HIV/AIDS and HCV in Prisons
A Select Annotated Bibliography
Bleach & Other Disinfectants
One strategy to reduce the risk of HIV transmission through the sharing of injection equipment is to provide liquid bleach or other disinfectants for sterilizing needles and syringes. A growing number of prison systems has done this. This section contains documents about the issues related to making bleach or other disinfectants available in prisons, including about research showing its limitations.
Essential Resources
Canadian HIV/AIDS Legal Network (2004).  Prevention: Bleach (Info sheet 5 in the series of info sheets on HIV/AIDS in prisons). Montreal: The Network, third revised and updated version.
A 2-page info sheet about bleach in prisons. Available in English and French via www.aidslaw.ca/Maincontent/issues/prisons.htm. A revised version in Russian will become available in 2006. The second, 2001 edition, is also available in Romanian.
Correctional Service Canada (1999). Evaluation of HIV/AIDS Harm Reduction Measures in the Correctional Service of Canada. Ottawa: CSC.
The evaluation of the HIV/AIDS harm reduction measures in the Canadian federal prison system examined whether there were any perceptual or behavioural barriers which influence the prisoners' utilization of bleach kits; what the prison system's implementation experience was with the bleach kits; and whether there were any unintended consequences related to the distribution of bleach kits. Because a research and evaluation component was not built in at the time of the development of the program, no systematic data was collected on behaviour changes as a result of the program. The evaluation found that, in general, prisoners had easy access to bleach, but that at a few prisons, access may not be discreet. Both prisoners and staff reported that bleach had become a "fact of life" in prisons. At all 18 institutions visited, staff could not recall any incident where bleach had been used as a weapon. Interviews with staff indicated that, with a few exceptions, staff concerns in terms of safety have abated. However, the research team said that it had "no confidence that the distribution of bleach alone will effectively reduce transmission of infection from Hepatitis or HIV." It concluded: "It is the opinion of the evaluation team ... that because of the clandestine and furtive nature under which injection drug users operate in prison settings; of the primitive and make shift equipment used to inject drugs; and, of the tendency of injection drug users to "cut corners" when their cravings overcome their judgment, there is no guarantee that the use of bleach alone will effectively reduce transmission of infection from HIV or Hepatitis C." The research team reported that the issue of needle and syringe programs had been raised by prisoners in 14 of the 18 institutions the team visited, and quoted prisoners as saying: "I think it is hypocritical just to have a bleach program. It is smoke and mirrors. If you really want to do something, you get a needle exchange program. The bleach program is good because it is a foot in the door."
Correctional Service Canada (2004). Guidelines 821-2 - Bleach Distribution. Ottawa: CSC.
Available via www.csc-scc.gc.ca/text/plcy/cdshtm/821-2-gl_e.shtml.
Guidelines 821-2 - Bleach Distribution provide detail on how bleach shall be made accessible to prisoners. Bleach has been available in federal (and many provincial) prisons in Canada for many years, but it was felt that clearer guidelines were needed to ensure effective and safe distribution. Among other things, the guidelines state that:
- "full-strength (between 5.25% and 7%) household bleach shall be utilized as the disinfecting agent" (paragraph 6)
- bleach kits "shall consist of:
- one 1-ounce opaque plastic bottle of bleach, labelled with a notice reading "Bleach, Do Not Drink or Inject";
- one 1-ounce empty opaque plastic bottle for water; and
- instructions on the proper cleaning of syringes and needles" (paragraph 7)
- "every newly-admitted inmate shall be issued one bleach kit following reception into federal custody and shall be offered a kit on each occasion of reception upon transfer to another institution" (paragraph 9)
- "there will be a minimum of three designated locations in each institution where inmates can refill an empty bottle with bleach or obtain a bottle of bleach. Appropriate locations are those affording the inmate privacy to the extent possible. In no instance shall an inmate be required to approach a staff member in order to obtain refills" (paragraph 11)
- "an inmate in possession of quantities of bleach in excess of the one-ounce bottle is considered to be in possession of contraband unless prior authorization has been obtained" (paragraph 14)
- "the possession of a one-ounce bottle of bleach is not in itself sufficient evidence of drug usage or other activity constituting a disciplinary offence" (paragraph 15).
Dolan K, Wodak A, Hall W (1999). HIV risk behavior and prevention in prison: a bleach program for inmates in NSW. Drug and Alcohol Review, 18: 139-143; and Dolan K et al. (1994). Bleach Availability and Risk Behaviours in New South Wales. Technical Report No 22. Sydney: National Drug and Alcohol Research Centre.
Summary available via ndarc.med.unsw.edu.au/ndarc.nsf/website/Publications.reports
A study monitoring prisoners' risk behaviours and access to disinfectants in 1993. Over a third of respondents reported having easy access to either disinfecting tablets or liquid bleach. Three quarters of respondents who injected reported sharing, but virtually all of the sharers (96%) reported using a disinfectant. Since this study, syringe cleaning instructions have been revised and a subsequent study found that prisoners were beginning to adopt the revised cleaning methods (see Dolan et al., 1996; Dolan & Wodak, 1998, infra).
 Other Resources
Dolan KA, Wodak AD (1998). A bleach program for inmates in NSW: an HIV prevention strategy. Aust N Z J Public Health, 22(7): 838-840; and Dolan K et al. (1996). Bleach Easier to Obtain But Inmates Still at Risk of Infection in New South Wales Prisons. Technical Report No 34. Sydney: National Drug and Alcohol Research Centre.
