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. Author manuscript; available in PMC: 2019 Dec 1.
Published in final edited form as: Drug Alcohol Depend. 2018 Oct 6;193:42–47. doi: 10.1016/j.drugalcdep.2018.09.003

Utilization of opioid agonist therapy among incarcerated persons with opioid use disorder in Vancouver, Canada

Nikki Bozinoff 1,2, Kora DeBeck 1,3, M-J Milloy 1,4, Ekaterina Nosova 1, Nadia Fairbairn 1,4, Evan Wood 1,4, Kanna Hayashi 1,5,*
PMCID: PMC6239888  NIHMSID: NIHMS1509854  PMID: 30340144

Abstract

Background:

Inability to access opioid agonist therapy (OAT) in correctional settings has previously been reported in Vancouver, Canada, and is associated with harms among people with opioid use disorder (OUD), including overdose death. We investigated the prevalence and correlates of OAT utilization within correctional settings among incarcerated persons with OUD in Vancouver.

Methods:

Data were derived from three prospective cohorts of people who use drugs in Vancouver between 2005 and 2016. Using multivariable generalized estimating equations, we examined factors associated with OAT utilization among participants with OUD reporting incarceration in the past six months.

Results:

Among 597 eligible participants, 207 (34.7%) contributed 325 reports of having utilized OAT while incarcerated. Of those, 295 (90.8%) were continuations and 30 (9.2%) were new initiations of OAT while incarcerated. For those currently on OAT (at the time of interview), in multivariable analyses, non-fatal overdose (adjusted odds ratio [AOR]=0.49, 95% confidence interval [CI]: 0.29–0.82) and daily prescription opioid use (AOR=0.42, 95% CI: 0.20–0.85) remained independently and negatively associated with having utilized OAT while incarcerated. For those not currently on OAT, none of the variables considered had significant associations with utilization of OAT while incarcerated.

Conclusions:

Utilization of OAT in correctional settings was low in our sample. Utilization of OAT was significantly and negatively associated with overdose and ongoing prescription opioid misuse if OAT was continued upon release from correctional settings. Findings underscore the urgent need for improved utilization of OAT in correctional settings, and linkage to community care to prevent harms such as overdose.

Keywords: opioid agonist therapy, incarceration, opioid use disorder, overdose, British Columbia

1. Introduction

Vancouver, British Columbia (BC), Canada, like many areas in North America, is currently struggling with an opioid overdose crisis. Across the province, 931 unintentional overdose deaths related to illicit drugs were reported in 2016 (61.8% involving fentanyl), an increase from 531 in 2015, and 341 in 2014 (British Columbia Coroners Service, 2017a), prompting the Provincial Health Officer to declare a public health emergency in April 2016. In spite of this measure, the number of opioid overdose deaths increased another 43% in 2017 (British Columbia Coroners Service, 2017b).

People with substance use disorders are over-represented in corrections systems, with 69% of Canadian federal inmates reporting substance abuse problems (Kunic and Grant, 2006). Nine percent of men and 16% of women in federal correctional institutions reported injecting opioids in the six months prior to incarceration (Zakaria et al., 2010) and similarly, in provincial correctional settings, 7.5% reported using heroin and 35.3% reported using other opioids in the year prior to incarceration (Kouyoumdjian et al., 2014). It is well documented that illicit opioid use persists in correctional facilities (Small, 2005; Wood et al., 2006a), with 10–20% of incarcerated persons testing positive for opioids on random urine drug screening (Kendall and Pearce, 2000). Release from correctional settings has been associated with an increased risk of overdose death in multiple settings (Binswanger et al., 2013; Binswanger et al., 2007; Bird and Hutchinson, 2003; Farrell and Marsden, 2008; Groot et al., 2016; Kouyoumdjian et al., 2016) presumably due to involuntary detoxification of opioid-dependent clients while incarcerated and resultant loss of tolerance (Binswanger et al., 2012; Strang et al., 2003; Tagliaro et al., 1998). Therefore, ensuring access to opioid agonist therapy (OAT) for people with opioid use disorder (OUD) in these settings is important to address the ongoing opioid overdose crisis.

