Coercion into addiction treatment and subsequent substance use patterns among people who use illicit drugs in Vancouver, Canada

Background: Although patient motivation is generally recognized as critical for addiction treatment success, many people who use drugs (PWUD) are coerced into receiving treatment. We sought to assess the prevalence and correlates of, and drug use patterns before and after, reporting being coerced into addiction treatment among PWUD in Vancouver, Canada.

Methods: Data from three linked prospective cohort studies of community-recruited PWUD in Vancouver, Canada were analyzed between September 2005 and June 2015. Factors associated with time to coerced addiction treatment were identified using an extended Cox model adjusting for substance use and sociodemographic variables. We then used McNemar’s test and non-linear growth curve modeling to compare: a) changes in substance use patterns before and after coerced addiction treatment; and, b) changes against two groups of matched controls who voluntarily accessed treatment and did not access treatment.

Results: Among 3,196 participants, 399 (12.5%) reported being coerced into addiction treatment at some point during the study period. In multivariable extended Cox regression, time to coercion was positively associated with non-fatal overdose (Adjusted Hazards Ratio [AHR] = 1.66), incarceration (AHR=1.77), and cocaine use (AHR=1.33), while employment (AHR=0.73) and daily cannabis use (AHR=0.74) were negatively associated with coercion (all p<0.05). In non-linear growth curve analyses, there were no statistically significant differences in before versus after patterns of substance use between those coerced into treatment versus either of the two control groups (all p > 0.05).

Conclusion: Among our study sample, there were no statistically significant improvements in substance use outcomes among participants reporting coerced addiction treatment or either control group (voluntary treatment and treatment naïve). Study findings suggest the need for a comprehensive understanding of how to effectively engage PWUD in evidence-based and high-quality voluntary addiction treatment services and to re-examine policies that promote coercion in substance use care.