Methadone Maintenance Treatment Program in Prisons from the Perspective of Medical and non-Medical Prison Staff: A Qualitative Study in Iran

Document Type : Original Article


1 Kurdistan Research Center for Social Determinants of Health (KRCSDH), Kurdistan University of Medical Sciences, Sanandaj, Iran

2 Iran Prisons Organization, Health and Treatment Department, Tehran, Iran

3 Regional Knowledge Hub, and WHO Collaborating Centre for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

4 GFATM Projects in Prisons, United Nations Development Program, Tehran, Iran

5 Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

6 Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

7 School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran


As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran.
On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons.
This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants’ views “reduction of illegal drug use and high-risk injection”, “reduction of potentially high-risk behaviors” and “making positive attitudes” were the main advantages of MMT in prisons, while issues such as “inaccurate implementation”, “lack of skilled manpower” and “poor care after release from prison” were among the main shortcomings of MMT program.
MMT program in Iran’s prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.


Main Subjects


    1. Navadeh S, Mirzazadeh A, Gouya MM, Farnia M, Alasvand R, Haghdoost AA. HIV prevalence and related risk behaviours among prisoners in Iran: results of the national biobehavioural survey, 2009. Sex Transm Infect 2013; 89: iii33-6.  doi: 10.1136/sextrans-2013-051295
    2. Zamani S, Kihara M, Gouya MM, Vazirian M, Nassirimanesh B, Ono-Kihara M, et al. High prevalence of HIV infection associated with incarceration among community-based injecting drug users in Tehran, Iran. J Acquir Immune Defic Syndr 2006; 42: 342-6.  doi: 10.1097/01.qai.0000219785.81163.67
    3. Stahl W, Sies H. beta-Carotene and other carotenoids in protection from sunlight. Am J Clin Nutr 2012; 96: 1179S-84S.  doi: 10.3945/ajcn.112.034819
    4. Haghdoost AA, Mirzazadeh A, Shokoohi M, Sedaghat A, Gouya MM. HIV trend among Iranian prisoners in 1990s and 2000s; analysis of aggregated data from HIV sentinel sero-surveys. Harm Reduct J 2013; 10: 32.  doi: 10.1186/1477-7517-10-32
    5. Beyrer C, Jittiwutikarn J, Teokul W, Razak MH, Suriyanon V, Srirak N, et al. Drug use, increasing incarceration rates, and prison-associated HIV risks in Thailand. AIDS Behav 2003; 7: 153-61. 
    6. Macalino GE, Vlahov D, Sanford-Colby S, Patel S, Sabin K, Salas C, et al. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. Am J Public Health 2004; 94: 1218-23. 
    7. Vanichseni S, Kitayaporn D, Mastro TD, Mock PA, Raktham S, Des Jarlais DC, et al. Continued high HIV-1 incidence in a vaccine trial preparatory cohort of injection drug users in Bangkok, Thailand. AIDS 2001; 15: 397-405. 
    8. Kushwaha S, Kramer J, Kates M. Isolation and characterization of C50 -carotenoid pigments and other polar isoprenoids from Halobacterium cutirubrum. Biochimica et Biophysica Acta (BBA)-Lipids and Lipid Metabolism 1975; 398: 303-14. 
    9. Dolan KA, Wodak A. HIV transmission in a prison system in an Australian State. Med J Aust 1999; 171: 14-7. 
    10. Taylor A, Goldberg D, Emslie J, Wrench J, Gruer L, Cameron S, et al. Outbreak of HIV infection in a Scottish prison. BMJ 1995; 310: 289-92. 
    11. Razzaghi E, Nassirimanesh B, Afshar P, Ohiri K, Claeson M, Power R. HIV/AIDS harm reduction in Iran. Lancet 2006; 368: 434-5.  doi: 10.1016/s0140-6736(06)69132-0
