International Journal of Drug Policy 100 (2022) 103523

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International Journal of Drug Policy

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Commentary

Addressing the complex substance use and mental health needs of people
leaving prison: Insights from developing a national inventory of services in
Canada
Tara Marie Watson a,∗, Paul Victor Benassi a,b,c, Branka Agic a,c, Asha Maharaj a,
Sanjeev Sockalingam a,b,d
a Centre for Addiction and Mental Health (CAMH), 1000 Queen Street West, Toronto, ON, M6J 1H4, Canada
b Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada
c Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
d
Institute of Medical Science, University of Toronto, 1 King’s College Circle, Toronto, ON, M5S 1A8, Canada

a r t i c l e i n f o a b s t r a c t

Keywords: Internationally, transitions from prison to the community are often precarious experiences for people who are
Substance use services living with substance use and mental health concerns. In Canada, a continuing opioid overdose crisis and over-
Mental health services lapping challenges related to the COVID-19 pandemic have generated urgency for scaling up community-based
Incarceration
services that can meet the complex substance use and mental health needs of people leaving prison. In this
Harm reduction
commentary, we reflect on our experience with and knowledge gained by developing a national inventory of
Community re-entry
Canada substance use and mental health services for criminal justice-involved persons who are re-entering the commu-
nity. We learned that there is a scarcity of such community-based services specific to criminal justice-involved
populations and a glaring lack of information about culturally safe and appropriate supports. Stakeholders from
organisations across Canada identified that communities need a comprehensive array of low-barrier services,
inclusive of harm reduction and substance use treatment services, to meet the diverse needs of people leaving
prison. We recommend building greater investment in and awareness of community-driven, local programs, as
well as enhancing efforts to engage people with lived and living experience in service design and provision. We
also briefly describe a few programs to highlight examples of how to operationalise the themes that we observed
to emerge while developing a national inventory of community-based substance use and mental health services
for criminal justice-involved persons.

In this commentary, we reflect on our experience with developing a
national inventory of community-based substance use and mental health
services in Canada for people who are transitioning out of correctional
settings and re-entering the community. We share what we learned in
the hopes that the knowledge generated from our work can be harnessed
to enhance awareness, operation, and funding of these important sup-
ports for people leaving prison.
Background
People living with substance use and mental health issues are over-
represented in correctional systems worldwide (e.g., Baranyi et al.,
2019; Beaudette & Stewart, 2016; Fazel & Seewald, 2012; Fazel, Yoon,
& Hayes, 2017; Mental Health Commission of Canada, 2021a;
Michalski, 2017; Prins, 2014), necessitating attention to the presence
and quality of substance use and mental health supports for criminal
justice-involved persons. For example, a systematic review that identi-
fied 24 international studies involving a total of 18,388 prisoners found
that nearly a quarter of newly incarcerated men and women had an al-
cohol use disorder, with similar estimates, though potentially higher for
women, for drug use disorders (Fazel et al., 2017). In Canada, our geo-
graphic location, a national prevalence rate of 73% has been observed
for any current mental disorder among men newly admitted to the fed-
eral correctional system, with the highest prevalence rates for alcohol
and substance use disorders (Beaudette & Stewart, 2016).
There are multiple, often overlapping determinants that increase the
likelihood of people living with substance use and mental health issues
becoming incarcerated, including key social determinants of health such
as income, housing, and access to quality health services (Mental Health
Commission of Canada, 2020a,b). For instance, people engaging in sub-

∗
Corresponding author.
E-mail address: TaraMarie.Watson@camh.ca (T.M. Watson).

