Drug Abuse
SERVICES
Of course, risk reduction activities are not limited to counselling and training. You have to create the conditions that allow prisoners to act according to the rules of risk reduction. One thing that is vital here is providing the tools and materials that people need to behave safely.
In addition to facilitating safer behaviour, handing out this material provides an opportunity to pass along the message of safer behaviour. As stated above (see this chapter 2, 2.4 - 2.6) making contact and talking about sensitive things like safer use and safer sex is not always easy. Services providing risk reduction materials to inmates can facilitate and support this work. They can be a catalyst to start a discussion about the issue.
9.1 Provision of disinfectants for cleaning injecting equipment
Disinfectants are key components in HIV prevention strategies. In prisons they have become a form of risk reduction that copes with the reality that syringes do exist in prison but avoid the problem of not wanting to provide new, sterile injection equipment. The use of bleach for cleaning injecting and tattoo equipment is an effective tool for preventing transmission of HIV and other blood-borne diseases (e.g. HCV). The method used for cleaning with full strength household bleach is both simple and effective when it is done properly (as described in chapter 2, 6.1). The widespread availability of bleach for household purposes gives intravenous drug users the opportunity to take preventive measures in a discrete manner.
One of the first bleach programs in a prison was started by a prison officer in Ireland. He was confronted with a stark political reality, in which pragmatic preventive health or HIV prevention was prohibited. The officer saw to it that each toilet in his institution contained a bottle of bleach and trained the drug dependent inmates on proper cleaning techniques and safer behaviour.
In Europe several different modes of official distribution exist:
u    On admission, a ‘pocket pharmacy’ is handed out to all
inmates in Switzerland, containing condoms, plaster, a small bottle of polyvidonum-iodum and a leaflet with instructions of how to use bleach; (see Bolli 2001)
u    Direct access to bleach in bathrooms or toilets (Denmark
and Finland). as in some places distribution in bathrooms,
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etc., is not possible due to sabotage
u From medical departments
u    From the penitentiary administration (1 small bottle of 120ml
at 12° for every prisoner, every 15 days; France).
u    A ‘health kit’ including bleach and instructions on how to
clean needles most effectively, given to every inmate on home leave or on exit from the institution.
If you choose a person-to-person method of distributing disinfectants, you can consider the following channels:
u    Inmate HIV/AIDS peer counsellor
u    Institutional stores
u    Cleaning personnel
u    Inmate clerks working on different units
u    Social/health worker
u    Doctor/nurse in a prison unit
u Community HIV/AIDS or drug services
If you choose an anonymous distribution strategy, disinfectants can simply be made available from the following spots:
u In inmate washrooms and shower areas on the ranges
u    In laundry rooms on the units (or in the residential houses)
u    In recreation areas, such as the gymnasium and TV room
u In the washroom area of the gym
u    In the visiting and correspondence area
u On corridors, where major inmate movement occurs
u    In the kitchen on each unit
u    In the inmate washroom in health care centres
(compare also Haslam et al. 1999)
The options you choose will depend on the specific institutional context. The following criteria may help to choose the most suitable method of disinfectant distribution in your situation:
u    The degree of anonymity and confidentiality necessary
for distribution
u    How easily accessible the distribution point is
(opening hours, informal access, sufficient quantity, etc.) u    The reach and extent of distribution is related to
w The available resources
w Whether the main focus is on general hygiene needs or solely on disinfecting syringes
w The need to realise a pragmatic, informal, ‘unsensational’ distribution
w The level of acceptance, support and involvement of prison and medical staff
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u    The need to communicate information about the appropri-
ate application of disinfectants, and the best way
of achieving that;
u    Whether the inmates use disinfectant properly or whether
there are risks involved, e.g. self-injury
u    The desire to control the quantities given out;
u    The desire to use the distribution as a means of contacting
or counselling drug-using inmates on risk reduction;
u        The need to monitor the inmate’s use of disinfectants and
any change in skills, attitudes and behaviour.
Instructions on the proper use of disinfectants is an inevitable prerequisite for distributing or accepting the distribution of disinfectants. This can be done by a leaflet or other written material, or by counselling or training (through prison or community service staff or peer educators). (The information on cleaning injecting equipment can be found in 2,6.1 and 6.2)
When you choose an option where inmates can refill their private bottles from a dispenser bottle, you should keep in mind that experience has shown that prisoners sometimes do not refill their private bottles, because they fear being revealed as drug users. The mode of distribution can be improved by providing discreet access in a public space (for examples, see above). However, anonymous access to allow refilling private bottles might also include some risks. If a dispenser bottle is freely accessible (and can simply be opened by anybody) you cannot guarantee the quality of the disinfectant. Bleach exposed to air gradually loses its effectiveness. Additionally, in the worst case inmates could even tamper with the disinfectant. This can include serious risks if certain inmates have a negative attitude towards drug-using inmates.
