!
" !%
&

"

#

$

'( ) *

!
Injection drug use has been associated with
severe health and social harms.[1, 2] High rates
of disease, death, crime, and the accompanying
costs are drug-related harms experienced
throughout the world. Injection drug use has also
been identified as a key risk characteristic for
HIV infection in many countries around the
world.[3] Explosive epidemics of HIV/AIDS
have emerged in various settings, demonstrating
that HIV can spread rapidly once established
within communities of injection drug users
(IDUs). [4, 5] The dynamics of IDU-driven HIV
epidemics present unique challenges, giving
policy makers and health authorities little time to
respond in an effort to contain outbreaks of HIV
infection.
"
!
Incarceration is a common event among IDUs.
Evidence from the United States indicates that
approximately 80 percent of IDUs have a history
of imprisonment,[6] and a 12-city World Health
Organization study of HIV risk behaviour
among IDUs found that between 60 and 90
percent of respondents reported a history of
imprisonment
since
commencing
drug
injection.[7] Available evidence indicates that a
substantial proportion of drug users inject drugs
while in prison, with 50% or more of drug users
from several countries reporting injection while
in prison.[8-11] In one study in Russia where
20% of prisoners reported injecting drugs while

in prison, 14% of these individuals stated that
their first injection occurred within a penal
institution.[12]
Worldwide, levels of HIV prevalence within
inmate populations tend to be much higher than
in the general population [13]. HIV prevalence
among prisoners varies considerably across
settings, although several countries have reported
HIV prevalence among prisoners to be between
10-25%.[14-17]
The jurisdictions with the
highest HIV-prevalence in prisons (apart from
countries with large heterosexual HIV epidemics)
are areas where HIV infection in the general
community is “pervasive among IV drug users,
who are dramatically over-represented in
correctional institutions”.[18] Incarceration has
also been associated with HIV infection in
several countries,[19-21] and evidence of rapid
spread of HIV infection has been observed within
specific prison settings, including in countries in
Eastern Europe and the former Soviet Union
(fSU).[11, 22, 23]
Within prisons, the prevalence of injection drug
use and HIV infection, combined with the high
rate of turnover of the prison population, create
the potential for efficient and widespread
transmission of infectious diseases and other
drug-related
harms.
However,
these
characteristics also present opportunities for the
treatment of drug addiction and the prevention of
infectious disease transmission among a
substantial number of disadvantaged individuals.

!
In most areas of the world, the mainstay of
dealing with the problem of injection drug use
has been targeted law enforcement.[2] However,
despite the resources spent on the “zerotolerance” strategy, success has not been
achieved.[24] Since the early 1990s, in many
countries, supply and demand for drugs has
increased, purity of drugs has improved, and the
price of drugs has decreased.[25] Among the
more effective interventions for the prevention of
social and health-related harms among IDUs is
the provision of addiction treatment services.[26,
27] While there is no single treatment modality
that will work in every circumstance, previous
studies have demonstrated the beneficial effect of
substitution therapies, detoxification programs,
peer-support programs, and other treatment
strategies.[28-30] However, in most settings, the
demand for addiction services far exceeds
supply.[2, 31, 32]
Despite the potentially explosive dynamics of
IDU-driven HIV epidemics, there is evidence
indicating that HIV epidemics among IDUs have
been prevented, stabilized, and reversed in
various locations throughout the world.[33, 34]
One review of settings with large populations of
IDUs suggested that some cities have managed to
maintain low HIV seroprevalence among IDUs
due to: (1) the implementation of HIV prevention
measures while seroprevalence was still
relatively low; (2) the implementation of syringe
exchange programs; and (3) the provision of
outreach services to IDUs.[33] Other important
factors in addressing IDU-driven HIV epidemics
include the provision of substitution therapies
(e.g., methadone), involving drug users in the
design and implementation of interventions, and
ensuring that measures are responsive to changes
in risk practices and provide adequate
coverage.[35, 36]
There is also evidence, however, to indicate that
dual epidemics of injection drug use and
HIV/AIDS have occurred due to a failure on the
part of governments to quickly implement
appropriate interventions.[1] In some settings, a
failure to respond quickly to these emerging

