Drug use and opioid substitution treatment for prisoners

Drug use is prevalent throughout prison populations, and, despite advances in drug treatment programmes for inmates, access to and the quality of these programmes remain substantially poorer than those available for non-incarcerated drug users. Because prisoners may be at greater risk for some of the harms associated with drug use, they deserve therapeutic modalities and attitudes that are at least equal to those available for drug users outside prison. This article discusses drug use by inmates and its associated harms. In addition, this article provides a survey of studies conducted in prisons of opioid substitution therapy (OST), a clinically effective and cost-effective drug treatment strategy. The findings from this overview indicate why treatment efforts for drug users in prison are often poorer than those available for drug users in the non-prison community and demonstrate how the implementation of OST programmes benefits not only prisoners but also prison staff and the community at large. Finally, the article outlines strategies that have been found effective for implementing OST in prisons and offers suggestions for applying these strategies more broadly

Substitution treatment for opioid addicts in Germany

BACKGROUND: After a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987. The number of patients in MMT – first low because of strict admission criteria – increased considerably since the 1990s up to some 65,000 at the end of 2006. In Germany each general practitioner (GP), who has completed an additional training in addiction medicine, is allowed to prescribe substitution drugs to opioid dependent patients. Currently 2,700 GPs prescribe substitution drugs. Psychosocial care should be made available to all MMT patients. RESULTS: The results of research studies and practical experiences clearly indicate that patients benefit substantially from MMT with improvements in physical and psychological health. MMT proves successful in attaining high retention rates (65 % to 85 % in the first years, up to 50 % after more than seven years) and plays a major role in accessing and maintaining ongoing medical treatment for HIV and hepatitis. MMT is also seen as a vital factor in the process of social re-integration and it contributes to the reduction of drug related harms such as mortality and morbidity and to the prevention of infectious diseases. Some 10 % of MMT patients become drug-free in the long run. Methadone is the most commonly prescribed substitution medication in Germany, although buprenorphine is attaining rising importance. Access to MMT in rural areas is very patchy and still constitutes a problem. There are only few employment opportunities for patients participating in MMT, although regular employment is considered unanimously as a positive factor of treatment success. Substitution treatment in German prisons is heterogeneous in access and treatment modalities. Access is very patchy and the number of inmates in treatment is limited. Nevertheless, substitution treatment plays a substantial part in the health care system provided to drug users in Germany. CONCLUSION: In Germany, a history of substitution treatment spanning 20 years has meanwhile accumulated a wealth of experience, e.g. in the development of research on health care services, guidelines and the implementation of quality assurance measures. Implementing substitution treatment with concomitant effects and treatment elements such as drug history-taking, dosage setting, co-use of other psychoactive substances (alcohol, benzodiazepines, cocaine), management of 'difficult patient populations', and integration into the social environment has been arranged successfully. Also psychosocial counseling programmes adjuvant to substitution treatment have been established and, in the framework of a pilot project on heroin-based treatment, standardised manuals were developed. Research on allocating opioid users to the 'right' form of therapy at the 'right' point in time is still a challenge, though the pilot project 'heroin-based treatment' brought experience with patients who do not benefit from methadone treatment. There is also expertise in the treatment of specific co-morbidity such as HIV/AIDS, hepatitis and psychiatric disorders. The promotion and involvement of self-help groups plays an important part in the process of successful substitution treatment

A qualitative assessment of an abstinence-oriented therapeutic community for prisoners with substance use disorders in Kyrgyzstan.

BACKGROUND: Kyrgyzstan, where HIV is concentrated in prisons and driven by injection drug use, provides a prison-based methadone maintenance therapy program as well as abstinence-oriented therapeutic community based on the 12-step model called the "Clean Zone." We aimed to qualitatively assess how prisoners navigate between these treatment options to understand the persistence of the Clean Zone despite a lack of evidence to support its effectiveness in treating opioid use disorders. METHODS: We conducted an analysis of policy documents and over 60 h of participant observation in February 2016, which included focus groups with a convenience sample of 20 therapeutic community staff members, 110 prisoners across three male and one female prisons, and qualitative interviews with two former Clean Zone participants. Field notes containing verbatim quotes from participants were analyzed through iterative reading and discussion to understand how participants generally perceive the program, barriers to entry and retention, and implications for future treatment within prisons. RESULTS: Our analyses discerned three themes: pride in the mission of the Clean Zone, idealism regarding addiction treatment outcomes against all odds, and the demonization of methadone. CONCLUSION: Despite low enrollment and lack of an evidence base, the therapeutic community is buttressed by the strong support of the prison administration and its clients as an "ordered" alternative to what is seen as chaotic life outside of the Clean Zone. The lack of services for Clean Zone patients after release likely contributes to high rates of relapse to drug use. The Clean Zone would benefit from integration of stabilized methadone patients combined with a post-release program