    12. Dolan KA, Shearer J, MacDonald M, Mattick RP, Hall W, Wodak AD. A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug Alcohol Depend 2003; 72: 59-65. 
    13. Farrel M, Gowing L, Marsden J, Ling W, Ali R. Effectiveness of drug dependence treatment in HIV prevention. International Journal of Drug Policy 2005; 16S: 67-75. 
    14. Gossop M, Marsden J, Stewart D, Treacy S. Outcomes after methadone maintenance and methadone reduction treatments: Two-year follow-up results from the National Treatment Outcome Research Study. Drug Alcohol Depend 2001; 62: 255-64. 
    15. De Maeyer J, Vanderplasschen W, Camfield L, Vanheule S, Sabbe B, Broekaert E. A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals. Int J Nurs Stud 2011; 48: 1244-57.  doi: 10.1016/j.ijnurstu.2011.03.009
    16. De Maeyer J, Vanderplasschen W, Lammertyn J, van Nieuwenhuizen C, Sabbe B, Broekaert E. Current quality of life and its determinants among opiate-dependent individuals five years after starting methadone treatment. Qual Life Res 2011; 20: 139-50.  doi: 10.1007/s11136-010-9732-3
    17. Heimer R, Catania H, Newman RG, Zambrano J, Brunet A, Ortiz AM. Methadone maintenance in prison: evaluation of a pilot program in Puerto Rico. Drug Alcohol Depend 2006; 83: 122-9.  doi: 10.1016/j.drugalcdep.2005.11.004
    18. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT, O'Grady KE. A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease. J Subst Abuse Treat 2009; 37: 277-85.  doi: 10.1016/j.jsat.2009.03.002
    19. Larney S, Toson B, Burns L, Dolan K. Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarceration. Addiction 2012; 107: 372-80.  doi: 10.1111/j.1360-0443.2011.03618.x
    20. Ball JC, Lange WR, Myers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 1988; 29: 214-26. 
    21. Morrow K, Costello T. HIV, STD and hepatitis prevention among women in methadone maintenance: a qualitative and quantitative needs assessment. AIDS Care 2004; 16: 426-33.  doi: 10.1080/09540120410001683367
    22. Langendam MW, van Brussel GH, Coutinho RA, al. e. The impact of harm-reduction-based methadone treatment on mortality among heroin users. Am J Public Health 2001; 91: 774-80. 
    23. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009; (3): CD002209. 
    24. Cabral M, Cence K, Zeni J, Tsai S, Durrer A, Foltran L, et al. Carotenoids production from a newly isolated Sporidiobolus pararoseus strain by submerged fermentation. Eur Food Res Technol  2011; 233: 159-66.  doi: 10.1007/s00217-011-1510-0
    25. Dolan KA, Shearer J, White B, Zhou J, Kaldor J, Wodak AD. Fouryear follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addiction 2005; 100: 820-8. 
    26. Acosta MC, Marsch LA, Xie H, Guarino H, Aponte-Melendez Y. A web-based behavior therapy program influences the association between cognitive functioning and retention and abstinence in clients receiving methadone maintenance treatment. J Dual Diagn 2012; 8: 283-93.  doi: 10.1080/15504263.2012.723317
    27. Lin C, Wu Z, Rou K, Pang L, Cao X, Shoptaw S, et al. Challenges in providing services in methadone maintenance therapy clinics in China: service providers' perceptions. Int J Drug Policy 2010; 21: 173-8.  doi: 10.1016/j.drugpo.2009.09.002
    28. Wickersham JA, Marcus R, Kamarulzaman A, Zahari MM, Altice FL. Implementing methadone maintenance treatment in prisons in Malaysia. Bull World Health Organ 2013; 91: 124-9.  doi: 10.2471/blt.12.109132