Summary available via ndarc.med.unsw.edu.au/ndarc.nsf/website/Publications.reports
Syringe cleaning guidelines for IDUs were revised in 1993. This paper examines efforts by IDUs in NSW prisons to adopt the revised guidelines in 1994. 229 inmates nearing release were visited and asked to call a toll free number for an interview once released. Respondents (102) did not differ from non-respondents (127). Many respondents (64%) reported ever injecting and many of these reported injecting (58%), sharing (48%) and syringe cleaning (46%) when last in prison. Virtually all (97%) who shared syringes reported cleaning the syringes with bleach. A variety of cleaning methods were used, but only 23% of respondents reported adopting the revised syringe cleaning guidelines. Tattooing (38%) was reported more often than sexual activity in prison (4%). There was a significant improvement in easy access to bleach from 38% in 1993 (see Dolan, Wodak, Hall, 1999; Dolan et al., 1994) to 54% in 1994 in prisons. A new methodology for prison research was found to be feasible in this study. The potential for HIV to spread in prison still poses major public health challenges.
Ford PM et al. (1999). HIV and hep C seroprevalence and associated risk behaviours in a Canadian prison. Canadian HIV/AIDS Policy & Law Newsletter, 4(2/3): 52-54.
Available at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/spring99/prisons.htm.
Concludes that we must "stop pretending that weak bleach solutions are the answer to anything. There is no good evidence to suggest that strong bleach works, let alone solutions that can be drunk with impunity."
Kapadia F et al. (2002). Does bleach disinfection of syringes protect against hepatitis C infection among young adult injection drug users? Epidemiology, 13(6): 738-741.
A study showing that bleach disinfection may provide some protection against HCV.
Small W et al. (2005). Incarceration, addiction and harm reduction: inmates' experience injecting drugs in prison. Substance Use & Misuse, 40: 831-843.
The goal was to qualitatively examine HIV risk associated with injecting inside British Columbia prisons. The study concludes that "the harms normally associated with drug addiction, and injection drug use are exacerbated in prison," and that "bleach distribution is an inadequate solution." Prisoners participating in the research "were in agreement that bleaching of equipment does not occur consistently, and most likely bleaching is performed too quickly when it is done." Prisoners also claimed that the supply and quality of bleach is inconsistent, and that bleach is not always kept in an appropriate, accessible location. Prisoners asserted that syringes are what they really need access to: "They give you bleach, why don't they give you needles."
Taylor A, Goldberg D (1996). Outbreak of HIV infection in a Scottish prison: why did it happen? Canadian HIV/AIDS Policy & Law Newsletter, 2(3): 13-14.
Available at
www.aidslaw.ca/Maincontent/otherdocs
/Newsletter/April1996/14avrilE.html
Explains why, even if bleach is available in prison, it may remain unused or ineffectively used.
US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention (1993). HIV/AIDS Prevention Bulletin, 19 April 1993.
States that "bleach disinfection should be considered as a method to reduce the risk of HIV infection from re-using or sharing needles and syringes when no other safer options are available."
World Health Organization (2004). Evidence for Action Technical Papers: Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users. Geneva: WHO, 2004.
www.who.int/hiv/pub/prev_care/ en/effectivenesssterileneedle.pdf
At page 31 recommends: "Disinfection and decontamination schemes are not supported by evidence of effectiveness and should only be advocated as a temporary measures where there is implacable opposition to NSPs in certain communities or situations (e.g. correctional facilities)."
Needle and Syringe Programs
Essential Resources
Canadian HIV/AIDS Legal Network (2004). Prevention: Sterile Needles (Info sheet 6 in the series of info sheets on HIV/AIDS in prisons). Montreal: The Network, third revised and updated version.
Available in English and French via www.aidslaw.ca/Maincontent/issues/prisons.htm. A revised version in Russian will become available in 2006. The second, 2001 edition, is also available in Romanian.
A 4-page info sheet about international developments on needle exchange in prisons, and what we can learn from them.
Dolan K, Rutter S, Wodak A (2003). Prison-based syringe exchange programmes: a review of international research and development. Addiction, 98, 153-158.
Good summary of evaluations of prison needle exchange programs in Switzerland, Germany, and Spain.
Kerr T, Jürgens R (2004). Syringe Exchange Programs in Prisons: Reviewing the Evidence. Montreal: Canadian HIV/AIDS Legal Network.
Available in English and Russian via www.aidslaw.ca/Maincontent/issues/prisons.htm.
A 10-page review of the evidence.
Lines R, Jürgens R, Betteridge G, Stöver H, Latishevschi D, Nelles J (2004). Prison Needle Exchange: A Review of International Evidence and Experience. Montreal: Canadian HIV/AIDS Legal Network.
Available at www.aidslaw.ca/Maincontent/issues/prisons.htm in English, French, and Russian (in a modified version adapted for fSU and CEE countries).
The most comprehensive and detailed report available on the international experience of prison syringe exchange programs in Switzerland, Germany, Spain, Moldova, Kyrgyzstan, and Belarus. Reports that evaluations of needle and syringe programs in prison have shown that reports of drug use decreased or remained stable over time, and that reports of syringe sharing declined dramatically. No new cases of HIV, hepatitis B or hepatitis C transmission were reported. The evaluations found no reports of serious unintended negative events, such as initiation of injection or the use of needles as weapons. Staff attitudes were generally positive. Overall, the reviews indicated that prison syringe exchange programs are feasible and do provide benefit in the reduction of risk behavior and the transmission of blood-borne infection without any unintended negative consequences.
Lines et al. (2005). Taking action to reduce injecting drug-related harms in prisons: The evidence of effectiveness of prison needle exchange in six countries. International Journal of Prisoner Health 1(1): 49-64.