https://doi.org/10.1016/j.drugpo.2021.103523

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T.M. Watson, P.V. Benassi, B. Agic et al.
stance use and/or living with mental illness while also experiencing
homelessness or precarious housing are more likely to come into con-
tact with the criminal justice system for varied reasons (e.g., Roy et al.,
2016). Broader structural determinants also play a major role in the
connections between substance use, mental health, and the overrepre-
sentation of specific groups in prison, inclusive of ongoing histories of
systemic oppression, social marginalization, and, in turn, disproportion-
ately applied criminal justice responses (Mental Health Commission of
Canada, 2020a,b). These complex connections are strongly evident in
prevalence rates, too, especially for people with intersecting identities
(Seng, Lopez, Sperlich, Hamama & Reed Meldrum, 2012). For exam-
ple, national prevalence rates for alcohol and substance use disorders
are markedly higher among incarcerated First Nations, Inuit, and Métis
men compared to non-Indigenous men (Beaudette & Stewart, 2016), and
while 79% of federally incarcerated women in Canada meet criteria for
a current mental disorder, that figure is nearly 96% for federally incar-
cerated First Nations, Inuit, and Métis women (Correctional Service of
Canada, 2018). Such overrepresentation by race and gender also neces-
sitates attention to whether substance use and mental health supports
for criminal justice-involved persons are culturally safe and appropriate,
where needed.
When leaving prison, people generally face major barriers related to
housing, income and employment, family and support network reuni-
fication, and access to health and social services (Barrenger, Draine,
Angell, & Herman, 2017; Hu et al., 2020; Visher & Travis, 2003).
These barriers during transitions to the community contribute to a
well-documented cycle of re-arrest and re-incarceration, and such bar-
riers are often more pronounced for those living with substance use
and/or mental health issues given their higher needs for specialised
supports and interventions (Denton, Foster, & Bland, 2017; Hu et al.,
2020; Kirwan et al., 2019; Wilton & Stewart, 2017). Discharge or re-
lease planning is frequently inadequate and starts “too late”, leading to
disruptions in continuity of care between prison and the community,
inclusive of interruptions to substance use service and treatment ac-
cess (Hu et al., 2020; Lennox et al., 2020; Walker, Higgs, Stoové, &
Wilson, 2018). Release from prison is thus a precarious transitional pe-
riod, associated with acute risk for suicide, overdose, and other health-
related harms (Kouyoumdjian, Kiefer, Wobeser, Gonzalez, & Hwang,
2016; Merrall et al., 2010).
More research is needed on the substance use and mental health out-
comes of individuals when they re-enter the community from prison,
and the impacts of corresponding service provision, with emphasis on
collecting more race-based and gender-sensitive data (Mental Health
Commission of Canada, 2020a,b). More of this research will better in-
form system planning and programming decisions. Nonetheless, there
is more than enough evidence to assert that transitions from prison to
the community are especially challenging for members of specific popu-
lations, including racialised and gender-diverse populations. In Canada,
for instance, members of Black communities and First Nations, Inuit, and
Métis peoples – who are already disproportionately overrepresented in
prison – are likely to confront institutional bias in risk assessments that
affects rehabilitative pathways and release from prison (Cardoso, 2020;
Public Safety Canada Portfolio Corrections Statistics Committee, 2020).
For women and gender-diverse individuals, especially those who also
identify as members of First Nations, Inuit, or Métis or other racialised
communities, there are often added concerns that complicate commu-
nity transitions and their health-related outcomes including, but not lim-
ited to, ongoing histories of colonial and domestic violence, trauma, and
childcare responsibilities, plus a lack of culturally safe and appropriate
services (e.g., Murdocca, 2020; Salem, Nyamathi, Idemundia, Slaughter,
& Ames, 2013).
