Transcript Folie 1

Treatment and Harm Reduction
in Prison and
Continuity of Care
Caren Weilandt
WIAD (Scientific Institute of the German
Medical Association), Bonn
EMCDDA Conference Lisbon 6-8 May 2009
EC Experts’ Report on Prevention, Treatment,
and Harm Reduction Services in Prison
pulished November 2008
Consortium (WIAD, Bonn, University Bremen and
Centre for Interdisciplinary Addiction Research,
Hamburg)
The full report is available at EC and other webpages
http://ec.europa.eu/health/ph_determinants/life_style/drug/drug_call_en
.htm#obj
EMCDDA Conference Lisbon 6-8 May 2009
Acknowledgements
 Heino Stöver, Bremen Institute for Drug Research
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(BISDRO), University of Bremen
Doris Radun, Robert Koch-Institute, Berlin
Christina Hartwig, Centre for Interdisciplinary Addiction
Research (CIAR), University of Hamburg
Katja Thane, Centre for Interdisciplinary Addiction
Research (CIAR), University of Hamburg
Heike Zurhold, Centre for Interdisciplinary Addiction
Research (CIAR), University of Hamburg
Methodology
 Search
– Databases, publications
– National reports EMCDDA focal points
– WHO Europe, Pompidou group, UNAIDS,
UNODC
– Contacts to national and international experts
EMCDDA Conference Lisbon 6-8 May 2009
Prison background data
 600,000 prisoners, approx. 2 Mio per year
 Average 121 per 100,000 (56 Slo-337Est)
 Increasing number of prisoners in many
countries; esp. female prisoners
 Average 5% female
 8-35% migrants
 Overcrowding: average prison density 109
EMCDDA Conference Lisbon 6-8 May 2009
Prison density per 100 places
0,0
Cyprus
Greece*
Hungary
Italy
Spain
Czech Rep.*
Poland
France
Belgium*
Portugal*
Sweden
Slovenia
Austria*
Germany
Finland
Slovakia
United Kingdom
Denmark
Estonia
Ireland*
Netherlands
Latvia
Lithuania
Luxemb ourg
Malta
"EU average"
Bulgaria
Romania
20,0
40,0
60,0
80,0
100,0
120,0
140,0
160,0
180,0
160,6
156,9
144,9
131,5
129,5
115,6
114,0
113,5
113,0
109,1
103,3
102,1
101,1
100,6
99,1
99,0
96,4
95,6
95,1
94,5
92,6
85,0
80,5
80,2
62,6
109,6
122,8
104,0
Ref.: Council of Europe, SPACE 2004.1
EMCDDA Conference Lisbon 6-8 May 2009
Sentenced prisoners by main
offence: drug offences in percent
0,0
Portugal*
Greece*
Italy
Malta*
Sweden
Netherlands
Luxembourg
Spain
Denmark
Ireland*
Finland
United Kingdom
France
Cyprus
Germany
Slovenia
Latvia
Lithuania
Czech Republic*
Estonia
Slovakia
Hungary
"EU average"
Romania
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
45,0
41,5
38,1
35,4
31,7
23,1
22,5
22,4
21,5
21,4
19,6
17,9
16,9
15,7
14,7
14,6
11,0
8,5
4,8
4,4
4,4
3,0
1,7
18,5
1,6
Ref.: Council of Europe, SPACE 2004.7
EMCDDA Conference Lisbon 6-8 May 2009
Spread of HCV among
Prisoners
 High risk behaviour and high risk
environment: HCV-prevalence 50-90%
 Poor understanding of HCV dynamics
 Unsafe injecting common
 Tattooing widespread
 Sharing of razors etc.
EMCDDA Conference Lisbon 6-8 May 2009
Prison are high risk
environments
 Loss of health protective means
 High risk of overdose after release
 Self harm over-represented
 Discontinuation of treatment
 Sexual violence (underreporting)
EMCDDA Conference Lisbon 6-8 May 2009
Health Consequences for
prisoners
 drug related deaths after release
 suicide attempts
 self harm
 drug use related diseases are manifold
higher than outside prisons walls
 unsafe injections, sexual practices,
tattooing and piercing
EMCDDA Conference Lisbon 6-8 May 2009
Health Consequences for
prison staff
 Risk of infections with blood borne diseases
while searching cells or by accidental
needle stick injuries
 Violence
 Lack of understanding of addiction
EMCDDA Conference Lisbon 6-8 May 2009
Knowledge and Attitudes of prison
staff
… lack of staff (88,6%)
… lack of safety for prison staff (46,5%)
… Overcrouding = Problem (62,8%)
… lack of information on infectious diseases (44,7%)
… high infections risk Hepatitis B/C, TB, HIV (42-50%)
… Violence among prisones (98,3%)
Against the introduction of HR measures:
needles and syringes:
67%
steril tattooing eqipement: 79%
EMCDDA Conference Lisbon 6-8 May 2009
Transmission of BloodBorne-Viruses in Prisons
 HIV outbreaks
 Transmission of HCV/HBV
 Imprisonment independent predictor for
HCV
 Tattooing/piercing
EMCDDA Conference Lisbon 6-8 May 2009
EC Council
Recommendation???