An article summarizing the main issues addressed in the above report.
Ministerio Del Interior/Ministerio De Sanidad y Consumo (2003). Needle Exchange in Prison. Framework Program. Madrid: Ministerio Del Interior/Ministerio De Sanidad y Consumo.
Detailed plan and guidelines used for the implementation of needle exchange programs in Spanish prisons. Essential for anyone wishing to see how a successful needle exchange program can be established in a prison. Available in Spanish, English, and French. Another, less comprehensive, document on the same issues, entitled "Elements key for the installation of programs of exchange ok (sic) syringes in prison" (Elementos clave para la implantacion de Programas de Intercambio de Jeringuillas en Prision) is available via
http://www.msc.es/Diseno/informacion
Profesional/profesional_prevencion.htm.
Ontario Medical Association (2004). Improving Our Health: Why is Canada lagging behind in establishing needle exchange programs in prisons? Toronto: The Association.
Available via www.oma.org/phealth/health.htm.
This report is largely based on the report by Lines at al (supra) and comes to the same conclusions and recommendations: NEPs in prisons work, and they should be implemented quickly. The report is important, however, because it clearly demonstrates that issues related to HIV/AIDS in prisons are public health issues, and that the medical community is concerned about the lack of attention devoted to health care and prevention in prisons. According to the report, "[m]any physicians in Ontario who are involved in the provision of medical care within the prison system have expressed concerns that the quality of care available in prisons is often far below that which is available to the general population. The absence of NEPs in Canadian prisons is a prime example of this gap." The report continues by saying:
"Issues concerning prisoners do not seem to be of high concern to the public. People should be concerned, not only because the health of prisoners is at stake but also, because prisoners do return to the community. There is a high rate of turnover in prisons, especially provincial prisons. Prisoners returning to the community, if infected with HIV or hepatitis C (HCV), can and do infect others. The OMA believes that not only is this happening now but that it will continue to happen. This situation constitutes a clear and present health crisis." It further concludes:
"The OMA believes that the many radical changes that have occurred since the beginning of the HIV/AIDS epidemic, including the fact that what was once an untreatable terminal disease can now be treated thus prolonging life, have resulted in the need to change how people living with HIV/AIDS in prisons receive care, and how people in prisons access prevention measures."
The report calls for an "urgent response," stating that "[w]here political will is combined with a solid implementation plan, NEPs in prisons can quickly become a reality." It follows a February 1996 Position Statement on Blood Borne and Sexually Transmitted Viral Infections by the Australian Medical Association, which stated that "[e]ffective prevention among prison populations requires the establishment of preventative education programs, needle exchange programs for intravenous drug users and safe sex programs for those involved in high risk sexual behaviour."
Rutter S et al. (2001). Prison-Based Syringe Exchange Programs. A Review of International Research and Program Development (NDARC Technical Report No. 112). Sydney: National Drug and Alcohol Research Centre, University of New South Wales.
Available via ndarc.med.unsw.edu.au/ndarc.nsf/website/Publications.reports.
Another, earlier, but very comprehensive, review of the results of needle and syringe programs in prisons.
Stöver H, Nelles J (2003). 10 years of experience with needle and syringe exchange programmes in European prisons: A review of different evaluation studies. International Journal of Drug Policy, 14: 437-444.
Another review of the results of needle and syringe programs in prisons based on the experience in Switzerland, Germany, Spain, and Moldova. Makes suggestions for the installation of such programs.
Wolfe D (2005). Pointing the Way: Harm Reduction in Kyrgyz Republik. Bishkek: Harm Reduction Association of Kyrgyzstan "Partners' network".
Available via http://www.soros.org/initiatives/ihrd
This paper seeks to identify the process by which Kyrgyzstan mounted its response to HIV/AIDS. It describes how Kyrgyzstan became the only country in Central Asia, and as of November 2005 the only country besides Moldova and Belarus in the Commonwealth of Independent States to establish syringe exchange programs in prisons. These programs began in 2002; 12 prisons had adopted needle exchange by the end of 2004; and there are plans for the expansion of the program to all prisons. The paper highlights that action in Kyrgyzstan was taken rapidly, before there were any documented cases of HIV among prisoners; that there has been steady scale up; that the programs are tailored to prisoners' needs (eg, in addition to receiving alcohol pads, cotton, and sterile syringes for themselves, some volunteers take needles to perform secondary exchange for prisoners not willing or able to come to the exchange point; and that the program is integrated with other health services and provides links to harm reduction and HIV prevention upon release.
Other Resources
Australian Injecting and Illicit Drug Users League (no date). Discussion Paper: Prison-Based Syringe Exchange Programs (PSE Programs). Canberra: AIVL.
Available via http://www.aivl.org.au/default.asp.
A review of the issues related to prison-based needle and syringe programs. Proposes an approach that builds on and takes the best aspects of existing programs "while still addressing the specific needs and issues for the Australian prisons context." Contains a discussion of the issues related to the use of retractable syringes.
Australian National Council on Drugs (no date). Needle and Syringe Programs. Position Paper. Canberra: ANCD.
States that "[s]ince their introduction in 1987, needle and syringe programs have made a significant contribution to the prevention of the spread of HIV and other blood borne viral infections." In a section on prisons, it says that "[t]he failure to reduce the risk of hepatitis C and other blood-borne viral infection transmission in prisons severely undermines the work being conducted in the community with injecting drug users." It recommends that "each jurisdictional department responsible for the management of prisons and juvenile detention centres, in consultation with staff, health authorities and relevant community-based organisations, develop occupationally safe and culturally appropriate policies, protocols and procedures regarding the introduction of trial needle and syringe programs within at least one of its prisons and juvenile detention centres."
