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Opioid agonist treatment (OAT) programmes in prisons play a significant role in preventing the human immunodeficiency virus (HIV). Despite its proven effectiveness, both the availability and coverage of prison OAT programmes remain low. This Indonesian study explores facilitators of, and barriers to, the delivery of methadone programmes in prisons using the social ecological model (SEM).

The study used a qualitative case study approach comprising two prisons with, and one prison without, methadone programmes. Purposive and snowball sampling was used to recruit study participants. In total, 57 in-depth interviews were conducted with prison governors, health-care staff, prison officers and prisoners. Data was analysed thematically.

The study findings identified facilitators of and barriers to the delivery of prison OAT programmes at all three levels of the SEM as follows: intrapersonal barriers including misperceptions relating to HIV transmission, the harm reduction role of OAT programmes, methadone dependency and withdrawal symptoms; interpersonal barriers such as inflexible OAT treatment processes and the wide availability of illicit drugs in prisons and; social-structural barriers, notably the general lack of resources.

The findings highlight the importance of and overlap between, organisational and inter-personal, as well as intrapersonal factors. Such an approach is particularly important in the context of the implementation and delivery of methadone programmes in low/middle income countries, where the lack of resources is so significant.

Three main strategies for improvement were suggested as follows: the development of comprehensive education and training programmes for prisoners and all prison staff; the re-assessment of practices relating to the delivery of methadone, and a comprehensive review of harm reduction strategy in prisons, that should consider the role of prisoners’ families to increase support for prisoner participation; the re-assessment of prison policies to support the delivery of methadone programmes in prisons.

The author suggests that ongoing international support and national drug policies are vital to the continuation and sustainability of methadone programmes in prisons.

This study contributes to the overall evidence base for OAT programmes in middle-income prison contexts.

In spite of the effectiveness of opioid antagonist treatment (OAT) in reducing injecting drug use and needle sharing, programmes in prison continue to be largely stigmatised. This affects programme participation and the quality of programmes delivered. This study aims to explore how Indonesian prison staff and prisoners perceived and experienced stigma relating to prison OAT programmes and identify potential strategies to alleviate this stigma.

Three prisons in Indonesia were selected as part of a qualitative case study. Two of the prisons provided OAT, in the form of methadone maintenance treatment (MMT). Purposive and snowball sampling were used to recruit study participants. In total, 57 semi-structured interviews were conducted with prison governors, health-care staff, prison officers and prisoners. Prisoners included both participants and non-participants in methadone programmes. The data were analysed thematically.

MMT programme participants were perceived by both prison staff and other prisoners to be engaged in illicit drug use, and as lazy, poor, dirty and unproductive people. They were also presumed to be HIV-positive. These multi-layered, intersectional sources of (inter-personal) stigma amplified the effects on prisoners affecting not only their quality of life and mental health but also their access to prison parole programmes, and therefore the possibility of early release. In addition, organisational factors – notably non-confidential programme delivery and lack of both family and institutional supports for methadone prisoners – exacerbated the stigmatisation of MMT programme participants.

Effective strategies to alleviate stigma surrounding OAT programmes such as MMT programmes are urgently needed to ensure participation in and the quality of programmes in prisons.

Many prisoners reported experiencing stigma relating to their participation in MMT programmes in both the methadone prisons studied. They often emphasised the ways that this stigmatisation was amplified by the ways that MMT programme participation was associated with drug use and HIV infection. However, these intersecting experiences and concerns were not recognised by health-care staff or other prison staff. Effective strategies to alleviate stigma surrounding OAT programmes such as MMT programmes are urgently needed to ensure participation in and the quality of programmes in prisons.

The model of methadone maintenance treatment (MMT) in the United States has (for better or for worse) influenced the development of MMT elsewhere. This paper sheds light on the origins and progression of MMT and its application today. This perspective may prove helpful to persons and agencies attempting to develop MMT or whose MMT programmes are being subject to ever‐increasing restrictions. The demographics, social and economic risk factors, impact of poly‐substance use and co‐occurring psychiatric disorders (dual diagnosis), and existing evidence supporting dosing and therapeutic interventions in MMT are reviewed and illustrated with a case study.

