Substance use disorders are treatable medical conditions that are inextricably linked with health and social consequences for the individual, those around them, and for society as a whole. Coerced participation in treatment is generally a last resort to intervene in hopes of preventing a future crisis, but concerns remain about the potential harms caused by mandated treatment.
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Coerced treatment for substance use disorder remains a fairly common approach to mitigate the harms associated with substance use. Coercion involves the exertion of legal, formal, and informal pressure to mandate people who use drugs into treatment. Research on the effectiveness of formal coerced treatment has produced mixed results and remains inconclusive. Some studies have found that voluntary treatment produced higher reductions in substance use than coerced treatment, while other studies have found the opposite. Of concern is the potential unintended harms associated with coercive interventions which are intended to help. If coercion is harmful, it might backfire and increase substance use or damage the trust between health care providers and people with substance use disorders, reducing the likelihood of future treatment engagement or recovery. This study compared levels of substance use among people who experienced coerced treatment, voluntary treatment, and no treatment at all.
Data for this study were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. The At-Risk Youth Study included street-involved youth age 14-26, the Vancouver Injection Drug Users Study included HIV-negative adults who inject drugs, and the AIDS Care Cohort to Evaluate Exposure to Survival Services included HIV-positive adults who use drugs.
The outcome variables were substance use (e.g., cocaine: yes/no, heroin: yes/no, cannabis: yes/no etc.) and the main question of interest was whether participants who were coerced into treatment (defined as formal coercion by criminal justice), versus entered treatment voluntarily or received no treatment differed on these substance use outcomes. Given the study was naturalistic and did not randomize participants into one of these three groups, the research team tried to equate the three groups on variables that might also influence substance use outcomes so that the participants in each group were as similar as possible apart from their group membership (i.e., that they were coerced, voluntary, or received no treatment). Variables used to match participants between groups included age, sex, ethnicity, non-fatal overdose, incarceration, and sex work.
Data collected between 2005-2015 yielded 2,653 participants in the final sample who had a 2-year time frame in which variables were self-reported every 6 months.
Comparisons between groups (coerced treatment, voluntary treatment, or no treatment) showed no differences in substance use. Rates of substance use were stable over 2 years –before and after treatment – and this stability was similar whether someone was coerced, went voluntarily, or went to no treatment at all.
Additionally, within each group there was no change in substance use from baseline to follow-up. Meaning rates of substance use were stable at each follow-up within each group.
12.5% (n=399) of the 2,653 participants reported formal coercion into treatment from criminal justice.
Further analysis tested informal coercion from physicians as opposed to criminal justice but found no difference in the results.
Less derived benefit, or even potential unintended harms, associated with coerced treatment for substance use disorder is the subject of a long-standing ethical debate. In this longitudinal follow-up study, less benefit from coerced treatment would be evidenced by the coerced group showing higher levels of substance use compared to the voluntary treatment group or no treatment group. Instead, substance use in the coerced group was equivalent to the voluntary treatment and no treatment group. This implies that individuals coerced into substance use disorder treatment did at least as well as other more voluntary patients and is not less helpful or harmful, at least in terms of substance use outcomes.
A primary goal of treatment is to reduce harmful substance use and the consequences associated with it. Notably, none of the groups (coerced, voluntary, or no treatment) showed change in substance use over time. This runs counter to expectations and a large body of evidence showing the clinical benefit of voluntary treatment.
The participants in this study faced high challenges like street-involvement, injection drug use, and HIV. This is an at-risk sample characterized by many risk factors and potentially low recovery capital (i.e., recovery resources). The lack of significant improvement over time for any of these groups could also reflect the severity of substance use disorder, health complications, and the relentless conditions associated with street involvement. Insufficient services to address these challenges may have contributed to a lack of significant improvement.
One big limitation of this study, however, was that it measured substance use in a binary and dichotomous way (i.e., “any cocaine use in the past 6 months – yes/no”, “any heroin use in the past 6 months – yes/no”). This kind of very broad dichotomous measurement is not sensitive enough to capture other highly meaningful reductions in substance use – participants could have drastically reduced the frequency and intensity of use but this would not be captured by the “any use” at all measure.
