The Fight Over Forced Rehab
As a teenager in Los Angeles, Marshall Smith earned a reputation as a party boy. He moved to British Columbia after high school and continued to drink throughout his twenties while working in the provincial corrections system, first as a guard and later in administrative roles. In 2001, he took a job doing municipal affairs with the provincial government, contributing to Vancouver’s bid for the 2010 Olympics. Then, one night in a club, he tried cocaine for the first time. He quickly grew addicted and also began using methamphetamine, a drug that provides raging, frenetic highs. Within months, his life and career crumbled. “I hung up my suit and tie and vanished into the streets,” he says.
Smith spent the next four years haunting Vancouver’s Downtown Eastside. He lived in hotel rooms, on street corners and, at one point, in a shipping container. He was repeatedly arrested for drug possession. Smith lost a lot of weight, and his health was declining fast. One day, a police officer caught him with enough meth in his pocket to get him sentenced. The cop, who had known Smith for a few years, offered him an ultimatum: treatment or jail. Within days, Smith checked himself into a publicly funded facility in Maple Ridge, B.C., for a 35-day stay. There, he took part in group therapy, support group meetings and one-on-one counselling. It was the first time in years he’d lived without drugs, and it worked. He’s been drug-free ever since.
Within months of getting out of Maple Ridge, Smith leveraged his experiences in government and corrections—and his life experience as a drug user—to land a job in 2008 as executive director at the Baldy Hughes Therapeutic Community in Prince George. By that time, much of the discourse on addiction management in B.C. was centred on harm reduction: curbing the direct risks of drug use through tools like supervised injection sites and clean syringes. Baldy Hughes, by comparison, was a recovery centre, providing counselling, life skills and leadership lessons with the aim of helping patients to stop their drug use, not do it more safely. Smith was not opposed to harm reduction in principle, but he questioned its growing centrality in the midst of a worsening addiction and overdose crisis. After all, the thing that turned his life around wasn’t a free crack pipe. It was a quasi-enforced stay in abstinence-focused treatment.
In the coming years, harm reduction solidified itself as the drug-management method of choice in Canada, with a proliferation of supervised injection sites and safe-supply facilities. The idea behind harm reduction was to meet drug users where they were: if people were going to use illicit drugs, it was better to at least minimize their harmful effects. But Smith never stopped believing in abstinence and, as the death toll from the overdose crisis grew, politicians and activists also called for more hardline approaches. Among the most radical and controversial ideas: to force severely addicted and mentally unwell users into treatment, whether they want it or not.
Marshall Smith has become one of the key players in a movement toward this tougher approach. He was a central architect of Alberta’s addictions recovery model, which emphasizes total abstinence rather than harm reduction. And this April, Premier Danielle Smith’s government took the province’s tough-on-drugs agenda a step further, introducing the Compassionate Intervention Act. If passed, it will allow adults and youth to be mandated into addictions treatment if they’re deemed a risk to themselves or others. Meanwhile, in B.C., a handful of involuntary treatment beds opened this year for a smaller subset of substance users—people in custody awaiting sentencing. It’s an experiment that will be watched closely across the nation, both by people who think involuntary treatment is a chance for Canada to finally control its addictions crisis—and by those who believe it’s an unconscionable civil rights violation.
For more than a century, Canada’s approach to treating drug addiction has swung between punitive and permissive, voluntary and involuntary. The first asylums for the mentally ill were built in the early 1800s and, by the turn of the 20th century, addiction alone—even in the absence of other psychological problems—was considered enough to merit admission, often involuntary. By the 1950s, asylums began to empty, and provinces began introducing standalone, voluntary addiction treatment programs, which expanded rapidly over the next few decades.
In 1998, Canada took a step back toward a tougher approach when the country’s first drug treatment court opened in Toronto as a collaboration between Ontario’s Centre for Addiction and Mental Health, the Provincial Court of Ontario, the Toronto police and Justice Canada. In drug treatment courts, individuals whose criminal activities are related to substance use receive supervised treatment instead of incarceration. This is sometimes referred to as coerced treatment, rather than involuntary—you don’t have to accept treatment, but the alternative is jail.