epidemics has been followed by more
generalized HIV epidemics in which non-IDU
members of communities are increasingly
becoming infected with HIV through sexual
contacts.[3]
While effective HIV prevention and drug
treatment interventions exist, some of these
remain unpopular among politicians.[24] In some
countries, such as the United States, effective
interventions have not been implemented despite
widespread support from scientific and medical
bodies in these countries.[37, 38] Among the
effective albeit controversial of these programs is
methadone maintenance therapy (MMT).
#
$
Methadone is a long-acting synthetic opiate
agonist that is easily absorbed when taken orally
and has a half-life of approximately 24-36 hours,
allowing once daily administration.[39] Studies
have demonstrated that methadone is successful
in blocking the effects of opiate withdrawal
symptoms and the euphoria produced by short
acting opioids. [40] As a result, methadone
maintenance therapy (MMT) is effective in
reducing major risks, harms and costs associated
with untreated opiate addiction among patients
attracted into and successfully retained in
MMT.[41, 42] Research has demonstrated that
the use of MMT leads to reductions in, and even
the elimination of, use of opiates,[43-48] as well
as reductions in criminal activity, unemployment,
and mortality rates.[43, 44, 49-54] MMT is also
associated with reduced HIV and viral hepatitis
transmission rates,[51, 55-58]
and several
studies examining the relationship between MMT
and HIV risk factors have also shown reductions
in risk behaviors including needle sharing,
number of sexual partners, engaging in sex
without condom use, and exchange of sex for
drugs or money.[46, 59-62] MMT has also been
shown to be highly cost-effective,[54, 63-65]
with every dollar (US) spent on MMT resulting
in a saving of 4-5 dollars. [66, 67]
While some have questioned whether MMT
would be effective in treating addicted
individuals using home-produced derivatives of

+

poppy such as “chornaya” and “hanka”, there is
no pharmacological basis to such concerns, as
MMT is first and foremost an opiate and not a
“heroin-specific” agonist. The efficacy of MMT
in treating individuals addicted to opioids other
than heroin was confirmed in a previous study
showing no differences in MMT treatment
outcomes among individuals who use heroin and
those who use other opioids.[68]

%
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 are starting
MMT programs or planning to do so in the next
few years [69-71]. This trend follows
recommendations for the introduction and
expansion of methadone within prisons by
several prominent organizations, including the
World Health Organization.[72]
Arguments for Provision of Prison-Based MMT
Several arguments for the provision of MMT in
prisons have been presented:[73]
• First, it has been argued that MMT be
provided to all individuals who have received
MMT outside of prisons. This point is
particularly relevant in light of findings
indicating that people taken off methadone
once incarcerated often return to narcotic use,
usually within the penal institutions, and often
via injection.[74]
• Second, it has been suggested that MMT can
be used for detoxification purposes for opiate
addicted individuals as a means to reduce
withdrawal symptoms and alleviate anxiety
upon entry into prisons.
• Third, the provision of MMT will reduce
high-risk injecting behaviours among
prisoners who inject drugs and thereby reduce
the spread of the infectious diseases.
• Fourth, the provision of MMT may serve to
increase prisoners’ participation in abstinence-

based treatment programs within and outside
of prisons.
• Fifth, the provision of MMT for those nearing
release may help to reduce risk for overdose,
as many prisoners resume injecting once
released from prisons, but do so with
increased risk for fatal overdose as a result of
reduced tolerance to opiates.[73]
• Lastly, the provision of MMT may reduce the
likelihood that newly released prisoners will
return to crime, given the evidence that MMT
reduces participation in illegal activities,
particularly
among
newly
released
prisoners.[49]
Evaluations of Prison-Based MMT
A number of evaluations of prison-based MMT
programs have indicated positive results. For
example:
• results from a randomized-controlled trial of
the MMT program in prisons in New South
Wales, Australia indicated lower rates of
heroin use, injection drug use and syringe
sharing among those enrolled in MMT
compared to controls;[75]
• evaluations of an existing prison-based MMT
program in Australia have shown reduced
levels of drug use and participation in the
prison drug trade;[76]
• likewise, a study of newly released injection
drug using prisoners in Australia found that
prisoners maintained on methadone reported
lower levels of risk behaviour in prisons than
untreated prisoners;[77]
• a study conducted in the United States found
that addicted prisoners who received MMT in
prison were more likely to seek drug
treatment upon release from prison than
prisoners who received methadone for
detoxification purposes only;[78]and in
Canada, the federal prison system expanded
access
to
MMT
after
evaluations
demonstrated that MMT had a positive impact
on release outcome and on institutional
behaviour.[79]
Determinants of Success
There are several features associated with MMT
and its implementation in prisons that should be

