The alarming number of overdose deaths in Canadian correctional facilities warrant an urgent, multi-faceted response from the federal government. The state has a responsibility to protect the health and human rights of those in custody.
In early February, Ontario’s Office of the Chief Coroner held an inquest into the tragic deaths of five individuals in federal custody at Collins Bay Institution due to fentanyl toxicity. The public heard from families, correctional facility staff, community groups and experts on the conditions under which Shane Gammie, age 35, Christopher Sipes, 51, Qinlong Xue, 26, Quinn Borde, 39, and Shimon Abrahams, 41, died, including inadequate mental health supports, significant gaps in harm reduction services and overly punitive measures. These measures included disproportionate consequences for those found to be in possession of tobacco, as was the case for Mr. Gammie, a father of three who had completed his high school diploma and engaged in substance use disorder treatment while incarcerated. He struggled with nicotine dependence, received disciplinary charges for possession of tobacco, and was transferred back to a medium security facility shortly before his release, potentially contributing to the circumstances under which he died of a fentanyl overdose.
The inquest recommendations urged Correctional Services Canada (CSC) to “increase availability of medications to treat opioid use disorder, consistent with options that might be available in a health care setting outside a penitentiary.” But while the occurrence of opioid-related deaths in federal custody demands expanded treatment availability, CSC instead has made significant policy and medication formulary changes that narrow treatment options.
Rather than ensuring low barrier access to opioid agonist therapy (OAT), CSC has limited first-line treatment for opioid use disorder to extended-release injectable buprenorphine.
OAT refers to long-acting opioid medications that are used to reduce withdrawal and cravings and have been shown, through extensive research, to reduce mortality. OAT includes medications like methadone, buprenorphine and slow-release oral morphine. Buprenorphine comes in various formats, including a daily tablet, daily film or monthly injection. OAT guidelines suggest a patient-centered approach in which treatment is individualized, to allow for selection of the treatment that will be most effective, with the fewest side effects, for the person taking it.
The CSC policy change, which took effect Oct 1, 2025, removed sublingual buprenorphine/naloxone from the formulary, making it available only through physician-initiated exceptions, while methadone is now considered second-line treatment, contrary to national guidelines.
Clinicians, lawyers and community organizations have since heard of individuals in custody being forced to transition to injectable buprenorphine, which is accompanied by fear, risk of destabilization, experiences of severe withdrawal and medication side effects. Pressure to accept injectable buprenorphine is daunting for those with needle phobias, exacerbated by frequent reports of injection site pain and other complications.
More than 150 clinicians and researchers sent a letter to CSC to express urgent concern about this directive, which removes patient autonomy, diminishes the quality of care individuals receive compared to the community, and potentially undermines overdose prevention efforts.
The research studies used to justify the new policy have methodological limitations in some cases and are not applicable to the Canadian correctional context in others. In fact, several authors from one of the studies supporting feasibility of extended-release buprenorphine in correctional settings have since published a commentary to express concern and clarify the evidence. The authors, respected clinicians and researchers in this field, highlight that the studies CSC looked to were largely non-randomized and had small sample sizes of predominantly male participants while others involved extended-release buprenorphine products that are not available in Canada. Several studies were conducted in regions in which fentanyl and other high potency opioids were less common.
Despite ongoing dialogue, one concern that has not been addressed is cost and availability of extended-release injectable buprenorphine. On the Ontario public formulary, this treatment costs a minimum of $550 per month, whereas the cost of the maximum dose of sublingual buprenorphine/naloxone is under $200. Many individuals receiving injectable buprenorphine require supplemental sublingual buprenorphine/naloxone, increasing the cost. Furthermore, injectable buprenorphine can only be administered by trained health-care providers and is not available in every community, which poses a risk of disruption in care during post-carceral transitions, a time when overdose risk is already high.
CSCs’ obligation to provide health care that is equivalent to that offered in the community, which in this case would involve unencumbered access to all forms of OAT, is an internationally recognized principle under the Mandela Rules: “Prisoners should enjoy the same standards of health care that are available in the community and should have access to necessary health-care services free of charge without discrimination on the grounds of their legal status.” The rules demand continuity of treatment and care for various health conditions including substance use disorder.
Shane Gammie, Christopher Sipes, Qinlong Xue, Quinn Borde and Shimon Abrahams should be here with us today, as should the thousands of others who have died in custody in Canada.
Those incarcerated are being offered a reasonable OAT. There options for OAT are not as broad as those not in detention, but it seems likely that oral options would be far more likely to be diverted and misused. overall, this policy seems reasonable.