{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T04:04:39Z","timestamp":1783915479947,"version":"3.55.0"},"reference-count":45,"publisher":"Wiley","issue":"8","license":[{"start":{"date-parts":[[2026,3,5]],"date-time":"2026-03-05T00:00:00Z","timestamp":1772668800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,3,5]],"date-time":"2026-03-05T00:00:00Z","timestamp":1772668800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Addiction"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and aims<\/jats:title>\n                    <jats:p>Prison needle exchange programs (PNEPs) are evidence\u2010based, cost\u2010effective interventions that prevent transmission of blood\u2010borne viruses. PNEPs were introduced in a minority of Canadian federal prisons in 2018; however, participation is contingent on a mandatory approval process known as a \u201cThreat Risk Assessment\u201d (TRA). Although the TRA seeks to protect institutional safety and staff well\u2010being, it has delayed access and restricted program participation. We aimed to explore prison administrators' perceptions of the TRA, including its goals and potential alternatives, within the broader PNEP policy objective of facilitating access to clean needles\/syringes for people who inject drugs in prison.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design and setting<\/jats:title>\n                    <jats:p>Qualitative analysis using semi\u2010structured interviews across nine Canadian federal prisons with PNEPs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Twenty\u2010seven institutional heads, including Wardens, Assistant Wardens of Operations and Chiefs of Health Services.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measurements<\/jats:title>\n                    <jats:p>Matland's Ambiguity\u2010Conflict model informed this analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>Institutional heads largely described the TRA as a security tool, a clear goal consistent with low ambiguity, but whose aims often conflicted with PNEP goals of low\u2010threshold access, placing implementation in a high conflict\u2010low ambiguity political implementation paradigm. In this paradigm, top\u2010down decision making, underpinned by carceral logic and moral hazard framing, prioritizes institutional security over public health. Many also perceived the TRA's function as symbolic, primarily to appease labour partners and demonstrate due diligence to external bodies, an interpretation that increases ambiguity around the TRA's true purpose consistent with high conflict\u2010high ambiguity implementation. Participants proposed two pragmatic alternatives to reduce conflict: re\u2010assigning the TRA to Health through a more bottom\u2010up decision making approach, characteristic of low conflict\u2010high ambiguity experimentation implementation; and streamlining the current TRA process within Operations, consistent with a low conflict\u2010low ambiguity administrative implementation paradigm. A minority advocated to eliminate the TRA and grant automatic PNEP enrolment, aligning with community norms and international practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Within Canadian federal prisons, the \u201cThreat Risk Assessment\u201d (TRA) appears to be a structural process obstacle within the prison needle exchange program (PNEP) policy that fails to provide low threshold access to PNEPs due to the prioritization of institutional safety at the cost of public health. Alternative options to the current TRA process clarify actionable levels for policy refinement that preserve safety, improve access and better align with evidence and public health goals.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/add.70376","type":"journal-article","created":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T19:08:10Z","timestamp":1772996890000},"page":"2091-2103","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Gatekeeping harm reduction in Canadian Federal Prisons: Perspectives on the threat risk assessment for the prison needle exchange program by prison administrative leadership"],"prefix":"10.1111","volume":"121","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2724-0496","authenticated-orcid":false,"given":"Nadine","family":"Kronfli","sequence":"first","affiliation":[{"name":"Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health Centre  Montreal Canada"},{"name":"Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service McGill University  Montreal Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nashira","family":"Popovic","sequence":"additional","affiliation":[{"name":"Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health Centre  Montreal Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elise","family":"Weiss","sequence":"additional","affiliation":[{"name":"Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health