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Drug use and risk behaviour in prisons and upon release in four European countries. Overdose upon release: Challenges and strategies from (ex-) prisoners’ points of view - Final report
Abstract and Figures
For prisoners with a history of drug use, and particularly opioid use, the risks related to drug use and especially overdose and death are extremely high in the immediate period after release due to high rates of relapse and lower opioid tolerance (Farrell and Marsden, 2008; Merral et al. 2010; Pierce et al. 2016; Marsden et al. 2017). Much still needs to be done in order to ensure that people with a history of drug use are sufficiently cared for when released from prison. Harm-reduction measures need to be in place for ex-prisoners to be able to readjust to freedom without relapsing into drug use and the extreme risk of fatal overdose when released.
The EU project ‘My first 48h out’ aims to address the gaps in the continuity of care for long-term drug users in prison and upon release, by supporting life-saving interventions for the prevention of overdose and the reduction of other risks related to drug use, and for the establishment of a treatment path that is not interrupted upon release.
The specific objectives of the project are:
1. To complement knowledge on risk behaviour for drug users in prison and upon release by giving a voice to drug-user communities through qualitative research in four European countries;
2. To advocate and promote the implementation of life-saving services for drug users in prison and upon release by producing hands-on guidelines for policy-makers and practitioners from prison health services on how to promote, initiate and manage services related to overdose prevention through naloxone programmes and related training and capacity building;
3. To educate grass-roots organisations and drug users, as well as practitioners working with them in prison and upon release on the risks related to drug use upon release and risk reduction practices, through the production of practical and accessible educational materials;
4. To produce and disseminate knowledge and good practice on continuity of care – including medical care and drug treatment (provision of substitution treatment, antiretroviral therapy (ART) and hepatitis treatment) and social support;
5. To co-construct and disseminate evidence and good practice on continuity of care and harm reduction in prison and upon release to a wider European public of different stakeholders, promoting active interaction between stakeholders from different countries, through a European ‘knowledge and expertise web portal’.
Work on continuity of care and treatment, harm reduction and the prevention of deaths linked to drug use and overdose for people in the criminal justice system and in prison requires approaches that can meaningfully address the different groups of stakeholders and beneficiaries that have a say in the introduction, development, definition, design, delivery, monitoring and accessing of appropriate services. These involve: policy-makers in the area of health and criminal justice, prison administration representatives and security staff in prison, health and social sector professionals working in the criminal justice system (such as those in government justice, interior, health or social services departments, and different organisational structures in different Member States), health and social sector practitioners, grass-roots organisations, NGOs and other services providing care for people who use drugs and clearly the end beneficiaries, the drug users, who will be meaningfully involved in the current project.
This report presents the results of one of the specific objectives of the project (1). A multi-country (Belgium, France, Germany and Portugal) qualitative study looking at issues related to: risk behaviour related to drug use upon release, prisoners’ and drug users’ perspectives, personal experiences of incarceration, individual risk reduction mechanisms, knowledge of risks and overdose prevention, and strategies to avoid risks when being released.
Approximately 30 prisoners and/or drug users with a prison experience were targeted for involvement in the research in each of the four countries. Focus groups and semi-structured qualitative interviews have been implemented in prisons and/or with drug users with a previous experience of detention currently attending community services.
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... Neben der physischen Gesundheit ist eine Inhaftierung auch mit psychosozialen Gesundheitsrisiken verbunden. Faktoren wie Angst, Einsamkeit, Verlust von Wohnraum, Stress, fehlende Bezugspersonen, Überforderung und der Umgang mit der Haftsituation selbst können Gründe für den Konsum in Haft und bei Haftentlassung darstellen [12,13]. Die Konsummuster und konsumierten Hauptsubstanzen unterscheiden sich von denen außerhalb der Haft, bedingt durch geringe Verfügbarkeiten und hohe Preise wechseln einige Gefangene auf andere Substanzen oder in eine Substitutionstherapie in Haft [6,13,14]. ...
... Faktoren wie Angst, Einsamkeit, Verlust von Wohnraum, Stress, fehlende Bezugspersonen, Überforderung und der Umgang mit der Haftsituation selbst können Gründe für den Konsum in Haft und bei Haftentlassung darstellen [12,13]. Die Konsummuster und konsumierten Hauptsubstanzen unterscheiden sich von denen außerhalb der Haft, bedingt durch geringe Verfügbarkeiten und hohe Preise wechseln einige Gefangene auf andere Substanzen oder in eine Substitutionstherapie in Haft [6,13,14]. Nach der Haftentlassung stellen Stressoren wie Obdachlosigkeit, Arbeitslosigkeit, fehlende soziale Bezüge und soziale Isolation ein signifikantes Rückfallrisiko dar [13,15]. Aufgrund der durch den Haftaufenthalt gesunkenen Toleranz des Körpers gegenüber Opioiden erhöht sich des Risikos einer Überdosierung mit Todesfolge [16]. ...
