This discussion paper critically evaluates the persistent use of compulsory drug treatment in East and Southeast Asia and provides robust evidence and case studies advocating for voluntary, community-based alternatives. It challenges the widespread view that people who use drugs must be coerced into treatment to become "functional" members of society. The report emphasizes that involuntary treatment is largely ineffective, driven by stigma and punitive ideologies, and often exacerbates health harms and social exclusion.

Instead, the discussion paper proposes voluntary, evidence-based, community-centred care that integrates health, social support, and harm reduction. Key principles include non-punitive approaches, informed consent, the right to refuse treatment, and the recognition of relapse as a part of recovery, not a reason for punishment.

The discussion paper features successful models from countries such as China, Indonesia, and Malaysia, where community and health partnerships have improved outcomes without involuntary care.

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UNAIDS & UNODC. (2022). Compulsory drug treatment and rehabilitation in East and Southeast Asia: Voluntary community-based alternatives. United Nations Office on Drugs and Crime. https://www.unodc.org/documents/southeastasiaandpacific//Publications/2022/UNODC_Compulsory_Treatment_Report_2022.pdf

This working paper makes a compelling case that harm reduction is not only compatible with, but essential to, a human rights framework. Pineau argues that voluntary, person-centred harm reduction aligns with two key human rights principles: human dignity and the capabilities approach, as conceptualized by Martha Nussbaum and Amartya Sen. These frameworks emphasize the right of individuals to make autonomous choices, access care without coercion, and participate fully in society regardless of substance use.

The paper critiques coercive and prohibitionist drug policies, linking them to systemic human rights violations including incarceration, denial of health care, increased overdose risk, and stigmatization. Coercion and involuntary treatment are framed as state mechanisms that strip people who use drugs (PWUD) of their dignity and agency, undermining public health goals and deepening marginalization.

Pineau further highlights the dangers of co-opting harm reduction into punitive or biomedical control systems. He calls for non-coercive, grassroots-informed, and participatory models that elevate lived experience and reject moralistic abstinence-based interventions.

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Pineau, N. (2021). Harm reduction and human rights: Emphasizing the dignity and capabilities of people who use drugs (Vol. 10, No. 1). McGill Human Rights Internships Working Paper Series. 

This longitudinal study followed 671 people who inject drugs (PWID) in Tijuana, Mexico, from 2011 to 2017 to assess the relationship between involuntary drug treatment (IDT) and non-fatal overdose. The findings demonstrated that recent experiences of IDT significantly increased the odds of a non-fatal overdose (Adjusted Odds Ratio [AOR]: 1.76; 95% CI: 1.04–2.96). Notably, most involuntary treatment in Mexico occurred in informal, abstinence-only residential facilities with little oversight and no evidence-based interventions. The study also found that overdose risk increased with frequency of injection, tranquilizer use, and assistance from “hit doctors,” and decreased with age.

Importantly, the study emphasizes that forced treatment does not improve outcomes but instead contributes to overdose vulnerability due to decreased drug tolerance and lack of post-discharge support. The authors note that IDT can mirror conditions of incarceration and that a human rights-based, voluntary treatment framework is essential.

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Rafful, C., Orozco, R., Rangel, G., Davidson, P., Werb, D., Beletsky, L., & Strathdee, S. A. (2018). Increased non-fatal overdose risk associated with involuntary drug treatment in a longitudinal study with people who inject drugs. Addiction, 113(6), 1056–1063. https://doi.org/10.1111/add.14159

This article reviews the research on involuntary treatment for adults with substance use disorders (SUD) who have not been charged with a crime. This type of treatment, where people are forced into care without their consent, has become a hot topic in Canada due to rising drug poisonings and public concerns about substance use. But is it effective?

The authors looked at 10 international studies and found that voluntary treatment works better than involuntary treatment. People who choose to go to treatment are more likely to stay, have better outcomes, and face fewer harms like overdose. In contrast, people forced into care often relapse shortly after, are more likely to overdose, and less likely to continue with treatment.

Some studies showed small short-term benefits from involuntary care, especially when programs included aftercare, housing support, and medication. But these programs are expensive, hard to run fairly, and come with major ethical concerns, especially around trauma, consent, and the risk of further harming marginalized groups.

