John Koehn and Evan Wood
Drug and alcohol addiction are among society’s most costly diseases. The Canadian Centre on Substance Abuse recently estimated that the cost to Canadian society is over $40 billion annually and criminal justice costs account for a significant proportion of these expenditures.
Fortunately, several forms of addiction treatment have been shown to dramatically improve rates of recovery thereby reducing criminal activity, rates of incarceration and rates of recidivism upon release from prison.
For these reasons, it is distressing to see that the Whitehorse Correctional Centre is denying inmates access to methadone maintenance therapy when they are incarcerated.
Methadone is one of society’s most highly studied medications. Randomized trials have consistently shown that as an intervention for the treatment of heroin dependence, methadone retains patients in treatment and decreases heroin use at a significantly higher rate than treatments that do not use opioid replacement.
In addition, studies have shown how methadone maintenance treatment prescribed in prison reduces mortality and rates of infectious disease transmission. With respect to improved community safety upon release from prison, a recent randomized clinical trial found that providing methadone in prison increases the likelihood that incarcerated individuals will access addiction treatment once released and significantly reduces injection drug use, even six months later. Given that drug-related mortality is extremely high among people recently released from prison, this treatment is literally a life-saver.
Incarceration of individuals with a history of untreated heroin addiction is also challenging from a public health perspective. According to a recent report of the Global Commission on Drug Policy, incarceration has been identified as a risk factor for acquiring HIV infection in countries of western and southern Europe, Russia, Canada, Brazil, Iran and Thailand.
This is problematic with respect to HIV control, but also for the taxpayer, given that the average cost of each case of HIV transmission is approximately $500,000 in health-care expenditures. In addition to preventing the spread of dangerous infections like HIV, should we not be employing interventions proven to work in order to prevent incurring these future health-care costs?
While everyone agrees that individuals who are violent or are otherwise a threat to society should be incarcerated until they are no longer a risk, there is increasing evidence that approaching drug addiction as a criminal justice issue has been costly and ineffective.
For instance, a recent study published in the British Medical Journal found that, despite an estimated $1 trillion spent on the war on drugs in North America in recent decades, the inflation-adjusted price of heroin has decreased by over 80 per cent in recent decades while the purity of the drug increased by 60 per cent.
In other words, drugs have become more accessible even as enforcement efforts have been increased. Just as was the case with alcohol prohibition, organized crime has simply overwhelmed drug law enforcement’s best efforts.
In turn, our justice system has punished those people who suffer from substance use disorders and are most in need of addiction treatment. While having an addiction does not negate an individual’s responsibility for crimes committed or other consequences of their use, perhaps is time to rethink our strategy and begin to properly invest public resources in evidence-based addiction treatment.
What then is the alternative to ineffective criminal justice measures? Clearly, outpatient addiction treatment needs to be dramatically expanded.
To prevent the social consequences of addiction, such as incarceration, through early and effective therapies is certainly the ideal. For those that engage in criminal activity and end up behind bars, society also needs to invest in treatments proven to aid in recovery from substance-use disorders, even if for no other reason than to prevent future re-incarceration and expensive health outcomes related to injection drug use.
Providing methadone in prison is safe and reduces unsafe activities like intravenous needle use in prisons. With a large body of evidence to guide us, we need to recognize that effective drug treatment plays a crucial role in improving health outcomes for incarcerated individuals. It is one reason why the World Health Organization has listed methadone as an essential medicine and endorses its use in this population.
In fact, Canada is a signatory to international treaties that stipulate that prisoners must receive health care in prison that is consistent with what we all enjoy in the community. In this context, denying methadone to incarcerated individuals is a violation of international law.
The challenges of delivering health services in rural and northern areas are undoubtedly different than in urban centres. The implementation of specialized programs, like methadone maintenance therapy, may prove difficult in some settings and so seem expendable.
However, the problems of drug addiction are very real in these settings, and we can’t ignore the positive track record of prison-based methadone maintenance, and the risks to public health and safety, if this program becomes unavailable to incarcerated patients.
Evan Wood, MD, PhD, is a professor of medicine at the University of British Columbia where he holds the university’s Canada Research Chair in Inner City Medicine. John Koehn, MD, is a family physician who has also practised medicine at a federal prison. Both are part of the St. Paul’s Hospital Goldcorp Fellowship in Addiction Medicine based in Vancouver, B.C.