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Global State of MAT in prisons and
International Prison Health
Standards
Training on
Opioid Agonist Treatment (OAT) in prisons in Ukraine
26-27 June 2023, Kyiv, Ukraine
Prof. Dr. Heino Stöver
Institute of Addiction Research
Frankfurt University of Applied Sciences
No conflict of interest to declare
1. Key Recommendations of
Prison Healthcare
“…the role of prisons as important
settings to address health
inequalities and to recognize the
status of people in prison as a
disadvantaged group in terms of
health and well-being.”
Lisbon conclusions from the World Health Organization (WHO) international meeting on prisons and
health (2017)
http://www.euro.who.int/__data/ assets/pdf_file/0004/365971/Lisbonconclusions.pdf?ua=1
Availability, accessibility,
acceptability, and quality of health
care services in prisons
McLeod (2020)
Prison Health Care Governance – Clinical
Independence is Key
“Unrestricted clinical independence for health
care providers constitutes the bedrock of
ethically sound health care for individuals in
detention, and is based on the assertion that the
sole task of health care professionals is to
evaluate, protect, or improve their patients’
physical and mental health.”
Pont et al. (2018): Prison Health Care Governance: Guaranteeing Clinical Independence . In
American Journal of Public Health, 4/18
Essentials for effective commissioning of prison
healthcare:
•increased accessibility,
•improved continuity of care,
•improved quality of data and intelligence,
•understanding needs,
•collaborative working,
•clear evidence base on what works and is cost
effective
•the inclusion of the views of people living in
prison, their families and the whole prison
workforce.
Leaman J, Richards AA, Emslie L and O‘Moore EJ: Improving health in prisons – from evidence to policy to implementation –
experiences from the UK. In: International Journal of Prisoner Health 13; 139-147, 2017;
see also: Zulaika et al. (2012): A new prison health care model: the experience of the Basque Country. In: Rev Esp Sanid Penit
2012; 14: 91-98
CPT
(Extract from the 3rd General Report,
1993)
71. In order to guarantee their independence in
health care matters, the CPT considers it important
that health care personnel in prison should be
aligned as closely as possible with the mainstream
of health care provision in the community at large.
72. Whatever the formal position under which a
prison doctor carries on his activity, his clinical
decisions should be governed only by medical
criteria.
Council of Europe R (98)7
12. The role of the ministry responsible for
health should be strengthened in the domain of
quality assessment of hygiene, health care and
organisation of health services in custody, in
accordance with national legislation. A clear
division of responsibilities and authority should
be established between the ministry responsible
for health or other competent ministries, which
should co-operate in implementing an
integrated health policy in prison.
Council of Europe R(2006)2
European Prison Rules
40.1 Medical services in prison shall be
organised in close relation with the general
health administration of the community or
nation
40.2 Health policy in prisons shall be integrated
into, and compatible with, national health
policy.
Moscow Declaration on Prison Health (2003)
The WHO established in its 2003
Moscow Declaration the essential
need to establish close links
between —or to integrate—
public health care services
and those in prison
WHO (2003) Moscow Declaration: http://www.euro.who.
int/data/assets/pdf_file/0007/98971/E94242.pdf
24/2: Health care services
should be organised in close
relationship to the general
public health administration
and in a way that ensures
continuity of treatment and
care, including for HIV, TB
and other infectious
diseases, as well as for drug
dependence.
www.unodc.org/documents/justi
ce-and-prison-reform/GA-
RESOLUTION/E_ebook.pdf
Strasbourg Conclusions on Prison and Health
“The subordination of prison health services
under the jurisdiction of health ministries is the
most effective way to guarantee the professional
independence and ethical conduct of prison
health staff.”
•COVID-19 as an opportunity for developing systems further
and gave a concrete example about health information
systems and how the pandemic created an interoperable
system in many countries.
COVID-19 as a key excercise in the
organization of prison health
Tavoschi, S Mazzilli, D Petri, V Busmachiu, I Stylianou,F Meroueh, H Stöver, A Rosello, R Ranieri, L Baglietto (2022): COVID-19
vaccination in prison settings: a model to design tailored vaccine delivery strategies, October 2022. In: The European Journal of
Public Health 32(Supplement_3) DOI: 10.1093/eurpub/ckac129.388
Pont et al. (2022): Jörg Pont, Stefan Enggist, Heino Stöver, Hans Wolff (2022): Covid-19 Lessons for Health and Human Rights
in Prison , Pages 205-220
Experience of health professionals, police staff and prisoners in Italy informs WHO COVID-19 guidelines for prisons’, World
Health Organization Regional Office for Europe, 28 May 2020,
www.euro.who.int/en/countries/italy/news/news/2020/5/experience-of-health-professionals,-police-staff-and-prisoners-in-italy-
informs-who-covid-19-guidelines-for-prisons.
