Needles in Prison: Where is Public Health Behind Bars?

“Our government has a zero-tolerance policy for drugs in our institutions.”  This comment comes from Canada’s Public Security Minister Vic Toews, responding the 2012 Federal lawsuit filed by four HIV groups and a former Canadian Correction inmate seeking a supervisory injunction – a court order that would force Ottawa to establish Canadian prison-based syringe access programs (PSAPs).

You may be asking yourself: “Drugs are illegal and prisons are drug-free, so why would we give inmates needles to commit a crime?”

The reality is prisons are not drug-free and needle-free; never have been, never will be.

Contrary to the assumption that prisons are a highly restricted, secure environment, virtually no prison in the world has been able to keep drugs completely out. Needles are easily smuggled in or can be made from various items already in prisons (see example here). These needles are shared, often for a fee, between anywhere from 10 to 20 inmates.

Roughly 80 percent of inmates arrive with substance use problems and incarceration has absolutely no effect on reducing injection drug use.  The Correctional Service of Canada itself admitted that 17 percent of male and 14 percent of female inmates reported injecting drugs while in prison – 60 percent of the time with a used syringe.

The danger here is that our prisons have become hot spots for HIV and hepatitis C virus (HCV) transmission. To begin with, HIV and HCV prevalence rates in prisons are at least 10 and 30 times higher than the population as a whole. A Vancouver study estimated 21 percent of all HIV infections among people in Vancouver who inject drugs were acquired in prison.

In the face of our government’s “zero tolerance” policies, Canada has acknowledged that drug use does exist in its institutions. Currently, bleach kits, which inmates can use to sterilize syringes, are available upon request. Advocates for PSAPs see bleach kit programs as a step in the right direction. But these programs have also come under scrutiny. Research shows inmates report limited access to such programs, particularly because they come with increased surveillance and stigmatization from correctional officers.

In addition to principles based on prohibition, the reason the Correctional Service of Canada has not moved forward with PSAPs is because of the concern that inmates may turn syringes on officers and use them as weapons. What is the evidence behind this?

In the 60 PSAPs across 12 countries introduced since 1992, there have been no reports of needles from PSAPs being used as weapons. Rather, evidence shows:

  • Reduced needle sharing
  • Reduced needle pricks
  • Decreased HIV and HCV transmission (also safer for officers if they do get pricked)
  • No increase in drug use or injecting
  • Reduced drug overdoses
  • Increased referrals to drug treatment programs
  • Effectiveness in a wide range of institutions

Despite this compelling evidence, PSAPs remain a tough sell in Canada. One possible reason why prison health has not been prioritized by the public may be due to a misconception that people stay in prison forever. But prisoners (including those who have contracted HIV and HCV) do not stay behind bars forever. Over 95 percent of people are eventually released back into the community. They are our brothers and sisters, mothers and fathers, sons and daughters. They are part of our communities – making prison health a vital component of public health.

Ignoring this fact not only harms public health more broadly, but, by definition, also violates human rights. HIV advocacy groups argue many rights are violated by refusing PSAPs, including the right to the highest attainable standard of health.

If not evidence, what will it take to introduce true public health and human right standards for Canadians behind bars?


Author: Alissa Greer, Research Project Coordinator at Rocky Mountain Poison and Drug Center

*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Why Opioid Substitution Treatment is a good thing

Opioids are medicines chemically related to the compounds found in the opium poppy, a plant that has been used therapeutically for thousands of years. Opioids are commonly used in modern medicine to treat pain. Because they can also create feelings of euphoria, opioids may also be used for recreational or other non-medical purposes. For some people, regular on-going use of opioids may lead to dependence or addiction, for which opioid substitution treatment (OST) is among the most effective medical interventions.

Opioid substitution treatment was first practiced in the early 20th century, when doctors prescribed maintenance doses of codeine, morphine or heroin to patients who were dependent on these drugs. However, law enforcement intolerance for this compassionate approach resulted in the arrest and punishment of physicians. As a result, the medical profession quickly abandoned the practice.

ImageOST was revived in the 1960s when physicians in Vancouver experimented with prescribing oral methadone to patients who were chronic heroin users. In the 1980s, the injection of opioids became a more acute public health concern because of transmittable diseases such as HIV spreading due to needle sharing. Since the 1990s, OST in British Columbia has expanded steadily, and a recent report on HIV by the Office of the Provincial Health Officer indicated that it has contributed to declining rates of HIV among people who inject drugs. Likewise, the World Health Organization has endorsed OST as one of themost promising methods of reducing drug dependence and has included methadone on its list of essential medicines.

Methadone and Suboxone™ are the primary medications used for OST in Canada. For most patients, methadone is successful because it can be taken orally and has a long-lasting effect.  Suboxone™ is an alternative to methadone for patients who may have unpleasant side-effects or other medical reasons for not using methadone.

There are several key factors that contribute to the success of OST: it prevents the patient from experiencing withdrawal symptoms, it reduces the physical craving of opioids, and it blocks the feeling of euphoria from illicit opioid use. In addition, OST patients report stability in their daily routines, a reduction of criminal activity, and an increased feeling of safety from the harms associated with illicit drug-seeking, injection and, for some, involvement in the sex trade.

There are many population-level benefits to OST, including the reduction of fatal opioid overdose and the transmission of diseases such as HIV and hepatitis C. Additionally, OST is cost-effective. It is less expensive than untreated opioid dependence, and as part of a well-managed care program, OST can retain patients in treatment and reduce the risk of relapse to non-medical opioid use.    

Since its revival as a medical intervention, OST has proven to be both an effective treatment for opioid dependence and an important way to reduce injection drug use and associated risks. In BC, OST is an important part of a comprehensive health system response to opioid dependence, and continual effort is being made to identify areas of improvement in service provision and health outcomes for those who are opioid dependent. Also, new research on OST, including studies conducted in British Columbia, is suggesting that other kinds of opioid medications—including diacetylmorphine and hydromorphone—may be useful alternatives to methadone or Suboxone, especially for patients who do not respond well to other treatments. 

Some critics object to maintenance prescribing as a medical practice, suggesting that people with substance dependence problems should not be allowed to continue using any psychoactive substances. However, people with eating disorders are not expected to give up eating food, nor are people with sex addiction necessarily expected to become celibate. In some ways, OST is comparable to nicotine replacement therapy, or the medical use of nicotine-containing skin patch or chewing gum as a replacement for tobacco. Addictions are complex phenomena, and scientific evidence clearly shows that OST can be a valuable therapeutic intervention for people seeking medical help to deal with opioid dependence.

 What are your thoughts about opioid substitution treatment?


*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC