Drug Abuse

13 Treatment improvement guideline on treatment in the Criminal Justice System

Guidelines for treatment improvement

Moretreat-project
Elaboration: Katarzyna D?browska Department Studies on Alcohol and Drug Dependence Institute of Psychiatry and Neurology, Warsaw
October 2008

The content of this report does not necessarily reflect the opinion of the European Commission. Neither the Commission nor anyone acting on its behalf shall be liable for any use made of the information in this publication.

Content

1 Introduction
1.1 Material
1.2. Definition of the target groups and prison
1.3 Context
1.4 Relevance of the problem
1.5 Aim of the guideline

2 Evidence base
2.1 Different treatment interventions
2.2 Special issues under different treatment modalities

3 Recommendations
3.1 Testing for infectious diseases
3.2 Treatment of infectious diseases
3.3 Abstinence oriented programmes
3.4 Detoxification
3.5 Substitution
3.6 Needle exchange
3.7 Provision of bleach
3.8 Provision of condoms
3.9 Case management
3.10 Clients’ needs
3.11 Continuity of care
3.12 Staff competences

 

1 Introduction

1.1 Material

As the number of studies on treatment in Criminal Justice System identified in the frame of the “Moretreat” project is small this guideline is mainly based on two reports:
• Stöver H., Hennebel L.C., Casselmann J. (2004) Substitution treatment in European Prisons. A study of policies and practices of substitution treatment in prisons in 18 European countries and
• Stöver H., Weilandt C., Zurhold H., Hartwig C., Thane K. (2007) Final report. The status –quo of prevention, treatment and harm reduction services for people in prisons and in reintegration services for persons on release from prisons.
• Both reports are reviews of existing studies and knowledge on treatment offered in prison conditions. Also this paper was inspired by four other documents, released by WHO UNAIDS and UNODC (2007) in the “Evidence for Action Technical Papers Series”, as well:
• Interventions to address HIV in Prisons –Prevention of sexual transmission.
• Interventions to address HIV in Prisons –Drug dependence treatment.
• Interventions to address HIV in Prisons – HIV care, treatment and support.
• Interventions to address HIV in Prisons – Needle and syringe programmes and decontamination strategies.

1.2. Definition of the target groups and prison

This guideline is focusing on illicit drug users and especially problematic drug users who are subjects to prevention, treatment and harm reduction programmes offered in the framework of the Criminal Justice System.
The term “prison” is used for all places of detention no matter if the person is in police detention, pre-trial/remand prison, or run by law enforcement, or has already got a prison sentence.
 

1.3 Context

This section is based on EMCCDA (2002) report Drug use in prison which allows to recognize in short how care for drug users in prison is organized across Europe. Since 1995, an expansion of services for drug users in prison has been noted (Ambrosini, 2001, citied in EMCDDA, 2003) and measures to prevent the transmission of infectious diseases have been introduced. However, compared to the community they have been introduced with a considerable time lag.
The extent to which prisons are covered and the level of service provision vary considerably between and within countries and even states and regions or even within prisons in one and the same state/region. Notable exception in terms of high coverage is Scotland, which has drug counsellors in every prison; Spain where addiction services are available in 71 out of 73 prisons, Sweden, where a third of the estimated number of inmates with drug problems were covered by treatment motivation programmes in the year 2000; and England and Wales, where since 1999 all prisons have specialised external drug teams (CARAT – Counselling, Assessment, Referral, Advice and Throughcare services) which aim to cover drug-using prisoners’ needs from intake to aftercare – although a bottleneck seems to be the lack of referral possibilities. In Scotland, prisoners can now also receive transitional care during the first 12 weeks after release, to facilitate their return to the community.
Health care services in prison are traditionally provided by the prison’s own health care staff under the authority of the Ministries of Justice, but prison systems across the EU rely to a large extent on additional external expertise and resources. The services provided by external agencies are general drug prevention information and education, treatment motivation programmes and preparation for release, including referral to community based treatment and to aftercare.
Striving towards “equivalence of care” between community and the prison health care services France in 1994, England/Wales in 2005, and Italy in 2008 have shifted responsibility for health care in prisons to their Ministries of Health and thus involved local and regional health care agencies on a statutory basis (also in Norway, and some cantons of Switzerland). Concrete cooperation agreements between the judiciary system and public or non-governmental health services were also established in Ireland in 1999, Portugal in 1999 and Spain in 2000, and in some states of Germany to increase the quality and coverage of care for imprisoned drug users.
External drugs specialists play an important role in the support to drug users in most, if not all, European prison systems. In Germany, the history of the work in prisons of external drugs agencies and of specialised internal drugs services dates back to the mid-1980s and in 2000, more than 350 drugs counsellors provided their services in German prisons; however, the coverage of this service varies between the federal states (Länder). In recent years many of these external drug counsellor posts have been abolished in several ‘Länder’. In 2000, the involvement of external professionals continued to be an important trend in France; and, in Italy, the public drugs services SerT noted a large increase in client numbers, due to their new responsibility with regard to prisoners. The Spanish national strategy on drugs (2000–08) defined the participation of external specialists in the care of drug users in prisons as a priority, and multi-annual cooperation plans between prisons and NGOs have resulted in more than half of the addiction care services (GAD) in Spanish prisons being staffed by external NGO experts. In Belgium and Greece, non-governmental organisations (NGOs) are so far the primary providers of the limited services that are available to drug users in prisons.

Written information materials on drugs and drug-related infectious diseases seem to be available in most prisons in the EU and Norway; however, systematic and repeated opportunities to address prevention issues face-to-face are rare and often depend on the initiative of external agencies or individual prison staff.

Detoxification is offered through medical prison services or in specialised detoxification wards, but quality guidelines are often lacking. A programme through which 1,200 to 1,500 prisoners received detoxification per year has been described as being provided in an ‘essentially unstructured and unsupervised fashion, with no follow-up or medium to long-term planning’ (Department of Justice Equality and Law Reform, 1999). However, quality standards are starting to be introduced, for example the prison service order of December 2000 requests that all prisons in England and Wales offer qualified detoxification services. From 2006 on the prisons in England started the “Integrated Drug Treatment System” (IDTS), featuring in particular the provision of opioid substitution treatment, and the uniting of two separate treatment services in prisons: psychosocial drug treatment, known by the acronym CARATs, and clinical substance misuse management previously described as ‘detoxification’ services (Marteau/Stöver 2009).