,

noted. For example, optimal treatment outcomes
have generally been correlated with a number of
programmatic factors including: sufficient
methadone dosing, high level and quality of
psycho-social care services, duration of treatment
retention, and patient identification with the rules
of the MMT program and staff of treatment
centres.[43, 80-83] Clearly, while MMT has
proven effective for individuals who are attracted
and retained in treatment, innovative and flexible
approaches must be implemented to ensure that
the full potential of this approach is realized.
Given the rigid routines and rules within prisons,
the emphasis on abstinence from drugs, as well
as the lack of psychosocial programs in many
systems, successful implementation of MMT in
prisons presents unique challenges. Although
prison medical services (particularly those in
Eastern Europe and fSU are challenged by a lack
of appropriate funding, MMT has been shown to
be highly cost-effective due the impact of MMT
on a variety of outcomes, including crime and
HIV-infection.[54, 63, 65-67, 84]
MMT more effective than other forms of
treatment
Several arguments have been made against the
implementation of MMT in prison settings. Some
critics consider methadone as just another moodaltering drug, the provision of which delays the
necessary personal growth required to move
beyond a drug-centered existence.[85] Some also
object to MMT on moral grounds, arguing that it
merely replaces one drug of dependence with
another.[85] However, research studies have
shown that MMT has been found to be more
effective than detoxification programs in
promoting retention in drug treatment and
abstinence from illicit drug use.[28, 65] As well,
while some have expressed concern about the
feasibility of implementing MMT in prison
settings, experience has shown that these
difficulties can be overcome.
Given the poor outcomes associated with
untreated opiate addiction, including increased
risk for HIV infection,[86] the lack of effective
treatment options for those addicted to

opiates,[87] and the fact that methadone is
currently the most effective treatment for opiate
addiction,[88] it is clear that MMT can play a
role in reducing harm among prisoners.
&
'
A wealth of scientific evidence has shown that
MMT is the most effective intervention available
for the treatment of opiate dependence. MMT has
been associated with reductions in risk
behaviour, illicit drug use, criminal behaviour,
participation in sex work, unemployment,
mortality, and HIV transmission. Many of the
concerns raised about MMT have been shown to
be unfounded. In particular, MMT has not been
shown to be an obstacle to the cessation of drug
use, and in fact, MMT has been found to be more
effective than detoxification programs in
promoting retention in drug treatment programs
and abstinence from illicit drug use.
MMT has increasingly been established in prison
settings. Evaluations of prison-based MMT have
been highly and consistently favourable, showing
that the MMT is associated with substantial
declines in HIV risk-behaviour (e.g., syringe
sharing), decreased levels of drug use,
participation in the prison-based drug trade, and
increased participation in drug treatment
following release from prison.
Given the existing evidence of the growing
problems of injection drug use and HIV/AIDS in
prisons in Eastern Europe and the fSU, it is clear
that the time to act is now. A failure to
implement effective drug treatment and HIV
prevention measures could result in further
spread of HIV infection among IDUs, the larger
prison population, and could potentially lead to
generalized epidemics in the local non-IDU
population. Further spread of HIV would lead not
only to greater suffering for affected individuals
and their families, but also would be result in
substantial and avoidable health care costs.
Despite the controversy concerning MMT, the
evidence is clear. MMT is effective, and should
be considered an essential response to the dual
epidemics of injection drug use and HIV/AIDS.

-

/ !
//
* 0
"/ )
)
0
) /
$
)
!
!
13 !
)
!
!=
1 >
1
?

