“Well everyone I know who gets clean is dead within a year, so that’s kind of a worry”: OAT Access Among a Cohort of Post-Incarceration Peer-Support Program Participants in British Columbia

“Well everyone I know who gets clean is dead within a year, so that’s kind of a worry”: OAT Access Among a Cohort of Post-Incarceration Peer-Support Program Participants in British Columbia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “Well everyone I know who gets clean is dead within a year, so that’s kind of a worry”: OAT Access Among a Cohort of Post-Incarceration Peer-Support Program Participants in British Columbia Juls Budau, Dibbya Pravas Dasgupta, Kate Roth, Mo Korchinski, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8904539/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background : People leaving correctional centres have an elevated risk of overdose death, particularly within the first two weeks of release. Opioid agonist treatment (OAT) is an evidence-based pharmacological treatment that reduces mortality risk. This study used a mixed-method approach to examine OAT access among people recently released from correctional facilities to identify facilitators and barriers to OAT retention both in custody and community. Methods : Between February and August 2023, the PREVAIL Project recruited 120 persons leaving provincial correctional centres in British Columbia who reported using illicit substances within six months to their incarceration. Peer support workers were trained as researchers and administered surveys and interviews on the day of release, as well as one- and two-months following release, about experiences before, during, and immediately after incarceration. Data on illicit drug use, withdrawal, and access to OAT were analyzed using descriptive statistics and thematic analysis. Results : The rate of OAT utilization among participants was higher (59%) during incarceration compared to post-release (35%). The majority (73%) of participants reported experiencing withdrawal from illicit substances while in custody. Some participants reported that OAT medications had insufficient dosage or timeliness to prevent withdrawal. Among participants who received OAT in custody, 28% were unsure if they had a prescription or released without an OAT prescription. A higher proportion of OAT recipients who were released from men’s prisons did not leave with a prescription. Participants also reported several barriers to post-release OAT retention, including daily dispensation policies, transportation availability, and challenges associated with transferring prescriptions between pharmacies. Conclusions : OAT uptake and access was high while participants were in correctional centres, but continuity was interrupted when participants both entered and exited incarceration, particularly for those exiting men’s prison. As well, retention post-release was limited by a number of systemic factors. The findings of this study suggest that there is a need to expediate access to health care during intake to correctional centres, strengthen the continuity of care post-release, and reduce barriers to OAT in community. Improving access to continuous OAT has the potential to reduce overdose mortality and increase retention in substance use treatment post-release. Trial registration: Not applicable. opioid agonist treatment opioid use disorder prison health correctional health mixed methods Background In British Columbia (BC), the illicit drug supply has killed almost 17,000 people since 2016 and is now the leading cause of death among persons 10 to 59 years of age. 1 Over the past decade, the primary driver of drug poisoning events (overdose) in BC has been illicit fentanyl, which has replaced heroin and is routinely detected in cocaine, MDMA, and counterfeit tablets in BC. 1 Benzodiazepines have also become pervasive in the unregulated opioid supply, complicating withdrawal and overdose presentations. 2 , 3 In Canada, people leaving incarceration are 12 to 20 times more likely to experience overdose mortality than the community population, with the greatest risk occurring in the first two weeks post-release. 4 – 7 This risk elevation is attributed to the combination of an overrepresentation of opioid use disorder (OUD) among incarcerated people and cessation or reduction of opioid use during incarceration, which reduces opioid tolerance, which greatly increases risk of post-release overdose if illicit opioid use resumes. 5 , 8 , 9 Opioid agonist treatment (OAT), which includes medications such as buprenorphine, methadone, and slow-release oral morphine, is an evidence-based approach to reducing overdose deaths among people with OUD. 10 – 12 OAT reduces opioid-related physical cravings, and withdrawal symptoms. Additionally, OAT medications maintain a steady state of opioid tolerance, which reduces risk of overdose if other opioid use occurs. The toxic drug crisis has intensified the protective effect of OAT against fatal overdose, as OAT discontinuation is associated with a 65% increase in relative risk of mortality following the introduction of fentanyl into the unregulated opioid supply. 10 OAT’s life-preserving properties have also shown to be effective in the post-release period, particularly when treatment is initiated in custody and continued in community. 11 , 13 Moreover, OAT retention for post-incarcerated people is associated with increased engagement in treatment programs and employment and reduced high-risk injection behavior and recidivism. 11 Despite the protective effect of OAT, treatment disruption is common for those entering and leaving incarceration. 11 , 14 , 15 A US-based study found that such disruptions may hinder future OAT engagement, as participants previously on OAT but not permitted access while incarcerated—forcing them to experience opioid medication withdrawal—were hesitant to restart after release, especially if they had remained abstinent for the duration of their sentence. 15 Without OAT continuity, risk of resuming illicit drug use post-release increases, even among people who were motivated to remain abstinent. Schroeder et al. 16 conceptualize this reduction of motivation to remain abstinent as ego-depletion , wherein a person’s cognitive resources are strained, decreasing capacity for impulse control and emotional regulation. Lack of housing and income, uncertainty about the future, loss of structure, competing responsibilities, guilt, the overwhelm of reintegration, and return to previous drug-using settings contribute to illicit drug use as a coping strategy after release. 16 , 17 This paper explores barriers to OAT retention from the perspective of people recently released from incarceration during the toxic drug crisis in BC. The findings are from the “Preventing overdose among formerly incarcerated persons during a public health emergency” (PREVAIL) project, which studied the experiences of people seeking overdose prevention interventions after release from provincial correctional centres in BC. The PREVAIL Project was approved by the UBC Human Research Ethics Board (H22-02236). Methodology Research Design The PREVAIL project partnered with a non-profit community organization, Unlocking the Gates Services Society (UTG), which employs staff with a history of incarceration to provide support for people leaving provincial correctional centres. UTG staff were given training in research ethics, informed consent, data privacy and security, interview techniques, and database usage and were responsible for recruiting participants and data collection. Between February and August of 2023, PREVAIL recruited people leaving provincial correctional centres in BC who self-reported using illicit substances within six months prior to their incarceration. On their day of release, eligible participants were met by a UTG staff member and enrolled in the project, where they received a cell phone preloaded with overdose prevention apps and a three-month phone plan; a naloxone kit; and a care bundle that included safer sex supplies, hygiene supplies, toiletries, and art supplies. Indigenous participants also received a locally foraged Indigenous medicine bundle. UTG staff provided transportation to a desired location, such as to a sober living home, treatment centre, shelter, or home community. Participants received UTG peer support for three months, which prioritized any necessary steps to ensure OAT continuity, such as appointment scheduling, advocacy, or transportation. The cell phone facilitated on-going communication with UTG staff and while the prepaid phone plan was time-limited, participants were able to keep the phone after the study period or if they withdrew. Data Collection : UTG staff conducted surveys and interviews on participant experiences before, during, and after incarceration at three time points: 1) the day of release from incarceration (baseline); 2) one-month post-release; and, 3) two months post-release. Participants were offered a $ 30 honorarium for each survey and a $ 50 honorarium for each interview completed. Baseline data was collected in-person, and follow-up data could be collected either in-person or via telephone. Consent from participants was obtained at all three time points and participants could withdraw from the study at any time. The baseline survey contained questions about lifetime overdose events, substance use leading up to most recent incarceration, as well as access to withdrawal management medication, OAT, and other healthcare while incarcerated. Follow-up surveys focused on OAT continuity, substance use, and overdose events since the last completed survey. Survey questions were adapted from a longitudinal study on harm reduction service clients by the BC Centre for Disease Control. 