Centre  Montreal Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Stoov\u00e9","sequence":"additional","affiliation":[{"name":"Behaviours and Health Risks Burnet Institute  Melbourne Australia"},{"name":"School of Public Health and Preventive Medicine Monash University  Melbourne Australia"},{"name":"Australian Research Centre in Sex, Health and Society La Trobe University  Melbourne Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8533-2957","authenticated-orcid":false,"given":"Lise","family":"Lafferty","sequence":"additional","affiliation":[{"name":"Centre for Social Research in Health University of New South Wales (UNSW)  Sydney Australia"},{"name":"The Kirby Institute, University of New South Wales (UNSW)  Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olivia","family":"Price","sequence":"additional","affiliation":[{"name":"Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health Centre  Montreal Canada"},{"name":"National Drug and Alcohol Research Centre UNSW Sydney  Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynn M.","family":"Madden","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section of Infectious Diseases, AIDS Program Yale School of Medicine  New Haven CT USA"},{"name":"APT Foundation  New Haven CT USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2212-2028","authenticated-orcid":false,"given":"Behzad","family":"Hajarizadeh","sequence":"additional","affiliation":[{"name":"The Kirby Institute, University of New South Wales (UNSW)  Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew R.","family":"Lloyd","sequence":"additional","affiliation":[{"name":"The Kirby Institute, University of New South Wales (UNSW)  Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7860-693X","authenticated-orcid":false,"given":"Frederick L.","family":"Altice","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section of Infectious Diseases, AIDS Program Yale School of Medicine  New Haven CT USA"},{"name":"APT Foundation  New Haven CT USA"},{"name":"Department of Epidemiology of Microbial Diseases Yale School of Public Health  New Haven CT USA"},{"name":"Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine University of Malaya  Kuala Lumpur Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,3,5]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1093\/epirev\/mxx019"},{"key":"e_1_2_9_3_1","unstructured":"LinesR J\u00fcrgensR BetteridgeG St\u00f6verH LaticevschiD NellesJ.Prison needle exchange: lessons from a comprehensive review of international evidence and experience: Canadian HIV\/AIDS legal network.2004. Available from:https:\/\/www.hivlegalnetwork.ca\/site\/wp-content\/uploads\/2013\/04\/PNEP-ENG.pdf"},{"key":"e_1_2_9_4_1","volume-title":"Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations","author":"World Health Organization","year":"2022"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.240648"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.5694\/mja2.52640"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/s1473-3099(25)00630-9"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(24)00275-5"},{"key":"e_1_2_9_9_1","unstructured":"Public Safety Canada.Prison Needle Exchange Program;2025. Available from:https:\/\/www.publicsafety.gc.ca\/cnt\/trnsprnc\/brfng-mtrls\/prlmntry-bndrs\/20200621\/017\/index-en.aspx"},{"key":"e_1_2_9_10_1","unstructured":"Harm Reduction International.Global state of harm reduction 2024. 9th edition. London: Harm Reduction International;2024. Available from:https:\/\/hri.global\/flagship-research\/the-global-state-of-harm-reduction\/the-global-state-of-harm-reduction-2024\/"},{"key":"e_1_2_9_11_1","unstructured":"United Nations General Assembly.Basic principles for the treatment of prisoners. Point 9 of resolution a\/RES\/45\/111 68th plenary meeting. New York NY: United Nations General Assembly;1990. Available from:https:\/\/digitallibrary.un.org\/record\/105348?ln=en"},{"key":"e_1_2_9_12_1","unstructured":"ThompsonS.PNEP\/OPS Progress Update. Session: Implementing needle and syringe programs in Canada: Voices From the Front Line. The 24th international AIDS conference Montreal Canada2022"},{"key":"e_1_2_9_13_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-025-24935-y"},{"key":"e_1_2_9_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugpo.2024.104540"},{"key":"e_1_2_9_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugpo.2024.104549"},{"key":"e_1_2_9_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1553-7250(08)34030-6"},{"key":"e_1_2_9_17_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.conctc.2026.101642","article-title":"Enhancing uptake of the Canadian prison needle exchange program using a non\u2010randomized stepped\u2010wedge cluster type 1 hybrid implementation trial: The NEXUS study