In some countries, external agencies are also directly involved in providing longer-term treatment of addiction. Examples are the small intramural programmes for drug users in Denmark and Norway, which are run by specialised external drugs agencies (‘import model’), and substitution treatment in Spanish, French and Italian prisons. The high coverage in Spain has been achieved through the massive involvement of external drugs services (Stöver/MacDonald/Atherton 2006).

Nine EU countries have structured abstinence-oriented treatment programmes inside prisons and Norway provides a treatment motivation programme. The total number of places is, compared with the estimated number of prisoners with drug problems, very low. However, in Spain, 8 984 prisoners participated in the 18 available drug-free treatment programmes in 2000 and, in England and Wales, 3 100 entrants were registered in the 50 intensive treatment programmes in 2000/01. In Sweden, 10% of prison facilities, with a capacity to receive 500 prisoners, are specially reserved for voluntary and compulsory treatment of drug users (Lýsen,2001) and, in Finland, 18% of incoming prisoners participate in alcohol or drug rehabilitation programmes (Jungner, 2001) In the Austrian prison “Wien-Favoriten”, specialised exclusively in the care of addicts, 110 treatment places are available; Denmark has 30 places and Ireland has nine. The Norwegian treatment motivation programme can take 18 prisoners in charge per year (EMCCDA, 2002: Table 14 OL: Abstinence-oriented treatment ).

Except for Greece, Sweden and some states in Germany, substitution treatment is now formally approved in prisons in all EU countries and Norway. However, even in countries where a large percentage of problem drug users in the community are in substitution treatment, prisons often follow a detoxification policy only. For example, coverage rates in prisons in Germany and the Netherlands are thought to be between 1 and 4% (Stöver, 2001; WIAD-ORS, 2001, cited in EMCDDA, 2002) compared to an estimated coverage of 30 to 50 % in the community. Most prison maintenance policies indicate the treatment only during short-term sentences, for pregnant drug users, and for those with long addiction careers or severe mental or physical health problems. Initiation of substitution treatment in prisons is rare, even though it is legally possible in most countries. The major exception is Spain, where substitution rates inside and outside prison correspond.

Ten EU countries and Norway run drug-free wings or prisons. The purpose of some of them is not only to protect non-dependent inmates from drugs, but also to provide treatment in a drug-free environment. Prisoners under methadone substitution are usually excluded from drug-free wards. There are 20 drug-free addiction guidance departments in Dutch prisons spale for 446 prisoners; however, one third of the capacity remained unused in 1999. Sweden has 356 places in drug-free units and, in Finland, where currently 10% of all prison wards are drug free, an expansion to 50% is envisaged. Portugal recently opened seven drug-free wards with 195 places, evaluated as a ‘great success’ and is planning two more units.

1.4 Relevance of the problem

1.4.1 Epidemiology/nature and extent

The source of data used in this section is the Council of Europe Annual Penal Statistics: SPACE I. The prison population in the member states of the European Union comprised of 559,597 prisoners (including pre-trial prisoners) on 1st September 2006, while 35,910 persons in Romania and 12 218 persons in Bulgaria (the two new member states from 2007), were in prison at that time. Therefore, issues of prison and health in prison in particular affect directly more than half a million people at an appointed date and more than a million during a year, because of the high turn-over rate due to entrances and releases in the prison population. In each of the six biggest countries of the European Union, with exception of Italy more than 50,000 persons are in prison at the appointed date,: 86,676 in the United Kingdom, 79,146 in Germany, 88,647 in Poland, 64,120 in Spain, 57,876 in France and 38,309 in Italy. Almost 75% of the prisoners in the European Union are to be found in the six biggest member states. These absolute figures might help to assess the weight and importance of imprisonment rates per country in order to make it possible to compare the states despite their very different population size. It is also necessary to keep in mind that particular countries differently define and construct their prison population in general. Additionally, all following comparisons can only be regarded as approximations because of various differences and irregularities in the national statistics (Stöver at al., 2007). As Stöver et al. (2007) stated, drawing a detailed picture of the extent and nature of drug use in prisons is often difficult because it is an activity that occurs in extreme secrecy. Discovery of needles, positive drug tests among prisoners and official statistics of known and sentenced drugs user are indicators reflecting only a part of the actual situation.

According to a recent survey among the Ministries of Justice of the European Member States eight countries reported that 10-30 % of the female prisoners have a drug problem while in other eight 40-60% of the female prisoners as drug users (Zurhold and Haasen, 2005 cited in Stöver et al. 2007).

A review of studies on the prevalence of drug dependence in prisoners reveals a substantial heterogeneity in the history of drug use but underlines as well the higher proportion of drug problems among female inmates (Fazel et al. 2006, cited in Stöver et al. 2007). The review of 13 studies with a total of 7,563 prisoners shows a drug dependence that varied from 10 to 48 % in male prisoners and 30 to 60 % in female prisoners.

A Polish study on prevalence drug use among prisoners shows that 20.3% of all prisoners made an attempt to use any illegal psychoactive substance in prison. Three percent reported intravenous drug use, while 1.3% were sharing needles and syringes (Sierosławski, 2007).

1.4.2 Health problems: HIV and hepatitis

There is a high risk of acquiring HIV and hepatitis in prison for those who continue to inject drugs and share injecting equipment. Several studies conducted outside penal institutions reveal a strong correlation between previous detention and the spread of infectious diseases. Staying in prison has become an independent predictor for the acquisition of hepatitis C. Although injecting drug use in prison seems to be less frequent than in the community, each episode of injecting is more dangerous than outside due to lack of sterile injecting equipment, the high prevalence of sharing and already-widespread infectious diseases (Stöver et al. 2007).

A study carried out in 25 European prisons in 1996-1998 (Rotily and Weilandt, 1999, cited in Stöver et al. 2007) found an overall prevalence of HIV infection of 5.7%, with substantially higher rates in prisons in Portugal (19.7%) and Spain (12,9%). The proportion of prisoners living with HIV is many times higher than the proportion in the general population (for example, 25 times higher in Germany) Rates of hepatitis B virus and hepatitis C virus infection and TB in inmate population are also generally many times higher than in population as a whole.