21 The semi-structured interview guide prompted questions about community reintegration, employment, family and relationships, substance use, overdose events, substance use treatment (including inpatient recovery services, OAT, or pharmaceutical alternative medications), and usefulness of the care bundles. Analysis Data were coded by two team members, and primary analysis for this paper was completed by a research team member (JB1) with living experience of being on OAT and lived experience of benzodiazepine tapering. Data on access and barriers to OAT, overdose history, substance use, and withdrawal during custody were identified, analyzed thematically, and organized chronologically to understand rates of OAT access relative to rates of OAT eligibility along the continuum of incarceration. All findings and analysis were presented to an advisory committee of formerly incarcerated people for feedback and additional insight. Results A total of 120 participants were recruited at the time of their release from provincial correctional centres. At baseline, 120 surveys and 110 interviews were completed. At one-month post-release, 59 surveys and 42 interviews were completed. At two-months post-release, 36 surveys and 29 interviews were completed. The participant cohort comprised 76.6% men (N = 92), 19.1% women (N = 23) and two people who identified as Two-Spirit (Table 1 ). Thirty-nine percent of participants self-identified as Indigenous. The majority of participants (72%) had an overdose event within their lifetime (Table 2 ). Pre-Incarceration Substance Use . The majority of participants reported using illicit opioids three or more days per week prior to their most recent incarceration, with 52% of participants reporting daily usage. Of those participants who reported regular opioid use before being incarcerated, 63% had an active OAT prescription on the day they were incarcerated. Participants described experiences with accessing OAT prior to being incarcerated during their one-on-one interviews, which included barriers to access such as long waits for appointments: That was my whole plan before I was even arrested, was to get on Suboxone. But all the doctors that were going to see wouldn’t book me an appointment right away; it was always a month or two down the road. Others described losing OAT access due to provincial cut-off policies for patients required to do witnessed, daily dispensed dosing. These policies mandate prescription termination after four missed doses of methadone or six missed doses of oral buprenorphine. 18 One participant said, “I missed my prescription right before I got incarcerated. So, they cut me off, but I was working that program and it is a good program.” Withdrawal. The rate of OAT utilization among all participants increased while in custody, from 35% of participants entering custody with an active OAT prescription to 59% receiving OAT while in custody (Table 3 ). Despite high rates of OAT utilization, 73% of participants reported experiencing withdrawal when they entered custody. For some participants who were prescribed OAT, this was due to delays in access. One participant reported: “After the first three weeks, after I detoxed, I ended up on Suboxone.” Some withdrawal experiences in custody may have been due to consuming illicit opioids adulterated with non-opioids such as benzodiazepines, which can cause additional symptoms (such as hallucinations) not treated by OAT: I’d never had closed eye, open eye hallucinations before detoxing, to a very, very extreme level. Still to this day I'm not sure what’s real and what’s not during that time… And that isn’t a normal symptom of withdrawal from fentanyl. Post-Release Prescriptions . Survey data shows that among participants who received OAT in custody, almost a quarter of participants (24%) were released without a prescription for OAT continuation in community and 4% responded “Don’t Know”. This fracture in treatment was much more prominent among those released from men’s prison, with 27% of male participants who received OAT while incarcerated reporting they did not receive a prescription upon release and 6% answering “Don’t Know,” compared to 11% of women participants released without a prescription and none responding that they didn’t know. In a follow-up interview, a participant who had resumed illicit opioid use after release described how being discharged without an OAT prescription ultimately led to him discontinuing his treatment and returning to regular illicit opioid use: You know, they didn’t release me with a script or anything, but I knew that there is places I can go to get one… [I] felt like I could just, you know, fight through it and then, I wasn’t like super, super sick. It was just the lack of the energy and feeling lethargic and weak and that’s kind of, no appetite, those kind of things, and not feeling like myself. Just kind of wanting to do nothing and just laze around. So, I think not holding a script was a mistake. I should have just tried to get a script on my first or second day out and continue to work with it. Interview data suggest that the “Don’t Know” response was largely caused by the common practice in BC of prescribers faxing or electronically sending the prescription directly to a pharmacy. Participants answering “don’t know” either didn’t know if the prescription had actually been sent at all or didn’t know to which pharmacy it was sent. In either scenario, participants described frustration with this uncertainty: I know that it was faxed to the drug store and they didn’t talk to me about where I was getting released or anything...I’m going to have to figure that out actually... I’m going to have to see a doctor. Another participant discussed how frustration over the uncertainty around their OAT prescription impacted relationships with staff at their recovery home, who interpreted their stress as disrespect: When we first came in here, you know how I was worried about my [slow-release oral morphine], remember? Would you say I was being rude over the phone? See, the one guy said I was being very rude and very bad. I got in trouble for being like that, right… and the guy, he said these things, I was being belligerent and what-not…. And he’s been giving me crap for just doing things that I haven't been doing, so I’ve got somebody against me there, so it’s very hard, you know. In contrast, people who were released with an OAT prescription expressed a sense of relief and hope for stability: “ I was given one [an OAT prescription] and I feel good about it because it just makes it so I can continue my dose instead of jumping around, like what was happening.” Barriers to OAT Continuity in Community . Among participants who were on OAT while in-custody, the majority (72%) reported being released with a prescription for OAT treatment in community. However, participants reported numerous additional barriers to OAT access after release. Participants experienced challenges with pharmacy access (including transportation barriers and mandated daily dispense), physician access, and provincial OAT cut-off policies. During the data collection period, an ongoing transit strike in the Greater Vancouver Regional District created a significant barrier to accessing pharmacies to fill OAT prescriptions: No, I couldn’t get my Suboxone renewed. I mean, I had it for two weeks, but it was a pain in the ass, because I had to go pick it up, right? So, with no buses, how the fuck can