The model soon expanded nationwide. Vancouver’s first drug treatment court, in the Downtown Eastside, opened in 2001. Two years later, the federal government spent $23 million to open and operate more in Ottawa, Winnipeg, Regina and Edmonton. Around the same time, judges began handing out conditional sentences, which worked similarly: rather than jail time, offenders could satisfy any number of conditions, including addiction treatment.
This was all happening at the same time as harm reduction expanded. The movement traces its roots to the 1980s AIDS crisis, when several countries, including Canada, distributed clean syringes to drug users to prevent the spread of HIV. The overdose epidemic in Vancouver in the mid-’90s prompted calls for supervised injection facilities where people who used drugs could do so with sterile equipment, monitored by trained staff who could intervene if there was a medical issue and connect users to community services. By the early 2000s, the federal government had made harm reduction a pillar of its drug policy and, in 2003, Health Canada granted a legal exemption from Canada’s drug laws to allow for North America’s first supervised injection site, called Insite, to open in Vancouver’s Downtown Eastside.
The popularity of harm reduction has waxed and waned over the years, depending on which party is in charge. Its expansion slowed during the Harper years—the prime minister’s health minister called Insite “an abomination”—but picked up again after the Liberals regained power in 2015. Harm reduction’s primary goal isn’t to cure people of addiction, though harm-reduction facilities are used to provide counselling and referrals for treatment. A study of 902 Insite users published in 2011 found that 95 of them quit using for at least six months. Most of those had entered voluntary treatment programs.
The federal government has credited harm reduction with saving thousands of lives in Canada—particularly as street drugs, tainted by fentanyl and other synthetic opioids, have grown more lethal. But as the drug crisis has grown, so has public backlash. Users of supervised sites often congregate outside, instilling fear in those living nearby. A few high-profile instances of violence have shaken even the most sympathetic members of the public: in 2020, an overdose-prevention worker in Vancouver was stabbed to death by a 23-year-old addict during a fight. In 2023, a 44-year-old mother of two in Toronto was killed outside a safe-consumption site in the city’s Leslieville neighbourhood in broad daylight. She was caught in the crossfire of a shooting between alleged drug dealers; a safe-injection worker helped one of the shooters escape in an Uber and later pleaded guilty to being an accessory to the crime.
Politicians on the right started calling for drastic addictions treatment measures. In 2024, Pierre Poilievre said he supported involuntary treatment for minors, as well as prisoners found to be incapable of making their own decisions. That same year, Brampton Mayor Patrick Brown suggested allowing police to seize drug users who have severe addictions and mental illness and detain them in psychiatric facilities. Ontario Premier Doug Ford backed the idea—he’s called supervised consumption sites “the worst thing that could ever happen to a community,” and his government has closed many of them. New Brunswick Premier Blaine Higgs, during his failed run for re-election last year, promised to build involuntary care centres in provincial prisons.
Canadians at large have also been receptive. More than 80 per cent of respondents to a 2019 opinion poll by the Angus Reid Institute were in favour of some form of compulsory drug treatment. A more recent poll last year, conducted in B.C., found similar results. Meanwhile, the nationwide death toll from the opioid epidemic has grown dramatically: roughly 2,800 people died from overdoses in 2016. By 2023, that number had risen to 8,500.
Daniel Vigo trained to be a psychologist and psychiatrist at the University of Buenos Aires. In 2010, he heard about the health crisis brewing in Vancouver’s Downtown Eastside as the result of addiction and overdoses, in addition to the resulting brain injuries, and he started visiting the area. He was working at the time as a psychiatrist in Buenos Aires, but he was growing dissatisfied with treating one patient at a time. In 2017, he completed a doctorate in public health at Harvard and that year moved to Vancouver, taking a job as an assistant professor at Simon Fraser University, in Burnaby, B.C.