1.5 Aim of the guideline

Aim of this guideline is to identify research evidence on best practices in drug treatment in prison setting in European Union. Relevant recommendations that follow constitute its crucial component.

2 Evidence base

2.1 Different treatment interventions

Generally the interventions for drug and alcohol dependence vary greatly throughout Europe and range from 12-Steps programmes to auricular acupuncture, therapeutic communities and provision of substitution programmes, cognitive-behavioural methods and educational programmes (Harrison et al. 2003; Merino 2003). In order to survey drug programmes in the criminal justice system in the EU, 36 programmes had been analysed by Merino (2003). The analysis revealed that programmes aiming at crime reduction along with early intervention are most common (24%; 23%). These interventions are followed by harm reduction (19%) and social integration (14%). In addition, drug free programmes, psychotherapy, drug-free wings and counselling are main offers for crime and demand reduction.

Many studies have shown that criminal justice interventions as stand-alone without associated opioid dependence treatment, have very limited impact on drug using behaviour and recidivism among individuals with drug use. There is a consensus among professionals that drug treatment can be effective if it is based on the needs of prisoners, is of sufficient length and quality and there is continuity of aftercare in prison and in the community (Ramsay, 2003). It is a combination of treatment in prison and follow-up treatment afterwards that provides the best impact (Stöver et al. 2004; see also Kastelic et al. 2008 )

All in all it can be stated that “positive experience from in-prison treatment helps inmates to continue treatment after release, reduces relapse rates and related health risks, and also reduces delinquency recidivism” (Uchtenhagen 2006, cited in Stöver et al. 2007).

This chapter is focused on effectiveness and usefulness of different treatment interventions, measures in prison settings and consists of seven topics:

1. Testing of infectious diseases and vaccination
2. Drug testing
3. Health care for prisoners with AIDS and Hepatitis
4. Abstinence-oriented programmes
5. Detoxification
6. Harm reduction
7. Case management

2.1.1 Testing of infectious diseases and vaccination

Testing for infectious diseases includes testing for diseases such as HIV, HCV, HBV and HAV, but also for TB and for syphilis (Bick 2007). Testing of infectious diseases and vaccination in a prison setting is significant factor to ensure the prisoners health during incarceration and to ensure the health of their families and friends after discharge. Therefore not only the individual risk but the public health aspect has to be put in the fore. Besides, the knowledge of an infectious disease is a prerequisite to organize and receive the appropriate care (WHO et al. 2007). According to a database on diseases in prison elaborated by the WHO, disease testing mostly takes place on admission rather than on release, with the exceptions of Estonia, Finland and Lithuania, where HIV is tested both on admission and on release. In Latvia, Luxembourg and Belgium half of the prisoners are tested for infectious diseases (WHO). If there is mandatory HIV testing in prison, the patient confidentially needs to be addressed cautiously. This is of particular importance if the test reveales a positive result (MacDonald et al. 2006). The knowledge of the HIV status is essential for receiving the adequate care, treatment and support. There are major differences upon access to voluntary HIV testing. Also there are still differences in the way HIV tests are offered: voluntary or mandatory. It has been shown, that offering HIV test voluntary resulted in a large number of prisoners accepting HIV testing and counselling. Liddicoat et al. (2006) showed that offering HIV test upon incarceration in combination with a brief group counselling and an individual informed consent significantly increased HIV testing rates compared to a historical cohort. In the intervention group 73.1% accepted HIV testing, whereas in the control group only 18% did it (73,1% vs. 18%; p<0,0001). It is known, that mandatory HIV testing and segregation of HIV-positive inmates are counterproductive (Jacobs 1995). One way to encourage voluntary testing, as proposed by Bausermann et al (2003) is offering oral tests to inmates. The entrance in the prison poses a good opportunity to test prisoners for hepatitis. There are various forms in which this is done: upon request, testing only prisoners at risk or routinely testing all prisoners. All viral hepatitis forms present a major challenge to the prison health systems (Spaulding et al. 2006) therefore screening and vaccination are ways to face and handle this problem. To sum up, vaccination against HAV should be offered to prisoners at risk (Neff, 2003, Whiteman et al. 1998) whereas HBV vaccine (Kuo et al. 2004, Sutton et al, 2006) should be made available for all prisoners.

2.1.2 Drug testing

Drug testing is the testing of individuals for their drug use. The aim of drug testing is to detect drug use in the prison, to identify drug users and to achieve information about the level of drug use and the type of drugs used (MacDonald 1997). The testing in prison is usually done by urinalysis; other possibilities would be hair or blood analysis. The frequency as well as the mode of testing can vary considerably: on admission and/or release, before/after holidays or weekend leaves, by suspicion of drug consumption, per random routine, mandatory for all prisoners or only subgroups (Dean 2005). Mandatory drug testing is one factor found to influence drug-use patterns in prisons. It may decrease or alter drug use due to the fear of detection and sanctioning (Edgar and O'Donnell 1998; Prendergast et al. 2004; Scottish Prison Service 2000, cited in Dean 2005). But mandatory testing can also have unintended outcomes. In the English pilot trial the percentage of positive tests for opiates and benzodiazepines rose from 4.1% to 7.4% (Gore et al. 1996). A survey among prisoners and staff concluded mandatory drug testing to be counterproductive, especially without adequate follow-up like treatment and counselling programmes. It can also increase the tension inside prison and deflects attention from other important issues (MacDonald 1997), as shown by the number of assaults increased by 20% from 1993 to 1995 (Gore et al. 1996). Although some forms of drug testing can give a good estimation on the prevalence of drug use (Gore et al.1999; Fraser and Zamecnik 2002; Harrell and Kleiman 2002) even if not all users will be detected (Edgar and O'Donnell 1998) other studies claim that mandatory drug testing seriously underestimates the prisoners need for harm reduction (Bird et al. 1997). As the difficulties of mandatory drug testing can be serious, not only regarding the transmission of diseases but also the tension inside the institution, such programmes, if needed at all, should always be linked with adequate treatment and counselling programmes (MacDonald 1997), but to this inmates might fear sanctioning and therefore don’t approach staff (Hughes 2000a). The form and mode of drug testing should be carefully considered and research recommends that resources should be shifted from mandatory testing to other interventions (e.g. Gore and Bird 1996; Dean 2005).