If you want to avoid stigmatisation or the involuntary ‘coming-out’ of drug users or where there is no clear policy on the distribution of disinfectants, you could make them accessible in a wider context (e.g. bleach for simply cleaning and washing purposes or iodine for the treatment of injuries or skin diseases). Distribution of disinfectants for cleaning syringes is then ‘hidden’ in this broader context. This broader approach could be, for example, ‘health promotion’ or ‘hygiene’ (cleaning surfaces, toilets, razors) and can be used to transmit ‘hidden messages’. In Scotland, sterilising tablets are handed out to inmates with concrete instructions how to use them for sterilising mugs, cutlery, razors, chamber pots and injecting equipment.
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One fear of many prison officials is what to do when inmates drink bleach or misuse it in some other way. There should be a first aid service provided by the prison doctor.
First aid measures and other precautions:
u    If bleach has been ingested by a prisoner, that person
should drink warm water or milk and seek medical attention immediately. Vomiting must not be induced.
u    In the event that bleach has been inhaled by an inmate,
that person should be removed to an area with plenty of fresh air and medical attention should be sought.
u    In the event that bleach comes into contact with a person’s
eyes, rinse thoroughly with lukewarm water for at least 10 minutes while holding the eyelids open and seek medical attention to ensure there are no burns to the eyes.
u Where bleach has come into contact with a person’s skin, thoroughly wash the affected area as well as any contaminated clothing (adapted from Correctional Service Canada 1986).
9.2 Needle exchange programs
On the basis of a study on practice and policy concerning the provision of sterile syringes for drug users in the European Union, the World Health Organisation/Regional Office for Europe elaborated recommendations of HIV/AIDS prevention for drug users in prisons as long ago as 1991. According to these guidelines, the following measures should be taken:
u    Measures to reduce the number of i.v. drug users
u Measures to prevent drug use
u    Information about the risks of intravenous routes of
administration
u    Information about the risks of sharing used needles
u    Demonstration of disinfecting techniques, provision of
disinfectants and equipment for hygienic drug use (alcohol swabs, plaster)
u    Provision of sterile syringes
Two years later, the WHO guidelines on HIV/AIDS in prison (WHO 1993) stressed the principle of equivalence: “...in countries where clean syringes and needles are made available to injecting drug users in the community, considerations should be given to providing clean injecting equipment during detention and on release to prisoners who request this.”
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Until now, pilot projects under which clean drug injection equip- ment is made available in prisons have been launched as trials in Switzerland, Germany and Spain. Currently, this measure is carried out in 19 prisons. The results of the evaluation of these programs are encouraging and all projects have been continued after the pilot phase.
What can be learned from the process of implementing and running these projects? First of all, there is no general recipe for how to introduce needle exchange programs into the prison system. Every prison has to find its own way. Some keywords in this context are
u    participation (of management, staff, outside agencies such
as AIDS and drug services and inmates as well)
u anonymity and
u    confidentiality.
Recommendations
The following general recommendations on needle exchange programs have been elaborated at the European Conference on Prison and Drugs, held 1998 in Oldenburg/Germany:
1. Prisons have the responsibility for providing prisoners with access to adequate measures to prevent infection and promote health.
2. Needle exchange is a sensitive area for prison services in many European countries. It is necessary to carry out surveys in prisons that are considering the introduction of needle exchange, to find out how much injecting drug use exists within the prison prior to implementation.
3. Needle exchange programs can be useful and integral parts of a general approach to drug and health services in prisons. They should be provided as part of a range of services that include health promotion measures, counselling, drug-free treatment and substitution treatment.
4. To protect all parties participating in infection prevention and health promoting measures (such as needle exchange), legal ramifications must be clarified in advance of introduction of the measures. Legal issues need to be clarified especially concerning special groups such as juveniles and inmates in substitution treatment. Clarification of these issues is the responsibility of the government department involved. The results of this clarification should be published.
5. The choice of distribution, either through machines or through personal contact, depends on the specific conditions within the respective prison settings. Continuity of availability of sterile
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syringes should be guaranteed, whether distributed by prison or community staff.
6. The successful implementation of needle exchange programmes in prison requires the establishment and the maintenance of acceptance among the prison staff and inmates, among political and legal authorities, professionals and the public at large
7. Participation in needle exchange programs should be strictly confidential, so that the participants need not fear negative consequences during their remaining sentence.
8. The distribution facilities should be located in easily accessible areas.
9. Effective infection prevention can only be achieved if measures of instrumental prevention are supplemented by counselling and information. Mandatory education and voluntary training for inmates and prison staff at all participating levels should also be provided. The following issues are of particular rele vance:
a) basic knowledge about drug consumption and infection risks,
b) means of transmission and infection prevention,
c) safer use and safer sex,
d) drug-related first-aid.