you do that? I asked welfare to help me with transportation. She’s like, “What do you want us to do? We’re not paying for cabs.” Most participants receiving OAT in community, particularly methadone, were required to have their doses supervised by a pharmacist, meaning they were required to travel to a pharmacy every day. This mandate further exacerbated transportation challenges for many participants. One participant was even not permitted take-home doses when his usual pharmacy was closed on the weekends and instead had to travel to a different pharmacy—a 20-minute bus ride or 30-minute walk away. This also required an official prescription transfer from Pharmacy A to Pharmacy B before the weekend, then back to Pharmacy A each Monday, increasing the potential for error and creating further uncertainty and barriers to care: The problem is that the prescriptions keep getting messed up in between pharmacies…. I’ve got two of them; I’ve got the (Pharmacy A) and they're open Monday to Friday, but Saturday, Sunday they're closed. And then they’ve made me go to (Pharmacy B) for my other. Unable to access their pharmacy or keep up with daily witnessed dispensations, several participants reported that they missed their doses and subsequently had their OAT treatment cut-off, as per provincial policy. Other participants were required to find a community-based physician immediately upon release despite being provided with a prescription: “ I got to go find a doctor tomorrow. They gave it to me one day (laughs). Yeah. That’s what I have. Yeah. Got to go find a doctor tomorrow, they said.” Discussion and Recommendations Findings from this study contribute to the growing body of research that shows even those who are motivated to remain on OAT following release from prison face systemic barriers, such as a lack of reintegration supports 19 ; lack of pre-release planning for community treatment, often due to early or unexpected releases or releases occurring outside clinic hours; 20 and long waitlists for community OAT clinics. 17 Through examining participant experiences, the PREVAIL project reveals opportunities for improvement in both correctional and community substance use health care, particularly for those transitioning both in and out of correctional centres. The majority of participants (73%) reported that they experienced substance withdrawal when they entered correctional centres. This suggests that people are experiencing a gap in care as they transition from community into custody. This gap may be due in part to the unpredictable period of time between initial arrest and arrival at a provincial correctional centre. During this time, people are held in municipal police cells and may not have access to health care, including limited access to any medications prescribed to them. The length of stay in city cells depends on the day of arrest, as transfers to provincial correctional facilities only occur Monday to Friday. A Friday arrest can result in a 72-hour delay in municipal cells, increasing risk of entering withdrawal prior to receiving withdrawal management care from provincial correctional health services. This gap in care has become more dangerous due to the changing illicit opioid supply. Withdrawal symptoms occur much more rapidly as well as more severely with illicit fentanyl use compared to heroin, due to fentanyl’s higher strength but shorter half-life. 21 This intensifies the impact of the care gap in municipal cells, as well as the impact from delayed medical care and insufficient OAT doses within provincial correctional centres that some participants reported. Additionally, the widespread presence of benzodiazepines in BC’s illicit fentanyl supply 2 , 3 suggests that some participants may have been reporting non-opioid withdrawal symptoms. Benzodiazepine withdrawal is not treated by OAT but, if left unmanaged, can be fatal. 2 Additionally, many participants experienced challenges in maintaining OAT continuity when transitioning back to community. Almost a quarter of participants receiving OAT while in custody reported not receiving a prescription at their time of release. This suggests a gap in post-release planning and highlights a need for further research into how this gap occurs, particularly amongst those released from men’s correctional centres, who were more likely to experience treatment fracture when transitioning back to community compared to those released from women’s facilities. Although the majority of participants on OAT while in custody did receive a prescription for treatment at release, many barriers to treatment retention exist in community settings. 2 , 3 The most prominent issue for participants attempting OAT continuity after release was pharmacy access. Widespread mandated daily dispensing for witnessed OAT consumption is part of a larger provincial issue of OAT access, which requires each daily dose be dispensed where the prescription was initially filled, unless an official pharmacy transfer is requested. A transfer can only occur if both the receiving and sending pharmacy are open. These administrative barriers make it more challenging for people to seek and maintain OAT treatment. Findings from PREVAIL also highlight the importance of the social determinants of health on post-release OAT treatment outcomes. Participants reflected on challenges with transportation that hindered their ability to access their designated pharmacy and receive daily OAT dispensations. Limited transportation, when combined with mandated daily dispense dosing, creates barriers to both OAT uptake and retention. 14 Other barriers related to the social determinants of health can include lack of resources, such as cell phones to contact clinics; lack of identification; lack of contact information; and OAT-related stigma from family members. 14 There are several opportunities to improve OAT treatment access for people experiencing incarceration in BC. To reduce the experience of withdrawal and improve continuity during transitions from community to custody during initial incarceration, policies are needed to support the dispensation of active OAT prescriptions to people held in municipal cells. Additionally, people who regularly use illicit opioids should be screened for concurrent benzodiazepine withdrawal when entering both municipal cells and provincial correctional centres in order to more safely manage withdrawal from all substances. Given the high rate of withdrawal within our participants, reports of suspected unmanaged and potentially fatal withdrawal from benzodiazepines, and preexisting research showing that unmanaged substance withdrawal increases risky substance use during incarceration 11 , 13 and hinders future OAT attempts 15 , it may be advisable to implement withdrawal management medical units within provincial correctional centres. An increase in dedicated health care staff with OAT expertise could also reduce instances of people being released without an OAT prescription. 2 , 3 To address continuity and access issues for daily dispense-mandated OAT patients in BC, we recommend utilizing PharmaNet, the provincewide data system for tracking prescriptions, to allow for any OAT-dispensing pharmacy to assess if an OAT patient has already received their daily dose, and if not, to be able to dispense that dose. This would reduce barriers for recently released people in particular, who, as the PREVAIL findings show, may be experiencing challenges in identifying or travelling to the specific pharmacy holding their prescription. Such a system could also ease release planning for correctional health staff, as this would eliminate the need to have health care staff available to write new prescriptions for OAT patients with already active prescriptions exiting incarceration. As well, to further improve community OAT access, we recommend updating dispensation guidelines to allow for increased take-home doses. Rationale for daily and witnessed dispensations center on safety concerns for patients and the larger community; however, research on relaxed OAT dispensation guidelines in response to the COVID-19 pandemic shows an absence of negative consequences associated with increased take-home OAT doses. 28 When take-home privileges are left to prescriber discretion, social, racial, and economic inequities are often amplified. 