There are no Canadian studies yet, and experts warn that any move toward involuntary care in Canada would need new legislation, dedicated facilities, and strong oversight to avoid causing more harm than good.

The authors conclude that the best approach is to invest in accessible, voluntary treatment and support options (like harm reduction services, peer support, and wraparound care) before considering any form of forced treatment.

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Cooley, E., Bahji, A., & Crockford, D. (2023). Involuntary treatment for adult non offenders with substance use disorders?. Canadian Journal of Addiction, 14(2), 25-31.

This evidence brief provides a comprehensive analysis of involuntary treatment (InvTx) for severe substance use disorders (SSUDs), examining its legal foundations, evidence base, ethical considerations, and stakeholder perspectives.

InvTx refers to the practice of detaining individuals without consent for treatment when they are considered to be a danger to themselves or others and lack capacity due to SSUD. While permitted under provincial and territorial mental health acts, its application to substance use is inconsistent and often only allowed when a concurrent mental health diagnosis is present.

The report emphasizes that InvTx lacks strong evidence for long-term effectiveness. While it may extend a person’s stay in care, it does not consistently reduce substance use or recidivism. In some instances, it increases the risk of overdose after discharge. Additionally, InvTx can discourage individuals from seeking care voluntarily and may lead to trauma, particularly when treatment environments are not trauma-informed.

Patients and caregivers express that voluntary, community-based treatment options are both preferred and often unavailable. InvTx environments have been described as intimidating or even retraumatizing, especially for women, Indigenous peoples, and marginalized groups. Clinicians, too, report moral distress in using InvTx.

Ethical tensions are central to the debate, particularly regarding autonomy and human rights. InvTx may violate international commitments like the United Nations Convention on the Rights of Persons with Disabilities and the UN Declaration on the Rights of Indigenous Peoples.

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Canadian Centre on Substance Use and Addiction. (2025). Involuntary treatment for severe substance use disorders: Evidence brief.

This study provides evidence on the ineffectiveness and harms associated with involuntary treatment for substance use disorder (SUD). Conducted through a retrospective chart review of 22 patients subjected to involuntary commitment from a hospital in Massachusetts, the study found that 100% of patients relapsed within one year, with a median time to relapse of just 61 days. Moreover, all patients had at least one SUD-related emergency department (ED) visit, and 78.6% had at least one SUD-related hospital admission during that same period.

Notably, the involuntary treatment occurred under Massachusetts’s Section 35 law, which permits civil commitment for SUD and can involve incarceration in carceral settings, particularly for men. Two of the patients in the study died within a year of release, underscoring the risks associated with these interventions.

These findings challenge the assumption that forced treatment reduces harm or mortality. On the contrary, forced care was associated with continued or worsened health outcomes, raising serious questions about its ethical justification and clinical utility.

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Messinger, J. C., Vercollone, L., Weiner, S. G., Bromstedt, W., Garner, C., Garza, J., Joseph, J. W., Sanchez, L. D., Im, D., & Bukhman, A. K. (2023). Outcomes for patients discharged to involuntary commitment for substance use disorder directly from the hospital. Community Mental Health Journal, 59(6), 1300–1305. https://doi.org/10.1007/s10597-023-01112-2

This discussion paper emphasizes that drug dependence is a multifaceted, chronic health disorder requiring voluntary, person-centred, evidence-informed care. It firmly advocates that treatment should never be forced except in rare, legally defined crisis situations involving imminent harm. The report explicitly states that "drug dependence treatment... should not be forced on patients," and that “only in exceptional crisis situations of high risk to self or others, compulsory treatment should be mandated for specific conditions and periods of time as specified by the law”

The discussion paper stresses that effective treatment is contingent upon voluntary engagement and recognizes the harm that coerced or penal-based interventions can cause. It outlines that punitive measures such as incarceration or forced labor have not been scientifically recognized as treatment and should not be imposed in lieu of healthcare. Instead, the preferred approach is diversion into voluntary treatment as an alternative to criminal sanctions, preserving patient agency.

