EMCDDA Conference Lisbon 6-8 May 2009 Treatment and Harm Reduction in Prison and Continuity of Care Caren Weilandt WIAD (Scientific Institute of the German Medical Association), Bonn

EMCDDA Conference Lisbon 6-8 May 2009 EC Experts’ Report on Prevention, Treatment, and Harm Reduction Services in Prison pulished November 2008 Consortium (WIAD, Bonn, University Bremen and Centre for Interdisciplinary Addiction Research, Hamburg) The full report is available at EC and other webpages

Acknowledgements  Heino Stöver, Bremen Institute for Drug Research (BISDRO), University of Bremen  Doris Radun, Robert Koch-Institute, Berlin  Christina Hartwig, Centre for Interdisciplinary Addiction Research (CIAR), University of Hamburg  Katja Thane, Centre for Interdisciplinary Addiction Research (CIAR), University of Hamburg  Heike Zurhold, Centre for Interdisciplinary Addiction Research (CIAR), University of Hamburg

EMCDDA Conference Lisbon 6-8 May 2009 Methodology  Search –Databases, publications –National reports EMCDDA focal points –WHO Europe, Pompidou group, UNAIDS, UNODC –Contacts to national and international experts

EMCDDA Conference Lisbon 6-8 May 2009 Prison background data  600,000 prisoners, approx. 2 Mio per year  Average 121 per 100,000 (56 Slo-337Est)  Increasing number of prisoners in many countries; esp. female prisoners  Average 5% female  8-35% migrants  Overcrowding: average prison density 109

EMCDDA Conference Lisbon 6-8 May 2009 Prison density per 100 places

EMCDDA Conference Lisbon 6-8 May 2009 Sentenced prisoners by main offence: drug offences in percent

EMCDDA Conference Lisbon 6-8 May 2009 Spread of HCV among Prisoners  High risk behaviour and high risk environment: HCV-prevalence 50-90%  Poor understanding of HCV dynamics  Unsafe injecting common  Tattooing widespread  Sharing of razors etc.

EMCDDA Conference Lisbon 6-8 May 2009 Prison are high risk environments  Loss of health protective means  High risk of overdose after release  Self harm over-represented  Discontinuation of treatment  Sexual violence (underreporting)

EMCDDA Conference Lisbon 6-8 May 2009 Health Consequences for prisoners  drug related deaths after release  suicide attempts  self harm  drug use related diseases are manifold higher than outside prisons walls  unsafe injections, sexual practices, tattooing and piercing

EMCDDA Conference Lisbon 6-8 May 2009 Health Consequences for prison staff  Risk of infections with blood borne diseases while searching cells or by accidental needle stick injuries  Violence  Lack of understanding of addiction

EMCDDA Conference Lisbon 6-8 May 2009 Knowledge and Attitudes of prison staff … lack of staff (88,6%) … lack of safety for prison staff (46,5%) … Overcrouding = Problem (62,8%) … lack of information on infectious diseases (44,7%) … high infections risk Hepatitis B/C, TB, HIV (42-50%) … Violence among prisones (98,3%) Against the introduction of HR measures: needles and syringes: 67% steril tattooing eqipement: 79%

EMCDDA Conference Lisbon 6-8 May 2009 Transmission of Blood- Borne-Viruses in Prisons  HIV outbreaks  Transmission of HCV/HBV  Imprisonment independent predictor for HCV  Tattooing/piercing

EMCDDA Conference Lisbon 6-8 May 2009 EC Council Recommendation???  Impact assessment done in 2008  Specific and operational objectives on –Prevention –Treatment –Harm reduction –Reintegration –Monitoring/analysis of drug use among prisoners

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Prevention (1/2)  Improving education, information and communication –tailor-made prevention material (e.g. youth, migrants, women) –Provide accurate and non-judgemental information –Increase the knowledge, attitudes and skills of both prisoners and staff with regard to drug use, drug related infectious diseases, drug injecting, STIs, tattooing and piercing  Tackle the problem of physical, psychological and sexual violence around drug trafficking, consumption and sexual contacts

