Methadone maintenance expands inside federal prisons

In an attempt to curb rising HIV and hepatitis C infection rates and to lower recidivism rates, federal prisons have begun offering methadone maintenance treatment (MMT) to any prisoner with an opiate addiction.

The Correctional Service of Canada (CSC) expanded access to MMT in federal prisons May 2. It estimates that up to 800 prisoners may enter the program within 3 years at an annual cost of more than $10 000 each, or a potential annual total of roughly $8 million.

The new program builds on a 1998 initiative that allowed federal prisoners to continue receiving methadone if they had been in an MMT program in the community before their arrest. In March 1999 the program was temporarily modified to allow, under exceptional circumstances, MMT for severely addicted offenders. As of December 2001, 304 federal prisoners were receiving MMT through these programs, but there was no money for expansion. Of that total, 230 inmates had been receiving methadone in the community prior to their arrest. Another 74 inmates had started receiving it in 2001 under the “exceptional circumstances” provision, 47 of them in the Pacific region.

The problem, says Dr. Françoise Bouchard, CSC's director general, health services, is that the application of “exceptional circumstances” differed across the country. “It was up to individual judgements. We decided to make it more concrete.”

The new program was announced shortly after inmate Barry Strykiwsky settled his court case alleging that Ottawa had violated his Charter rights by not providing him with MMT, a treatment available to other Canadians addicted to heroin. Strykiwsky asked prison officials for MMT in 1998. Even though he had the support of his physician, he was refused.

“I'm encouraged by the new program,” said the head of the Canadian HIV/AIDS Legal Network, Ralf Jürgens, “but I'm dismayed that they waited until the case went to court.”

Bouchard says the CSC was already moving in this direction, but “we needed to measure the impact of [the initial] program.” A CSC study of the impact of the original MMT program found that after a year, 41% of inmates who were receiving MMT were readmitted to prison, compared with 58% of addicted inmates who were not on the program. In a study of 636 former inmates, injection drug users reported significantly more needle sharing (72.6% vs. 51.8%) than users who had not been in prison (Can J Infect Dis 2002; 13 [Suppl A] ).

The new program may also slow the spread of HIV and hepatitis C infections. Among those who agreed to be tested, 1.8% were HIV positive at the end of 2002. In 1989, there were 24 known HIV-positive federal inmates; in 2001, there were 223. (At the end of 2001, the rate of hepatitis C infection among federal inmates who have been tested was 23.6%.)

CSC says this “dramatic rise … in the past decade is linked in large measure with the substance-abuse practices and associated lifestyles of many of these offenders” before they arrive in prison.

Despite CSC's “zero tolerance” for drug abuse in prisons, the problem is pervasive. The service estimates that 70% of inmates have drug or alcohol abuse problems when they enter prison. “It's logical that they would try to sustain [their habit] while in here,” says Bouchard. “This [MMT] is not only a harm-reduction measure, but it is designed to stop drug substance abuse. It's the only effective medical treatment for opiate drug users.”

According to a CSC study, 80% of inmates have abused alcohol or drugs and 34% used injection drugs prior to their incarceration; 11% reported using them while in custody, and 25% said they were under pressure to smuggle drugs into the institution.

Jürgens is pushing for needle-exchange programs in prisons — he says they have proven effective in Europe and do not increase drug use or threats to staff. “There's clearly a need for the federal prison system to do a pilot study.”

Needle-exchange programs as a harm-reduction measure are being considered, says Bouchard, but their implementation is not imminent.

Provincial prisons

Addicted inmates at provincial prisons (where sentences under 2 years are served) have fewer harm-reduction options. Inmates who were in an MMT program outside prison are eligible for in-prison treatment (if available) in all provinces except PEI and Newfoundland. No provinces offer it to addicted inmates who were not previously on a program. — Barbara Sibbald, CMAJ