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Program Profile: New South Wales (Australia) Prison Methadone Maintenance Program

Evidence Rating: No Effects - One study No Effects - One study

Date: This profile was posted on September 23, 2011

Program Summary

This program aims to reduce recidivism, prevent the spread of blood-borne viral infections (HIV and hepatitis) in prison, and encourage continuation of treatment in the community following release. The program is rated No Effects. Overall, the evidence did not find a significant difference between the prison methadone maintenance treatment group and the control group on measures of mortality, reincarceration, hepatitis C virus seroconversion and treatment retention.

Program Description

Program Goals

The New South Wales Prison Methadone Program provides prison-based methadone maintenance treatment (MMT) for incarcerated injecting drug users (IDUs) dependent on opioids. The goals of the prison-based MMT program are to reduce recidivism, prevent the spread of HIV and hepatitis in prison, and encourage the continuation of treatment in the community following an inmate’s release from prison.

 

Methadone is a synthetic opioid agonist used in maintenance therapy or as a withdrawal agent for drug users dependent on opioids, such as heroin and oxycodone. It is taken orally on a daily basis and reduces the use of opioids through cross tolerance, which can result in a reduction of withdrawal symptoms, less desire to use opioids, and reduced euphoric effect when opioids are ingested. MMT programs are generally community based, but Australia is one of a few countries that operate and offer a prison-based program.

 

Program Theory

The prison methadone program began as a prerelease program that targeted IDUs with extensive drug careers and histories of incarceration (although inmates with less extensive drug careers and fewer prior incarcerations are now admitted). The program has been modified over the years to reflect a maintenance treatment philosophy. This includes shifting the concentration of MMT to not only reduce heroin injection and use but also to minimize the spread of blood-borne viral infections, such as HIV and hepatitis C.

 

Australia’s National Methadone Guidelines provide four basic categories where MMT might be appropriate for prisoners: 1) withdrawal; 2) continuation of treatment for those on methadone before imprisonment; 3) commencement of treatment for those who are heroin dependent on prison entry or who have used heroin in prison in a harmful way, including those who are HIV positive; and 4) the reduction of intravenous opioid use upon release (Dolan et al. 2002, 14).

 

Target Population/Eligibility

The program is targeted toward incarcerated IDUs who are addicted to opioids. To determine eligibility for MMT, inmates are assessed by trained nurses who have experience conducting a standardized Corrections Health Methadone Assessment. The assessment is followed by a medical review by a corrections health career medical officer. The medical officer makes appropriate medical observations and confirms drug use history and any treatment history. Inmates found suitable for the methadone program are placed on a waitlist, which can last 6 months. If inmates are assessed as requiring priority placement (they are HIV positive), then they immediately begin the methadone program.

 

Services Provided

When inmates begin the prison methadone program, they start on a 30-milligram (mg) dose. This dosage increases by 5 mg every 3 days until a 60-mg dose is achieved. Inmates in MMT are subject to the usual security arrangements, which means they are subject to ‘lockdowns’ and not allowed unscheduled movements that may interrupt treatment or stabilization periods.

 

Drug and alcohol counseling is also available to all inmates in prison. Inmates treated through the prison methadone program are offered the opportunity to transfer to community-based methadone programs, to continue treatment following release.

 

Target Sites

The prison methadone program is available at five prison facilities in the Sydney, Australia, metropolitan area (John Morony, Long Bay Complex, Metropolitan Remand Centre, Parramatta, and Silverwater) and seven prisons outside the metropolitan area (Bathurst, Cessnock, Goulburn, Grafton, Junee, Lithgow, and Tamworth). If inmates are located in a prison that does not offer the methadone program, they may be moved to one that does.

 

Key Personnel

The Department of Corrective Services (DCS) is in charge of running the prison system in New South Wales. However, the health needs and services of prisoners are the responsibility of the Corrections Health Service (CHS), which is part of the Department of Health and is separate from the DCS. The National Methadone Guidelines stipulate that the medical staff prescribing methadone to prisoners should be independent of the DCS, to minimize conflicts of interest. Therefore, trained medical staff from the CHS administers the methadone doses.

Evaluation Outcomes

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Study 1

Overall, Dolan and colleagues (2005) did not find significant differences between the prison methadone maintenance treatment (MMT) group and the control group on measures of mortality, reincarceration, hepatitis C virus (HCV) seroconversion, and treatment retention.

 

All-Cause Mortality

At the time of the 4-year follow-up, 17 of the original 382 study participants in the original randomized controlled trial died from the date of the first interview to May 2002 (when the death record check was performed). However, there was no statistically significant difference in morality risk between the prison methadone maintenance treatment (MMT) group compared with the control group.

 

Reincarceration

Of the study participants who had been released from prison, 280 have been reincarcerated. There was no significant difference between the number of treatment group members who were reincarcerated (n=143) and the number of control group member reincarcerated (n=137) since first release from prison.

 

HCV and HIV Seroconversion

The HIV incidence rate was quite low (only two cases were found, so comparison between treatment and control groups was not possible). In contrast, there were 16 cases of HCV seroconversion found in the treatment group and 23 cases in the control group. However, the difference in HCV incidence rate between the groups was not statistically significant.

 

Retention in First MMT Episode

There was an overall attrition rate of 63 percent. The treatment group had 152 participants drop out of its first methadone treatment episode, while the control group had 123 participants drop out. However, this difference was not significant.

