Prisons are not the right place for treating drug dependent men and women, and countries should develop policies for alternatives to imprisonment. As long as these alternatives have not been developed and implemented, prison authorities are faced with this specific population, in need of treatment, care and support. Research has shown that substitution therapy is the most effective way to treat opioid dependence, to reduce the risk of HIV and hepatitis C transmission, and to reduce the risk of overdose.
The course is based on the expertise of scientists and medical doctors/psychiatrists/healthcare professionals working in the field of substitution treatment in prisons. Relevant international literature and databases have been reviewed in order to develop the best evidence-based guidance. The publication follows the guidance and recommendations of several international publications such as the WHO Regional Office for Europe: Prisons and Health, 2014. A WHO guide to the essentials in prison health, the UNODC/UNAIDS/WHO framework for HIV prevention, care, treatment and support in prison settings, as well as the WHO/UNAIDS/UNODC Evidence for actions technical paper: Interventions to address HIV in prisons – Drug dependence treatment.
See "Introduction" for more information about the course.
In the first part, we present a summary of the basic issues discussed in the course. This course is designed as a self-study online. We recommend taking a few minutes to read a short manual to the course in the introductory section.
17 key takeaway points
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In this part you'll find out the main goals of MAT, you'll see how differ agonists from antagonists and you'll read about the benefits of MAT
According to UN World Drug Report 2020 there are an estimated 11.3 million injecting drug users worldwide, and at least 10% of all cases of HIV infection worldwide result from unsafe injecting behaviour – in countries in Eastern Europe and central Asia, up to 90%. Many drug users spend years of their lives going in and out of prison. Generally, prisoners are often from the poorest sectors of society and consequently already have worse health than other social groups. Being in prison commonly exacerbates existing health problems, especially with vulnerable groups such as drug users.
The most common form of MAT is methadone maintenance treatment. Methadone has been used to treat heroin and other opioid dependence for decades. The more recently developed buprenorphine is also quite commonly used in some countries. Both have been proven to greatly reduce the risk of HIV infection by reducing drug injection and improving the health and quality of life of opioid dependent people.
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In this part you'll find out to use methadone in substitution therapy, you'll see how differ substitution treatment regimens, you'll read how to use buprenorphine and sustained-release morphine in substitution therapy. At the end you'll find out how to use naltrexone as a prevent to addiction.
MAT programmes vary in duration, dosage and scheme. Although much evidence indicates that 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.
Methadone is a cheap, safe medication with no lasting deleterious physical or physiological effects. Methadone should be provided pursuant to the same professional and ethical standards that apply to all other health services. Findings have consistently demonstrated significant benefits associated with both methadone and buprenorphine maintenance treatment.
In this part you'll read how to use buprenorphine in MAT. Buprenorphine is a prescribed medication with weaker opioid agonist activity than methadone. It is acceptable to heroin users, has few side effects and is associated with a relatively mild withdrawal syndrome.
In this part you'll read how to use sustained-release morphine in MAT
Naltrexone is a pure opiate antagonist and, as such, is not considered a substitution medication agonist. It has received attention when used for ultrarapid detoxification under general anaesthesia - a practice that is not without risk to the patient. In addition to its use as a rapid detoxification agent, Naltrexone has also been used for decades as a longer-term blocking agent (full opiate antagonist) in maintenance treatment.
Summary table and description of substitution agents. One-page, A4 PDF sheet convenient to print & pin.
Naloxone is given intranasally, i.v. or subcutaneously. It is a well-known opioid antidote without addictive potential and it reverses heroin effects. The nasal spray can be administered by lay-person bystanders: families, friends and staff.
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The Clinical Opiate Withdrawal Score (COWS)
Dosage Guide for (sublingual) Buprenorphine Maintenance Treatment
Dosage Guide for Methadone Maintenance Treatment
In this part you'll find out how to implement MAT in a prison and you'll read about the role of psychological and social care in prison.
In this part we showing how to implement MAT in a prison
Example substitution guidelines for penal institutions in Austria
This video presents the model of MAT in managing opioid dependence of inmates in the Republic of Moldova. It was produced by the Council of Europe's Pompidou Group in collaboration with the Moldovan Department of Penitentiary Institutions for the training of prison staff.
In this part you'll find out the basic information for the patient on MAT, you'll read about how a patient can continue treatment after commencement or termination of prison sentence. At the end we describing the links between MAT and treatment of blood-borne infections (eg HIV / AIDS, HBV, HCV) and others (eg tuberculosis or sexually transmitted diseases).
Basic information for the patient on MAT
The information how a patient can continue MAT after commencement or termination of prison sentence
MAT may also play an important role in police detention and pre-trial detention institutions. Existing substitution treatments should be continued in police detention and pre-trial detention centres and remand prisons.
In this part we presentation of the ethical basis of MAT
Drug addiction is subject to strong ideological and cultural conceptions, which influence treatment approaches and treatment goals of drug addiction. Access to treatments and the choice of treatments are often decided on ideological rather than medical considerations.
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