Opioid substitution therapy in prisons: reviewing the evidence
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Opioid substitution therapy in prisons: reviewing the evidence.

Betteridge R, Jrgens R., Kerr T.
Canadian HIV/AIDS Legal Network, 2008.

Brief but thoroughly researched review commends prison methadone programmes as causing no substantial problems while improving the climate in prison, reducing drug use and infection risk behaviours, and improving post-release treatment uptake and recidivism rates.

Summary Within prisons the prevalence of injecting and HIV infection, combined with the high turnover of the prison population, create the potential for efficient and widespread transmission of infectious diseases and other drug-related harms. However, prisons also present opportunities for the treatment of drug dependence and the prevention of disease transmission among a substantial number of disadvantaged individuals. Most of the 15 old European Union (EU) member states and several newer member states have prison-based methadone maintenance programmes. These also exist in other countries including Australia, Canada, the USA, Iran, and Indonesia. Several prison systems in Eastern Europe and the former Soviet Union have initiated methadone maintenance programmes or are planning to do so. This trend follows recommendations from the World Health Organization and other UN agencies.

A wealth of scientific evidence has shown that methadone maintenance is the most effective intervention available for the treatment of opiate dependence, associated with reductions in risk behaviour, illicit drug use, crime, sex work, unemployment, mortality, and HIV transmission. Methadone maintenance has been found to be more effective than detoxification programmes in promoting treatment retention and abstinence from illicit drug use.

Evaluations of prison-based methadone maintenance programmes have been highly and consistently favourable. Such programmes have been associated with substantial declines in HIV risk behaviour (eg, sharing syringes), decreased levels of drug use and participation in the prison-based drug trade, and increased participation in drug treatment following release from prison. The available evidence also suggests that methadone maintenance programmes have a positive effect on criminal recidivism and re-incarceration. Finally, studies have shown that methadone maintenance has a positive effect on the prison environment. Although concerns have often been raised initially about security, violent behaviour, and diversion of methadone, these problems have not emerged or have been successfully addressed once programmes were established.

From a public health perspective, initiating and rapidly expanding methadone maintenance programmes is a priority for responding to the dual epidemics of injection drug use and HIV infection among prisoners. Given the evidence of entrenched epidemics of injection drug use and HIV infection in prisons in many countries in Eastern Europe and the former Soviet Union, it is clear that inaction on the part of prison officials will result in increased morbidity and mortality among drug dependent prisoners. Moreover, the failure to implement methadone maintenance could result in further spread of HIV infection among prisoners who inject drugs and the prison population as a whole, and could potentially lead to generalised epidemics in communities into which prisoners are released. Such further spread of HIV would lead not only to greater suffering for affected individuals and their families, but also would result in substantial, avoidable health care costs.

Last revised 27 February 2009. First uploaded 27 February 2009

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