1. Drugs and Prison in Europe: State of Play
Linda Montanari, Luis Royuela, Dagmar Hedrich
Health Without Barriers
Cagliari, 3rd June 2015

2. Background information

3. EMCDDA (European Monitoring Centre on Drugs and Drug Addiction)
WHAT AREAS COVERS? ?
Epidemiology: use and consequences
Interventions drug users: prevention, treatment, harm reduction, best practices
Drug market and supply
New drugs: early warning system
WHAT IS IT?
EU decentralised Agency established in 1993 in Lisbon
28 MS + TK; NO; + candidate/potential candidates, neighbouring countries
Mandate: provide factual, objective, reliable and comparable information at European level on drugs and drug addiction and consequences
WHAT ARE THE MAIN OUTPUTS?
EDR
Statistical Bulletin
Country overviews
PODs
Insights
EU Action Plan Evaluation
Most data we present and report are probably well known among the public, but we are trying to provide evidence

4. Available data sources on drugs and prison (28 EU MS, NO, TK - Annual)
B) Qualitative data:
1. Workbook on Prison
National profile and Organisation
Drug use and related problems among prisoners
Drug-related health responses in prison
Quality assurance of drug-related health prison responses
New developments
2. Legislation and policy:
Analysis on alternatives to prison
Quantitative data:
Drug use among prisoners
(LTP before and during prison, regular and current use, LT injecting
2. People entering drug treatment in prison (TDI)
3. Infectious diseases in prison settings
(HIV, HBV, HIV)
4. Drug Law offences

5. Drug Use among Prisoners in Europe: a complex relation
prisoners at 1st September 2012

6. Problems drug users Prison
European research on PDU and their experience with prison:
30%–75% of PDU have been in prison once (Ravndal, Amundsen, 2010)
PDU increase the risk of imprisonment, especially because of Crimes committed to support drug use (Gaffney, 2008, ACMD, 1996) and has disruptive effect on vulnerable populations
Imprisonment associated with higher risk of drug use and earlier relapse after inpatient treatment (Smyth, 2010)
Prisons as places to reach drug users not in contact with other services for research on PDU and interventions
1) Big overlap between PDU and Prison Population: in fact we talk about vulnerable population
2) 30-75% based on several samples of opioids, amphetamines, cocaine, users
3) Malesa are more likely than females to be imprisoned and serve longer sentences

7. Drug Law Offences for use/possession and for supply (~ 15% of all sentenced prisoners are for DLO)
Source: EMCDDA data - last available data

8. Drug users Prison 80% of prisoners use tobacco (20–30% gen. pop.)
Lifetime prevalence of drug use among prisoners
Prisoners sentenced for a drug offence (10–25%)
Substance use disproportionally higher among drug users than among the gen pop:
Prison Gen pop
Cannabis
Cocaine
Amphetamines
Heroin 0-39% <1
Levels of prevalence of different drugs are proportionally correspondent to the levels in the community: same hierarchy: cannabis, cocaine, amphetamines, heroin
Differences between countries are similar in and outside prison: (e.g. UK: cannabis, SP: cocaine; PL: amph; PT: heroin, etc)
Large differences due to methodological limitations
80% of prisoners use tobacco (20–30% gen. pop.)
Source: EMCDDA data - last available data

9. Drug use (ever) within prison: heroin, cocaine, amphetamines (%out of all prisoners)
Source: Statistical bulletin 2014
In press a book on drug use in prison at global level.
Few studies existing, mainly from Europe, some from other parts of the world. Only 59 studies found:
40 in EU
11 in America (only 3 in US)
8 from other countries
Drugs enter into prison: many users stop when they enter prion, but some continue, some start, some switch to other substance (research show that 1/3 of prisoners add another more dangerous drug)
Only 11 countries provided data
High level of use: up to 57% of cocaine, 31% heroin, 23% amph. In SP
Mirroring the national situation in terms of prevalence
Big country differences
In press book on drug use in prison at global level: we have contributed with a chapter on prevalence. Few studies existing, mainly from Europe, some from other parts of the world. Only 59 studies found, 40 in EU, 11 in America (only 3 in US) and 8 from other countries

10. Infectious Diseases HIV+ among IDUs in EU prisons: up to 40%
HCV+ among IDUs in EU prison:
up to 91%
Odd Ratios for IDUs with Prison/No Prison experience:
HIV: up to 3 OR
HCV: up to 7 OR
HIV is 5.6 among IDUs with prison’s experience and 2.6% among IDUs with no prison experience
HCV: 63% among IDUs with prison’s experience and 43% among IDUs with no prison experience
Increase risk of infection in general among IDUs with prison history
OR for Hep C
1.1 in Greece
7 in Sweden
19 in Cyprus