Unlike many U.S. and other Canadian jurisdictions (Wakeman and Rich, 2015), in federal and provincial correctional facilities in BC, OAT can be initiated for persons with OUD, or continued for those already prescribed OAT prior to incarceration. Methadone maintenance therapy (MMT) has been available in provincial correctional settings in BC since 2002 and buprenorphine/naloxone has been available since 2010 (Burgmann, 2016). However, according to media reports, many incarcerated persons had reported being unable to access OAT while incarcerated (Burgmann, 2016), placing them at risk of unintentional overdose while incarcerated and upon release. In provincial correctional settings, a private corporation administered health care services prior to September 2017. Under the corporation, policy documents indicate that “patients who are suitable and have requested to participate in the BC Suboxone or Methadone Maintenance Programs are evaluated according to the criteria outlined in the most recent version of the Methadone Guideline, published by the College of Physicians and Surgeons of BC” (Chiron Health Services Inc., 2016). However, clients must self-identify as requiring OAT during an initial health assessment or other clinical encounter, and the nurse then books an appointment with a physician based on a priority system; pregnancy, debilitating illness, comorbid HIV/HCV, injection drug use, and individuals started on Suboxone taper protocols who wish to stay on OAT are given highest priority (Chiron Health Services Inc., 2016). Additionally, there are no minimum time requirements stipulated for accessing a prescribing physician following completion of a priority assessment (Chiron Health Services Inc., 2016). Furthermore, the absence of needle and syringe and other harm reduction programs in correctional settings also places individuals at risk of acquiring blood-borne infections, such as HIV and hepatitis C virus (HCV; Small, 2005). Given the known harms associated with untreated OUD in the correctional system, and the fact that OAT is, in theory, available to all people held in federal and provincial correctional facilities in BC, our setting presents a unique opportunity to explore gaps in care delivery and its potential contribution to the overdose crisis in this setting. In this exploratory study, we aimed to investigate the prevalence and correlates of OAT utilization within correctional settings among incarcerated persons with OUD in Vancouver, BC.

2. Material and methods

2.1. Participants

Data for this study were obtained from the At-Risk Youth Study (ARYS), the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS) and the Vancouver Injection Drug Users Study (VIDUS), three ongoing, open prospective cohort studies of people who use drugs in Vancouver, Canada. These cohorts have been described in detail previously (Tyndall et al., 2003; Wood et al., 2006b). Briefly, snowball sampling and extensive street-based outreach methods were employed to recruit participants for all three studies. To be eligible for ARYS, participants had to be aged 14–26 years at enrollment, use illicit drugs other than or in addition to marijuana in the past month, be street-involved, reside in the greater Vancouver area, and provide written informed consent. Youth who were homeless or using services for homeless youth were considered “street-involved” in this study. To be eligible for ACCESS, participants had to be HIV-positive, and report using an illicit drug other than or in addition to cannabis in the past month. To be eligible for VIDUS, participants had to be HIV-negative and report injecting a drug at least once in the month preceding enrollment. For both ACCESS and VIDUS, participants had to be aged 18 or older at the time of enrollment, reside in the greater Vancouver area, and provide written informed consent. All three cohorts employed harmonized data collection and follow-up procedures to allow for combined analyses. Specifically, at enrolment, and every six months, participants completed harmonized interviewer-administered questionnaires that included questions related to demographic information, drug use patterns and other behaviors and exposures, and provided blood samples tested for HIV (for HIV-negative individuals), HIV clinical monitoring (for people living with HIV) and HCV antibodies. At each study visit, participants were provided with a stipend ($30 CDN) for their time. The University of British Columbia/Providence Health Care Research Ethics Board approved the studies.

