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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


Implementation

Country/territory with prison MMT (n=31)


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


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


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


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


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)


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• Dole, 1969 (USA)• Dolan, 2003 (Australia)• Kinlock, 2008 (USA)• Bayanzadeh, unpublished manuscript (Iran)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


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)


Results: Prison drug injecting


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)


Results: Post-release heroin use


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)


Results: Re-incarceration


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)


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


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


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


Discussion: Re-incarcerationDiscussion: Re incarceration• Risk of re-incarceration reduced by 62%

• Conclusion: Treatment significantly reduces risk of re-incarcerationincarceration


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


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


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

Contact:

[email protected]://ndarc med unsw edu auhttp://ndarc.med.unsw.edu.au

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