1. Prof. Dr. Heino Stöver, University of Bremen
Drug treatment in prisons with special emphasis on Opioid Substitution Treatment and Harm Reduction Prison Health Expert Group of the Northern Dimension Partnership in Public Health and Social-welbeing, 7th Meeting, Vilnius, Lithuania, February 9 – 10, 2009
Prof. Dr. Heino Stöver, University of Bremen

2. Part I. Background Information

3. Prison background data
>600,000 prisoners, approx. 1 Mio per year
Average 121 per 100,000 (56 Slo-337Est)
Increasing number of prisoners; esp. female prisoners (average 5% female)
8-35% migrants
Overcrowding

4. Key problems: knowledge, perception & understanding of drug dependence
The understanding of the phenomenon ‘drug dependence’ by staff, doctor, prisoners, partners, families
The belief in abstinence
Control myths re drug use and infectious diseases by management
Prison as a ‘drug free setting’ – no need for harm reduction
NGOs as ‘security risks’?
Discontinuity of treatment, care, and support
Acquisition and use of drugs dominates life in many penal institutions

5. The context of the problem: drug use in prisons
drug-related deaths, drug-induced cases of emergency, increase in the number of drug users, dealer hierarchies, debts, mixed drugs, drugs of poor quality, incalculable purity of drugs, and risks of infection (HIV and hepatitis), pressure for prisoners and families…

6. Injecting & needle sharing in prison (WHO, A. Verster 2007)
France, Germany, Italy, Netherlands, Scotland, Sweden
This table summarises the information we have on the prevalence of injecting and needle sharing in a number of countries, prisons and from a number of studies.
While most study samples are relatively low, we see that injecting rates of up to 34or 74% of the prison population are reported. Even more worrying are the rates of needle sharing among drug injectors in prison settings of between 66-94% of those who inject.

7. Drug use in prisons
Regular drug use or dependence prior to imprisonment is reported for 8 % to 73 % of inmates,
7–38 % of the prison population have ever injected drugs
8–51 % of inmates report having used drugs within prison, high percentage of drug users among women
10–42 % report regular drug use
1–15 % have injected drugs while in prison
3-26% first used drugs while they were incarcerated
up to 21% of injectors initiated injecting in prison

8. Drug-related infectious diseases in prisons: The example of Germany
IDUs
HCV
HIV
Prisons
21,9 - 29,6 %
14, %
0,8 % - 1,2 %
General population
0,3%
0,4% - 0,7%
0,05%
Factor
73 – 98
26 – 32
16 – 24

9. Prison as high risk environment
Loss of health protective means
High risk of overdose after release
Self harm over-represented
Discontinuation of treatment
Sexual violence (rape), Violence
These include the impact on mental health, the risk of suicide and self-harm, the need to reduce the risk of drug overdose on release and the harm resulting from inappropriate imprisonment of people requiring facilities unavailable in prison or in overcrowded prisons.

10. Health Consequences for prisoners
drug related deaths
suicide attempts,
self harm
drug use related diseases (mental illnesses, STIs, TB, etc ) are manifold higher than outside prisons walls
unsafe injections, sexual practices, tattooing and piercing
HIV outbreaks

11. Health Consequences for prison staff
infections with blood borne diseases while searching cells or by accidental needle stick injuries
Violence
Lack of understanding of addiction

12. Spread of HCV among Prisoners
High risk behaviour and high risk environment: HCV-prevalence 50-90% among IDUs, (Germany: >17% of all inmates)
Poor understanding of HCV dynamics
Unsafe injecting common
Tattooing widespread
Sharing of razors etc.
In many studies independent predictor for the likelihood of HCV infection: periods of incarcerations
I. Lack of means to protection (needle exchange projects)
Despite gaps in our knowledge, there is sufficient evidence to address the two most frequent modes of transmission: injecting drug use and tattooing. About a quarter of prisoners inject drugs while incarcerated.3 Virtually all drug injecting occurs with used injecting equipment shared among numerous partners. Therefore, the primary goal has to be to reduce drug injecting in prison. One way to achieve this is to reduce the number of drug injectors in prison.5 There is abundant evidence that community-based methadone treatment reduces injecting, crime and the subsequent incarceration of drug users,6 yet only a third of the demand for methadone treatment is met in the community.6
II. HCV transmission in prison may also occur through tattooing. One way to reduce tattoo-related hepatitis C transmission is to train select inmates in infection control procedures and to provide them with autoclaves and single-use ampoules of ink. Penalties for tattooing in prison should be removed. Allowing professional tattooists to visit prison is likely to be too expensive for inmates

