Methadone maintenance reduces injecting in prison

Concurrent Initiation of Hepatitis C and Opioid Use Disorder Treatment in People Who Inject Drugs

BACKGROUND

People who inject drugs have a high prevalence of hepatitis C virus (HCV) and significant disease associated with drug use; however, HCV treatment often occurs in absence of interventions to address opioid use disorder and drug use-related harms. The impact of concurrent initiation of opioid agonist therapy (OAT) on HCV treatment and drug use outcomes is unknown.

METHODS

In this prospective, open-label, observational trial at a harm reduction organization's drop-in center in Washington, DC, 100 patients with chronic HCV infection, opioid use disorder, and ongoing injection drug use were treated with sofosbuvir-velpatasvir for 12-weeks and offered buprenorphine initiation. The primary end point was sustained virologic response (SVR), and secondary end points included uptake of and retention in OAT, change in risk behavior, and determinants of SVR.

RESULTS

Eighty-two patients (82%) achieved SVR, which was not associated with baseline OAT status (P = .33), on-treatment drug use (P >.99), or imperfect daily adherence (P = .35) but was significantly associated with completing 2 or more 28-pill bottles of sofosbuvir-velpatasvir (P < .001) and receiving OAT at week 24 (P = .01). Of 67 patients not already receiving OAT at baseline, 53 (79%) started OAT. At week 24, 68 (68%) patients were receiving OAT. Receipt of OAT was associated with fewer opiate-positive urine drug screens (P = .003), lower human immunodeficiency virus risk-taking behavior scores (P < .001), and lower rates of opioid overdose (P = .04).

CONCLUSIONS

The Novel Model of Hepatitis C Treatment as an Anchor to Prevent HIV, Initiate Opioid Agonist Therapy, and Reduce Risky Behavior study demonstrates high uptake of buprenorphine collocated with HCV treatment, and it shows that concurrent initiation of OAT with HCV treatment can result in high rates of SVR while reducing risks associated with drug use.

CLINICAL TRIALS REGISTRATION

NCT03221309.

Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments

Purpose Within-prison drug injection (WPDI) is a particularly high HIV risk behavior, yet has not been examined in Central Asia. A unique opportunity in Kyrgyzstan where both methadone maintenance treatment (MMT) and needle-syringe programs (NSP) exist allowed further inquiry into this high risk environment. The paper aims to discuss these issues. Design/methodology/approach A randomly selected, nationally representative sample of prisoners within six months of release in Kyrgyzstan completed biobehavioral surveys. Inquiry about drug injection focused on three time periods (lifetime, 30 days before incarceration and during incarceration). The authors performed bivariate and multivariable generalized linear modeling with quasi-binomial distribution and logit link to determine the independent correlates of current WPDI. Findings Of 368 prisoners (13 percent women), 109 (35 percent) had ever injected drugs, with most (86 percent) reporting WPDI. Among those reporting WPDI, 34.8 percent had initiated drug injection within prison. Despite nearly all (95 percent) drug injectors having initiated MMT previously, current MMT use was low with coverage only reaching 11 percent of drug injectors. Two factors were independently correlated with WPDI: drug injection in the 30 days before the current incarceration (AOR=12.6; 95%CI=3.3-48.9) and having hepatitis C infection (AOR: 10.1; 95%CI=2.5-41.0). Originality/value This study is the only examination of WPDI from a nationally representative survey of prisoners where both MMT and NSP are available in prisons and in a region where HIV incidence and mortality are increasing. WPDI levels were extraordinarily high in the presence of low uptake of prison-based MMT. Interventions that effectively scale-up MMT are urgently required as well as an investigation of the environmental factors that contribute to the interplay between MMT and WPDI.

