A turf battle between provincial ministries has stalled efforts to distribute the opioid antidote naloxone to prisons in Ontario, further limiting access to the life-saving drug for people at high risk of overdosing.
For three years, public-health doctors have called on the province to distribute take-home naloxone kits to prisons for newly released inmates, who can be in particular danger from opioids. More recently, they have urged the province to provide naloxone kits through hospital emergency departments, which have had a 72-per-cent increase in visits due to opioid overdoses in the past decade, according to figures obtained by The Globe and Mail.
As of last month, the Ministry of Health had no plans to expand its program for public-health units, which restricts distribution of the take-home kits to needle-exchange sites, spokesman David Jensen said. That has left the ministry in charge of correctional services to improvise a solution for inmates leaving prison.
"This is a failed program," said Meldon Kahan, medical director of the Substance Use Service at Women's College Hospital in Toronto. "They are not reaching the people who really need it."
The Health Ministry's stand shows the gaps in the Ontario government's response to an opioid crisis sweeping the nation, and puts the province increasingly out of step with other regions in responding to a surge in overdose deaths linked to illicit fentanyl. A recent Globe investigation found that traffickers can easily order the highly potent, low-cost drug online from overseas and have guaranteed shipments to Canada.
The American Heart Association's 2015 cardiovascular care guidelines say patients treated for an overdose in emergency rooms and inmates released from prison are among the groups that benefit most from naloxone. British Columbia, Alberta and Saskatchewan provide take-home kits to patients treated in hospital for opioid overdoses. Alberta hands out kits to inmates upon release, and British Columbia launched a pilot program 10 months ago at two correctional centres with plans to expand it province-wide.
The response in Ontario has been more muted. Health Minister Eric Hoskins announced in May that Ontario would join B.C. and Alberta in setting up a separate naloxone program for pharmacies, providing the kits free of charge and over the counter without a prescription. But barriers to access remain, especially in rural and northern Ontario, where pharmacies are few and far between.
Under Ontario's naloxone program for municipal public-health units, only clinics that hand out clean needles to addicts can give the first-aid treatment, which reverses the symptoms of an overdose in minutes, to members of the public to take home. The shortcoming has led to grassroots efforts to circumvent the rules.
A plan to distribute naloxone to released prison inmates ground to a halt over the past six months in a jurisdictional row between officials with the Ministry of Community Safety and Correctional Services and the Ministry of Health, multiple public health sources have told The Globe and Mail.
The rift between the two ministries dates back to at least Jan. 11, when the correctional ministry's senior medical consultant, Lori Kiefer, wrote to the province's regional medical officers of health proposing a take-home naloxone program for all Ontario inmates returning to the community.
In a letter obtained by The Globe, she asked medical officers in regions with a correctional facility to develop "a common protocol and explore means by which to deliver a program for this population at risk."
When word of Dr. Kiefer's plan reached the Ministry of Health department that is responsible for naloxone distribution in Ontario, staff there refused to take action on it, complaining that corrections staff had overstepped their authority, according to those familiar with the discussions.
"There was 100 per cent uptake on the part of public health to do this," said Rosana Salvaterra, medical officer of health for Peterborough, Ont. "My understanding is that bureaucrats working within their respective ministries have shut this initiative right down."
The corrections ministry refused a request to speak with Dr. Kiefer. "It's important to know that we are in the early stages of looking at the delivery of Take Home Naloxone kits in a correctional setting," spokesman Andrew Morrison said, without elaborating on when any such program might be launched.
Mr. Jensen confirmed that the Health Ministry would not provide the kits to Correctional Services. He said it was told it could go ahead on its own and "purchase and distribute naloxone to inmates as they see fit."
Instead of different ministries working in silos, Dr. Salvaterra said, the government should set up a provincially co-ordinated naloxone program. Pamela Leece, a resident in the public health and preventive medicine program at the University of Toronto, said it makes more sense to deal with naloxone in prisons as a health rather than a corrections issue. "There's a high-risk population that needs intervention," Dr. Leece said.
Dr. Kiefer's initiative was based in part on a recent research paper she co-wrote, which found that an Ontario inmate's chance of dying by an overdose spikes to 56 times the national average in the two weeks after release.
"If we're interested in reducing deaths from overdose, it just makes sense to deliver programs in places where people who use drugs spend time," said Fiona Kouyoumdjian, a prison physician and lead author of the study. "Given the state of our justice system, those people tend to be concentrated in our correctional facilities."
Several communities in Ontario, including Peterborough and Waterloo Region, are attempting to buy naloxone on their own and make it a staple of hospital emergency departments. Dr. Kahan is making the drug available in hospitals in seven communities as part of a project he is spearheading that integrates treatment for opioid addiction and primary care.
Kieran Michael Moore, associate medical officer of health for KFL&A Public Health, an agency representing Kingston and neighbouring communities, said it is crucial for him to be able to provide naloxone kits in a region that houses 10,000 inmates.
"This is not rocket science," he said. "We don't know why it hasn't quickly come to fruition."