Additionally, the report identifies the criminalization of people who use drugs and stigmatizing policies as major barriers to accessing care. It calls for the decriminalization of drug use and stresses the importance of low-threshold, non-judgmental, culturally competent services that are accessible and rooted in community networks.

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United Nations Office on Drugs and Crime & World Health Organization. (2008). Principles of drug dependence treatment: Discussion paper.

This review critically analyzes 30 years of research on legal coercion in substance use treatment. While the use of compulsory or coerced treatment has gained traction globally, especially in response to substance-related crime and pressure on the criminal justice system, the evidence base remains deeply mixed and inconclusive.

Coerced treatment (where clients are given a choice between treatment or legal sanctions) and compulsory treatment (where individuals are legally forced into treatment) are often conflated with voluntary treatment, obscuring important distinctions. Research indicates that although legal pressure can increase initial treatment entry and sometimes retention, outcomes vary significantly and are influenced more by individual motivation, perceived coercion, and treatment match than legal status alone.

Methodological flaws, such as over-reliance on referral source to define coercion, lack of standardized assessment tools, and limited long-term follow-up, undermine many studies. Importantly, many individuals labeled as “voluntary” are also responding to social, financial, or medical pressures.

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Klag, S., O’Callaghan, F., & Creed, P. (2005). The use of legal coercion in the treatment of substance abusers: An overview and critical analysis of thirty years of research. Substance Use & Misuse, 40(12), 1777–1795. https://doi.org/10.1080/10826080500260891

The guidelines strongly supports voluntary, patient-centred approaches to care. A core principle outlined in the guideline is that treatment must be based on patient rights, preferences, and dignity. Specifically, the guideline states: “Patient-informed consent is mandatory, and treatment should not be forced.” This reinforces the need for voluntary engagement in care, with forced or involuntary treatment only considered in exceptional medical situations (e.g., when a patient is unconscious).

The guideline also emphasizes that patients should be fully informed of all treatment options and the potential consequences of refusing care. Providers are encouraged to co-create care plans with patients, respecting individual goals and circumstances, rather than imposing uniform or mandated treatment pathways. A patient-centred approach is described as a standard of care, requiring providers to treat patients as autonomous individuals capable of making informed decisions about their health.

The guidelines critique withdrawal management on its own, especially in involuntary contexts such as incarceration, as insufficient and even dangerous. For example, forced withdrawal (e.g., during imprisonment) is associated with a significantly elevated risk of overdose upon release, due to reduced tolerance. One study cited in the guideline found that people were three to eight times more likely to die of a drug-related cause within two weeks of release from prison compared to later periods, highlighting the harms of abrupt and unsupported withdrawal.

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Canadian Research Initiative in Substance Matters (CRISM). (2024). Update to National Guideline for the Clinical Management of Opioid Use Disorder.

This commentary critically examines the use and impacts of involuntary interventions for people who use drugs (PWUD), including compulsory drug detention centres and legally coerced treatment from multiple jurisdictions around the world.

The commentary notes that involuntary interventions for people who use drugs (PWUD) are often ineffective and can be harmful, with evidence showing they increase the risk of overdose, particularly after forced abstinence lowers a person’s drug tolerance. A study in Tijuana found nearly double the risk of non-fatal overdose among those with a history of involuntary treatment.

Many such interventions, especially in Latin America and Southeast Asia, lack due process and are associated with human rights abuses, including forced labor and violence.

Even in the absence of abuse, involuntary treatment underperforms compared to voluntary, evidence-based options. Continued reliance on these methods may stem from stigma, limited access to care, and misconceptions that PWUD lack decision-making capacity.

The commentary recommends scaling up low-barrier, voluntary, evidence-based treatment as a more ethical and effective response. It also emphasizes the need to distinguish between civil commitment and detention-based models that often serve punitive, rather than therapeutic, functions. Ultimately, expanding voluntary treatment could eliminate the perceived need for coercive interventions and reduce drug-related harms.

