Table_1_Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia’s full-scale invasion, and contested methadone objects.DOC

BackgroundAfter pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia’s full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions.
MethodsIn-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion.
FindingsCriminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of “methadone” varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture’s rules and lacked the social ties necessary to procure drugs illegally.
ConclusionIt appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.

背景
经过预试验后，美沙酮于2021年首次被引入乌克兰监狱，作为全国推广策略的一部分，用于治疗阿片类物质使用障碍，并预防人类免疫缺陷病毒（HIV）和丙型肝炎病毒（HCV）的传播。东欧及中亚地区监狱的阿片类激动剂治疗（OAT）推广工作一直受到犯罪亚文化不同程度影响的阻碍——这种与正式监狱管理部门并行运作的社会层级体系实施了法外非正式治理。本研究探讨了影响乌克兰监狱中美沙酮治疗开展的社会环境因素，包括俄罗斯全面入侵乌克兰期间出现的变化，以及被剥夺自由者（PDL）从冲突地区流离至非冲突地区的情况。

方法
2021年1月至2022年10月，在仅有的两所正在为被剥夺自由者（PDL）引入美沙酮治疗的乌克兰监狱中开展了深度定性访谈（样本量N=37），其中被剥夺自由者共18名。这两所监狱在全面入侵发生后仍持续提供美沙酮治疗。此外还访谈了4名前被剥夺自由者及15名监狱工作人员。访谈内容被录音、转录并翻译成英文。四位作者独立对数据进行审阅、编码，并采用现象学框架开展数据分析，梳理出与犯罪亚文化、药物使用、美沙酮治疗开展以及俄罗斯入侵期间的动态变化相关的主题。

结果
研究对象对犯罪亚文化的认知存在分歧：部分人认为其强烈劝阻特定群体的药物使用，而另一些人则认为其影响力已式微，仅为遥远过去的残留。不过，亚文化对美沙酮治疗开展的影响尚不明确。被剥夺自由者与监狱工作人员难以清晰界定、表述娱乐性使用的非法街头购得美沙酮与医学处方美沙酮之间的差异。因此，“美沙酮”这一概念在推广过程中存在不同解读，可能导致受试者在选择这一循证治疗方案时产生认知冲突。2022年俄罗斯入侵乌克兰后，冲突地区的被剥夺自由者被转移至已引入美沙酮治疗的非冲突地区。由于这些被剥夺自由者被隔离，不受既有犯罪亚文化规则的约束，且缺乏非法购药所需的社会关系网络，监狱环境反而更有利于他们启动美沙酮治疗。

结论
乌克兰监狱中的犯罪亚文化呈现出动态变化的特征，且似乎因俄罗斯入侵受到了差异化影响。随着监狱中美沙酮治疗推广范围的扩大，区分监狱亚文化所传递的负面美沙酮认知与正式监狱管理部门所倡导的医学治疗意义至关重要。当前俄罗斯对乌克兰的入侵为改变这一现状提供了潜在的契机。