Canadian Human Rights Commission (2003). Protecting Their Rights. A Systemic Review of Human Rights in Correctional Services for Federally Sentenced Women. Ottawa: The Commission.
Available via www.chrc-ccdp.ca/publications/reports-en.asp.
In its report, the Canadian Human Rights Commission recommended that the Correctional Service of Canada implement a pilot needle exchange program in three or more correctional facilities, at least one of them a women's facility, by June 2004.
Correctional Service Canada (1999). Final Report of the Study Group on Needle Exchange Programs. Ottawa: CSC (unpublished paper).
A working group on needle exchange programs established by the Correctional Service of Canada recommended that the Service "obtain ministerial approval in principle for a multi-site NEP [needle exchange program] in men and women's federal correctional institutions..."
Davies R (2004). Prison's second death row. The Lancet, 364: 317-318.
Needle sharing has spread HIV through prisons worldwide. But prevention programs that suppl;y clean needles to drug users are not available in the majority of prison systems. Rachael Davies asks why.
Dolan K et al. (1996). Is syringe exchange feasible in a prison setting? Medical Journal of Australia, 164: 508.
Dolan K, Wodak A, Rutter S (1996). Is syringe exchange feasible in a prison setting? [reply letter] Medical Journal of Australia, 165: 59.
Editor (1996). Austalian Medical Association calls for needle exchange programs for prisoners. Canadian HIV/AIDS Policy & Law Newsletter, 2(4): 25.
Available at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/July1996/23needlee.html
Equipo integrante de la comision de trabajo y redactor del program de intercambio de jeringuillas en la prision de Basauri (JA Aguirre Esunza et al). El program de intercambio de jeringuillas de la prision de Basuari (Bizkaia) (1997-99).
Available in Spanish only via www.msc.es/Diseno/informacionProfesional/profesional_prevencion.htm.
This is the report on the evaluation of the pilot needle exchange program at Basauri prison in Spain. Among other things, it concludes that the needle exchange program did not lead to increased drug use, and that needles have not been used as weapons.
Federal Office of Justice (1992). Provision of sterile syringes and of disinfectant: Pilot project in correctional institutions; judicial admissibility [original in German; French translation available]. Berne, Switzerland, 9 July 1992.
An opinion on the judicial admissibility of prison-based needle and syringe programs under Swiss law, concluding that such programs are compatible with Swiss legislation. For a summary in English and French, see Jürgens R (1995). Switzerland: provision of sterile needles in prisons declared judicially admissible. Canadian HIV/AIDS Policy & Law Newsletter, 1(3): 2. Available at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/April1995/304.htm
Gross U (1998). Wissenschaftliche Begleitung und Beurteilung des Spritzentauschprogramms im Rahmen eines Modellversuchs der Justizbehöerde der Freien und Hansestadt Hamburg. Evaluationsbericht eines empirischen Forschungsprojects. Kriminologisches Forschungsinstitut Niedersachsen. (Evaluation of the prison needle exchange program in Hamburg)
While all other evaluations of prison-based needle and syringe programs have been favourable, this evaluation reports mixed results. In this German prison, some of the positive effects that were documented in other evaluations could not be observed, primarily because access to needles and syringes (through an automatic dispenser that broke down frequently) remained limited and therefore needle sharing continued (although, as reported by Heinemann and Gross, 2001, infra, among those who participated in the long-sectional design performed by a medical study group, the frequency of needle-sharing decreased significantly). In addition, some prisoners reported that the fact that they could obtain clean needles and syringes may have tempted them to go back to injection drug use while they had previously switched to other forms of drug use because of the fear of infecting themselves with HIV and/or HCV.
Heinemann A & Gross U (2001). Prevention of blood-borne virus infections among drug users in an open prison by vending machines. Sucht 2001; 47(1): 57-65.
Article in German, with English abstract. The feasibility and acceptance of a needle exchange pilot project in an open prison for males in Hamburg, Germany, was studied by a sociological and a medical research team. By retrospective analysis before the onset of the program, 5(2) hepatitis B and 2(0) hepatitis C seroconversions in the whole study group (among IDUs) were detected which must have happened in prison. No seroconversions were observed during the program. In the sociological research, many prisoners reported insufficient supply with syringes after the start of the program, mainly due to frequent break downs of the vending machines. However, among those who participated in the long-sectional design performed by the medical study group, the frequency of needle-sharing decreased significantly. Among the interviewed staff members, unfavourable attitudes towards the project did not improve during the first year. The authors suggested that, should the program be extended to other prisons, the supply of syringes by medical staff or drug services be considered, in order to increase staff acceptance of the program.
Hirsbrunner HP et al. (1997). Evaluation et suivi de la prévention du VIH et de la toxicomanie dans les établissements pénitentiaires d'Hindelbank: Rapport final ŕ l'intention de l'Office fédéral de la santé publique. Berne: Service psychiatrique de l'Université de Berne.
The follow-up evaluation, after another year of operation, of the needle-distribution program at Hindelbank institution in Switzerland. The first evaluation was conducted by Nelles and Fuhrer, 1995, infra. Available in German and French.
Hughes RA (2000). Lost opportunities? Prison needle and syringe exchange schemes. Drugs: Education, Prevention and Policy, 7(1): 75-86.
