Science misapplied: mandatory addiction screening and treatment for welfare recipients in Ontario
=================================================================================================

* Philip B. Berger

On May 3, 2001, the Honourable John Baird, Ontario's Minister of Community and Social Services, announced his government's plan to implement addiction screening, assessment and treatment — all mandatory — for people receiving welfare benefits under the Ontario Works Act, 1997.1 Bizarrely, the Ontario government will be ordering treatment for a medical condition that does not qualify as a disability under the companion Ontario Disability Support Program Act, 1997.2 Although universal or random tests for the presence of addictive substances are not being contemplated, such testing can be ordered as part of the mandatory comprehensive assessment proposed by the Minister. The Minister's purported objective is to assist people with addictions if “there is reason to believe their addiction is posing a barrier to employment.” Those who fail to comply with the plan's requirements will be deemed ineligible for welfare benefits.

The Ontario government has singled out welfare recipients with the effect of stereotyping them as particularly affected by substance abuse problems. A study of participants in 5 social service programs in the United States indicated that rates of drug and alcohol problems in welfare recipients were no greater than those among the general population or among people who did not receive welfare benefits.3 A report from the 1990 Ontario Health Survey found that living in subsidized housing was negatively associated with substance use.4 The Centre for Addiction and Mental Health in Toronto has reported that 70% of drug users are employed.5

Obsessed with addiction, the Ontario government is neglecting the many legitimate barriers to employment. Child care responsibilities, the dependence of elderly parents on employable children, transportation costs, unaffordable housing and the unavailability of jobs that pay even minimally adequate wages all represent barriers for which the Ontario government has provided little relief.

The Ontario government is proceeding despite almost universal opposition from addiction experts and over objections from Ontario's Human Rights Commissioner.5,6 The Minister has acknowledged that “there was certainly not a lot of enthusiasm for the mandatory nature of any of our welfare reforms.”7 The proposal is the most radical application of mandatory testing and treatment in Canada. No other provincial government has similar legislation targeting an entire sector.

Such mandatory measures have been used in some circumstances. Many jurisdictions require drug testing for convicted criminals and people involved in motor vehicle accidents; in such cases, the authority for testing arises from the criminal justice system. Under a program established in 1991 by the Nova Scotia government, the Family Court of Nova Scotia can order parents with an established history of addiction and whose children are being monitored by child protection agencies to undergo mandatory drug testing for up to 12 months.8 In all these situations, those involved are protected by legal safeguards with a much higher threshold for testing and treatment than the threshold applied to people on welfare. Drug testing of certain employees is widespread, particularly in the United States, and occurs mostly in the case of occupations that could affect the safety and security of others or in which the expectation of privacy is diminished (for example, Olympic athletes).9 Employees can choose whether to work for an employer that requires drug testing as a condition of employment, and athletes can choose whether to participate in sports activities monitored by drug testing. Welfare is a matter of survival rather than choice for impoverished people. The consequences of refusing screening and testing for welfare recipients will be devastating: the denial of any income and other support, including coverage for prescription drugs.

The Centre for Addiction and Mental Health in Toronto reports that conditional treatment for some employees and convicted criminals can be beneficial;5 however, the Centre also cautions that the potential benefits in the welfare population might be offset by increased crime and social disruption among those who lose benefits.

The Ontario government plan calls for the mandatory referral (by case workers) of welfare recipients suspected of addiction to specialized welfare staff. The specialized staff will use the CAGE test as one of several screening tools for drug use. The CAGE questionnaire was designed as a screening tool to raise a physician's index of suspicion that a person may be dependent on alcohol.10 The CAGE-AID (Adapted to Include Drugs) and the Drug CAGE are variants of the CAGE test developed to screen for drug use. The sensitivity and specificity of these tests varies considerably, depending on the population studied, the number of criteria necessary to define a positive test, the types of street drugs used and the manner in which the interviewer introduces the questionnaire.11,12,13,14,15

No randomized trials have been published on the application of CAGE and related tests to populations in which people who test positive will be forced into treatment and penalized for refusing treatment. Welfare recipients who use alcohol or drugs could easily provide the answers necessary to escape detection by the CAGE test and therefore escape mandatory assessment and treatment. The Ontario government's use of the CAGE test is an example of the state's misapplication of science for the purpose of achieving ideologically motivated social change.

Finally, the Ontario government claims that it has “given careful consideration to legal issues.” Yet it is silent on the issue of patient consent. The Canadian Medical Protective Association (CMPA) has outlined the requirements for valid consent based on Canadian law.16 One element of valid consent is that it must be voluntary and, in the CMPA's phrase, “free of any suggestion of duress or coercion.”

The Ontario government plans to refer welfare recipients for a compulsory “professional, comprehensive assessment” and to demand that some recipients attend outpatient programs for mandatory treatment as a condition of receiving benefits. Both diagnosis and treatment will require the involvement of physicians and both could occur under duress and coercion.

Physicians, guided by professional ethics, will need to determine whether their allegiance is to the state or to the individual patient. The Board of Trustees of the Centre for Addiction and Mental Health has publicly opposed mandatory drug testing and treatment.17 Medical associations and professional regulatory bodies should follow its example and take a public stand against the Ontario government's plan to force welfare recipients to undergo screening, assessment and treatment for addiction.

## Footnotes

*   *Competing interests:* None declared. 

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