In order to be effective, MAT, as any other type of treatment, must be:
- based on the needs of prisoners;
- provided for the right period of time and at the right dose required by the particular person; and
- provided with continuity, upon imprisonment and also following release.
As mentioned above, effective treatment has many benefits for individuals by helping them stay alive; reducing the risk of infection, particularly with HIV and hepatitis; achieving abstinence or a stabilised pattern of use; stabilising their social life; improving physical health; and reducing criminal activity. It also benefits society by improving public health; reducing emergencies and hospitalisation; reducing the spread of HIV and other infectious diseases; reducing social welfare costs; and reducing costs to the criminal justice system.
MAT programmes vary in duration, dosage and scheme. Although much evidence (Zickler, 1999) indicates that MAT, especially methadone treatment, is more effective when higher dosages are prescribed on a maintenance basis, many programmes focus on short-term detoxification with decreasing dosages.
Applying MAT solely in the form of detoxification restricts its therapeutic potential. Maintenance treatment aims to stabilise health and achieve social rehabilitation. As research indicates, for most opiate- dependent people (WHO, United Nations Office on Drugs and Crime and UNAIDS, 2004).
Already in 1990, the WHO Regional Office for Europe (1990) suggested standard terms for methadone treatment divided into four categories:
- short-term detoxification: decreasing doses over one month or less;
- long-term detoxification: decreasing doses over more than one month;
- short-term maintenance: stable prescribing over six months or less; and
- long-term maintenance: stable prescribing over more than six months.
In addition, distinguishing between low-threshold programmes and high-threshold programmes is important. The distinction between these types can be broadly summarized as follows:
- are easy to enter;
- are oriented towards harm reduction;
- have as a main goal to relieve withdrawal symptoms and craving and improve people’s quality of life; and
- offer a range of treatment options.
- are more difficult to enter and may have selective intake criteria;
- are abstinence-oriented (which could include abstinence from methadone);
- do not have flexible treatment options;
- adopt regular (urine) control;
- have an inflexible discharge policy (illegal opiate use not being consented); and
- include compulsory counselling and psychotherapy.
The concept of “low threshold” should not be regarded as synonymous with “low quality”.
In general, low-threshold programmes are more successful in serving harm reduction purposes for both the addicted individual and society, by rapidly engaging and retaining people in treatment. For those with a chaotic lifestyle due to their drug habit such programmes are associated with better treatment outcomes, and thus meeting the aims of substitution treatment.
Given the often chronic nature of opiate addiction, MAT can be compared to other treatments that are effective in treating serious chronic relapsing conditions such as hypertension and diabetes. These diseases, like opioid dependence, are chronic, require daily treatment, and have a high risk of adverse effects if treatment is stopped.
It is recognised that drug dependence is a chronic disorder that is prone to relapse, even after significant periods of recovery, abstinent phases in prisons, and an effective treatment must be of a continuous nature. Yet, treatment of dependence, too, often consists of multiple episodes of acute care, rather than a plan of continuing care that is agreed between the clinician and the patient.
TREATMENT CRITERIA AND TREATMENT PLAN
Two internationally accepted diagnostic criteria cover drug dependence: the tenth revision of the International Classification of Diseases (ICD-11) (WHO, 1992) and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013).
MAT should be restricted to people who meet the clinical criteria for opioid dependence. However, restrictive regulations regarding the admission and inclusion criteria of a MAT maintenance are counterproductive with regard to access to treatment and preventing HIV and hepatitis transmissions. Issues such as the maximum dose or maximum length of treatment should be left to the practitioner’s clinical judgement, based on the assessment of the individual. Decisions on MAT are clinical decisions to be taken exclusively by medical professionals and must not be influenced in any way by non-medical staff or the prison administration.
In principle, everyone who is opioid-dependent and in need of treatment and expresses a desire for MAT can become stabilized under such treatment after appropriate assessment and treatment induction. However, it is recommended that the availability of treatment places is taken into account when adopting admission criteria. Age, length of opioid dependence, physical and mental health and personal motivation of the opioid-dependent person should all be considered. Some groups, such as pregnant women or people living with HIV or other illnesses, should be given priority. This, however, should not entail compulsory HIV-antibody testing.
Furthermore, since release from prison is associated with an increase in drug related death due to restart of drug, mostly opioid use after a period of abstinence or reduced use (during which opioid tolerance may have been reduced) treatment should be prioritised to those about to be released from prison.
The individual treatment plan will depend on the objectives of the treatment, which are established on the basis of the resources available, the needs and wishes of the respected person and the professional opinion of the doctor. Issues to consider when establishing a treatment plan include:
- client goals;
- current circumstances;
- available resources;
- past history of treatment outcomes; and
- evidence regarding safety, efficacy and effectiveness.
Opioid dependence is associated with a range of medical, legal and psychosocial problems. A person is suitable for MAT if the individual and social harms associated with the opioid use are likely to be reduced by entering into treatment. Additional problems should be addressed from the very beginning, either by the programme itself or through referral to an appropriate service.
RISKS AND LIMITATIONS
The most significant risk of methadone and other opioid agonists is overdose, which can be fatal. Research evidence (Verster & Buning 2003) indicates that the highest risk of overdose is when methadone treatment is begun. Low doses are therefore recommended at the beginning of treatment. However, once a stable dose is achieved (after about two weeks), the risk of overdose death is substantially reduced compared with the risk before treatment.
There are some other negative aspects of MAT. The most important is the fact that, in most cases, a person has to receive treatment for a long period of time. The long-term aspect negatively affects both public spending and the individual person.
The drug user becomes a long-term patient who depends on the medication and often also on the person who prescribes it. In some cases, this dependency can lead to a passive attitude where the user adopts through a state of “learned helplessness” to adopt a “sick role”. Involvement of the drug user in defining treatment goals, in decisions on dosing and, as much as possible, offering choice and empowerment may reduce this attitude.
Furthermore, the dependency on the medication and the associated stigma surrounding it might cause difficulties when patients want to move from one place to another or simply travel and take their medication with them after being released.
There are potentially serious negative effects that need to be brought to patient’s attention before they start treatment so that they can give informed consent to treatment. However, the benefits of MAT clearly outweigh these potential negative effects, both for the individual and for society.
POLYVALENT DRUG USE
Clear and transparent protocols and guidelines should be in practice regarding the use of several other drugs of prisoners when incarcerated. In particular benzodiazepines, barbiturates, and alcohol which are posing severe health risks for MAT. In these cases, the continuity of MAT should be thoroughly discussed from case to case. The options should ideally be considered within a multi-professional team and – if available – together with the drug counselling service of the prison. Future plans and achievements should be determined and agreed upon, taking into account the prisoner’s wishes and resources.
POLITICAL LEADERSHIP AND CLEAR POLICIES AND PROTOCOLS
In order to harmonise MAT in prisons in one country it is of utmost importance to have comparable treatment standards of how to conduct this treatment in prisons. This is important in order to have comparable regulations once a prisoner is being referred to another facility.
In prisons, protocols and practices of MAT are often more oriented towards the institution’s needs and requirements rather than each patient’s needs and wishes. For instance, the approximately five to ten minutes required for supervising the sublingual intake of buprenorphine is regarded as excessively time-consuming. Instead, methadone is prescribed.
Opioid users may complain about changes in their substitution drug and see double standards with regard to what happens in the community. Clear communication with the prisoner is obligatory when intending to replace one substitution drug with another.