2.1.3 Health care for prisoners with HIV/AIDS and hepatitis

Despite different opinions of correctional healthcare providers the delivery of HIV/AIDS care in correctional institutes is less comprehensive than in community settings (De Groot 2000; Bernard et al. 2007). The cohort of persons entering prisons consists of persons already lacking access to proper medical resources. Therefore correctional institution in which structural barriers to health care are removed and the prisoner is capable, should offer HAART to all HIV-infected prisoners. There has been evidence that often treatment is initiated in prison. Altice and Mostashari (2001, 1998) report that up to 67% of HIV-positive prisoners first received HAART while in prison (Mostashari et al. 1998; Altice et al. 2001). The success of a therapeutic intervention is revealed by the adherence to the programme. A Spanish study carried out by Soto Blanco and colleagues (2005) showed that the compliance to HAART was higher than in the community. Predictors of noncompliance were for instance poor or lack of ability to follow the prescribed treatment regime, no visits in a month, difficulties in taking the medication or methadone maintenance treatment (Soto Blanco et al. 2005). It had been evaluated that attitudes related to trust in medications and the health system have a significant impact on the compliance to HAART. The prisoner’s view of the person who is dispending the medication will have a probably undeterminable effect of the adherence of HAART (Mostashari et al. 1998). Among of the other factors that have an impact on the adherence of HAART are modalities of administration. In general three different modalities are differentiated: directly observed therapy (DOT), modified DOT and keep on person (KOP) (Pontali 2005). DOT refers to a system in which the prisoners go to the medical unit or pharmacy and swallow the medication under sight check. During this routine visits the medical staff can record possible side effects, give brief counselling to the patient and react quickly to signs of discomfort of the patient. It can be said that the adherence within is higher compared to KOP, but it should be kept in mind, that the routine visits of the patient involve the loss the confidentially as the prisoners fear to get “discovered” by other inmates. The difference in a modified DOT is that here the patient receives the daily doses in one package. It is up to the nurse to watch the patient swallow. So the medical staff gets in contact with the patient every day, but the inmate is fully responsible. KOP (sometimes called self-administered therapy (SAT) is the system that allows the inmates to keep a monthly or weekly rations of medication in their cells and take them independently. Here the confidentially and privacy rights of the patients are fully secured (Pontali 2005). The literature is inconsistent about the evidence about which modality to prefer. Babudieri et al. (2000) reported that DOT compared to modified DOT was associated with a better virological and immunological response (Babudieri and al. 2000). Contrarily, it was reported that the degree of adherence was similar in all three regimens. But selection bias needs to be considered, that only highly motivated patients tend to choose KOP (Stöver et al. 2007). Continuity of care seems to be a very important issue. Wood et al. (2003), Palepu (2003, 2004) and Stephenson et al. (2005) (cited in WHO et al, 2007c) all found that transition between prison and the community is often associated with interruptions in treatment, with negative effects on virological and immunological outcomes. A study of Springer et al. (2004, cited in WHO,2007a) showed that the gains in health conditions of prisoners made during the term of incarceration were lost among re-incarcerated persons, because of relapse to drug use, discontinuation of therapy and, possibly, uncontrolled mental illness. This underscores the need for linkage to aftercare services for prisoners with HIV infection upon their release (Spaulding et all, 2002, citied in WHO, 2007c). The treatment for HCV has improved substantially over the last decade and it has been shown to be efficient. Depending on the genotype either a 24-to 48-week combination therapy of pegylated interferon and ribavirin is given. This combination achieves an overall sustained virologic response (SVR) of 50% to 80% subjects. However, the genotype 2 and 3 have a higher success rate, with a SVR at about 76-80%, than genotype 1 with SVR for 46-54% (Fried et al. 2002).
It has been shown that treatment for HCV is also feasible and successful for marginalized groups such as IDUs. Although a very high proportion of HCV-infected IDUs circle through the correctional system for their large proportion no therapeutic attempt is being made. Only four studies were identified which evaluated a prison-based treatment of HCV. The most recent study was undertaken in France, where 37 medical units of French prisons participated. In this prospective cohort study 217 patients were included. They were treated with a combination of pegylated interferon alpha and ribavirin. Six months after the completion of treatment 200 patients were analysed regarding their SVR (sustained viral response). Ninety five patients (47.5%) experienced a SVR. Data was missing for 61 patients and 24 patients were non-responders (Remy et al. 2006). A Canadian study designed as a retrospective analysis of medical files from 10 federal correctional facilities included 114 inmates. Analysis was performed for 80 treatment subjects. 66.3% of this treatment sample achieved SVR. Those with Genotype 2 and 3, injecting drug use and completion of treatment were significantly more likely to achieve SVR (Farley and al. 2005). In the study conducted by Allen et al (2003), 93 incarcerated patients were treated with interferon alpha and ribavirin. SVR were achieved by 46% (26 out of 53) after 6 months of treatment.