Pilarinos, A., Barker, B., Nosova, E., Milloy, M-J., Hayashi, K., Wood, E., Kerr, T., & DeBeck, K. (2021). Coercion into addiction treatment and subsequent substance use patterns among people who use illicit drugs in Vancouver, Canada. Addiction, 115(1), 97-106. DOI: 10.1111/add.14769.
l
Coerced treatment for substance use disorder remains a fairly common approach to mitigate the harms associated with substance use. Coercion involves the exertion of legal, formal, and informal pressure to mandate people who use drugs into treatment. Research on the effectiveness of formal coerced treatment has produced mixed results and remains inconclusive. Some studies have found that voluntary treatment produced higher reductions in substance use than coerced treatment, while other studies have found the opposite. Of concern is the potential unintended harms associated with coercive interventions which are intended to help. If coercion is harmful, it might backfire and increase substance use or damage the trust between health care providers and people with substance use disorders, reducing the likelihood of future treatment engagement or recovery. This study compared levels of substance use among people who experienced coerced treatment, voluntary treatment, and no treatment at all.
Data for this study were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. The At-Risk Youth Study included street-involved youth age 14-26, the Vancouver Injection Drug Users Study included HIV-negative adults who inject drugs, and the AIDS Care Cohort to Evaluate Exposure to Survival Services included HIV-positive adults who use drugs.
The outcome variables were substance use (e.g., cocaine: yes/no, heroin: yes/no, cannabis: yes/no etc.) and the main question of interest was whether participants who were coerced into treatment (defined as formal coercion by criminal justice), versus entered treatment voluntarily or received no treatment differed on these substance use outcomes. Given the study was naturalistic and did not randomize participants into one of these three groups, the research team tried to equate the three groups on variables that might also influence substance use outcomes so that the participants in each group were as similar as possible apart from their group membership (i.e., that they were coerced, voluntary, or received no treatment). Variables used to match participants between groups included age, sex, ethnicity, non-fatal overdose, incarceration, and sex work.
Data collected between 2005-2015 yielded 2,653 participants in the final sample who had a 2-year time frame in which variables were self-reported every 6 months.
Comparisons between groups (coerced treatment, voluntary treatment, or no treatment) showed no differences in substance use. Rates of substance use were stable over 2 years –before and after treatment – and this stability was similar whether someone was coerced, went voluntarily, or went to no treatment at all.
Additionally, within each group there was no change in substance use from baseline to follow-up. Meaning rates of substance use were stable at each follow-up within each group.
12.5% (n=399) of the 2,653 participants reported formal coercion into treatment from criminal justice.
Further analysis tested informal coercion from physicians as opposed to criminal justice but found no difference in the results.
Less derived benefit, or even potential unintended harms, associated with coerced treatment for substance use disorder is the subject of a long-standing ethical debate. In this longitudinal follow-up study, less benefit from coerced treatment would be evidenced by the coerced group showing higher levels of substance use compared to the voluntary treatment group or no treatment group. Instead, substance use in the coerced group was equivalent to the voluntary treatment and no treatment group. This implies that individuals coerced into substance use disorder treatment did at least as well as other more voluntary patients and is not less helpful or harmful, at least in terms of substance use outcomes.
A primary goal of treatment is to reduce harmful substance use and the consequences associated with it. Notably, none of the groups (coerced, voluntary, or no treatment) showed change in substance use over time. This runs counter to expectations and a large body of evidence showing the clinical benefit of voluntary treatment.
The participants in this study faced high challenges like street-involvement, injection drug use, and HIV. This is an at-risk sample characterized by many risk factors and potentially low recovery capital (i.e., recovery resources). The lack of significant improvement over time for any of these groups could also reflect the severity of substance use disorder, health complications, and the relentless conditions associated with street involvement. Insufficient services to address these challenges may have contributed to a lack of significant improvement.
One big limitation of this study, however, was that it measured substance use in a binary and dichotomous way (i.e., “any cocaine use in the past 6 months – yes/no”, “any heroin use in the past 6 months – yes/no”). This kind of very broad dichotomous measurement is not sensitive enough to capture other highly meaningful reductions in substance use – participants could have drastically reduced the frequency and intensity of use but this would not be captured by the “any use” at all measure.