Ongoing incident hepatitis C virus infection among people with a history of injecting drug use in an Australian prison setting, 2005-2014: The HITS-p study

Hepatitis C virus (HCV) transmission is high in prisons. This study investigated trends in HCV incidence and associated factors among a cohort of prisoners with a history of injecting drug use in New South Wales, Australia. Data were available from the Hepatitis C Incidence and Transmission Study-prisons (HITS-p) from 2005 to 2014. Temporal trends in HCV incidence were evaluated. Factors associated with time to HCV seroconversion among people with ongoing injecting was assessed using Cox proportional hazards. Among 320 antibody-negative participants with a history of injecting drug use (mean age 26; 72% male), 62% (n=197) reported injecting drug use during follow-up. Overall, 93 infections were observed. HCV incidence was 11.4/100 person-years in the overall population and 6.3/100 person-years among the continually imprisoned population. A stable trend in HCV incidence was observed. Among the overall population with ongoing injecting during follow-up, ≥weekly injecting drug use frequency was independently associated with time to HCV seroconversion. Among continuously imprisoned injectors with ongoing injecting during follow-up, needle/syringe sharing was independently associated with time to HCV seroconversion. This study demonstrates that prison is a high-risk environment for acquisition of HCV infection. Needle and syringe sharing was associated with HCV infection among continually imprisoned participants, irrespective of frequency of injecting or the type of drug injected. These findings highlight the need for the evaluation of improved HCV prevention strategies in prison, including needle/syringe programmes and HCV treatment.

Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations

Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.

[Cartography of psychoactive heterotopias: a look at the medical, legal and social discourses regarding drug use]

This article traces a map of the social control of drugs through the politics of space, according to the Foucaultian concept of "heterotopia." Firstly, a brief genealogy of the use of psychotropic substances in different times and cultures is described, up to the introduction of the prohibitionist paradigm. Attention is paid to the way in which power has marked, separated and enclosed certain rituals and uses of pleasure in physical and symbolic sites. The itinerary is focused on the Spanish context to establish a dialogue between the various policies of space that have come into being and have overlapped in the construction and management of a problem which has been rendered an object to the gazes, mechanics and discourses of the medical, legal, and social fields. In this way, the intersections between the liminal spaces of drug use and the harm reduction paradigm are analyzed, including therapeutic strategies with prescribed drugs, from methadone programs to the new heroin programs.

A review of pharmacological interactions between HIV or hepatitis C virus medications and opioid agonist therapy: implications and management for clinical practice

Global access to opioid agonist therapy and HIV/hepatitis C virus (HCV) treatment is expanding but when used concurrently, problematic pharmacokinetic and pharmacodynamic interactions may occur. Articles published from 1966 to 2012 in Medline were reviewed using the following keywords: HIV, AIDS, HIV therapy, HCV, HCV therapy, antiretroviral therapy, highly active antiretroviral therapy, drug interactions, methadone and buprenorphine. In addition, a review of abstracts from national and international meetings and conference proceedings was conducted; selected reports were reviewed as well. The metabolism of both opioid and antiretroviral therapies, description of their known interactions and clinical implications and management of these interactions were reviewed. Important pharmacokinetic and pharmacodynamic drug interactions affecting either methadone or HIV medications have been demonstrated within each class of antiretroviral agents. Drug interactions between methadone, buprenorphine and HIV medications are known and may have important clinical consequences. Clinicians must be alert to these interactions and have a basic knowledge regarding their management.

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Prediction of Treatment Entry and Completion in Prison

The present report is an intent-to-treat analysis involving secondary data drawn from the first randomized clinical trial of prison-initiated methadone in the United States. This study examined predictors of treatment entry and completion in prison. A sample of 211 adult male prerelease inmates with preincarceration heroin dependence were randomly assigned to one of three treatment conditions: counseling only (counseling in prison; n= 70); counseling plus transfer (counseling in prison with transfer to methadone maintenance treatment upon release; n= 70); and counseling plus methadone (methadone maintenance in prison, continued in a community-based methadone maintenance program upon release; n= 71). Entered prison treatment (p <. 01), and completed prison treatment (p< .001) were significantly predicted by the set of 10 explanatory variables and favored the treatment conditions receiving methadone. The present results indicate that individuals who are older in age and have longer prison sentences may have better outcomes than younger individuals with shorter sentences, meaning they are more likely to enter and complete prison-based treatment. Furthermore, implications for the treatment of prisoners with prior heroin dependence and for conducting clinical trials may indicate the importance of examining individual characteristics and the possibility of the examination of patient preference.

Public health implications for adequate transitional care for HIV-infected prisoners: five essential components

In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.

Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment

BACKGROUND

Although diacetylmorphine has been proven to be more effective than methadone maintenance treatment for opioid dependence, its direct costs are higher. We compared the cost-effectiveness of diacetylmorphine and methadone maintenance treatment for chronic opioid dependence refractory to treatment.

