Alberta has become a leader in opioid use disorder (OUD) treatment within provincial corrections. Correctional Health Services developed an innovative opioid agonist therapy (OAT) program over the last decade. A more recent partnership with the Virtual Opioid Dependency Program has resulted in immediate asynchronous virtual assessment for an OUD diagnosis and OAT treatment for inmates who meet the OUD screening criteria on admission. Since the program's launch, there have been several quality improvement initiatives undertaken that have eliminated waitlists for OAT initiation, and there have been reductions in drug overdose mortality, both within correctional centres and after release.

Introduction

Alberta Canada, along with the rest of North America, has faced a rising problem of opioid use over the last decade (The Lancet 2021). The rise of fentanyl, carfentanil (an extremely potent, synthetic opioid) and other high-potency drugs has caused marked increases in fatal and non-fatal overdoses. Between 2016 and 2019, more than 2,000 Albertans died from an opioid overdose (Government of Alberta 2019). In response, the Alberta government has implemented several innovative changes to respond to the challenge. As of early 2024, opioid-related deaths have begun to decline in Alberta (Government of Alberta 2026). This is further evidenced by the decrease in opioid-related deaths (8.8%) across Canada between 2023 and 2024, a decline that appears to be largely attributable to Alberta, which observed a decline of about 36% (Health Infobase 2026).

A key area of focus for innovation has been to improve opioid use disorder (OUD) treatment in Alberta's provincial correction facilities. In 2017, the medical examiner's office in Alberta determined that 41% of all community opioid overdose fatalities were people who had a provincial corrections history in the five years prior to their death (Government of Alberta 2019). Thus, the correctional setting was a prime target for intervention. Alberta's Correctional Health Services (CHS) has responded to this evolving problem with solutions intended to meet the needs of the people it serves throughout their incarceration. Today, all new arrivals are screened for OUD on admission, assessed and offered treatment when appropriate, typically within 24 hours after admission. Waitlists for opioid agonist therapy (OAT) have been eliminated, resulting from the expansion of the CHS OAT program and collaboration with the Virtual Opioid Dependency Program (VODP) (Recovery Alberta 2026). This paper provides an overview of the evolution of the OAT program in Alberta's provincial correctional centres and the innovative and successful collaboration with the community VODP to address the opioid crisis.

Overview of CHS in Alberta

Evolution of CHS reporting structure

As is typical in many jurisdictions in Canada, Alberta's CHS was previously operated by and reported to the Ministry of Justice. The reporting structure was shifted to the public healthcare system to ensure the provision of important healthcare services. Starting in 2010, the public healthcare agency in Alberta took responsibility for healthcare service provision within correctional institutions. In 2024, responsibility was further assigned directly to a new agency responsible specifically for mental health and addiction care, Recovery Alberta. An important additional change to the leadership structure of CHS occurred in 2023. Before that time, operational management of CHS services was led in a regional way. To correct fragmentation and improve consistency of care, a dedicated provincial lead for CHS was created. The new position was designed to ensure sole focus on the oversight and management of operations in all 10 provincial correctional centres. These changes have provided clear and dedicated leadership and accountability.

An additional foundational improvement occurred with the implementation of an electronic medical record (Connect Care – Epic) for CHS in late 2024 (Alberta Health Services 2026). It is anticipated that this improvement will assist with further data analysis, program evaluation and quality of care improvement in the coming years. This medical record is consistent across service delivery in the public healthcare system and ensures that staff have access to real-time information that is relevant to the care of the person in front of them. CHS is now fully integrated with the rest of Alberta's health system, including primary and acute care.