... Die Konsummuster und konsumierten Hauptsubstanzen unterscheiden sich von denen außerhalb der Haft, bedingt durch geringe Verfügbarkeiten und hohe Preise wechseln einige Gefangene auf andere Substanzen oder in eine Substitutionstherapie in Haft [6,13,14]. Nach der Haftentlassung stellen Stressoren wie Obdachlosigkeit, Arbeitslosigkeit, fehlende soziale Bezüge und soziale Isolation ein signifikantes Rückfallrisiko dar [13,15]. Aufgrund der durch den Haftaufenthalt gesunkenen Toleranz des Körpers gegenüber Opioiden erhöht sich des Risikos einer Überdosierung mit Todesfolge [16]. ...
Zusammenfassung
In Gefängnissen sind Personen, die Drogen gebrauchen, im Vergleich zur Allgemeinbevölkerung überdurchschnittlich häufig vertreten. Der Konsum illegaler Substanzen, insbesondere von Opioiden, geht insbesondere im Setting Haft mit hohen physischen und psychischen Gesundheitsrisiken einher. Der Beitrag gibt einen Überblick über die Konsumprävalenzen, existierende Maßnahmen im Strafvollzug sowie mögliche Maßnahmen zur Schadensminimierung in Haft und bei Haftentlassung.
... L'importance de la continuité des soins après la détention ne peut être sous-estimée, car la consommation de drogues en détention semble augmenter le risque d'overdose mortelle après libération (Stoever et al., 2019). A contrario, la prise en charge pendant la détention semble avoir une influence positive sur la récidive et la consommation de substances. ...
... A contrario, la prise en charge pendant la détention semble avoir une influence positive sur la récidive et la consommation de substances. La connexion entre l'intérieur et l'extérieur de la prison est donc indispensable pour assurer la continuité des soins et obtenir des effets à long terme , dans Vandevelde et al., 2016Stoever et al., 2019). ...
In Belgium, the care offered to prisoners who use drugs is being in development. Based on this observation, the Federal Public Service for Public Health, in collaboration with the Federal Public Service for Justice, have set up a pilot project since December 2017 aiming at the care of this specific population in three prisons of the country. The objective of this pilot project was to develop a care model, an instrument for a common screening procedure with the aim of ultimately extending the specific care offer to other prisons in the country in the coming years. After two years of existence, this pilot project was evaluated in order to identify the strengths of the programme and those that needed to be adjusted. This evaluation was carried out by a team of researchers affiliated with Ghent University (Ugent) and the National Institute of Criminalistics and Criminology in Brussels (NICC). As a result, recommendations for policy, the project and prisons were formulated. Our contribution will discuss these recommendations and at the same time identify some preconditions for the implementation of such a project in other prisons.
... Despite promising experiences reported in Scotland and other parts of the world [31], this strategy of mortality prophylaxis appears to be widely neglected. As the findings of this study indicated, most persons who inject drugs know about the risks of overdose but also need more information to manage overdose situations [33]. ...
Background
Prisoners report much higher prevalence rates of drug use and more harmful consumption patterns than the general population. People who use drugs have above-average experiences with the criminal justice system in general, and the prison system and subsequent release situations in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose. The EU-funded project ‘My first 48 hours out’ aimed to address the gaps in continuity of care for long-term drug users in prison and upon release, with a special focus on drug user’s perspectives on needs and challenges upon release.
Methods
A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users’ perceptions of drug use and risk behaviour upon prison release, experiences of incarceration and release, and strategies to avoid risks when being released. In total, 104 prisoners and recently released persons with a history of drug use participated in semi-structured interviews and focus groups discussions on these topics.
Results
Respondents pointed out that there are numerous challenges for people who use drugs when released from prison. Lack of stable housing and employment support were frequently mentioned, as well as complex administrative procedures regarding access to services, health insurance and welfare benefits. Besides structural challenges, individual issues may challenge social reintegration like ‘old habits’, mental health problems and disrupted social networks. As a result, (ex-)prisoners adopt individual strategies to cope with the risks and challenges at release.
