Dagmar Hedrich, Linda Montanari, Alessandra Bo, Bruno Guarita, Chloé Carpentier, Isabelle Giraudon, Luis Royuela, Lucas Wiessing « Good prison health – Better Public health – Safer Society » Oslo – 24 November 2009 Monitoring drug use, health problems and responses in prison population in Europe

EMCDDA (European Monitoring Centre for Drug and Drug Addiction) A decentralised agency of the European Union, established in Lisbon 1995 with about 100 staff Mission: to collect, analyse and disseminate objective, reliable and comparable information on drugs and drug addiction and their consequences To promote exchange of best practice Audience: policy makers, scientists and researchers, practitioners and the general public Based on a network of national institutions (30 countries)

Prevention & Re- habilitation Activities Coordination Unit The REITOX Network Austrian Health Institute Scientific Institute Public Health National Board of Health National R&D Centre for Welfare & Health French Observatory for Drugs & Drug Addiction Secretariat Nat. Drug Commission Nat. Monitoring Centre for Drugs and Drug Addiction State Centre for Drug abuse Prevention Institute for Therapy Research University Mental Health Research Institute Health Research Board Estonian Drug Monitoring Centre Min. of Health Nat. Centre for Epidemiology Portuguese Institute for Drugs & Drug Addiction Government Deleg. to the National Plan on Drugs National Institute of Public Health Dept Min. of Health Nat. Bureau for Drug Prevention Institute Public Health Board of Ministers for Drug Dependencies and Drug Control European Commission Direction de la Santé Trimbos Institute SIRUS Min. of Health Drug Control Department National Commission for Dependencies National Centre for Addictions National Anti- Drugs Agency

BE SI HR DK AT CZ PL LT LV EE SK RO HU BG EL TR MT CY IE UK PT ES NL IT DE BE LU FR UK FISE NO Below 100 per popBetween per population Between per population More than 201 per population Prison Population Rate in the European countries (27 MS + Hr, Tk) Source: Council of Europe Annual Penal Statistics (SPACE I) 2006 Population demographic data: EUROSTAT

Prison Population Rate in the EU27 by country (* population) Source: Council of Europe Annual Penal Statistics (SPACE I) 2006 Population demographic data: EUROSTAT

Drugs as a major factor in imprisonment in EU Most EU countries: 10-30% of all sentenced inmates convicted for drug offences (SPACE, 2006) Drug offences represent the main reason for entering prison Plus property crime (robbery, burglary, etc.) to support a drug addiction Considerable differences between detention centres and between countries Countries with highest rates of drug offenders are the drug entry or transit countries

Drug use in prison population (some studies since 2002) Before prison: Half of those surveyed in prison were regular drug users Over a third have injected drugs Current drug use (LYP-LMP): 10-48% males and 30-60% females (Fazel et al. literature review) Within prison: 1% to 50% have used drugs Up to 12% reported a daily use in the last month (one study) 1%-31% have injected a drug at least once (selected samples) Source: EMCDDA Annual Report 2008, Statistical Bulletin

Patients entering drug treatment in prison in 2007 in 5 countries (Ge, Fr, Cy, Sk, Sw) 3274 drug clients (22% new) (from 95 Cy to 625 in Fr) 91% males (from 87% in Sk to 99% in Cy) Mean age: 32 y. males and 34 y. females Primary drug (relevant differences between countries): 28% opioids; 24% stimulants; 17% cannabis; 7% cocaine; 24% other drugs More females (35%) than males (28%) opioid users 36% injectors of primary drug among patients entering treatment in prison (similar to patients outside prison)

HIV prevalence in IDUs in prisons and among IDUs outside prison Source: EMCDDA Annual Report 2009, Statistical Bulletin CountryYear of studySample size% positivePrevalence in IDUs outside prison (n) Belgium – Flemish Community %0.5% - 1.9% (186 – 623) Belgium - French Community %3.4% (267) Bulgaria %0.8% (487), Sofia Czech Republic %0.1% (3100) Germany – Berlin %3.2% (2350) Ireland %3.5% (509), 1998 Spain %36.4% (9068) Luxembourg %3.5% (142) Malta %1.3% (77) Finland %0.2% (1486), 2006 UK – E&W, ever IDUs %0.9% (3366) Croatia %0.0% (128), Zagreb

CountryYear of studySample size% positivePrevalence in IDUs outside prison (n) Belgium – Flemish Community %37.9% (195) Belgium – French Community %- Bulgaria %52.4% (487), Sofia Czech Republic %29.9% (686) Germany – Berlin %- Ireland %72.3% (65), Dublin 2003 Greece %51.7% (286) Italy - Brescia-Mombello Monza Milano-Opera %- Luxembourg %81.3% (268) Malta %34.4% (180) Finland %38.4% (146) Sweden - Gothenburg %- UK – Scotland, mainly Glasgow %46.9% (348) UK – E&W, ever IDUs %41.0% (3366) Croatia %- HCV antibody prevalence in IDUs in prisons and among IDUs outside prison Source: EMCDDA Annual Report 2009, Statistical Bulletin

HBV antibody (aHBc) prevalence in IDUs in prisons and among IDUs outside prison CountryYear of studySample size% positivePrevalence in IDUs outside prison (n) Germany – Berlin %- Ireland %- Greece %29.1% (1013), 2006 Luxembourg %24.7% (239) Sweden %- UK – England & Wales (ever IDUs) %22.0% (3363) Croatia %- Source: EMCDDA Annual Report 2009, Statistical Bulletin

Mortality among prisoners and drug related deaths after release from prison Poor health of prisoners, especially drug users, and higher mortality rates compared to general population High drug-related post-release mortality rates compared to general population Standardised mortality ratio (SMR) comparing drug related deaths of released prisoners with a reference population England and Wales (Farrel et al., 2007):29 males and 69 females (one week after release) Denmark (Christensen at al., 2006):29 (males and females; first two weeks after release) France (Verger at al., 2003):124 males years and 274 males years (first year after release)

EU policy framework on drugs and prison I. Council Recommendation of 2003 on prevention and reduction of health-related harm II. EU-Drugs Strategy 2005 – 2012: EU-AP : Objective 9: “provide access to health care for drug users in prison” (21) develop services for drug users in prison equivalent to services outside prison in order to reduce drug related health problems; particular attention to period after prison release (22) implement indicators to monitor drug use, health problems, service delivery

Services provided to prisoners in European countries Information on drugs and health Screening for infectious diseases and vaccination Detoxification Substitution treatment Drug-free treatment approaches Preparation for release Relevant differences between countries and detention centres in level of provision

Substitution/maintenance is not available in prisons Exists in nearly all prisons Exists in a majority of prisons (but not in nearly all of them) Exists in more than a few prisons but not in a majority of them Exists in just a few prisons Availability of substitution treatment in the prison system (2006 data) (Source: Expert Rating; Reitox National Focal Points, 2008)

Provision of substitution/maintenance treatment (OST) in the community and availability of OST programmes in the prison system in 2007 (expert rating)

Level of provision of selected health responses to prisoners in 28 European countries (n. countries) Source: EMCDDA Annual Report 2009; expert rating on 26 EU MS + Norway and Turkey

Conclusions Drug use is major factor of imprisonment in Europe Drug users represent a substantial proportion of the prison population Health related problems, especially infectious diseases, more common among prisoners than among drug users in the community or in the general population Drug related mortality is high, especially in the immediate period after prison release Interventions for drug users in prison (drug treatment and health interventions) still not widely available in European prisons, but some European countries have several interventions options Need to for more comparable European information on drug use and responses in prison Monitoring and research should be improved at European level

Thank you four your attention