For the present analysis, participants were included if they had completed an interview between September 2005 and May 2016. Because we were interested in understanding utilization of OAT for those with OUD while incarcerated, the sample was restricted to those observations where incarceration in the past six months was reported, defined as having been in prison, jail or detention (yes vs. no) and to cases where OUD was presumed. In this case, OUD was presumed if the participant reported at least daily use of any illicit opioids (including non-medical use of prescription opioids), or were on OAT (i.e., methadone or buprenorphine/naloxone) in the past six months at the study visit where incarceration was reported, or in the visit immediately prior to the study visit when incarceration was reported. In this way, we aimed to capture all participants eligible for OAT while incarcerated. Baseline data for this analysis were derived from the first visit where incarceration in the last six months was reported.

2.2. Measures

Our outcome of interest was self-reported utilization of OAT (i.e., methadone or buprenorphine/naloxone) while incarcerated (yes vs. no). We selected a range of variables that we hypothesized might be associated with utilization of OAT while incarcerated. Socio-demographic characteristics included: age (per 10 years older); sex (female vs. male); and ethnicity (white vs. other). Substance use patterns included heavy alcohol use; ≥ daily cocaine use; ≥ daily crack cocaine use; ≥ daily crystal methamphetamine use; ≥ daily heroin use; and ≥ daily prescription opioid use (all yes vs. no, all by any route). Heavy alcohol use was defined according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria for “heavy” or “at-risk” drinking: an average of >3 alcoholic drinks per occasion or >7 drinks per week in the past six months for women, and an average of >4 alcoholic drinks per occasion or >14 drinks in total per week in the past six months for men (NIAAA, 2005). Drug use patterns while incarcerated included: use of heroin; cocaine; and crystal methamphetamine (all yes vs. no, all by any route). Other variables considered included: non-fatal overdose; hepatitis C virus seropositivity; and reported syringe sharing (all yes vs. no). We also included a variable indicating cohort designation (VIDUS vs. ACCESS vs. ARYS). All drug use and behavioral variables referred to activities or experiences in the past six months and were treated as time-varying variables.

2.3. Analyses

First, we compared the baseline sample characteristics among those who did and did not utilize OAT while incarcerated at least once during the study period by using Pearson’s Chi-square test (for categorical variables) and the Wilcoxon rank sum test (for continuous variables). Fisher’s exact test was used when one or more of the cells contained expected values less than or equal to five.

Next, in order to identify a set of variables that best explain a higher or lower odds of utilizing OAT while incarcerated, we employed multivariable generalized estimating equations (GEE) with logit-link function, which provided standard errors adjusted by multiple observations per person using an exchangeable correlation structure. Further, given that the factors potentially associated with utilization of OAT while incarcerated may change depending on whether or not OAT was discontinued after being released from correctional settings, we stratified the analysis by whether the participant reported being on OAT at the time of interview (yes vs. no). To fit our multivariable GEE models, we used an a priori-defined backward model selection process based on the examination of quasilikelihood under the independence model criterion statistic (QIC). In brief, all variables significant at the p<0.10 threshold in bivariable analyses were entered in a full multivariable GEE model. After examining the QIC value of the models, the variable with the largest p-value was removed and a reduced model was built. This iterative process was continued until a model with the lowest QIC value was selected. All statistical analyses were performed using R, version 3.2.4 (R Foundation for Statistical Computing, Vienna, Austria). All p-values are two sided.

3. Results

In total, 597 individuals met the eligibility criteria of having presumed opioid use disorder and reporting incarceration in the last six months. These individuals completed a median of two (interquartile range [IQR]: 1–3) study visits involving a report of incarceration in the last six months, and contributed 1251 observations to the present analysis. The median number of days incarcerated for each observation was 20 (IQR: 3–60) days. The majority (n=576; 96.5%) had a history of injection drug use at baseline. Baseline data stratified by utilization of OAT while incarcerated are reported in Table 1. As shown, the median age of our sample at baseline was 35.9 years (IQR: 26.8–43.3), 194 (32.5%) were female, and 362 (60.6%) self-reported white ethnicity. At baseline, 420 (70.4%) participants reported ≥ daily heroin use and 102 (17.1%) reported ≥ daily prescription opioid use in the last six months.