Conclusion
Measures to prepare prisoners for release often do not focus on the individual and specific challenges of persons who use drugs. Psychosocial and medical support need to be improved and adjusted to drug users’ needs inside and outside prison. To improve the quality and continuity of care around release, the perspectives and coping strategies of people who use drugs should be used to better address their needs and barriers to treatment.
Buprenorphin, seit vielen Jahren als Schmerzmittel zugelassen, ist im Jahre 2000 in Deutschland als Substitutionsmittel zugelassen worden und stellt seitdem eine bedeutende Erweiterung der Palette der Medikamente zur Behandlung der Opioidabhängigkeit dar. Bisher sind 7 Medikamente in Deutschland zur Behandlung der Opioidabhängigkeit in verschiedenen Zubereitungen zugelassen (vgl. Abb. 4). Mittlerweile produzieren verschiedene Hersteller Buprenorphinprodukte.
Im November 2018 hat das erste Depot-Buprenorphin die EU-Zulassung erhalten. Mit dem neuen Medikament könnte sich die Substitutionsbehandlung für Buprenorphinpatient*innen künftig vereinfachen, denn das Depot-Buprenorphin erhalten die Opioidabhängigen nur einmal pro Woche oder Monat subkutan injiziert. Damit soll die selbstbestimmte Lebensführung der Substitutionspatienten verbessert und ihre gesellschaftliche Wiedereingliederung erleichtert werden (DAZ 2019).
Die Aufgabe der vorliegenden, aus zwei Teilen bestehenden, Studie, war ein Vergleich des Vergabeaufwandes der im deutschen Justizvollzug bisher verwendeten Substitutionsmittel mit dem neuen Substitutionsmedikament Buvidal®.
Dabei wurde geprüft, ob und in welchem Umfang personelle, sächliche und finanzielle Ressourcen des Justizvollzuges durch den nur noch wöchentlichen bzw. monatlichen Einsatz von Depot-Präparaten eingespart werden können.
Im ersten Teil wurden die für die Substitution benötigten personellen, sächlichen und finanziellen Ressourcen ermittelt. Insbesondere Informationen über:
- den Umfang der tatsächlich im Zusammenhang mit Substitution anfallenden Tätigkeiten als da sind:
o administrative Tätigkeiten
o die eigentliche Substitutionsbehandlung (Vergabe des Substitutionsmittels)
o Kontrollen auf Beikonsum
o Tätigkeiten bei Beginn und am Ende der Substitutionsbehandlung
o Wartezeiten (bedingt durch die besondere Struktur des Justizvollzuges)
- den jeweiligen Zeitbedarf
o für Holen und Zurückbringen der Patient*innen von und zum Haftraum
o für Wartezeiten des medizinischen Personals
o für Einnahmekontrollen und begleitende Diskussionen bei Betrugsversuchen
o für alle im Zusammenhang mit der Substitution anfallenden Tätigkeiten
- den Umfang der Substitution
- das eingesetzte Substitutionsmittel und dessen Häufigkeit
- die durchschnittliche Tagesdosis des eingesetzten Substitutionsmittels
- interne Personalkosten
- externe Personalkosten
Im zweiten Teil ist anhand bestimmter Parameter eine gesundheitsökonomische Modellrechnung vorgenommen worden.
Background Prisoners report much higher prevalence rates of drug use and more harmful patterns of use than the general population [1]. People who use drugs have also an above-average experience with the criminal justice system in general, the prison system and the subsequent release situation in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose [2–5]. The EU-funded project ‘My first 48h out’ aimed to address the gaps in the continuity of care for long-term drug users in prison and upon release and had a special focus on drug user’s perspectives on challenges upon release.
Methods A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users’ perceptions of drug use and risk behaviour upon prison release, experiences of incarceration, knowledge of risks and overdose prevention, individual risk reduction mechanisms and strategies to avoid risks when being released. Therefore, interviews and focus groups based on a semi-structured interview with (ex-) prisoners in four countries were implemented.
Results 104 (Ex-) prisoners pointed out that there are a lot of challenges for people who use drugs at release from prison. Mainly named are a lack of housing and employment support and also a complex administrative procedure regarding services, health insurance and welfare benefits. Beside these structural challenges there are individual challenges like old habits, drug use (overdose) and the situation outside prison. As a result of a lack of support (ex-) prisoners use individual strategies to cope with the risks and challenges at release.
Conclusion There are measures to prepare prisoners for release, but mostly they do not focus on individual and specific challanges of poeple who use drugs. Mainly psychosocial and medical support need to be improved and adjusted inside and outside prison. To implement measures the individual needs and strategies of people who use drugs should be utilized, as they show the specific needs of drug users at release.