In the mid-2010s, he says, doctors in B.C. had noticed that more patients admitted to hospitals in psychological distress were also suffering from severe addictions. Some were turning up over and over. Part of the problem, doctors suspected, had to do with fentanyl, which had made street drugs considerably more dangerous by the mid-2010s. During a fentanyl overdose, a user’s breathing slows so much that the brain can be starved of oxygen. Within minutes, brain cells begin to die. Those who survive are often left with permanent brain injuries that may lead to memory problems, speech difficulties, a loss of coordination and emotional problems like impulsivity, mood swings and, sometimes, psychosis.
At the time, provinces could only legally keep patients in hospitals against their will when they exhibited some kind of acute psychological crisis—whether or not exacerbated by drug use—that presented a danger to themselves or others. Once the immediate crisis passed, they could no longer be forcibly detained. In B.C., doctors had slightly more leeway than in other provinces. They were allowed to extend involuntary admissions for months at a time in extreme cases—and many were doing so. Between 2008 and 2017, the number of people with substance-use disorders admitted to hospitals for involuntary psychiatric care increased by 120 per cent, even when adjusting for population growth. “The government was wondering, ‘Is this legal?’ ” says Vigo. With his expertise on mental health and addiction, the province tapped him to write a report on involuntary care for substance abuse, which would gather the existing evidence on the matter, figure out how it would work with the province’s powers under its Mental Health Act and recommend what to do next.
The paper he produced argued that yes, substance-use disorders could be considered a subset of mental disorders. (They already were in most authoritative psychiatry manuals.) That meant these conditions were also grounds for involuntary treatment under B.C.’s existing Mental Health Act. In June of 2024, Premier David Eby appointed Vigo B.C.’s first chief scientific adviser for psychiatry, toxic drugs and concurrent disorders. In his new job, Vigo recommended the creation of new, highly secure facilities where people held under the Mental Health Act could receive involuntary treatment, housing and support.
He laid out three specific scenarios under which people with substance-use disorders could be admitted for involuntary care: if they had simultaneous mental disorders; if they had an acute and severe psychiatric condition with unknown causes; or if they had ongoing mental impairment after an acute crisis had passed. All pertain to people with overlapping psychiatric and addiction problems. Crucially, the recommendations did not permit the authorities to hold people solely for addiction. But under Vigo’s guidelines, a physician could point to the patient’s history, conclude their drug use meant they’d be back shortly and hold them for longer to treat their mental illness.
The first 10 beds created under Vigo’s recommendations opened this April at the Surrey Pretrial Services Centre, a high-security remand centre for men detained while awaiting trial. During that time, patients receive therapy to help them learn skills to manage impulses and anger. Another six to 10 beds will open in a new, secure housing facility in the Vancouver suburb of Maple Ridge in June, with a goal of eventually housing 18 beds. Vigo says patients will also receive therapy. The facility, he says, will look like a small village. “We’ve created a more humane system, which includes a house with a beautiful garden. It’s secure, with one-on-one supervision and treatment.”
As B.C. took small steps toward mandating treatment for a select subset of patients, Alberta took giant leaps. By 2018, Marshall Smith had become a well-known advocate for addiction treatment in B.C. But the provincial government, he says, wasn’t receptive to his calls for abstinence-based treatment. “They weren’t interested in doing anything other than what they were doing, which was just a massive continuation and expansion of harm-reduction services,” he says.
In 2019, Alberta Premier Jason Kenney poached Smith, hiring him as chief of staff for the minister for mental health and addiction. His job: to build a new approach to drug treatment that deprioritized harm reduction and emphasized abstinence and recovery. Three years later, Marshall Smith became chief of staff for newly elected Premier Danielle Smith (no relation). That same year, the province amended provincial regulations to prohibit most prescriptions for safe supply—a form of harm reduction in which people are prescribed safer alternatives to illegal drugs. It also reduced supervised consumption capacity. Between 2019 and 2023, the number of booths at supervised-consumption sites fell from 37 to 24, and the only location in the province for safely inhaling drugs, in Lethbridge, was closed. Meanwhile, the province beefed up its supply of abstinence-based treatment facilities for addictions such as cocaine, fentanyl and alcohol: it added more than 2,700 residential treatment and recovery spaces in 2023 alone, bringing its total to over 6,700.
