Initiation of MAT in prison
Historically there has been limited availability of MAT in prisons. However, the principle of equivalence with health care offered in community settings suggests that MAT should be available and accessible to all prisoners according to their health needs. Since many prisoners experience immediate relapse after release, they should have an informed choice of either detoxification or maintenance. Currently (2021), 26 of the 27 EU states and 42 of the 47 Council of Europe states provide opioid substitution treatment in some or all prisons.
Given the often relapsing/remitting nature of opiate dependence, detoxification alone is only effective in producing long-term change for a minority of users. The benefits of MAT programmes can be maximised by:
- retaining clients in treatment;
- prescribing higher rather than lower doses of methadone;
- orientating programmes towards maintenance rather than abstinence;
- offering counselling, assessment and treatment for psychiatric and somatic co-morbidities and for social problems;
- using and strengthening the therapeutic alliance between clinician and patient to reduce the use of additional drugs.
There are three scenarios where it may be appropriate to initiate users onto opiate maintenance in the prison setting. These are:
- immediately upon admission to prison;
- during the sentence;
- a period of time before release.
Several studies have shown that here is an extremely high risk for drug using prisoners to relapse and overdose shortly after release. Overdoses on release and suicides in prisons were key elements in some countries to integrate ST in prisons. In order to avoid relapse and overdose post prison release, it is recommended that the prisoner is maintained on a stable dose until released.
Also there is an extremely high risk for drug using prisoners to relapse and overdose shortly after release.
Overdoses on release and suicides in prisons were key elements in some countries to integrate MAT in prisons.
Some drug users are successful in achieving a permanent state of abstinence whilst in prison. However, detoxification alone is seldom effective in producing long-term change for the majority of drug users. The benefits of MAT programmes can be maximised by retaining clients in treatment, prescribing higher rather than lower dosages of methadone, orientating programmes towards maintenance rather than abstinence, offering counselling, assessment and treatment of psychiatric co-morbidity, and social treatments and strengthening the therapeutic alliance between clinician and patient to reduce the use of additional drugs.
It depends on several factors whether detoxification programmes or continuity of MAT is offered/applied in prisons.
Institution related factors are e.g., lack of resources and/or personnel, which results in a limitation of the treatment places available, poor knowledge, lack of supporting regulations and guidelines, dependence on the development of MAT in the community, opposing MAT policy for the prison setting or restrictive MAT policy outside in the communities. Patient-related factors: Sometimes prisoners wish to detoxify quickly and become completely drug free; they do not wish to have contacts with drugs and drug users anymore or to hear or talk about dependence and drug related problems. They either intend to utilise imprisonment as a drug free period or wish to start a new life and be ready and ‘clean’ upon their release from prison. However, doctors and nurses can sometimes be opposed to such a goal when they feel that the prisoner’s timescales for detoxification are too rapid, too ambitious and therefore not realistic. Relapses with a risk of overdose are likely to happen, in particular when detoxification occurs too fast.
One key element is to choose an individual approach in that sense that the doctor explains clearly to the patient the advantages and disadvantages of a quick versus a long detoxification.
Relapses after detoxification are extremely common and detoxification on its own therefore rarely constitutes adequate treatment of substance dependence. The options include managing withdrawal on admission as gradual detoxification, proceeding to abstinence-oriented treatment or proceeding to long-term MAT. Successful outcome of interventions requires that they are as client-tailored as possible and applied by using a case-by-case approach.
It is important to accept that drug users are a very heterogeneous population. Their needs may be different according to the stage they are at in their drug using career, their level of self-efficacy and their degree of social support. Such factors may contribute to the preference of a faster rather than a slower reduction scheme. The treatment needs may also be different for women than they are for men.
DOSING AND SUPERVISON OF INTAKE
As there is no such a thing as average dosage, dosage questions should be left up to the doctor-patient-relationship and should be adjusted according to individual needs. However, there should be the possibility and sufficient time to negotiate the needs of the patients to either reduce or increase dosage.
Each patient presents a unique clinical challenge, and there is no way of prescribing a uniform best methadone dose as a ‘gold standard’ for all patients to achieve a specific blood level. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately ‘enough’ methadone in methadone maintenance treatment.
The dose has to be adjusted to a level that can reduce craving and then block any use of heroin as an euphoriant.
For dosages and more detailed regime suggestions (short or long term detoxification or maintenance) please refer to the EuroMethwork Methadone Guidelines at http://www.q4q.nl/methwork/guidelines/guidelinesuk/methadone%20guidelines%20english.pdf
In contrast to community treatment settings, relatively low dosages might be sometimes sufficient in the prison setting for two reasons:
- in the prison the universal supervision of intake guarantees an almost 100% consumption of the MAT medication and
- the number of other drugs taken is substantially reduced compared to the situation in the community.
Research indicated that the average MAT dose varied considerably in prisons (from 30 to 70 mg). In contrast to community practice, some doctors believed that low doses were sufficient on the basis that 100% intake was guaranteed and that the amount of other drugs used is significantly lower in prison.
