Background

Health risks in prisons

  • Prisons are extremely high-risk environments for HIV,HCV, and TB transmissions because of overcrowding, poor nutrition, limited access to prevention measures, continued illicit drug use, unprotected sex, and tattooing and piercing.
  • Injecting drug users are vulnerable to infection with HIV, HCV and other blood borne viruses as a result of sharing or reusing injecting equipment and drug solution, sexual contact with other injecting drug users, high-risk sexual activity and tattooing and piercing with non-sterile equipment. There is a high level of injecting use amongst men and women prior to their arrival in prison. Female drug users may be more likely to use their partner’s injecting equipment and often have difficulty in negotiating low risk sexual practices and condom use. Injecting drug users are relatively more likely to be involved in the sex industry.
  • Injecting drug use is in Europe the dominant mode of transmission of hepatitis C virus. Infection with hepatitis C virus results in chronic infection in at least 50–85% of cases. About 7–15% of chronically infected people progress without antiviral treatment to liver cirrhosis within 20 years, and of these, a proportion will subsequently develop liver cancer.
  • The costs of law enforcement, court time and imprisonment together contribute substantially to the social costs associated with opioid dependence.
  • On release, prisoners with opioid dependence are at risk of relapse and overdose. Between 70% and 98% of the people who have been imprisoned for drug related crimes and not treated during their incarceration relapse within the year following release.

To reduce drug use and its harm in prisons, prison systems should encourage drug users not to use drugs at all; and if they continue to use, not to inject; and if they inject, not to share injection equipment.
Providing both drug dependence treatment and harm reduction programmes in prison is therefore essential (Stöver et al. 2007).

A consensus is growing that drug dependence treatment can be effective in prison if it responds to the needs of prisoners and is of sufficient length and quality and if after care is provided upon release.

There are many types of drug dependence treatment, but they basically fall into two categories: medication-assisted treatment and abstinence-based programmes.

All forms of drug dependence treatment influence the risk of HIV transmission, but medication-assisted treatment programmes have the greatest potential to reduce injecting drug use and the resulting risk of spread of infection.

Medication-assisted treatment of opioid dependence (MAT as the most correct term, or in other terms ‘opioid substitution therapy’, ‘opioid agonist therapy’, ‘pharmacotherapy of opioid dependence’, ‘agonist replacement therapy’ or ‘agonist-assisted therapy’) is defined as the administration under medical supervision of a prescribed substance, pharmaceutically related to the one producing dependence, to people with substance dependence, for achieving defined therapeutic aims.

MAT is a form of health care for heroin and other opiate-dependent people using prescribed opioid agonists, which have some properties similar or identical properties to the ones of heroin and morphine on the brain and which alleviate withdrawal symptoms and block the craving for illicit opiates. Examples of opioid agonists are methadone, levoalpha-acetylmethadol, sustained-release morphine, codeine, buprenorphine (a partial agonist- antagonist) and, in some countries, diamorphine. Most of these substances, except for diamorphine, are characterized by a long duration of action and the absence of “rush”.

Antagonists, which reverse the effects of other opiates, are also used in treating opiate dependence. They occupy the same receptor sites in the brain as opiates and therefore block the effects of other opiates. However, they do not stop craving. If someone takes an antagonist and takes an opioid afterwards, the euphoric effects of the opioid are nullified as they cannot act on the brain. If the antagonist is taken after the opioid, an opioid-dependent person will immediately go into opioid withdrawal (so antagonists are contraindicated for people who have not been detoxified from opiates). Naltrexone is the opioid antagonist most used in treating opiate dependence. Naloxone is only used for the emergency reversal of opioid overdose situations. Buprenorphine is a partial agonist-antagonist and is being used increasingly to treat opioid dependence. There are combinations of naloxone with buprenorphine (1:4 ratio) to prevent the abuse of the medication via injection.


Illustration: Differences between agonists and antagonists

MAT is valuable because it provides an opportunity for opioid dependent drug users to reduce their exposure to high-risk behavior and to stabilize in health and social terms before addressing the physical adaptation dimension of dependence. MAT is generally considered for people who have difficulty in stopping their opioid use, coping with withdrawal and maintaining opioid abstinence. It is desirable for MAT drugs to have a longer duration of action, or half-life, than the drug they are replacing to delay the emergence of withdrawal and reduce the frequency of administration. This allows the person to focus on normal life activities without the need to obtain and administer drugs. Further, substituting prescribed medication for an illicit drug helps in breaking the connections with criminal activity while supporting the process of changing lifestyle.

Good quality treatment should be:

  • ongoing, in keeping with treatments for other chronic illness (e.g. antiviral/ antiretroviral treatment);
  • able to address the multiple problems that are risks for relapse – such as medical and psychiatric symptoms and social instability.
  • well integrated into society to permit ready access for monitoring purposes and to forestall relapse.

Other characteristics of good models include:

  • the adequacy of the period available for treatment.
  • the availability of close links to community health and drug services; the amount of retraining provided for the physicians and nurses involved.
  • and the extent to which the views of the prisoners themselves have been considered.

As pointed out by the joint position paper of WHO/UNODC/UNAIDS (2004) on Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention “no single treatment is effective for all individuals, therefore services should be sufficiently varied and flexible to respond to the needs of clients, their severity of dependence, personal circumstances, motivation and response to interventions. The rational management of opioid dependence calls for the balanced combination of pharmacotherapy, psychotherapy, psychosocial rehabilitation and risk reduction interventions.”
Seeking an equivalence of health care in the community and in prison this outlined diversity of treatment approaches needs to be transferred into the prison setting.

THE MAIN GOALS OF MAT

Although the goal of treatment may be to get people to stop using drugs, the main aims of MAT are based on the concepts of public health and harm reduction.

The aims of MAT are:

  • to assist people in remaining healthy until, with the appropriate care and support, they can achieve a drug-free life or, if they cannot or want to quit the programme, be in treatment for years or even for their lifetime.
  • to reduce the use of illicit or non-prescribed drugs.
  • to deal with problems related to drug misuse.
  • to reduce the dangers associated with drug misuse, particularly the risk of transmitting HIV, hepatitis B and C virus and other blood borne infections from injecting and sharing injecting paraphernalia.
  • to reduce the duration of episodes of opioid misuse.
  • to reduce the chances of future relapses to opioid misuse.
  • to reduce the need for criminal activity to finance drug misuse.
  • to stabilize the person where appropriate on a substitute medication to alleviate withdrawal symptoms.
  • to improve overall personal, social, and family functioning; and
  • to reduce the risk of drug-related death, particularly on the point of release from prison.
I - Introduction
II - What is medication-assisted treatment (MAT) of opioid dependence? Part I
III - What is medication-assisted treatment (MAT) of opioid dependence? Part II
IV - Medication-assisted treatment (MAT) of opioid dependence in prisons
V - Some basic information about medication-assisted treatment (MAT)
VI - Medical ethics aspects of MAT programmes in prisons