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Abstract People with opioid use disorders are overrepresented in correctional facilities, and are at high risk of opioid overdose. Despite the fact that buprenorphine/naloxone is the first line treatment for people with opioid use disorder, there are often institutional, clinical, and logistical barriers to buprenorphine/naloxone initiation in correctional facilities. Guided by the knowledge-to-action framework, this knowledge translation project focused on synthesizing knowledge and developing a tool for buprenorphine/naloxone initiation that was tailored to correctional facilities, including jails. This information and tool can be used to support buprenorphine/naloxone access for people in correctional facilities, in parallel with other efforts to address barriers to treatment initiation in correctional facilities.

Objective To describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.Design We used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.Setting Provincial prisons and general population in Ontario, Canada between 2015 and 2018.Participants Adults incarcerated in provincial prisons and people ages 15 years and older in Ontario.Main outcomes and measures Opioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.Results In prison, 6.9%–8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.Conclusions The increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

Abstract Background Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population. Methods We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method. Results Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care. Conclusions Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

BACKGROUND:Many people experience imprisonment each year, and this population bears a disproportionate burden of morbidity and mortality. States have an obligation to provide equitable health care in prison and to attend to care on release. Our objective was to describe health care utilization in prison and post-release for persons released from provincial prison in Ontario, Canada in 2010, and to compare health care utilization with the general population. METHODS:We conducted a population-based retrospective cohort study. We included all persons released from provincial prison to the community in 2010, and age- and sex-matched general population controls. We linked identities for persons released from prison to administrative health data. We matched each person by age and sex with four general population controls. We examined ambulatory care and emergency department utilization and medical-surgical and psychiatric hospitalization, both in prison and in the three months after release to the community. We compared rates with those of the general population. RESULTS:The rates of all types of health care utilization were significantly higher in prison and on release for people released from prison (N = 48,861) compared to general population controls (N = 195,444). Comparing those released from prison to general population controls in prison and in the 3 months after release, respectively, utilization rates were 5.3 (95% CI 5.2, 5.4) and 2.4 (95% CI 2.4, 2.5) for ambulatory care, 3.5 (95% CI 3.3, 3.7) and 5.0 (95% CI 4.9, 5.3) for emergency department utilization, 2.3 (95% CI 2.0, 2.7) and 3.2 (95% CI 2.9, 3.5) for medical-surgical hospitalization, and 21.5 (95% CI 16.7, 27.7) and 17.5 (14.4, 21.2) for psychiatric hospitalization. Comparing the time in prison to the week after release, ambulatory care use decreased from 16.0 (95% CI 15.9,16.1) to 10.7 (95% CI 10.5, 10.9) visits/person-year, emergency department use increased from 0.7 (95% CI 0.6, 0.7) to 2.6 (95% CI 2.5, 2.7) visits/person-year, and hospitalization increased from 5.4 (95% CI 4.8, 5.9) to 12.3 (95% CI 10.1, 14.6) admissions/100 person-years for medical-surgical reasons and from 8.6 (95% CI 7.9, 9.3) to 17.3 (95% CI 14.6, 20.0) admissions/100 person-years for psychiatric reasons. CONCLUSIONS:Across care types, health care utilization in prison and on release is elevated for people who experience imprisonment in Ontario, Canada. This may reflect high morbidity and suboptimal access to quality health care. Future research should identify reasons for increased use and interventions to improve care.

Substance use and substance use disorders are common in people who experience detention or incarceration in Canada, and opioid agonist treatment (OAT) may reduce the harms associated with substance use disorders. We aimed to define current physician practice in provincial correctional facilities in Ontario with respect to prescribing OAT and to identify potential barriers and facilitators to prescribing OAT.We invited all physicians practicing in the 26 provincial correctional facilities for adults in Ontario to participate in an online survey.Twenty-seven physicians participated, with representation from most correctional facilities in Ontario. Of participating physicians, 52% reported prescribing methadone and 48% reported prescribing buprenorphine/naloxone to patients in provincial correctional facilities. Nineteen percent of participants reported initiating methadone treatment and 11% reported initiating buprenorphine/naloxone for patients in custody. Participants identified multiple barriers to initiating OAT in provincial correctional facilities including concerns about medication diversion and safety, concerns about initiating treatment in patients who are not currently using opioids, lack of linkage with community-based providers and the Ministry of Community Safety and Correctional Services policy. Identified facilitators to initiating OAT were support from institutional health care staff and administrative staff, adequate resources for program delivery and access to linkage with community-based OAT providers.This study identifies opportunities to improve OAT programs and to improve access to OAT for persons in provincial correctional facilities in Ontario.

BACKGROUND:There is an increased risk of death due to drug toxicity after release from incarceration. The purpose of this study was to describe the timing, rate and circumstances of drug toxicity deaths following release from incarceration. This information can be used to help design potential preventive interventions. METHODS AND FINDINGS:We reviewed coroner's files to identify deaths in adults in Ontario between 2006 and 2013 caused by drug toxicity (n = 6,978) and these records were matched with provincial correctional records to identify individuals who died within one year of being released from incarceration (n = 702). Twenty percent (n = 137) of the 702 deaths occurred within one week of release. The majority (77%, n = 538) of deaths after release involved one or more opioids. Of the deaths involving opioids, intervention by another person may have been possible in 318 cases. CONCLUSIONS:Between 2006 and 2013 in Ontario, one in ten drug toxicity deaths in adults occurred within one year of release from provincial incarceration. These findings may help to inform the implemention and assessment of interventions aimed at reducing drug toxicity deaths following release from incarceration.

BACKGROUND: The Ontario FOBT Project is a pilot study of fecal occult blood testing (FOBT) for colorectal cancer screening conducted among age-eligible volunteers (50 to 75 years) in 12 of 37 public health regions in Ontario.

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.