Safer Tripping: Serotonergic Psychedelics and Drug Checking. Submission and Detection Rates, Potential Harms, and Challenges for Drug Analysis

Purpose of Review With the continuous emergence of new psychoactive substances, drug checking (DC) services are challenged by an increasingly complex drug market. Considering the resumed scientific and public interest in serotonergic psychedelics (SPs) like LSD, psilocybin, and 2C-B, we present the results of a literature search investigating the presence and proportion of SPs in DC samples. Recent Findings: In 15 identified reports, submission and detection rates of SPs were comparably low, but increasing. Samples contained considerable amounts of adulterations or analogues, mostly novel SPs with unknown toxicological profiles and in some cases potentially life-threatening effects. The detection of SPs, however, requires advanced analysis techniques currently not available to most DC services. Summary: Given the substantial proportion of novel SPs in DC samples and the associated risks, DC can be a valuable harm reduction and monitoring tool for SPs if analysis techniques with high sensitivity are employed

Oral health services in prison settings: A global scoping review of availability, accessibility, and model of delivery

: This review aimed at evaluating the state of availability, accessibility and model of delivery of oral health services in prisons, globally. Five databases of peer-reviewed literature and potential sources of grey literature were systematically searched. Inclusion criteria encompassed oral health papers related to prisons globally, with exclusion of certain article types. Selection involved independent evaluations by two researchers, followed by quality assessment. Data on the availability of oral health interventions in prisons came from 18 countries, while information on the model of delivery of the services is scarce. In addition, two sets of individual and organizational barriers toward oral health service uptake in prisons were revealed and discussed in the text. Lack of oral health services in prisons affects people living in prisons and jeopardizes their reintegration. Urgent and concrete international actions are required to ensure the availability, accessibility, and quality of oral health services among people living in prisons

Insufficient access to harm reduction measures in prisons in 5 countries (PRIDE Europe): a shared European public health concern

Background: Prisoners constitute a high-risk population, particularly for infectious diseases. The aim of this study was to estimate the level of infectious risk in the prisons of five different European countries by measuring to what extent the prison system adheres to WHO/UNODC recommendations. Methods: Following the methodology used in a previous French survey, a postal/electronic questionnaire was sent to all prisons in Austria, Belgium, Denmark and Italy to collect data on the availability of several recommended HIV-HCV prevention interventions and HBV vaccination for prisoners. A score was built to compare adherence to WHO/UNODC recommendations (considered a proxy of environmental infectious risk) in those 4 countries. It ranged from 0 (no adherence) to 12 (full adherence). A second score (0 to 9) was built to include data from a previous French survey, thereby creating a 5-country comparison. Results: A majority of prisons answered in Austria (100 %), France (66 %) and Denmark (58 %), half in Belgium (50 %) and few in Italy (17 %), representing 100, 74, 89, 47 and 23 % coverage of the prison populations, respectively. Availability of prevention measures was low, with median adherence scores ranging from 3.5 to 4.5 at the national level. These results were confirmed when using the second score which included France in the inter-country comparison. Overall, the adherence score was inversely associated with prison overpopulation rates (p = 0.08). Conclusions: Using a score of adherence to WHO/UNODC recommendations, the estimated environmental infectious risk remains extremely high in the prisons of the 5 European countries assessed. Public health strategies should be adjusted to comply with the principle of equivalence of care and prevention with the general community

'My first 48 hours out' : drug users’ perspectives on challenges and strategies upon release from prison

