Treatment of drug addiction in prisons zurhold@uke.de Treatment of drug addiction in prisons Experiences from Germany and EU Heike Zurhold Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg

Problem drug users in prisons ranging from 4 % (Poland) to 80 % (Sweden, Ireland) In 24 countries (86%) an initial screening for drug use problems is conducted

Germany and Serbia (2012) Germany Prison population rate: 80 World prison brief: http://www.prisonstudies.org Germany Prison population rate: 80 186 prisons Capacity: 78,000 66,000 prisoners Occupancy: 85% 15,000 drug addicts Serbia Prison population rate: 153 28 prisons Capacity: 7,000 11,000 prisoners Occupancy: 158% 4,500 drug addicts Per 100.000 national population Serbia: The healthcare system of drug addicts deprived of liberty is improving. In 2009 implemented: - voluntary and confidential counselling and testing for HIV and hepatitis C of all newly admitted patients, individual and group counselling on risk behaviours, HIV, HCV and overdosing Methadone substitution therapy is available to all who were on methadone treatment before admission: N=103 prisoners in OST as of 31 December 2009. drug-free units were opened at two Penal Correctional institutions: in Nis and the Special Prison Hospital in Belgrade. The prerequisite for prisoners to be at those units is their absolute abstinence from all psychoactive substances. On average, 29 persons were in the drug-free units in 2009 (capacity of the drug-free units is 43). Overcrowding: limited access to treatment and healthcare, increase of infectious diseases

Prevalence of drugs problems In Europe – about 1 million prisoners per year 10-30% sentenced for drug related offences Drugs problems are overrepresented in the prison population 10-45% report regular drug use in prison 1-31% inject at least one time in prison 3-26% first used drugs while incarcerated 90% 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 them HIV testing and counselling Condom programmes Drug dependence treatment Needle and syringe programmes Vaccination, diagnosis and treatment of viral hepatitis Prevention 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) Portugal: OST 1977, in prison 1999 6 6

Provision of drug treatment (28 countries) Maintenance treatment has not been introduced so far in Bulgaria, Cyprus, Hungary, Lithuania and Slovakia, Greece and Hungary. Greece along with Bulgaria, Cyprus and Slovakia as one of the countries where prison doctors are not allowed to prescribe long-term substitution treatment (EMCDDA, 2012). In Hungary, maintenance treatment has been officially allowed in prisons since in 2001, but has not yet been implemented. If available, not available in all prisons: Opioid maintenance treatment is implemented in all national prisons; Austria, Belgium, England, France, Ireland, Norway, Scotland and Slovenia. Naloxone: England/Wales and Scotland, Spain Naloxone is an opiate antagonist which can temporarily reverse the effects of an opiate overdose, providing more time for emergency services to arrive and treatment to be given. ‘Take home’ Naloxone can legally be administered by anyone for the purpose of saving a life. The supply of a “take home” Naloxone kit follows training on how to administer it safely and quickly. Nasal or muscular application 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

Healthcare in prisons in Germany Responsibility: Ministry of Justice Finances all physicians and treatment services in prison (including HIV; HCV treatment) Finances also staff of community services providing counselling in prison Prisoners: have the legal right of health care according to the standards of the health insurance Development of drug treatment Legal framework in place Promoted by prison administration and the whole prison staff Access of NGOs to prisons – complementary drug services Staff needs to understand the requirement to provide treatment, to prevent the spread of infectious diseases, need to be aware of the need for healthcare Staff should be integrated in decisions about implementing services, should know the work of NGOs

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 OS Available in 3 of 4 prisons Mainly if OST was started in community – rarely initiated in prison Best practice in NRW Recommendations for OST in prison (2010) Prison physicians have to argue if they not accept continuation of OST General problem: abstinence as target of prisons, resistance of physicians due to ideological attitudes Verantwortung für Gesundheitsdienst geht von Justiz zu Gesundheit über FR, IT, SE, NO, England & Wales Sweden, Spain and Italy are going to transfer the responsibility for prisoner health care to the same institutions that provide health care in the community In Finland, the administrative sector of the Ministry of Justice is currently exploring the transfer of prison health care to the general health care system.

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 objective To initiate drug treatment in community (treatment instead of punishment) Main services Individual counselling to motivate for residential treatment Groups for treatment preparation or relapse prevention Cooperation with internal drug services, courts, residential rehabs Continued care during imprisonment and after release • Beratung, Betreuung und Stabilisierung Inhaftierter mit Suchtproblemen • Übermittlung von Informationen und Zugang zu Informationsmaterial über Angebote der Suchthilfe • Beratungsgespräche mit Reflexion der bisherigen Lebenssituation und –weise • Konstruktive Auseinandersetzung mit der Abhängigkeitserkrankung • Möglichkeit der Aufarbeitung von Problemen im persönlichen und sozialen Bereich im Kontext des Substanzkonsums • Krisenintervention • Abklärung des Rehabilitationsbedarfs und der Rehabilitationsfähigkeit • Klärung der juristischen Voraussetzungen für den Beginn einer Behandlung außerhalb des Vollzuges • Erstellung eines Hilfeplanes auf der Grundlage einer qualifizierten Suchtdiagnostik • Erstellen eines Sozialberichtes, Hilfe bei der Beantragung der Übernahme der Kosten für medizinische Leistungen, Vervollständigen der Unterlagen etc. • Hilfe bei der Beantragung der Therapienebenleistungen (ALG II-Antrag bzw. SGB XII-Antrag) •  Abstimmung und Kooperation mit anstaltsinternen Diensten, Gerichten, Kostenträgern, Suchthilfeeinrichtungen u.a. Gruppenangebote zu Terapievorbereitung, Rückfallprävention

What works - evidence Evidence NO Evidence OST - Reduces mortality by one third, reduces injecting by 55-75% and sharing of injecting equipment by 47-73%1, reduces criminal offenses Therapy for HCV, HIV - Cost-effective, in case of HCV effective prevention TC- effective in all settings, reduces re-offending, relapse to drug use, supports community integration NSP – reduces sharing of drugs and injecting equipment Drug counselling – increases self-efficacy with regard to risk reduction NO Evidence Drug-free units supports during imprisonment, but persisting effect after release unclear Information, 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)

Conclusions High prevalence of PDU in prison does not mean to address this adequately For implementation OST there is a time gap of several years Principle of equivalence = driving force BUT Abstinence is dominant approach OST not fully implemented NSP still an exception Condom provision not available in all EU countries Safer tattooing? Alternatives to imprisonment = better healthcare HCV testing and treatment for hepatitis C is offered in prisons in all countries, with exception of Latvia and Bulgaria In 13 countries counselling and testing for HIV is available in all prisons while a low coverage of less than 50 % was reported from Czech Republic, Greece, Italy, and Spain. HCV treatment of less than 10 % was found in Estonia and Lithuania. In no more than in 19 European countries condoms are distributed to prisoners Condom provision: NGOs distribute condoms free of charge, but in Hungary the work of NGOs is not much supported by the prison management. Quite often condoms are only available on request at medical services or the prison health service. This procedure was reported from Slovenia, Finland, Belgium, Portugal, the Netherlands, France, Poland, and partly in Germany. In some prisons condoms can also be bought in prison shops. In Switzerland, condoms are distributed discretely through machines, while in Spain condoms are distributed monthly by prison guards. Germany PNSP is available only in one out of 190 prisons Moldowa (n=9), Luxembourg (n=1), Kyristan (n=10), Spain (n=30) Hand-to-hand, by peer workers, dispensing machines Scientific evaluations conducted in 11 prisons with syringe distribution programmes