11. Mortality of EU drug users after prison release
Extremely high risk of drug-induced deaths (‘overdoses’) in the first weeks after release from prison
European studies on excess mortality risk (SMR) after prison release:
England/Wales (first week): X 29 (M) X 69 (F)
Denmark (first two weeks): X 62 for males and females
France (first year): X 24 (M 15-34); X 274 (M 35-54)
Ireland: comparison Drug Related Deaths with prison / with no prison:
- 28% of DRD had left prison since one week % of DRD had left prison since one month
Mortality in prison is high compared to the general population of the same age and excluding cause of deaths not existing in prison (car accidents)
Suicide is the leading cause of death
Focusing on causes directly related to drug use, the highest risk of death happens after prison release:
6 out of 10 deaths in the 12 weeks after release are drug related (US study)
SMR: standardised mortality risk: excess mortality risk

12. Drug related interventions in prison: Policy, Treatment, Harm Reduction

13. Treatment for drug users in prison: EU policy framework
Council Resolution Nov 2002 on drug treatment in prison
4 EU Drugs Action Plans ( ; 2005–2008; ; )
drug services for people in prison and develop alternatives to prison
provide access to health care for drug users in prison…”
implement indicators to monitor drug use, problems and services”
2004: EP recommendation on the Rights of prisoners in the EU
EU Drug Strategy :
“scale up and develop drug demand reduction measures in prison...
proper health assessment of the health situation and needs of prisoners at all stages including arrest, imprisonment and after release”
Two principles considered of by the EU countries:
Equivalence of care between community and prison
Continuity of care
Source: 2012 Selected Issue on Drugs and Prison

14. National policies
Governance of prison health: Trend towards prison health being managed by Ministry of Health (7 countries);
Partnerships with civil organisations in all countries (except Turkey)
15 countries have specific prison objectives in national drugs strategy;
10 countries have prison health strategies addressing drug use;
Only 3 countries (ES, LU, UK) have dedicated prison-drugs strategies
Improved provision of health care for drug users in prison has been an objective in the action plan on drugs, and fifteen EU Member States, as well as Croatia and Norway, specifically address drug-related prison health in their national drug policies.
In ten EU Member States, drug-related prison health is covered in a national prison health strategy, in a strategy dedicated specifically to drug-related prison health, or in both.
Improved provision of health care for drug users in prison has been an objective in the action plan on drugs, and 16 EU Member States, as well as Norway, specifically address drug-related prison health in their national drug policies.
Under Ministry of Health: FR IT SI ES UK NO SE (NO since 1988, SE since 1980, FR since 1994)
c): BE, IE, SP, LV, LT, NL, RO, SK, HR, CZ, FR, UK (with prison objectives in their national strategy
D): IE, SP, LV, HU, FI, PL, SE, HR, FR (with prison health strategy)
E): LU, PT, NO (with prison drugs strategy
(Source: Selected issue 2012)

15. Drug Treatment and Harm Reduction
Detoxification as ‘default’ treatment for most opioid users
Low-intensity drug treatment available in all countries;
Mainstay: individual/group counselling; support by specialised providers from community
Inpatient treatment: abstinence-oriented/drug free, including TC
Increasing provision of OST in many countries
Needles/Syringes Exchange Programmes (NSP)
Infectious Diseases Interventions (ID)
In many countries, detoxification is still the ‘default’ treatment for the majority of opioid users entering prison.
Low-intensity drug treatment was reported to be available in prison systems in all countries except Cyprus.
Outpatient treatment of drug dependence: counselling, support by specialised providers from the community;
Inpatient treatment: abstinence-oriented/drug free, incl. TCs;
Increasing provision of OST in many countries.

