Continuity of care for drug users in prisons and beyond in four European countries -Final report- March 2019 Neither the European Commission nor any person acting on its behalf is responsible for the use which might be made of the information contained herein. Heino Stöver,1 Daniela Jamin,1 Orphée Sys,2 Wouter Vanderplasschen,2 Marie Jauffret- Roustide,3 Laurent Michel,4 Philippe Trouiller,4 Mariana Homem,5 Vânia Mendes,5 Andreia Nisa5 1. University of Applied Sciences, Institute of Addiction Research (ISFF), Frankfurt (DE) 2. Department of Special Needs Education, Ghent University, Belgium (BE) 3. Cermes3, Inserm U988, UMR CNRS 8211, EHESS, Université Paris Descartes, Paris (FR) 4. Pierre Nicole Centre, French Red Cross, CESP/Inserm U1018, Paris (FR) 5. APDES, Agência Piaget para o Desenvolvimento, Villa Nova de Gaia (PT) Corresponding address: Frankfurt University of Applied Sciences Institute of Addiction Research (ISFF) Nibelungenplatz 1 D-60318 Frankfurt Tel.: +49 69 1533 2823 Email: [email protected] www: https://www.frankfurt-university.de/de/hochschule/fachbereich-4-soziale-arbeit- gesundheit/forschung/forschungsinstitute/institut-fuer-suchtforschung-isff/ Layout: Eva Stiekema ([email protected]) Source (cover): Heino Stöver Contents PART 1 – SUMMARY OF PROJECT AND COUNTRY SITUATIONS 1 INTRODUCTION ............................................................................................................ 1 2 BACKGROUND.............................................................................................................. 2 2.1 GENERIC BACKGROUND ............................................................................................................... 2 2.2 SITUATION IN THE FOUR COUNTIES ............................................................................................... 3 2.2.1 Situation in Belgium ........................................................................................................... 3 2.2.2 Situation in France ........................................................................................................... 15 2.2.3 Situation in Germany ....................................................................................................... 19 2.2.4 Situation in Portugal ......................................................................................................... 29 3 GAPS BETWEEN NATIONAL LEGISLATION AND PRACTICE .................................34 4 METHODOLOGY ..........................................................................................................37 4.1 RESEARCH METHODS ................................................................................................................ 37 4.1.1 Participants ...................................................................................................................... 38 4.1.2 Procedure and data collection ......................................................................................... 40 4.1.3 Instruments ...................................................................................................................... 41 4.1.4 Data analysis ................................................................................................................... 42 4.2 THE RESEARCH TEAMS AND THE ROLE OF THE SCIENTIFIC COMMITTEE ......................................... 42 4.3 ETHICAL ISSUES AND ANONYMITY ............................................................................................... 42 4.4 LIMITATIONS AND CHALLENGES ................................................................................................... 43 5 RESULTS ......................................................................................................................45 5.1 MEDICAL SUPPORT AVAILABLE FOR USERS INSIDE ....................................................................... 45 AND OUTSIDE PRISON ............................................................................................................................ 45 5.1.1 Health insurance .............................................................................................................. 45 5.1.2 Access to general support and care when entering prison ............................................. 47 5.1.3 HIV / ART / HCV .............................................................................................................. 50 5.1.4 OST .................................................................................................................................. 52 5.1.5 Naloxone .......................................................................................................................... 55 5.1.6 Psychiatric care ................................................................................................................ 56 5.1.7 Harm reduction tools (needle exchange, clean equipment, bleach,…) ........................... 58 5.2 SOCIAL SUPPORT AVAILABLE FOR USERS INSIDE AND OUTSIDE PRISON ......................................... 60 5.2.1 Psychosocial support in general ...................................................................................... 60 5.2.2 Housing ............................................................................................................................ 67 5.2.3 Work and education ......................................................................................................... 69 5.2.4 Finances and administration ............................................................................................ 72 5.2.5 Drug-related treatment ..................................................................................................... 74 5.2.6 Leisure time and relationships ......................................................................................... 77 5.2.7 Other types of support ..................................................................................................... 80 5.3 SPECIFIC PREPARATION FOR RELEASE ........................................................................................ 81 5.4 CHALLENGES ON RELEASE ......................................................................................................... 86 5.4.1 (Ex-) prisoners point of view ............................................................................................ 86 5.4.2 Professionals’ point of view ............................................................................................. 91 5.5 COOPERATION .......................................................................................................................... 93 5.5.1 Cooperation between prisons and external services ....................................................... 93 5.5.2 Cooperation inside prison ................................................................................................ 96 5.5.3 Cooperation in the community ......................................................................................... 99 6 CONCLUSION AND RECOMMENDATIONS ................................................................99 6.1.1 Barriers of continuity of care ............................................................................................ 99 6.1.2 Promising practices........................................................................................................ 102 6.1.3 Suggestions to overcome barriers ................................................................................. 107 REFERENCES ................................................................................................................... 109 ANNEX .............................................................................................................................. 116 Key questions regarding national legislation and policies ................................................... 117 Summary of results from key questionnaire ........................................................................... 124 Questionnaire individual interviews ex-prisoners .................................................................. 136 Questionnaire individual interviews ex-prisoners .................................................................. 140 Questionnaire focus groups prisoners .................................................................................... 146 Questionnaire individual interviews professionals outside prison ...................................... 149 Questionnaire individual interviews professionals inside prison ........................................ 152 Part 1 – Summary of project and country situations 1 Introduction For prisoners1 with a history of drug use, in particular opioid use, the risks related to drug use and especially overdose and death are extremely high in the immediate period after release due to high rates of relapse and lower opioid tolerance (Farrell and Marsden, 2008). Much still needs to be done in order to ensure that people with a severe history of drug use are sufficiently cared for when released from prisons. Harm-reduction measures need to be in place for ex-prisoners to be able to readjust to freedom without relapsing back into drug use and to prevent the extreme risk of fatal overdose when released. The EU project ‘My first 48h out’ aims to address the gaps in continuity of care for long-term drug users in prison and upon release, by supporting life-saving interventions for the prevention of overdoses and the reduction of other risks related to drug use, and for the establishment