29 Therefore, province-wide guidance for more widespread access to take-home privileges would be beneficial. Conclusion The findings of this study suggest that although there is an increase in OAT treatment uptake while people are incarcerated in BC’s provincial correctional centres, there are still gaps in care as people move from community into custody and back. Given the on-going and rapidly changing toxic drug crisis, there is an urgent need to strengthen this continuity of care. Addressing these gaps will ensure that people can effectively manage withdrawal, increase retention of substance use treatment, and overall reduce their risk of both non-fatal and fatal overdose. Declarations Trial registration Not applicable. Author Contribution JB1 identified and organized relevant data for this manuscript.JB1 and AS wrote main manuscript text.AS and DPD prepared and analyzed quantitative data.DPD prepared all figures.KR was the PREVAIL project research manager.MK was an advisor on the project and oversaw the hiring and training of the peer researchers.JB2 coded the qualitative data.All authors reviewed and edited the manuscript. Acknowledgement We acknowledgement and appreciate the immense input and critique from the Priorities and Engagement in Research in Correctional Health (PERCHbc) peer advisory committee, as well the ongoing support from the Unlocking the Gates Society. Data Availability Data for this project is not available publicly due to confidentiality considerations. References BC Coroner’s Service. Unregulated Drug Deaths in BC. 2024. Accessed September 1, 2024. https://app.powerbi.com/view?r=eyJrIjoiMDg2ZGZmOGItZGQ1Ny00NTY3LThiYmEtYmExN2M0YmFjYTUxIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9 Wilson P, Day T. Benzodiazepine Withdrawal in the Context of Benzodiazepine-Contaminated Opioids: Practice Implications. J Nurse Practitioners. 2024;20(1):104858. 10.1016/J.NURPRA.2023.104858 . Russell C, Law J, Bonn M, Rehm J, Ali F. The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions. Int J Drug Policy. 2023;111:103933. 10.1016/J.DRUGPO.2022.103933 . BC Centre on Substance Use. BCCSU Drug Checking. Accessed September 3. 2024. https://drugcheckingbc.ca/ Kinner SA, Gan W, Slaunwhite A. Fatal overdoses after release from prison in British Columbia: a retrospective data linkage study. Can Med Association Open Access J. 2021;9(3):E907–14. 10.9778/CMAJO.20200243 . Keen C, Kinner SA, Young JT, et al. Periods of altered risk for non-fatal drug overdose: a self-controlled case series. Lancet Public Health. 2021;6(4):e249–59. 10.1016/S2468-2667(21)00007-4/ATTACHMENT/F818F4C8-5B16-418E-A2C1-4CDA8B42359A/MMC1.PDF . Gan WQ, Kinner SA, Nicholls TL, et al. Risk of overdose-related death for people with a history of incarceration. Addiction. 2021;116(6):1460–71. 10.1111/ADD.15293 . Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ. 1998;316(7129):426–8. 10.1136/bmj.316.7129.426 . 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BMJ Open. 2014;4(4):e004666. 10.1136/BMJOPEN-2013-004666 . Russell C, Pang M, Nafeh F, et al. Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada. Int J Qual Stud Health Well-being. 2022;17(1). 10.1080/17482631.2022.2094111 . Fox AD, Maradiaga J, Weiss L, Sanchez J, Starrels JL, Cunningham CO. Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder. Addict Sci Clin Pract. 2015;10(1). 10.1186/S13722-014-0023-0 . Schroeder SE, Drysdale K, Lafferty L, et al. It’s a revolving door: Ego-depletion among prisoners with injecting drug use histories as a barrier to post-release success. Int J Drug Policy. 2022;101. 10.1016/j.drugpo.2021.103571 . Jamin D, Vanderplasschen W, Sys O, et al. 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Tables Table 1 Participant Demographics at Release Gender N % Women 23 19.66 Man 92 78.63 Two-Spirit 2 1.71 Age Group =40 46 39.32 Relationship Status Single 72 62.61 Partnered, living separately 21 18.26 Partnered, living with my partner 17 14.78 Prefer to describe / Don’t know 5 4.35 Ethnic Group* African or Caribbean 6 5.17 European 40 34.48 Asian 5 4.3 Indigenous 46 39.66 Hispanic or Latinx 4 3.45 Others 11 9.48 Prefer to describe / Don’t know 15 12.93 Level of Education Did not complete high school 46 39.66 High school degree or equivalent 37 31.9 Higher education college/university 27 23.28 Prefer to describe / Don’t know 6 5.18 Have Children Yes 62 52.99 No 50 42.74 Prefer to answer / Don’t know 5 4.27 Fixed Address to Receive Mail Yes 66 56.41 No 45 38.46 Prefer to answer / Don’t know 6 5.12 Table 2 Self-Reported Participant Overdose Events Characteristics Total Women Men Overdose Event (Lifetime) 83 (72.2%) 14 (58.3%) 69 (75.8%) Multiple Overdoses (Lifetime) 68 (59.1%) 13 (54.2%) 55 (60.4%) 5–10 Overdoses (Lifetime) 20 (17.4%) 6 (24.0%) 14 (15.4%) 11 + Overdoses (Lifetime) 12 (10.4%) 1 (4.2%) 11 (12.1%) Overdose in 6 Months Prior to Release 60 (52.2%) 10 (41.7%) 50 (54.9%) Uncertainty About Overdose in 6 Months Prior to Release 17 (14.8%) 3 (12.5%) 14 (15.4%) Table 3 Opioid Agonist Treatment and Period of Incarceration Incarceration Stage Yes % No % Didn't Know / No Response % Prior to Incarceration 35 57 8 During Incarceration 59 32 9 After Incarceration 43 45 12 Additional Declarations No competing interests reported. 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Budau","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACxgbmBiABQswHmInUwgjTwpZAnBYGBrgWHgPitDDPSGz+wLjjsGz/jJxv0gU1DPL8DYTsmJHYJsF45rDxjBu526RnHGMwnHGACC0MjG2HExtAWngbGBIYiNACdBhQy/wbOc/AWuSJ0NIgAdKy4UYOG1iLAUEtPQ/bJBLPpBtvPPPM2HrGMQnDjYS0GLYnH/7wcYe17LzjyQ9vF9TYyMsR1NIAJBIQfAkC6oFAnrCSUTAKRsEoGPEAAET/RROyECcLAAAAAElFTkSuQmCC","orcid":"","institution":"University of British Columbia","correspondingAuthor":true,"prefix":"","firstName":"Juls","middleName":"","lastName":"Budau","suffix":""},{"id":634382921,"identity":"f2e120db-ca02-4cb0-a97e-3754e03f7753","order_by":1,"name":"Dibbya Pravas Dasgupta","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Dibbya","middleName":"Pravas","lastName":"Dasgupta","suffix":""},{"id":634382924,"identity":"c18f5b7c-e97b-44a2-92d1-b61e90cc1385","order_by":2,"name":"Kate Roth","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Roth","suffix":""},{"id":634382925,"identity":"aede78bf-199c-4083-a9fd-2540a32e613a","order_by":3,"name":"Mo Korchinski","email":"","orcid":"","institution":"Unlocking the Gates, British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Mo","middleName":"","lastName":"Korchinski","suffix":""},{"id":634382927,"identity":"d8942401-fd20-45c8-8e3a-f5c70d3f2aed","order_by":4,"name":"Sean O’Callaghan","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Sean","middleName":"","lastName":"O’Callaghan","suffix":""},{"id":634382929,"identity":"28c29438-69b2-4c24-9378-20481c3b3859","order_by":5,"name":"Jenyo Banjo","email":"","orcid":"","institution":"Centre for Advancing Health Outcomes","correspondingAuthor":false,"prefix":"","firstName":"Jenyo","middleName":"","lastName":"Banjo","suffix":""},{"id":634382932,"identity":"89832fc0-5db9-42cf-847f-3c80ad82ddbe","order_by":6,"name":"Beth Snow","email":"","orcid":"","institution":"Centre for Advancing Health Outcomes","correspondingAuthor":false,"prefix":"","firstName":"Beth","middleName":"","lastName":"Snow","suffix":""},{"id":634382934,"identity":"bea8d305-924f-41cc-8c45-3527dc5185ba","order_by":7,"name":"Karen Urbanoski","email":"","orcid":"","institution":"Canadian Institute for Substance Use Research","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Urbanoski","suffix":""},{"id":634382936,"identity":"d57b5cde-d95b-43a2-88c7-9dc357d3928a","order_by":8,"name":"Amanda Slaunwhite","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Slaunwhite","suffix":""}],"badges":[],"createdAt":"2026-02-17 22:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8904539/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8904539/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108806003,"identity":"935c4e1b-f29e-43b9-b2f4-e7710e967639","added_by":"auto","created_at":"2026-05-08 15:27:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":284391,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8904539/v1/62a4c3b9-2e7c-4154-b61e-4c87c7437bfc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Well everyone I know who gets clean is dead within a year, so that’s kind of a worry”: OAT Access Among a Cohort of Post-Incarceration Peer-Support Program Participants in British Columbia","fulltext":[{"header":"Background","content":"\u003cp\u003eIn British Columbia (BC), the illicit drug supply has killed almost 17,000 people since 2016 and is now the leading cause of death among persons 10 to 59 years of age.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Over the past decade, the primary driver of drug poisoning events (overdose) in BC has been illicit fentanyl, which has replaced heroin and is routinely detected in cocaine, MDMA, and counterfeit tablets in BC.