    29. Wickersham JA, Zahari MM, Azar MM, Kamarulzaman A, Altice FL. Methadone dose at the time of release from prison significantly influences retention in treatment: implications from a pilot study of HIV-infected prisoners transitioning to the community in Malaysia. Drug Alcohol Depend 2013; 132: 378-82.  doi: 10.1016/j.drugalcdep.2013.01.005
    30. Sheerin I, Green T, Sellman D, Adamson S, Deering D. Reduction in crime by drug users on a methadone maintenance therapy programme in New Zealand. N Z Med J 2004; 117: U795. 
    31. Eshrati B, Taghizadeh-Asl R, Dell CA, Afshar P, Millson PME, Kamali M, et al. Preventing HIV transmission among Iranian prisoners: Initial support for providing education on the benefits of harm reduction practices. Harm Reduct J 2008; 5: 21.
    32. Larney S, Dolan K. A literature review of international implementation of opioid substitution treatment in prisons: Equivalence of care? Eur Addict Res 2009; 15: 107-12. 
    33. Manikandan M, Hasan N, Wu H-F. Rapid detection of haloarchaeal carotenoids via liquid–liquid microextraction enabled direct TLC MALDI-MS. Talanta 2013; 107: 167-75. 
    34. Zamani S, Farnia M, Tavakoli S, Gholizadeh M, Nazari M, Seddighi AA, et al. A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran, Iran. Int J Drug Policy 2010; 21: 167-72.  doi: 10.1016/j.drugpo.2009.03.001
    35. Keshtkaran A, Mirahmadizadeh AR, Heidari AR, Javanbakht M. Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran. Iran Red Cres Med J 2014; 16: e7801. 
    36. Alavian SM, Mirahmadizadeh A, Javanbakht M, Keshtkaran A, Heidari A, Mashayekhi A, et al. Effectiveness of Methadone Maintenance Treatment in Prevention of Hepatitis C Virus Transmission among Injecting Drug Users. Hepat Mon 2013; 13: e12411.  doi: 10.5812/hepatmon.12411
    37. Krueger RA. Focus groups: a practical guide for applied research. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 
    38. Ritchie J, Spencer L, O’Connor W. Carrying out qualitative analysis. In: Ritchie J, Lewis J,  editors. Qualitative research practice: A guide for social science students and researchers. London: Sage Publications; 2004. p. 219-62.
    39. McKenzie M, Nunn A, Zaller ND, Bazazi AR, Rich JD. Overcoming obstacles to implementing methadone maintenance therapy for prisoners: implications for policy and practice. J Opioid Manag 2009; 5: 219-27. 
    40. Philbin MM, Zhang F. Exploring stakeholder perceptions of facilitators and barriers to accessing methadone maintenance clinics in Yunnan Province, China. AIDS Care 2010; 22: 623-9.  doi: 10.1080/09540120903311490
    41. Hedrich D, Alves P, Farrell M, Stover H, Moller L, Mayet S. The effectiveness of opioid maintenance treatment in prison settings: a systematic review. Addiction 2012; 107: 501-17.  doi: 10.1111/j.1360-0443.2011.03676.x
    42. Lin C, Detels R. A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China. Drug Alcohol Depend 2011; 117: 45-9.  doi: 10.1016/j.drugalcdep.2011.01.004
    43. Lin C, Wu Z, Detels R. Opiate users' perceived barriers against attending methadone maintenance therapy: a qualitative study in China. Subst Use Misuse 2011; 46: 1190-8.  doi: 10.3109/10826084.2011.561905
    44. Farnia M, Ebrahimi B, Shams A, Zamani S. Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran. Int J Drug Policy 2010; 21: 422-4.  doi: 10.1016/j.drugpo.2010.03.008
    45. Magura S, Rosenblum A, Lewis C, Joseph H. The effectiveness of in-jail methadone maintenance. J Drug Issues 1993; 23: 75. 
    46. Smye V, Browne AJ, Varcoe C, Josewski V. Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm Reduct J 2011; 8: 17.  doi: 10.1186/1477-7517-8-17