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Prevention (2/2)  Provide internal and external counselling in order to promote risk reduction and to facilitate access to appropriate treatment, care and support services  Involve NGOs (confidential partners for sensitive topics like unprotected sex, illicit drug use)  Integrate families and communities in prevention strategies (very important in the period before and after release, maintenance of achievements)

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Treatment (1/2)  Offering diversity of counselling, treatment, care, and support (social services, drug-care units, drug counselling and drug treatment services)  Improved Strategies of “therapy instead of punishment”  Motivational interventions (offered by professionals inside or outside prisons or peers) help to increase motivation for change and compliance with treatment regime

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Treatment (2/2)  Reduction of drug related morbidity and mortality by improved screening and treatment of infectious diseases  Reduction of overdose mortality (reference to community treatment facilities on release, overdose prevention activities before release)  Offer protected environment (e.g. drug free units) to motivated drug users

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: HR (1/2)  Access to evidence based measures to reduce the prevalence and incidence of BB infections –“safer use” training facilitated by information –safer use kits containing sterile injection material, disinfectants and instructions how to use them –syringe/needle exchange programmes  Support safer sex –information material –easily accessible condoms and lubricants –possibility of conjugal visits for inmates with their spouses/ partners

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: HR (2/2)  Improvement of voluntary testing opportunities (HIV, hep, STDs, TB), stick to personality rights and data protection rules  Free vaccination for prisoners and staff  Reduce drug related mortality by implementation of measures to reduce morbidity, and the risks of overdose deaths (drug treatment opportunities which minimise uncontrolled use, relapse prevention interventions after detoxification, staff competence to apply resuscitation in case of acute overdosing).  Reduce intravenous drug use and needle sharing by offering substitution maintenance treatment for all IDUs in prison

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Reintegration (1/1)  Connect prison drug services with community services  Seamless provision of care after release: improve collaboration between prison and community health care services  Involve NGO services already during prison sentence in care and treatment planning

EMCDDA Conference Lisbon 6-8 May 2009 Operational Objectives: Monitoring (1/1)  Standards for monitoring, documentation, analysis and reporting on prevalence, incidence and trends of drug use, infectious diseases and related risk behaviours inside prisons should be developed and implemented in all EU MS.  Standards should be developed on EU level (i.e. a common EU protocol and instruments which allow collecting comparable and reliable data)  A standard protocol including a standard questionnaire and methodological and ethical recommendations about how to implement a prison survey on health and drug-related issues.

EMCDDA Conference Lisbon 6-8 May 2009 Need for research  Epidemiology of infec. diseases and health risks in the prison setting (cross sectional and longitudinal)  Identifying key figures for a monitoring system  Evaluation of the long-term effects of interventions and derivation of ‘Good Practice’  In-prison treatment and intervention monitoring: what works and why?  Obstacles of transfer of harm reduction measures into the prison setting  Cost effectiveness and cost benefit of in-prison and throughcare programmes  Better understanding of drug use patterns (drugs, frequency, amounts, routes of administration)  qualitative research

EMCDDA Conference Lisbon 6-8 May 2009 EU and MS policy  Acknowledgement of the prisons as priority settings for effective health responses  Continuous development of alternatives to imprisonment  Need for comparable and reliable information on situation and responses to drug use in prison  Promotion of exchange of good practice between MS  Closing the ‘treatment gap’ to prevent undermining health gains achieved in the community (prisons can provide opportunity for effective interventions)

EMCDDA Conference Lisbon 6-8 May 2009

Under development  UNODC Toolkit for HIV Situation and Needs Assessment in Prison Settings  Draft will be out for field testing end of May 2009

EMCDDA Conference Lisbon 6-8 May 2009 SANCO funded project

EMCDDA Conference Lisbon 6-8 May 2009 DG JLS funded Project On the Outside: Continuity of care for people leaving prison Sainsbury Centre for Mental Health 2008

EMCDDA Conference Lisbon 6-8 May 2009 Good prison health is good public health ! Thanks for your attention!