The current context adds even more challenging layers to prison-
to-community transitions. Canada continues to experience a years-
long, devastating opioid overdose crisis, prompting increasingly press-
ing needs to scale up effective substance use interventions (e.g.,
Ivsins, Boyd, Beletsky, & McNeil, 2020; Strike & Watson, 2019). Since
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International Journal of Drug Policy 100 (2022) 103523
the 2020 start of the global COVID-19 pandemic, the opioid over-
dose crisis has only worsened in many Canadian communities, with
documented increases in drug-related mortality due to a constella-
tion of overlapping factors such as reduced harm reduction and treat-
ment service access, increased toxicity in the unregulated drug sup-
ply, and physical distancing policies prompting many people to use
drugs alone (Gomes et al., 2021). Moreover, the pandemic and its
associated public health responses are having unintended, detrimen-
tal impacts on prison populations. Measures such as limiting visitors
to and movement within prisons exacerbate prisoners’ social isola-
tion (Public Health Agency of Canada, 2020), while COVID-19 health
risks and fears can intensify substance use and mental health symp-
toms for many in prison, especially for those with pre-existing issues
(Mental Health Commission of Canada, 2021a). Although there are
calls for greater decarceration efforts to be part of COVID-19 responses
(Ricciardelli & Bucerius, 2020), community-based measures to promote
physical distancing and government-initiated lockdowns that spell tem-
porary closures of many in-person harm reduction and treatment ser-
vices have exacerbated the known drug-related risks for people leaving
prison (Mental Health Commission of Canada, 2021a; Mukherjee & El-
Bassel, 2020). In addition to the life-saving potential of certain substance
use services such as harm reduction programs, other community-based
programs that address, for example, mental health, housing, finances,
education, and legal assistance, offer critical supports that improve qual-
ity of life and safety for those leaving prison (e.g., Stewart, Farrell-
MacDonald, & Feeley, 2017), and such programs have also been subject
to drastic changes and reduced access due to the pandemic. As prisoner
health is internationally recognised as a key area of public health and
human rights (Enggist, Møller, Galea, & Udesen, 2014), urgently needed
are greater awareness and implementation of services that can meet the
complex and varied health and social needs of people leaving correc-
tional settings.
Next, we provide a brief background to the project upon which this
commentary is based, followed by our reflections and recommendations
related to key themes that emerged while reviewing relevant literature
and compiling information for a national service inventory.
Developing a national inventory of community-based substance
use and mental health services for criminal justice-involved
persons
In response to multiple stakeholder consultations regarding priority
areas for action in mental health among people in contact with the crimi-
nal justice system, the Mental Health Commission of Canada – a national
non-profit organization that develops and mobilizes resources to support
the mental health of Canadians – funded a project in 2020 to develop
a national inventory of active community-based services and supports
for criminal justice-involved persons. We designed the project for and in
collaboration with the Mental Health Commission of Canada. As we are
based at the Centre for Addiction and Mental Health – Canada’s largest
research and teaching institute dedicated to mental health and addic-
tions – we focused the inventory on substance use and mental health
services for people who are transitioning away from the criminal justice
system. As our organisations share commitments to achieving health eq-
uity, a key objective for inventory development was to locate, as much
as possible, services and supports designed to address the needs of spe-
cific populations such as women, First Nations, Inuit, and Métis, and
other racialised groups.
To find community-based programs for the inventory, we adopted a
multi-pronged approach inclusive of: a librarian-assisted rapid review of
relevant academic and grey literature; searches of service-specific search
engines and program websites; and a brief survey of open-ended ques-
tions emailed to stakeholders at relevant organisations across Canada
(e.g., provincial/territorial health services, non-governmental organi-
sations, clinical and research institutes, and criminal justice agencies).
We emailed the survey questions to approximately 50 knowledgeable
T.M. Watson, P.V. Benassi, B. Agic et al.
stakeholders identified through our existing professional contacts and
networks. While the literature review identified promising evidence-
informed practices, responses from stakeholders identified current ser-
vice gaps. Our team met regularly with project staff from the Mental
Health Commission of Canada and received input on all major steps and
deliverables, including our methods and drafts of the inventory, from an
expert advisory group that was engaged by the funder.
Before we share our main reflections and recommendations related
to the project, it is important for international readers to understand
that Canada has a federal correctional system plus 13 provincial and
territorial correctional systems that operate very differently from one
another. The federal system, overseen by the Correctional Service of
Canada, is responsible for administering sentences of two years or
longer, while the provincial/territorial systems manage sentences under
two years in length. These correctional systems have adopted their own
approaches to health-related programming and community re-entry,
representing many jurisdictional differences and nuances that are be-
yond the scope of this commentary (e.g., McLeod & Martin, 2018). For
the national inventory we developed, we had a multi-jurisdictional fo-
cus and broadly searched for active community-based substance use
and mental health services that were designed or appeared promis-
ing for criminal justice-involved persons, including those leaving fed-
eral and/or provincial/territorial correctional settings. That said, early
in inventory development, our team agreed to prioritise community-
driven services over programs embedded in the criminal justice system.
As such, we generally excluded from the inventory (with a few excep-
tions) therapeutic programs and residences operated by the Correctional
Service of Canada, mental health and wellness courts, drug treatment
courts, and forensic hospital settings.
