Need for and availability of harm reduction in Irish prisons

1
Need for and availability of harm reduction in
Irish prisons
Jean Long
2

• A prisoner is potentially worse than a slave,
  because the slave is the property of someone
  whose interest is to keep his property in
  serviceable condition,
• whereas the prisoner is owned by nobody,
• unless it be the state which is ultimately
  responsible for his imprisonment.
• Consequently the conditions of prisons and
  its prisoners is no bad indication of the
  development of any society and its degree of
  civilisation
• The State of the Prisons in England and Wales
  (Ruck 1929)

3
What is known?Reseach to date.

• Commissioned by the Department of Justice,
  Equality and Law Reform
• Allwright S, Bradley F, Long J, Barry J, Thornton
  L, Parry JV. Prevalence of antibodies to
  hepatitis B, hepatitis C and HIV and risk factors
  in Irish prisoners results of a national cross
  sectional survey (British Medical Journal
  200032178-82)
• Long J, Allwright S, Barry J, Reaper-Reynolds S,
  Thornton L, Bradley F, Parry JV. Prevalence of
  antibodies to hepatitis B, hepatitis C and HIV
  and risk factors in entrants to Irish prisons a
  national cross sectional survey (British Medical
  Journal 20013231-6)
• Hannon, F., Kelleher, C., and Friel, S. General
  Healthcare Study of the Irish Prisoner
  Population. (Dublin The Stationery Office 2000)

4
Reseach to date, cont..

• Independent research
• Dillon, L. Drug Use among Prisoners An
  Exploratory Study. Dublin Health Research Board,
  2002.
• Long J. Fear and denial how prisoners cope with
  risk of or diagnosis with hepatitis C (abstract,
  Irish Journal of Medical Science, 2003)
• Long J, Allwright S, and Begley C. Prisoners
  views of injecting drug use and harm reduction in
  Irish prisons (International Journal of Drug
  Policy 2004, 15 139-149)

5
Incidence of hepatitis C

• Incidence of hepatitis C was 66 per 100 person
  years
• 30 per cent higher than estimates in other
  countries
• History of imprisonment and frequent injecting
  were associated with testing positive for
  hepatitis C
• Smyth B, O'Connor JJ, Barry J, Keenan E.
  (2003) Retrospective cohort study examining
  incidence of HIV and hepatitis C infection among
  injecting drug users in Dublin. Journal of
  Epidemiology and Community Health, 57, 310-311.

6
Prevalence of blood-borne viruses among prisoners
in Ireland
7
Injecting drug use

• Inmates
• 43.2 ( 509/ 1178) had ever injected
• 20.8 ( 104/501 ) started injecting in prison

• Entrants
• 7 (14/197) of those entering prison for the
  first time reported ever injecting drugs vs 40
  (157/394) of those previously in prison
• 18.5 ( 29/157) started injecting in prison

8
Prevalence of blood-borne viruses among injector
prisoners in the Republic of Ireland
9
Risk factors for hepatitis C among injectors
 

• Sharing needles in prison (adjusted odds ratio 4
  times more likely)
• Those who commenced injecting more than three
  years prior to the study (adjusted odds ratio 1.6
  times more likely)
• Spent three or more of the last 10 years in
  prison (adjusted odds ratio 2 times more likely)
• One or more doses of hepatitis B (adjusted odds
  ratio 2 times more likely)

 
10
Numbers of opiate-related deaths investigated by
the Dublin City and County Coroners, 1997 to 2001

Byrne R. (2001 and 2002) Opiate-Related Deaths
Investigated by the Dublin City and County
Coroners 1998 to 2000. Dublin University of
Dublin, Addiction Research Centre.
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Why do we need harm reduction

• Hepatitis C is endemic in Irish prisons
• Injecting drug use, time spent in prison and
  sharing needles in prison are risk factors for
  the spread of infection
• A substantial number of opiate-related deaths
  occur in or just after leaving prison

12
United Nations Charter for prisoners

• While prisoners are deprived of their liberty
  they should have full access to medical care.
• Prisoners are sent to prison as punishment, not
  for punishment.
• Standard minimum rules for the treatment of
  prisoners (1977)

13
Both injectors and non injectors want and will
support programmes to address drug
misuse.Long J, Allwright S, and Begley C.
Prisoners views of injecting drug use and harm
reduction in Irish prisons (International Journal
of Drug Policy 2004, 15 139-149)
What do prisoners want?
14
Regular routine

• I use the gym. I use the school now and again
  and I'm working in the prison itself. So, I'm
  keeping myself active alright. I'm not just
  sitting around bored all day

15
Individual counselling for self-selected
prisoners is useful

• I believe like, to give up drugs, it's down to
  the person, they have to decide that, it's really
  them like.
• 99 of people that go for counselling they
  don't go in for the right reasons like

16
Drug free units

• Have separate units for people who don't use
  drugs, em, from my own experience, I've made a
  decision to be off drugs and I have been off
  drugs for, em, the last 17 months and er, I feel
  much better because of it but I would prefer to
  be away from drugs altogether

17
Methadone maintenance and detoxification

• For It is a good thing, from what I've seen
  on the maintenance. I've seen a lot of people
  that've been on maintenance have cut down a lot
  on drugs because if they'd have taken 60, 70ml of
  physeptone well then heroin's no good to them any
  more
• Against They're talking about bringing this
  maintenance methadone course in and anybody that
  wants be on it, you know? .But all that'll do,
  that'll just keep everybody stoned 24 hours a
  day, every day. You know what I mean?

