Opiate Substitution Treatment and Harm Reduction in prisons: the Geneva model PD Dr Hans Wolff University Hospitals Geneva

Plan Prisons in Switzerland Switzerland: Examples of realizations at the prison medicine unit in Geneva Opiate substitution treatment (OST) and harm reduction in prison Needle and syringe exchange

3 Language regions & bordering countries Switzerland

4 1 country – 26 cantons Switzerland

Incarceration in Switzerland General Population: 7 Mio 113 Prisons: 6065 detainees in 2011 – 78 detainees/100’000 inhabitants World (2008): 10.1 Mio detainees: ¼ in the US (2.3 Mio, 9 Mio/year ), ¼ in Russia and China USA (costs) $49 Billion/year, 70’000,-$/inmate/year

1.Information, education and communication 2.HIV testing and counselling 3.Treatment, care and support 4.Prevention, diagnosis and treatment of tuberculosis 5.Prevention of mother-to-child transmission of HIV 6.Condom programmes 7.Prevention and treatment of sexually transmitted infections 8.Prevention of sexual violence 9.Drug dependence treatment including Opioid Substitution Therapy 10.Needle and syringe programmes 11.Vaccination, diagnosis and treatment of viral hepatitis 12.Post-exposure prophylaxis 13.Prevention of transmission through medical or dental services 14.Prevention of transmission through tattooing, piercing and other forms of skin penetration 15.Protecting staff from occupational hazards Prevention in Prison The Comprehensive Package (UNOCD): 15 Key interventions

Reduce or stop illegal drug use Improve physical, mental and social well-being of the patient Prevent and reduce infectious diseases, including HIV and hepatitis Reduce mortality, in particular through overdose Reduce morbidity Improve the quality of life of the patient and his family Reduce public spending in health care Reduce public spending in the criminal justice system Opiate Substitution Treatment (OST) delivered appropriately will: Guidelines Euromethwork

Reduce mortality by overdose Carrieri & al 2006 n

I Sheerin & al. Reduction in crime by drug users on a methadone maintenance therapy in New Zealand. The New Zealand medical Journal; 12 March 2004 vol117, n°1190 ISSN Reduction of criminality Number of days with criminal act per week Two interviews (85 patients ) First interview before MMT (methadone maintenance treatment) The second, after a mean MMT of 57 months p<0,001 n

Cost-effective 1 $ invested in OST, Saves 38 $ (cost related to criminal activity, further incarcerations, unemployment, hospitalizations, medical follow-up) $1 $38 MMT CostSavings Gary A. Zarkin, Laura J. Dunlap, Katherine A. Hicks and Daniel Mamo Additional contact information Health Economics, 2005, vol. 14, issue 11, p

Harm Reduction International, The global state of harm reduction 2012 Access to OST in the community and in prison

Time gaps in the official introduction of OST in prisons: ~7-8y (Source: EMCDDA, Statistical Bulletin 2011, HSR tables) Thanks to H. Stöver

Opioid users in Geneva’s prison Epidemiology Prevalence: 8% Male : 95,3% Mean age : 29,7 Previous incarceration : 74,7 % Intravenous users : 39,9 % Used other substances (legal or illegal) : 94,8% – Cocaine :70,8% – Tranquilizers : 63,5% – Alcohol :55,4% – Canabis : 44,2%

Opiate substitution therapy (OST) in the prison of Champ-Dollon (Geneva) Start 1970 (formal authorization in 1996) Pragmatic approach Politics of 4 pillars (Prevention, Harm reduction, treatment, repression) MTD/Buprenorphine: – start or continue treatment – 5-10% with OST – 100% of those who wish or need substitution receive OST 0 overdose the last 10 years 14

Injecting & Syringe Sharing in Prison LocationN% injected% sharedReference Australia (NSW) 7 studies Potter 1989; Wodak 1989; Dolan 1996,1998, 1999; MacDonald 1994; Dolan & Wodak 1999 Canada4,28511 Correc. Services Canada 1995 Canada105 (F)19 Di Censo, Dias, Gahagan 2003 Canada>1, Small et al England Edwards et al 1999 Europe*87113 Rotily et al 2001 EU & Nor EMCDD 2005 Greece Koulierakis et al 1999 Mauritius RSA Mauritius 2005 Russia1, Frost, Tscherkov 2002 Russia27713 Dolan et al 2004 Thailand Thaisri et al 2003 USA47215% Clarke et al 2001

Distribution machine: Hindelbank, CH Hand-to-hand exchange: Geneva, CH Needle and syringe exchange

Hand-to hand distribution Injection/prevention kit Spain Injection/prevention kit Switzerland

Prevents HIV infection No negative consequences No increase of drug use or drug injection Needles not used as weapons Facilitate referral of drug users to drug dependence treatment programs Proof of efficacy of needle exchange programs in prison WHO 2007 Jürgens, Lancet Inf Dis 2009

Global availability of needle and syringe programs (NSP) in the community and in prisons Harm Reduction International, The global state of harm reduction 2012

Needle exchange at the prison of Champ-Dollon, CH Start 1996: principle of equivalence → cantonal law in 2000 Pragmatic approach (consider the fact that drugs enter each prison in the world) Support by prison authorities At entry: Information concerning the possibility to obtain injection material for free and in a confidential way Information at the medical unit (=confidentiality), then distribution at the cell door (=security)

Syringe exchange at the prison of Champ-Dollon,

Problems and solutions Initial mistrust, fear of the syringe as potential weapon (detention officers) – Frequent exchanges between stake holders improved acceptance of all – Improvement of the culture of dialogue – Prison direction implicated in public health strategies Proportion of needles returned to the health team – Trust building – Ask the detainees (=experts)

Problems and solutions II Acceptance by the detainees? Fear of denunciation? – Importance of confidentiality – Separation of the hierarchies (independence medical / prison staff) helps – Participative approach in the improvement process – Initiate other ways of syringe distribution Syringe sharing still exists – Evaluate situation properly – Other distribution methods (automates)?

Conclusions Addiction and associated health problems is of major concern in detention Effective harm reduction strategies exist OST, condom distribution and Needle exchange in prison are – Necessary and FEASABLE – Effective and low cost measures – Should be implemented in every prison – worldwide! Opportunity to improve the health of the entire community (improve public health!)