Transcript Inventory of Social and Health Policies, Measures and

Integrated responses to drugs
and infections across European
criminal justice systems
Drug and Alcohol Misuse
in the Criminal Justice System Conference
3rd April 2008
The Lowry Centre, Manchester
Prof. Dr. Heino Stöver, Bremen Institute for Drug
Research (BISDRO), University of Bremen)
Part I.
Background Information
Key problems
The understanding of the phenomenon
‘drug dependence’ by staff, doctor,
prisoners, partners, families
The belief in abstinence
Control myths re drug use and infectious
diseases by management
Prison as a ‘drug free setting’ – no need
for harm reduction
NGOs as ‘security risks’?
Discontinuity of treatment, care, and support
Prison background data
>600,000 prisoners, approx. 1 Mio per year
Average 121 per 100,000 (56 Slo-337Est)
Increasing number of prisoners; esp. female
prisoners
Average 5% female
8-35% migrants
Overcrowding: average prison density 109
The context of the problem:
drug use in prisons
drug-related deaths, drug-induced cases
of emergency, increase in the number of
drug users, dealer hierarchies, debts,
mixed drugs, drugs of poor quality,
incalculable purity of drugs, and risks of
infection (HIV and hepatitis), pressure for
prisoners and families…
Lifetime prevalence injecting drug use: 738% of all inmates (EMCDDA 1999-2004)
Injecting & needle sharing in prison
(WHO, A. Verster 2007)
Thailand
RF
Greece
England
Canada
Australia high
Australia Low
USA
Thailand
RF high
RF low
Mauritius high
Mauritius
Greece
England
Canada high
Canada low
Australia high
Australia low
% sharing
% injecting
100
90
80
70
60
50
40
30
20
10
0
80
70
60
50
40
30
20
10
0
Prison as high risk environment
Loss of health protective
means
High risk of overdose after release
Self harm over-represented
Discontinuation of treatment
Sexual violence (rape),
Violence =>
Rape and other forms of sexual violence:
Reports to authorities (R. Jürgens)
Only small minority of victims report to
prison authorities:
- 96 of 2,000 rapes reported (Dumond, 2006): « In
-
some ways, the victim is in a no-win
situation »
Other studies found that 29-32% of
victimized prisoners informed prison
officials (Struckman-Johnson, 1996; Nacci & Kane, 1983)
Only 9% of correctional officers charged
with direct supervision believed that rape
was a rare occurrence (Eigenberg, 1989)
Rape & other forms of sexual violence
in prisons: increased vulnerability (R. Jürgens)
Certain prisoners are at higher risk:
-
Young
First time offenders
With mental illness or development disabilities
Physically small or weak
Known to be homosexual
Transgendered
Not « tough » or « streetwise »
Not gang affiliated
Those previously sexually assaulted
Coping with drug use by
management
Denial
Abstinence, supply reduction basic
orientation
Acquisition and use of drugs dominates
life in many penal institutions
Drug use in prisons
Regular drug use or dependence prior to imprisonment
is reported for 8 % to 73 % of inmates,
7–38 % of the prison population have ever injected drugs
8–51 % of inmates report having used drugs within
prison, high percentage of drug users among women
10–42 % report regular drug use
1–15 % have injected drugs while in prison
3-26% first used drugs while they were incarcerated
up to 21% of injectors initiated injecting whilst in prison
Health Consequences for
prisoners
drug related deaths
suicide attempts,
self harm
drug use related diseases (mental
illnesses, STIs, TB, etc ) are manifold
higher than outside prisons walls
unsafe injections, sexual practices,
tattooing and piercing
Health Consequences for prison staff
infections with blood borne diseases while
searching cells or by accidental needle
stick injuries
Violence
Lack of understanding of
addiction
Transmission of BloodBorne-Viruses in Prisons
HIV outbreaks
Transmission of HCV/HBV
Imprisonment independent predictor for
HCV
Tattooing/piercing
Spread of HCV among Prisoners
High risk behaviour and high risk
environment: HCV-prevalence 50-90%
among IDUs, >17% of all inmates
Poor understanding of HCV dynamics
Unsafe injecting common
