Transcript What constitutes ‘success’ with drug problems?

If I ruled the world…
Presentation to Prisons and Beyond
NOMS Prison Drug Strategy Unit, in association with the Federation of Drug & Alcohol
Professionals (FDAP) and European Association for the Treatment of Addiction (EATA)
Leicester, 16th Feb 2006
Neil Hunt
Chair, UK Harm Reduction Alliance
Director of Research, KCA
Honorary Senior Research Associate, EISS,
University of Kent
…this would be fully implemented
“Healthcare in prisons should promote the health
of prisoners; identify prisoners with health
problems; assess their needs and deliver treatment
or refer to other specialist services as appropriate.
It should also continue any care started in the
community contributing to a seamless service and
facilitating throughcare on release.”
The Future Organisation of Prison Health Care Report by the Joint
Prison Service & NHS Executive Working Group
Dept of Health (1999)
Two important gaps
• Opioid substitution treatment
– Patchy provision at best
• Needle exchange
– Pilot work on discharge from Scottish prisons
But…to what extent are they feasible and
how well do they work in prisons?
Evidence: opioid substitution
treatment in prisons
• Heroin injecting and syringe sharing reduced in
Australia
Dolan et al (2003) A randomised controlled trial of methadone maintenance treatment
versus wait list control in an Australian prison system.. Drug and Alcohol Dependence.
72: 59-65
• Heroin use reduced in Puerto Rico
Heimer et al (2005) Methadone maintenance in prison: Evaluation of a pilot program in
Puerto Rico. Drug and Alcohol Dependence.
• Retention in MMT associated with reduced
mortality, re-incarceration rates and hepatitis C
infection in Australia
Dolan et al (2005) Four-year follow-up of imprisoned male heroin users and methadone
treatment: mortality, re-incarceration and hepatitis C infection. Addiction. 6: 820-828
• And forthcoming study of methadone treatment in
Scottish prisons
Methadone treatment also available in…
• Switzerland
• Germany
• Spain
Evidence: needle exchange in prisons
Stover & Nelles (2003) Review of 10 years experience in
46 prisons in 4 countries
• Results did not support fears that commonly arise in the
start-up of implementation of Needle Exchange
Programmes in Prisons.
• Syringe distribution was not followed by an increase in
drug use or injection drug use.
• Syringes were not misused, and disposal of used syringes
was uncomplicated.
• Sharing of syringes among drug users reduced.
Stover and Nelles (2003) Ten years of experience with needle and syringe
exchange programmes in European prisons. International Journal of Drug
Policy. 14: 437-444
Evidence: needle exchange in prisons
Lines et al (2004) Review of evidence from 6 countries
(Switzerland, Germany, Spain, Moldova, Kyrgyzstan, Belarus)
• Do not endanger staff or prisoner safety, and in fact, make prisons
safer places to live and work.
• Do not increase drug consumption or injecting.
• Reduce risk behaviour and disease (including HIV and HCV)
transmission.
• Have other positive outcomes for the health of prisoners.
• Have been effective in a wide range of prisons.
• Have successfully employed different methods of needle
distribution to meet the needs of staff and prisoners in a range of
prisons.
This report also provides detailed accounts of implementation
issues within prisons
Lines et al (2004) Prison needle exchange: lessons from a comprehensive review of international evidence and experience. Canadian HIV/AIDS Legal Network
Models that have been used
• Hand-to-hand distribution by prison nurse
and/or physician
• Hand-to-hand distribution by peer outreach
workers
• Hand-to-hand distribution by external
agencies/health workers
• Automated dispensing machines
Treatment in prison: expected best practice
WHO, UNAIDS, UNODC (2004)
“The evidence shows that such programmes should include
all the measures against HIV transmission which are
carried out in the community outside prisons, including
HIV/AIDS education, testing and counselling performed
on a voluntary basis the distribution of clean needles,
syringes and condoms, and drug-dependence treatment,
including substitution treatment. All these interventions
have proved effective in reducing the risk of HIV
transmission in prisons. They have also been shown to
have no unintended negative consequences.”
WHO, UNAIDS, UNODC (2004) Policy Brief: reduction of HIV transmission in prisons. Available
http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/
Is there a need in the UK?
