Position Statement on Access to Opioid Agonist Treatment

2020-01-23

The Opioid Overdose Crisis

More than 11,000 Canadians have died from an accidental opioid overdose since 2016.¹ Opioid use disorder and non-medical opioid use are associated with other detrimental health outcomes including non-fatal overdose, neonatal abstinence syndrome, social disruption, and injection drug use and its associated harms.^2–4 The complex nature of the opioid overdose crisis requires a multi-faceted, cross-sectoral response. Part of this response must include interventions in the Canadian correctional system.

There is a relationship between opioid use disorder and non-medical opioid use and the involvement with the criminal justice system. Because most drug use is illegal in Canada, many people who use drugs are imprisoned. The majority of street-involved people who use illicit opioids have a history of involvement with the criminal justice system.⁴ Rates of substance use and substance use disorders are higher for people who experience incarceration, and people continue to use substances while incarcerated.^5,6 Fatal opioid overdose is associated with a recent history of imprisonment.^7,8 In this context, it is critical that effective interventions aimed at reducing the harms associated with non-medical opioid use are widely available.

Opioid Agonist Treatment

Opioid agonist treatment (OAT) uses fixed, regular dosing of a long-acting opioid agonist medication to reduce symptoms of opioid withdrawal and craving as part of treatment for opioid use disorder. Canadian guidelines for treating opioid use disorder recommend OAT as first-line therapy.⁹ The World Health Organization guidelines for treating opioid use disorder state that OAT should be available to people in prison and be equivalent to community treatment options.¹⁰ Methadone and buprenorphine are the most commonly prescribed OATs in Canada, and slow release oral morphine is a third-line option.

OAT confers significant opioid-related and all cause mortality benefit for people with opioid use disorder.¹¹ OAT in correctional facilities is an effective intervention to reduce injection drug use and prevent transmission of blood-borne infections, and is associated with reduced post-incarceration mortality and opioid use.^12–15 From a societal perspective OAT is associated with earlier release from detention and lower rates of re-offending.^16,17

Access to Opioid Agonist Treatment in Canadian Correctional Facilities

Access to OAT in Canadian correctional facilities varies widely and is often worse than access to OAT in the community. Policies in some jurisdictions endorse the delivery of OAT in prison; however, without adequate resources access remains limited. There are gaps in initiating treatment, maintaining treatment, and continuity of treatment upon admission and release, and differences between provincial, territorial, and federal facilities.^18–21

Family physicians are health advocates who are called on to be socially accountable.^22,23 The College of Family Physicians of Canada (CFPC) promotes social justice as the pursuit and/or attainment of equity in society. ²⁴ Social justice focuses on addressing the social determinants of health and minimizing their negative effects on individuals’ health.^25,26 Accordingly, the CFPC Prison Health and Addictions Medicine Member Interest Groups advocate for best health care practices for people who experience incarceration and people who use drugs in Canada.^27,28

Therefore, the purpose of this CFPC position paper is to advocate for access to the same evidence-based therapy available in the community and to recommend that OAT be initiated and maintained for all appropriate candidates at provincial, territorial, and federal correctional facilities.

Recommendations

1. All people in detention who meet criteria for evidence-based OAT (including methadone, buprenorphine-naloxone, and slow release oral morphine) and who consent to receiving treatment should have access to opioid agonist therapy without delay.
2. All people receiving OAT in the community should continue, without interruption, an appropriate OAT upon admission to detention.
3. Anyone receiving OAT in detention should be connected to community-based addiction treatment to ensure uninterrupted continuity of care on release. Preparations for this transition should be started well before the release date so all partners are aware and the transition is seamless.
4. OAT should be used as one of a suite of evidence-informed interventions to engage patients in the opioid use disorder cascade of care, and to reduce or eliminate opioid-related morbidity and mortality in people who experience incarceration.

Conclusion

Health care standards in Canadian prison settings must achieve and maintain levels that at least meet the standards of medical care available to all Canadians. OAT is the standard of care for opioid use disorder, and is available in communities across Canada. To respect the dignity and human rights of people in prison, and as part of an effective public health response to the opioid overdose crisis, OAT should be widely available to people in detention across Canada.

¹ Special Advisory Committee on the Epidemic of Opioid Overdoses. National report: Opioid-related Harms in Canada Web Based Report. Ottawa: Public Health Agency of Canada; December 2019. Available from: https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html. Accessed 2019 Dec 12.

² Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559-574.

³ Fischer B, Varatharajan T, Shield K, Rehm J, Jones W. Crude estimates of prescription opioid-related misuse and use disorder populations towards informing intervention system need in Canada. Drug Alcohol Depend. 2018;189:76-79.

⁴ Fischer B, Cruz MF, Rehm J. Illicit opioid use and its key characteristics: a select overview and evidence from a Canadian multisite cohort of illicit opioid users (OPICAN). Can J Psychiatry. 2006;51(10):624-634.

⁵ Kouyoumdjian F, Schuler A, Matheson FI, Hwang SW. Health status of prisoners in Canada: Narrative review. CFP. 2016;62(3):215-222.