Tattooing widespread
Sharing of razors etc.
HIV in Prisons in Europe
Spain:
Italy:
France:
Switzerl.:
Greece:
10,0%
17,0%
13,0% (500 entries)
11,0% (cross- sectional in 5 pr.)
11,0%
Several other countries report lower levels of
HIV prevalence: Belgium, Finland,
Germany, United Kingdom
Prison Responses to Health
Challenges
Equivalence of health care
Throughcare
Lack of seamless provision of health care
Responsibility for health care
Involvement of NGOs
Lack of funding and human resources
Drug-free oriented treatment and prevention
Interruption of treatment: the case of substitution treatment
Absence of harm reduction measures
Lack of implementation of international standards and
guidelines
Missing links with community health care services
Proposal for a Council of Europe
‘Recommendation on drugs and prison’
1.
2.
3.
4.
Main recommendations (public health objective, range
of activities, evaluation, reporting)
Specific recommendations among prisoners to:
develop activities to prevent drug use
facilitate the access to treatment of drug users,
increase access to harm reduction/reintegration
services for (ex) prisoners and
To monitor/analyse drug use in prisons
Part II.
Responses
Framework for an effective response for HIV/AIDS
Prevention Care, Treatment and Support in Prison
Setting for Drug Users (modified after Wadih)
Regular assessment of
Achievements of targets
Securing
financial support
national & international
Improvement in
legislation and policy
Successful efforts
to prevent
HIV infections in prisons
Improvement in the
Improvement prison
quality of prison health
Health care practice & living
Care services
conditions of prisoners
Improvement working
Conditions, (HIV/AIDS, IDU)
knowledge, understanding
of staff -
Consensus on what works:
target group iv drug users
Information/Education/Communication
(IEC): how to reduce risks: for prisoners and
staff;
Distribution of prevention material
(needle/syringe programs/NSP, condoms)
Voluntary counselling and testing (VCT)
Antiviral-/antiretroviral treatment
Provision of drug treatment, especially
opioid substitution treatment (OST),
Introduction of methadone treatment and needle
and syringe programmes, in the 25 EU Member
States
no. countries providing
25
20
15
10
5
0
1965
1970
1975
1980
Methadone
1985
1990
1995
Needle/syringe programmes
2000
2005
10-year trend in the number of substitution
treatment clients in Europe (EU-15)
600 000
300 000
0
1993
1995
1997
2000
2003
Substitution Treatment for Opioid
Dependence in prisons
… works!
Reduces:
- level of injecting
- blood borne viruses transmission
- drug related prison violence and crime
following release
- recidivism
But needs adequate doses (>60mg)
Comprehensive approach
• Targeting both prison reform
and health reform needed
• HIV prevention integral part
of a comprehensive
approach (e.g. incl. TB)
• HIV prevention not a
technical intervention only
• HIV prevention, care,
treatment and support
planning with clear targets
and quantifiable output
indicators, regular assessment of achieving goals
Arabic, Chinese, English, French, Portuguese, Russian, Spanish
Education:
• Target-group specific information
material – ‘tailor-made‘ to the
specific needs of various groups
(e.g. juveniles, migrants)
• Guarantee of confidentiality in
counselling processes – the role
of external agencies
• ‘interactive‘ methods
• safer use/safer sex seminars
• Training inmates as peer HIV
educators
Peer Support
• Utilising the
expertise of the
target groups
• Self-Help in
different phases
of imprisonment
• Variety of health
topics (e.g.
• High rate of relapse and
recidivism
• High rate of mortality within the
first 2 days + 4 weeks after
release
• Drug use after release: finding
the right tone, learning from
experiences
• „Guided tour“ – orientation
• Risks (suicide, self-harm,
overdose)
• Screening of infectious
diseases….
• Drug use, addiction
• Support
Risks entrance phase
Self made drugs
 Self made syringes/needles
 Debths
 Violence/gangs
 Sexual contacts/consensual, rape,
prostitution, sex for money etc.
 dependencies