For more details regarding the project upon which this commentary
is based, readers can consult the final report (Mental Health Commission
of Canada, 2021b) and the national inventory of community-based sub-
stance use and mental health services for criminal justice-involved per-
sons (available online at http://mentalhealthcommission.ca/what-we-
do/mental-health-and-the-justice-system/).
Lessons learned and general recommendations in relation to
community-based services
Developing the national inventory revealed a scarcity of community-
based substance use and mental health services specific to criminal
justice-involved persons. Further, where such services exist, there is
typically little information about culturally safe and appropriate sup-
ports or program tailoring to address the needs of specific populations
such as First Nations, Inuit, and Métis communities, other racialised
communities, and women and gender-diverse people. While our ap-
proach was limited in finding some services designed and led by specific
communities – limitations we are exploring in another academic com-
mentary – we heard a need for greater investment in and recognition
of community-driven innovation in substance use and mental health
service development. This need was strongly expressed in relation to
Indigenous-led wellness services that offer, for example, traditional heal-
ing practices, involvement of Elders, and culturally grounded, trauma-
informed care practices that address ongoing experiences of colonial vi-
olence. An example of such a program included in the national inventory
is a comprehensive clinic integrated into a local service network in the
province of Québec that facilitates access to culturally relevant health
and social services for Indigenous peoples. While not specifically a com-
munity reintegration program, this program adopts an approach con-
sistent with cultural practices and safety to provide an array of services
related to mental health, substance use, chronic disease prevention, fam-
ily issues, and more – services highly relevant to those leaving prison.
Numerous stakeholder respondents and project advisory members sim-
ilarly reported needs to develop more services that appropriately sup-
port members of other racialised communities, and women and gender-
diverse people, acknowledging the disproportionate criminal justice sys-
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International Journal of Drug Policy 100 (2022) 103523
tem impacts, custodial sentencing, and heightened risk of everyday vio-
lence faced by these populations, and their relative underrepresentation
in program design and leadership (see again Mental Health Commission
of Canada, 2020a,b).
To these points, we recommend enhancing efforts that build correc-
tional and health system and service provider awareness of local re-entry
support programs, and that advocate for greater funding of community-
driven programs. This recommendation aligns well with much interna-
tional literature on the importance of community-responsive and cul-
turally appropriate programs, including studies and commentaries fo-
cused on successful grassroots-led prevention and harm reduction initia-
tives (e.g., Bardwell, Kerr, Boyd, & McNeil, 2018; United Nations Office
on Drugs and Crime, International Network of People Who Use Drugs,
Joint United Nations Programme on HIV/AIDS, United Nations Devel-
opment Programme, United Nations Population Fund, World Health Or-
ganization, United States Agency for International Development, 2017;
Watson, Kolla, van der Meulen, & Dodd, 2020). Similarly, another ma-
jor theme we observed during inventory development was the immense
value of participatory approaches to design and implementation of
community-based substance use and mental health services for people
leaving prison. Engagement with current or potential service users in
developmental and operational processes, and at all stages of prison-
to-community transitions, helps to ensure that programs are grounded
in lived and living experience, responsive to service user needs, and
build capacity (e.g., Hu et al., 2020; Janssen et al., 2017). Participa-
tory approaches are also critical for addressing the underrepresentation
of specific priority populations in service development (Mental Health
Commission of Canada, 2020b). Therefore we further underscore our
recommendations with consideration of greater funding allocation to-
wards highly participatory and diverse community-driven programs that
can help to address the complex health and social needs among people
leaving prison.