16. Estimated availability of residential drug-free treatment in European prisons
Existing in most countries but
to a different extent
Not available in (3): FR, SK, BG
Level of availability:
Available at an unknown level: (5) NO,
SP, BE, CY
Full availability: 3 (LT, LU, HR)
Extensive: 10 (PT, IT, MT, GE, AT, NL,
SK SI, PL, UK)
Limited: 5 (NO, FIN, EE, CZ, GR)
Rare: 3 (IE, LV, RO)
Therapeutic communities or special inpatient wards
27 countries providing information (TK not providing)
Not available in (3): FR, SK, BG
Available in 24 countries:
Available at an unknown level: (5) NO, SP, BE, CY
Full availability: 3 (LT, LU, HR)
Extensive: 10 (PT, IT, MT, GE, AT, NL, SK SI, PL, UK)
Limited: 5 (NO, FIN, EE, CZ, GR)
Rare: 3 (IE, LV, RO)

17. Prisons — Opioid Substitution Treatment
Cumulative number of EU countries with OST in community and prison
Not available in CY, GR, LT, SK
Can be initiated in prison in all countries except 4
(CZ, LV, PL, Northern Ireland)
Coverage of all prisoners:
- >10% in 7 countries
3-10% in 9 countries
<3% in the other countries
Year of launch of OST in the community and in prison
Not available in Greece, Cyprus, Lithuania, Slovakia
OST usually with both methadone and buprenorphine
Used for maintenance and detoxification
OST can be initiated in prison in all countries except 4
(Czech Republic, Latvia, Poland, Northern Ireland)
Coverage out of all prisoners:
- >10% in 7 countries
3-10% in 9 countries
<3% in the other countries

18. Harm reduction in prisons
Infectious Diseases Interventions
Mainly information to prisoners and staff; structured programs, including information on condom use and cleaning injecting equipment in few countries
HIV, Hepatitis C, B, TB anonymous/voluntary testing offered in most countries
Scarce data on provision of hepatitis C treatment - few prisoners treated
Hepatitis B vaccination programs exist in 16 countries
Condoms provision in 10 countries but with limitations
Needles Exchange Syringes Programmes (NSP)
Research shows reductions in risky injecting and sharing
Modalities: machines, face-to-face, external workers, trained peers
Existing in: SP, LU, RO, GE (Berlin), PT (pilot project) at varying provision levels
Prevention of overdose
Pre-release counselling on overdose risk
Training on first aid and overdose management
Need to optimise referral to achieve continuity of care
Distribution of naloxone among opioid users leaving prison
Infectious Diseases
Testing Hep. C in 17 countries
Hepatitis B vaccination programmes in prison exist in 16 of the 26 countries that were able to provide information, and drug users are their main target group.
Some countries report specific accelerated schedules, others the general use of the combined hepatitis A and B vaccine.
Data on the uptake of such vaccinations are, however, extremely scarce.
In Scotland, hepatitis B vaccination has been offered to all prisoners within 24 hours of admission since 1999, and, since 2000, all prisoners diagnosed with HCV infection have been offered the hepatitis A vaccine. Since 2009, both vaccines are routinely offered to all drug-using prisoners on admission.
Survey respondents perceived the availability of individual counselling on drug-related risk behaviour as either rare or limited in 13 countries, while such counselling was seen as being available to a majority or nearly all of those who need it in 11 countries.
Safer drug use training was offered in prisons in 12 countries, but availability was mainly perceived as limited or rare (10 countries). Such training was not available in seven countries, and 11 countries provided no information on the availability of this measure.
Condoms availble in: BE, DK, EE, SP, FR, LT, LU, PT, RO, FIN
National priorities (expert opinion):
Hepatitis vaccination programmes, esp. Hep. B (13)
Voluntary testing and counselling (12)
Drug-free treatment (10, of which 8 also prioritised opioid maintenance)
OST initiation (10) and long-term maintenance (7) [Total:15]
Risk assessment (5) and Dissemination of Information on infectious diseases (6)– less prioritised
NSP
1 syringe machine in women’s prison in Berlin, Germany continues to operate; a pilot project in Portugal was not accepted by prisoners.
Prison NSPs operate
Prevention overdose:
New publication of October 2014
In Scotland since the increase in 2011 in distribution of naloxone kits in prison % of DRD in the first 4 weeks after release decreased from 8.4% in 2011 to 4.7% in 2013

19. Summary points

20. Highlights and issues….
Big overlap between drug users and prisoners in Europe
Drug related health and social correlates important problem
High turnover and recidivism and links with the outside community
European countries implementing treatment and HR measures, but to limited and varying extent (coverage and flexibility)
Data still scarce, data quality is limited and country comparability poor
40% of offenders reoffend within three years after release (Irish study)

21. Methodological EMCDDA developments
EMCDDA contribution towards a methodological framework for monitoring drugs and prison in Europe (COR-DROGUE 15/2/2014)
Questionnaire on drug use among prisoners in Europe
( studies/eqdp) (EQDP) (piloting phase in CZ, PL, PT, IT, SP)
Survey of drug-related health facilities in European prisons (EFSQ-P) (in liaison with WHO)

22. THANK YOU FOR YOUR ATTENTION