\u003csup\u003e1\u003c/sup\u003e Benzodiazepines have also become pervasive in the unregulated opioid supply, complicating withdrawal and overdose presentations.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn Canada, people leaving incarceration are 12 to 20 times more likely to experience overdose mortality than the community population, with the greatest risk occurring in the first two weeks post-release.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e This risk elevation is attributed to the combination of an overrepresentation of opioid use disorder (OUD) among incarcerated people and cessation or reduction of opioid use during incarceration, which reduces opioid tolerance, which greatly increases risk of post-release overdose if illicit opioid use resumes.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOpioid agonist treatment (OAT), which includes medications such as buprenorphine, methadone, and slow-release oral morphine, is an evidence-based approach to reducing overdose deaths among people with OUD.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e OAT reduces opioid-related physical cravings, and withdrawal symptoms. Additionally, OAT medications maintain a steady state of opioid tolerance, which reduces risk of overdose if other opioid use occurs. The toxic drug crisis has intensified the protective effect of OAT against fatal overdose, as OAT discontinuation is associated with a 65% increase in relative risk of mortality following the introduction of fentanyl into the unregulated opioid supply. \u003csup\u003e10\u003c/sup\u003e OAT\u0026rsquo;s life-preserving properties have also shown to be effective in the post-release period, particularly when treatment is initiated in custody and continued in community.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Moreover, OAT retention for post-incarcerated people is associated with increased engagement in treatment programs and employment and reduced high-risk injection behavior and recidivism.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite the protective effect of OAT, treatment disruption is common for those entering and leaving incarceration.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e A US-based study found that such disruptions may hinder future OAT engagement, as participants previously on OAT but not permitted access while incarcerated\u0026mdash;forcing them to experience opioid medication withdrawal\u0026mdash;were hesitant to restart after release, especially if they had remained abstinent for the duration of their sentence.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Without OAT continuity, risk of resuming illicit drug use post-release increases, even among people who were motivated to remain abstinent. Schroeder et al.\u003csup\u003e16\u003c/sup\u003e conceptualize this reduction of motivation to remain abstinent as \u003cem\u003eego-depletion\u003c/em\u003e, wherein a person\u0026rsquo;s cognitive resources are strained, decreasing capacity for impulse control and emotional regulation. Lack of housing and income, uncertainty about the future, loss of structure, competing responsibilities, guilt, the overwhelm of reintegration, and return to previous drug-using settings contribute to illicit drug use as a coping strategy after release.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis paper explores barriers to OAT retention from the perspective of people recently released from incarceration during the toxic drug crisis in BC. The findings are from the \u0026ldquo;Preventing overdose among formerly incarcerated persons during a public health emergency\u0026rdquo; (PREVAIL) project, which studied the experiences of people seeking overdose prevention interventions after release from provincial correctional centres in BC. The PREVAIL Project was approved by the UBC Human Research Ethics Board (H22-02236).\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e \u003cstrong\u003eResearch Design\u003c/strong\u003e \u003cp\u003eThe PREVAIL project partnered with a non-profit community organization, Unlocking the Gates Services Society (UTG), which employs staff with a history of incarceration to provide support for people leaving provincial correctional centres. UTG staff were given training in research ethics, informed consent, data privacy and security, interview techniques, and database usage and were responsible for recruiting participants and data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eBetween February and August of 2023, PREVAIL recruited people leaving provincial correctional centres in BC who self-reported using illicit substances within six months prior to their incarceration. On their day of release, eligible participants were met by a UTG staff member and enrolled in the project, where they received a cell phone preloaded with overdose prevention apps and a three-month phone plan; a naloxone kit; and a care bundle that included safer sex supplies, hygiene supplies, toiletries, and art supplies. Indigenous participants also received a locally foraged Indigenous medicine bundle. UTG staff provided transportation to a desired location, such as to a sober living home, treatment centre, shelter, or home community.\u003c/p\u003e \u003cp\u003eParticipants received UTG peer support for three months, which prioritized any necessary steps to ensure OAT continuity, such as appointment scheduling, advocacy, or transportation. The cell phone facilitated on-going communication with UTG staff and while the prepaid phone plan was time-limited, participants were able to keep the phone after the study period or if they withdrew.\u003c/p\u003e \u003cp\u003e \u003cem\u003eData Collection\u003c/em\u003e: UTG staff conducted surveys and interviews on participant experiences before, during, and after incarceration at three time points: 1) the day of release from incarceration (baseline); 2) one-month post-release; and, 3) two months post-release. Participants were offered a \u003cspan\u003e$\u003c/span\u003e30 honorarium for each survey and a \u003cspan\u003e$\u003c/span\u003e50 honorarium for each interview completed. Baseline data was collected in-person, and follow-up data could be collected either in-person or via telephone. Consent from participants was obtained at all three time points and participants could withdraw from the study at any time.\u003c/p\u003e \u003cp\u003eThe baseline survey contained questions about lifetime overdose events, substance use leading up to most recent incarceration, as well as access to withdrawal management medication, OAT, and other healthcare while incarcerated. Follow-up surveys focused on OAT continuity, substance use, and overdose events since the last completed survey. Survey questions were adapted from a longitudinal study on harm reduction service clients by the BC Centre for Disease Control.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe semi-structured interview guide prompted questions about community reintegration, employment, family and relationships, substance use, overdose events, substance use treatment (including inpatient recovery services, OAT, or pharmaceutical alternative medications), and usefulness of the care bundles.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAnalysis\u003c/strong\u003e \u003cp\u003eData were coded by two team members, and primary analysis for this paper was completed by a research team member (JB1) with living experience of being on OAT and lived experience of benzodiazepine tapering. Data on access and barriers to OAT, overdose history, substance use, and withdrawal during custody were identified, analyzed thematically, and organized chronologically to understand rates of OAT access relative to rates of OAT eligibility along the continuum of incarceration. All findings and analysis were presented to an advisory committee of formerly incarcerated people for feedback and additional insight.