Study on Assistance To Drug Users in Prisons 2001 Dr. Heino Stöver, Carl von Ossietzky University of Oldenburg Project leader: Petra Paula Merino, EMCDDA, Drug Demand Reduction EMCDDA scientific report Study on Assistance To Drug Users in Prisons Acknowledgement 4 Preface 1 Introduction 2 PART I: METHODOLOGY AND DEFINITIONS 4 I.1. Methodology 4 I.2. Definitions 4 PART II: DESCRIPTION OF THE SITUATION 8 II.1. Introduction 8 II.2. Prevalence of drug use among prisoners 8 II.3. What do we know about drug use in prison: drugs, patterns and frequency of use, routes of administration? 14 II.4 Drug use and drug related deaths after release from Prison 20 II.5 Infectious diseases in European Prisons 22 II.5.1. HIV/AIDS 22 II.5.2. Hepatitis B/C 24 II.5.3. Tuberculosis 27 II.6. Specific target groups: women, migrants and young offenders 27 II.6.1. Women 27 II.6.2. Migrants 30 II.6.3. Young offenders 30 PART III: DESCRIPTION OF THE RESPONSES 31 III.1. Introduction 31 III.2. Organisation and practice of health care and assistance provided to drug users in prisons 32 III.2.2. Heath care organisation 33 III.2.3. The principle of 'eQuivalence' in international guidelines and recommendations 36 1 Study on Assistance To Drug Users in Prisons III.2.4. Medical services and examination 38 III.2.5. Training of doctors and staff 39 III.3. Prevention offers 40 III.3.1. Prevention of drug use 40 III.3.1.1. Supply reduction 42 III.3.1.2. Demand reduction 44 III.3.2. Prevention of sexual transmission 45 III.3.2.1. Provision of condoms 46 III.4. Abstinence oriented treatment 48 III.4.1. Detoxification 49 III.4.2. Drug free units and drug free wings 51 III.4.3. Therapeutic Communities in prison 56 III.5. Substitution Treatment 56 III.5.1. Key issues of methadone prescription 66 III.5.2. Standards and guidelines for methadone prescription 69 III.5.3. Provision of Original Substances in Prisons in Switzerland. 73 III.6. Harm-reduction measures 74 III.6.1. The transfer of harm reduction strategies into the prison setting 75 III.6.2. Blood Screening and HIV testing 76 III.6.3. Training and seminars 77 III.6.4. Vaccination Programmes 80 III.6.5. Provision of disinfectants 80 III.6.6. Needle exchange programmes 84 III.7. Community Links 91 III.7.1. Pre-Release units and release 92 III.7.2. Aftercare 93 III.7.3. Working with families and maintaining family ties 94 III.7.4. Through care 95 III.7.5. Therapeutic Communities for sentenced offender outside prison 96 PART IV: EVALUATION OF DEMAND AND HARM REDUCTION INTERVENTIONS IN PRISONS IN THE EU 99 IV.1. Introduction 99 IV.2. Evaluation criteria 100 2 Study on Assistance To Drug Users in Prisons IV.3. Results of evaluations 100 CONCLUSIONS 109 Health risks 111 Drug free treatment 113 Substitution treatment 113 Transfer of harm reduction measures into prisons 114 Knowledge 115 APPENDICES: EUROPEAN GUIDELINES AND RECOMMENDATIONS 119 A1 Prison and Drugs 1998: European Recommendations (The European Network of Drug and HIV/AIDS Services in Prison/Carl von Ossietzky University of Oldenburg) 119 A2 Prison and Drugs 1998: Youth and Women – European Recommendations (The European Network of Drug and HIV/AIDS Services in Prison) 123 A3 Conclusions of ‘The European Peer Support Project phase 3: Risk reduction activities in prison' (Trimbos Institute Utrecht/The Netherlands; Carl von Ossietzky University Oldenburg/germany, January 1998) 126 A4 European Guidelines on HIV/AIDS and Hepatitis in Prison (Milan, May 1999, Launched by the European Network on HIV and Hepatitis Prevention in Prison) 128 A6 Council Of Europe, Committee Of Ministers, Recommendation No. R (98) 71 Of The Committee Of Ministers To Member States Concerning The Ethical And Organisational Aspects Of Health Care In Prison 137 REFERENCES 145 LIST OF EXPERTS INVOLVED 158 USEFUL WEBSITES 164 FEED-BACK FORM 166 3 Study on Assistance To Drug Users in Prisons Acknowledgement This report would not have been possible without the support of many European experts in the field of drug use, infectious diseases and prisons, who have been involved in this study (see chapter ‘list of experts involved’). Thanks also to those who contributed to this report and provided much valuable information: Jan van den Brand, Murdo Bijl, Chloé Carpentier, José Carron, Johannes Feest, Jutta Jacob, Djamel Khodja, Sheila R. McNerney, Carlo Reuland, Harald Spirig, Charlotte Trabut, Franz Trautmann. Finally, thanks to all those who gave their time to participate in this study. 