England and Wales
Representative sample from 8/135 prisons
Ever injected
First injected in
prison
(injectors)
Ever injected in
prison
(injectors)
n (%)
n (%)
n (%)
Shared in prison
(prison injectors)
n (%)
Male
n = 2769
660 (24%)
36 (6%)
195 (31%)
147 (75%)
Female
n = 407
117 (29%)
3 (3%)
29 (26%)
20 (69%)
Young
offender
n = 714
30 (4%)
1 (3%)
6 (20%)
3(50%)
Weild et al. (2000) Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in
England and Wales: a national survey Communicable Disease and Public Health. 2: 121-126.
Scotland (15 prisons)
May/June 2005
(77% response rate from ALL Scottish prisoners)
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Half of prisoners (50%) had used drugs in prison
Three quarters (76%) reported decreased drug use in prison
17% reported increased drug use
A third (34%) had used drugs in prison in the past month
67% who used drugs in the past month used heroin
126 (3%) reported injecting in prison in the last month.
78 (62%) prisoners had shared their injecting equipment
Scottish Prison Service
http://www.sps.gov.uk/Uploads/42078F46-343E-4D93-8AC8-7E62AEB37482.pdf
Northern Ireland (3 prisons)
• March to November 2005
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Committed on drug related charges - 134
Passive dog indications among visitors - 1486
Dependent on committal – Heroin 72
Heroin finds – 18.2g + 14 tablets
Needle finds - none
• Paucity of data
– History of injecting?
– Injected/used heroin in prison?
– Shared injecting equipment in prison?
Northern Ireland Prison Service Drug Report
http://www.niprisonservice.gov.uk/module.cfm/opt/14/area/Drug%20Report/page/drugseizures/
So, there does seem to be some need.
But…prisons are different to the
wider community
Services need to reflect the vulnerability
and particular circumstances of prisoners.
For example:
– Prisoners with serious mental health problems
– Prisoners assessed as presenting a serious risk
of violence
– Prisoners who use prison as a life event that
enables abstinence
– Prisoners are subject to a far higher level of
surveillance and control
And…
Services have to be adapted to reflect the
requirements of a secure environment
– Prisons have a duty of care that differentiates
them from community services
– Optimum models of service provision do not
necessarily translate across from community
services directly
I think this all means…
• Protecting the interests of those who use the
prison environment constructively as a
relatively drug-free environment
• Drawing on best evidence of ‘what works’
in prisons elsewhere
• Only a fool would pretend we have all the
answers
So, if I ruled the world…
• We would roll out opioid substitution treatment
(i.e. methadone AND buprenorphine treatment)
across UK prisons vigorously
• We would roll out needle exchange, but more
cautiously
• We would simultaneously undertake a rigorous
and comprehensive programme of quantitative and
qualitative evaluation
Reference summary
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Dept of Health (1999) The Future Organisation of Prison Health Care Report by the Joint Prison
Service & NHS Executive Working Group.
Dolan et al (2003) A randomised controlled trial of methadone maintenance treatment versus wait list
control in an Australian prison system.. Drug and Alcohol Dependence. 72: 59-65
Heimer et al (2005) Methadone maintenance in prison: Evaluation of a pilot program in Puerto Rico.
Drug and Alcohol Dependence.
Dolan et al (2005) Four-year follow-up of imprisoned male heroin users and methadone treatment:
mortality, re-incarceration and hepatitis C infection. Addiction. 6: 820-828
Stover and Nelles (2003) Ten years of experience with needle and syringe exchange programmes in
European prisons. International Journal of Drug Policy. 14: 437-444
Lines et al (2004) Prison needle exchange: lessons from a comprehensive review of international
evidence and experience. Canadian HIV/AIDS Legal Network
http://www.iprt.ie/files/iprt/prison_needle_exchange__lessons_from_a_comprehensive_review_of_in
ternational_evidence_and_experience.pdf
WHO, UNAIDS, UNODC (2004) Policy Brief: reduction of HIV transmission in prisons.
http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/
Weild et al. (2000) Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England
and Wales: a national survey Communicable Disease and Public Health. 2: 121-126.
http://www.hpa.org.uk/cdph/issues/CDPHVol3/no2/bbv.pdf
Scottish Prison Service 2005 National Prisoner Survey
http://www.sps.gov.uk/Uploads/42078F46-343E-4D93-8AC8-7E62AEB37482.pdf
Northern Ireland Prison Service Drug Report
http://www.niprisonservice.gov.uk/module.cfm/opt/14/area/Drug%20Report/page/drugseizures//
Neil Hunt
e: [email protected]
t: 01622 717652
m: 07780 665 630