18
Needle exchange

• For Clean needles, and syringes it's probably
  a good idea cos there's no point in saying that
  it's going to encourage them cos they're going to
  do it anyway, do you know what I mean?
• Against Needle exchange? Oh Miss, T'would
  be bad, bad news.

19
Prisoners wishes

• Range of drug services in prison to mirror the
  range currently available in the community
• Prisoners could be an important resource in the
  planning of drug services

20
What has happened since these studies?

• During 2000 and 2001, the Irish Prison Service
  along with other agencies developed both drug
  treatment service plans and health care plans
• Introduced,
• Evidence based methadone treatment services
  expansion of drug free units provision of
  hepatitis B vaccine and employment of registered
  nurses
• There is, of course, much more to do.
• Comprehensive harm reduction,
• Hepatitis C and STI treatment, drug free
  treatment and mental health care
• Need for routine health care and drug treatment
  information

21
Reports to date

•  Irish Prison Services. Report of the Steering
  Group on Prison Based Drug Treatment Services.
  (Dublin Department of Justice Equality and Law
  reform, 2000).
• Group to Review the Structure and Organisation of
  Prison Health Care. Report of the Group to Review
  the Structure and Organisation of Prison Health
  Care Services. The Stationery Office, Dublin
  (2001).
• Irish Prison Service. Irish Prison Drug Service
  Policy. (Final draft with the Minister of
  Justice, Equality and Law Reform since December
  2002).
• Health Needs Assessment Sub-Group. A Health Needs
  Assessment for the Irish Prison Service (Final
  draft with the Minister of Justice, Equality and
  Law Reform for several months).

22
In general, what works

• Comprehensive personal development programme
• Broad range of drug treatment options including
• drug free units, therapeutic communities,
  detoxification and methadone maintenance.
• Adequate number of formal treatment places

23
Disinfectants

• Cleaning injecting equipment with bleach has not
  been shown to be effective in reducing the spread
  of hepatitis C
• Hepatitis C is our most common virus
• Do not recommend bleach in Ireland as you may
  give false hope
• Kapadia F, Vlahov D, Des Jarlais D, Strathdee S,
  Ouellet L, Kerndt P et al. (2002) Does bleach
  disinfection of syringes protect against
  hepatitis C infection among young adult injection
  drug users? Epidemiology, 13, 738-741
• Hagan H and Thiede H. (2003) Does bleach
  disinfection of syringes help prevent hepatitis C
  transmission? Epidemiology, 14, 628-629.

24
Needle and syringe exchange

• Needle exchange in prisons is feasible and
  creates a safer atmosphere
• Consider a limited needleand syringe
  exchangeprogramme
• Dolan K, Rutter S and Wodak A. (2003)
  Prison-based syringe-exchange programmes a
  review of international research and development.
  Addiction, 98, 153-158.

25
Hepatitis B vaccine

• Safe and effective vaccine available
• In Ireland hepatitis B vaccine is recommended
  prisoners and injecting drug users
• Department of Justice, Equality and Law Reform
  policy
• Published information indicate that the vast
  majority who had accessed vaccine had done so
  while in prison
• Problem with delayed administration
• Strengthen prison and community based hepatitis B
  vaccination programmes

26
Overdose

• Incidence of non-fatal overdoses in Irish prisons
  is unknown
• Management of overdose must be delegated to
  health rpofessionals and ambulance crews
• A combination of interventions are required and
  naloxone is only one small part
• Current interventions to prevent and manage
  overdose need to be documented
• Comprehensive and consistent response is required
• Sporer KA (2003) Strategies for preventing
  heroin overdose. British Medical Journal, 326
  442-444.
• National Medicines Information Centre.
  (2003) Use of Naloxone in the Management of
  Opiate Dependence Syndrome. Dublin, National
  Advisory Committee on Drugs.

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Recommendations for harm reduction

• Do not
• Promote the use of disinfectants
• Do
• Introduce a broad range of formal treatment
• Expand hepatitis B vaccination
• Introduce overdose prevention and management
• Commence needle exchange programmes
• Introduce health information systems
• Consider in the future
• Outreach workers and safer injecting techniques

28
The group endorses the concept that there
should be equivalence of care between the prison
population and the general population pg9
point 1

• Review of the Structure and Organisation of
  Prison Health Care Services (May 2001)

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Acknowledgements

• Prisoners who participated
• Management and officers working in the
  participating prisons
• Department of Justice, Equality and Law Reform
  for allowing the team access to the prisons and
  provided funding for the prevalence studies
• Health Research Board in Ireland who provided
  funding for the qualitative study
• Staff at the Department of Public Health and
  Primary Care, Trinity College, in particuylar Dr
  Shane Allwright