2.1.4 Abstinence-oriented programmes

Not many studies have been conducted on the effectiveness of psychosocial interventions in the prison setting (Strang et al. 2007) and a need for more studies on effectiveness of treatment programmes was stressed (Costall et al. 2006). The number of studies indicates that it is important for prison systems to develop particular strategies for prison drug treatment rather than simply just reflecting those strategies that exist in the community (Turnbull and Sweeney 1999). In a study among Polish female drug using prisoners TC was found inadequate in a context of incarceration where values of prison sub-culture may be in conflict with values promoted by TC approach (Moskalewicz et al. 2008). Studies have shown that many prisoners do not perceive the prison environment to be supportive for those who wish to abstain from drug use (Swann & James, 1998, citied in WHO et al 2007b). Generally there is a growing consensus that drug treatment programmes in prison can be effective if they are based on the needs and resources of prisoners and are of sufficient length and quality (Ramsay 2003). The effectiveness of TC on reducing recidivism for incarcerated drug users was shown (Pearson and Lipton 1999), other treatment approaches including cognitive-behavioural interventions and 12-step programmes were declared as promising but there were not enough studies to evaluate (Pearson and Lipton 1999). Two RCTs (Wexler et al. 1999; Sacks et al. 2004) were identified on TC in prison, both from the USA. TC in prison was associated with reductions in criminal activity, recidivism, and relapse, compared to a prison control group. For the re-incarceration rate no significant difference was found at 12 months but at five years it was (Smith et al. 2006; Strang et al. 2007). No effectiveness of boot-camps (a military-style scheme) for young offenders was demonstrated in two US studies, as the outcomes of treatment group did not differ from the control group (Strang et al. 2007). For incarcerated women case management, skills training, and TCs are especially recommended (Lewis and Lewis 2006). On drug-free units, a German study found significant lower criminal recidivism in regular programme completers than in drop-outs (Heinemann et al. 2002). There are some indicators that drug-free units reduce drug use, and some conflicting evidence on recidivism (WHO et al. 2007b). Counselling programmes in prison seem to be effective in reducing re-offending but not drug use, and voluntary programmes seem to be more effective than mandatory programmes, but the study quality on these issues is not good (WHO et al. 2007b). As summed up by Stöver et al. (2007), abstinence-based treatment programmes provide a good opportunity for those prisoners who are motivated and capable to cease using drugs.

2.1.5 Detoxification

It seems that detoxification with medication is rarely available throughout European prisons, although opioid detoxification without medical assistance is not recommended. As Stöver et al. (2007) stressed, there is a lack of evidence for detoxification programmes, with only two studies published. Therefore further research is needed. In a Southern England in all-male prison a RCT for opioid detoxification was conducted. The study employed a randomised double-blind, two-group comparison design to compare the relative efficacy, side effect profiles and participant acceptability of opioid detoxification. The used medications were methadone and lofexidine. Only 68 patients commenced the treatment. Thirty-two patients received lofexidine and 36 patients, respectively, methadone. The socio-demographic profiles and patterns of opioid use were comparable. Twenty-one patients were loss to-follow up due to various reasons. Withdrawal scores showed very similar patterns and derived withdrawal scores indices showed no significant differences between treatment groups (Howells et al. 2002). In an Australian prison the introduction of naltrexone was evaluated. Participants were recruited from 14 prisons. Data were analysed from two subsets drawn from 204 male inmates who participated in a former unsuccessful randomised trial. Patients from first sub-sample received naltrexone (n=68) and patients in the second sub-sample were divided into three groups: naltrexone (n=14), methadone (n=21) or buprenorphine (n=21). All were administrated over 24 months. Retention rates were analysed for subjects in the second sub-sample. Retention in methadone was significantly higher compared to Naltrexone. The evaluation of this study yield at a negative result for naltrexone for prisoners (Shearer et al. 2007).

2.1.6 Harm reduction

Harm reduction programmes aim to limit as far as possible drug-use related health risks to individuals, community and society. The introduction of harm reduction measures is relatively new to prison systems and is often perceived as threatening to the traditional abstinence-oriented drug policy in prisons (Stöver et al. 2007). Harm reduction include: substitution treatment, syringe exchange schemes, provision of bleach to decontaminate injecting equipment and provision of condoms.

Substitution treatment

One of the most important reviews of existing literature on the substitution treatment issue has been done by Kate Dolan and Alex Wodak in their “International review of methadone provision in prisons” (1996). Some of their key findings are as follow:

• significant reduction in sharing injection equipment have been documented for among a group of incarcerated intravenous drug users in Spain who, along with control group, participated in a prison based methadone programme (Marco, 1995).
• in an array of studies, correctional staff perceived prison methadone maintenance programmes (PMMP) to have reduced anxiety amongst prisoners, causing inmates to be less irritable and easier to manage (Gorta, 1992, Herzog, 1993, Magura et al, 1993).
• inmates in New South Wales reported decreases in drug use, drug-related prison violence, crime following release (Bertram & Gorta, 1990a) and considered PMMP to be more effective at preventing HIV in prison than in the community (Bertram&Gorta, 1990b).
• in several studies negative side-effects of PMMT often feared by prison staff, such as stand over tactics or a black market for methadone, were reported not to have occurred.

Stöver et al (2004) reviewed studies appearing between 1995 and 2003 focusing on drug use and related risk behaviours. According to that review methadone maintenance treatment can reduce injecting risk behaviour in penal institutions. One crucial point is that, for MMT to be effective, a moderately dose of methadone must be prescribed and the prescription must last for the entire period of imprisonment. Moreover, MMT provision was shown to be effective in reducing heroin use, drug injection and syringe sharing. A sufficiently high dosage (more than 60 mg) also seems to be important for an increased retention rate, which then can be used for additional health care services. The initiation of MMT also contributes to a significant reduction in serious drug charges and in behaviour related to activities in the drug subculture. Offenders participating in MMT had lower readmission rates and were readmitted at a slower rate than Non-MMT patients. There is evidence that continued MMT in prison has a beneficial impact on transferring prisoners into drug treatment after release (Stallwitz&Stöver 2007). Research into the subjective experiences of inmates participating in substitution programmes reveals the heterogeneity of prescriptions practices in prisons. In particular, short courses of methadone detoxifications were frequently experienced as insufficient and inadequate. Most striking was the inconsistency in methadone maintenance prescription inside prison compared to the community.