Tattooing
How was the procedure with the last
tattooing session?
 Availability of bleach?
 Boiling possible?
 Any information about the last tattoo of
staff members?

Condoms & other measures to decrease sexual
transmission (WHO, Verster 2007, modified)
Providing condoms is feasible in
prison settings
No security problems or other
negative consequences
Prisoners use condoms when
accessible
Need for measures to combat, report
rape and sexual abuse
Provision of Bleach
Obstacles in accessibility?
 Next best solutions! Cannot reüplace
NSPs
 Which bleach can be used for
syringes?
 What is the exact procedure?
 Doubts about the effectiveness

- Conditions in prisons reduce
probability of effective
decontamination
Evidence of Needle Exchange Programs (NSPs)
(WHO,
Verster 2007, modified)
Prison
Am Hasenburg (D)
Basauri (Es)
Hannoversand (D)
Hindelbank (CH)
Lehrter Strasse &
Lichtenburg (D)
Lingen/GrossHesepe (D)
Incidenc
e
HIV&HCV
Needle
sharing
Drug use Injecting
No increase
No increase
No increase
No increase
No increase
No increase
No HIV
Decrease
No increase
No HIV but
HCV
No increase
No increase
No HIV
No increase
No increase
No HIV
(Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001)
Prepared by
Rick Lines
Ralf Jürgens
Glenn Betteridge
Heino Stöver
Dumitru Laticevschi
Joachim Nelles
Published by the
Canadian HIV//AIDS Legal
Network
2nd edition 2006
English and French
www.aidslaw.ca
Opioid Substitution Therapy (OST)
(WHO, Verster 2007, modified)
OST most effective treatment for opioid
dependence
OST in prisons are feasible and effective
- reduce IDU, associated needle
sharing and other risk behaviour
OST in prisons
- facilitates post-release treatment
- decreases re-incarceration
- has positive effects on institutional
behaviour
Beneficial Effects of Opioid Substitution
Treatment (OST) for Prisoner and Prisons
• Mortality: Need to expand prison based
programmes and links to community based
programmes to reduce opiate related
mortality soon after release from prison.
Prison Methadone Maintenance to reduce
mortality, detoxification alone increases
mortality!
• Control related issues (e.g. management
of opiate addicted inmates)
Form and media
Print/electronic
 Newspapers
 Leaflets
 Broadcasting/TV (e.g. I.R. of Iran)
 Poster
 Quiz/competitions/prize
 Films, fotos
 ´…

HIV/AIDS care, treatment & support (WHO, Verster
2007, modified)
 Prisoners respond well to ART
 Adherence rates can be as high/higher than in
the community
 Careful discharge & linkage to community care
 As ART becomes available in low- and middleincome countries it is critical to ensure
availability in prison systems
 Ensuring continuity of care is fundamental for
successful treatment scale-up
Springer et al., 2004; Srisuphanthavorn et al., 2006; Winarso et al., 2006, Soto Blanco, Perez,
March, 2005; Pontali, 2005, Wood et al., 2003; Palepu, 2003; Stephenson et al., 2005;
Springer et al., 2004
Part III.
Methods
Form and media
Print/electronic
 Newspapers
 Leaflets
 Broadcasting/TV (e.g. I.R. of Iran)
 Poster
 Quiz/competitions/prize
 Films, fotos
 ´…

Conclusions (1/3)
Globally and within HIV/AIDS
remains a major public health
issue as does Hep. C
Prisons remain a major gap,
transmission of infectious
diseases in prisons & prison
release mortality need a coherent
and measured response
Principle of equivalence:
Conclusions (2/3)
• Close connection between prison
and community health care
services
• Development of transparency of
practice and policies – for inmates
and the community professionals
• Health care standards and clear
guidelines on the basis of
evidence-based knowledge
Conclusions (3/3)
• Close connection between prison
and community health care
services
• Development of transparency of
practice and policies – for inmates
and the community professionals
• Health care standards and clear
guidelines on the basis of
evidence-based knowledge
„... Prisoners are the community. They come
from the community, they return to it. Protection
of prisoners is protection of our communities “
(Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in
Prisons)
[email protected]
Further
Information
:
www.archido.de
www.archido.de