All of this was a prelude to the Compassionate Intervention Act, which was tabled in the provincial legislature last month by the province’s addictions minister, Dan Williams. If passed, it will allow a family member, guardian, health-care professional or police officer to submit an application for an individual to be considered for treatment. If the person is deemed to be at risk of causing harm to themselves or others, an apprehension order can be issued, and police can bring them to an assessment centre. They may receive one of two types of treatment: up to three months in an intervention centre, or up to six in a community-based setting.
Anticipating a wave of new patients, the province plans to spend $180 million on two new 150-bed recovery and treatment centres in Calgary and Edmonton. That’s enough for 3,600 month-long stays every year.
The plan is proceeding without the involvement of Marshall Smith, who left his government role last October. (This February, the former head of Alberta Health Services alleged that he and others in government inappropriately interfered in procurement processes. Smith has denied the allegations, which are unproven, and has sued for defamation.)
Smith believes that involuntary treatment should only be used for the worst cases—though he also says Canada is filled with them. “In any city, you can see people standing in the middle of intersections, completely lost,” he says. “They can’t look after their basic hygiene, their mental health is clearly compromised. They’re smoking crystal meth right out in the open. We’ve got to stop kidding ourselves—we’re all guilty of avoidance and denial as we clutch our Starbucks and our cellphones and walk past these people every day, sometimes stepping over them, not even recognizing that they’re there.”
Public criticism of Alberta and B.C.’s approach have been swift, and loud. In Alberta, the NDP opposition described the government’s involuntary treatment act as the “culmination of their failed drug policy.” The Canadian Public Health Association has called on the province to abandon the legislation, saying it would allow for “sweeping up individuals who do not meet the criteria for addiction” and would “expand criminalization under the guise of care.” In the online B.C. publication The Tyee, one commentator decried Alberta’s new recovery centres as “drug jails” and compared them to Soviet gulags, perfect for disappearing dissidents. In B.C., Vigo’s recommendations also touched off a storm of controversy. “This is not treatment, it is trauma,” said Dave Hamm, the president of the Vancouver Area Network of Drug Users.
Laura Johnston is a lawyer and adjunct professor at UBC and the University of Victoria. She’s also legal director of Health Justice, a non-profit focused on the laws and policies that shape mental-health and substance-use treatment in B.C. Her group has collected stories from people who have been detained under the province’s Mental Health Act. One person, a refugee and trans woman, fled police during a wellness check. She was restrained, strapped to a gurney on the ride to a hospital, sedated on arrival and held for days on suspicion of being a drug user. Johnston doesn’t believe there’s sufficient evidence to justify involuntary treatment—and she says any expansion of state power to do so must be accompanied by powerful safeguards. Her group isn’t calling for a complete end to the practice, but it is pushing for an independent legal review of B.C.’s Mental Health Act, review boards, guardrails and oversight.
Vigo also acknowledges the ethical qualms around involuntary care. His own report, from 2019, notes that B.C.’s Mental Health Act has been criticized for allowing involuntary treatment. But as a physician, he says, he has the duty to balance a person’s right to liberty with their right to care—and liberty has preconditions. Someone in a manic episode, he says, is not exercising their freedom. A physician’s duty, he says, is to help the impaired person regain it. “Doing nothing is catastrophic,” he says. “The ones paying with their brains are the same people supposedly being protected from involuntary care.” For those patients, denying involuntary care is tantamount to denying care entirely.
And yet the real-world evidence in favour of forced treatment remains scanty. Robert Tanguay is a psychiatrist who founded the Newly Institute, a chain of clinics offering addiction treatment in B.C, Alberta, Nova Scotia and New Brunswick. He is a frequent adviser on Alberta’s mental health and addictions policy. In 2023, he collaborated with Angie Hamilton, a retired Toronto lawyer and co-founder of the support group Families for Addiction Recovery, on a review of 42 previous studies on involuntary care, involving more than 350,000 participants from around the world. Despite the breadth of the review, their conclusion was ambiguous: they couldn’t determine whether involuntary treatment was helpful, harmful or neither.