Prisoners should be informed about the dose they are prescribed unless they specifically request not to know.
The supervision of intake (of methadone either in liquid or tablets) should be conducted whenever possible by medical staff. This is to ensure that the substance is swallowed completely and not diverted and to avoid other prisoners blackmailing patients in methadone programmes to sell or provide their portion, and finally to avoid overdoses from prisoners with no opiate tolerance. In most cases, control is carried out by letting patients talk afterwards.
In some setting the guards dispense the medication, when there is no medical staff on duty.
There is a consensus that the intake of MAT drugs (as well as the intake of other psychoactive substances, antidepressants etc.) has to be supervised in order to make sure the drug has been swallowed adequately and to avoid other prisoners blackmailing patients in methadone programmes to sell or provide their portion, and finally to avoid overdoses from prisoners with no opiate tolerance.
Dispensing of sublingual buprenorphine may require quite some time, because it takes at least 5 minutes until it is completely dissolved. The recent introduction of subcutaneous depot preparations allows to get by this problem.
The assessment and consequences of medically ordered urine controls vary considerably.
Urine analysis is an issue that has been much debated in the field. Although urine controls are a vital part of the initial medical assessment of the patient (for confirmation that the patient is actually using opiates), they are often used as a form of control over patients to see if they are not continuing to use illegal drugs with their medication. Many professionals question its effectiveness as a positively contributing factor to the success of treatment. It is argued that the information can also be obtained by asking the patient, which would save a lot of time and money. It goes without saying that this requires a good patient-doctor relationship which is based on respect and mutual trust and that results of urine tests within the scope of MAT programs must remain in medical confidentiality.
However, it is also argued that a positive urine sample should never be a reason for discontinuing treatment, since this is the evidence for symptoms of the condition the patient is being treated for, i.e., their drug dependence.
DROPPING OUT OF SUBSTITUTION PROGRAMME
If a patient abuses or manipulates the MAT medications, in some programmes he/she can be excluded from the MAT programme. However, it is very important that the patient has been included in the MAT programme for a sample period of time, and that his/her dosage was high enough.
Some other programmes exclude patients because of being physical or even verbal violent against co-patients or staff. In any case the dosage should be tapered gradually.
MAT should never be a kind of reward for good behaviour or withheld as punishment but a part of a normal treatment within a variety of medical and psychosocial options.
Generally opioid dependent people living in prisons should always be given the chance to return into the MAT programme.
THE ROLE OF PSYCHO-SOCIAL CARE
The combination of physical, psychological and social dimensions contributes to the complexity of drug dependence. In order to successfully treat the disease and overcome drug dependence, it is necessary to address both, the physical and psychosocial dimensions of the disease. For many dependent drug users this may entail substantial physical, psychological and lifestyle adjustments – a process that typically requires a lot of time.
MAT, therefore, must not only deal with the opioid dependence on its own but also with psychiatric, medical and social problems (WHO 2009).
Psycho-social care is therefore regarded as an additional and necessary part of treatment to support the medical part of the MAT treatment in prison. According to the EMA authorisation of depot buprenorphine preparations for MAT, accompanying psycho-social support is required.
CO-PRESCRIPTION OF BENZODIAZEPINES AND USE OF OTHER DRUGS
The use of other drugs is widespread among drug users, mostly to bridge the gap between the lack of availability of the preferred opiate (merely heroin) use. The using patterns often constitute an additional dependence with severe syndromes and problems in detoxification.
People with opioid dependence and injecting drug users frequently use a range of psychoactive substances in addition to opioids, including alcohol. Research has shown that the use of cocaine in combination with opioids is, in particular, a factor that is associated with treatment failure. In addition, where drugs such as cocaine are used by injection, the effectiveness of opioid substitution therapy in managing risk behaviours is reduced. At the same time, research evidence indicates that when individuals with opioid dependence are retained in treatment, levels of use of cocaine are reduced, along with levels of opioid use.
ETHICAL BASIC OF MAT
Drug dependence is a chronic recurring illness. The optimal goal of therapy, cure, hardly ever is achieved. Modern addiction therapy is increasingly based upon the term harm reduction, i.e. reducing suffering, completed by precise clarification and treatment of psychosocial co-morbidities. When choosing MAT, cost awareness is of course an issue, i.e. methadone is the first choice. In case of severe side-effects of methadone, a switch to another better tolerated medication is to be considered. Patients successfully on substitution before imprisonment should continue the same medication in prison. Relapses should not lead to termination of substitution treatment as relapses are inherent in addiction. Instead, they should lead to a reassessment whether the treatment can be optimized. In particular, it should be clarified whether the medication dosage is sufficient. If relapses continue to occur in spite of a higher dosage, it might be necessary to switch to a different substitution drug. However, if a patient repeatedly misuses or diverts the prescribed substitution drugs he should be gradually withdrawn from the substitution program as obviously he is lacking the necessary motivation and discipline.