13. HIV in Prisons in Europe
Spain: 10,0%
Italy: ,0%
France: 13,0% (500 entries)
Switzerl.: 11,0% (cross- sectional in 5 pr.)
Greece: 11,0%
Estonia: 12-13%
HIV prevalence: Belgium, Finland, Germany (1%)
Greek Researchers found that 55% of 100s use drugs in prisons, and over 57% inject drugs. 90% of these injecting in prisons shared needles.
In Spain, prisoners represent 0.1% of the population but 7% of those with AIDS.
Sources: Davies, Goyer, HIV Education Prison Project, Prison Health Care News

14. Part II. Responses: Opioid Substitution Treatment

15. Key problems: Coping with drug use by management
Denial
supply reduction basic orientation
Abstinence oriented measures,
Organisational strategies (Drug Free Units)
Ignorance of evidence-based knowledge

16. Consensus on what works: target group iv drug users
Information/Education/Communication (IEC): how to reduce risks: for prisoners and staff;
Voluntary counselling and testing (VCT)
Antiviral-/antiretroviral treatment
Distribution of prevention material (needle/syringe programs/NSP, condoms)
Provision of drug treatment, especially opioid substitution treatment (OST),
Sufficient availability & easy access to treatment
Oral substitution treatment: Reduces illicit heroin use, injecting and needle sharing, high numbers of sex partners
Cochrane review on substitution = Gowing et al 2005
Enhanced prevention and information on risk behaviour
Outreach work to establish contact with ‘hard-to-reach’ and high risk groups, education on risk reduction
Access to sterile syringes and other injection material, condom distribution
Incentives to inf. disease screening and vaccination (VCT)
Access to medical treatment of infectious diseases

17. Introduction of methadone treatment and needle and syringe programmes, in the 25 EU Member States
This slide here shows again the previously mentioned trend in adopting substitution treatment as a modality,
And combines it with the rate of adoption of syringe exchange as response measure.
You can see that – following 1985 – NSP became increasingly common among EU countries; nowadays its available in 24 countries and planned in the remaining one – Cyprus.
There were of course large controversies surrounding the introduction of this measure – and levels of provision and utilisation are not at all homogenous across the EU. However, it is an acknowledged response across the region and levels of distribution of sterile syringes are in some countries considerable:

18. 10-year trend in the number of substitution treatment clients in Europe (EU-15)
This slide shows, for the 15 member states of the EU up to 2003, the estimated number of clients in substitution treatment.
It is estimated that in the EU more than half a million opioid users received substitution treatment in 2003, which represents one-third of the currently estimated 1.5 million problem opioid users (EMCDDA, 2006).
This suggests that the implementation of this treatment for opioid users is large in the European Union, however, there seems also room for still increasing the coverage of substitution treatment among opioid users, in the light of its proven effectiveness to reduce illicit consumption and associated risks.
The new Member States and candidate countries account for only a small fraction of the clients in substitution treatment in the European region, which can partly be explained by lower levels of opioid use in these countries. Although the overall provision of substitution treatment remains low in these countries, there are some indications of increases in Estonia, Lithuania and Bulgaria.
Data sources for the different estimates:
EMCDDA Annual report 1998, 2001 and See further detailed information in: EMCDDA Annual report 2003, Table 3 development of substitution treatment in the 15 EU Member States and Norway. The data for 2003 were submitted via ST Treatment by National Reitox Focal Points in 2004

19. Substitution Treatment for Opioid Dependence in prisons
… works!
Reduces:
level of injecting
blood borne viruses transmission
drug related prison violence and crime following release
recidivism
But needs adequate doses (>60mg)

