Opioid Substitution Treatment in Prison

KEY POINTS

• It is estimated that approximately one third of the prisoners are opiate dependent, and many more are experienced in drug use. In several prisons, this amounts to three quarters of the prison population.
• Prisons are extremely high-risk environments for blood borne virus transmission because of overcrowding, poor nutrition, limited access, continued illicit drug use (“hygienic relapse”), unprotected sex.
• All forms of drug dependence treatment have the potential to influence the risk of HIV and hepatitis C transmission, but substitution treatment programmes have the greatest potential to reduce injecting drug use and the resulting risk of spread of infection.
• The position paper WHO, UNODC and UNAIDS recently published on substitution maintenance therapy concludes that providing substitution maintenance therapy of opioid dependence is an effective strategy for preventing HIV/AIDS that should be considered for implementation as soon as possible in communities at risk of HIV infection.
• Opioid substitution maintenance treatment has expanded substantially in the European Union in the past 5–10 years.
• The prescription for substitution therapy and administration of opioid agonists to persons with opioid dependence – in the framework of recognised medical practice approved by competent authorities – is in line with the 1961 and 1971 Conventions on narcotic drugs and psychotropic substances. Given the existing evidence of the growing problems of injecting drug use, HIV/AIDS and hepatitis C in prisons in Eastern Europe and in the countries of the former Soviet Union, it is clear that the time to act is now. A failure to implement effective drug treatment and HIV and hepatitis C prevention measures could result in further spread of HIV and hepatitis C infection among IDUs, the larger prison population, and could potentially lead to generalized epidemics in the local non-IDU population.
• IDUs who do not enter treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment.
• The death rate of people with opioid dependence in methadone maintenance treatment is one-third to one quarter the rate for those not in treatment.
• Similar to in the community, making substitution treatment available to prisoners has the potential of reducing injecting and syringe-sharing in prisons. In addition, prisoners participating in methadone maintenance treatment have lower readmission rates than those not participating.
• Recidivism among substance misusing prisoners: Between 70 and 98 % of those who have been imprisoned for drug-related crimes and not treated during the course of their incarceration relapsed within the year following release.
• The most common form of substitution treatment is methadone maintenance treatment. Methadone has been used to treat heroin and other opiate dependence for decades. The more recently developed buprenorphine is also quite common in some countries. Both have been proven to greatly reduce the risk of HIV infection by reducing opioid use, drug injection, needle-sharing and improving the health and quality of life of opiate-dependent people.
• Providing methadone maintenance treatment is therefore an effective strategy for preventing HIV and hepatitis C transmission that should be implemented as soon as possible in communities (including prisons) at high risk of HIV infection.
• Research has shown that methadone maintenance treatment is more effective than detoxification programmes in promoting retention in drug treatment and abstinence from illicit drug use.
• The health services for individuals in prisons or correction houses should be equivalent to those provided outside the correctional system.
• Continuity of care is required to maintain the benefits of methadone maintenance treatment.
• Before methadone maintenance treatment is started, participants must be provided with relevant information, especially on the risk of overdose and the potential risks of multiple drug use and interaction with other medications.
• Before starting treatment, the drug user should be informed about the primary physician’s obligations to the state, to the prison and to the prisoner.