Prison Needle Exchange: Lessons from a Comprehensive Review ...

could significantly improve the health and safety of prisoners, prison staff, and the community
by instituting needle exchange programs.
Methadone maintenance therapy
a partial solution to the harms of IDU
Methadone is a crucial element of a comprehensive harm-reduction strategy, both in prisons
and in the community, as it provides an important option for injection-drug-using prisoners
who wish to stop injecting heroin. Taken orally, methadone is successful in blocking the
effects of opiate withdrawal symptoms. 273 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. 274 MMT is
associated with reduced HIV and viral hepatitis transmission
rates. 275 Worldwide, an increasing number of correctional systems
are offering MMT to prisoners. 276 Evaluations of MMT programs in
prisons have indicated positive results. 277 For example, results from
a prison in New South Wales, Australia, indicated lower rates of
heroin use, injection drug use, and syringe sharing among those
enrolled in MMT compared with prisoners in a control group. 278
In Canada, in May 2002 CSC expanded access to MMT. 279 Under the new policy, prisoners
on methadone maintenance at the time of incarceration may continue methadone, and
prisoners who meet the expanded access criteria may apply to initiate MMT while incarcerated.
The expansion of access criteria for MMT was based in part on evaluations undertaken
by CSC demonstrating that MMT has a positive impact on release outcome and on institutional
behaviour. 280 Access to MMT in provincial and territorial prisons varies widely. 281
Despite its value, there are several reasons why providing methadone maintenance in the
absence of needle exchange is an insufficient response to the risk of HIV and HCV transmission
in prisons via injection drug use. The primary reason is that MMT, as a form of drug
treatment for heroin dependence, does not benefit prisoners who do not access the treatment
program. There are at least four potential circumstances in which prisoners will not access,
or not have access to, MMT. First, prisoners who inject heroin may choose not to access
MMT. Second, despite an addiction to heroin, prisoners may not meet all of the criteria for
admission to the MMT program or may fail to meet ongoing eligibility criteria once on
MMT. Third, under current CSC policy, limits have been placed on the number of prisoners
enrolled in MMT at any one time, based on the capacity to administer the program within
each institution. The issue of lack of capacity and resources is not unique to CSC and is likely
shared by a number of Canadian provincial/territorial systems. Fourth, it takes time to
process an application for MMT and to initiate MMT once a prisoner is accepted into the
program. Therefore, there will be numerous situations where prisoners with a heroin addition
will continue to inject heroin and potentially engage in high-risk behaviours, despite the
existence of MMT programs within the prison.
Additionally, under accepted guidelines, MMT is only for drug users who are physically
dependent upon opiates according to standard criteria (usually those set out in the Diagnostic
and Statistical Manual of Mental Disorders, published by the American Psychiatric
Association). Therefore, MMT is not medically indicated for people who are occasional or
recreational users who inject opiates, who again will likely continue to inject and to share
syringes where needle exchange is not provided. Within prisons, barriers often exist to the
optimal provision of methadone. As a medical therapy, a methadone program requires the
involvement of a prison physician who is both trained in methadone provision and philo-
Methadone is a crucial
element of a comprehensive
harm-reduction strategy,
both in prisons and
in the community.
62 Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience