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- Page navigation anchor for RE: Secure Care: More Harm Than Good (1) (the Commentary) and Reply to Letters to the Commentary (2) (the Reply)RE: Secure Care: More Harm Than Good (1) (the Commentary) and Reply to Letters to the Commentary (2) (the Reply)
We agree with the authors of the Commentary that secure care is not the solution to the overdose crisis. We further agree that evidence-based addiction treatment for youth is largely non-existent and urgently needed. Unfortunately, the title of the Commentary, “Secure Care: More Harm than Good” is not supported by the authors’ references.
Evidence on Effectiveness of Secure Care
We concur with Warshawski and colleagues that the references used in the Commentary do not support the conclusion that secure care is ineffective. (3) Further, the references used in the Reply, if anything, support the opposite conclusions to those reached in the Reply which concludes, “Coerced addiction treatment interventions have been found to be inadequate in reducing negative substance use outcomes (8) while increasing mental duress (9) and risk of overdose (10).”
Contrast that with what those references actually concluded:
8. “Voluntary treatment for SUD generally yielded better outcomes; nevertheless, we also found improved outcomes for CA (compulsorily admitted) patients. It is important to keep in mind that in reality, the alternative to CA treatment is no treatment at all and instead a continuation of life-threatening drug use behaviours. Our observed outcomes for CA patients support the continuation of CA treatment.” (4)
9. “In-patient treatment reduces mental distress for both CA (compulsorily admitted) and VA (voluntarily admitted) patients. The time...
Show MoreCompeting Interests: Daphne Jarvis was retained by Families for Addiction Recovery to provide legal advice on the issues addressed in this response. - Page navigation anchor for Reply to Letters to CMAJ Commentary ‘Secure care: more harm than good’Reply to Letters to CMAJ Commentary ‘Secure care: more harm than good’
We thank Clark and colleagues for their presentation of an ethical perspective on secure care in response to our previously published commentary on this topic (1, 2). We fully agree that the ethical criteria presented in their letter (3, 4) are critical considerations in this important discussion. In our assessment outlined below, we conclude that secure care fails many of these fundamental ethical tests and is therefore ethically problematic on numerous fronts. Consistent with our original commentary (2), this leads us to call for increased investments in voluntary treatment services and other supports as opposed to secure care policies.
In describing the first ethical criteria for considering secure care, Clark and colleagues state “If evidence does not support effectiveness of secure care in meeting treatment goals, such infringement on youth autonomy is ethically problematic.”(1) While secure care has not been specifically evaluated, there is an existing body of literature on the use of coercion in addiction treatment that raises significant doubts about the expected ability of secure care to reduce negative outcomes among people who use drugs (5-7). Coerced addiction treatment interventions have been found to be inadequate in reducing negative substance use outcomes (8) while increasing mental duress (9) and risk of overdose (10). Given that secure care infringes on the autonomy of those who it targets, it would seem to us that when deciding whether or not to...
Show MoreCompeting Interests: None declared. - Page navigation anchor for An ethical perspective on the use of secure care for youth with severe substance useAn ethical perspective on the use of secure care for youth with severe substance use
As clinical ethicists, we read with interest the recent commentary of Pilarinos et al Secure Care: More Harm Than Good [1]. In British Columbia, discussion is ongoing regarding secure care legislation for youth involved in high-risk substance use (HRSU) [2], and we commend these authors for bringing their concerns forward. We encourage application of an ethical lens, incorporating ethical principles and consideration of a range of ethical issues, in development of policy and treatment programs for this population.
Prior to consideration of intervention contrary to individual’s wishes, a significant risk of harm must be established. Harms of HRSU by youth can range from decreased school performance to death by overdose [3]. Longer term, yet less clearly documented effects, such as impacts on the developing brain, are also of serious concern [3,4].
Overriding autonomy by means of involuntary treatment should never be taken lightly, as this can cause significant harms. Many youths possess the capacity and legal authority to make health care decisions [5,6]. However, some scholars posit that individuals with severe substance use disorders may struggle to follow through on decisions to reduce or abstain from substance use due to the neurobiologic effects of addiction—leading to actions that go against their authentic values or best interests [7]. The question of whether an individual with a severe substance use disorder can be capable of making autonomous decisi...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Secure care: more harm than goodRE: Secure care: more harm than good
Re: “Secure care: more harm than good”
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British Columbia (BC) is the epicenter of the illicit drug overdose crisis in Canada. There were 1422 overdose deaths in 2017 and 23 of these deaths occurred in children (age 10–18 years) (1) . Rates of illicit drug deaths in this age group doubled between 2015 and 2016 and doubled again between 2016 and 2017.
The BC Coroners Service has reported that 31% of youth with fatal overdoses had a previous non-fatal overdose (2), an association also described in adults (3) . It is therefore understandable that the families and caregivers of youth with dangerous substance use disorders (SUD) have called upon the province of BC to join the rest of Canada and provide mandated care, or secure care, for youth with dangerous patterns of drug use who refuse voluntary treatment (4,5). Some, however, oppose mandated care.
In a recent CMAJ commentary, Pilarinos et al., state that “existing evidence suggests that mandatory addiction treatment does not lead to significant improvements in substance use outcomes” (6). The meta-analysis by Tanner-Smith cited to support this assertion, comes to no such conclusion. The authors compared traditional youth courts to juvenile drug courts and concluded that “[juvenile] drug courts were not found to be categorically more or less effective than traditional court processing for reducing recidivism or drug use. The great variability in effects, nonetheless, suggests that there may be effective drug...Competing Interests: None declared.