This article explores some of the issues that surround debates around prison needle and syringe exchange schemes (PNSES). The focus is on the UK, although the article draws on international sources. The following questions are addressed: Are PNSES unrealistic and unpopular? Do PNSES conflict with the duties and principles of the prison service and its staff? Do PNSES affect levels of drug use and drug injection in prison? Would PNSES affect levels of infections? Will drug injectors use PNSES? Will PNSES affect safety and security? The article concludes with a call for a much fuller debate on the issue of PNSES.
Jacob J, Stöver H (1997). Germany - needle exchange in prisons in Lower Saxony: a preliminary review. Canadian HIV/AIDS Policy & Law Newsletter, 3(2/3): 30-31.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Spring1997/21STOVERE.html
Provides a preliminary review of the needle-distribution pilot project undertaken in two prisons in Lower Saxony.
Jacob J, Stöver H (2000). The transfer of harm-reducton strategies into prisons: needle exchange programmes in two German prisons. International Journal of Drug Policy, 11: 325-335.
Presents the results of the social scientific evaluation of the needle exchange pilot projects undertaken in two prisons in Lower Saxony. The study used a multi-methodological approach: documentation of the project practice, half standardized, longitudinal examination of prisoners (n=224) and staff (n=153), qualitative examination of management, selected groups of prisoners, staff and external organizations (AIDSHelp-Groups; n=75) for at least two times. The evaluation intended to be dynamic, process accompanying, in order to communicate the empirical data and developments already during the pilot phase.
Jürgens R (1994). HIV prevention taken seriously: provision of syringes in a Swiss prison. Canadian HIV/AIDS Policy & Law Newsletter, 1(1): 1-3.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Fall1994/102.htm
A short article describing the pilot project for provision of syringes in the Swiss prison of Hindelbank that started in May 1994, as well as the views of the Swiss Federal Public Health Department about the project: "The Department is of the opinion that inmates should have the same possibilities as people outside prisons to protect themselves against HIV infection."
Jürgens R (1996). HIV/AIDS in Prisons: Final Report. Montréal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society, at 52-66.
Includes an account of the early history of the introduction of prison needle exchange programs.
Jürgens R (1997). More needle exchange programs in prisons. Canadian HIV/AIDS Policy & Law Newsletter, 3(2/3): 30.
A short note providing an update on the implementation of needle and syringe programs in prisons. Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Spring1997/20REALTAE.html
Jürgens R (2004). Portugal: Report recommends needle exchange or safe injection sites. Canadian HIV/AIDS Policy & Law Review, 9(1): 48.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/vol9no12004/prisons.htm#p3.
A report released in late 2003 by Portugal's Justice Ombudsman (Provedor de Justica) recommended that Portugal set up needle exchange programs or safe injection sites in prisons.
Jürgens R (2004). Canada: Study provides further evidence of risk of hepatitis C and HIV transmission in prisons. HIV/AIDS Policy & Law Review, 9(3): 45-46.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/vol9no32004/prisons.htm#p3
Refers to an unpublished study undertaken in a Canadian federal prison by Wylie which also explores the issue of whether making needles and syringes available in prisons could potentially lead to increased injection drug use. One of the prisoners interviewed reported that the lack of access to clean injection equipment was a factor in his decision to stop injecting. However, for the other prisoners who stopped injecting, their decision to stop was influenced by other factors. The authors conclude that "there is potential for some increase in the number of injectors as a result of the introduction of needle exchange," but that "the reduction in the potential for transmission created by the availability of clean needles would likely outweigh any increased transmission potential created by increased injection drug use."
Langkamp H (2000). Risks of syringe exchange programmes in prisons prevail. British Medical Journal, 321: 1406-1407.
Makes reference to the studies by Vlahov et al. (1993; see supra, in the section on transmission) and Gross (1998, see supra in this section) and argues that the decisive factor in the incidence of hepatitis C in prisons has been the availability of heroin. Goes on to say: "In Bavarian prisons a strict zero tolerance policy is followed in relation to drugs. Under these circumstances a syringe exchange programme would be misunderstood as accepting drugs. Prisons would be flooded with heroin immediately. The situation would be out of control and infection rates would rise considerably."
Lines R, Jürgens R (2004). Prison syringe exchange programs: Can they be implemented in Canada? In: Thomas G (ed). Perspectives on Canadian Drug Policy: Volume II. Kingston: John Howard Society of Canada.
Available at www.johnhoward.ca/document/drugs/perspect/volume2/cover.htm.
A summary of Lines et al (Prison Needle Exchange: A Review of International Evidence and Experience), supra.
Meyenberg R, Stöver H, Jacob J, Pospeschill M. Infektionsprophylaxe im Niedersächsischen Justizvollzug. Oldenburg: BIS-Verlag, 418 pp.
This book provides a detailed review of the first phase of the "Prevention of Infections in Penal Institutions" pilot project (which includes a needle-distribution pilot project) undertaken in two prisons in Lower Saxony. For a summary in English and French, see Jacob and Stöver, 1997, supra.
Nachevaluation der Drogen- und HIV-Prävention in den Anstalten in Hindelbank (1997). Schlußbericht zu Handen des Bundesamtes für Gesundheit. Berne: BAG.
The follow-up report to the evaluation of the Drug and HIV prevention project at Hindelbank penitentiary (see infra, Nelles and Fuhrer, 1995).
Nelles J, Harding T (1995). Preventing HIV transmission in prison: a tale of medical disobedience and Swiss pragmatism. The Lancet, 346: 1507.
Describes how Dr Franz Probst, a part-time medical officer working at Oberschöngrün prison in the Swiss canton of Solothurn, began distributing sterile injection material without informing the prison director: the world's first distribution of injection material inside prison began as an act of medical disobedience.
