By Marvin Ross

As the number of those addicted to substances increases and the deaths as a result continue to rise, people are clutching for solutions. One potential solution favoured by some families is involuntary treatment and that is now being proposed by some right wing governments like Alberta and New Brunswick. The $64,000 question, however, will that work?

Involuntary treatment for those with serious mental illnesses does work despite how controversial it is with civil libertarians who would prefer to see people die in back alleys but with their human rights intact. It works because mental illness is a no fault condition caused by various abnormalities many of which have yet to be completely isolated and defined. Science does know, however, that certain drugs will alleviate depression, the worst symptoms of psychosis, the mood swings of mood disorders and the obsessions of OCD.

These drugs have been developed with an hypothesis as to why they might help and then carefully tested over years through various clinical trial stages until the developers can prove to the regulatory agencies that the benefits outweigh the harms. I’ve personally seen them perform miraculous transformations in people as have many others. Involuntary treatment is needed in a number of cases because the ill person lacks insight into the disease. That lack of insight is part of the disease called anosognosia.

In some ways, drug addiction is more complex than serious mental illnesses. No one with a serious mental illnesses decides to become ill, but as the National Institute of Drug abuse states:

“Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent, which is why drug addiction is considered a “relapsing” disease—people in recovery from drug use disorders are at increased risk for returning to drug use even after years of not taking the drug. “

Proponents of involuntary treatment for addiction, I’m told, are citing anosognosia as a reason why it is needed. That concept is valid for those with serious mental illness but does it translate to addiction? It turns out that there is very little in the research literature on anosognosia for addiction. One paper from 2016 suggested that “In addiction, notably Alcohol Use Disorder (AUD), patients often have a tendency to fail to acknowledge the reality of the disease and to minimize the physical, psychological, and social difficulties attendant to chronic alcohol consumption. This lack of awareness can reduce the chances of initiating and maintaining sobriety.” 

All of this is speculation.

A more recent paper also suggested this might be a relevant avenue for research and concluded that:

“Compromised insight in substance use disorder may be relevant to a constellation of behaviors that suggest a lack of behavioral awareness linked to drug use. Future work needs to refine and advance the measurements, continuing to investigate insight problems in addiction that may become important therapeutic targets. “

At the moment, all of this is also speculation.

One cynical (ie realistic) physician said that “All addicts know they are addicts. They just lie to themselves (and others) about how often or how recently they relapsed. And all alcoholics know they drink, they just lie to themselves and the docs about how much they drink. And this kind of lying really demonstrates they do not suffer from anosognosia, they are merely human.”

What is most important is the availability and cost of treatment for that addiction. When it comes to mental illness which is covered by universal health care, Canada is deficient. We do not have enough psychiatrists treating those with serious mental illness with only 13.1 psychiatrists/100,000 population. Switzerland has 52, the UK 18 and Norway 25. The Canadian Medical Association suggests we need 15.

The Canadian Psychiatric Institute and the Treatment Advocacy Center in the U.S. suggest that an appropriate number of psychiatric beds be 50 per 100,000. In a comparison of 35 countries, Canada ranks 29th in beds slightly ahead of New Zealand, the U.S., Chile and a few others.

Addiction treatment in Canada is a mix of public and private programs and many of the programs insist that new patients be sober when they join. Canada Drug Rehab provides considerable information on the various programs that exist and evaluations of the types of programs. In a blog on private versus public rehab in BC, they point out that public programs often come with major downsides including:

Wait times

High patient to doctor ratios

Outdated practices

Lack of personalized care

Poor post-treatment care

Those who have access to private addiction or substance abuse treatment can access the core advantages of private care, which are:

Fast admission (sometimes in just days)

Long and thorough treatment

Personalized care

Choice over environment and amenities

A diverse range of therapies and treatments

Post-recovery services

What is evident is that if we are serious about rehab, we need a lot more publicly funded evidence based programs that are accessible for those who need them. This is far more crucial than arguing about the need for involuntary treatment when the programs that can successfully treat people are not really there to begin with.

The need for adequate resources for both mental illness and addictions should be the focus for all.

In Part Two coming next week, Dr Dawson will outline what an involuntary program for those with addictions might look like.

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