Reducing the number of suicides in prison has been highlighted as an international priority. To date, however, studies examining prison suicides in Belgium are lacking. Therefore, adopting a retrospective record-based approach, we sought to investigate all suicides occurring in the whole Belgian prison estate during a 17-year period. The results underline the need for suicide prevention among prisoners in Belgium, and echo prior findings that restrictive preventive measures should be combined with psychosocial interventions in order to address the causes of prisoners being suicidal. Such strategies are ideally embedded within a comprehensive suicide prevention policy on a national level.
Die Illegalität der gehandelten Substanzen bildet den Ausgangspunkt, auf dem nahe-zu sämtliche Probleme im Umgang mit dem Phänomen des Drogenhandels beruhen. Daher ist es schwierig, im Rahmen der bestehenden Drogenprohibition Handlungs-empfehlungen für Politik, Polizei, Justiz sowie Prävention zu formulieren. Repressive Maßnahmen werden auch in Zukunft Verhaltensanpassungen der Handeltreibenden nach sich ziehen und sind kein geeignetes Mittel, um die Nachfrage nach illegalen Substanzen zu reduzieren oder überhaupt nachhaltig zu beeinflussen. Der weit überwiegende Teil des Einzelhandels sowie die Konsumierenden sind – das ist ein zentrales Ergebnis des Forschungsprojekts – nicht oder nur geringfügig in organisier-te Strukturen involviert, so dass entsprechende Strafverfolgungsaktivitäten kaum etwas zur Bekämpfung dieser Strukturen beitragen können. Die weitgehenden Befugnisse der Strafverfolgungsbehörden, die konkret mit organisierter Kriminalität begründet werden, sind in solchen Fällen unverhältnismäßig. Zudem ist die gängige, äußerst weit gefasste Definition von „Organisierter Kriminalität“ in Frage zu stellen: Durch ihre regelmäßigen Kontakte mit Lieferanten und Abnehmern würden im Grun-de auch die meisten „User-Dealer“ unter diese Definition fallen, obwohl sie kaum et-was mit typischen OK-Methoden und -Strukturen zu tun haben. Die Strafverfolgung dieser Personen geht mithin an der „Bekämpfung“ organisiert-krimineller Strukturen vorbei.
Auch für Drogenhilfe, Prävention und (lokale) Drogenpolitik lassen sich aus dem For-schungsprojekt einige praktische Schlüsse ziehen, die im Folgenden, geordnet nach den verschiedenen Handlungsfeldern (Politik, Polizei, Justiz, Prävention), aufgeführt und begründet werden.
This chapter reviews the spread of harm reduction services in european criminal justice systems, and their evaluation. It begins with a discussion of the tensions and contradictions inherent in providing harm reduction services (which may accept continued drug use) in
criminal justice settings (that do not). It then draws on research carried out for the Connections project, for its predecessor the European Network on Drug and Infections
Prevention in Prisons and on the information gathered by the European Monitoring Centre for Drugs and Drug Addiction. It examines services such as needle and syringe exchange, opiate substitution and distribution of condoms and disinfectants in prisons. It also
examines harm reduction services that have been developed in the context of police custody, and in the attempt to provide through-care and aftercare to drug users who pass through the criminal justice system. The chapter concludes that the tensions between harm reduction and criminal justice aims can be overcome in providing effective services to reduce drug-related harms.
Introduction and aims:
The aims of this study were to describe the prevalences of injection practices and needle/syringe sharing in people who use drugs in French prisons, and to investigate associated factors.
Design and methods:
Using the ANRS-Coquelicot survey (2011-2013), a random sample of 1718 people who used drugs in free society was included. Information regarding a history of incarceration, drug-injection practices inside prison and needle/syringe sharing was collected during interviews.
Results:
In our sample, 65.5% reported a history of injection and 57.4% had been incarcerated at least once. Among those who reported both of these conditions, 14% reported injection practices inside prison, 40.5% of whom had shared needles/syringes. In the multivariable model, the following variables were associated with injection practices inside prison: being a Russian-speaking detainee, having spent more time in prison, and having started to inject before 1996 and especially before 1987. Being Russian speaking was also associated with needle/syringe sharing in prison.
Discussion and conclusions:
The prevalences of injection practices and needle/syringe sharing in prisons are alarmingly high. Effective interventions to prevent the transmission of infectious diseases among people who use drugs in the prison setting are essential. The implementation of international recommendations on the principle of equivalence between prisons and the community is still very limited in most countries, and should be complemented with tailored interventions for the most vulnerable prison populations, especially Russian-speaking detainees.
