Eby and Rustad Agree on Involuntary Treatment. Experts Say They’re Wrong

Conservative Party of BC Leader John Rustad and NDP Leader David Eby both say they will introduce involuntary treatment for people who use drugs or have mental health issues.

Rustad made his announcement last Wednesday, shortly after news broke about the tragic death of Brianna MacDonald, a 13-year-old who died while living unhoused in Abbotsford and using drugs from the unregulated toxic supply, also known as street drugs.

Eby made a similar promise Sunday, saying work would start immediately.

Brianna’s family told CTV News that she used unregulated substances to self-medicate her mental illness and that she was placed in youth care but ran away before ending up in a homeless encampment, where she died.

In a statement published on its website, the Conservative Party of BC said it would commit to “involuntary treatment for individuals, especially children, suffering from severe addiction” and there is an “urgent need to protect vulnerable British Columbians from the devastating effects of addiction.”

The statement then makes three commitments.

First, to introduce a law to allow for involuntary treatment for all ages if a person is at “serious risk due to addiction.”

Second, to build low-security facilities for “individuals who pose a risk to themselves or others, ensuring they receive the proper care in a safe environment.”

And third, to “establish units to provide targeted care for those experiencing severe addiction or mental health crises.” This will improve patient care and reduce emergency room pressure, the statement continues.

Eby’s plans were announced Sunday in a government news release.

“People with addiction challenges, brain injuries and mental-health issues need compassionate care and direct and assertive intervention to help them stabilize and rebuild a meaningful life,” Eby said in the release.

The release said people with "long-term concurrent mental-health and addiction challenges” would “get secure and dignified care by opening highly secure facilities for people under the Mental Health Act throughout the province, as well as secure treatment within BC Corrections.”

The first facility will open in Maple Ridge in “coming months,” it said, with plans to expand across the province and use existing mental health beds in hospital.

It also promised “a designated mental-health unit in a B.C. correctional centre to provide rapid treatment for people with mental-health and addiction challenges being held on remand or sentenced to custody,” starting with a 10-bed facility at the Surrey Pretrial Services Centre.

The Tyee spoke with experts about how involuntary detention would work in practice.

None of the parties’ calls to action address the toxic drug supply, which is the reason more than six people per day are dying in B.C., said Gillian Kolla, assistant professor of population health and applied health sciences at Memorial University of Newfoundland, and collaborating scientist at the Canadian Institute for Substance Use Research at the University of Victoria.

The prevalence of substance use disorder has remained steady over the last decade, according to Health Canada, so it’s not that more people are using drugs today but that more people are dying when they use drugs because the unregulated supply is so toxic, she said.

“Severe addiction” is not a medical term, she added — substance use disorder and opioid use disorder are, and it’s important to use official terms when talking about policy.

Ultimately, what’s really needed is to invest in affordable housing and mental health services, Kolla added.

When we give people housing, Kolla said, their “health and social outcomes and mental health improves dramatically.”

There doesn’t appear to be a single party in Canada prepared to make the investment necessary to actually tackle the housing shortage across the country, she added.

Involuntary treatment for substance use disorder

Involuntary treatment is “putting the cart before the horse,” Kolla told The Tyee.

B.C. doesn’t have enough spaces in voluntary, trauma-informed, evidence-based treatment programs as it is, she said. The province first needs to build out a comprehensive and accessible system of evidence-based harm reduction and evidence-based treatment supports so that it can provide people with the intervention they want at the time they ask for it.

Residential treatment doesn’t have stronger outcomes than community-based treatment, and abstinence-based approaches can increase a person’s risk of overdose and death because a person’s tolerance drops quickly, Kolla added.

This puts them at a higher risk of overdose because the next time they use substances, they might use them in isolation instead of accessing harm reduction services like supervised consumption sites and their tolerance will be lower.

Involuntary treatment has lower success rates than voluntary treatment, Kolla said.

“We have very, very strong research that it doesn’t work,” she said.

Kolla said the gold standard of evidence-based treatment for opioid use disorder is opioid agonist treatment, and there is a growing and strong evidence base for prescribed safer supply. OAT prescribes people with opioid use disorder methadone and/or buprenorphine, which helps them stabilize and reduce their risk of overdose.

Prescribed safer supply provides people at high risk of overdose with a prescription for opioids or stimulants to separate them from the unregulated toxic drug supply.

Kenneth Fung, a clinical associate professor at the University of British Columbia’s school of population and public health, said involuntary treatment could be subjected to a constitutional challenge if a government tried to enact legislation around it, “but medically it is the norm in many non-western-culture countries.”

Indefinitely apprehending people ‘who pose a risk’

Last week’s commitment to “creating secure facilities designed for treatment of individuals who pose a risk to themselves or others” wasn’t the first time Rustad proposed apprehending people on mental health grounds.

In June Rustad told the Greater Victoria Chamber of Commerce he also wants “indefinite apprehension of permanently brain-damaged habitual offenders... on mental health grounds. That could include invoking the notwithstanding clause in the Charter of Rights to bypass constitutional concerns if need be.”

However, provinces and territories already have legislation that can do this, Kolla said.