Table 1.

Baseline characteristics of incarcerated people with OUD, stratified by having utilized OAT while incarcerated (n=597).

Characteristic Total (%) N= 597 Ever utilized OAT while incarcerated p-value
Yes (%) N= 207 No (%) N=390
Age (median [IQR])€ 35.9 (26.8–43.3) 37.1 (29.2–43.9) 34.6 (26.2–42.8) 0.024
Female 194 (32.5) 60 (29.0) 134 (34.4) 0.182
White 362 (60.6) 119 (57.5) 243 (62.3) 0.251
Heavy alcohol use* 80 (13.4) 26 (12.6) 54 (13.8) 0.652
Daily cocaine use*θ 78 (13.1) 31 (15.0) 47 (12.1) 0.324
Daily crack use*θ 282 (47.2) 107 (51.7) 175 (44.9) 0.100
Daily crystal methamphetamine use*θ 94 (15.7) 25 (12.1) 69 (17.7) 0.073
Daily prescription opioid use*θ 102 (17.1) 26 (12.6) 76 (19.5) 0.032
Daily heroin use*θ 420 (70.4) 128 (61.8) 292 (74.9) 0.001
Heroin use while incarcerated*θ 44 (7.4) 18 (8.7) 26 (6.7) 0.367
Cocaine use while incarcerated*θ 43 (7.2) 21 (10.1) 22 (5.6) 0.043
Crystal meth use while incarcerated*θ 19 (3.2) 4 (1.9) 15 (3.8) 0.205
Non-fatal overdose* 109 (18.3) 32 (15.5) 77 (19.7) 0.197
Syringe sharing* 74 (12.4) 26 (12.6) 48 (12.3) 0.947
Hepatitis C positive 473 (79.2) 174 (84.1) 299 (76.7) 0.034
Cohort ARYS 134 (22.5) 31 (15.0) 103 (26.4) 0.010
VIDUS 323 (54.1) 123 (59.4) 200 (51.3)
ACCESS 140 (23.5) 53 (25.6) 87 (22.3)
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*

Refers to activities in the last six months

θ

Refers to substance use by any route (IV, oral, intranasal, smoked)

€

refers to continuous variable, p-value is generated from Wilcoxon rank-sum test

ACCESS: AIDS Care Cohort to evaluate Exposure to Survival Services; ARYS: At-Risk Youth Study; IQR: interquartile range; OAT: opioid agonist therapy; OUD: opioid use disorder; VIDUS: Vancouver Injection Drug Users Study

A total of 207 (34.7%) participants reported having utilized OAT while incarcerated at some point during the study period. Of the 1251 observations, only 325 (26.0%) included a report of utilizing OAT while incarcerated. Among them, 295 (90.8%) were continuations on OAT and only 30 (9.2%) were new initiations of OAT. Among those who continued their OAT, the median number of days participants waited prior to receiving their first dose was two days (IQR:1–3). Among those who started OAT while incarcerated, the most common duration to wait was 2–3 days. Among the 325 observations where OAT while incarcerated in the last six months was reported, 167 (51%) observations included a report of current community supervision defined as bail, conditional sentencing, diversion, parole or probation, while 107 (33%) reported no community supervision and the remainder did not respond.

The location of detention as well as the proportion of observations in each location with a report of OAT utilization is reported in Table 2. Most observations involved a report of being detained in provincial correctional settings (654 observations). Fifty percent of those observations in federal correctional settings also involved a report of utilizing OAT while 35.3% and 14.7% of those observations in provincial and local correctional settings respectively involved a report of OAT utilization.

Table 2.