METHODS

We constructed a semi-Markov cohort model using data from the North American Opiate Medication Initiative trial, supplemented with administrative data for the province of British Columbia and other published data, to capture the chronic, recurrent nature of opioid dependence. We calculated incremental cost-effectiveness ratios to compare diacetylmorphine and methadone over 1-, 5-, 10-year and lifetime horizons.

RESULTS

Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each of the time horizons. Over a lifetime horizon, our model showed that people receiving methadone gained 7.46 discounted quality-adjusted life-years (QALYs) on average (95% credibility interval [CI] 6.91-8.01) and generated a societal cost of $1.14 million (95% CI $736,800-$1.78 million). Those who received diacetylmorphine gained 7.92 discounted QALYs on average (95% CI 7.32-8.53) and generated a societal cost of $1.10 million (95% CI $724,100-$1.71 million). Cost savings in the diacetylmorphine cohort were realized primarily because of reductions in the costs related to criminal activity. Probabilistic sensitivity analysis showed that the probability of diacetylmorphine being cost-effective at a willingness-to-pay threshold of $0 per QALY gained was 76%; the probability was 95% at a threshold of $100,000 per QALY gained. Results were confirmed over a range of sensitivity analyses.

INTERPRETATION

Using mathematical modelling to extrapolate results from the North American Opiate Medication Initiative, we found that diacetylmorphine may be more effective and less costly than methadone among people with chronic opioid dependence refractory to treatment.

The effectiveness of opioid maintenance treatment in prison settings: a systematic review

AIMS

To review evidence on the effectiveness of opioid maintenance treatment (OMT) in prison and post-release.

METHODS

Systematic review of experimental and observational studies of prisoners receiving OMT regarding treatment retention, opioid use, risk behaviours, human immunodeficiency virus (HIV)/hepatitis C virus (HCV) incidence, criminality, re-incarceration and mortality. We searched electronic research databases, specialist journals and the EMCDDA library for relevant studies until January 2011. Review conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-one studies were identified: six experimental and 15 observational. OMT was associated significantly with reduced heroin use, injecting and syringe-sharing in prison if doses were adequate. Pre-release OMT was associated significantly with increased treatment entry and retention after release if arrangements existed to continue treatment. For other outcomes, associations with pre-release OMT were weaker. Four of five studies found post-release reductions in heroin use. Evidence regarding crime and re-incarceration was equivocal. There was insufficient evidence concerning HIV/HCV incidence. There was limited evidence that pre-release OMT reduces post-release mortality. Disruption of OMT continuity, especially due to brief periods of imprisonment, was associated with very significant increases in HCV incidence.

CONCLUSIONS

Benefits of prison OMT are similar to those in community settings. OMT presents an opportunity to recruit problem opioid users into treatment, to reduce illicit opioid use and risk behaviours in prison and potentially minimize overdose risks on release. If liaison with community-based programmes exists, prison OMT facilitates continuity of treatment and longer-term benefits can be achieved. For prisoners in OMT before imprisonment, prison OMT provides treatment continuity.

Medication-assisted treatment for opioid dependence: making a difference in prisons

This article explores the evolving evidence supporting the provision of opioid maintenance therapies to incarcerated populations.

Drug use and opioid substitution treatment for prisoners

Drug use is prevalent throughout prison populations, and, despite advances in drug treatment programmes for inmates, access to and the quality of these programmes remain substantially poorer than those available for non-incarcerated drug users. Because prisoners may be at greater risk for some of the harms associated with drug use, they deserve therapeutic modalities and attitudes that are at least equal to those available for drug users outside prison. This article discusses drug use by inmates and its associated harms. In addition, this article provides a survey of studies conducted in prisons of opioid substitution therapy (OST), a clinically effective and cost-effective drug treatment strategy. The findings from this overview indicate why treatment efforts for drug users in prison are often poorer than those available for drug users in the non-prison community and demonstrate how the implementation of OST programmes benefits not only prisoners but also prison staff and the community at large. Finally, the article outlines strategies that have been found effective for implementing OST in prisons and offers suggestions for applying these strategies more broadly.

Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings

The link between injection drug use and HIV has been extensively described. Despite worldwide prevention efforts, injection drug use continues to be a risk factor for HIV transmission and both HIV and injection drug use continues to spread across the globe. Although methadone has demonstrated multiple health benefits including the reduction in injection drug use and HIV acquisition, the utilisation of methadone in many areas of the world remains one of secondary, rather than primary, HIV prevention. As a result, many who finally begin methadone enter treatment having accumulated medical and mental health problems as a result of delayed treatment. Rapid access to treatment and a more aggressive policy that realizes that methadone can help reduce opioid drug use is necessary if methadone is effectively going to act as primary HIV prevention. To delay access to methadone only increases the probability that the individual will acquire an infectious disease that is more costly to the individual in terms of morbidity and mortality and more costly to society as a whole.

Maintenance therapy and 3-year outcome of opioid-dependent prisoners: a prospective study in France (2003-06)

AIMS

To describe the profile of imprisoned opioid-dependent patients, prescriptions of maintenance therapy at imprisonment and 3-year outcome in terms of re-incarceration and mortality.

DESIGN

Prospective, observational study (France, 2003-06).

SETTING

Health units of 47 remand prisons.

PARTICIPANTS

A total of 507 opioid-dependent patients included within the first week of imprisonment between June 2003 and September 2004, inclusive.

MEASUREMENTS

Physicians collected socio-demographic data, penal history, history of addiction, maintenance therapy and psychoactive agent use, general health status and comorbidities. Prescriptions at imprisonment were recorded by the prison pharmacist. Re-incarceration data were retrieved from the National Register of Inmates, survival data and causes of death from the National Registers of vital status and death causes.

FINDINGS

Prison maintenance therapy was delivered at imprisonment to 394/507 (77.7%) patients. These patients had poorer health status, heavier opioid use and prison history and were less socially integrated than the remaining 113 patients. Over 3 years, 238/478 patients were re-incarcerated [51.3 re-incarcerations per 100 patient-years, 95% confidence interval (CI) 46.4-56.2]. Factors associated independently with re-incarceration were prior imprisonment and benzodiazepine use. After adjustment for confounders, maintenance therapy was not associated with a reduced rate of re-incarceration (adjusted relative risk 1.28, 95% CI 0.89-1.85). The all-cause mortality rate was eight per 1000 patient-years (n = 10, 95% CI 4-13).

CONCLUSIONS

Prescription of maintenance therapy has increased sharply in French prisons since its introduction in the mid-1990s. However, the risk of re-imprisonment or death remains high among opioid-dependent prisoners. Substantial efforts are needed to implement more effective preventive policies.

Methadone maintenance treatment reduces heroin injection in New South Wales prisons

The purpose of this study was to examine whether methadone maintenance treatment reduces injecting risk behaviour (and therefore transmission of blood-borne viral infections) among prisoners in New South Wales (NSW), using comparison of retrospective reports of drug use in prisons for people who received standard drug treatment, time-limited methadone treatment and methadone maintenance treatment. The setting for the study was the NSW prison system. One hundred and eighty-five injecting drug users who had been recently released from NSW prisons were recruited in 1993. Self-reported drug use and injecting risk behaviour were compared in inmates who received standard drug treatment (counselling), time-limited methadone treatment and methadone maintenance treatment. HIV status was determined by serology. Intervention comprised high and low dose methadone treatment and counselling. The groups were similar in terms of most basic demographic characteristics but subjects who had been maintained on methadone reported a significantly lower prevalence of heroin injection, syringe sharing and scored lower on an HIV Risk-taking Behavioural Scale than subjects who received standard drug treatment and time-limited methadone treatment. This study suggests that methadone treatment is associated with reduced injecting risk behaviour in prison with adequate (greater than 60 mg) dose and duration in treatment. These treatment conditions are known to increase effectiveness in community-based methadone programmes. Prospective studies are required to evaluate the effectiveness of methadone programmes in the prevention of HIV and other blood-borne viral infections among IDU prisoners.

A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release

AIMS

This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release.

DESIGN

A three-group randomized controlled trial was conducted between September 2003 and June 2005.

SETTING

A Baltimore pre-release prison.

PARTICIPANTS

Two hundred and eleven adult pre-release inmates who were heroin-dependent during the year prior to incarceration.

INTERVENTION

Participants were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71).

