Prison Needle Exchange Programs Reduce Healthcare Costs

Canada’s prison needle exchange programs (PNEPs) not only reduce bloodborne infections but also are cost-effective, according to a new study. 

The results suggest that every dollar invested in current PNEPs or in expanding these programs would save $2 in hepatitis C and injection-related infection treatment costs.

This return on investment strongly supports the ongoing maintenance and expansion of these programs, the authors state.

“Needle exchange programs are evidence-based strategies that prevent transmission of bloodborne viruses, reduce injection-related infections, improve access to medical care, and facilitate entry into substance dependence programs for people who inject drugs,” first author Farah Houdroge, PhD, a mathematical modeler at the Burnet Institute in Melbourne, Australia, said in a statement.

The research was published on December 16 in CMAJ.

‘Good Economic Sense’

“Needle exchange programs have been shown to be effective in the community, so there is a strong rationale for them in prison settings, including the current program,” senior author Nick Scott, PhD, head of modeling and biostatistics at the Burnet Institute, told Medscape Medical News. 

“Previous work has focused only on the health benefits of these programs. We know exchange programs can prevent hepatitis C and injection-related infections, but these infections are expensive to treat, so we sought to consider whether PNEPs could have any economic benefits,” Scott said.

To do so, the researchers developed a mathematical model to simulate hepatitis C transmission and injection-related infections in the population of Canadian federal prisons. They then compared a scenario with no changes to current PNEP coverage vs a scenario in which the PNEP coverage increased to reach 50% of people who inject drugs in prison. Next, they estimated the number of infections and the treatment costs avoided.

The model showed that expanding PNEP coverage to reach 50% of people who would inject drugs in federal prisons from 2025 to 2030 would prevent an additional 15% of new hepatitis C infections and 8% of injection-related infections, compared with keeping the current level of coverage.

“This [study] supports current plans to increase PNEP coverage as making good economic sense,” Scott said. “Globally, this is also important, as not many countries have PNEPs, and none have looked at the economics, so this study can support other countries in implementation and scale-up,” he added.

Inadequate Implementation 

In an accompanying commentary, Benedikt Fischer, PhD, adjunct professor of medical and health sciences at the University of Auckland in New Zealand, and colleagues pointed out that incarcerated individuals tend to be disproportionately affected by a wide range of chronic diseases, including mental health and substance use disorders. 

In Ontario, where fentanyl or fentanyl analogues have largely driven opioid-related overdose deaths, 8460 deaths related to opioids were reported between 2015 and 2020. Of these deaths, 2207 (26.1%) were in incarcerated individuals, resulting in a crude mortality rate per 10,000 person years for this population that was 45 times higher than for nonincarcerated individuals, wrote Fischer and colleagues.

“Prison-based programs aimed at mitigating the health harms of substance use by correctional inmate populations should be carefully evaluated as part of their implementation, as has been done by Houdroge and colleagues in the related research with specific respect to needle exchange programs,” they added. 

“Without systematic expansion of and increased access to such programs, prisoners in Canada will remain at unnecessarily high risk of ill health and death from the adverse consequences of substance use.”

“The article shows that these needle exchange programs are not only cost-effective, but also that they are actually saving society money,” Jürgen Rehm, PhD, senior scientist at the Institute for Mental Health Policy Research of the Centre for Addiction and Mental Health in Toronto, told Medscape Medical News. Rehm did not participate in the study. 

“The savings in healthcare costs for treating hepatitis C and injection-related infections are higher than the costs for the PNEPs. Their analysis is economically sound over a number of years,” said Rehm.

The current number of implementations of the PNEP is too low, he added. “The needle exchange program is only running in a minority of federal prisons: currently 11 out of 43 institutions, or roughly 1 in 4. In 2019, it was nine. If we scaled up to reach to those who inject drugs in prison, we would improve the health of those in prisons and we would save money. This is a clear win-win situation, and we can only speculate as to why such programs are expanding so slowly. In sum, if Canada continues to expand needle exchange programs in prisons at the current rate, it is losing an opportunity to improve the health of prison inmates and the financial situation of healthcare in prisons.”

The study was supported by the National Health and Medical Research Council of Australia. Scott and Rehm reported having no relevant financial relationships.