Editor’s note: While both authors contributed to the writing of this piece, the anecdote that leads the article is from Elliott’s personal experience.
Most nights after class during my undergrad, my mother and I would meet in the parking garage of the National Gallery in Ottawa and drive home together. The routine never changed: Right on Sussex, loop onto Murray, cross King Edward to St. Patrick, and so on, while Rob Zombie or Nickelback crooned through the speaker system of our 2006 Honda Civic.
We would often hit the red light at Murray and King Edward, the one with the Shepherds of Good Hope looming over. There might be a few people with cups knocking on windows for something to eat, or others huddled under a blanket on the sidewalk. The light would change, we would mouth a “sorry” if there was no change in the car, and the flow of traffic would gently pull us home.
If you are familiar with the city, you might recognize the street names. If you have spent more than a few months downtown, then you might even be able to picture the routine I am describing.
The marks left by a rapidly spreading opioid epidemic in our city are startling. Open drug use is a regular phenomenon on any bus ride or drive downtown. Forget that: A phenomenon conjures up the idea of irregularity but regular substance abuse, paramedics on sight to manage an impending overdose or the aftermath of someone using have all become staples of the drive past city shelters.
Unfortunately, this is not unique to Ottawa. Substance abuse has risen drastically across Canada since the start of the pandemic in 2020, as have feelings of depression and anxiety linked to income, gender and social status: 35 per cent of those surveyed by the Mental Health Commission of Canada reported experiencing moderate-to-severe mental health concerns.
In October, Conservative Party leader Pierre Poilievre voiced support for involuntary addiction treatment for minors and prisoners, whereby people experiencing addictions would be diagnosed by medical professionals and forcibly entered into rehabilitation programs. He is not the first politician to be quoted on this: “Compassionate Care,” as it has been called in Alberta, has been at the centre of controversy for years now. In September, British Columbia announced that it plans to move forward with a version of involuntary care as well. Ontario mayors, too, are moving in that direction.
Fatigue can wear on even the most empathetic of communities. It is hard to maintain compassion for a growing group of people whose suffering becomes present in your daily life, but whose suffering you do not fully understand. To that end, compassionate care certainly feels like the easiest answer. However, the policy is inherently problematic. Who defines the success of compassionate care: The person counting faces outside a shelter, or the person who has been whisked away on court order?
Compassionate care certainly feels like the easiest answer. However, the policy is inherently problematic.
One common finding that undermines involuntary care is that there hasn’t been enough research showing that it works; in many cases, research has shown that involuntary care can be traumatic or even deadly. In cases where involuntary rehabilitation has been implemented, the risk of overdose increases dramatically after release: One 2016 study found that 22 per cent of involuntary care patients experienced an overdose at six months post-involuntary care, compared to one per cent who participated voluntarily.
Involuntary care assumes that people put into care do not have the capacity to make decisions on their own, based on the assumption that addicts do not know, or are not willing, to do what is good for themselves. This begs the question – who will decide for the population that can’t decide for themselves? Inequities in Ontario health care remain. A recent study indicated that nearly 30 per cent of Indigenous peoples in Toronto have experienced some form of health-care discrimination. Until decisionmakers have been trained to address stigma both in mental illness and addiction, as well as cultural, racial or ethnic blind spots, involuntary care cannot be a viable solution.
Involuntary care is a clear step away from progressing health care. Health is personal. Health care needs to be individualized. Treating addiction needs to be measured by more than days since active addiction. It cannot be measured against the same metrics used in involuntary psychiatric care (a frequent comparison in the involuntary care debate).
Instead of pursuing a solution proven to fail just because it temporarily relieves the public of witnessing the issue, we must strive to address root causes. Rather than seeking mandatory rehabilitation, why not invest in community health centres that offer harm reduction tactics like safe injection sites? One 2011 study found that after opening a safe injection site, fatal overdose rates decreased by 35 per cent. Safe injection sites have also proven to positively impact the number of ambulance services attending to opioid-related overdoses. And contrary to what some politicians claim, safe injection sites do not increase drug-related crime.
By providing this brief respite, we can utilize harm reduction workers to engage with and better understand the needs of those using. With additional funding, provinces could empower site workers through training and other resources to offer more personalized care plans.
In a country as diverse and rapidly changing as Canada, the call for involuntary care cannot be seen as a solution. We need to fund initiatives that seek to understand the underlying factors that drive substance abuse, much the same as we would work to understand the cause of any chronic physical impairment.
We do not need compassionate care: We need a country that cares with compassion.
The struggle is, there is a not insignificant portion of people with severe addictions who are incapable with regards to decision making and their substance use. Harm reduction strategies are important, but they can only reduce harm, not treat it or prevent it. We need a multi-pronged approach for dealing with the opioid/addiction crisis, and there is no one solution for the heterogeneous-ness of addiction.
The stark reality is that for the individuals who are incapable with their substance use/medical decisions, not exercising Parens Patriae, the state’s duty to protect vulnerable people, is an injustice. It can feel wrong to be coercive, but how can we as a society continue to allow vulnerable, trapped (and incapable of stopping by themselves) continue to suffer in the horrible cycle of addiction? The medical system already does protect other individuals lacking capacity (ie. those with dementia, those with psychosis, those with intellectual disabilities) and assigns substitute decision makers to help facilitate decisions in their best interest, so why do we discriminate against those with severe addictions? Sure, we can certainly increase cultural competence of the assessors, but we should strive to complete (life-saving) assessments of capacity.
It is true, mandated treatment has limited evidence, but truthfully, so does most treatment in severe addiction. If you examine at Werb 2016, mandated treatment is as effective as voluntary treatment. Portugal also has had success employing some coercion in significant addiction. I would argue mandated treatment is one part of the solution for some with severely entrenched addiction, and neglecting this tool because “it’s too coercive” is an emotional stance with a veneer of compassion (and is discriminatory to these vulnerable people when we do it for other vulnerable groups), because certainly, what we are doing now is not working.
Brilliant work, guys. It is hard sometimes to get rid of the gut response over this kind of topics. I appreciate the perspective and hope we can work it out as a society.