Treatment of drug addiction in prisons

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

ustri

a

Bel

gium

Den

mar

k

Eng

land

Est

onia

Fran

ce

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

Finl

and

Gre

ece

Hun

gary

Irela

nd

Italy

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 year10-30% sentenced for drug related offencesDrugs problems are overrepresented in the

prison population10-45% report regular drug use in prison1-31% inject at least one time in prison3-26% first used drugs while incarcerated90% 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

ITPT

MT, 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 ScotBE

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

Detoxif

icatio

n with

opiat

e ago

nists

Provisi

on of

nalox

one

OST

Contin

ued O

ST at pr

ison e

ntry

Initia

ted O

ST at pr

ison e

ntry

Initia

ted O

ST befor

e rele

ase

08

1624 21 19

24 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 prisonPrisoners: have the legal right of health care according to the

standards of the health insurance

Development of drug treatmentLegal framework in placePromoted by prison administration and the whole prison staffAccess 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 prisonsMainly 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

OSTGeneral 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 services

Individual counselling to motivate for residential treatmentGroups for treatment preparation or relapse preventionCooperation with internal drug services, courts, residential rehabsContinued care during imprisonment and after release

What works - evidenceEvidenceOST - Reduces mortality by one third, reduces injecting by 55-75% and sharing of injecting equipment by 47-73%1, reduces criminal offensesTherapy for HCV, HIV - Cost-effective, in case of HCV effective preventionTC- effective in all settings, reduces re-offending, relapse to drug use, supports community integrationNSP – reduces sharing of drugs and injecting equipmentDrug counselling – increases self-efficacy with regard to risk reduction

NO EvidenceDrug-free units supports during imprisonment, but persisting effect after release unclearInformation, 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)

ConclusionsHigh prevalence of PDU in prison does not mean

to address this adequatelyFor implementation OST there is a time gap of

several yearsPrinciple of equivalence = driving force BUT

Abstinence is dominant approachOST not fully implementedNSP still an exception Condom provision not available in all EU countriesSafer tattooing?

Alternatives to imprisonment = better healthcare