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

This is a prison-based, methadone maintenance program in Australia, which is designed 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. There were no statistically significant effects on rates of mortality, recidivism, or hepatitis C infections.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

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.

Study

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. No subgroup analyses were conducted.  

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

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

Following are CrimeSolutions-rated programs that are related to this practice:

Opiate Maintenance Therapy for Persons for Persons Who Use Heroin and Cocaine

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 persons who abuse heroin and cocaine abusers, but Ineffective for cocaine abstinence.

Evidence Ratings for Outcomes

	Drugs & Substance Abuse - Heroin/opioids
	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 individuals who are in prison or jail. The practice is rated Ineffective for reducing recidivism. A meta-analysis found that incarcerated persons in narcotics maintenance treatment have significantly greater odds of recidivating than comparison subjects. However, the practice is rated Promising for decreasing the odds of drug relapse post-release.

Evidence Ratings for Outcomes

	Drugs & Substance Abuse - Multiple substances
	Crime & Delinquency - Multiple crime/offense types

Methadone Maintenance Therapy

This practice involves a medication-assisted treatment for individuals with opioid dependence. Methadone is a long-acting synthetic opioid analgesic that works as a pharmacologic intervention to prevent or reverse withdrawal symptoms, reduce opiate cravings, and bring about a biochemical balance in the body in order to reduce the illicit use of opioids. The practice is rated Effective for reducing use of heroin/opioids but rated No Effects for reducing criminal activity and mortality.

Evidence Ratings for Outcomes

	Drugs & Substance Abuse - Heroin/opioids
	Drugs & Substance Abuse - Mortality
	Drugs & Substance Abuse - Mortality

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?