Pilarinos, A., Barker, B., Nosova, E., Milloy, M-J., Hayashi, K., Wood, E., Kerr, T., & DeBeck, K. (2021). Coercion into addiction treatment and subsequent substance use patterns among people who use illicit drugs in Vancouver, Canada. Addiction, 115(1), 97-106. DOI: 10.1111/add.14769.
l
Coerced treatment for substance use disorder remains a fairly common approach to mitigate the harms associated with substance use. Coercion involves the exertion of legal, formal, and informal pressure to mandate people who use drugs into treatment. Research on the effectiveness of formal coerced treatment has produced mixed results and remains inconclusive. Some studies have found that voluntary treatment produced higher reductions in substance use than coerced treatment, while other studies have found the opposite. Of concern is the potential unintended harms associated with coercive interventions which are intended to help. If coercion is harmful, it might backfire and increase substance use or damage the trust between health care providers and people with substance use disorders, reducing the likelihood of future treatment engagement or recovery. This study compared levels of substance use among people who experienced coerced treatment, voluntary treatment, and no treatment at all.
Data for this study were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. The At-Risk Youth Study included street-involved youth age 14-26, the Vancouver Injection Drug Users Study included HIV-negative adults who inject drugs, and the AIDS Care Cohort to Evaluate Exposure to Survival Services included HIV-positive adults who use drugs.
The outcome variables were substance use (e.g., cocaine: yes/no, heroin: yes/no, cannabis: yes/no etc.) and the main question of interest was whether participants who were coerced into treatment (defined as formal coercion by criminal justice), versus entered treatment voluntarily or received no treatment differed on these substance use outcomes. Given the study was naturalistic and did not randomize participants into one of these three groups, the research team tried to equate the three groups on variables that might also influence substance use outcomes so that the participants in each group were as similar as possible apart from their group membership (i.e., that they were coerced, voluntary, or received no treatment). Variables used to match participants between groups included age, sex, ethnicity, non-fatal overdose, incarceration, and sex work.
Data collected between 2005-2015 yielded 2,653 participants in the final sample who had a 2-year time frame in which variables were self-reported every 6 months.
Comparisons between groups (coerced treatment, voluntary treatment, or no treatment) showed no differences in substance use. Rates of substance use were stable over 2 years –before and after treatment – and this stability was similar whether someone was coerced, went voluntarily, or went to no treatment at all.
Additionally, within each group there was no change in substance use from baseline to follow-up. Meaning rates of substance use were stable at each follow-up within each group.
12.5% (n=399) of the 2,653 participants reported formal coercion into treatment from criminal justice.
Further analysis tested informal coercion from physicians as opposed to criminal justice but found no difference in the results.
Less derived benefit, or even potential unintended harms, associated with coerced treatment for substance use disorder is the subject of a long-standing ethical debate. In this longitudinal follow-up study, less benefit from coerced treatment would be evidenced by the coerced group showing higher levels of substance use compared to the voluntary treatment group or no treatment group. Instead, substance use in the coerced group was equivalent to the voluntary treatment and no treatment group. This implies that individuals coerced into substance use disorder treatment did at least as well as other more voluntary patients and is not less helpful or harmful, at least in terms of substance use outcomes.
A primary goal of treatment is to reduce harmful substance use and the consequences associated with it. Notably, none of the groups (coerced, voluntary, or no treatment) showed change in substance use over time. This runs counter to expectations and a large body of evidence showing the clinical benefit of voluntary treatment.
The participants in this study faced high challenges like street-involvement, injection drug use, and HIV. This is an at-risk sample characterized by many risk factors and potentially low recovery capital (i.e., recovery resources). The lack of significant improvement over time for any of these groups could also reflect the severity of substance use disorder, health complications, and the relentless conditions associated with street involvement. Insufficient services to address these challenges may have contributed to a lack of significant improvement.
One big limitation of this study, however, was that it measured substance use in a binary and dichotomous way (i.e., “any cocaine use in the past 6 months – yes/no”, “any heroin use in the past 6 months – yes/no”). This kind of very broad dichotomous measurement is not sensitive enough to capture other highly meaningful reductions in substance use – participants could have drastically reduced the frequency and intensity of use but this would not be captured by the “any use” at all measure.
Pilarinos, A., Barker, B., Nosova, E., Milloy, M-J., Hayashi, K., Wood, E., Kerr, T., & DeBeck, K. (2021). Coercion into addiction treatment and subsequent substance use patterns among people who use illicit drugs in Vancouver, Canada. Addiction, 115(1), 97-106. DOI: 10.1111/add.14769.
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