Background Prisoners report much higher prevalence rates of drug use and more harmful consumption patterns than the general population. People who use drugs have above-average experiences with the criminal justice system in general, and the prison system and subsequent release situations in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose. The EU-funded project 'My first 48 hours out' aimed to address the gaps in continuity of care for long-term drug users in prison and upon release, with a special focus on drug user's perspectives on needs and challenges upon release. Methods A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users' perceptions of drug use and risk behaviour upon prison release, experiences of incarceration and release, and strategies to avoid risks when being released. In total, 104 prisoners and recently released persons with a history of drug use participated in semi-structured interviews and focus groups discussions on these topics. Results Respondents pointed out that there are numerous challenges for people who use drugs when released from prison. Lack of stable housing and employment support were frequently mentioned, as well as complex administrative procedures regarding access to services, health insurance and welfare benefits. Besides structural challenges, individual issues may challenge social reintegration like 'old habits', mental health problems and disrupted social networks. As a result, (ex-)prisoners adopt individual strategies to cope with the risks and challenges at release. Conclusion Measures to prepare prisoners for release often do not focus on the individual and specific challenges of persons who use drugs. Psychosocial and medical support need to be improved and adjusted to drug users' needs inside and outside prison. To improve the quality and continuity of care around release, the perspectives and coping strategies of people who use drugs should be used to better address their needs and barriers to treatment

Health Outcomes for Clients of Needle and Syringe Programs in Prisons

High levels of drug dependence have been observed in the prison population globally, and the sharing of injecting drug equipment in prisons has contributed to higher prevalence of bloodborne diseases in prisoners than in the general population. Few prison needle and syringe programs (PNSPs) exist. We conducted a systematic review to assess evidence regarding health outcomes of PNSPs. We searched peer-reviewed databases for data relating to needle and syringe programs in prisons. The search methodology was conducted in accordance with accepted guidelines. Five studies met review inclusion criteria, and all presented evidence associating PNSPs with one or more health benefits, but the strength of the evidence was low. The outcomes for which the studies collectively demonstrated the strongest evidence were prevention of human immunodeficiency virus and viral hepatitis. Few negative consequences from PNSPs were observed, consistent with previous evidence assessments. More research is needed on PNSP effectiveness, and innovative study designs are needed to overcome methodological limitations of previous research. Until stronger evidence becomes available, policymakers are urged to recognize that not implementing PNSPs has the potential to cause considerable harm, in light of what is currently known about the risks and benefits of needle and syringe programs and PNSPs and about the high prevalence of human immunodeficiency virus and viral hepatitis in prisons

National and sub-national HIV/AIDS-related mortality in Iran, 1990–2015: a population-based modeling study

Surveillance of HIV/AIDS mortality is crucial to evaluate a country’s response to the disease. With a modified estimation approach, this study aimed to provide more accurate estimates on deaths due to HIV/AIDS in Iran from 1990 to 2015 at national and sub-national levels. Using a comprehensive data set, death registration incompleteness and misclassification were addressed by demographical and statistical methods. Trends of mortality due to HIV/AIDS at national and sub-national levels were estimated by applying a set of models. A total of 474 men (95% uncertainty interval [UI]: 175–1332) and 256 women (95% UI: 36–1871) died due to HIV/AIDS in 2015 in Iran. Peaked in 1995, HIV/AIDS-related mortality has steadily declined among both genders. Mortality rates were remarkably higher among men than women during the period studied. At the sub-national level, the highest and the lowest annual percent change were found at 10.97 and −1.36% for women, and 4.04 and −3.47% for men, respectively. The findings of our study (731 deaths) were remarkably lower than the Joint United Nations Programme on HIV and AIDS (4000) but higher than Global Burden of Disease (339) estimates in 2015. The overall decrease in mortality due to HIV/AIDS may be attributed to the increasing burden of noncommunicable diseases; however, the role of the national and international organizations to fight HIV/AIDS should not be overlooked. To decrease HIV/AIDS mortality and to achieve international goals, evidence-based action is required. To fast-track targets, the priority must be to prevent infection, promote early diagnosis, provide access to treatment, and to ensure treatment adherence among patients. Keywords HIV, AIDS, mortality, estimation, modeling, Ira