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 120 participants were recruited at the time of their release from provincial correctional centres. At baseline, 120 surveys and 110 interviews were completed. At one-month post-release, 59 surveys and 42 interviews were completed. At two-months post-release, 36 surveys and 29 interviews were completed. The participant cohort comprised 76.6% men (N\u0026thinsp;=\u0026thinsp;92), 19.1% women (N\u0026thinsp;=\u0026thinsp;23) and two people who identified as Two-Spirit (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thirty-nine percent of participants self-identified as Indigenous. The majority of participants (72%) had an overdose event within their lifetime (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003cb\u003ePre-Incarceration Substance Use\u003c/b\u003e. The majority of participants reported using illicit opioids three or more days per week prior to their most recent incarceration, with 52% of participants reporting daily usage. Of those participants who reported regular opioid use before being incarcerated, 63% had an active OAT prescription on the day they were incarcerated. Participants described experiences with accessing OAT prior to being incarcerated during their one-on-one interviews, which included barriers to access such as long waits for appointments:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThat was my whole plan before I was even arrested, was to get on Suboxone. But all the doctors that were going to see wouldn\u0026rsquo;t book me an appointment right away; it was always a month or two down the road.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers described losing OAT access due to provincial cut-off policies for patients required to do witnessed, daily dispensed dosing. These policies mandate prescription termination after four missed doses of methadone or six missed doses of oral buprenorphine.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e One participant said, \u003cem\u003e\u0026ldquo;I missed my prescription right before I got incarcerated. So, they cut me off, but I was working that program and it is a good program.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eWithdrawal.\u003c/b\u003e The rate of OAT utilization among all participants increased while in custody, from 35% of participants entering custody with an active OAT prescription to 59% receiving OAT while in custody (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Despite high rates of OAT utilization, 73% of participants reported experiencing withdrawal when they entered custody. For some participants who were prescribed OAT, this was due to delays in access. One participant reported: \u003cem\u003e\u0026ldquo;After the first three weeks, after I detoxed, I ended up on Suboxone.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome withdrawal experiences in custody may have been due to consuming illicit opioids adulterated with non-opioids such as benzodiazepines, which can cause additional symptoms (such as hallucinations) not treated by OAT:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI\u0026rsquo;d never had closed eye, open eye hallucinations before detoxing, to a very, very extreme level. Still to this day I'm not sure what\u0026rsquo;s real and what\u0026rsquo;s not during that time\u0026hellip; And that isn\u0026rsquo;t a normal symptom of withdrawal from fentanyl.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePost-Release Prescriptions\u003c/b\u003e. Survey data shows that among participants who received OAT in custody, almost a quarter of participants (24%) were released without a prescription for OAT continuation in community and 4% responded \u0026ldquo;Don\u0026rsquo;t Know\u0026rdquo;. This fracture in treatment was much more prominent among those released from men\u0026rsquo;s prison, with 27% of male participants who received OAT while incarcerated reporting they did not receive a prescription upon release and 6% answering \u0026ldquo;Don\u0026rsquo;t Know,\u0026rdquo; compared to 11% of women participants released without a prescription and none responding that they didn\u0026rsquo;t know.\u003c/p\u003e \u003cp\u003eIn a follow-up interview, a participant who had resumed illicit opioid use after release described how being discharged without an OAT prescription ultimately led to him discontinuing his treatment and returning to regular illicit opioid use:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou know, they didn\u0026rsquo;t release me with a script or anything, but I knew that there is places I can go to get one\u0026hellip; [I] felt like I could just, you know, fight through it and then, I wasn\u0026rsquo;t like super, super sick. It was just the lack of the energy and feeling lethargic and weak and that\u0026rsquo;s kind of, no appetite, those kind of things, and not feeling like myself. Just kind of wanting to do nothing and just laze around. So, I think not holding a script was a mistake. I should have just tried to get a script on my first or second day out and continue to work with it.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterview data suggest that the \u0026ldquo;Don\u0026rsquo;t Know\u0026rdquo; response was largely caused by the common practice in BC of prescribers faxing or electronically sending the prescription directly to a pharmacy. Participants answering \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; either didn\u0026rsquo;t know if the prescription had actually been sent at all or didn\u0026rsquo;t know to which pharmacy it was sent. In either scenario, participants described frustration with this uncertainty:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI know that it was faxed to the drug store and they didn\u0026rsquo;t talk to me about where I was getting released or anything...I\u0026rsquo;m going to have to figure that out actually... I\u0026rsquo;m going to have to see a doctor.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant discussed how frustration over the uncertainty around their OAT prescription impacted relationships with staff at their recovery home, who interpreted their stress as disrespect:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen we first came in here, you know how I was worried about my [slow-release oral morphine], remember? Would you say I was being rude over the phone? See, the one guy said I was being very rude and very bad. I got in trouble for being like that, right\u0026hellip; and the guy, he said these things, I was being belligerent and what-not\u0026hellip;. And he\u0026rsquo;s been giving me crap for just doing things that I haven't been doing, so I\u0026rsquo;ve got somebody against me there, so it\u0026rsquo;s very hard, you know.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast, people who were released with an OAT prescription expressed a sense of relief and hope for stability: \u0026ldquo;\u003cem\u003eI was given one [an OAT prescription] and I feel good about it because it just makes it so I can continue my dose instead of jumping around, like what was happening.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBarriers to OAT Continuity in Community\u003c/b\u003e. Among participants who were on OAT while in-custody, the majority (72%) reported being released with a prescription for OAT treatment in community. However, participants reported numerous additional barriers to OAT access after release. Participants experienced challenges with pharmacy access (including transportation barriers and mandated daily dispense), physician access, and provincial OAT cut-off policies.\u003c/p\u003e \u003cp\u003eDuring the data collection period, an ongoing transit strike in the Greater Vancouver Regional District created a significant barrier to accessing pharmacies to fill OAT prescriptions:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eNo, I couldn\u0026rsquo;t get my Suboxone renewed. I mean, I had it for two weeks, but it was a pain in the ass, because I had to go pick it up, right? So, with no buses, how the fuck can you do that? I asked welfare to help me with transportation. She\u0026rsquo;s like, \u0026ldquo;What do you want us to do? We\u0026rsquo;re not paying for cabs.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Most participants receiving OAT in community, particularly methadone, were required to have their doses supervised by a pharmacist, meaning they were required to travel to a pharmacy every day. This mandate further exacerbated transportation challenges for many participants. One participant was even not permitted take-home doses when his usual pharmacy was closed on the weekends and instead had to travel to a different pharmacy\u0026mdash;a 20-minute bus ride or 30-minute walk away. This also required an official prescription transfer from Pharmacy A to Pharmacy B before the weekend, then back to Pharmacy A each Monday, increasing the potential for error and creating further uncertainty and barriers to care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe problem is that the prescriptions keep getting messed up in between pharmacies\u0026hellip;. I\u0026rsquo;ve got two of them; I\u0026rsquo;ve got the (Pharmacy A) and they're open Monday to Friday, but Saturday, Sunday they're closed. And then they\u0026rsquo;ve made me go to (Pharmacy B) for my other.