20. Opioid Substitution Therapy (OST) (WHO, Verster 2007, modified)
OST most effective treatment for opioid dependence
OST in prisons
facilitates post-release treatment
decreases re-incarceration
has positive effects on institutional behaviour
helps reduce risk of overdose upon release
Puerto Rico: Heimer et al., 2005; Spain: Boguna, 1997; Canada: Johnson et al., 2001; Stöver et al. 2004
The second key interventions: drug dependence treatment
A wealth of scientific evidence has shown that, in the community, OST is the most effective intervention available for the treatment of opioid dependence: improving the physical and social wellbeing of the patient and has been associated with reductions in risk behaviour, illegal drug use, mortality, and HIV transmission as well as in criminal behaviour.
Now, a substantial body of research has delivered significant findings regarding the effectiveness of OST in prison settings.
The effectiveness and acceptability of OST and in particular of MMT in prison settings have been shown in studies from Australia, Western Europe, Canada, United States, and Iran. Among the most significant findings are:
Adequate prison-based OST programmes appear to be effective in reducing injecting drug use and associated needle sharing.
Adequate prison-based OST programmes have additional and worthwhile benefits. In particular, studies found that
OST in prison significantly facilitates entry and retention in post-release treatment compared to prisoners enrolled in detoxification programmes;
re-incarceration is significantly less likely among those prisoners who receive OST while incarcerated;
OST has a positive effect on institutional behaviour by reducing drug-seeking behaviour and thus improving prison safety; Although prison administrations often initially raise concerns about security, violent behaviour and diversion of methadone, these problems do not emerge once the OST programme is implemented
OST may help to reduce risk of overdose for those nearing release.

21. Substitution coverage rate in prisons (EU <1st May 2004 Stöver/Hennebel/Casselman 2004)
3 countries provided no substitution treatment in prisons (Czech Republic, Greece and Sweden)
< 10% Poland (0,3%), Finland (1,5%), Germany (3,5%), Belgium (5%),
< 15% Italy (12%), Portugal (10-17%), France, Scotland (14%)
< 55% Slovenia (32%), Austria (33%), Ireland (46%), Denmark (55%)
> 55% Spain 82% (21,600 from 26,400)
Approx. 120,000 problematic drug users in prisons approx. 30,000 receive ST (25%)
Problematic caculations, because figures often base on estimations etc.
7% without Spain

22. Beneficial Effects of Substitution Treatment for Prisoner and Prisons
Reduction of drug use and related risk behaviour (e.g. sharing of needles/equipment)
Morbidity: physical and psychological effects (e.g. anxiety of inmates) Mortality: Need to expand prison based programmes and links to community based programmes to reduce opiate related mortality soon after release from prison.
Control related issues (e.g. management of opiate addicted inmates)
Thanks to the pioneers Alex Wodack and Kate Dolan in Australia:
MMT patients least likely to report injecting heroin, sharing syringes Crucial point: MMT effective when moderately hig dose, entire period of imprisonment. MMT patients scored lower on the HIV risk-taking scale.
MMT reducing impact on anxiety amongst prisoners, easier to manage + No conflicts between treated and untreated + No negative side-effects of PMMT (e.g. black market) feared by staff + Staff feels ambivalent or negative towards PMMT + ...inmates as well NSW/Australia prison staff lacked an understanding of the aims and objectives of PMMT
Canadian study significant reduction in „serious drug charges“ during and after PMMT
Heterogenity of experiences highlighting the inconsistencies in prison prescribing policies (no treatment, painkillers/sedatives, meth. And lofexidine) + Treatment determined by doctor‘s view and not by injector‘s treatment needs + User‘s views are useful, reliable accounts offering a rich source of data for policies, practices
Suitable medication? + Subjective preferences and perceived needs should be considered

23. Part III.Responses: Harm Reduction

24. Comprehensive approach
Harm reduction is an integral part of a comprehensive social and health approach
Dissonanz-Shaping‘from health psychology: the gap between risks and coping abilitis should not be too big. If it is tooo big the health goals to be achieved can be rejected easily and not be integrated into the self concept.
The strength of ‚dissonance‘ should remain ‚acceptable‘ . No confrontation. !