Needle exchange

Needle exchange is one of the important measures of harm reduction. The term refers to all kind of injecting equipment distribution to people who inject drugs. Prison needle exchange programmes (PNEP), also called needle and syringe programmes or syringe exchange programmes, are often accompanied by counselling or other services (WHO et al, 2007). A number of reviews on PNEPs have been undertaken, and gathered evidence for the effectiveness of PNEP (Rutter et al. 2001; Stöver and Nelles 2003; Lines et al. 2005; Lines et al. 2006; WHO et al. 2007d). All studies indicate that the implementation of such measures is possible and feasible with no security problems (e.g. Kerr et al. 2004). One of the most important results is the massive decline of needle sharing; a German project in Berlin found 71% of needle sharing before the start of the PNEP, decreasing to 11% at four-month follow up and to almost zero afterwards (Stark et al. 2006). Another outcome from a Swiss evaluation is the decrease over time of injecting drug use after implementing a harm-reduction programme including needle exchange in a female prison (Nelles et al. 1999). Other evidence from those countries where prison needle exchange programmes exist demonstrates that such programmes 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. A drastic reduction in overdoses is reported in some prisons and also increased referral to drug treatment programmes. PNEP has successfully cohabited in prisons with other drug addiction prevention and treatment programmes (Meyenberg et al. 1999; Nelles and Stöver 2002). The method of distribution needs to be considered, as machines may be unreliable (Heinemann and Gross 2001), and on the other hand a personal distribution won’t be anonymous; there are advantages and disadvantages for both (Stöver and Nelles 2003). Another international review on PNEP evaluation found 6 evaluations on PNEP and all were in favour of the program due to the fact that needle sharing decreased dramatically, no new cases of transmission of BBV (blood born viruses) were reported, and no serious negative events occurred (Dolan et al. 2003). A further more recent literature review and additional interviews on six countries with PNEP (Germany, Switzerland, Spain, Moldova, Belarus, Kyrgyzstan) found similar outcomes in very different prison settings: high and low security, large and small institutions, for men and women, single cell and dorm, needle distribution by machines, peers or hand to hand from medical staff:
• no injuries of staff were reported in evaluation reports.
• syringes were not used as weapons.
• drug use or injecting did not increase (only one out of twelve studies found that it did in some cases).
• PNEP can increase uptake of drug treatment services.
• PNEP is very effective to decrease needle sharing (only one study found small increase).
• abscesses and fatal overdoses decreased in some prisons (Lines et al. 2005; Lines et al. 2006).

Prison staff usually but not always was in favour of PNEP, as fear of needle accidents or use as a weapon were expressed (e.g. Heinemann and Gross 2001; Dolan et al. 2003). This emphasizes the importance of adequate staff training on issues of harm reduction. PNEP should be accompanied by such measures like information, and counselling. A Dutch study then found hardly any injecting drug use in prison and therefore no need for a needle exchange programme (van Haastrecht et al. 1997), so the need of PNEP in each prison should be carefully monitored and evaluated, as the drug use behaviour of prisoners might change over time. Evidence of research is all in favour of PNEP, as well as the numerous overviews and reviews on the topic. Important international organisations like WHO and the Council of Europe strongly recommend the implementation of PNEP (Rutter et al. 2001) as an effective measure of HIV and HCV prevention, to reduce the risk of infectious diseases and other harms connected with injecting drug use. WHO stresses that carefully evaluated pilot programmes of prison-based needle and syringe programmes may be important in allowing the introduction of these programmes, but they should not delay the expansion of the programmes, particularly where there already is evidence of high levels of injecting in prisons (WHO et al. 2007d).

Provision of bleach

There is no evidence of effectiveness of decontamination with bleach in the community and therefore it seems rather unlikely to be effective in prison. Disinfection as a means of HIV prevention is of varying efficiency, and is regarded only as a secondary strategy to syringe exchange programmes (WHO Europe, 2005). Where bleach programmes are implemented, bleach should be made easily and discreetly accessible to prisoners in various locations in the prison, together with information and education about how to clean injecting equipment and information about limited efficacy of bleach as a disinfectant for un-activating HIV and particularly HCV (WHO et al. 2007d). The effectiveness of disinfection procedures is also largely dependent upon the method used. A study in 1993 raised doubts about the effectiveness of the’2x2x2’ method in the decontamination of used injecting equipment (Shapshak and al. 1993). Scottish research on the effectiveness of bleach provision in a Scottish long-term prison found the measure being suboptimal (Champion et al. 2004), but together with other interventions (substitution treatment, HBV vaccination, staff training and counselling) there was no evidence for new HIV infections after 12 months of the programme, whereas before there was a massive HIV-outbreak in one Scottish prison (Goldberg and al. 1998). A new review by the WHO recommends bleach only as a second-line strategy after PNEP, due to the rather complicated decontamination process (WHO et al. 2007d). The WHO reported that concerns that bleach might be used as a weapon proved unfounded, and that this “has not happened in any prison where bleach distribution has been tried” (UNAIDS 1997, p 6).

Provision of condoms

The provision of condoms aims at preventing STDs by sexual contacts. Condom use is internationally accepted as the most effective method for reducing the risk of the sexual transmission of HIV and other BBVs (WHO and UNAIDS, 2001). Water-based lubricants reduce the probability of condom breakage and dental dams reduce the risk of STD transmission during oral sex (WHO et al. 2007a). Condoms are likely to be the most effective method for preventing STDs. No serious negative effects of condom provision in prisons have been found, and the provision of condoms seems feasible in a wide range of prison settings (Stöver et al. 2007). Although there is a body of research on sexual activity in prison, there are not many studies evaluating the distribution of condoms in prison. Perkins (1998) examined the accessibility of condoms in European prisons and found a wide range of different policies “...on a continuum spanning endorsement of free distribution within prison to total prohibition”. No negative consequences have been reported from those prison systems where condoms are available and the provision seems feasible in a wide range of prison settings (Jürgens 2006). The provision did not compromise prison security and safety, and there was no increase in sexual activity found (WHO et al. 2007a). Another study found decreased risk behaviour after the initiation of condom distribution and high levels of condom use among prisoners (WHO et al. 2007). Condoms need to be easily and discreetly accessible, in varying anonymous locations as prisoners often might fear to be detected as gay (WHO et al. 2007a). Despite the availability of condoms, barriers exist to their use in many prisons, and there is often poor knowledge among prisoners of sexual risk behaviour and individual risk prevention (Todts and al. 1997; WHO et al. 2007a). Furthermore there is evidence that condoms, dental dams, and water-based lubricants are not easily and discreetly available, or are not available on a 24-hour basis. In many prisons, consensual sex is also prohibited, which can result in prisoners being reluctant to access safer sex measures for fear of identifying themselves as engaged in such activities. In order to maximize HIV prevention efforts in prison, and reduce the risk of transmission via unsafe sex, condoms, dental dams, and water-based lubricants should be easily and discreetly available through a variety of distribution channels. Experience has shown that discreet areas such as toilets, waiting rooms, workshops, or day rooms are options that increase the confidentiality of prisoners accessing condoms. Other important measures alongside with condom provision are educational and informational activities for prisoners and staff on topics of STDs and the provision of condoms (WHO et al. 2007a).

