Information users require
The absolute condition for an effective start of MAT is to provide the user with relevant information, in particular on the risk of overdose, which should include the following:
- the delay of a peak effect of the MAT drug (methadone 2–4 hours);
- the accumulation of the MAT drug over time resulting in a greater effect (methadone over 3–5 days or more), even on a fixed dose;
- the risks of multiple drug use while in MAT, especially other opiates, cocaine, benzodiazepines and alcohol; and
- the potential interaction with other medication.
In addition, users need information about MAT and drugs in general and about particular rules and expectations. Drug users often do not understand the goals pursued with the MAT, nor do they have enough information about the specific medication used or the rules they have to follow. Prisoners should be asked to sign an informed consent form once they have clearly understood all relevant information.
ANONYMITY AND CONFIDENTIALITY OF TREATMENT
Every prisoner should know before getting any sort of treatment the primary physician’s obligation: to the state, to the prison or to the prisoner.
Although securing anonymity and confidentiality within a prison is difficult, attempts have been made to administer MAT drugs in a way that protects prisoners, either by putting all drug users together in one wing or delivering substitution drugs discreetly with other pharmaceuticals.
Other prisoners and staff should not be made aware that a prisoner is a drug user or in MAT. The fear is that if somebody knows about the drug dependence, it will lead to consequences for the actual sentence in terms of disadvantages (such as access to work, qualification or jobs), prejudices, loss of privileges or simply the negative attitude of staff and other prisoners. Moreover, the drug users fear pressure from other prisoners who wish to participate in the MAT treatment in terms of smuggling MAT drugs.
However, informing properly trained guards and other staff involved in work with the prisoner can be useful, particularly in the observation of patients with particular vulnerability due to co-existing mental health problems. Shutting guards completely out of the psychosocial and health care support also seems to build barriers between the different professionals and sometimes enhances prejudices and misunderstandings about the prisoner and drug use. Hence, basic cooperation, information and training of prison staff, including guards, are needed to ensure that staff members have positive or at least better attitudes towards drug users.
Patients on MAT who follow the rules in their therapeutic agreement should be able to enjoy all the same privileges as other prisoners. Decisions regarding flexible release should be made based on the therapist’s individual judgement. Flexible releases should be planned and performed gradually.
Take-home dosages can be given as privileges for visits or periods of leave outside prison that are longer than 24 hours. The prisoner receiving the MAT must be able to continue with such treatment and must have the possibility of being included in other programmes after release. The physician decides about patient’s ability to work for those included in MAT programmes in prisons.
Ongoing contributions from opioid users are valuable in order to improve the quality of health care; most prisoners have had previous, personal experience of prison health care and MAT inside prison and in the community (either detoxification or maintenance).
Acknowledging and integrating prisoner’s experiences and expertise in involving opioid users in developing, designing and delivering interventions is critical to increasing their appropriateness and reach.
Support groups or educational programmes should be established or incorporated into the overall HIV treatment programme for injecting drug users. Former injecting drug users often have unique success in educating and motivating current injecting drug users to take steps to access effective care.
LINK WITH TREATMENT OF BLOOD-BORNE VIRUSES (E.G. HIV/AIDS, HBV, HCV) AND OTHER INFECTIONS (E.G. TB, STIs)
MAT offers opportunities for improving the delivery of antiretroviral therapy and for treatment of chronic hepatitis B and C, tuberculosis and other diseases to opioid users. MAT enables opioid-dependent drug users to stabilise their lives and avoid or manage many of the complications of injecting drug use. It is therefore seen as an essential component in strategies for retaining active injecting drug users in treatment. It also provides additional entry points for scaling up antiretroviral therapy, improves drug adherence and increases access to care.
MAT programmes can be of great importance to injecting drug users living with HIV by:
- offering HIV testing for injecting drug users;
- referring them to HIV services;
- liaising with HIV services regarding treatment and care;
- preparing injecting drug users for treatment with antiretroviral therapy;
- stabilising an injecting drug users’ drug dependence to a point where he or she is able to engage in antiretroviral therapy
- dispensing antiretroviral therapy in conjunction with MAT;
- monitoring and managing the side effects of antiretroviral therapy;
- monitoring and managing interaction between methadone or buprenorphine and antiretroviral therapy; and
- supporting individual and family through the lifelong commitment to antiretroviral therapy.
This daily contact with MAT programmes has potentially huge advantages for access and adherence to antiretroviral therapy.