⁶ Fazel S, Yoon IA, Hayes AJ. Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women. Addiction. 2017;112(10):1725-1739.

⁷ Groot E, Kouyoumdjian FG, Kiefer L, Madadi P, Gross J, Prevost B, et al. Drug toxicity deaths after release from incarceration in Ontario, 2006-2013: Review of Coroner’s Cases. PloS One. 2016;11(7):e0157512.

⁸ BC Coroners Service Death Review Panel. A review of illicit drug overdoses. Report to the Chief Coroner Of British Columbia. 2018. Available from: www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/death-review-panel/bccs_illicit_drug_overdose_drp_report.pdf. Accessed 2019 Dec 12.

⁹ Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, et al. Management of Opioid Use Disorders: A national clinical practice guideline. CMAJ. 2018;190(9):E247-E257.

¹⁰ World Health Organization. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva, CH: WHO; 2009. Available from: https://apps.who.int/iris/bitstream/handle/10665/43948/9789241547543_eng.pdf?sequence=1. Accessed 2019 Dec 12.

¹¹ Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.

¹² Kamarulzaman A, Reid SE, Schwitters A, Wiessing L, El-Bassel N, Dolan K, et al. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet. 2016;388(10049):1115-1126.

¹³ Hedrich D, Alves P, Farrell M, Stöver H, Møller L, Mayet S. The effectiveness of opioid maintenance treatment in prison settings: a systematic review. Addiction. 2012;107(3):501-517.

¹⁴ Green TC, Clarke J, Brinkley-Rubinstein L, Marshall BD, Alexander-Scott N, Boss R, et al. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry. 2018;75(4):405-7.

¹⁵ Kinlock TW, Gordon MS, Schwartz RP, O’Grady K, Fitzgerald TT, Wilson M. A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release. Drug Alcohol Depend. 2007;91(2-3):220-227.

¹⁶ Russolillo A, Moniruzzaman A, McCandless LC, Patterson M, Somers JM. Associations between methadone maintenance treatment and crime: a 17‐year longitudinal cohort study of Canadian provincial offenders. Addiction. 2018;113(4):656-667.

¹⁷ MacSwain M, Farrell MacDonald F, Cheverie M. Post-release outcomes of Methadone Maintenance Treatment Program (MMTP) participants: A comparative study (Research Report R-322). Ottawa, ON: Correctional Service Canada; 2014.

¹⁸ Kouyoumdjian FG, Patel A, To MJ, Kiefer L, Regenstreif L. Physician prescribing of opioid agonist treatments in provincial correctional facilities in Ontario, Canada: A survey. PloS One. 2018;13(2):e0192431.

¹⁹ Baker R. Human rights complaint filed over federal inmates' access to opioid treatment. CBC News. 2018 Jun 04. Available from: www.cbc.ca/news/canada/british-columbia/human-rights-complaint-opioid-treatment-1.4688486. Accessed 2019 Dec 12.

²⁰ White P. Canada’s prison agency to review treatment of inmates with opioid addictions. The Globe and Mail. 2017 Jul 17. Available from: www.theglobeandmail.com/news/national/canadas-prison-agency-to-review-treatment-of-inmates-with-opioid-addictions/article35715017/. Accessed 2019 Dec 12.

²¹ CBC News. Treatments in prison not the same across the board: John Howard Society. CBC News. 2015 Mar 01.. Available from: www.cbc.ca/news/canada/newfoundland-labrador/treatments-in-prison-not-the-same-across-the-board-john-howard-society-1.2975091. Accessed 2019 Dec 12.

²² Shaw E, Oandasan I, Fowler N, eds. CanMEDS-FM 2017: A competency framework for family physicians across the continuum. Mississauga, ON: The College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Accessed 2019 Dec 12.

²³ Buchman S, Woollard R, Meili R, Goel R. Practising social accountability: From theory to action. CFP. 2016;62(1):15-18.

²⁴ The College of Family Physicians of Canada. The CFPC Social Justice Lens Worksheet. Mississauga, ON: College of Family Physicians of Canada; 2018. Available from: www.cfpc.ca/uploadedFiles/Health_Policy/_PDFs/SJ_Lens_Final_Print.pdf. Accessed 2019 Dec 12.

²⁵ Wilkinson R, Marmot M, eds. Social determinants of health: The solid facts. 2nd ed. Copenhagen, DK: World Health Organization; 2003. Available from: www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf. Accessed 2019 Dec 12.

²⁶ Canadian Nurses Association. Social Justice: a means to an end, an end in itself. 2nd ed. Ottawa, ON: Canadian Nurses Association; 2010. Available from: www.cna-aiic.ca/~/media/cna/page-content/pdf-en/social_justice_2010_e.pdf. Accessed 2019 Dec 12.

²⁷ College of Family Physicians of Canada. Prison Health Community website. www.cfpc.ca/Prison_Health_Program_Committee/. Accessed 2019 Dec 12.

²⁸ College of Family Physicians of Canada. Addiction Medicine Community website. www.cfpc.ca/Addiction_Medicine_Program_Committee/. Accessed 2019 Dec 12.