Neil Hunt Chair, UK Harm Reduction Alliance Director of Research, KCA Honorary Senior Research Associate, EISS, Univers

1. If I ruled the world…Presentation to Prisons and BeyondNOMS Prison Drug Strategy Unit, in association with the Federation of Drug & Alcohol Professionals (FDAP) and European Association for the Treatment of Addiction (EATA)Leicester, 16th Feb 2006 Neil Hunt Chair, UK Harm Reduction Alliance Director of Research, KCA Honorary Senior Research Associate, EISS, University of Kent

2. …this would be fully implemented “Healthcare in prisons should promote the health of prisoners; identify prisoners with health problems; assess their needs and deliver treatment or refer to other specialist services as appropriate. It should also continue any care started in the community contributing to a seamless service and facilitating throughcare on release.” The Future Organisation of Prison Health Care Report by the Joint Prison Service & NHS Executive Working Group Dept of Health (1999)

3. Two important gaps • Opioid substitution treatment • Patchy provision at best • Needle exchange • Pilot work on discharge from Scottish prisons But…to what extent are they feasible and how well do they work in prisons?

4. Evidence: opioid substitution treatment in prisons • Heroin injecting and syringe sharing reduced in Australia Dolan et al (2003) A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system.. Drug and Alcohol Dependence. 72: 59-65 • Heroin use reduced in Puerto Rico Heimer et al (2005) Methadone maintenance in prison: Evaluation of a pilot program in Puerto Rico. Drug and Alcohol Dependence. • Retention in MMT associated with reduced mortality, re-incarceration rates and hepatitis C infection in Australia Dolan et al (2005) Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addiction. 6: 820-828 • And forthcoming study of methadone treatment in Scottish prisons

5. Methadone treatment also available in… • Switzerland • Germany • Spain

6. Evidence: needle exchange in prisons Stover & Nelles (2003) Review of 10 years experience in 46 prisons in 4 countries • Results did not support fears that commonly arise in the start-up of implementation of Needle Exchange Programmes in Prisons. • Syringe distribution was not followed by an increase in drug use or injection drug use. • Syringes were not misused, and disposal of used syringes was uncomplicated. • Sharing of syringes among drug users reduced. Stover and Nelles (2003) Ten years of experience with needle and syringe exchange programmes in European prisons. International Journal of Drug Policy. 14: 437-444

7. Evidence: needle exchange in prisons Lines et al (2004) Review of evidence from 6 countries (Switzerland, Germany, Spain, Moldova, Kyrgyzstan, Belarus) • 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. • Have other positive outcomes for the health of prisoners. • Have been effective in a wide range of prisons. • Have successfully employed different methods of needle distribution to meet the needs of staff and prisoners in a range of prisons. This report also provides detailed accounts of implementation issues within prisons Lines et al (2004) Prison needle exchange: lessons from a comprehensive review of international evidence and experience. Canadian HIV/AIDS Legal Network

8. Models that have been used • Hand-to-hand distribution by prison nurse and/or physician • Hand-to-hand distribution by peer outreach workers • Hand-to-hand distribution by external agencies/health workers • Automated dispensing machines

9. Treatment in prison: expected best practice WHO, UNAIDS, UNODC (2004) “The evidence shows that such programmes should include all the measures against HIV transmission which are carried out in the community outside prisons, including HIV/AIDS education, testing and counselling performed on a voluntary basis the distribution of clean needles, syringes and condoms, and drug-dependence treatment, including substitution treatment. All these interventions have proved effective in reducing the risk of HIV transmission in prisons. They have also been shown to have no unintended negative consequences.” WHO, UNAIDS, UNODC (2004) Policy Brief: reduction of HIV transmission in prisons. Available http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/

10. Is there a need in the UK?

11. England and Wales Representative sample from 8/135 prisons Weild et al. (2000) Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey Communicable Disease and Public Health. 2: 121-126.

12. Scotland (15 prisons) May/June 2005 (77% response rate from ALL Scottish prisoners) • Half of prisoners (50%) had used drugs in prison • Three quarters (76%) reported decreased drug use in prison • 17% reported increased drug use • A third (34%) had used drugs in prison in the past month • 67% who used drugs in the past month used heroin • 126 (3%) reported injecting in prison in the last month. • 78 (62%) prisoners had shared their injecting equipment Scottish Prison Service http://www.sps.gov.uk/Uploads/42078F46-343E-4D93-8AC8-7E62AEB37482.pdf

13. Northern Ireland (3 prisons) • March to November 2005 • Committed on drug related charges - 134 • Passive dog indications among visitors - 1486 • Dependent on committal – Heroin 72 • Heroin finds – 18.2g + 14 tablets • Needle finds - none • Paucity of data • History of injecting? • Injected/used heroin in prison? • Shared injecting equipment in prison? Northern Ireland Prison Service Drug Report http://www.niprisonservice.gov.uk/module.cfm/opt/14/area/Drug%20Report/page/drugseizures/

14. So, there does seem to be some need.

15. But…prisons are different to the wider community Services need to reflect the vulnerability and particular circumstances of prisoners. For example: • Prisoners with serious mental health problems • Prisoners assessed as presenting a serious risk of violence • Prisoners who use prison as a life event that enables abstinence • Prisoners are subject to a far higher level of surveillance and control

16. And… Services have to be adapted to reflect the requirements of a secure environment • Prisons have a duty of care that differentiates them from community services • Optimum models of service provision do not necessarily translate across from community services directly

17. I think this all means… • Protecting the interests of those who use the prison environment constructively as a relatively drug-free environment • Drawing on best evidence of ‘what works’ in prisons elsewhere • Only a fool would pretend we have all the answers

18. So, if I ruled the world… • We would roll out opioid substitution treatment (i.e. methadone AND buprenorphine treatment) across UK prisons vigorously • We would roll out needle exchange, but more cautiously • We would simultaneously undertake a rigorous and comprehensive programme of quantitative and qualitative evaluation

19. Reference summary • Dept of Health (1999) The Future Organisation of Prison Health Care Report by the Joint Prison Service & NHS Executive Working Group. • Dolan et al (2003) A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system.. Drug and Alcohol Dependence. 72: 59-65 • Heimer et al (2005) Methadone maintenance in prison: Evaluation of a pilot program in Puerto Rico. Drug and Alcohol Dependence. • Dolan et al (2005) Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addiction. 6: 820-828 • Stover and Nelles (2003) Ten years of experience with needle and syringe exchange programmes in European prisons. International Journal of Drug Policy. 14: 437-444 • Lines et al (2004) Prison needle exchange: lessons from a comprehensive review of international evidence and experience. Canadian HIV/AIDS Legal Network • http://www.iprt.ie/files/iprt/prison_needle_exchange__lessons_from_a_comprehensive_review_of_international_evidence_and_experience.pdf • WHO, UNAIDS, UNODC (2004) Policy Brief: reduction of HIV transmission in prisons. • http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/ • Weild et al. (2000) Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey Communicable Disease and Public Health. 2: 121-126. • http://www.hpa.org.uk/cdph/issues/CDPHVol3/no2/bbv.pdf • Scottish Prison Service 2005 National Prisoner Survey • http://www.sps.gov.uk/Uploads/42078F46-343E-4D93-8AC8-7E62AEB37482.pdf • Northern Ireland Prison Service Drug Report • http://www.niprisonservice.gov.uk/module.cfm/opt/14/area/Drug%20Report/page/drugseizures//

20. Neil Hunt e: nhunt@kca.org.uk t: 01622 717652 m: 07780 665 630