Opioid use disorder (OUD), which contributes to the ongoing overdose crisis claiming over 21 lives across Canada a day, is even more severe within correctional settings. In North America, OUD is a critical public health concern among incarcerated populations, with individuals being up to 129 times more likely to die from an overdose within the first two weeks of release from custody than the general population.

To better understand treatment best practices for this high-risk, and often overlooked population, researchers at the Center for Addiction and Mental Health (CAMH) have conducted the first comprehensive review of available studies evaluating the use of extended-release buprenorphine (XR-BUP ) weekly and monthly injections as a treatment for OUD within correctional facilities. This extensive literature review reveals insights that could reshape addiction treatment practices in these settings and beyond.

The review, published in The American Journal of Drug and Alcohol Abuseanalyzed ten international studies published since 2018 that examined the usage of XR-BUP in correctional populations, looking at participant treatment preferences, drug use, retention rates, safety, costs, and barriers. The aim was to understand whether XR-BUP’s extended dosing schedule could improve treatment access and recovery outcomes.

The review showed XR-BUP to be highly effective and safe, with retention rates as high as 92%, re-incarceration rates as low as 8%, and 55% of patients achieving opioid-negative urine tests compared to 38% using other treatments. .

“(XR-BUP) offers a powerful new approach to address the high relapse and overdose risks faced by those transitioning out of correctional facilities,” says Dr. Leslie Buckley, Chief of Addictions at CAMH. “With this treatment, we can potentially reduce the logistical and social burdens associated with daily dosing and help patients sustain recovery as they reintegrate into their communities.”

This study builds on previous research exploring traditional daily treatments like methadone and buprenorphine for currently and recently incarcerated populations. While effective, these treatments require daily clinic visits, creating barriers for individuals lacking community ties or stability after release.

In contrast, XR-BUP is an injectable medication that provides a steady dose over the course of a week or a month, depending on the formulation, eliminating the need for daily dosing. Although XR-BUP still requires clinic visits for administration, the frequency varies based on the dosing schedule, offering participants longer and more flexible intervals between appointments.

Participants in this recent review appreciated this flexibility and the reduced opioid withdrawal and cravings over a longer period of time. They also found the private administration of XR-BUP to be more dignified, reducing the stigma associated with treatment.

One of the most significant findings of the study was that individuals who received an XR-BUP injection experienced an 80% reduction in the risk of overdose mortality within the first month after their release.

“The opioid crisis poses a serious health risk for incarcerated populations,” says Cayley Russell, Research Manager with the Ontario Node of the Canadian Research Initiative in Substance Matters (CRISM), housed at CAMH, and the study’s first author.

“Our findings show that XR-BUP is safe and feasible, with no reports of diversion, overdoses, or deaths. This highlights the life-saving potential of administering XR-BUP treatment at the time of discharge to reduce the risk of overdose post- release and throughout the period of incarceration.”

Beyond the significant health benefits, XR-BUP also shows potential for addressing the administrative challenges faced by correctional facilities and health care providers. While initially more expensive, XR-BUP proves cost-effective over time. Monthly injections reduce the need for daily supervision by staff, and the decreased risk of overdose minimizes the need for interventions, hospitalizations, and related health care expenses.

Additionally, higher retention rates lead to fewer re-incarcerations and mitigate broader societal impacts of untreated OUD.

Despite its clear advantages, the implementation of XR-BUP is not without challenges. The review highlights barriers to XR-BUP treatment, including hesitancy about a newer medication, fear of needles, and mild to moderate side effects such as injection site discomfort, constipation, fatigue, and nausea. Addressing these concerns through patient education can empower informed decisions about treatment options.

“By contributing to and leading research on treatment options like XR-BUP, CAMH is advancing evidence-based practices that align with our strategic goals to lift societal health, get upstream of health challenges, and address mental health and addiction needs more effectively,” says Dr. Shannon Lange, Scientist at CAMH and co-author of the review.