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Prison methadone maintenance treatment:Prison methadone maintenance treatment: Implementation and meta-analytic review
Sarah Larney, Kate Dolan and Alex WodakProgram of International Research and Training
National Drug and Alcohol Research CentreUNSW A t liUNSW, Australia
International Harm Reduction Conference
Barcelona, 2008
Prison methadone maintenance treatment
BackgroundBackground• Methadone maintenance treatment (MMT) is an effective
treatment for heroin dependencetreatment for heroin dependence
Reduced• Reduced• Heroin use
HIV i k• HIV risk• Mortality
C i• Crime
Prison methadone maintenance treatment
Background and AimsBackground and Aims• Increased implementation supported by WHO, UNODC,
UNAIDSUNAIDS• Reduces injecting reduces HIV transmission
in prisonsin prisons
• Meta analysis to identify what we know and what we• Meta-analysis to identify what we know, and what we don’t know
Prison methadone maintenance treatment
Methods• Meta-analysis: Statistically combining results from two or
more studies examining the same intervention
• For each study, calculate an effect estimate
• Effect estimates are weighted
• Weighted effect estimates combined to calculate summary effect estimate
Prison methadone maintenance treatment
MethodsSearched Scopus Web of Science PubMed• Searched Scopus, Web of Science, PubMed
G lit t A t t d bibli h• Grey literature: Annotated bibliography
I l i it i• Inclusion criteria:• Randomised controlled trial of methadone
maintenance treatment commenced in prison settingmaintenance treatment commenced in prison setting
Prison methadone maintenance treatment
MethodsMethods• Individual and pooled effect estimates (risk ratios)
calculated using random effects modelcalculated using random effects model
Heterogeneity assessed using I2 with >50% considered• Heterogeneity assessed using I2, with >50% considered substantial heterogeneity
Prison methadone maintenance treatment
Results: Study selection flow chartP i MMT i h lPrison MMT reports with relevant outcomes identified and screened for inclusion (n=16)
Reports excluded (non-randomised studies)
(n=11)Reports identified as randomised
controlled trials (n=5)
( )
Reports excluded from meta-analysis (n=1)
Reports included in meta-analysis (n=4)
Prison methadone maintenance treatment
Results• 4 randomised controlled trials, 531 participants, all male:
• Dole, 1969 (USA)• Dolan, 2003 (Australia)• Kinlock, 2008 (USA)• Bayanzadeh, unpublished manuscript (Iran)
• Data available for:• Prison heroin use • Prison drug injecting• Post-release heroin use• Re-incarceration
Prison methadone maintenance treatment
Results: Prison heroin use
Study Risk ratio (95% CI)
Bayanzadeh 0.23 (0.14, 0.38)
Dolan 0.53 (0.40, 0.71)
Pooled 0.36 (0.16, 0.82)
• Significant heterogeneity - I2=88%• Test for overall effect: Z=2 44 (p= 01)• Test for overall effect: Z=2.44 (p=.01)
Prison methadone maintenance treatment
Results: Prison drug injecting
Study Risk ratio (95% CI)
B d h 0 24 (0 11 0 54)Bayanzadeh 0.24 (0.11, 0.54)
Dolan 0.45 (0.35, 0.59)
Pooled 0.37 (0.20, 0.68)
• Significant heterogeneity - I2=56%• Test for overall effect: Z=3 24 (p= 001)• Test for overall effect: Z=3.24 (p=.001)
Prison methadone maintenance treatment
Results: Post-release heroin use
Study Risk ratio (95% CI)
D l 0 83 (0 63 1 10)Dole 0.83 (0.63, 1.10)
Kinlock 0.69 (0.53, 0.90)
Pooled 0.76 (0.62, 0.92)
• Heterogeneity not significant - I2 = 6%• Test for overall effect: Z=2 76 (p= 006)• Test for overall effect: Z=2.76 (p=.006)
Prison methadone maintenance treatment
Results: Re-incarceration
Study Risk ratio (95% CI)
D l 0 28 (0 11 0 68)Dole 0.28 (0.11, 0.68)
Kinlock 0.46 (0.22, 0.95)
Pooled 0.38 (0.22, 0.67)
• Heterogeneity not significant - I2 =0%• Test for overall effect: Z=3 37 (p= 0007)• Test for overall effect: Z=3.37 (p=.0007)
Prison methadone maintenance treatment
Discussion: Prison heroin useDiscussion: Prison heroin use• Evidence weak – significant effect, but very high
heterogeneityheterogeneity
Four non randomised studies all found reductions with• Four non-randomised studies – all found reductions with treatment
• Conclusion: Effect exists, but has not been captured with precisionprecision
Prison methadone maintenance treatment
Discussion: Prison drug injectingDiscussion: Prison drug injecting• Evidence weak – significant effect, but significant
heterogeneityheterogeneity
Non randomised studies reduced heroin injection but• Non-randomised studies - reduced heroin injection, but no difference in injection of other drugs
• Conclusion: Inconclusive. Treatment may reduce heroin injection not enough evidence to say that it reducesinjection, not enough evidence to say that it reduces level of injecting drug use
Prison methadone maintenance treatment
Discussion: Post-release heroin useDiscussion: Post release heroin use• Risk of heroin use after prison reduced by 24%
• Conclusion: Treatment reduces heroin use after release from prisonfrom prison
Prison methadone maintenance treatment
Discussion: Re-incarcerationDiscussion: Re incarceration• Risk of re-incarceration reduced by 62%
• Conclusion: Treatment significantly reduces risk of re-incarcerationincarceration
Prison methadone maintenance treatment
LimitationsLimitations• Very few randomised studies
N d i d b t ll d i d d t ll d• Non-randomised, but well designed and controlled studies needed (e.g. Heimer, et al., 2006)
• Incomplete reporting of data
Prison methadone maintenance treatment
Conclusions
• Strong evidence to support methadone as a treatment to reduce heroin use after prison and re incarcerationreduce heroin use after prison and re-incarceration
• Good evidence that methadone reduces heroin use in• Good evidence that methadone reduces heroin use in prison
• Unknown if methadone reduces injecting drug use in prisonprison
Prison methadone maintenance treatment
RecommendationsRecommendations
• If methadone is available in the community it should beIf methadone is available in the community, it should be implemented in prisons
• Test the hypothesis that prison MMT reduces drug injecting/HIV transmissionj g
• Prison methadone advocates should focus on reduced heroin use and re-incarceration as benefits of treatment
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