Addiction and coercion: To force or not force people into treatment

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.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

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.

HOW WAS THIS STUDY CONDUCTED?

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.

WHAT DID THIS STUDY FIND?

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.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

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.

LIMITATIONS

This study did not include individual treatment factors such as duration, intensity, and quality, future studies that are able to account for these would be beneficial.
The current study does not provide insight into how to improve treatment services.
Although participants were matched on similar background factors to strengthen conclusions, bias may still arise due to other unmeasured variables confounding this relationship.
Other sources of coercion, such as the child welfare system and social workers, were not included in the study.

BOTTOM LINE

For individuals and families seeking recovery: The intent of this study was to explore if coerced treatment was harmful to people as evidenced by increases in substance use compared to voluntary treatment or no treatment at all. Additionally, they investigated if coerced treatment reduced substance use over time. Ultimately no increases or reductions in substance use were observed for any group. This could have been due to the dichotomous (any vs no use) outcome measure being insufficiently sensitive to capture other meaningful changes beyond complete and total abstinence during the follow-up periods. Although the larger body of research on coercive treatment is considered inconclusive, the literature on voluntary treatment is strong when approached with front-line treatments. If someone you know needs to address harmful substance use, consider ways to maximize the effectiveness by including indicators of quality addiction treatment when seeking help.
For treatment professionals and treatment systems: Coerced treatment for substance use disorder raises some concerns about the potential unintended harm that might be caused. This needs to be weighed against the harms of allowing hazardous and harmful use to continue, which in some cases can result in premature death of the individual. This study found no difference in the magnitude of before and after substance use patterns between those coerced into treatment versus voluntary treatment or among those that received no treatment. Increases in substance use were not observed in the coerced group which implies it was not harmful in terms of substance use, but reductions in substance use were not observed either. Additionally, a subgroup analysis found the same results for physician coerced versus criminal justice. If you have patients that were coerced into treatment participation, others have suggested it can be useful to evaluate assumptions about involuntary treatment to determine how to best alleviate counterproductive feelings of coercion.
For scientists: The body of research on coerced versus voluntary treatment remains mixed but several studies have shown that coerced patients do at least as well if not slightly better than voluntary patients. This study is no different in that it found that a coerced group of participants who use drugs did at least as well as patients voluntarily entering treatment and when compared to those who received no treatment at all. These results emphasize the need for inclusion of other more sensitive measures of outcome as the lack of differences and changes could have been due to the dichotomous (any vs no use) outcome measure used being insufficiently sensitive to capture other meaningful changes beyond complete and total abstinence during the follow-up periods. Also, more research is needed to understand who in particular may need or benefit from coerced treatment versus who may show less, or non, response, or even harm.
For policy makers: Coercion into treatment is practiced throughout the world and raises concerns about violations of human rights. In contrast, coerced treatment also can save lives and help people get treatment they would not ordinarily choose and yet can benefit from. The research is not conclusive about its effect on substance use. For example, this study did not find harm associated with coerced treatment from criminal justice in terms of increased substance use compared to voluntary treatment or no treatment at all, but it also did not find a benefit in terms of reduced substance use. This lack of findings could have been due to the dichotomous (any vs no use) outcome measure used being insufficiently sensitive to capture other meaningful changes beyond complete and total abstinence during the follow-up periods.

CITATIONS

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.