protocol","author":"Price O","year":"2026","journal-title":"Contemp Clin Trials Commun"},{"key":"e_1_2_9_18_1","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2019.00064"},{"key":"e_1_2_9_19_1","unstructured":"Correctional Service Canada.Prison Needle Exchange Program: Government of Canada;2020. Available from:https:\/\/www.canada.ca\/en\/correctional-service\/programs\/offenders\/health-services\/prison-needle-exchange-program\/faq.html"},{"key":"e_1_2_9_20_1","unstructured":"Correctional Service Canada.Guidelines 200\u20131: Policy Instruments.2018. Available from:https:\/\/www.canada.ca\/en\/correctional-service\/corporate\/acts-regulations-policy\/commissioners-directives\/guidelines\/200-1.html"},{"key":"e_1_2_9_21_1","doi-asserted-by":"publisher","DOI":"10.1093\/oxfordjournals.jpart.a037242"},{"key":"e_1_2_9_22_1","doi-asserted-by":"publisher","DOI":"10.1177\/10442073050150040401"},{"key":"e_1_2_9_23_1","doi-asserted-by":"publisher","DOI":"10.1017\/S1474746405002915"},{"key":"e_1_2_9_24_1","doi-asserted-by":"publisher","DOI":"10.1080\/02671522.2013.879335"},{"key":"e_1_2_9_25_1","doi-asserted-by":"publisher","DOI":"10.1017\/S0047279420000082"},{"key":"e_1_2_9_26_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugpo.2023.104283"},{"key":"e_1_2_9_27_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugpo.2026.105197"},{"key":"e_1_2_9_28_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugpo.2021.103455"},{"key":"e_1_2_9_29_1","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzm042"},{"key":"e_1_2_9_30_1","unstructured":"Union of Canadian Correctional Officers.Prison Needle Exchange Program (PNEP);2023. Available from:https:\/\/ucco-sacc-csn.ca\/files\/prison-needle-exchange-program-pnep\/"},{"key":"e_1_2_9_31_1","doi-asserted-by":"publisher","DOI":"10.1186\/s40352-025-00332-w"},{"key":"e_1_2_9_32_1","doi-asserted-by":"publisher","DOI":"10.2105\/ajph.2011.300374"},{"key":"e_1_2_9_33_1","doi-asserted-by":"publisher","DOI":"10.1080\/14754835.2019.1617121"},{"key":"e_1_2_9_34_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12910-021-00688-2"},{"key":"e_1_2_9_35_1","doi-asserted-by":"publisher","DOI":"10.1186\/s43058-024-00573-0"},{"key":"e_1_2_9_36_1","first-page":"379","article-title":"Abolish carceral logic","volume":"17","author":"Lopez CE","year":"2022","journal-title":"Stanford J Civil Rights Liberties"},{"key":"e_1_2_9_37_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11896-024-09659-w"},{"key":"e_1_2_9_38_1","doi-asserted-by":"publisher","DOI":"10.24908\/ss.v21i2.15784"},{"key":"e_1_2_9_39_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(08)70305-0"},{"key":"e_1_2_9_40_1","unstructured":"MackeyKM BeechEH WilliamsBE AndersonJK YoungS ParrNJ.Effectiveness of syringe services programs: a systematic review. Washington DC: Evidence Synthesis Program Health Services Research and Development Service Office of Research and Development Department of Veterans Affairs;2023. Available from:https:\/\/www.hsrd.research.va.gov\/publications\/esp\/syringeservice.cfm"},{"key":"e_1_2_9_41_1","volume-title":"Street\u2010level bureaucracy: dilemmas of the individual in public service","author":"Lipsky M","year":"2010"},{"key":"e_1_2_9_42_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(16)30856-X"},{"key":"e_1_2_9_43_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(18)30469-9"},{"key":"e_1_2_9_44_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(25)00277-4"},{"key":"e_1_2_9_45_1","volume-title":"Prisons and health","author":"World Health Organization","year":"2014"},{"key":"e_1_2_9_46_1","unstructured":"National Harm Reduction Coalition.Training Guide: Guide to Developing and Managing Syringe Access Programs. Module 2: Operational Issues;2010. Available from:https:\/\/harmreduction.org\/issues\/syringe-access\/guide-to-managing-programs\/module-2-operational-issues\/"}],"container-title":["Addiction"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/add.70376","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/add.70376","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/add.70376","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T03:16:42Z","timestamp":1783912602000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/add.70376"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,5]]},"references-count":45,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1111\/add.70376"],"URL":"https:\/\/doi.org\/10.1111\/add.70376","archive":["Portico"],"relation":{},"ISSN":["0965-2140","1360-0443"],"issn-type":[{"value":"0965-2140","type":"print"},{"value":"1360-0443","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,5]]},"assertion":[{"value":"2025-09-26","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-02-03","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-03-05","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}