This preliminary small-scale research aims to achieve an insight into drug use offenders’ rehabilitation experiences both in and out of prison, as well as considering how perceptions of the public may inhibit their successful reintegration into society.

A mixed-methods approach was used, with five semi-structured interviews conducted alongside the distribution of the Attitude towards prisoners questionnaire among the general public (n = 106) in the North-West region of England.

Participants recalled a mixture of experiences, highlighting the presence of contraband in prisons to be an inhibiting factor of successful rehabilitation. Additionally, participants expressed the need for more support when preparing for release such as confirmation of accommodation and possible employment. Questionnaires also indicated the public to perceive offenders negatively (M = 76, SD = 16.99), thus presenting a further challenge in the resettlement of drug use offenders.

Findings highlight that improving practices to decrease the presence of contraband in prisons, monitoring an individual’s use of methadone, preparing an individual for their release from prison and educating the public would reduce some of the obstacles experienced by drug use offenders.

This study outlines some of the obstacles that drug use offenders experience when attempting to end their drug use activity and criminal engagement.

Through its 1922 Act on poisonous substances and more recent national normative guidance, Morocco attempts to address high prevalence of HIV among people who inject illegal opioids, and to lift legal and policy barriers to the availability of opioid-based essential controlled medicines. This paper aims to map the Moroccan opioid regulation environment, with a focus on responses to the legal and illegal markets.

The policy paper focuses on legal provisions for the control of opioids for pain relief and methadone for substitution therapies. It reviews existing reported data from official national, regional and international sources, studies and grey literature. It allows, by presenting the current state of affairs, to measure the limited pace of policy changes.

The authors provide a clear mapping of the laws and regulations restricting access to opioids in Morocco; the health impacts on populations; and an overall overview of institutional barriers to policy change despite more efforts such as the introduction of opioid agonist therapies.

Due to limited available data and sources, the policy paper exploits the maximum of existing evidence from national and international sources to provide an overall review of opioid control policies in Morocco.

To the best of the authors’ knowledge, this policy paper is among the first to explore the legal environment of opioid use and control in Morocco, to highlight policy reforms, and to analyse the barriers to access to opioids.

Buprenorphine (Subutex) was piloted in two Scottish prisons between 2004 and 2006 and consequently used within other penal establishments in Scotland. This 2007 qualitative study aimed to explore the use of Subutex and its associated effects on 14 participants on detoxification programmes.

All participants were male, aged from 21 to 44 years with prison sentences ranging from a few months to life imprisonment. Buprenorphine was unavailable to female prisoners at the time of this study. Participants were recruited from seven Scottish prisons. All 14 participants were on detoxification programmes, each was prescribed Subutex, and each was selected from a larger investigation that included both those undergoing detoxification and maintenance (n=21). All participants had previously also used methadone on previous detoxification programmes.

It can be concluded that the majority of detoxification participants within this study indicated that Subutex was a more effective treatment than methadone as it helped reduce craving, eased the process of withdrawal and improved sleeping patterns. In addition, the majority of participants noted higher levels of motivation and the ability to set goals towards obtaining an improved quality of life.

This study provides an alternative perspective to the use of Subutex within prison settings, when compared with results from previous quantitative studies reported. The study also highlights inconsistencies drawn from studies in this area, which may be an artefact of study design. It is recommended that further qualitative studies be conducted to explore further this alternative perspective. Finally, the issue of methodological approach taken should be addressed within the context of a related, but independent, research forum.

There is limited research documenting recovery experiences of residential service users. The purpose of this paper is to explore the perceptions service users on methadone have about recovery. In depth, semi structured 1-1 interviews with seven poly drug using homeless males between the ages of 37 and 46 and analysed using NVivo software. Results are presented thematically. Participants conform to “recovery” norms allowing stigma and shame of illicit drug use to be attributed to former addict identities. Participants on methadone maintenance report inner conflict arising from changing societal and cultural norms that equate recovery with abstinence. Tensions were revealed in true motivations for active rather than passive participation in adopting group work norms.