Nelles J, Fuhrer A (1995). Drug and HIV prevention at the Hindelbank penitentiary. Abridged report of the evaluation results of the pilot project. Berne: Swiss Federal Office of Public Health.
The first-ever evaluation of a needle-exchange program in prison.
Nelles J, Fuhrer A (eds) (1997). Harm Reduction in Prison: Strategies Against Drugs, AIDS and Risk Behaviour. Berne: Peter Lang AG.
A summary of the proceedings of a symposium on harm reduction in prisons, held in Berne, Switzerland, in March 1996. At the symposium, the initial results of the first scientifically evaluated needle-exchange project in prison were presented and discussed to "prepare a scientific basis for subsequent political decisions." Articles in English, French, or German.
Nelles J et al. (1998) Provision of syringes: the cutting edge of harm reduction in prison? British Medical Journal, 317(7153): 270-273.
Describes the needle exchange project at Hindelbank institution in Switzerland and provides the results of its evaluation.
Nelles J et al. (1999). Evaluation der HIV- und Hepatitis-Prophylaxe in der Kantonalen Anstalt Realta. Schlussbericht. Berne: Universitäre Psychiatrische Dienste Bern.
The report of the evaluation of the HIV and hepatitis prevention program (including needle distribution) at a Swiss prison for men. It concludes: « A la prison pour hommes de Realta aussi, les craintes initiales de voir la distribution de seringues stimuler la consommation de drogues et favoriser l'application intraveneuse de drogues ne se sont pas confirmées. Dans l'ensemble, la distribution de seringues n'a pas posé de problčmes.... On peut en conclure qu'il serait judicieux d'envisager l'introduction ŕ large échelle de telles mesures de protection de la santé, y inclus la distribution de seringues stériles, dans tous les établissements pénitentiaires de Suisse. » In German, with summaries of the main results in French. A short version of the report (under the title: Drug, HIV and Hepatitis Prevention in the Realta Cantonal Men's Prison: Summary of the Evaluation) is, however, available in English, French, and German, and can be obtained from the Swiss Federal Office of Public Health, Berne, Switzerland.
Nelles J, Fuhrer A, Hirsbrunner HP (1999). How does syringe distribution affect consumption of illegal drugs by prisoners? Drug and Alcohol Review, 18(2): 133-138.
A 12-month harm reduction program which included syringe exchange was introduced into the only female prison (Hindelbank) in Switzerland. The program was studied for 12 months (pilot phase). After the program was completed, there was follow-up 12 months later (follow-up phase). Baseline data were collected on 137 of 161 prisoners. Follow-up data were collected on 57 of 64 prisoners. Participants were interviewed several times about their use and injection of drugs and their shared use of syringes. Additional data on the number of syringes exchanged were also collected. Reports of drug use and injection in prison did not increase. The exchange of syringes was related to drug availability. Frequency of drug use increased in relation to duration of incarceration. Frequency of drug use decreased the longer the project had been implemented. None of the main arguments raised against the introduction of syringe distribution into prison, such as assault or an increase in drug injecting, was evident in this study.
Rutter S et al. (1995). Is Syringe Exchange Feasible in a Prison Setting? An Exploration of the Issues. Technical Report No 25. Sydney: National Drug and Alcohol Research Centre, 1995.
Summary available via http://ndarc.med.unsw.edu.au/ndarc.nsf/website/Publications.reports.
A study conducted to consider the issues raised by syringe-exchange programs in prison and to assess their possible benefits, adverse consequences, and the feasibility of implementing them. The study found that needle and syringe exchange is feasible in Australian prisons.
Smyth B (2000). Health effects of prisons (letter). British Medical Journal, 321: 1406.
Argues that "[e]xamination of the currently available research evidence ... indicates that provision of needle exchange could possibly cause an increase in transmission of bloodborne viral infection in prisons." Points out that many injectors stop injecting in prisons, and hypothesises: "injectors who inject in prison tend to do so unsafely, but as so many injectors cease injecting during their sentence, the incidence of infection (and other adverse effects such as accidental overdose) drops among the total population of imprisoned injectors." Continues by saying that "there has been insufficient examination of the reasons why so many injectors cease or curtail injecting while in prison. There are many possible explanations for this finding, but the absence of available injecting equipment could be an important factor. Although there is no evidence that provision of needle exchange encourages individuals to start injecting in the community, implementation of such a service could cause many more of these established injectors to opt to continue injecting while in prison." Concludes by saying that "the introduction of needle exchange in prison could ultimately be shown to have a beneficial effect in reducing harm, but its introduction now would be premature while we have a poor understanding of the factors that mediate the observed reduction of injecting in this setting."
Wehrlin M (1994). Gutachten. Verweigerung der Abgabe von Sterilem Injectionsmaterial in Bernischen Strafvollzugsanstalten und Allfällige Rechtliche Sanktionen gegen die HIV-Präventionspolitik des Kantons Bern. Berne: Advokaturbüro Wehrlin, Fuhrer, Hirt.
(see also infra, section on "Legal, Ethical, Human Rights Issues")
World Health Organization (2004). Evidence for Action Technical Papers: Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users (PDF Version). Geneva: WHO.
www.who.int/hiv/pub/prev_care/en/effectivenesssterileneedle.pdf
At pages 17-18, reviews the evidence about NEPs in prisons. Concludes at page 30 that "on the available evidence, there is a strong case for establishing and expanding NSPs in correctional facilities in many countries."
