Negotiating care and control: practitioner discretion and support for mandatory treatment in community-based addiction services

Drug policy medicalization has shifted addiction services into health-led hybrid systems, where therapeutic care and social control coexist. We examined how frontline practitioners in Taiwan navigate this patient-offender paradigm and the individual and organizational factors associated with support for mandatory treatment.

We conducted a national vignette experiment (n = 635; 92.3% response rate) among frontline staff across 22 Taiwanese Drug Prevention Centers. Participants responded to methamphetamine-use scenarios varying by client gender and socioeconomic position (SEP). We used regression modeling to analyze individual-level support for mandatory treatment alongside center-level factors, including caseload density, professional plurality, and shared perceptions of dangerousness.

Perceived dangerousness was the strongest correlate of both crime-oriented responses (β = 0.25, p < 0.001) and support for mandatory treatment (β = 0.35, p < 0.001), whereas prior exposure to physical violence from clients was associated with lower endorsement of health-oriented responses. Health-oriented responses remained positively associated with support for mandatory treatment after adjustment (β = 0.20, p < 0.001). Neither client gender nor SEP was independently associated with support for mandatory treatment.

Support for mandatory treatment was associated primarily with therapeutic reasoning under conditions of perceived risk rather than punitive intent. Health-led reforms may inadvertently sustain coercive practices by framing compulsory intervention as therapeutic. Policy should shift from risk-based to rights-based frameworks to limit coercive practices in addiction services.