SUBSTITUTION TREATMENT IN THREE PORTUGUESE PRISONS M.J. Campos*; L. Fernandes**; J. Almeida*; L. Mendão*; R. Freitas* GAT – Grupo Português de Activistas sobre Tratamentos de VIH/SIDA* Faculdade de Psicologia e Ciências de Educação – Oporto University** Portugal Sponsored by DG JLS European Commission

Aims and objectives Reduction of drug-related crime in prisons – the impact of opioid substitution treatment (OST) on the manageability of opioid-dependent prisoners - Austria, England, Germany, Italy, Portugal, Slovenia, Spain Extensive literature review on opioid substitution treatment in Europe Qualitative interviews with key persons Standardized questionnaires with inmates (one to one) Standardized questionnaires with prison staff (health workers and guards)

Portuguese drug situation Estimated problematic drug users (EMCDDA) Patients on OST: (IDT) methadone: buprenorphine: Source: INE, Anuário Estatístico de Portugal 2006 ( ); DGSP ( ).

Length of current sentence Source: DGSP Portugal

Prevalence of prison based OST in Portugal Prison population: (DGSP ) Prevalence of drug users in prisons: 25 to 42% (IDT – 2002) Prevalence of problematic drug users among prisoners: – (27% - 45%) (IDT ) Number of prisoners on OST: 734 Substitution coverage rate in prisons: % (IDT – 2007)

Study participants Prison nameNumber of prisoners Number prisoners on OST Number of participants Number of staff Number of health workers Number of participants HW/G EP Linhó naltrexone 6 2 naltrexone (8 HW 5 G) EP Porto*922 HIV 116 (12,6%) 129 HIV 46 (35,7%) (8 HW 10 G) EP Sintra** (HIV 9) (HCV16) (7 HW 5 G) TOTAL 3 male prisons (8%)83 (49,4%) (23 HW 20 G) * Opioid induction treatment ** Confidentiality guarantee

Demographic data - prisoners n=87

Demographic data - guards and health workers VariableGuards (n=20) Health Workers (n=23) Sex Male Female Age Groups 20 – – 50 > Time working in prisons with OST < 1 yrs 1 – 5 yrs >5 yrs Education Semi-skilled Trained College/university degree

Information level on OST (G and HW)

Drug history VariableNumberPercentage Age at first use of opioid drugs (n=87) < 15 years 16 – – – 24 > % 27,5% 20,6% 12,6% 10,3% Age when first injected drugs (n=50) < 16 years 17 – – 24 > % 32% 18% 20% Duration of regular opioid drug use (n=87) < 5 years 5 – – 15 >15 NA ,5% 19,5% 25,3% 31,1% 12,6% Prisoners who ever injected drugs in prison (n=50) Prisoners who for the first time injected drugs in prison (n=50) % 4%

Risk behaviors VariableOutside prisonInside prison Ever shared with someone else needles22 (44%)13 (26%) syringes14 (28%)13 (26%) other equipment (filters, spoons, water, etc) 27 (54%)15 (30%) n = 50

Additional drug use and access to OST in prison VariableOutside prison Inside prison Use of drugs cannabis alcohol opiates/heroin injectable cocaine pills ecstasy 50,5% 31% 34,5% 31% 16,1% 9,2% 74,7% 4,6% 13,8% 2,3% 26,4% 3,4% VariablePercentage Current treatment in prison Maintenance treatment started in prison 37% Continuance of OST started outside prison 61% NA2%

Confidentiality n = 87

Drug use %

Physical violence %

Psychological violence %

Changes in physical state %

Changes in general atmosphere %

Study problems Bias in the study sample The three prisons were chosen by DGSSP Only one prison – Oporto – is actively inducing OST Many guards refuse to participate Unsafe environment - some prisoners admitted to lie during the interviews due to the fact they didn’t believe in the confidentiality

Findings When and where OST is available there is: Improvement of the general prison atmosphere recognized both by prisoners and prison staff Decrease of violence and conflicts between prisoners and between prisoners and guards Reduction of illicit drug use and IV drug use Improvement in prisoners physical, psychological and overall well-being

Study results Prisoners: –extreme long length of incarceration – 50% with > 5 yrs –increase of cannabis (50%) and pills (60%) consumers –26% IVDU kept injecting in prison – syringe exchange programs, with severe limitations and without participants, only exists in two prisons (one covered by the study) –almost 50% of the responders considered access to OST difficult or very difficult Prison staff (health workers - guards): –poor information and training ( %) OST coverage –below official numbers 8% vs %

Recommendations I OST is a proven and effective strategy to successfully prevent HIV, AIDS and hepatitis among incarcerated injecting drug users. To be effective, OST should be: Based on the individual conditions and needs, taking into account their experiences and knowledge Organized as a multidisciplinary team Provided for the right period of time and at the right dosages Provided with the same substitution/maintenance drugs as in the community Provided with continuity, upon imprisonment and also following release and Have clear protocols and guidelines, with understandable rules Include psycho-social care, self-help groups and the support of NGOs

Recommendations II Education, information and training should be provided on treatment options as well as on the general impact of OST in prisons; OST should be integrated into existing drug and/or infectious disease prevention, treatment, care and support strategies; OST should become an understandable and transparent treatment option. Misconceptions and myths should be addressed; OST should be scaled up to cover all in need. Syringe exchange programs should urgently become effective and broadly accessible in Portuguese prisons

Acknowledgements staff and prisoners who agreed to provide such wealth of information the Portuguese study team and BISDRO – Bremem Institute for Drug Research, University of Bremen WIAD – Scientific Institute of the German Medical Association, Bonn Pedro Silvério Marques Ana Pisco Wim Vandevelde GAT – Grupo Português de Activistas sobre Tratamentos de VIH/SIDA Faculdade de Psicologia e Ciências de Educação – Oporto University