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnable to access their pharmacy or keep up with daily witnessed dispensations, several participants reported that they missed their doses and subsequently had their OAT treatment cut-off, as per provincial policy.\u003c/p\u003e \u003cp\u003eOther participants were required to find a community-based physician immediately upon release despite being provided with a prescription: \u0026ldquo;\u003cem\u003eI got to go find a doctor tomorrow. They gave it to me one day (laughs). Yeah. That\u0026rsquo;s what I have. Yeah. Got to go find a doctor tomorrow, they said.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion and Recommendations","content":"\u003cp\u003eFindings from this study contribute to the growing body of research that shows even those who are motivated to remain on OAT following release from prison face systemic barriers, such as a lack of reintegration supports\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e; lack of pre-release planning for community treatment, often due to early or unexpected releases or releases occurring outside clinic hours;\u003csup\u003e20\u003c/sup\u003e and long waitlists for community OAT clinics.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Through examining participant experiences, the PREVAIL project reveals opportunities for improvement in both correctional and community substance use health care, particularly for those transitioning both in and out of correctional centres.\u003c/p\u003e \u003cp\u003e The majority of participants (73%) reported that they experienced substance withdrawal when they entered correctional centres. This suggests that people are experiencing a gap in care as they transition from community into custody. This gap may be due in part to the unpredictable period of time between initial arrest and arrival at a provincial correctional centre. During this time, people are held in municipal police cells and may not have access to health care, including limited access to any medications prescribed to them. The length of stay in city cells depends on the day of arrest, as transfers to provincial correctional facilities only occur Monday to Friday. A Friday arrest can result in a 72-hour delay in municipal cells, increasing risk of entering withdrawal prior to receiving withdrawal management care from provincial correctional health services. This gap in care has become more dangerous due to the changing illicit opioid supply. Withdrawal symptoms occur much more rapidly as well as more severely with illicit fentanyl use compared to heroin, due to fentanyl\u0026rsquo;s higher strength but shorter half-life.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This intensifies the impact of the care gap in municipal cells, as well as the impact from delayed medical care and insufficient OAT doses within provincial correctional centres that some participants reported. Additionally, the widespread presence of benzodiazepines in BC\u0026rsquo;s illicit fentanyl supply \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e suggests that some participants may have been reporting non-opioid withdrawal symptoms. Benzodiazepine withdrawal is not treated by OAT but, if left unmanaged, can be fatal.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdditionally, many participants experienced challenges in maintaining OAT continuity when transitioning back to community. Almost a quarter of participants receiving OAT while in custody reported not receiving a prescription at their time of release. This suggests a gap in post-release planning and highlights a need for further research into how this gap occurs, particularly amongst those released from men\u0026rsquo;s correctional centres, who were more likely to experience treatment fracture when transitioning back to community compared to those released from women\u0026rsquo;s facilities.\u003c/p\u003e \u003cp\u003eAlthough the majority of participants on OAT while in custody did receive a prescription for treatment at release, many barriers to treatment retention exist in community settings.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The most prominent issue for participants attempting OAT continuity after release was pharmacy access. Widespread mandated daily dispensing for witnessed OAT consumption is part of a larger provincial issue of OAT access, which requires each daily dose be dispensed where the prescription was initially filled, unless an official pharmacy transfer is requested. A transfer can only occur if both the receiving and sending pharmacy are open. These administrative barriers make it more challenging for people to seek and maintain OAT treatment.\u003c/p\u003e \u003cp\u003eFindings from PREVAIL also highlight the importance of the social determinants of health on post-release OAT treatment outcomes. Participants reflected on challenges with transportation that hindered their ability to access their designated pharmacy and receive daily OAT dispensations. Limited transportation, when combined with mandated daily dispense dosing, creates barriers to both OAT uptake and retention.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Other barriers related to the social determinants of health can include lack of resources, such as cell phones to contact clinics; lack of identification; lack of contact information; and OAT-related stigma from family members.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are several opportunities to improve OAT treatment access for people experiencing incarceration in BC. To reduce the experience of withdrawal and improve continuity during transitions from community to custody during initial incarceration, policies are needed to support the dispensation of active OAT prescriptions to people held in municipal cells. Additionally, people who regularly use illicit opioids should be screened for concurrent benzodiazepine withdrawal when entering both municipal cells and provincial correctional centres in order to more safely manage withdrawal from all substances. Given the high rate of withdrawal within our participants, reports of suspected unmanaged and potentially fatal withdrawal from benzodiazepines, and preexisting research showing that unmanaged substance withdrawal increases risky substance use during incarceration\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and hinders future OAT attempts\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, it may be advisable to implement withdrawal management medical units within provincial correctional centres. An increase in dedicated health care staff with OAT expertise could also reduce instances of people being released without an OAT prescription.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo address continuity and access issues for daily dispense-mandated OAT patients in BC, we recommend utilizing PharmaNet, the provincewide data system for tracking prescriptions, to allow for any OAT-dispensing pharmacy to assess if an OAT patient has already received their daily dose, and if not, to be able to dispense that dose. This would reduce barriers for recently released people in particular, who, as the PREVAIL findings show, may be experiencing challenges in identifying or travelling to the specific pharmacy holding their prescription. Such a system could also ease release planning for correctional health staff, as this would eliminate the need to have health care staff available to write new prescriptions for OAT patients with already active prescriptions exiting incarceration.\u003c/p\u003e \u003cp\u003e As well, to further improve community OAT access, we recommend updating dispensation guidelines to allow for increased take-home doses. Rationale for daily and witnessed dispensations center on safety concerns for patients and the larger community; however, research on relaxed OAT dispensation guidelines in response to the COVID-19 pandemic shows an absence of negative consequences associated with increased take-home OAT doses.\u003csup\u003e28\u003c/sup\u003e When take-home privileges are left to prescriber discretion, social, racial, and economic inequities are often amplified.\u003csup\u003e29\u003c/sup\u003e Therefore, province-wide guidance for more widespread access to take-home privileges would be beneficial.