’COVID-19 info video encourages vaccination among prison population’, Irish Red Cross, www.redcross.ie/covid-19-
response/covid-19-info-video-encourages-vaccination-among-prison-population, [accessed on 21 January 2022].
Harm Reduction International and Penal Reform International, COVID-19 vaccinations for prison populations and staff: Report
on global scan, December 2021, p.30.
HIV prevention, testing, treatment, care and support in
prisons and other closed settings: a comprehensive
package of interventions
2. OAT: evidence, obstacles, and
progress
The PNSP Manual (1/3)
•Review of 21 studies (incl. 6 RCTs) shows that OST is
effective among the prison population:
++ reduced heroin use, injecting and syringe-sharing in
prison, if doses adequate;
++ increases in treatment entry and retention after release;
++ post-release reductions in heroin use;
+ pre-release OST reduces post-release deaths;
+/- evidence regarding crime and re-incarceration equivocal;
? lack of studies addressing effects on incidence HIV/HCV;
Disruption of continuity of treatment, especially due to brief
periods of imprisonment, associated with very sigificant
increases in HCV incidence.
Systematic OAT review of
prison1
1 Hedrich et al. 2012; Addiction
Health & Wellbeing Journal Club - 03/03/2017
Maciej Czachorowski
Epi-scientist
PHE National Health & Justice Team
The PNSP Manual (1/3)
One cohort study (Larney et al., 2014) enrolling N=16 715 opioid dependent
people who were in prison between 2000 and 2012 showed that:
•being in OST was associated with a 74% lower hazard of dying in prison
(adjusted HR (AHR) 0.26; 95% CI 0.13 to 0.50), compared to time not in
OST
•being in OST was associated with a 87% lower hazard of unnatural death
(adjusted HR (AHR) 0.13; 95% CI 0.05 to 0.35), compared to time not in
OST
•being in OST was associated with a 94% lower all-cause mortality hazard
during the first 4 weeks of incarceration (adjusted HR (AHR) 0.06; 95% CI
0.01 to 0.48), compared to time not in OST
•being in OST was associated with a 93% lower hazard of unnatural death
during the first 4 weeks of incarceration (adjusted HR (AHR) 0.07;
95% CI 0.01 to 0.59), compared to time not in OST
Further evidence of OAT in
prisons1
1 EMCDDA 2021
Adopted to the national situation and
translated into several languages (e.g.
Russian, Czech, Lithuanian, Latvian,
Estonian etc.)
Also available as E-Learning course;
see: www.harmreduction.eu
The PNSP Manual (1/3)
•Abstinence predominant concept
•Juridical concerns
•Lack of knowledge
•Lack of infrastructure
•Mixing up OAT medications with street
drugs by staff and medical doctors
•Political reasons
Ostacles: Why is the introduction of
OAT going so slow1?
1 Stöver et al. 2020
•Prison-based OAT is a highly effective means
of treating opioid use disorder
•OAT is a starting point and stable therapy for
treating other disorders and infectious
diseases
•Highly effective of reducing the risk of death
(75% reduction) among people in the first 4
weeks after release from prison.
Conclusions
3. Roles and responsibilities of
prison staff and health care
workers
The PNSP Manual (1/3)
•OAT a treatment like any other
•State-of-the-art treatment – highly
effective and efficient
•Daily supervised intake of methadone
•Urine controls
•Documentation
•Doctor-patient-relationship
•Ongoing communication
Roles and responsibilities
of medical staff1
1 Kastelic, Pont, Stöver 2008
The PNSP Manual (1/3)
•No discrimination or stigmatization!
•Daily guidance to the medical unit
•Understanding the philosophy of OST
Roles and responsibilities
of security staff1
1 Kastelic, Pont, Stöver 2008
The PNSP Manual (1/3)
•OAT and psycho-social care
•OAT as a basis for further planning
•OAT and throughcare
•OAT and rehabilitation
Roles and responsibilities
of health care staff and social worker1
1 Kastelic, Pont, Stöver 2008
4. Risks (overdose, diversion etc.)
and how to mitigate them
•Risk of overdose can be minimized by proper
anamnesis (including information by treating
doctor outside)
•Start low and go slow: dosing needs to be
done individually
•Confirmation of identity
•Supervision of intake
•“Sing a little song…” in order to prevent
diversion
Risks: overdose and diversion
5. Reduction of post-release
mortality and OAT
•Physiological: desensitisation to
opiates
•Fatal OD if pre-incarceration dose is
consumed at liberty
•Behavioural:
•Acute injection (increases drug
bioavailability and respiratory effects )
•Concurrent with alcohol and
benzodiazepine (tranquilliser) (exacerbates
suppression of respiratory drive)
•Concurrent with cocaine (induction of
cardiovascular arythmias)
Factors contributing to increased risk of acute death
upon release in people with opioid use disorder (OUD)
31
•Excess mortality risk in the first weeks after re
lease
•European studies on excess mortality risks:
•England/Wales (first week): X 29 (M) X 69 (F)
•Denmark (first two weeks): X 62 (M/F).