2.1.7 Case management

Case management is a type of outpatient, intensive and individualized care provided by one caregiver (or a team) during a well-defined period, intended to guarantee the continuity of care and coordination of services for a limited number of persons. Since the beginning 1990’s case management became a widespread intervention as a reaction to the limitations of existing services and in order to help drug abusers with multiple and chronic problems. From that point onwards, hundreds of projects have been implemented – both within criminal justice and substance abuse treatment system aiming at:
• enhancing treatment access, participation and retention.
• improving treatment results concerning alcohol and drug use, employment, psychological problems and criminality.
• promoting coordination and continuity of care. Any conclusion about the effectiveness of case management for substance abusers is at the moment premature and even unwarranted, given the relative scarcity of randomized and controlled trials, especially concerning some specific models of case management. Several studies of case management among drug abusers involved in the criminal justice system have shown that coercion may help to enhance treatment participation and retention, which is associated with positive effects on clients’ drug use and criminal involvement. Empirical evidence concerning the effectiveness of judicial case management is still lacking, but available data do not show compelling evidence of its effectiveness. Positive effects of this intervention are reduced drug use and relapse rates, increased treatment participation and retention and less violation of judicial conditions. Both in the field of substance abuse treatment and in criminal justice system, the value of case management has been proven, but due to lack of sufficient number of randomized and controlled studies this intervention can not -at the moment –be considered as an evidence-based practice (Geenens et al, 2007).

2.2 Special issues under different treatment modalities

Special issues as prisoner’s needs assessment, qualifications and attitudes of staff and continuity of care are taken into consideration in this section. These issues are regarded as important for quality and adequacy of treatment offered in prison condition and should be included into the guideline.

2.2.1 Prisoner’s needs assessment

It is important to accommodate those prisoners who are not motivated or able to stop using drugs, but do need to better understand how to reduce the harms associated with drug use. Research has highlighted the need for treatment providers, in any setting, to identify the needs of clients and their goals, whether this be maintenance or abstinence, and provide support in accordance with this. The needs of women must be treated specifically. Mostly the different needs of women in prison are not mentioned specifically. As Palmer (2004, 2007) pointed out the complexity and severity of the drug use in women’s prisons is far greater than for the male counterparts. Therefore the clinical management or overall management of women in prison needs addressing separately to the needs of men ( Stöver et al, 2004). Henderson (1998, citied in Zurhold et al. 2005) pointed out that compared to men, female inmates show a high incidence of severe mental disorders such as depression and coexisting psychiatric disorders. Health problems seem to be among the most important concerns of female offenders today. Several studies from the United States, Australia and New Zealand agree that women prisoners show a high prevalence of health problems and psychological and psychiatric disorders (Zurhold et al. 2005). In England and Wales, United Kingdom, 90% of women prisoners have diagnosable mental disorders, substance misuse or both. It is estimated that at least 75% of women arriving in prison have some sort of drug related problems at the time of arrest. Staff working in women’s prisons should be aware of the particular risks of self-harm among women in custody. It is essential that the specific hygiene needs of women should be met from reception with adequate supplies according to individual need (Palmer, 2007).

2.2.2 Qualifications and attitudes of staff

As Spitzer stated (2004) prisoners have the right to receive state of art medical care. The manifold developments in the field of addiction medicine, psycho-social support need to be transferred to the medical and psycho-social services in prisons. Not only the introduction of new substitution drugs, but also topics as the nature of addiction, comorbidity, interactions with other drugs should be discussed permanently. Also the attitude of staff and their relationship towards prisoners in substitution treatment has to be discussed during vocational trainings. As pointed out by Michel (2004, citied in Stöver et al. 2004) in their study on substitution treatment in French prison, the vast majority of doctors interviewed prescribing substitution drugs has not been educated in areas of drug addiction. In some countries a special training before employment as a doctor in prison is envisaged (The Netherlands), in some others countries, e.g. Germany, a special training for doctors on addiction medicine is required (in the community and in the prison) before the start of substitution treatment ( Stöver et al, 2004).
The training seminars should focus on adequate behaviour patterns as part of measures initiated to prevent the spread of infections in prison. A single training on behaviour change, however will not be efficient without accompanying structural changes in the prison setting. According to interviews with prison staff, the three following goals need to be met (Stöver and Trautmann, 2001):
• identification staff with the goal of preventing infection (change attitudes).
• acquiring basic medical knowledge.
• accepting and meeting individual and collective needs for safety (citied in Stöver et al. 2007).

2.2.3 Continuity of care

Porporino et al (2002, citied in Stöver et al. 2004) pointed out that continuity of treatment provision is one of the key concepts, particularly following release, and that it is linked to re-offending rates. Many studies have shown that in particular, engagement in transitional aftercare has been proven as crucial for reducing post-prison recidivism (Simpson & Knight, 1999; Vigilante et al. 1999; Butzin et al, 2002, citied in Stöver et al. 2004). Effective and successful drug treatment in prison requires a continuum of care that takes the drug-using inmate from the correctional environment to the re-integrative processes of community-based treatment offers (Hiller et al, 1999, citied in Stöver et al. 2004). This applies not only to drug free interventions but also to substitution therapy (Stöver et al, 2004). As most prisoners will eventually be released, careful prison discharge planning is essential for preserving the health care advances made in prison, and it requires a comprehensive approach (Spaulding et al. 2002, Springer & Altice, 2005, cited in WHO et al. 2007a). Studies among female drug users in prisons and after release showed, that problems which women must deal with after leaving the prison are unemployment, lack of roof over head, lack of possibilities to continue education, somatic and psychological problems. Some of them are not able to sustain abstinence. In connection with a long-lasting isolation and long-term abuse period women have no basic social skills and the social reintegration is difficult for them. They have a problem in everyday life organization, cope with stress and emotions. In the first period they feel helpless in the face of everyday problems. They need support of institutions and relatives and friends. Effective penitentiary and post-penitentiary help (psychological help, professional reintegration, social help, learning how to copy with withdrawal symptom) are needed. Respondents think that it is important to facilitate personal links with an institution which they are supposed contact after leaving the prison (Moskalewicz et al. 2008).