 Impact assessment done in 2008
 Specific and operational objectives on
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Prevention
Treatment
Harm reduction
Reintegration
Monitoring/analysis of drug use among prisoners
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Prevention (1/2)
 Improving education, information and
communication
– tailor-made prevention material (e.g. youth, migrants, women)
– Provide accurate and non-judgemental information
– Increase the knowledge, attitudes and skills of both prisoners
and staff with regard to drug use, drug related infectious
diseases, drug injecting, STIs, tattooing and piercing
 Tackle the problem of physical, psychological
and sexual violence around drug trafficking,
consumption and sexual contacts
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Prevention (2/2)
 Provide internal and external counselling in order
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to promote risk reduction and to facilitate access
to appropriate treatment, care and support
services
Involve NGOs (confidential partners for sensitive
topics like unprotected sex, illicit drug use)
Integrate families and communities in prevention
strategies (very important in the period before
and after release, maintenance of achievements)
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Treatment (1/2)
 Offering diversity of counselling, treatment, care,
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and support (social services, drug-care units,
drug counselling and drug treatment services)
Improved Strategies of “therapy instead of
punishment”
Motivational interventions (offered by
professionals inside or outside prisons or peers)
help to increase motivation for change and
compliance with treatment regime
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Treatment (2/2)
 Reduction of drug related morbidity and
mortality by improved screening and
treatment of infectious diseases
 Reduction of overdose mortality
(reference to community treatment
facilities on release, overdose prevention
activities before release)
 Offer protected environment (e.g. drug
free units) to motivated drug users
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
HR (1/2)
 Access to evidence based measures to reduce
the prevalence and incidence of BB infections
– “safer use” training facilitated by information
– safer use kits containing sterile injection material,
disinfectants and instructions how to use them
– syringe/needle exchange programmes
 Support safer sex
– information material
– easily accessible condoms and lubricants
– possibility of conjugal visits for inmates with their
spouses/ partners
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
HR (2/2)
 Improvement of voluntary testing opportunities (HIV, hep,
STDs, TB), stick to personality rights and data protection
rules
 Free vaccination for prisoners and staff
 Reduce drug related mortality by implementation of
measures to reduce morbidity, and the risks of overdose
deaths (drug treatment opportunities which minimise
uncontrolled use, relapse prevention interventions after
detoxification, staff competence to apply resuscitation in
case of acute overdosing).
 Reduce intravenous drug use and needle sharing by offering
substitution maintenance treatment for all IDUs in prison
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Reintegration (1/1)
 Connect prison drug services with
community services
 Seamless provision of care after release:
improve collaboration between prison and
community health care services
 Involve NGO services already during
prison sentence in care and treatment
planning
EMCDDA Conference Lisbon 6-8 May 2009
Operational Objectives:
Monitoring (1/1)
 Standards for monitoring , documentation,
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analysis and reporting on prevalence, incidence
and trends of drug use, infectious diseases and
related risk behaviours inside prisons should be
developed and implemented in all EU MS.
Standards should be developed on EU level (i.e.
a common EU protocol and instruments which
allow collecting comparable and reliable data)
A standard protocol including a standard
questionnaire and methodological and ethical
recommendations about how to implement a
prison survey on health and drug-related issues.
EMCDDA Conference Lisbon 6-8 May 2009
Need for research
 Epidemiology of infec. diseases and health risks in the
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prison setting (cross sectional and longitudinal)
Identifying key figures for a monitoring system
Evaluation of the long-term effects of interventions and
derivation of ‘Good Practice’
In-prison treatment and intervention monitoring: what
works and why?
Obstacles of transfer of harm reduction measures into the
prison setting
Cost effectiveness and cost benefit of in-prison and
throughcare programmes
Better understanding of drug use patterns (drugs,
frequency, amounts, routes of administration)  qualitative
research
EMCDDA Conference Lisbon 6-8 May 2009
EU and MS policy
 Acknowledgement of the prisons as priority settings
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for effective health responses
Continuous development of alternatives to
imprisonment
Need for comparable and reliable information on
situation and responses to drug use in prison
Promotion of exchange of good practice between MS
Closing the ‘treatment gap’ to prevent undermining
health gains achieved in the community (prisons can
provide opportunity for effective interventions)
EMCDDA Conference Lisbon 6-8 May 2009
EMCDDA Conference Lisbon 6-8 May 2009
Under development
 UNODC Toolkit for HIV Situation
and Needs Assessment in Prison
Settings
 Draft will be out for field testing end of
May 2009
EMCDDA Conference Lisbon 6-8 May 2009
SANCO funded project
www.TCJP.eu
EMCDDA Conference Lisbon 6-8 May 2009
DG JLS funded Project
On the Outside: Continuity of care
for people leaving prison
Sainsbury Centre for Mental Health
2008
EMCDDA Conference Lisbon 6-8 May 2009
Good prison health is good
public health!
Thanks for your attention!
EMCDDA Conference Lisbon 6-8 May 2009