She pointed to B.C.’s Mental Health Act, which allows police to apprehend people against their will and physicians to detain people indefinitely if they are determined to be a risk to themselves or others, or are at risk of deteriorating if they leave medical care.

The Mental Health Act applies to all people in B.C. and doesn’t require a law to be broken to be applied.

There’s also forensic law, where a crime is committed but there is reason to believe mental illness impacted a person’s ability to understand what they were doing. Under forensic law, people can be determined to be not criminally responsible or unfit to stand trial.

If someone is unfit to stand trial, they may be admitted to the Forensic Psychiatric Hospital in Coquitlam or a Forensic Psychiatric Regional Clinic, where they will receive treatment until they are well enough to take part in court proceedings, according to a BC Mental Health and Substance Use Services page about court-referred mental health assessment and treatment.

People can already be indefinitely detained under B.C.’s Mental Health Act or the mental disorder provisions of the Criminal Code, said Kevin Love, a lawyer with the non-profit law firm the Community Legal Assistance Society.

There is no automatic release date as there is with a criminal sentence, Love said. A person detained under the Mental Health Act will be released when a director of the hospital or expert panel determines they no longer meet the criteria for ongoing detention. People detained under the mental disorder provisions of the Criminal Code will be held until an expert panel says it is safe for them to reintegrate into the community, he added.

“We need to tread very, very carefully any time we’re talking about removing people’s rights like their basic right to freedom and autonomy,” Kolla said. Apprehending someone under the vague terminology of brain injury would not pass muster within the courts, she added.

However, Kolla said she appreciates Rustad raising awareness about how people can suffer a brain injury when they overdose.

Kolla also said more supports are needed for people who have suffered overdose-related brain injury that centre on compassion, care and meeting people where they're at.

It takes only four minutes of reduced breathing during an overdose to start doing damage to the brain, which can lead to injury if oxygen is cut off or reduced for long enough, or if a person overdoses multiple times.

This can impact a person’s ability to control their movement, and affect decision-making, impulse control or interactions with other people and can, for example, make someone more likely to get into a fight if they have lower impulse control.

The Tyee previously reported that it’s possible more than 600,000 Canadians have an overdose-related brain injury.

It’s important to understand that it’s the overdose, not the substance use itself, that is causing injury, Kolla said. A person who uses substances and/or has a brain injury still has the right to make decisions about their own care, she added.

The BC NDP introduced a program to support people with brain injury related to substance use in May 2023.

More mental health facilities

Last week’s Conservative commitment to “establish units to provide targeted care for those experiencing severe addiction or mental health crises” seems to fit with an item on the Conservative Party of BC website “ideas” page that calls to “reopen and revitalize mental health facilities.”

When people see someone in mental distress, who may also be experiencing homelessness, poverty or substance use, they want to help but don’t know how, Kolla said.

Building mental health facilities might sound like a tidy solution, because the person in distress can go there and receive treatment, care and housing, but opening these facilities is a costly proposal that would open very few beds to meet a very large need, she said.

But involuntary treatment, or the threat of involuntary treatment, creates mistrust in the health-care system, can prevent people from calling 911 during an overdose and further alienates people who need help, according to signatories of a 2023 public letter from Pivot Legal Society that critiqued the NDP’s interest in expanding involuntary care.

Involuntary care can be quite traumatizing and can increase a person’s risk of overdose when they exit treatment, Kolla said.

People have very complex reasons for why they use drugs, Kolla said, adding that trauma and negative past experiences are common reasons for substance use. Cutting off someone’s access to substances doesn’t treat a person’s trauma, she added.

Kolla said there isn’t strong evidence that providing mental health care within a facility has better outcomes than community-based treatment, which can be provided in a more cost-effective way. Canada is also struggling with health-care staffing shortages, Kolla said, so calls to open more facilities raise questions of where the staff will come from.

More people detained today than at the height of Riverview

Today, there are more than 33 times as many people detained annually under the Mental Health Act than there were patients in 2002 at Riverview psychiatric hospital, a decade before the facility finally closed its doors.

Riverview is the facility that generally gets pointed to when politicians speak about reopening mental health facilities.

Riverview Hospital operated from 1913 until 2012, treating patients for mental health and substance use-related health issues. According to a May 2022 article in the Health Law in Canada journal, Riverview was closed gradually in a decade-long process, starting in 2002 and concluding in 2012.

In 2002 there were 850 patients at the facility detained under the Mental Health Act, and all 850 were transferred to other Mental Health Act-designated facilities when Riverview closed, according to the article.

The Office of the Ombudsperson said the number of people detained under the Mental Health Act has steadily increased since then.

A 2019 report found that in 2014-15 there were just under 20,500 involuntary admissions to facilities in B.C. under the Mental Health Act, with 15,000 people detained in facilities across the province.

In 2020-21 there were 28,386 involuntary admissions and almost 20,000 people detained, according to previous reporting by The Tyee.

The Riverview Lands were renamed səmiq̓ʷəʔelə in 2021, after being given the name by the kʷikʷəƛ̓əm First Nation, or Kwikwetlem First Nation.

Today, there are two facilities on site and several refurbished buildings run by Coast Mental Health where 289 people are receiving treatment for mental health, addictions or both, according to CTV News.

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