CHS workforce and services

CHS comprises highly trained health professionals who are accredited, regulated and belong to communities of practice. Staff dedicated to providing these services include nurses, nurse practitioners, physicians, pharmacists, social workers, dentists, addiction counsellors, psychiatrists, program coordinators and administrators. These teams are present in all 10 of Alberta's correctional centres,¹ and deliver healthcare services in accordance with applicable legislation and Accreditation Canada standards.² Primary care makes up the majority of CHS service provision, as correctional patients require basic medical care for a range of issues, including wound care, minor illness, infections and chronic medical conditions. Services also include preventative measures, such as the sexually transmitted and blood-borne infection opt-out program, immunization clinics, medication management and delivery, prenatal/postnatal care, chronic disease management, urgent dental care, pharmacy services, diagnostic imaging and lab work and telehealth-facilitated specialty clinics. Additionally, when needs exceed program capacity, emergency and hospital-level care are provided, including coordinated transport between settings.

OUD and the corrections custodial population

CHS provides addiction and mental health services, given that approximately 60% of custodial patients possess either a mental health or addiction disorder, and many have concurrent disorders (Butler et al. 2022). Comorbidity of complex mental health and primary medical concerns is high (Launders et al. 2022). Weekes et al. reported in 2004 that nearly half of all incarcerated people in the Canadian federal correctional system identified as having a problem with substance use, and just over a quarter indicated they had used opioids within six months of their most recent arrest (Weekes et al. 2004). Many also suffer from OUD, which is defined as “a medical condition characterized by a problematic pattern of opioid use leading to clinically significant impairment or distress” (American Psychiatric Association 2013). People with OUD experience symptoms that include an overwhelming desire to use opioids, heightened opioid tolerance and severe withdrawal symptoms upon discontinued use. The condition is characterized by ongoing cycles of relapsing use and steadily increased tolerance. The personal, social and economic consequences of OUD are very significant. Treatment of OUD requires long-term therapy, including psychosocial and pharmacological interventions (Day et al. 2022).

OAT in CHS

Delivery of OUD treatment medications has traditionally been challenging in the corrections space because many people do not enter the system with an established diagnosis or were not taking treatment medications at the time of arrest. Before the incorporation of CHS into the public healthcare system, access to confirmatory community records was not rapidly feasible. Additionally, the medications themselves carry the potential for abuse, arising from the risk of medication trafficking. OAT is the key pharmacological intervention for the management of OUD (CAMH 2021). In Alberta's provincial correctional centres, the four medications used include buprenorphine-naloxone, injectable buprenorphine, methadone and slow-release oral morphine. The primary objective of the program is to rapidly initiate OAT for correctional patients with OUD during their stay, to prevent suffering, to decrease the likelihood of medical complications from withdrawal in the provincial correctional centre and to successfully transition them to a continuation of OAT in the community.

Early evolution of OUD management

The OAT program in Alberta's provincial correctional facilities has evolved considerably. Traditionally, the ability to treat people found to be suffering from OUD while in custody was very limited. Methadone and buprenorphine-naloxone were available only for people who had already been initiated in the community before admission to the correctional centre. In 2016, CHS launched an OAT initiation pilot program involving methadone and buprenorphine-naloxone for newly admitted people suffering from OUD. The program's success spurred expansion to all provincial correctional centres the following year. Participation caps and waitlists were implemented due to high program demand, and variation in processes emerged due to the unique characteristics of each centre. Program refinements were required over the ensuing years as fentanyl emerged as the dominant street opioid in Alberta.

Program improvement measures

Several measures aimed at improving the OAT program were undertaken starting in 2019. Formal program evaluation and patient survey learnings resulted in better data collection and monitoring methods, ongoing education for patients and staff, the establishment of virtual clinics in centres with less consistent access to OAT prescribers and improved in-centre OAT delivery methods via regular medication lines. The Alberta government provided additional funding for OAT services in 2020 and introduced the OAT Gap Coverage Program³ in the community, facilitating treatment medication coverage for inmates on release (Primary and Preventative Health Services 2025) in 2021. Increased funding permitted hiring of new program-specific staff (i.e., OAT coordinators and nurse practitioners) to maintain the waitlists, complete assessments and ensure referrals and release planning occurred. The result was a rise in OAT screenings and initiations provincially, as evidenced in Figures 1 and 2 in the 2020–2021 period. However, the COVID-19 pandemic and persistence of challenges at Edmonton Remand Centre (ERC), the largest facility in Alberta and home to more than 40% of the entire provincial corrections custodial client population, meant that further innovation was required to bring down the waitlist and resultant delay in OAT initiations (Government of Alberta 2018).