MEASUREMENTS

Addiction Severity Index at study entry and follow-up. Additional assessments at 6 months post-release were treatment record review; urine drug testing for opioids, cocaine and other illicit drugs.

FINDINGS

Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants.

CONCLUSIONS

Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

A pilot survey of attitudes and knowledge about opioid substitution therapy for HIV-infected prisoners

A majority of inmates in the state of Connecticut Department of Corrections use opioids or are opioid dependent before incarceration. None of the state's prisons offer opioid substitution therapy other than for detoxification or maintenance therapy for women during pregnancy. On release to the community, most prisoners relapse to drug use and this has been associated with higher recidivism rates, and less adherence to antiretroviral medications for HIV-infected persons. Nationally and internationally, methadone (METH) and buprenorphine (BUP) have been found to decrease relapse to drug use, decrease recidivism rates, improve adherence to antiretroviral medications, decrease HIV-risk taking behaviors, and improve mortality. However, the general knowledge about opioid substitution therapy among correctionalfacility staff has been reported as substandard. This pilot study compiled results of answers to anonymous surveys from 27 individuals who work directly with inmates in a patient-care capacity for the Connecticut Department of Corrections (CT DOC) and CT DOC case-management referral program (Project TLC) in the year 2006. The surveys included questions regarding current attitudes and knowledge about opioid substitution therapy for prisoners. A minority of respondents refer released prisoners with a history of opioid dependency to METH or BUP treatment. The majority of correctional workers and case-management referral workers did not have knowledge about BUP or METH's ability to improve health and decrease HIV risk taking behaviors. This study found that more education of individuals treating and caring for HIV-infected opioid dependent prisoners is needed.

Ethical and human rights imperatives to ensure medication-assisted treatment for opioid dependence in prisons and pre-trial detention

Opioid dependence is a complex medical condition affecting neurocognitive and physical functioning. Forced or abrupt opioid withdrawal may cause profound physical and psychological suffering, including nausea, vomiting, diarrhoea, extreme agitation and/or anxiety. Opioid-dependent individuals are especially vulnerable at the time of arrest or initial detention, when they may, as a result of their chemical dependency, be coerced into providing incriminating testimony, or be driven to engage in risky behaviour (such as sharing needles in detention) in order to avoid painful withdrawal symptoms. Upon incarceration, many opioid-dependent prisoners are forced to undergo abrupt opioid withdrawal (both from legally prescribed agonist therapy such as methadone as well as illicit opioids). Physical and psychological symptoms attendant to withdrawal may impair capacity to make informed legal decisions, and cause prisoners to risk HIV and other blood-borne diseases by sharing injection equipment. Although prisons must provide at least the standard of care to prisoners that is available in the general population, medication-assisted treatment, endorsed by international health and drug agencies as an integral part of HIV prevention and care strategies for opioid-dependent drug users, is unavailable to most prisoners. Medication-assisted treatment is a well-studied and validated pharmacological therapy for the medical condition known as opioid dependence. The failure to ensure prisoner access to this medical therapy threatens fundamental human rights protections against cruel, inhuman or degrading treatment and rights to health and to life. It also poses serious ethical problems for health care providers, violating basic principles of beneficence and non-maleficence (i.e., do good/do no harm). Governments must take immediate action to ensure access to opioid substitution to prisoners to ensure fulfilment of ethical and human rights obligations.

Clinical care of the HIV-infected drug user

HIV/AIDS and chemical dependency, the latter often intertwined with mental illness, are complex, overlapping spheres that adversely influence each other and the overall clinical outcomes of the affected individual. Each disorder individually impact tens of millions of people adversely, with explosive epidemics described worldwide. This article addresses the adverse consequences of HIV/AIDS, drug injection, the secondary comorbidities of both, and the impact of immunosuppression on presentation of disease as well as approaches to managing the HIV-infected drug user.

Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: Qualitative study

BACKGROUND

Evidence highlights the prison as a high risk environment in relation to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission associated with injecting drug use.

METHODS

We undertook qualitative studies among 209 injecting drug users (IDUs) in three Russian cities: Moscow (n = 56), Volgograd (n = 83) and Barnaul in western Siberia (n = 70).

RESULTS

Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasize the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely shared, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated.

CONCLUSION

This study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.