Different approaches
The following three modes of distribution have proved to be successful:
Needle exchange slot machines, discreetly located in different wards to allow anonymous access
Advantages:
u Guarantee of easy access u High degree of anonymity u 1:1 exchange
Disadvantages:
u    No control over who is using the slot machines
(inmates might use the syringe of program participants and get their own syringe).
u Machines can be damaged by inmates and staff who are not in favour of this program, which can result in technical problems.
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nd-to-hand provision by staff of the medical unit or the son doctor
Advantages:
u    Can serve as an opportunity for counselling and therapy
u    Facilitates making contact with formerly unknown drug
users
u    High control over access
Disadvantages:
u    Low degree of anonymity and confidentiality, possibly result-
ing in a relatively low participation rate
u    Probability of ‘informal participation’ by inmates who send
others instead of participating themselves officially, because they mistrust the staff.
Hand-to-hand provision by community HIV/AIDS or drug counselling services
Advantages:
u    Can serve as an opportunity for counselling and therapy
u    Facilitates making contact with formerly unknown
drug users
u    High control over access
u    Can offer some degree of anonymity and confidentiality
Disadvantages:
u    Syringes are only available at limited times during
the week
u    Anonymity and confidentiality might be limited as the involved
community services might have to provide information on participation rate to prison management
u    Mistrust by prison staff of the ‘intruding’ community services
staff providing syringes
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Examples from practice
Needle exchange via slot machines: women’s prison Vechta/ Germany (since 15th of April 1996)
Information: As part of the admission procedure, at the beginning of a term of imprisonment every inmate is informed in good time, by means of a multilingual information paper about the modalities of participation in the needle exchange project. Further relevant information (safer use, safer sex) is given in the admission unit by staff who have experience working with drug users. The information meetings for inmates that complement the exchange of syringes are designed to provide extensive information about the risks involved in injecting drug use, about how to reduce health-damaging forms of consumption and how to practise safer use techniques in the period after imprisonment. The drug users are also informed about the rules of the project:
u    They should only have a syringe on them when it needs
to be exchanged
u    Lending or selling syringes is prohibited
u    Each inmate may only possess one syringe
u    The syringe must be left in the prison if the inmate is
transferred to another prison
Moreover, a “safer sex” and “safer use” training is offered once a week to all interested inmates.
Access: Needles can be exchanged in 5 sections of the prison, excluding the “leave” section, the home for mothers and children and the admission unit. A dummy syringe, which must be inserted into the machine to obtain a sterile syringe, is only handed out to those drug-addicted inmates who have been examined by the prison doctor and whose addiction has been documented in their medical record. The machines were placed in five easily accessible places in the prisons. Besides syringes, the machines also dispense heat-sealed alcohol swabs and ascorbic acid in adequate portions, filters, plaster and ampoules holding a sodium chloride solution. Trained staff from the health care unit maintains the machines on a daily basis, i.e. refilling them with new equipment and discharging the used syringes.
Exclusions: Inmates participating in a methadone program are excluded from the needle exchange because they signed a contract, renouncing any additional consumption of drugs. Minors require their parents’ declaration of consent.
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Staff: At the beginning of the project, the prison staff were given the opportunity to participate in a one-day information seminar. In addition to this, special information meetings are offered which the staff may attend during working hours, in order to keep them up-dated about first aid, prophylaxis of infection, pharmacology and the handling of drug addicts.
Remarks: Possession of drugs is still prosecuted. Therefore the project cannot be considered a liberalisation of drug consumption in detention but should be viewed as dealing with the reality of drug consumption in prison. Due to the legal context and the philosophy of the project, no increase in cell searches or extention in urine sampling has been conducted.
Needle exchange via hand-to-hand provision: men’s prison in Lingen I, Dept. at G roß- Hesepe/Germany-(since 15th of July 1996)
Information: Different from the approach chosen in Vechta, no machines were set up in the prison of Groß Hesepe. Here, the staff of the drug counselling service and the health care unit of the prison hand out sterile syringes to inmates in exchange for used ones during fixed hours each day in a tea-room.
In addition to the exchange of syringes, further support services are offered:
u    Individual counselling on HIV/AIDS provided by the
staff of the health care unit, the drug counselling service and the regional AIDS support group
u    Handing out of multilingual information papers on HIV/
AIDS, safer sex and safer use
u    Information meetings on HIV/AIDS and hepatitis
Support measures like training courses on first aid are also offered for the prison staff to brush up and deepen their existing knowledge. Information meetings are organised at irregular intervals by the drug counselling service and the AIDS support group.