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Bazazi, A. R. (2018). Unpacking involuntary interventions for people who use drugs. Addiction, 113(6), 1064–1065. https://doi.org/10.1111/add.14202

This study assessed the impact of a 2017 pilot program in Massachusetts that simplified the process for physicians and police to petition for involuntary substance use treatment under Section 35. By accepting written affidavits instead of requiring in-person court appearances, the number of petitions in one jurisdiction rose by over 270% within two years.

Most individuals committed were experiencing homelessness, had co-occurring mental health diagnoses, and had previously sought voluntary treatment, highlighting the complexity of their needs.

While the streamlined process improved access to care for high-risk individuals, it also raised ethical concerns around autonomy, consent, and the effectiveness of forced treatment. The study suggests that involuntary care may reach individuals with limited social supports but emphasizes the importance of ensuring such interventions are ethically justified and provide meaningful, person-centered support.

It recommends a multidisciplinary approach that includes dual-diagnosis treatment and calls for further research on long-term outcomes, as the study did not assess post-treatment effectiveness.

Overall, the findings illustrate both the expanded use and potential risks of involuntary care in substance use treatment, especially when voluntary services remain inaccessible or underfunded.

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Coffey, K. E., Aitelli, A., Milligan, M., Niemierko, A., Broom, T., & Shih, H. A. (2021). Use of involuntary emergency treatment by physicians and law enforcement for persons with high-risk drug use or alcohol dependence. JAMA Network Open, 4(8), e2120682. https://doi.org/10.1001/jamanetworkopen.2021.20682

This systematic review conducted by the Canadian Society of Addiction Medicine Policy Committee critically examines whether involuntary treatment for individuals with substance use disorders (SUDs) produces meaningful, evidence-based outcomes. Drawing from 42 studies involving 354,420 participants, the review found that involuntary treatment (defined as any treatment not fully chosen by the individual) generally does not yield better outcomes than voluntary treatment. Only 7 studies showed improved results for involuntary treatment, mostly in terms of short-term treatment retention, with only one study showing a temporary reduction in substance use, which disappeared upon follow-up.

Crucially, involuntary treatment was often associated with worse outcomes, including higher relapse rates, reduced treatment engagement, and increased mortality. Notably, one study reported that 98% of people involuntarily detoxed from opioids relapsed within a year, having received no opioid agonist therapy (OAT). The review emphasizes that treatment motivation and quality of care were rarely addressed, with only 11 studies providing evidence-based treatment and only 5 accounting for psychiatric co-morbidities. Motivation for change, a known predictor of positive outcomes, was measured in just 11 of the 42 studies.

The review concludes that "there is a lack of high-quality evidence to support or refute involuntary treatment for persons with SUD", and that better research is needed to inform public policy. It raises ethical and practical concerns over involuntary treatment practices, particularly when they fail to provide evidence-based care and ignore the role of patient autonomy.

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Bahji, A., Leger, P., Nidumolu, A., Watts, B., Dama, S., Hamilton, A., & Tanguay, R. (2023). Effectiveness of involuntary treatment for individuals with substance use disorders: A systematic review. Canadian Journal of Addiction, 14(4). https://doi.org/10.1097/CXA.0000000000000188

Disclaimer

We’ve chosen to include the 2023 study Effectiveness of Involuntary Treatment for Individuals with Substance Use Disorders: A Systematic Review by Bahji et al. in our Research Hub because it helps paint a fuller picture of the current evidence.

This review looks at dozens of studies from around the world, and even though one of its authors (Dr. Rob Tanguay) is a lead architect of Alberta’s Compassionate Intervention Act, we believe it’s important to include a wide range of sources so Albertans can make informed decisions.

Given Dr. Tanguay’s active leadership role in the development and promotion of Alberta’s involuntary treatment legislation, readers should be aware of a potential conflict of interest when evaluating the conclusions and framing of the study.

That said, the results of the review still support what many advocates and people with lived and living experience already know: involuntary treatment is broadly ineffective when compared to voluntary, person-centred care. While the paper compiles a variety of findings, it notes that most studies on forced treatment show limited or unclear benefit and that in many cases, voluntary treatment produces better outcomes.

We’re sharing this resource to promote education, transparency, and critical thinking, especially when policies are being made that affect people’s lives and rights.