0

1

0

1

2

) /
1
1
) 0
45
. - ,6
789:+:;
!(5
. - ,6
78:.7<;
5

+<<
-

(
1

%

3
*
/
/

"53!

$

!
*
2A BC )
)

/*
*

!
1 )0
25
/
!

@
)) 5
*
" / 66
:; ,4)
// >
5:+8:1
!
!
)
/
* //
1 D 2%+<
<
,;

+1 A
'
2 $
$2
) /
5
! *
-.4
,>
5,<8 ,91
,1 E
5
/
)/ 5
0 +<
<,1 E
+<
<,1
-1
2 )
15
(
) 5
!
)* @
))
)$
1
66
7; 4
:>
5
3
.689.1
.1
$/
E
0
A
DF
15 8
/ *$
))
D
G
H
1
66-;
:4<>
5--,8.<1
91
5
/
$ ! /
!
/
/ /)
1 $ $
5
)
"
66
61
71 D
52) 8
)$
) @
"
!
!
5 / //
0 !!
0 *
)/!
A
B
I
)
0
0
) 1 F *5A
B
I 1
66
.1
:1
*
F%
5
" 0 *) !
!
))
/
1 D @6
6<;
,<
<4
97,9>
5,:,8-1
61
%
F
2
0 2 " %5 *
3
@
)E
"/
!
" D *
)
!
1 )0 0
) +<
<;
++4
->
5
+<68+ 91
<1
)
FF
!
F5
0 *)
@
))
F
/
1
+<<
<;6.4
:>
5+<78 91
1
/ %
15
!
!
D
/
5
/ / *
)$
1 D2
!
+<<
,;,4>
5
+.1
+1 3
* 15
")
3
1
')
*
+<<
+; -4)/
/ D>
578
+,1
,1
"D 2 D
"5
/*
' 0)
5
0 8
)$
1 %'/
D
+<<
<;.4
->
5
+-.8.<1
-1 D0)
F D)
D
15G
!
/
)
5/
I
H
1
)
/
+<
<,;,64
+>
5
+. 871
.1 D)
2 2
'"I
2 I* "
*
5
0
DI /
5
*
! /
/
1 " * ) )0 +<
<<;
,-4
.>
5
-, 891
91
'F
**
5
/*
" 3
DI
1 D I% !
66
:;+4
->
56
78+<
-1
71 ")!
) 5
/
)
!
/ *
1
$ ! +<
<;+4>
5.1
:1
2
2 "
A5
0
)
! ! )
!
!
E
!
66
71
%)
! )0
+<
<
+;6+4 >
57:68 76-1
61
/ $
%
15
!
!
@
))
D
1 % J)
)
! $ +<<
+;+64>
5
:986
-1
+<1" %
D )
15
$
"
! )
$
@
)) 1 % J
)
)
! $
) " *
66
:;: )/
/ 5 -<8 1
+ 1 $
2A )
/
15
* @
)
/
$
!
)*
8
/
1
+<<,;74
9>
5
::786
,1
++1 $
F 0
'
% 15
B)0
!
!
/
1 D2%66
.;
, <4
96
7.>
5
+:686
+1
+,1 /
/
F
* ) 5G
0
)
!
/
H
12
4 ) >+<
<,;,64
:>
5
7678:<
,1
+-1 )
'5 ) / 0
/)
0
5
+. $
!*
1 )0
"/ 6
66; -4>
5-8+61
+.1 A
' $
2A /
2
15 /
!)//$
8
/
!
!
)
! !
*
/
5*
!
*
I
)1
@
+<<
,;9:4
+>
59.861
+91
A 5
80 !
8 !
! *
$ ! ) 0
)
* 1 '* )
"*
6
::;
++4
.>
5
9<689,91

.