We further heard in our project that system navigation assistance is
needed by many people re-entering the community from prison, as their
social support networks may be absent, lacking, or disrupted. This assis-
tance may be required on a day-to-day basis, at least initially, to help ser-
vice users with reminders, getting to and from appointments, and sup-
portive accompaniment and check-ins. Hence it is important that numer-
ous communities across Canada have and sustain their local branches
of agencies like John Howard Society (http://johnhoward.ca/) and the
Canadian Association of Elizabeth Fry Societies (http://www.caefs.ca/)
that channel lived and living experience in their programs through peer
support and mentorship, providing and connecting people leaving incar-
ceration with relevant community-based health and social services. Also
aligned with existing evidence, we learned that people with histories of
incarceration can foster meaningful, inclusive experiences in commu-
nity re-entry when they are recognised as peer specialists and part of the
support network that helps to connect people with services and navigate
the complex landscape of the addictions and mental health care sectors
(e.g., Barrenger, Maurer, Moore, & Hong, 2020; Fortune, Arai, & Lyons,
2020; Portillo, Goldberg, & Taxman, 2017). Moreover, people with lived
and living experience may possess and transfer their in-depth knowledge
of local, culturally safe and appropriate supports. With these considera-
tions, we recommend greater efforts to engage, retain, and meaningfully
empower and compensate people with lived and living experience in the
provision of substance use and mental health services for people leaving
prison.
Developing the national inventory also highlighted community de-
mand for a comprehensive array of low-barrier health-related services.
For instance, stakeholders said that availability should increase for 24-
hour and 7-days-a-week services, including drop-in or easy-to-access
harm reduction supports and mobile mental health units, and addic-
tions and crisis support lines. This aligns with literature showing that
numerous variables – at service user, service provider, and/or system
levels (e.g., appointment delays) – can negatively impact the ability
of individuals to access and follow up with substance use and mental
T.M. Watson, P.V. Benassi, B. Agic et al.
health services (e.g., Festinger, Lamb, Kountz, Kirby, & Marlowe, 1995;
Priester et al., 2016; Ross et al., 2015). In particular, we heard that many
smaller and remote communities would benefit from greater availabil-
ity and coverage of such services, which also reflects Canadian studies
showing significant geographic variability in services in rural areas (e.g.,
McEachern et al., 2016).
A key example of a substance use service model that attempts to ad-
dress the above concerns, and was included in our inventory, is the rapid
access addiction medicine (RAAM) clinic. Open to the general popula-
tion and intended to address existing care sector gaps, RAAM clinics are
generally designed as appointment- and referral-free walk-in settings
where service users can gain fast access to and referrals for evidence-
based substance use treatment, inclusive of medical and psychosocial
interventions (Wiercigroch, Sheikh, & Hulme, 2020). Staffing at RAAM
clinics may include psychiatrists, peer support workers, nurse practi-
tioners, counsellors, and social workers. An emerging clinic model in
Canadian contexts, we identified RAAM clinics in multiple types of sites
(e.g., community health centres) in several provinces, showing that this
type of model is translatable across settings and larger regional levels.
Although not specific to criminal justice-involved populations, we in-
cluded RAAM clinics in the inventory because they offer low-barrier
substance use services and were recommended by stakeholders as an
emergent model of care that is accessible to those who have few or no ac-
tive connections to community-based care providers. Government fund-
ing, support from health sector leadership, and reproducible evaluation
frameworks are important factors in boosting the spread and sustain-
ability of this type of low-barrier program (Wiercigroch et al., 2020).
In developing the national inventory, we also learned that having a
diverse suite of substance use and mental health services for criminal
justice-involved persons is key in terms of service type and availabil-
ity. Some examples stakeholder respondents noted included group and
individual psychotherapies and addictions counselling, opioid substitu-
tion treatment, detoxification and withdrawal supports, various harm
reduction programs, and more. A wide spectrum of community-based
harm reduction services – including, among others, needle and syringe
distribution programs, supervised consumption services, naloxone kit
distribution and overdose prevention training, drug checking services,
and safer supply programs – are well endorsed by international evidence
and emerging research (e.g., Harm Reduction International, 2020; Strike
& Watson, 2019). Given the elevated risk of overdose among people re-
leased from prison (Kouyoumdjian et al., 2016; Merrall et al., 2010),
and considerable variation in individual readiness for other types of sub-
stance use interventions, harm reduction service coverage was seen by
some stakeholders as a priority. An example of a harm reduction pro-
gram we identified for the national inventory, located at a community
health centre in the province of Ontario, was described as a referral-
and cost-free, sex-positive, and trans-inclusive program supported by
people with lived and living experience. In partnership with another
multi-service organisation focused on the needs of homeless and precar-
iously housed women, this program operates as a drop-in with activities
designed to provide education and information on health, safer sex/sex
work and drug use practices, and social justice. This program also speaks
to the themes of having appropriate, inclusive, and community-led ser-
vices, as an example of one that is highly responsive to the needs of
women and gender-diverse people who engage in sex work and/or use
drugs, a population that is also likely to come into contact with the
criminal justice system.