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study suggest that although there is an increase in OAT treatment uptake while people are incarcerated in BC\u0026rsquo;s provincial correctional centres, there are still gaps in care as people move from community into custody and back. Given the on-going and rapidly changing toxic drug crisis, there is an urgent need to strengthen this continuity of care. Addressing these gaps will ensure that people can effectively manage withdrawal, increase retention of substance use treatment, and overall reduce their risk of both non-fatal and fatal overdose.\u003c/p\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eTrial registration\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJB1 identified and organized relevant data for this manuscript.JB1 and AS wrote main manuscript text.AS and DPD prepared and analyzed quantitative data.DPD prepared all figures.KR was the PREVAIL project research manager.MK was an advisor on the project and oversaw the hiring and training of the peer researchers.JB2 coded the qualitative data.All authors reviewed and edited the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledgement and appreciate the immense input and critique from the Priorities and Engagement in Research in Correctional Health (PERCHbc) peer advisory committee, as well the ongoing support from the Unlocking the Gates Society.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData for this project is not available publicly due to confidentiality considerations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBC Coroner\u0026rsquo;s Service. 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Int J Qual Stud Health Well-being. 2022;17(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17482631.2022.2094111\u003c/span\u003e\u003cspan address=\"10.1080/17482631.2022.2094111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics at Release\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo-Spirit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartnered, living separately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartnered, living with my partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer to describe / Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnic Group*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican or Caribbean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuropean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndigenous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic or Latinx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer to describe / Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not complete high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school degree or equivalent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education college/university\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer to describe / Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave Children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer to answer / Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFixed Address to Receive Mail\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer to answer / Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Reported Participant Overdose Events\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverdose Event (Lifetime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83 (72.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69 (75.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple Overdoses (Lifetime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (59.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (60.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 Overdoses (Lifetime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (24.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026thinsp;+\u0026thinsp;Overdoses (Lifetime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverdose in 6 Months Prior to Release\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (52.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncertainty About Overdose in 6 Months Prior to Release\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpioid Agonist Treatment and Period of Incarceration\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncarceration Stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDidn't Know / No Response\u003c/p\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrior to Incarceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuring Incarceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfter Incarceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"opioid agonist treatment, opioid use disorder, prison health, correctional health, mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-8904539/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8904539/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: People leaving correctional centres have an elevated risk of overdose death, particularly within the first two weeks of release. Opioid agonist treatment (OAT) is an evidence-based pharmacological treatment that reduces mortality risk. This study used a mixed-method approach to examine OAT access among people recently released from correctional facilities to identify facilitators and barriers to OAT retention both in custody and community.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Between February and August 2023, the PREVAIL Project recruited 120 persons leaving provincial correctional centres in British Columbia who reported using illicit substances within six months to their incarceration. Peer support workers were trained as researchers and administered surveys and interviews on the day of release, as well as one- and two-months following release, about experiences before, during, and immediately after incarceration. Data on illicit drug use, withdrawal, and access to OAT were analyzed using descriptive statistics and thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The rate of OAT utilization among participants was higher (59%) during incarceration compared to post-release (35%). The majority (73%) of participants reported experiencing withdrawal from illicit substances while in custody. Some participants reported that OAT medications had insufficient dosage or timeliness to prevent withdrawal. Among participants who received OAT in custody, 28% were unsure if they had a prescription or released without an OAT prescription. A higher proportion of OAT recipients who were released from men’s prisons did not leave with a prescription. Participants also reported several barriers to post-release OAT retention, including daily dispensation policies, transportation availability, and challenges associated with transferring prescriptions between pharmacies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: OAT uptake and access was high while participants were in correctional centres, but continuity was interrupted when participants both entered and exited incarceration, particularly for those exiting men’s prison. As well, retention post-release was limited by a number of systemic factors. The findings of this study suggest that there is a need to expediate access to health care during intake to correctional centres, strengthen the continuity of care post-release, and reduce barriers to OAT in community. Improving access to continuous OAT has the potential to reduce overdose mortality and increase retention in substance use treatment post-release.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"“Well everyone I know who gets clean is dead within a year, so that’s kind of a worry”: OAT Access Among a Cohort of Post-Incarceration Peer-Support Program Participants in British Columbia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 10:22:53","doi":"10.21203/rs.3.rs-8904539/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"245327796736174578133550696071762692135","date":"2026-05-04T15:27:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68925971419889905917515144889577460237","date":"2026-04-29T06:40:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T16:33:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T07:26:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T07:25:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2026-02-17T22:08:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"25c6b0c5-b6af-4c6d-870e-e5cf4589ab09","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"245327796736174578133550696071762692135","date":"2026-05-04T15:27:21+00:00","index":30,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T10:22:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 10:22:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8904539","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8904539","identity":"rs-8904539","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}