Facilitators and barriers to scaling up methadone maintenance therapy in Malaysian prisons: using nominal group technique with custodial staff.

Access to methadone maintenance treatment (MMT) in prison is essential for treatment of opioid use disorder (OUD). This study aims to identify barriers and facilitators to expanding MMT in prisons, which is paramount to guide implementation. Custodial staff are key stakeholders. The authors used nominal group technique (NGT), a rapid, mixed-methods strategy, with ten custodial officers with six months employment, to identify perceived barriers and potential solutions to MMT scale-up in Malaysia's largest prison where MMT has been available since 2010. NGT provided a list with rank-ordering of perceived barriers and facilitators. Recorded notes contextualized the list. Most (N = 8) participants accurately recognized MMT as effective treatment for OUD. Among the 12 barriers listed, the 2 top-ranked barriers included perceived inadequate knowledge about MMT by both persons deprived of liberty (PDL) and custodial staff, followed by concerns about the quality of the MMT program (e.g. access, dosing and restrictions) and low perceived motivation by PDL to initiate methadone while incarcerated. Facilitators included: educational and motivational tools designed for PDL to guide in decision-making; training programs for custodial officers' and designing a quality MMT program, especially regarding adequate dosing. Few studies consider the vital perspective of custodial staff in implementation of health-care programming in low- and middle-income country (LMIC) prisons. Custodial staff identified barriers and offered actionable facilitators for scaling up MMT in the LMIC prison setting. Education-oriented solutions included a decision aid for PDL and programming for custodial staff. Ensuring quality programming, hallmarked by ease-of-access to MMT and adequate dosing, may facilitate scale-up.