Opiate Substitution Treatment and Harm Reduction in prisons : the Geneva model

1. Opiate Substitution Treatment and Harm Reduction in prisons: the Geneva model PD Dr Hans Wolff University Hospitals Geneva Hans.wolff@hcuge.ch

2. Plan • Prisons in Switzerland • Switzerland: • Examples of realizations at the prison medicine unit in Geneva • Opiate substitution treatment (OST) • and harm reduction in prison • Needle and syringe exchange

3. Language regions & bordering countries Switzerland

4. 1 country – 26 cantons Switzerland

5. Incarceration in Switzerland • General Population: 7 Mio • 113 Prisons: 6065 detainees in 2011 • 78 detainees/100’000 inhabitants World (2008): 10.1 Mio detainees: ¼ in the US (2.3 Mio, 9 Mio/year ), ¼ in Russia and China USA (costs) $49 Billion/year, 70’000,-$/inmate/year

6. Prevention in PrisonThe Comprehensive Package (UNOCD): 15 Key interventions • Information, education and communication • HIV testing and counselling • Treatment, care and support • Prevention, diagnosis and treatment of tuberculosis • Prevention of mother-to-child transmission of HIV • Condom programmes • Prevention and treatment of sexually transmitted infections • Prevention of sexual violence • Drug dependence treatment including Opioid Substitution Therapy • Needle and syringe programmes • Vaccination, diagnosis and treatment of viral hepatitis • Post-exposure prophylaxis • Prevention of transmission through medical or dental services • Prevention of transmission through tattooing, piercing and other forms of skin penetration • Protecting staff from occupational hazards

7. Opiate Substitution Treatment (OST) delivered appropriately will: • Reduce or stop illegal drug use • Improve physical, mental and social well-being of the patient • Prevent and reduce infectious diseases, including HIV and hepatitis • Reduce mortality, in particular through overdose • Reduce morbidity • Improve the quality of life of the patient and his family • Reduce public spending in health care • Reduce public spending in the criminal justice system Guidelines Euromethwork http://www.q4q.nl/euromethwork/

8. Reduce mortality by overdose n Carrieri & al 2006

9. Reduction of criminality Two interviews (85 patients ) First interview before MMT (methadone maintenance treatment) The second, after a mean MMT of 57 months Number of days with criminal act per week p<0,001 n I Sheerin & al. Reduction in crime by drug users on a methadone maintenance therapy in New Zealand. The New Zealand medical Journal; 12 March 2004 vol117, n°1190 ISSN 11758716

10. Cost-effective $38 1 $ invested in OST, Saves 38 $ (cost related to criminal activity, further incarcerations, unemployment, hospitalizations, medical follow-up) $1 Cost Savings MMT Gary A. Zarkin, Laura J. Dunlap, Katherine A. Hicks and Daniel Mamo Additional contact information Health Economics, 2005, vol. 14, issue 11, p 1133-1150

11. Access to OST in the community and in prison Harm Reduction International, The global state of harm reduction 2012

12. Time gaps in the official introduction of OST in prisons: ~7-8y (Source: EMCDDA, Statistical Bulletin 2011, HSR tables) Thanks to H. Stöver

13. Opioid users in Geneva’s prison Epidemiology • Prevalence: 8% • Male : 95,3% • Meanage : 29,7 • Previousincarceration : 74,7 % • Intravenoususers : 39,9 % • Usedother substances (legal or illegal) : 94,8% • Cocaine :70,8% • Tranquilizers : 63,5% • Alcohol :55,4% • Canabis : 44,2%

14. Opiate substitution therapy (OST) in the prison of Champ-Dollon (Geneva) Start 1970 (formal authorization in 1996) Pragmatic approach Politics of 4 pillars (Prevention, Harm reduction, treatment, repression) MTD/Buprenorphine: start or continue treatment 5-10% with OST 100% of those who wish or need substitution receive OST 0 overdose the last 10 years 14

15. Injecting & Syringe Sharing in Prison

16. Distribution machine: Hindelbank, CH Needle and syringe exchange Hand-to-hand exchange: Geneva, CH

17. Hand-to hand distribution Injection/prevention kit Spain Injection/prevention kit Switzerland

18. Proof of efficacy of needle exchange programs in prison • Prevents HIV infection • No negative consequences • No increase of drug use or drug injection • Needles not used as weapons • Facilitate referral of drug users to drug dependence treatment programs WHO 2007 Jürgens, Lancet Inf Dis 2009

19. Global availability of needle and syringe programs (NSP) in the community and in prisons Harm Reduction International, The global state of harm reduction 2012

20. Needle exchange at the prison of Champ-Dollon, CH Start 1996: principle of equivalence → cantonal law in 2000 Pragmatic approach (consider the fact that drugs enter each prison in the world) Support by prison authorities At entry: Information concerning the possibility to obtain injection material for free and in a confidential way Information at the medical unit (=confidentiality), thendistribution at the cell door (=security)

21. Syringe exchange at the prison of Champ-Dollon, 2001-2011

22. Problems and solutions Initial mistrust, fear of the syringe as potential weapon (detention officers) Frequent exchanges between stake holders improved acceptance of all Improvement of the culture of dialogue Prison direction implicated in public health strategies Proportion of needles returned to the health team Trust building Ask the detainees (=experts)

23. Problems and solutions II Acceptance by the detainees? Fear of denunciation? Importance of confidentiality Separation of the hierarchies (independence medical / prison staff) helps Participative approach in the improvement process Initiate other ways of syringe distribution Syringe sharing still exists Evaluate situation properly Other distribution methods (automates)?

25. Conclusions Addiction and associated health problems is of major concern in detention Effective harm reduction strategies exist OST, condom distribution and Needle exchange in prison are Necessary and FEASABLE Effective and low cost measures Should be implemented in every prison – worldwide! Opportunity to improve the health of the entire community (improve public health!)