While we acknowledge a tendency to highlight harm reduction pro-
grams – in part due to the challenges that these types of programs have
faced when it comes to funding, political acceptance, and community
implementation (e.g., Potier, Laprévote, Dubois-Arber, Cottencin, & Rol-
land, 2014; Watson et al., 2020) – we also recognise that many people
in correctional settings, particularly women, use periods of incarcera-
tion as opportunities to get sober (e.g., Bucerius, Haggerty, & Dunford,
2021). There is thus also a need to ensure community access to and/or
continuation of participation in substance use services that support so-
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International Journal of Drug Policy 100 (2022) 103523
briety. Notably, we heard from several stakeholders that Alcoholics
Anonymous and Narcotics Anonymous groups are the go-to (i.e., en-
couraged by correctional staff and other service providers) low-barrier
substance use interventions for people leaving prison. However, these
specific group programs are often Christian faith-based and less relevant
for people from other spiritual backgrounds and specific cultures. Again,
having an array of services is an important general recommendation to
help meet the varied and complex needs and preferences of people who
are leaving prison, especially for those with wide-ranging substance use
needs.
Conclusions
In the realm of community-based substance use and mental health
services for people leaving prison, the correctional and community-
based systems at work are invariably complex, as are the needs of the
service users. What do promising programs for this diverse population
look like in practice when they are developed for and by specific com-
munities, offer low-barrier access, and/or complement the existing spec-
trum of services? We have provided a few examples, but there is a mul-
titude of possibilities and no one-size-fits-all approach. A closer look
at any of the above examples, and many other programs we included
in a national inventory of community-based substance use and mental
health services for criminal justice-involved persons, would reveal how
challenging it is to operationalise the major themes and considerations
we engaged with in our work with the Mental Health Commission of
Canada. Given the complex substance use and mental health needs of,
and many social and structural barriers confronted by, people leaving
prison, said operationalisation is best conceptualised as flexible, adap-
tive, and creative, with specific communities involved and participatory
engagement at all stages. To the point about flexibility, adaptability,
and creativity, there is useful literature on intervention “spread” (i.e.,
replicating an intervention in other places or settings) and “scale-up”
(i.e., addressing infrastructural issues in implementation and achieving
widespread coverage) within complex systems. This literature broadly
instructs that when planning program changes in a complex system,
recommended principles include, among others, acknowledgement of
unpredictability, recognition of self organisation (i.e., that programs
will themselves adapt to different settings), development of adaptive
capability and creativity of staff, and strong attention to human rela-
tionships (Greenhalgh & Papoutsi, 2018, Greenhalgh & Papoutsi, 2019;
Lanham et al., 2013; Shaw, Shaw, Wherton, Hughes, & Greenhalgh,
2017; Willis et al., 2016). For those who are designing and implementing
community-based substance use and mental health programs – as well
as the array of other kinds of health and social services most needed by
people leaving prison, such as housing – drawing on an array of partic-
ipatory, culturally appropriate and safe, and community-driven frame-
works and approaches may be best to most effectively meet service user
and system needs.
In sum, further work is needed to examine the most effective and
inclusive ways in which the themes we describe and provide added sup-
port for in this commentary can be operationalised in practice. This com-
mentary underscores that building a stronger landscape of community-
based substance use and mental health services for people transitioning
from prison to the community should become an urgent goal and fund-
ing priority. While this urgency is apparent in many contexts around the
world, our current work puts a spotlight on this urgency in Canada, espe-
cially in the wake of COVID-19 and as North America’s opioid overdose
crisis continues with devastating impacts on individuals and communi-
ties, especially the most structurally marginalised.
Declarations of Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
T.M. Watson, P.V. Benassi, B. Agic et al.
Acknowledgements
The project to develop a national inventory of community-based sub-
stance use and mental health services for criminal justice-involved per-
sons that is described in this article was funded by the Mental Health
Commission of Canada.
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