The Canadian province of British Columbia has been influential in promoting libertarian drug policies, including decriminalizing drug use in both private and public settings, opposing formal or social pressure on drug-addicted individuals to seek treatment, and distributing drugs to addicted individuals for unsupervised use. Recently, the province’s liberal premier described these policies as a mistake and advocated for expanding involuntary care capacity, particularly for homeless individuals. Similar calls to rethink substance use disorder treatment have been made by a variety of policymakers, including the President of the United States, several governors, and mayors of major cities.
This article discusses three strategies aimed at increasing the number of people with substance use and other psychiatric disorders who seek treatment. The first strategy involves improving the quality and accessibility of addiction treatment. The addiction treatment industry currently ranges from high-quality programs to those with significant quality issues. For example, a secret shopper study revealed that many residential addiction treatment programs do not offer FDA-approved opioid agonist therapy, and some actively oppose it. Other challenges include a lack of integration with the broader healthcare system and a shortage of well-trained healthcare professionals. These quality issues likely deter individuals from entering and staying in treatment. Poor accessibility also poses a barrier, as many insurance plans still impose restrictions on substance use care that are not present for other health conditions.
To address these issues, a concerted effort to enhance the quality of low-quality programs and improve overall accessibility could encourage more individuals to seek treatment and make treatment more beneficial for everyone. However, implementing such policies will be challenging, given the significant cuts to Medicaid, the primary funder of addiction treatment in many areas. The opioid settlement funds could partially mitigate this challenge if used judiciously.
The second strategy involves policies that combine incentives and pressures to encourage treatment seeking and cessation of addictive substance use. These policies represent a shift from the recently popular “libertarian harm reduction” philosophy, which opposed any constraints on individual drug use. Two widely discussed approaches include making publicly provided housing contingent on not using addictive drugs and mandating individuals to treatment whose substance use poses threats to themselves or others.
Housing First vs. Recovery-Focused Housing
Housing First, originally developed for homeless individuals with serious mental illnesses, provides stable housing before addressing treatment and behavior change. However, this model has been overgeneralized to all people with substance use disorders, including those for whom addiction is the primary problem. Scientific evidence shows that Housing First does not reduce substance use, and in states that bar recovery housing, drug overdose deaths remain high. In contrast, recovery-focused housing, which does not allow addictive substance use and fosters a recovery-supportive culture, has strong evidence of benefiting people with addictions. Recovery housing offers both stable housing and improved health, whereas Housing First only provides the former.
The third strategy involves mandating individuals to addiction treatment. Addiction differs from many other disorders in that individuals are often ambivalent about behavior change due to the immediate rewards of drug use and impaired ability to weigh future consequences. Additionally, addiction often causes harm to others, providing a rational and ethical basis for applying pressure on addicted individuals to enter treatment. Two avenues exist for legally mandated treatment: drug courts and civil commitment.
Drug Courts and Civil Commitment
Drug courts offer individuals who commit crimes related to their addiction the option of court-monitored services as an alternative to a more typical sentence. These courts had broad bipartisan support but lost political traction during the period of defunding the police and decriminalizing drugs. However, rising crime, disorder, and overdose have made drug courts popular again. Civil commitment, which allows a judge to mandate involuntary treatment for individuals who pose a serious risk to themselves or others, is less common due to high standards of proof and the prevalence of criminal lawbreaking by addicted individuals.
Evidence on drug courts is consistently positive, showing lower arrest rates, higher treatment engagement, and lower substance use. However, some drug courts have been overly restrictive, limiting their potential. Civil commitment programs are harder to evaluate, but given the high mortality, morbidity, and victimization rates among addicted individuals living on the streets, it is likely that these programs produce relative improvements.
The bipartisan embrace of recovery housing and mandated addiction treatment in regions with diverse politics is a reaction to continued homelessness, addiction, disorder, and crime. Improving the quality and accessibility of care for all individuals, whether mandated or not, merits attention as a policy strategy. The evidence suggests that all three policies, if sufficiently resourced and thoughtfully implemented, can contribute to reducing the enormous suffering caused by these problems.
