results.

This is a bad idea, up and down, brought to us by right-wing pundits who have always wanted to take us back to the worst days of the Drug War.

It’s an important step to recognize the vulnerability of people who struggle with extreme forms of substance use disorders or mental health issues. For too long we were very, very concerned about infringing on individual rights and assuming someone was incompetent and taking away their autonomy. But we’ve gone too far and failed to recognize when people are a danger to themselves. The devil will be in the details, but at least it’s a much more realistic picture of vulnerability.

Youth are to a great extent hardwired to take risks, to discount the possibility of danger and to be emotional. They are hardwired to prioritize peer affiliation, they want to be cool with their subgroup. You take that predisposition for risky behaviour, and then you stir in a toxic drug supply. That’s where we’ve had 25 youth per year [in B.C.] dying over the last eight years since this toxic drug epidemic started.

Most of the youth who overdose who I’ve worked with are street entrenched, meaning they’re not eating or sleeping well. They have no one looking out for them, and they have been using drugs for weeks so their baseline mental function has been negatively impacted by drug use.

“It has to be done with a tender touch, but we need to hold these youth involuntarily.”

Once you’ve had an overdose, you’ve lost significant blood flow and oxygen to your brain, causing an inability to think clearly for at least the next couple of days to weeks. But in B.C., for people of all ages, once you’ve overdosed and are breathing OK again, you are then released from the hospital. This is akin to handing the keys back to a drunk driver; their judgment is too impaired.

It has to be done with a tender touch, but we need to hold these youth involuntarily if necessary, so that we can have a pause to the pattern of dangerous drug use. We can then offer treatment, harm reduction, safe supply, whatever needs to be offered to keep them safe and reconnect them with caregivers, food and housing.

Involuntary treatment won’t be a panacea, it won’t help everybody. But I think it’s a great move – and a brave one – given the opposition to it in some areas.

We had a lot of concerns about this initially as I don’t support involuntary treatment. But I’ve been reassured numerous times that this will apply to a minority of people who, in addition to substance-use disorders, have chronic brain injuries and concurrent mental health disorders.

What’s happening is that right now these people are going into the prison system, sometimes being put in segregation for 23 hours a day, will do three to six months in prison then be released to the street. Then it’s just rinse and repeat. We keep doing the same thing by putting this small number of people in prison and releasing them because they can’t access a regular treatment facility. My understanding is that this group, instead of going to prison, would be transferred to a secure facility that would support them in a more recovery-focused setting.

“It doesn’t change the toxic drug supply that is killing people.”

As long as involuntary treatment remains for that small minority of people and is an alternative to putting them in prison, and as long as those beds that are inside the prison are therapeutic and run with compassion and care for people who are struggling, it’s always a better option than to have somebody in segregation. I know how segregation feels and it’s terrible.

At the same time, of course I’m worried this may turn into a slippery slope. But for the time being, I’ve been reassured that’s not the case. We’ll see.

Whether you’re doing voluntary or involuntary treatment, it doesn’t change the toxic drug supply that is killing people. Addiction is a chronic, relapsing condition. Until we address the toxic drug supply, people who buy them will die.