OAT utilization by location of detention

Location of detention Total observations N=325 Observations involving a report of OAT utilization N (%)
Not reported 53 3 (5.7)
Federal 24 12 (50)
Local 497 73 (14.7)
Provincial 654 231 (35.3)
Youth detention center 23 6 (26.1)
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The results of bivariable and multivariable GEE analyses stratified by current OAT status are presented in Table 3. For those participants currently on OAT (at the time of interview), in multivariable analyses, non-fatal overdose (adjusted odds ratio [AOR]=0.49 95% confidence interval [CI]: 0.29–0.82) and daily prescription opioid use (AOR=0.42, 95% CI: 0.20–0.85) remained independently and negatively associated with having utilized OAT while incarcerated. For those participants not currently on OAT, none of the variables considered had significant associations with the outcome.

Table 3.

Bivariate and multivariable GEE analysis of factors associated with utilizing OAT while incarcerated among people with OUD stratified by current OAT status

Currently on OAT
N observations= 488		 Not currently on OAT
N observations= 759
Unadjusted Adjusted Unadjusted
Characteristic Odds Ratio p-value Odds Ratio (95% CI) p-value Odds Ratio p-value
Age € (per 10 years older) 1.10 (0.90–1.35) 0.363 1.01 (0.70–1.46) 0.971
Female 0.68 (0.45–1.03) 0.068 0.67 (0.44–1.01) 0.058 0.81 (0.39–1.69) 0.578
White 0.74 (0.49–1.10) 0.134 0.85 (0.45–1.62) 0.628
Heavy alcohol use* 1.00 (0.57–1.73) 0.989 0.94 (0.39–2.29) 0.897
Daily cocaine use*θ 1.43 (0.84–2.44) 0.193 0.89 (0.36–2.24) 0.807
Daily crack use*θ 0.85 (0.58–1.24) 0.401 0.95 (0.50–1.80) 0.881
Daily crystal meth use*θ 0.89 (0.50–1.56) 0.675 1.80 (0.85–3.81) 0.125
Daily prescription opioid use*θ 0.39 (0.20–0.76) 0.005 0.42 (0.20–0.85) 0.017 0.82 (0.38–1.81) 0.630
Daily heroin use*θ 0.69 (0.46–1.03) 0.071 0.79 (0.40–1.54) 0.490
Any heroin use while incarcerated*θ 0.61 (0.29–1.26) 0.183 1.79 (0.76–4.18) 0.181
Any cocaine use while incarcerated*θ 0.94 (0.42–2.13) 0.889 1.98 (0.77–5.12) 0.158
Any crystal meth use while incarcerated*θ 0.37 (0.07–1.85) 0.226 2.23 (0.65–7.68) 0.204
Non-fatal overdose* 0.46 (0.28–0.76) 0.003 0.49 (0.29–0.82) 0.007 1.57 (0.80–3.07) 0.190
Hepatitis C positive 1.28 (0.71–2.30) 0.413 1.34 (0.57–3.12) 0.500
Syringe sharing* 0.55 (0.27–1.10) 0.090 1.61 (0.66–3.92) 0.295
VIDUS vs. ARYS 0.85 (0.45–1.61) 0.625 0.84 (0.39–1.84) 0.667
ACCESS vs. ARYS 1.09 (0.55–2.17) 0.813 1.32 (0.50–3.50) 0.576
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*

Refers to activities in the last 6 months

θ

Refers to substance use by any route (IV, oral, intranasal, smoked)

“€”

refers to continuous variable, p-value is generated from Wilcoxon rank-sum test

ACCESS: AIDS Care Cohort to evaluate Exposure to Survival Services; ARYS: At-Risk Youth Study; IQR: interquartile range; CI: confidence interval; GEE: generalized estimating equations; OAT: opioid agonist therapy; OUD: opioid use disorder; VIDUS: Vancouver Injection Drug Users Study

**

4 observations had missing data about OAT status in one condition and were excluded from the GEE analyses

Table 4 provides details regarding the frequency of observations involving a report of prescription opioid use and non-fatal overdose stratified by OAT utilization while incarcerated and at current visit. Utilizing OAT while incarcerated and on release is associated with the lowest proportion of reports of daily prescription opioid use and non-fatal overdose.

