Overdoses as a result of opioid use disorder disproportionately affect people who have been recently released from the criminal justice system. Because of the illicit nature of most drug use, people who are affected by opioid use disorder often find themselves in and out of the system throughout their lifetimes.
However, researchers have found that better standards of care for these people can lower rates of reincarceration.
A systematic review by U of T researchers of opioid related interventions and incarceration has concluded that pharmacological intervention, such as opioid agonist treatment (OAT), could be an effective means of treating patients with opioid use disorder within incarcerated populations.
The co-authors concluded that correctional facilities should scale up OAT provision in order to decrease opioid-related overdoses and mortality rates, and improve the continuum of care for people with opioid dependence.
The effectiveness of opioid agonist treatment
The recommended treatment involves regular administration of long-acting opioid agonists — compounds such as methadone or buprenorphine-naloxone — in order to ease cravings or other symptoms of withdrawal.
OAT has been highly effective in reducing relapse, as well as opioid-related and all-cause mortality when treating patients with opioid use disorder. It has also reduced HIV and Hepatitis-C transmission rates, and is associated with social improvements in patients, such as better employment prospects and familial well-being.
Opioid use disorder treatment in Canadian correctional facilities
Despite what is known about the disproportionate rates of opioid use disorder among incarcerated populations, and the well-documented effectiveness of OAT, there are still significant barriers to the adequate provision of these treatments in prison settings.
Canada’s federal correctional system introduced OAT over 20 years ago, but its availability still varies widely between provincial, territorial, and federal facilities. Another barrier is the rapid transitions between prison and community that patients with short sentences face, as this makes it difficult to maintain treatment continuity after admission and release.
“The key finding in most studies is the need to provide a continuum of treatment before they go into the system, while they are in the system, and when they go back to the community,” said Dr. Monica Malta, an assistant professor in U of T’s Department of Psychiatry and lead author of the study, in an interview with The Varsity.
The prison setting is a promising opportunity to provide people who use drugs, and may not otherwise have access to substance-use related health care services, with prevention and treatment. The World Health Organization (WHO) maintains that incarcerated people who qualify for OAT and give consent should promptly receive it, and in a 1990 General Assembly Resolution the United Nations (UN) said that prisoners should have access to health services available in their countries, which includes OAT in Canada, without discrimination due to their incarceration.
When asked about what a continuum of treatment would ideally look like, and how that compares to the reality of Canadian prison systems, Malta explained that there is currently no standardized way of dealing with opioid dependence in prisons. “It depends on where this person is incarcerated and who is the health professional dealing with on a one-on-one basis.”
With the lack of a standardized policy that results in inconsistent coverage and quality of care, there are many prisons that do not offer OAT at all. A person receiving methadone treatment in their community could go to prison and not receive any treatment at all, which would force a painful withdrawal process — both WHO and the UN have identified this as a human rights violation.
Is it enough?
When considering substance dependence in the context of a chronic health condition, Malta emphasized that people need access to 24/7 low-threshold services “where they feel welcome any time, any day, no matter if they’re homeless or if they don’t speak English.” Malta also stressed that when witnessing an overdose, people who use drugs should not have to be afraid of re-entering the criminal justice system when calling emergency services to ask for help.
In many ways, these issues are symptoms of a larger problem.
There has been a shift in addressing substance use disorder as a health issue rather than a criminal one in Canada, and this has made substantial progress, with the legality of supervised consumption sites, implementation of naloxone programs, and availability of recreational drug checking services. However, the fact that the possession of many drugs is still a criminal offence makes it difficult to meaningfully address the health harms associated with drug use.
Without decriminalization, according to numerous public health experts, the pursuit of drug-related harm reduction will remain paradoxically at odds with the Criminal Code, which will continue to systematically disadvantage the health of people who use drugs.
Disclosure: Indhu Rammohan is the president of the Canadian Students for Sensible Drug Policy U of T Chapter.