In part this was due to the review’s broad scope. One study looked at American adolescents with substance-use disorders who underwent court-mandated outpatient treatment. The results were encouraging, showing a positive initial response to treatment. Other studies involved dramatically different circumstances. One looked at heroin users in China sent to compulsory detoxification centres, known for forced labour and human-rights abuses. Another complicating factor when trying to assess effectiveness is that those detained for involuntary treatment tend to be in worse shape than others. The better contrast, says Tanguay, is involuntary treatment versus no treatment at all.
In the absence of conclusive research, the most compelling evidence for either side comes down to anecdotes. I spoke to one former user, Guy Felicella, who at just 15 years old became addicted to heroin and cocaine and ended up homeless on Vancouver’s Downtown Eastside. One day in the early ’90s, he walked into a hospital gripped by paranoia after using speedballs—an injected mix of heroin and cocaine—for a solid week to stay awake so he could guard his belongings. The next thing he remembers is waking up strapped to a hospital bed. Staff had sedated him with an anti-psychotic; they told him he’d been asleep for days. The hospital mandated Felicella complete a 30-day stay in its psych ward, permitted under B.C.’s Mental Health Act. He met with psychiatrists and received medication for anxiety, but there was no harm-reduction aspect to his confinement. After a month he returned to the streets and went back to using.
Eventually, he became a regular at Vancouver’s Insite, where he injected his speedballs in relative safety. In 2013, he overdosed there. He says he would have died had a nurse not ventilated his lungs for him, squeezing a bag valve to keep him breathing. He sought therapy and was matched with Gabor Maté, the renowned addictions expert who at the time was a physician working with drug users in Vancouver. Maté asked him to open up about his childhood, and Felicella burst into tears. “I had put up walls my whole life to avoid being judged,” he says. Brick by brick, he took them down. Therapy led to an ADHD diagnosis, which explained many of his feelings of inadequacy. Slowly, it became easier to stay off drugs; that year, he stopped using. He’s been clean ever since.
I also spoke to users who believe being forced into treatment saved their lives. John, a 23-year-old man from North Vancouver, agreed to speak with me only if I used a pseudonym. He began using hydromorphone in 2021, at age 19. He and his friends obtained their supply from safe-supply depots. Offered in slow-release tablets, hydromorphone can produce similar effects to heroin when crushed, dissolved and ingested. John had already flunked out of high school and was wallowing in self-loathing. When he used, his problems vanished, gloriously resolved in the warm narcotic haze.
His parents gave him an ultimatum: go into recovery or get out of the house. In the fall of 2021, he let his parents drive him to Last Door Recovery, a private facility with locations in B.C. and Alberta that focuses on abstinence-only recovery using the 12-step model. A shared room cost his parents $10,000 a month. Cravings dogged him for months after he began treatment but, by February of 2022, his case worker approved a move to Last Door’s transitional facility, a house on the grounds where he could live with less supervision. John began working night shifts for a youth outreach team, keeping tabs on the kids after the counsellors left for the day. Now, three years later, he is taking courses at Vancouver Community College, upgrading his science credits in hopes of studying biochemistry at UBC. He considers his parents’ ultimatum an act of love: “I would never have gotten better on my own,” he says.
Even Marshall Smith, who left Danielle Smith’s staff last year, is not all-in on involuntary treatment. During New Brunswick’s 2024 election, incumbent Premier Blaine Higgs began talking about invoking the notwithstanding clause to protect the province from Charter-related legal challenges if it pursued involuntary treatment. Smith personally flew to New Brunswick to intervene. Sitting with Higgs and his cabinet, he told them not to pursue involuntary treatment without first building a robust system of voluntary care, as he’d been trying to do in Alberta. “Involuntary care can’t be the start of the conversation,” he says. “It’s what you do after the hard work of system building.”