Table 4.

Daily prescription opioid use and non-fatal overdose stratified by OAT utilization while incarcerated and at current visit

On OAT during incarceration and at current visit On OAT during incarceration but not at current visit No OAT during incarceration but on OAT at current visit No OAT during incarceration nor at current visit
N observations = 276 (%) N observations = 46 (%) N observations = 212 (%) N observations = 713 (%)
daily prescription opioid use 12 (4.35) 8 (17.39) 24 (11.32) 142 (19.92)
non-fatal overdose 29 (10.51) 13 (28.26) 44 (20.75) 133 (18.65)
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*

4 observations had missing data about OAT status in one condition and were excluded from the GEE analyses

4. Discussion

Our results demonstrate that, although people with OUD can access OAT in correctional settings in BC in theory, it is poorly utilized in practice. Of the 1251 observations involving a report of incarceration who presumably had OUD in our study, only 325 (26.0%) included a report of OAT utilization. This is consistent with data from European jurisdictions where two recent reviews revealed that less than 16% of people who use opioids were offered OAT (Larney and Dolan, 2009; Stover and Michels, 2010) in correctional settings that purported to support its use. Our results also demonstrated that among persons who did utilize OAT in correctional settings, the majority (90.8%) were continuations rather than new OAT starts. This indicates that in some cases, prescriptions for OAT are being continued but the more difficult work of identifying and diagnosing OUD is not being undertaken. Barriers to accessing health services in correctional settings have been well-documented and include long wait lists, under-skilled or non-empathic healthcare staff, and a lack of continuity of care (Plugge et al., 2008; Rabia et al., 2016). Barriers to OAT identified in European correctional settings with access to OAT on paper, include restrictive entrance criteria (for example OAT being limited to persons jailed for a particular length of time or age), and limitations of trained health personnel (Stover and Michels, 2010). It is not possible to infer from our results the barriers to new OAT starts in correctional settings in BC. However, greater institutional acknowledgement of gaps in treatment engagement and ensuring that skilled addiction medicine providers are in all corrections settings can be expected to improve OAT uptake among individuals with OUD and support overdose prevention efforts.

Echoing previous work (Bird et al., 2015; Degenhardt et al., 2014; Green et al., 2018; Marsden et al., 2017) we found that for those on OAT at the time of interview, having utilized OAT while incarcerated was negatively associated with non-fatal overdose and daily prescription opioid use. This finding raises questions about the ethics of failing to adequately support OAT initiation among incarcerated individuals with OUD in BC, other Canadian provinces, and jurisdictions in the United States, particularly as the opioid crisis intensifies.