Partnership with VODP

Not only did ERC house just under half of Alberta's corrections custodial population, but the reality of it being a remand centre means that lengths of stay for any individual held there are less predictable. Despite all the significant changes made in the CHS system, the centre had longer wait times for OAT than median and average lengths of stay in the centre. Thus, only people who remained in the centre longer than typical periods could receive assessment and initiation of OAT treatment. The result was that many clients who self-identified as having OUD were being released before they could be assessed. Seeking to tackle the growing issue, CHS leadership consulted with the in-community VODP (Recovery Alberta 2025) in late 2021. VODP is a publicly funded service also operated by the public healthcare agency, Recovery Alberta, a fact that permitted a joint submission for ethical, health law, health records management, administrative and regulatory body review.

The collaboration between CHS's OAT program and VODP at ERC began assessing and treating patients in July 2022 (demonstrated by the vertical red line in Figures 1 and 2). Notably, the new approach did not require additional staffing resources or any significant new financial costs. Every new admission to ERC was already screened by a nurse 24 hours per day to determine if a patient had any urgent medical issues. CHS added a screening question about opioid use to this assessment. If the person was identified as using opioids, they were offered treatment as usual with an assessment and treatment through in-person or virtual clinics. Alternatively, if they consented, the person could be offered rapid assessment and treatment using a novel approach called asynchronous telehealth.

For the asynchronous telehealth process, the on-duty nurse would start a video recording device and go through a series of questions about the person's opioid use and other drug use. The video is then uploaded to a secure healthcare server, where, on demand, addiction specialists at VODP could review the video and determine if there was enough evidence to support induction to treatment and make treatment orders for the patient to consider. The information gathered is typically adequate to make or confirm a diagnosis and to offer treatment recommendations. However, if the information was inadequate, further assessment could be arranged. In addition, all patients going through this process are provided with informational videos and documentation about treatment, followed by a voluntary option to provide a urine toxicology sample to support their report regarding opioid use near the time of their arrest and admission to the centre.

Collaboration successes

This collaboration with the VODP proved highly effective. By September 2022, waitlists for OAT had all but disappeared at ERC and all other provincial centres, as demonstrated in Figure 1. The average time for a correctional patient to receive their first dose of OAT dropped from 11.6 days in July 2022 (which itself was an improvement from before implementation) to less than a day (0.74 days) in June 2023. Moreover, increased OAT screenings coincided with a reduction in health service requests (HSRs) for OAT initiations by patients (Figure 1). The upward trend in screenings most likely indicates that they began to take place on admission prior to submission of an HSR, highlighting an improvement in program efficiency.

Between 2019 and 2024, there was a steady increase in OAT initiations, most notably with buprenorphine-naloxone (Figure 2). When CHS's OAT program began in 2019, there was an average of 91 OAT initiations during that year, which then plateaued in 2020 (average: 110). OAT initiations steadily began to increase again in 2021 (average: 243), 2022 (average: 414) and 2023 (average: 530) and remained stable in 2024 (average: 494).

Drug poisonings and fatalities

Preliminary data suggest that the OAT program, in collaboration with VODP, has had an important impact on people after release from a correctional centre. Analysis of five years of vital statistics data for deaths with a primary cause of drug poisoning⁴ indicate that the number of deaths in the year following discharge has been on the decline since 2021 (Figure 3a). This drop was apparent the year VODP collaboration was initiated (in July of 2022), and in 2023, when the program was in place for the full year, the number of deaths among correctional releases declined by almost half again (Figure 3a). In comparison, the overall population deaths due to these same codes did show some decline (as expected by drops in the correctional group), but by much less – virtually no change comparing 2023 to 2022, and by only about 30% comparing 2024 to 2023 (Figure 3b).