4 Study on Assistance To Drug Users in Prisons Preface The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is one of 11 decentralised agencies set up by the European Union to carry out specialised technical or scientific work. Established in 1993 and operational since 1995, the Centre’s main goal is to provide ‘objective, reliable and comparable information at a European level concerning drugs and drug addiction and their consequences’. Through the statistical, documentary and technical information it gathers, analyses and disseminates, the EMCDDA provides its audience – whether policy-makers, practitioners in the drugs field or European citizens – with an overall picture of the drug phenomenon in Europe. At its Helsinki meeting in December 1999, the Council of Europe formally adopted the European Union Drugs Strategy (2000–2004). The strategy has been translated into concrete action on the third EU action plan on Drugs. The Plan recommends that the Commission and Member States joint efforts to reduce the crime linked to drugs, notably juvenile and urban delinquency. In this context is recommended to consider the EMCDDA activities into the law and proactive in the EU Member States on the treatment of drug users and drug addicts in the criminal justice system, including following arrest, alternatives to prison, and treatment facilities within the penal system. Margareta Nilson 1 Study on Assistance To Drug Users in Prisons Introduction Prisons are mostly overcrowded1, stressful, hostile, and sometimes violent places, in which individuals coming from lower classes, ethnic and social minorities are overrepresented. Drug users and migrants belong to these groups in particular. Within the chain of law enforcement options that are available, imprisonment is a last resort. generally prisoners learn about crime in prisons and often without realising that they become identified as prisoners and conseQuently recidivism is more the rule than an exception (Farbring 2000). Prison also affects health of the inmates: “Prisons are an area of special concern. We know that in most countries the lower socio-economic strata are over-represented in the prison population. We also know that prison is a very disadvantageous environment for good health: lack of privacy, stress, reduced opportunities for social support, hygiene, overpopulation, which all have a negative impact on health.“ (goos 1997, 20). Consequently the WHO-consensus paper on „Mental Health Promotion in Prisons‘ is stating: „The WHO (Regional Office for Europe) Health in Prisons Project, aware that, in the absence of positive counter-measures, deprivation of freedom is intrinsically bad for mental health, and that imprisonment has the potential to cause significant mental harm ...“ (WHO 1998, 7). In a European study on health problems arising in prison health, three main problem areas were highlighted: substance abuse, mental health and communicable diseases (Tomasevski 1992). These three problem areas are closely interrelated since the mid-eighties. Already in 1988 the WHO (1990) made an analysis of drug use in prison and developed recommendations for managing health problems of drug users in prisons. This basic effort had led in the following decade to a number of international co- operation and exchange of information and experiences in tackling drug users’ health problems in prisons. Not only in European countries the number of prisoners has dramatically increased over the two last decades. Several factors contribute to that trend, like social developments of poverty, migration, violence and the politically accepted concept of incarceration and last but not least the widespread repressive legislation against drugs in the context of an increasing consumption. Today, more than 8 million people are held in penal institutions throughout the world – more than half in just three countries; China and Russia each have over one million prisoners and The United States has over two million prisoners. The situation of drug use is reflected in these custodial settings: As outside drugs are used especially by deprived people in the prisons. The drug free prison is an illusion. Nowadays, daily prison routine is dictated by drug-dependent inmates. The Ministries of Justice and Public Health even go as far as making the assumption that the drug problem rocks the foundations of the penal rehabilitation system. Some comments are going as far as stating that the prison is ”totally dominated by a drugs culture embodied in prisoners‘ attitudes, values and behaviours” (O’Mahony 1997a, 42). Drugs are seen as one of the main problems of the current prison system in Europe and other states on the world. A study released in July 2000 by the Justice Policy Institute (JPI) reports that the United States has 458,000 of its citizens incarcerated on non-violent drug charges. This number of drug offenders that the U.S. imprisons is 100,000 more than the entire prison population of the European Union (356,000 incarcerated for all crimes combined), even though the EU has 100 million more citizens than the United States (JPI 2000). The high costs of incarceration are of great importance as well: The study reveals that a Quarter of the amount Americans spend on prisons and jails in the year 2000 will be used to incarcerate non-violent drug offenders ($9.4 billion).