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Evaluation Methodology

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Study 1

The study by Dolan and colleagues (2005) looked at a cohort of 382 imprisoned male heroin users who had participated in a randomized controlled trial (RCT) of a prison-based methadone maintenance treatment (MMT) program in New South Wales (NSW) prison system from 1997 to 1998. The study was a 4-year follow-up that looked at the long-term impact of MMT on mortality, reincarceration after first release, hepatitis C virus (HCV) and HIV seroconversion, and treatment retention.

 

Participants from the original RCT were located between September and December 2000 through methadone clinics, probation and parole offices, and letter sent to their last known address. The original study included 191 members of the prison methadone treatment group and 191 members of the waitlist control group. At baseline, the male prisoners were on average 27 years old, 24 percent were Aboriginal or Torres Strait Islander, and the most serious offenses were robbery (31 percent), breaking and entering (22 percent), and assault (19 percent). There were no statistically significant differences between the group on characteristics and demographics. For this follow-up study, 236 participants (62 percent) from the original cohort were reinterviewed either in prison (n=201) or in the community (n=35). There were few significant differences between study participants who were and were not reinterviewed after 4 years. Compared with study participants who were lost at the follow-up, participants who were reinterviewed for this study were significantly more likely to be in prison at the follow-up period, had been reincarcerated more times, and began drug injecting at a younger age.

 

Data on the outcome measures of interest was collected from various sources in 2002. Mortality was assessed through the Australian National Death Index (NDI). The cohort data was matched to the NDI on different characteristics, such as name and date of birth. Reincarceration data was obtained from the New South Wales (NSW) Department of Corrective Services and the relevant departments in other Australian States and Territories. Methadone treatment data was obtained from the Pharmaceutical Services Branch of the NSW Department of Health in May 2002. Data on HIV and HCV was collected by asking study participants to provide a finger-prick blood sample. The date of seroconversion was taken as the midpoint between the last negative and first positive antibody tests.

 

All significance tests were two-tailed, using a 0.05 level of significance. T–tests were used for continuous variables, and the chi-square statistic was used for categorical data. Person-time methods using Cox regression models with time-dependent covariates were used to examine predictors of time-to-event outcomes, including death, reincarceration, hepatitis C seroconversion, and MMT dropout.

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Cost

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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Dolan, Kate A., James Shearer, Bethany White, Jialun Zhou, John Kaldor, and Alex D. Wodak. 2005. “Four-Year Follow-Up of Imprisoned Male Heroin Users and Methadone Treatment: Mortality, Reincarceration, and Hepatitis C Infection.” Addiction 100(6):820–28.
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Additional References

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These sources were used in the development of the program profile:

Dolan, Kate A., Alex D. Wodak, and Wayne D. Hall. 1998. “Methadone Maintenance Treatment Reduces Heroin Injection in New South Wales Prisons.” Drug and Alcohol Reviewer 17(2):153–58.



Dolan, Kate A., James Shearer, Bethany White, and Alex D. Wodak. 2002. A Randomised Controlled Trial of Methadone Maintenance Treatment in NSW Prisons. Sydney, Australia: National Drug and Alcohol Research Centre, University of New South Wales. NDARC Technical Report No. 155.



Dolan, Kate A., James Shearer, Margaret MacDonald, Richard Phillip Mattick, Wayne D. Hall, and Alex D. Wodak. 2003. “A Randomised Controlled Trial of Methadone Maintenance Treatment Versus Wait List Control in an Australian Prison System.” Drug and Alcohol Dependence 72:59–63.



Gjersing, Linn R., Tony Butler, John R.M. Caplehorn, Josephine M. Belcher, and Richard Matthews. 2007. “Attitudes and Beliefs Towards Methadone Maintenance Treatment Among Australian Prison Health Staff.” Drug and Alcohol Review 26(5):501–8.



Hall, Wayne D., Jeff Ward, and Richard Phillip Mattick. 1993. “Methadone Maintenance Treatment in Prisons: The New South Wales Experience.” Drug and Alcohol Review 12:193–203.


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Related Practices

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Following are CrimeSolutions.gov-rated practices that are related to this program:

Opiate Maintenance Therapy for Dual Heroin–Cocaine Abusers
A medication-assisted treatment for opioid dependence, including methadone, buprenorphine, and Levo-Alpha-Acetymethadol (LAAM). The overall goals are to help opioid-addicted patients alleviate withdrawal symptoms, reduce or suppress opiate cravings, and reduce the illicit use of opioids (such as heroin). The practice is rated Effective for achieving higher sustained heroin abstinence for dual heroin–cocaine abusers, but No Effects for cocaine abstinence for dual abusers.

Evidence Ratings for Outcomes:
Effective - One Meta-Analysis Drugs & Substance Abuse - Heroin/opioids
No Effects - One Meta-Analysis Drugs & Substance Abuse - Cocaine/crack cocaine



Incarceration-based Narcotics Maintenance Treatment
This practice attempts to reduce harms associated with drug dependency by prescribing synthetic opioid medication to opioid-addicted offenders who are in prison or jail. The practice is rated No Effects for reducing recidivism of offenders. A meta-analysis found that incarcerated offenders in narcotics maintenance treatment have significantly greater odds of recidivating than comparison offenders However, the practice is rated Promising for decreasing the odds of drug relapse post-release.

Evidence Ratings for Outcomes:
Promising - One Meta-Analysis Drugs & Substance Abuse - Multiple substances
No Effects - One Meta-Analysis Crime & Delinquency - Multiple crime/offense types
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Program Snapshot

Age: 18+

Gender: Male

Race/Ethnicity: White, Other

Setting (Delivery): Correctional, Other Community Setting

Program Type: Alcohol and Drug Therapy/Treatment, Aftercare/Reentry

Targeted Population: Alcohol and Other Drug (AOD) Offenders, Prisoners

Current Program Status: Active