Treatment of drug addiction in prisons Experiences from Germany and EU Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg [email protected].

Treatment of drug addiction in prisons

Experiences from Germany and EU

Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg

[email protected]

Heike Zurhold

Problem drug users in prisonsA

ustr

ia

Bel

gium

Den

mar

k

Eng

land

Est

onia

Fra

nce

Ger

man

y

Latv

ia

Lith

uani

a

Net

herla

nds

Por

tuga

l

Slo

vaki

a

Slo

veni

a

Spa

in

Bul

garia

Cyp

rus

Fin

land

Gre

ece

Hun

gary

Irel

and

Ital

y

Nor

way

Pol

and

Rom

ania

Sco

tland

Sw

eden

Data (n=14) Estimation (n=12)

0

10

20

30

40

50

60

70

80

90

% of PDU in prisons

In 24 countries (86%) an initial screening for drug use problems is conducted

Germany and Serbia (2012)

GermanyPrison population rate:

80186 prisonsCapacity: 78,00066,000 prisonersOccupancy: 85%15,000 drug addicts

SerbiaPrison population rate:

15328 prisonsCapacity: 7,00011,000 prisonersOccupancy: 158%4,500 drug addicts

World prison brief: http://www.prisonstudies.org

Overcrowding: limited access to treatment and healthcare, increase of infectious diseases

Prevalence of drugs problems

In Europe – about 1 million prisoners per year

10-30% sentenced for drug related offences

Drugs problems are overrepresented in the prison population10-45% report regular drug use in prison

1-31% inject at least one time in prison

3-26% first used drugs while incarcerated

90% relapse to heroin after release

15 Key Interventions to address HIV in prisons

UNODC (2012) has defined a comprehensive package of essential interventions for effective HIV prevention and treatment

Among themHIV testing and counsellingCondom programmesDrug dependence treatmentNeedle and syringe programmesVaccination, diagnosis and treatment of viral hepatitisPrevention of transmission through tattooing, piercing

and other forms of skin penetration

Time gaps in the official introduction of OST in prisons: about 7-8y (Source: EMCDDA, Statistical Bulletin 2)

SE

NL, UKDK

FI

IT

PTMT, AT LU

SI, ES, HR

DE, IE

PL,GRBE

FR, HU

LV, LT,BG

SK

CZ, RO,NO

CYTR

NL AT

DKIT

DE

FR, SIES

PT

LU, IE, NO HU

UK Scot

BE

PL, UK E&W,CZ, SE

HR

FI, RO,BG, EE TR

0

5

10

15

20

25

30

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

OST in the community OST in prison

Provision of drug treatment (28 countries)

OST-based detoxification is not available in: Bulgaria, Cyprus, Finland, Latvia, Lithuania, Portugal,

and Slovakia - OST is not available in: Bulgaria, Cyprus, Lithuania, Slovakia, Greece, Hungary

Detox

ificat

ion

with o

piat

e ag

onist

s

Provis

ion

of n

alox

one

OST

Contin

ued

OST at p

rison

ent

ry

Initia

ted

OST at p

rison

ent

ry

Initia

ted

OST bef

ore

rele

ase

0

8

16

24 21 1924 25

19

13

Number of countries providing

Healthcare in prisons in Germany

Responsibility: Ministry of JusticeFinances all physicians and treatment services in prison

(including HIV; HCV treatment)

Finances also staff of community services providing

counselling in prison

Prisoners: have the legal right of health care according to

the standards of the health insurance

Development of drug treatmentLegal framework in place

Promoted by prison administration and the whole prison staff

Access of NGOs to prisons – complementary drug services

OST in German prisons

In community – increase in OST to 50% of heroin addicts

(80,000 OST patients)

In prison: about 1,500 prisoners in OST (less than 10%) - In UK

and Luxembourg: about 20% in OSAvailable in 3 of 4 prisons

Mainly if OST was started in community – rarely initiated in prison

Best practice in NRWRecommendations for OST in prison (2010)

Prison physicians have to argue if they not accept continuation of

OST

General problem: abstinence as target of prisons, resistance of

physicians due to ideological attitudes

Drug counselling in prison

Provided by community NGOs with staff specifically dedicated to

work with drug dependent prisoners

Easy access to prisons with fixed dates in prison – supported by

prison administration

Main objectiveTo initiate drug treatment in community (treatment instead of

punishment)

Main servicesIndividual counselling to motivate for residential treatment

Groups for treatment preparation or relapse prevention

Cooperation with internal drug services, courts, residential rehabs

Continued care during imprisonment and after release

What works - evidenceEvidence

OST - Reduces mortality by one third, reduces injecting by 55-75% and sharing of injecting equipment by 47-73%1, reduces criminal offenses

Therapy for HCV, HIV - Cost-effective, in case of HCV effective prevention

TC- effective in all settings, reduces re-offending, relapse to drug use, supports community integration

NSP – reduces sharing of drugs and injecting equipment

Drug counselling – increases self-efficacy with regard to risk reduction

NO Evidence

Drug-free units supports during imprisonment, but persisting effect after release unclear

Information, education on infectious diseases - no clear decrease in injecting, no decrease of sexual risk behaviour

1 Larney, S. (2010): Systematic review of OST in prisons. Addiction (105)

Conclusions

High prevalence of PDU in prison does not mean to address this adequately

For implementation OST there is a time gap of several years

Principle of equivalence = driving force BUTAbstinence is dominant approachOST not fully implementedNSP still an exception Condom provision not available in all EU countriesSafer tattooing?

Alternatives to imprisonment = better healthcare