The opioid overdose crisis has killed almost 14,000 Canadians since 2016.

One flashpoint of this crisis is Canada’s correctional facilities. Opioid-related deaths are increasing among incarcerated people. Post-release, their prospects are even worse: in the two weeks after release, a prisoner’s risk of overdose is more than 50 times higher than in the general population. One in 10 of all overdose deaths is a prisoner released in the past year.

Despite this, our prisons and jails often delay or deny access to evidence-based treatments for opioid use disorder and fail to ensure appropriate supports on release.

Opioid agonist therapy

Governments have brought class-action lawsuits against pharmaceutical companies and prosecuted overprescribing doctors. Canada’s federal government is taking action on opioids.

But our divergent experiences as a physician, a legal academic and a formerly incarcerated harm reduction activist have taught us that much of the responsibility lies with government itself — specifically, its failure to provide prisoners with timely access to opioid agonist therapy (OAT) and ensure post-release continuity of treatment.

AP Photo/Kevin D. Liles

People incarcerated in Canada’s federal prisons and provincial-territorial jails are highly likely to have experienced childhood trauma, poverty and the corrosive effects of racism and colonialism. They are highly likely to struggle with addictions and mental illness. Incarcerated people, like many on the outside, use drugs as a form of coping.

OAT provides a medication (usually buprenorphine/naloxone or methadone) to prevent drug cravings and withdrawal symptoms. It is the first-line treatment for opioid use disorder and the standard of community-based care across Canada. OAT saves lives, reduces HIV and hepatitis C transmission, improves a host of social and psychological outcomes and is associated with a decreased risk of future criminal charges and imprisonment.

Legal standards for health care

Canadian and international law obliges prisons to provide incarcerated people with health care at community standards. But research, coroners’ inquests and prisoners’ rights groups all tell a similar story: too often, people are not provided addictions treatment on admission, whether or not they were being treated in the community. This means they go into acute withdrawal and are at increased risk of use, relapse and overdose.

THE CANADIAN PRESS/Andrew Vaughan

The result? Missed opportunities to provide care to people who desperately need it, and deaths with little oversight or accountability. While we pursue progressive solutions like decriminalization and safe supply, we must urgently make OAT available to everyone incarcerated who would benefit.

In Nova Scotia, the provincial health authority is responsible for delivering health care in the province’s jails, rather than Correctional Services, as is common in other provinces. Nova Scotia’s jails have a blanket policy ofnot providing prisoners with OAT unless they are already on it when they arrive. Those who are not on therapy suffer through withdrawal or find ways to keep using illicitly inside. This is a clear violation of the government’s legal obligation to provide equivalent health care in detention.

Provinces like Ontario, which have celebrated Nova Scotia’s wisdom in making correctional health care the responsibility of the Department of Health and Wellness instead of corrections, should take note: simply shifting responsibility is not enough to ensure sound policy.

Feeding a crisis by limiting OAT

As people who have lived or worked in prisons and with people who have been incarcerated, we have seen first-hand how limiting OAT in prison feeds the opioid crisis inside. It increases the demand for illicit drugs to be smuggled in or diverted.

In some institutions, those receiving OAT are subjected to a daily strip search: a degrading and re-traumatizing practice. Others who want the medication to prevent their own withdrawal symptoms target prisoners receiving OAT. People soon start diverting their medication, for instance by vomiting it up and straining it through a sock for someone else to use. If someone says no to a demand to divert their OAT, they may be subject to violence.

If someone is caught diverting, their OAT is discontinued, placing them at high risk of overdose. If treatment were not so intensely restricted, these adverse events could be reduced or eliminated.

AP Photo/The Evening News, Chuck Branham

There are a few glimmers of hope. Rhode Island implemented a statewide correctional OAT program and saw a 60.5 per cent reduction in one-year overdose mortality after release. In 2016, people incarcerated in British Columbia launched a Charter challenge over policies limiting access to OAT in B.C. jails; while that lawsuit settled, it contributed to increased access to the treatment. Access expanded further when the B.C. Ministry of Health took over provincial correctional health services in 2017.

But elsewhere, access to OAT in federal prisons or provincial jails continues to be denied or unreasonably delayed. This has led B.C.’s Prisoners’ Legal Services to launch a representative human rights complaint on behalf of federal prisoners with opioid use disorder, focused on access to OAT.

Federal, provincial and territorial governments need to step up and tackle the opioid epidemic at its flashpoint: our prisons and jails. Timely access to OAT for every incarcerated person who could benefit is required to turn the tide of death and ill health. Until we make these changes, Canada’s most vulnerable will continue to endure extraordinary suffering at the hands of our government and the body count will continue to rise.