This development is especially notable given that the average daily adult correctional population increased by 32.1% from 2020-21 to 2024-25, following a period of reduction in the correctional population due to the COVID-19 pandemic (Government of Alberta 2025). Updates in the 2024 vital statistics data may still occur and this data will be reviewed again in the coming months; however, any lags in data are expected among both correctional discharges and the general population.

Following the implementation of the collaboration with the VODP program at ERC, another round of patient surveys was conducted at all centres. Compared with their peers at other centres, patients at ERC reported higher levels of satisfaction, including a better understanding of resources and services available to them, the benefits and risks associated with OAT and increased optimism regarding the continuation of treatment in the community (Vetland and Mallinson 2024). As a result, collaboration with VODP was expanded to all the other provincial correctional centres through late 2023 and 2024.

Discussion

Program refinements undertaken by CHS have resulted in notable improvements for the correctional population with OUD. The steady increase in OUD screening and initiation on OAT upon admission into the correctional centre, coupled with the reduction of drug poisoning deaths in the community within one year of release, are very encouraging developments. The successful transition from the correctional centre directly to community programs and services is crucial for positive outcomes for correctional patients. The development of the Safe Transitions Policy in late 2023 highlights the current focus by CHS on this moment in the correctional patient journey. The policy requires discharge planning for all patients involving a healthcare professional and discussion regarding medications (i.e., a prescription is provided) and other supports (i.e., how to obtain personal identification and housing) available upon release, and where appropriate, a three-day's supply of bridge medications is provided. CHS staff also work to make strong connections for patients with community treatment providers to continue receiving treatment in the community. Importantly, CHS is working closely with Correctional Services Division staff throughout the correctional patient journey and is currently collaborating closely on improving discharge planning to ensure successful transitions to the community for all correctional patients, including those with less predictable stays in correctional centres such as remanded patients. When combined with the natural bridge to community treatment provided by the community-based VODP program and the continued build-up of programs and services throughout Alberta (i.e., ongoing expansion of treatment beds via recovery communities), there is strong reason for cautious optimism and a high need for ongoing monitoring and analysis of outcomes for correctional patients suffering from OUD.

Conclusion

Preliminary evidence of the OAT programs' effectiveness indicates that drug poisonings have declined, both in-centre and in-community post-release. These changes may be a component of why community overdose mortality appears to have declined in Alberta in 2024. The impact of these innovations on the management and treatment of OUD in the custodial setting has been profound. Indeed, Alberta's effort to bring corrections healthcare under the umbrella of the public healthcare system, with connections to other public programs for rapid assessment, treatment and release planning, appears to be bearing fruit. While there is a significant opportunity to complete further and more robust evaluation on the specific elements that have been part of these changes, decision-makers should be aware that thoughtful application of technology, empirically proven treatments, with an eye to compassionately alleviate suffering, may markedly improve outcomes in traditionally difficult-to-reach populations. The innovation with asynchronous telehealth as a tool to bring expert care to front-line corrections services without significant new costs in resource-strapped settings must not be ignored. Patients in the provincial corrections health system are, in fact, patients from the community and ultimately return as members of the community. Efforts to meet needs and provide appropriate treatment in this setting are well worth organizational focus and, in Alberta, may well be contributing to the stabilization of opioid overdose fatalities in the community observed over the last year.

Data availability and limitations

Facility Services Information System had issues with data entry in the early period of the OAT program, and data element adjustments were undertaken to ensure proper representation of activities and reporting requirements. Awareness of these adjustments is required for comparisons involving pre-2020 data.

Comments

Be the first to comment on this!