+71 %
0)/
+:1

"'

))/ 2
' A
I 2 D
F'5
/
! *
$
! /
/
1 ' %2 +<
<<;
,-,4:>
5+6<871
)
2
152
* :<8 $/$
$
(!
!
!/
/
5
I
1 % +<
<<;
+:,4<>
5,<
,8 <1
+61
8
/
J)
D
%
15 $
!
/
5
)
)
0)
0 *
)$
1
F
$
$ 66
6;.94
9>
5
-6
,8.<+1
,<1 ! F
"
%
5
$ )8
$ )
/
!
$
/
5 +8$
)
)$
1%)
6
6;.+4
+>
5 :8+91
, 1 "$
)
% '*
'5'!
K2
* !
! $ !
* !
1 B/
"
6
69;
--4
.>
5
9:7896
.1
,+1 A
"
0) 25 )
88 1 %)
! $
* ) 66-;
+94>
58 1
,,1
%
5 ))
*
)
@
)) 1
+<<<; -4)/
/ >
5
- 891
,-1
%
3
"
152
/*
//
)
!@
)) 1
%2 66
.;+7-4.>
5++98, 1
,.1 3
"
% A A
5
) $ * /
/
) @
1
66,;7
)// 5+9,861
,91 )
' )
A
0 52 )
)
5
!
!
!
$
(
/
$! 1
66
:;+4)// >
5+ 78,<1
,71
%
3
" $
"F5" )
*
/
! )/ /) / / 5
$
(
/
G
H
1
%)
! )0
6
6.;:.4 >
5.778
:-1
,:1
8 (
/
E 5
G
H
1
66
:;,. 4
6<.>
5
:,61
,61
%2
% /
52
1 5"D 2 1 )0
0) 5
/
*
(0
+
1D
5
A
A
;..+8.,1
-<1
$'E
52
!/
/
5 *
!
) 1 5A
$
% 12
2
2
!B/
/
1
L 5
6
6<1
- 1D
$F52
5 )/ 1 '
) /
* ! $
$#
)
6
6.;
+-.4
+>
5 -8+-1
-+1 "
0) 2 A 0)
$2
%
5
)
!
)
( I 5
!
1 %)
! $
* ) 6
69;+:4
,>
5
+- 861
-,1 D %"
5
'!
! *
!2
2
5
*
B)
1
L 5/
8
661
--1 )
00 " "
%
F5
)
/ / * )$4B >
5
0!
)
!
1A
5
6
:-1
-.1
' D
F' 0
I 2 52
8*
8
!/
/
5
I
1%
666;
+: 4 >
5<
<<8.1
-91
)
2
152
* :<8 $/$
$
(!
!
!/
/
5
I
G
H
1 % +<
<<;
+:,4<>
5,<
,8 <1
-71
A
) D
/ $ A
/
5
!
//
)
!
* ) ))
D
5 /
! /*
! 1
%
66;+94+>
5, ,8+<1
-:1
A
)
F 5'(/ )
/
)1
% )
0) 66
,; 64>
59.8
7:1
-61
"0
%
A B
%
'
$
'52
!
$
1
' %2
6
96;
+:<4
+.>
5,7+8.1
.<1F
3
I 25 /
*)
! 8
!
1
%)
!'
/
$6
7-;<
<4
+>
5<8 +1
. 1
"F A
AD5 )0 80
/
!
/ 0
!
1
6
76;+4
: - >
5
-:.8:1
.+1
"F $
5
2
5(/
(/
1% $
* ) 6
6;
+,4
+>
5 .8+ 1
.,1
0
2 !
"
@ 5
/
!
)/
!/
$
/
!
)1 )0
E #2 ) 66
:;,,4->
5
+: 68,-1
.-1
F
5" )
0$ ) )
/
$/
M
1 M2 %+<
<-; 74 6<>
5
E76.1
..1
*
% /
(
50
! 0 $ )
)
!
$* )
8
$
0
/
1
* !
2
6
6<;.<4>
5
67861
.91
2
0) ''52
/
!
5
! (/
D (
L
$
1 )0
" / 66
:; , )
// 5<
78 .1
.71 2 I
A
$F'2
15 )
)
!
$* )
*
* ) ))
8
)8 !
8
5 :8
/ / * ! 8)/1% J)
)
! $
6
6,;
94
6>
5<
-68.91
/