Pharmacokinetic drug interactions between opioid agonist therapy and antiretroviral medications: implications and management for clinical practice

BACKGROUND

Opioid dependence and HIV/AIDS are 2 of the most serious yet treatable diseases worldwide. Global access to opioid agonist therapy and HIV treatment is expanding but when concurrently used, problematic pharmacokinetic drug interactions can occur.

METHODS

We reviewed English, Spanish, French, and Italian language articles from 1966 to 2005 in Medline using the following keywords: HIV, AIDS, HIV therapy, antiretroviral therapy, HAART, drug interactions, methadone, and buprenorphine. Additionally, we reviewed abstracts from national and international meetings and conference proceedings. Selected references from these articles were reviewed as well.

RESULTS

Clinical case series and carefully controlled pharmacokinetic interaction studies have been conducted between methadone and most approved antiretroviral therapies. Important pharmacokinetic drug interactions have been demonstrated within each class of agents, affecting either methadone or antiretroviral agents. Few studies, however, have been conducted with buprenorphine. The metabolism of both therapies, description of the known interactions, and clinical implications and management of these interactions are reviewed.

CONCLUSIONS

Certain interactions between methadone and antiretroviral medications are known and may have important clinical consequences. To optimize care, clinicians must be alert to these interactions and have a basic knowledge regarding their management.

HIV in prison: what are the risks and what can be done?

Prisons are recognised worldwide as important sites for transmission of blood-borne viruses (BBVs). There are two reasons why transmission risks in prison are higher than in the community. First, in most western countries, many prison entrants have histories of injecting drug use, and thus already have high prevalences of BBVs. Second, the lack or under-supply of preventive measures (such as clean needle and syringes or condoms) in most prisons, combined with extreme social conditions, creates extra opportunities for BBV transmission. HIV prevalence in prisoners in more developed countries ranges from 0.2% in Australia to over 10% in some European nations. There are case reports of HIV being transmitted by sharing injecting equipment and sexual activity. Tattooing has been reported as a risk factor for the transmission of BBVs in prison. Access to condoms and needle and syringe programmes in prisons is extremely limited, despite success when they have been introduced. The vast majority of prison inmates are incarcerated for only a few months before returning to the community--thus they are, over the long term, more appropriately regarded as 'citizens' than 'prisoners'. Public health policy must involve all sections of the community, including prison inmates, if we are to reduce transmission of HIV and other BBVs.

Prevention of infectious disease transmission in correctional settings: a review

OBJECTIVES

To review studies defining risk factors for infectious disease transmission in correctional settings, to determine target objectives, and to assemble recommendations for health promotion in prisons and jails.

METHODS

Electronic databases were searched, using a specific search strategy, from 1993 to 2003.

RESULTS

The principal risk factors in correctional facilities are proximity, high-risk sexual behaviour and injection drug use. Based on the type of disease transmissions and epidemics reported in the literature, four diseases were targeted for which preventive measures should be implemented: tuberculosis, human immunodeficiency virus, hepatitis and sexually transmitted diseases. Knowledge of risk factors helps define effective preventive measures along five main themes of action: information and education, screening, limiting harm from risk behaviour by distributing condoms and exchanging syringes, treatment and vaccinations.

CONCLUSIONS

The effectiveness and feasibility of each of these actions have to be assessed in relation to the specificities of the correctional setting.

A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system

OBJECTIVES

The aim was to determine whether methadone maintenance treatment reduced heroin use, syringe sharing and HIV or hepatitis C incidence among prisoners.

METHODS

All eligible prisoners seeking drug treatment were randomised to methadone or a waitlist control group from 1997 to 1998 and followed up after 4 months. Heroin use was measured by hair analysis and self report; drugs used and injected and syringe sharing were measured by self report. Hepatitis C and HIV incidence was measured by serology.

RESULTS

Of 593 eligible prisoners, 382 (64%) were randomised to MMT (n=191) or control (n=191). 129 treated and 124 control subjects were followed up at 5 months. Heroin use was significantly lower among treated than control subjects at follow up. Treated subjects reported lower levels of drug injection and syringe sharing at follow up. There was no difference in HIV or hepatitis C incidence.

CONCLUSIONS

Consideration should be given to the introduction of prison methadone programs particular where community based programs exist.