3 Recommendations

3.1 Testing for infectious diseases

The literature research revealed that testing for infectious diseases and vaccination is a very important tool to promote and secure health in prison. Vaccination for Hepatitis B and A is highly recommended for prisoners. Similar to testing for infectious diseases, drug testing plays an important part in prison. It can have very different aims and methods. It has been observed that mandatory drug testing is rather expensive and can be counterproductive, due to an increasing tension in the prison. Level of evidence and need for future research: recommendation is based on outcome of studies; testing for infectious diseases and drugs need more evaluation studies.

3.2 Treatment of infectious diseases

Prison authorities should ensure that prisoners receive care, support and treatment equivalent to that available to people living with HIV in the community, including ART. Treating HIV-infected prisoners with ART (anti-retroviral therapy) will not only have an effect on the individual health but also an impact of public health outside the prison. It should be kept in mind that modalities of administration of HAART have different advantages and disadvantages and influence the adherence. The literature is inconsistent about the evidence about which modality to prefer. It has been shown that treatment for HCV is also feasible and successful for marginalized groups such as IDUs. Stöver et al. (2007) concluded that although there are only very few studies published on the topic of Hepatitis C treatment, the evidence seems to be clear. Treatment in infected inmates is feasible and safe. By reducing the HCV prevalence among inmates in prisons the prevalence of HCV in the general population is also reduced. Therefore, especially from a public health point of view the implementation of HCV treatment in prison and the access to care for all infected prisoners needs to be promoted. Level of evidence and need for future research: recommendation is based on outcome of studies; more studies are needed about advantages and disadvantages of different HART modalities, because literature is inconsistent.

3.3 Abstinence oriented programmes

Not many studies have been conducted on the effectiveness of psychosocial interventions in the prison setting and a need for more studies on effectiveness of treatment programmes was stressed. A number of studies indicate that it is important for prison systems to develop particular strategies for prison drug treatment rather than simply just reflecting those strategies that exist in the community. Generally there is a growing consensus that drug treatment programmes in prison can be effective if they are based on the needs and resources of prisoners and are of sufficient length and quality. Level of evidence & need for future research: recommendation is based on outcome of studies; not many studies were conducted on this issue, so it’s a need for further research.

3.4 Detoxification

Regarding treatment for drug dependency, detoxification with adequate medication is rarely available throughout Europe. There is no sufficient literature on this issue to formulate recommendation Level of evidence & need for future research: There is a lack of evidence for detoxification programmes in prisons, with only two studies published. More studies should be conducted on detoxification treatment.

3.5 Substitution

According to existing literature substitution treatment can reduce sharing injection equipment, can result in decreasing in drug use, drug-related prison violence, crime following release. In several studies negative side-effects of PMMT often feared by prison staff, such as stand over tactics or a black market for methadone, were reported not to have occurred. A sufficiently high dosage (more than 60 mg) also seems to be important for an increase in the retention rate, which then can be used for additional health care services. The initiation of MMT also contributes to a significant reduction in serious drug charges and in behaviour related to activities in the drug subculture. Offenders participating in MMT had lower readmission rates and were readmitted at a slower rate than NON-MMT patients. There is evidence that continued MMT in prison has a beneficial impact on transferring prisoners into drug treatment after release. Level of evidence & need for future research: recommendation is based on outcome of studies; it seems that this issue is pretty well elaborated.

3.6 Needle exchange

A number of reviews on PNEPs (prison needle exchange programmes) have been undertaken, and gathered evidence for the effectiveness of PNEP, so a further discussion on the implementation is needed, as evidence indicates that the implementation of such measures is possible and feasible with no security problems. Prisoners should have easy, confidential access to needles and syringes. Level of evidence & need for future research: recommendation is based on outcome of studies; there is need for studies which focus on the question why syringe provision in prisons is still so controversial.

3.7 Provision of bleach

There is no evidence of effectiveness of decontamination with bleach in the community and therefore it seems rather unlikely to be effective in prison. Disinfection as a means of HIV prevention is of varying efficiency, and is regarded only as a secondary strategy to syringe exchange programmes. Level of evidence & need for future research: recommendation is based on outcome of studies; need for future research should be considered.

3.8 Provision of condoms

Condoms are likely to be the most effective method for preventing STDs. No serious negative effects of condom provision in prisons have been found, and the provision of condoms seems feasible in a wide range of prison settings. Condoms should be made easily and discreetly accessible to prisoners so that they can pick them up at various locations in the prison. Level of evidence & need for future research: recommendation is based on outcome of studies; there are not many studies evaluating the distribution of condoms in prison.

3.9 Case management

Any conclusion about the effectiveness of case management for substance abusers is at the moment premature and even unwarranted, given the relative scarcity of randomized and controlled trials, especially concerning some specific models of case management. Several studies of case management among drug abusers involved in the criminal justice system have shown that coercion may help to enhance treatment participation and retention, which is associated with positive effects on clients’ drug use and criminal involvement. Empirical evidence concerning the effectiveness of judicial case management is still lacking, but available data do not show compelling evidence of its effectiveness. Positive effects of this intervention are reduced drug use and relapse rates, increased treatment participation and retention and less violation of judicial conditions. Level of evidence & need for future research: recommendation is based on outcome of studies; there is lack of studies concerning some specific models of case management.

3.10 Clients’ needs

Programmes offered in prison should be based on needs of clients and their goals, whether this be maintenance or abstinence, and provide support in accordance with this. The needs of women must be treated specifically. Mostly the different needs of women in prison are not mentioned specifically. Level of evidence & need for future research: recommendation is based on outcomes of studies, subjective needs should be in focus.

3.11 Continuity of care

Effective and successful drug treatment in prison requires a continuum of care that takes the drug-using inmate from the correctional environment to the re-integrative processes of community-based treatment offers. Very important is to facilitate personal links with an institution which people after release are supposed contact after leaving the prison. A careful prison discharge plan is essential for preserving the health care advances made in prison, and it requires a comprehensive approach. Level of evidence & need for future research: recommendation is based on outcomes of studies.

3.12 Staff competences

Prisoners have the right to receive state of art medical care. Staff should be offered vocational trainings including not only medical or therapeutic issue, but also the attitude of staff and their relationship towards drug using prisoners.
Level of evidence & need for future research: recommendation is based on outcomes of studies and authorities opinions.

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