25. Condoms & other measures to decrease sexual transmission (WHO, Verster 2007, modified)
Providing condoms is feasible in prison settings
No security problems or other negative consequences
Prisoners use condoms when accessible
Need for measures to combat, report rape and sexual abuse
Post Exposure Prophylaxis (PEP) available?
Correctional Service Canada, 1999; Dolan, Lowe & Shearer, 2004; May and Williams, 2002; Yap et al., 2007)
The third key interventions on preventing sexual transmission
available research and the experience of the many prison systems in different parts of the world in which condoms have been provided to prisoners for many years, without any reported problems, suggest that providing condoms in prisons is feasible in a wide range of prison settings.
No prison system allowing condoms has reversed its policy, and none has reported security problems or any other relevant major negative consequences.
In particular, it has been found that condom access is unobtrusive to the prison routine, represents no threat to security or operations, does not lead to an increase in sexual activity, and is accepted by most prisoners and correctional officers once it is introduced. Generally, only minor incidents of misuse such as water balloons, water fights and littering were recorded, and no incidents of drug concealment.
Studies have not determined whether infections have been prevented due to condom provision in prison. However, there is evidence that prisoners use condoms to prevent infection during sexual activity when condoms are accessible in prison. It can therefore be considered likely that infections have been prevented.
Finally, the evidence suggests that condoms are more likely to be used if they are easily and discreetly accessible to prisoners so that they can pick them up at various locations in the prison, without having to ask for them and without being seen by others.
However, the evidence also shows that provision of condoms is not enough to address the risk of sexual transmission of HIV in prisons.
Violence, including sexual abuse, is common in many prison systems. Measures to combat aggressive sexual behaviour such as rape, exploitation of vulnerable prisoners, and all forms of prisoner victimization are therefore as important as provision of condoms.

26. Obstacles in accessibility? Next best solutions! Cannot reüplace NSPs
Provision of Bleach
Obstacles in accessibility?
Next best solutions! Cannot reüplace NSPs
Which bleach can be used for syringes?
What is the exact procedure?
Doubts about the effectiveness
- Conditions in prisons reduce
probability of effective decontamination

27. Little change or reduction
Evidence of Needle Exchange Programs (NSPs) (WHO, Verster 2007, modified)
Prison
Incidenc eHIV
Needle sharing
Drug use
Injecting
Am Hasenburg (D)
No increase
Basauri (Es)
No HIV
Hannoversand (D)
Hindelbank (CH)
Decrease
Lehrter Strasse & Lichtenburg (D)
No HIV but HCV
Lingen/Gross- Hesepe (D)
Realta (CH)
Single cases
Vechta (D)
Vierlande (D)
Little change or reduction
Systematic evaluations of the effects of NSPs on risk behaviours and of their overall effectiveness in prisons were carried out in at least 10 projects in Switzerland, Germany, and Spain.
There is evidence that NSPs are feasible in a wide range of prison settings, including in men’s and women’s prisons, prisons of all security levels, and small and large prisons.
There is also evidence that providing clean needles and syringes is readily accepted by IDUs in prisons and
More importantly that they contribute to a significant reduction of syringe sharing over time
Which is if crucial importance for reducing HIV transmission.

28. Canadian HIV//AIDS Legal Network
Prepared by
Rick Lines
Ralf Jürgens
Glenn Betteridge
Heino Stöver
Dumitru Laticevschi
Joachim Nelles
Published by the
Canadian HIV//AIDS Legal Network
2nd edition 2006
English and French

29. Part IV. Responses Dublin Declaration

30. “Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia”
Signed in Dublin, 2004
Key document
33 actions for governments: - leadership - prevention - living with HIV (incl. treatment & care) - partnership in 53 WHO countries
see

31. Monitoring harm reduction in European prisons via the Dublin Declaration
To assess progress on commitments
Chapter 15 dedicated to situation in European prisons: - harm reduction - iv drug users - HIV in prisons

32. Dublin Action 9: By 2010, ensure through the scaling up of programmes that 80% of the persons at the highest risk of and most vulnerable to HIV/AIDS are covered by a wide range of prevention programmes providing access to information, services and prevention commodities and identifying and addressing factors that make these groups and communities particularly vulnerable to HIV infection ….