Zeegers Paget D (1999). Needle Distribution in the Swiss Prison Setting: A Breakthrough? Canadian HIV/AIDS Policy & Law Review, 4(2/3): 60-61.
Reviews the Swiss experience with needle distribution in prisons until 1998.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/spring99/prisons.htm#3
Substitution Treatment
Methadone maintenance treatment and other pharmacotherapies have been shown to be effective not only in reducing major risks, harms and costs associated with untreated opiate addiction among patients attracted into and successfully retained in such treatment, but are also associated with reduced HIV and viral hepatitis transmission rates. Therefore, an increasing number of prison systems have made such treatment available. In addition, in recent years extensive research has focused on the mortality of people released from prisons, noting a large number of deaths during the first weeks after discharge that are attributed to drug overdose. This phenomenon probably can be explained by the reduced tolerance to opiates during the imprisonment with the resumption of drug injecting upon release. This highlights the importance of substitution treatment not only as an HIV prevention strategy in prisons, but as a strategy to reduce overdose deaths upon release.
This section section contains articles and reports that provide information about all aspects of substitution treatment in prisons. To make materials more accessible, the section is divided into the following subsections:
- essential resources
- other resources
- heroin prescription
- mortality upon release
Essential Resources
Canadian HIV/AIDS Legal Network (2004). Prevention and Treatment: Methadone (Info sheet 7 in the series of info sheets on HIV/AIDS in prisons). Montreal: The Network, third revised and updated version.
A 2-page info sheet with short, easily accessible, essential information about methadone maintenance treatment in prisons. Available in English and French via www.aidslaw.ca/Maincontent/issues/prisons.htm. A revised version in Russian will become available in 2006. The second, 2001 edition, is also available in Romanian.
Correctional Service Canada (2003). Specific guidelines for methadone maintenance treatment. Ottawa: CSC.
Available at www.csc-scc.gc.ca/text/pblct/methadone/index_e.shtml
These guidelines provide a general background on prisoners and drug use, a section detailing the goals and objectives of MMT, admission criteria and quality assurance for MMT, and the role of the methadone intervention team (MIT); a section about the specific responsibilities of each MIT member; a section on dosing issues; a section on urine drug screening; a section on substance abuse interventions accompanying MMT; and a number of appendices.
Corrections Victoria (2003). Victorian Prison Opioid Substitution Therapy Program: Clinical and Operational Policy and Procedures. Melbourne: Corrections Victoria.
Available via www.legalonline.vic.gov.au/
CA2569020010C266/All/
5DED7F4C63FC14F8CA256E530082DE2C
?OpenDocument&1=Legal+System~&2=Prisons
~&3=Opioid+Substitution+Therapy+Program~
An excellent document with policy and procedures providing a framework for managing substitution treatments in Victorian prisons, in particular methadone and buprenorphine. They also provide guidelines for the clinical and operational management of prisoners prescribed these treatments and will set the benchmark for the introduction of further pharmacotherapies to treat opioid dependence in Victorian prisons.
Dolan K, Wodak A (1996). An international review of methadone provision in prisons. Addiction Research, 4(1): 85-97.
This is a good (albeit now partly outdated) review of the experience with methadone provision in prisons until 1996.
Dolan K 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.
See also: Dolan K et al. (2002). A Randomized Controlled Trial of Methadone Maintenance Treatment in NSW Prisons. Technical Report no 155. Sydney: National Drug and Alcohol Research Centre.
The first-of-its kind trial found that prison based MMT reduced heroin injecting.
Dolan K et al. (2005). Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addictions, 100(6): 820-828.
This study examined the long-term impact of methadone maintenance treatment on mortality, re-incarceration and hepatitis C seroconversion in imprisoned male heroin users. The study cohort comprised 382 imprisoned male heroin users who had participated in a randomized controlled trial of prison-based MMT in 1997/98 (see supra). Subjects were followed up between 1998 and 2002 either in the general community or in prison. Retention in MMT was associated with reduced mortality, reincarceration rates and hepatitis C infection. The study concluded that "prison-based MMT programs are integral to the continuity of treatment needed to ensure optimal outcomes for individuals and public health."
Johnson SL, van de Ven JTC, Gant BA (2001). Research Report: Institutional Methadone Maintenance Treatment: Impact on Release Outcome and Institutional Behaviour [No R-119]. Ottawa: Correctional Service Canada.
Available at www.csc-scc.gc.ca/text/rsrch/reports/r119/r119_e.shtml
Study documenting the positive impact of the introduction of MMT on release outcome and institutional behaviour.
Kerr T, Jürgens R (2004). Methadone Maintenance Therapy in Prisons: Reviewing the Evidence. Montreal: Canadian HIV/AIDS Legal Network.
A 10-page review of the evidence. Available in English, French, and Russian via www.aidslaw.ca/Maincontent/issues/prisons.htm.
Stallwitz A, Stöver H (in press). The impact of substitution treatment in prisons - a literature review.
A review of the literature on substitution treatment in prisons.
Stöver H, Hennebel LC, Casselmann J (2004). Substitution treatment in European prisons. A study of policies and practices if substitution in prisons in 18 European countries. London: The European Network of Drug Services in Prison (ENDSP).
Available via http://www.endipp.net/?pid=8
"Compared to services offered in the community, access to substitution treatment in prisons is inadequate in many countries across Europe." This study uncovers obstacles to the introduction of substitution treatment and explores limitations that prisoners encounter when attempting to access services. The objectives of the research were to conduct a literature review on substitution treatment in prisons; elaborate an inventory of substitution policy and practice in prisons; provide an overview of the national and regional developments of health care standards; identify "good practice" in the field of substitution treatment. It contains reports from 18 European countries, as well as a series of conclusions.