A qualitative design utilises small numbers of participants to gather rich data. In depth, semi structured 1-1 interviews conducted with seven poly drug using homeless males who have completed between ten and 15 weeks of a minimum 26-week residential treatment programme. Participants were aged 37-46. Results were analysed thematically using NVivo software.

Participants conform to “recovery” norms allowing stigma and shame of illicit drug use to be attributed to a former stigmatised addict identity. Participants on methadone maintenance report inner conflict arising from changing societal and cultural norms regards recovery and abstinence. A significant process of recovery involved adopting the norms of 12-step groups and TC therapy to gain enough trust to leave the therapeutic community (TC) unsupervised. This created tension regards motivation, were these individuals in recovery, or merely “faking it”?

A female perspective may have provided a more balanced discussion and yielded greater depth in results. Only one service was studied and the findings may be specific to that cohort. The duration of stay at the service of ten to 15 weeks is a relatively short time and excluded participants resident for six months or more. Longer term residents may have been more reflective and informative.

Encourage active options and increased debate on the variety of treatment options available to long term homeless opiate users who have failed to comply with previous treatments. While this is a small modest study, the rich data yields practical advice for policy makers and service providers.

This research study adds to an informed perspective by encouraging debate on methadone as a challenge to definitions of recovery that infer abstinence as a key definition of success.

There is a paucity of research documenting a Scottish TC service user perspective using qualitative methods on experiences of addiction, treatment and recovery.

The World Health Organisation and the International Council of Nurses (WHO/ICN, 1991) broadly define addiction nurses' roles into eight domains that suggest a set of core competencies required to work effectively within this challenging area of nurse practice. This paper reports on a survey of addiction centres across eight European countries. The survey explored the role of the nurse specifically within methadone substitution therapy programmes, with the intention of mapping perceived key roles against the ICN/WHO domains. While many of WHO/ICN domains were evident (provider of care; educator; counsellor; advocate) significant limitations were revealed in other domains.

This paper examines a common presentation to primary care and specialist drug services. Often patients who are experiencing opioid dependencies when stabilising on methadone often increase their consumption of alcohol. Also, increasingly so, polydrug use is a growing presentation with heroin, crack and alcohol use used in dependent patterns when presenting for treatment.There is often a lack of alcohol detoxification treatment packages given to those who are on methadone, and often some prescribers in the area of substance use regard an alcohol detoxification programme when prescribing methadone as too risky. This has led to a reluctance in general to prescribe an alcohol detoxification programme for many patients who request it. This is the case in Islington, London.This paper looks at a new service set up in Islington, London and looks at the way it has treated the cohort of patients who have presented with polydrug use, including alcohol. It has seen that patients who were more stable on their methadone and had longer histories in treatment were more likely to complete an alcohol detoxification programme with some ‘dry’ time off alcohol. It proposes that while there is a risk of prescribing alcohol detoxification regimes with methadone, there is a cohort of patients were this can be prescribed with a favourable outcome.

The purpose of this paper is to evaluate some of the wider aims and potential consequences of maintaining remand and short-term prisoners on methadone, rather than providing them with a rapid detoxification on first reception into prison. Consideration is given to the effects of methadone prescribing on treatment engagement; drug-related violence; treatment choice, including detoxification, maintenance and reduction doses; recidivism; and through care.

The author draws on qualitative data gathered during a wider study involving drug-using prisoners and prison drug workers exploring the influence of the therapeutic working alliance on outcomes in prison-based drug treatment.

Whilst participants reported advantages to the prescribing of methadone in prisons, such as reduced levels of bullying and drug-related violence in the prisons, they were also critical of many aspects of methadone prescribing which were intended to increase treatment choice, but in practice, often restricted choice. Drug workers reported that some drug-using prisoners were harder to engage with treatment when they were maintained on methadone.

Data were gathered from two “local” prisons in the same geographical area, and as such, the findings may not be applicable across all prison service establishments. Nonetheless, they highlight important considerations and wider policy implications that could be applicable.

Some previously unreported consequences of methadone prescribing in prisons are discussed, including its potential to increase, rather than decrease heroin use and accompanying crime.