Our results also demonstrate that the protective effects of OAT utilization in correctional settings disappeared if OAT is discontinued post-incarceration, which is consistent with studies demonstrating benefits of retention in OAT post-incarceration (Dolan et al., 2005; Hedrich et al., 2012). The OAT policy from provincial correctional settings during the study period does emphasize the importance of OAT continuation after release, and recommends that clients be encouraged and assisted in returning to their community prescriber or sourcing a new prescriber on release and provision of a two-week release prescription (Chiron Health Services Inc., 2016). However, coordinated aftercare planning for persons on OAT while incarcerated is difficult. A major barrier includes clients transitioning from private to public health care systems where personal health records are not shared. Additionally, clients in pre-trial settings may be released following a court appearance without prior notice, interfering with a physicians’ ability to assess a client and provide an OAT prescription prior to release. Fragmentation of care on discharge has previously been identified as a major barrier to care for incarcerated persons (Rabia et al., 2016), and our work highlights the importance of ensuring smooth transitions to community health care providers on discharge from correctional settings. Care-transition programs are already well described (although rarely implemented) for persons receiving HIV treatment and women receiving prenatal care (Lincoln et al., 2006; Myers et al., 2017). These may shed light on possible models of transitional care including employing physicians who work dually in correctional settings and in community (Lincoln et al., 2006), team-based discharge planning, intensive case management and the utilization of patient navigators (Koester et al., 2014; Myers et al., 2017). The recent transition of medical health services in the provincial correctional system from a private corporation to the publicly-funded Provincial Health Services Authority in September 2017 has the potential to facilitate improved care in correctional settings and improved discharge planning by bringing health care provision under a single public healthcare system framework. Additionally, newly implemented policies and procedures at the provincial level that have potential to improve utilization of OAT include provision of OAT by the next day of admission to the facility (and same day in the context of clinical opioid withdrawal), provision of a prescription for OAT on discharge, having the correctional setting healthcare team liaise with a community prescriber to facilitate an OAT prescription if released without notice, as well as overdose education and take home naloxone kit distribution prior to release. Similar provisions should be implemented in other detention locations such as the local and federal systems.

There are a number of limitations to this study. First, the reliability of our results may be limited by the fact that we did not conduct structured diagnostic interviews to make a diagnosis of OUD. Instead, we assumed that those who used illicit opioids at least daily, or reported current opioid agonist therapy had a diagnosis of OUD. Nevertheless, given the fact that (70.4%) participants reported daily heroin use and 102 (17.1%) reported using illicit prescription opioids daily, we believe that our inclusion criteria were conservative. Another limitation is that we were not able to capture those participants who were offered OAT but declined, nor those participants for whom OAT may have been medically contraindicated. Further, participants who died from overdose would also not be captured; however, this would bias our results toward the null. Unfortunately, our data was also limited by the fact that not all participants had completed a study visit immediately prior to the visit in which incarceration was reported. It is therefore not possible to ascertain the number of participants who were accessing OAT prior to incarceration. Our findings are also subject to response biases as a limitation of using self-report surveys; however, previous work has found that self-reporting among people who use drugs is generally congruent with actual behavior (Brener et al., 1995; Darke, 1998; Rosenbaum, 2009) and we expect that any response biases from participants in this study would underestimate the prevalence of drug use and therefore bias our results towards the null. Finally, since our sample was not recruited at random from correctional institutions, our findings may not be generalizable to all persons with OUD who are incarcerated.

5. Conclusion

In conclusion, utilization of OAT in correctional settings was low in our sample. Utilization of OAT while incarcerated was significantly and negatively associated with non-fatal overdose and ongoing prescription opioid use if OAT was continued upon release from correctional settings. Our findings underscore the urgent need for improved utilization of OAT in correctional settings, and the importance of linkage to community-based OAT programs upon release to prevent harms such as overdose.

Highlights.

  • Utilization of opioid agonist therapy (OAT) in correctional settings in Vancouver remains low

  • Most utilizing OAT were continuations rather than new initiations on the medication

  • Utilizing OAT was negatively associated with overdose if continued on release

Acknowledgments

The authors thank the study participants for their contribution to the research, as well as current and past researchers and staff.

Author Disclosures

Role of the Funding Source

The study was supported by the US National Institutes of Health (NIH) (U01DA038886, U01DA021525). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports EW. KH is supported by a CIHR New Investigator Award (MSH-141971), a Michael Smith Foundation for Health Research (MSFHR) Scholar Award, and the St. Paul’s Hospital Foundation. MJM is supported by a CIHR New Investigator Award, a MSFHR Scholar Award and the US NIH (U01DA021525 R01-DA0251525). His institution has received an unstructured gift from NG Biomed, Ltd., to support his research. KD is supported by a MSFHR/ St. Paul’s Hospital Foundation- Providence Health Care Career Scholar Award and a CIHR New Investigator Award.

Footnotes

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Conflict of Interest

None declared.

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