•France (first year): X 24 (M 15-34); X 274 (M 35-54)
•Ireland: comp. Drug Related Deaths prison/no prison:
–28% of DRD had left prison since one week
–18 % of DRD had left prison since one month
Source: 2012 Selected Issue; TBC: Baussano, 2010; Psychiatric disorders: Palijan, 2009
Drug Related Death after Release
6. Conclusions
•Prison-based OAT is a highly effective means
of treating opioid use disorder
•OAT is a starting point and stable therapy for
treating other disorders and infectious
diseases
•Highly effective of reducing the risk of death
(75% reduction) among people in the first 4
weeks after release from prison.
Conclusions
Support by stakeholders
Utilization of infrastructure:
Doctors, clinics, pharmacies
Services involved
Networks
Partnerships
Prisons: staff,
prisones,
Improve effectivity and efficiency on prison health
References
•EMCDDA (2017) European Drug Report 2017: Trends and Developments. Luxembourg: Publications Office of the European
Union, June 2017. Available online: http://www.emcdda.europa.eu/publications/edr/trends-developments/2017
•Statistical Bulletin 2017. EMCDDA Lisbon, June 2017. Available online: http://www.emcdda.europa.eu/data/stats2017_en
•EMCDDA (2017) Health and social responses to drug problems: a European guide. Luxembourg: Publications Office of the
European Union, October 2017. Available online : http://www.emcdda.europa.eu/publications/manuals/health-and-social-
responses-to-drug-problems-a-european-guide_en
•EMCDDA (2017) Drug consumption rooms: an overview of provision and evidence. EMCDDA Series: Perspectives on Drugs, June
2017. Available online : http://www.emcdda.europa.eu/topics/pods/drug-consumption-rooms
•EMCDDA (2016) Preventing opioid overdose deaths with take-home naloxone. EMCDDA Series: Insights. Luxembourg:
Publications Office of the European Union, 2016. Available online: http://www.emcdda.europa.eu/publications/insights/take-
home-naloxone_en
•EU Drugs Strategy 2013-2020. Available online: https://eur-lex.europa.eu/legal-
content/EN/TXT/?uri=celex%3A52012XG1229%2801%29
•EU Action Plan on Drugs. Available online: https://eur-lex.europa.eu/legal-
content/EN/TXT/?uri=CELEX%3A52017XG0705%2801%29
Websites
•Harm Reduction Coalition
In the Overdose Prevention section of their website they have a great selection of documents covering: News and Updates, Overview of Overdose, Tools and Best
Practice Information, and Policy and Advocacy documents.
•COPE Australia
Community Overdose Prevention and Education (COPE) is a community-based opioid overdose prevention initiative funded by the Victorian Government. COPE
provides training and support to primary health and community organisation staff. These trained staff will provide education to individuals who may be opioid users or
potential overdose witnesses, such as a family member or friend.
•Understanding the risks of mixing medications & street drugs
•AMA Webinars
The American Medical Association has resources available about Prescription Opioid Overdose and Public Health Responses.
•Ontario Harm Reduction Distribution Program: Naloxone Program
This website contains information relative to the Ontario Provincial Naloxone Program: naloxone order forms, staff training resources, and client educational
resources. It also has a comprehensive Community-Based Naloxone Distribution Guidance Document.
•Overdose Prevention Alliance
This website offers different manuals and tools for the implementation of a community-based overdose prevention program. It offers links to existing programs and
legal resources. It can help you locate the program nearest you.
•Breathe (the overdose game)
This website presents the "Breathe" game which is an instructional and entertaining way to learn, understand and try to respond to an overdose before it happens.
•EHRN: Training on Overdose Prevention & Response
The Eurasian Harm Reduction Network (EHRN) is a regional network with a mission to promote humane, evidence-based harm reduction approaches to drug use, with
the aim of improving health and protecting human rights at the individual, community, and societal level.
•Naloxone.Org.UK
Here is a comprehensive website about naloxone. It includes updates about the National Naloxone Program in Scotland and N-ALIVE, a large prison-based research
trial providing overdose and naloxone education to individuals being released. Links at the bottom of the page include a nalo xone finder, external resources, and
law/policy information.
•Project Lazarus
Community-based Overdose Prevention from North Carolina and the Community Care Chronic Pain Initiative.
•SPHERE
Useful downloadable resources including posters to engage with different audiences about overdose. Includes tools for drug an d alcohol treatment providers to
incorporate overdose into relapse prevention and discharge planning, conversation starters and an Opioid Overdose Prevention Card Game.
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