33. Providing prevention and treatment standards: 53 countries of Europ
Providing prevention and treatment standards: 53 countries of Europ. region
Condoms = 18
Syringe exchange = 6
Substitution treatment = 17
Bleach programmes = 9
Voluntary HIV testing and counselling = 9
Sexual health services = no data
Antiretroviral treatment =14

34. HIV prevention measures in prisons in the EU, outside and inside of prisons
As is clear fromthis figure, the provision of harm-reduction and HIV-prevention measures in prisons lags far behind the availability of these interventions in the community outside of prisons in these countries, most strikingly in the area of syringe exchange. While 24 of the 25 EU Member States have syringe exchange programmes in the community, only 3 of those 24 have initiated them in prisons.
This disparity led the Commission to conclude that, “harm reduction interventions in prisons within the European Union are still not in accordance with the principle of equivalence adopted by UN General Assembly, UNAIDS/WHO and UNODC, which calls for equivalence between health services and care (including harm reduction) inside prison and those available to society outside prison. Therefore, it is important for the countries to adapt prison-based harm reduction activities to meet the needs of drug users and staff in prisons and improve access to services.” Although it represents only approximately half of those countries covered by Dublin Declaration commitments, this survey clearly demonstrates the current gap in prison-based services, even among high-income countries in the region.
European Commission, April 2007

35. Conclusions (1/4)
Prisons remain a major gap, transmission of infectious diseases in prisons & prison release mortality need a coherent and measured response
Principle of equivalence: Consensus on the role and efficacy of substitution treatment and other evidence-measured interventions has to be acknowledged in prisons

36. Close connection between prison and community health care services
Conclusions (2/4)
Close connection between prison and community health care services
Development of transparency of practice and policies – for inmates and the community professionals
Health care standards and clear guidelines on the basis of evidence-based knowledge
The principle of equivalence
The principle of equivalence means that the health care measures (medical and psychosocial) successfully proven and applied outside prison should also be applied inside prison. With regard to support for drug using inmates in many ways this has turned out as wishful thinking. In most of the countries already basic prerequisites are not given (i.e., no throughcare of treatment, no adequate prevention means).
Nevertheless the principle of equivalence is the guiding criteria, with which prison drug services have to be measured in the context of the national drug service structure and the drug policies pursued in all EU member states. Especially the differentiation of drug services (including drug free treatment, methadone maintenance and harm reduction) outside is not reflected sufficiently inside prison. ‘Prison Health’ has to be integrated in the broader frame of ‘Public Health’.

37. Conclusions (3/4)
Dublin Declaration: 80% coverage of comprehensive HIV programmes and services in prisons by 2010?
Scaling – Up of services example OST: England
Proposal for a Council of Europe ‘Recommendation on drugs and prison’:
develop activities to prevent drug use
facilitate the access to treatment of drug users,
increase access to harm reduction/reintegration services for (ex) prisoners and
To monitor/analyse drug use in prisons

38. Conclusions (4/4) :Prison Responses to Health Challenges
Equivalence of health care
Throughcare
Lack of seamless provision of health care
Responsibility for health care
Involvement of NGOs
Lack of funding and human resources
Drug-free oriented treatment and prevention
Interruption of treatment: the case of substitution treatment
Absence of harm reduction measures
Lack of implementation of international standards and guidelines
Missing links with community health care services

39. „. Prisoners are the community
„... Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities “ (Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons)
By entering our penal facilities, prisoners are condemned to imprisonment for their crimes; they should not be condemned to be under pressure to continue their drug abuse or denied the means to protect themselves against communicable diseases. Govern­ments and prison authorities have a moral and legal responsibility to prevent the spread of HIV infection among prisoners and prison staff and to take care for those infected. They also have a responsibility to prevent the spread of HIV among communites. Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities“. (C. Goos, WHO, 1997, S.7)
Further Information :