9

.:1 M
)
.61 )
*
9<1 2
/
9 1 A

"3
)
"
15
!
* ) ))
0)
) 1 % J)
! $
6
6+;
.4
6>
5
:9.87 1
2L5 ) 0)
/*
5
)) /
)
1 %)
!
6
6:;74
->
5
6
8 :1
F
/
FF* E
15D * )
@
) ) 5* )
!
)
1
6
6<;+4
,>
5
+7.861
'2 I
A
$F 2
5
8
() 0 *
!
* ) ))
8
)8 !
8
5 /
!
/
!
!
1
% )
0) 6
6+;:4
->
5
,:686:1
9+1 A
'
$
(
%%
"5"
)
!
!
0 * !
1
%)
! )#
0) 6
69;++4
->
5
.<68+ 1
9,1 M
F D
FD
)2 5
8 !
! *
!
1
%)
!)
0
+<<
<;6
<
4
7>
5 <
<8 1
9-1 D
F5
8 !
! *
!
*
1
666;
6-4
->
5
-768::1
9.1 2
D
F
15
8 !
! *
!
/
:<8 $
(!
1
+<<
-;6
64
9>
5
7 :8+91
991 2
5
)/ 0
* 5 )$
*)
!
! *
!
!/)0
/*
)
$
1A
5 ) !2
66
<1
971
5 8
0 ! !
1A
5
66
-1
9:1 D
DD
% / ) D F ) $ D) E5
/
/
0)
/
/
!
1 )
/ +<
<-;
7,4
+>
5668+<
71
961 00 D5
2
(/
!
/
1
@
+<<
+;974<>
5 .-1
7<1D$
5
2
$
/
/
) A
1 D @66
:;, 94
7 -9>
57--8.1
7 1F 0
$
2F
% * DA
%F ) 5
/
)0
/
)0
!
!
/
K %
66:;
64>
5
+.8,<1
7+1 A
B
I 5A B F)
!
1 F *5
A B 6
6,1
7,1
A A
5
/ *
!
/
1 5A
%2
"
A1
1
2
2
B
B/ " /
/ 1
5
)0
66
:;,768,6
91
7-1
F
2 * %
D5D * )
) @
/
1
2
66
-;,64 >
5
.:.891
7.1
%2
2 2
"
A A
5
!
* )
)
/
$ 1 )
/ +<<
,;7+4>
5
.689.1
791 A
F
5
!
/
/
/ /8
/
1
*)
!
) A
/
!
*
* /8
/
)$ +1 $ $
5"
*
) A
/
!
*
* 1 6:71
771
A A
52
)
@
/
1 D @6
69;
, +4
7<
,6>
5 9+1
7:1 2 )
"
0)
1
1 % / 15
!
! *
! 8@
1 %)
! ) )
66
,;+,5
7.8661
761 D
"5
)
2
2
5 /
"
B)
)
D * )1
B
5
*
1 +<<
+1
:<1 M) A
5 )
5 /
!
/*
1 %)
! $
*
) 66
:;,<4>
5
:68671
: 1 2
$
A
$F 2 I
5 $
*
)
0
0)
K
8
)$ !/$
* 1 %2 66
,;+964.>
56
.,8 6.61
:+1 )
/
F
) 1 D5
$)
5
!
!
!
)
1
%)
!
6
:9;
+<57. 87 1
:,1
!
! 5 *
@
C/ /
) !
5
$
/!
!
8/
0
)
K )0
E #2 ) 66
6;,-4>
5
+ ,.8.,1
:-1 D
FM F D
)2 5
8 !
! *
!0)/
/
/$! /
E
1
+<<;694
6>
5+9787:1
:.1 %
&
"5
5
3 "/ 1 2
5
66
91
:91 3
DF
"
%
2 * A5
/
/ )
)
/
) 5 ) ! ! 8)/ )$
/ )
1
% )0
6
66;
6<
4
.>
5
+668,<,1
:71 3
D"
%
2
15
8
/
/
)
0
/ 0
!/
/
1 ') % )
0
+<<
+;+4
,>
5
++:8,-1
::1 F0
2 32
$%
5
'!
! *
!
)
0 *
*
@
)) 1
6
66;,4->
5:<78 :1

7