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Why Methadone Maintenance Treatment ?
Methadone is a long-acting synthetic narcotic that is taken orally to effectively block craving or withdrawal symptoms from opioids such as heroin. Many have recommended the introduction or expansion of MMT in prisons as an HIV-prevention strategy that provides people dependent on drugs with an additional option for getting away from needle use and sharing. The main aim of MMT is to help people get off injecting, not off drugs. Methadone dose reduction - with the ultimate goal of helping the client to get off drugs - is a longer-term objective.

Community MMT programs have rapidly expanded since the mid 1990s. There are ample data supporting their effectiveness in reducing high-risk injecting behaviour and in reducing the risk of contracting HIV. There is also evidence that MMT is the most effective treatment available for heroin-dependent injection drug users in terms of reducing mortality, heroin consumption, and criminality. Further, MMT attracts and retains more heroin injectors than any other form of treatment. Finally, there is evidence that people who are on MMT and who are forced to withdraw from methadone because they are incarcerated often “return to narcotic use, often within the prison system, and often via injection.” It has therefore been widely recommended that prisoners who were on MMT outside prison be allowed to continue it in prison.

Further, with the advent of HIV/AIDS, the arguments for offering MMT to those who were not following such a treatment outside are compelling. Prisoners who are injection drug users are likely to continue injecting in prison and are more likely to share injection equipment, creating a high risk of HIV transmission (see info sheets 2 and 3). As in the community, MMT, if made available to prisoners, has the potential of reducing injecting and syringe sharing in prisons.

Where Is It Being Offered ?
Worldwide, an increasing number of prison systems are offering MMT to prisoners, including most Western European systems (with the exception of Greece, Sweden, and two jurisdictions in Germany). Programs also exist in Australia and in the United States (at Rikers Island, New York City). Finally, an increasing number of Eastern European systems is starting MMT programs or planning to do so in the next years.

In Canada, methadone was rarely prescribed to anyone in prison until quite recently. However, this has changed, partly because of the recommendations urging prisons systems to provide MMT, partly because of legal action. One such case was in BC. An HIV-positive woman undertook action against the provincial prison system for failing to provide her with methadone. The woman had been refused continuation of MMT. She argued that, under the circumstances she found herself in, her detention was illegal. The prison system arranged for a doctor to examine the woman, and he prescribed methadone for her. After this, she withdrew her petition. In another case, a man with a longstanding, “serious heroin problem” was sentenced to two years less one day in prison - and thus to imprisonment in a provincial prison in Québec - because that prison had agreed to provide him with MMT. The defence had submitted that it was necessary to deal with the root causes of the man’s crimes, namely his heroin addiction, and that treatment with methadone was essential to overcoming that addiction.

In September 1996 the BC Corrections Branch adopted a policy of continuing methadone for incarcerated adults who were already on MMT in the community, becoming the first correctional system in Canada to make MMT available in a uniform way. On 1 December 1997 the federal prison system followed suit. Today, in the federal and in most provincial and territorial systems, prisoners who were already on MMT outside can continue such treatment in prison. However, few systems allow prisoners to initiate MMT while incarcerated. Only the federal system and the BC provincial system have formal methadone initiation programs, while Quebec, Saskatchewan, and Yukon allow MMT initiation under “exceptional circumstances”.

Are There Other Alternatives ?
Some prison systems are still reluctant to make MMT available, or to extend availability to those prisoners who were not receiving it prior to incarceration. Some consider methadone as just another mood-altering drug, the provision of which delays the necessary personal growth required to move beyond a drug-centred existence. Some also object to MMT on moral grounds, arguing that it merely replaces one drug with another. If there were reliably effective alternative methods of achieving enduring abstinence, this would be a meagre achievement. However, as Dolan and Wodak have explained, there are no such alternatives :

[T]he majority of heroin-dependent patients relapse to heroin use after detoxification ; and few are attracted into, and retained in drug-free treatment long enough to achieve abstinence. Any treatment [such as MMT] which retains half of those who enrol in treatment, substantially reduces their illicit opioid use and involvement in criminal activity, and improves their health and well-being is accomplishing more than “merely” substituting one drug of dependence for another.

In recent years, evaluations of prison MMT programs in Canada, Australia, and the US have provided clear evidence of their benefits.

Recommendations
MMT is a medically indicated form of treatment that should be available to opiate-dependent people regardless of whether they are outside or inside prison.
 

Additional Reading
R Lines. Action on HIV/AIDS in Prisons : Too Little, Too Late - A Report Card. Montreal : Canadian HIV/AIDS Legal Network, 2002. Contains information about access to MMT in Canadian prisons. Available at www.aidslaw.ca/Maincontent/issues/prisons/reportcard/toc.htm

T Kerr, R Jürgens. Methadone Maintenance Therapy in Prisons : Reviewing the Evidence. Montreal : Canadian HIV/AIDS Legal Network, 2004. Available via www.aidslaw.ca/Maincontent/issues/prisons.htm.

Correctional Service Canada. Research Report : Institutional Methadone Maintenance Treatment : Impact on Release Outcome and Institutional Behaviour. Ottawa : CSC Research Branch, 2002 (No R-119). Available via www.csc-scc.gc.ca/text/rsrch/reports/reports_e.shtml.

Third, revised and updated version, 2004. Copies of this info sheet are available on the Network website at http://www.aidslaw.ca/Maincontent/issues/prisons.htm and through the Canadian HIV/AIDS Information Centre (email : aidssida@cpha.ca). Reproduction of the info sheet is encouraged, but copies may not be sold, and the Canadian HIV/AIDS Legal Network must be cited as the source of this information. For further information, contact the Network (tel : 514 397-6828 ; fax : 514 397-8570 ; email : info@aidslaw.ca). Ce feuillet d’information est également disponible en français.

Funded by Health Canada under the Canadian Strategy on HIV/AIDS. The findings, interpretations, and views expressed in this publication are entirely those of the author and do not necessarily reflect the official policy or position of Health Canada.

© Canadian HIV/AIDS Legal Network, 2004