Active and Former Injection Drug Users Report of HIV Risk Behaviors During Periods of Incarceration

American prisons have increasing numbers of inmates incarcerated for drug offenses. This population is at high risk for HIV-infection and may continue HIV transmission risk behaviors while incarcerated. We find that 31% of injection drug users with a history of imprisonment had used illicit drugs in prison, and nearly half of these persons had injected drugs while incarcerated. Male gender and number of times incarcerated were associated with drug use in prison. Interventions for drug-using prisoners that are advocated in some European prisons, such as needle exchange programs and methadone maintenance, need attention in the United States.

Correlates of enrollment in methadone maintenance treatment programs differ by HIV-serostatus

OBJECTIVES

To identify correlates of enrollment in methadone maintenance treatment programs (MMTP) among a prospective cohort of injection drug users (IDUs) in Baltimore, Maryland.

METHODS

A total of 1480 IDUs undergoing semi-annual HIV tests and interviews were studied between 1994 and 1998, during which time a needle exchange program was introduced. Longitudinal analysis using generalized estimating equations was used to identify correlates of MMTP participation over time.

RESULTS

Although similar proportions of HIV-seropositive and -seronegative IDUs enrolled in MMTP during follow-up (26 versus 22%, respectively), correlates of enrollment differed by HIV-serostatus. Among HIV-seropositive participants, older age [adjusted odds ratio (AOR, 1.37)] was associated with enrollment in MMTP. Among HIV-seronegative IDUs, factors associated with not enrolling in MMTP were being African American (AOR, 0.22) and having been recently incarcerated (AOR, 0.62) or homeless (AOR, 0.72). In both groups, females were twice as likely to be enrolled in MMTP, and those with Medicaid were 1.5 times more likely to be enrolled. When behavioral factors were lagged one visit, needle exchange program attendance was positively associated with MMTP enrollment among HIV-negative IDUs (AOR, 2.10); however, this association diminished significantly over time as dedicated treatment slots for needle exchange program participants became saturated.

CONCLUSIONS

These findings underscore the need to improve access to MMTP, especially to certain subgroups such as African-Americans, the homeless, incarcerated and uninsured. Our data suggest that health care providers and needle exchange programs can facilitate enrollment into MMTP provided that adequate treatment slots are consistently available to this particularly vulnerable population.

Drug abuse of Finnish male prisoners in 1995

The purpose of the present research was to estimate the extent and variety of abuse of illegal drugs, use and misuse of hypnotics and sedatives and anabolic steroids in the Finnish prison population. The study was undertaken during October-November 1995 at four prisons, three of which were closed institutions and one an open prison; one of the three closed institutions was a juvenile prison. There was a total of 707 inmates in the prisons selected for the study. Questionnaires were given personally to all prisoners in the open prison and in the young prisoners' division in the juvenile prison, but in two large central prisons only some divisions were selected for the study. The questionnaires were completed by 354 prisoners; 75 prisoners refused to respond. A total of 27.7% of subjects reported taking illegal drugs while in their current prison and 70.1% had sometimes used them. Of those who were drug-free before their first imprisonment, 21.7% began using drugs in prison. At present hypnotics and sedatives were reported as in use by 41.8% of subjects, one-third as prescribed drugs and about 10% illicitly. A total of 3.7% of subjects reported taking anabolic steroids in the current prison. Cannabis and amphetamine were the most common illegal drugs reported. Intravenous drug use was reported by 19.2% of the respondents at some point in their lives, and 10.7% of prisoners had injected drugs in their current prison. Use of illegal drugs and misuse of drugs were significantly higher among young prisoners (< or = 25 years of age).

A mathematical model of HIV transmission in NSW prisons

A mathematical model was developed to estimate HIV incidence in NSW prisons. Data included: duration of imprisonment; number of inmates using each needle; lower and higher number of shared injections per IDU per week; proportion of IDUs using bleach; efficacy of bleach; HIV prevalence and probability of infection. HIV prevalence in IDUs in prison was estimated to have risen from 0.8 to 6.7% (12.2%) over 180 weeks when using lower (and higher) values for frequency of shared injections. The estimated minimum (and maximum) number of IDU inmates, infected with HIV in NSW prisons was 38 (and 152) in 1993 according to the model. These figures require confirmation by seroincidence studies.