Access: The tea-room is located next to the drug counselling service, a room that is difficult to see into. The inmates can reach it via the recreational ground. Prisoners intending to exchange syringes in the tea-room may also use the opportunity to obtain counselling if they wish. The participants in the exchange project are assured that the provision of syringes is anonymous. The staff who hand out the syringes have a duty to maintain confi-
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dentiality. All drug-addicted inmates may participate in the project.
Exclusion: Like in the prison in Vechta, inmates participating in a methadone program are excluded from the needle exchange because they signed a contract, renouncing any additional consumption of drugs.
Staff: Extensive discussions prior to the implementation of the project which were designed to make the project transparent, which helped staff to develop a great deal of sensitivity towards the drug problem and its medical and psycho-social implications. This provided a solid basis and the levels of acceptance required for a successful realisation of the project. The readiness of the prison staff to actively participate in the project was also reflected in the large number of staff who co-operated with those scientists involved in compiling the data for the first evaluation of the project.
9.3 Provision of condoms
There are substantial differences in the availability and the modes of provision of condoms in European prisons. A wide range of different policies can be found, ranging from free distribution to total prohibition. There are countries where sexual relations in prisons simply are prohibited and consequently, neither condoms nor lubricants are available for prisoners. In some countries, they can be obtained free of charge or are prescribed by the doctor as in England and Wales, while in others prisoners have to pay for them.
The key elements of an appropriate condom provision scheme are again, confidentiality and anonymity of access. Sex, especially men having sex with men and to some degree, women having sex with women, is a taboo that can lead to exclusion and stigmatisation.
In the provision of condoms, issues such as the method of distribution, by whom and where they are distributed are crucial to the reach of this service. Several modes of distribution are already being applied in European prisons.
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By the medical doctor (either by prescription or not), or by the medical service/unit through nurses
Each of these modes of condom provision does have advantages and disadvantages. The provision (or even prescription) via medical doctors means that inmates have to apply for a doctor’s visit in the morning, simply to get hold of a condom. This may be perceived by inmates as being a high threshold to access. A side effect of this is that the doctor then is informed about inmates’ (potential) sexual activities. This is also partly true for provision via a medical service or unit or through nurses. However, this is a reliable source of provision which is permanently in service and condoms may be obtained also when an inmate is visiting these services for other reasons. Finally, any condoms obtained through this modality are generally free of charge.
From the prison shop
The latter is not the case at the prison shop. Here, the inmates generally have to buy condoms. Another disadvantage is where there is no prison shop - which, in most cases is open every day except for the weekend - but a visiting merchant. This service is only available perhaps once a week, or even once a fortnight. Inmates might even have to order condoms in advance. However, sexual activities cannot always be planned in that way. Often, they just happen. Moreover, anonymity and confidentiality are hard to maintain with this service. Finally, condoms are quite expensive in relation to the moderate amount of money that most inmates have in prisons.
By prison social and health workers, or by the staff of community AIDS and drugs services
This seems to be quite a suitable way to provide condoms. Social or health workers in prisons are generally easy to contact and often are better trusted than security staff. Condoms can be distributed on a confidential basis. Community social and health workers tend to have even more trust and credibility in the eyes of the inmates. Of course, the latter’s success at distributing condoms will depend on how regular they visit a prison and how many condoms they hand out to each inmate.
When including community social and health service staff in training seminars on safer sex, they can leave some condoms used for exercises (see above) and inform inmates where and how they can get condoms in the future.
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Through inmates
Other inmates might be most trusted as they are peers. Nevertheless inmates often also make moral judgements and hold resentments against sexual activities, especially in male prisons when it comes to sex between men. But if peers are regarded as credible and trustworthy persons, this can be an appropriate way of giving out condoms.
Anonymous access
Apart from having people provide condoms to prisoners, condoms can also be made available anonymously. This can be done by either including condoms in the provision of a package of material or without personal interaction. Approaches tried successfully have included the following measures:
u    Include condoms in a release pack for inmates who go
on leave or are released. This measure expresses the need to protect oneself in both professional and private sexual relationships immediately after release.
u Dispense condoms at admission with different information material, e.g. including condom instruction and information on safer sex
u    Dispense a box of condoms in visiting rooms (conjugal
visit rooms)
u    Dispense condoms in waiting areas (doctor, social
worker, library)
u    Dispense condoms in counselling rooms, in an informal
way as ‘leftovers’, when community AIDS or drug services from inside or outside the prison are offering counselling.
Making condoms available without personal interaction offers a good opportunity to allow prisoners to obtain condoms without being seen by other inmates or staff.
Prohibition of condoms may be based on a lack of recognition of the problem but also on cultural and religious reservations. Often, availability is restricted because of single experiences when condoms were used for different purposes (such as hiding drugs in the body). These restrictions can be tackled in a debate, balancing the health interests (prevention of infectious diseases) and the cultural and religious boundaries and these occasional isolated cases of misuse.