World Health Organization (2004). WHO/UNODC/UNAIDS position paper - Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva: WHO, UNODC, UNAIDS.
Available in English and Russian: http://www.who.int/substance_abuse/publications/treatment/en/
A joint position statement on maintenance therapy for opioid dependence. Based on a review of scientific evidence and oriented towards policymakers, the paper covers a wide range of issues, from the rationale for this treatment modality, to the specific considerations regarding its provision for people living with HIV/AIDS.
World Health Organization (2005). Evidence for Action Technical Papers. Effectiveness of Drug Dependence Treatment in Preventing HIV among Injecting Drug Users (PDF Version). Geneva: WHO.
http://www.who.int/hiv/pub/idu/en/drugdependencefinaldraft.pdf
Reviews the evidence on substitution treatment and concludes that "policy-makers need to be clear that the development of drug substitution treatment is a critical component of the HIV prevention strategy among injecting opioid users." Also says: "There is a need to look at costs and expenditures within different social and cultural settings, but currently there is a major expenditure in many countries on imprisonment and prolonged incarceration in detention centres, approaches that are associated with very high relapse rates soon after release. There is no evidence to indicate that such an approach is cost effective and much to indicate that comparative cost-effectiveness evaluations need to be conducted if and when new pilot projects on agonist pharmacotherapy are started in some countries."
World Health Organization (2005). Status Paper on Prisons, Drugs and Harm Reduction (PDF Version). Copenhagen, WHO Europe.
http://www.euro.who.int/document/e85877.pdf
Summarizes the evidence on harm reduction, including substitution therapy, in prisons.
Other Resources
Anonymous (2003). Prisoner settles case for right to start methadone in prison. British Medical Journal, 326(7384): 308.
In July 1999, Dwight Lowe, a prisoner at Kent Institution previously using heroin, settled his case against Correctional Service Canada (CSC) in which he challenged as unconstitutional CSC's refusal to permit him to initiate methadone maintenance treatment while in prison. [CSC has since changed its policy, see Correctional Service Canada, 2003, supra]
Arroyo A et al. (2000). Methadone maintenance programs in prison: social and health changes. Adicciones, 12(2): 187-194.
The study aimed to assess the benefits of methadone treatment in opiate-dependent individuals, before and after being included in the program, and the effects of the simultaneous consumption of other drugs and illegal methadone. A study was designed with a pre-post intervention group. A single interview was performed and information about the situation of patients before and after the methadone treatment was obtained. The patients were a group of 62 prisoners from the Brians Penitentiary Center (Barcelona). Variables considered included labour activity, social and economic level, self control and self esteem, legal problems, psychiatric treatment, suicide attempts, sharing of injecting equipment, prostitution, irritability and drug addiction background. Social and self esteem improved during inclusion in the treatment program. Cocaine and cannabis consumption diminished significantly. However, alcohol, nicotine, benzodiazepines and designer drug consumption increased. The study concluded that methadone maintenance programs are a valid strategy in and out of penitentiary centers and diminish risk behaviour for HIV and hepatitis.
Bayanzadeh SA et al. (no date). A study of the effectiveness of psychopharmacological intervention in reducing harm/high risk behaviours among substance user prisoners.
A randomized controlled trial of MMT accompanied by psychological treatment versus standard psychiatric treatment of drug-dependent prisoners in Iran found significant differences between the experimental and control group in terms of the variables relating to drug use and drug injection. The 60 prisoners randomly assigned to the experimental group received methadone treatment in combination with cognitive-behavioural group therapy. The 60 prisoners in the control group received non-methadone drugs for the treatment of addiction as well as standard psychotherapeutic medications. In the beginning of the study, all of the 120 subjects were drug users, but following the implementation of the projects, only 21.1% of the subjects in the experimental group, compared to 93.5% of the subjects in the control group, continued to use drugs. Before the commencement of the study, 47.4% of the experimental group, compared to 25.8% of the control group injected drugs. After the completion of the 6-month study, 10.5% of the experimental group and 41.9% of the control group continued to inject drugs, a statistically significant difference.
Bellin E et al. (1999). High dose methadone reduces criminal recidivism in opiate addicts. Addiction Research, 7: 19-29.
This study demonstrated a 14% reduction in re-incarceration risk (adjusted for age, race and gender) for prisoners in the Riker's Island prison program who received high-does methadone (=60mg) (n=1423) compared to those who received low-does methadone (n=1371) (P<0,0002). See also Tomasino et al., 2001 and Magura et al., 1993.
Bertram S, Gorta A (1990). Views of recidivists released after participating in the NSW prison methadone program and the problems they faced in the community. Evaluation of the NSW Department of Corrective Services Prison Methadone Program. Study No 8. Sydney: Research and Statistics Division, New South Wales Department of Corrective Services, Publication no 21.
http://www.dcs.nsw.gov.au/information/research_and_statistics/research_publication/rp020.pdf
Bertram S, Gorta A (1990). Inmates' perceptions of the role of the NSW prison methadone program in preventing the spread of Human Immunodeficiency Virus. Evaluation of the NSW Department of Corrective Services Prison Methadone Program. Study No. 9. Sydney: Research and Statistics Division, New South Wales Department of Corrective Services.
Boguńa J (1995). Methadone maintenance in Catalonia. Report of the 2nd Seminar of the European Network of Services forDrug Users in Prison. Prison Resource Service: London, 1995, at 9-10.
See also Boguńa, J. In: O'Brien O (ed). Report of the 3rd European Conference on
Drug and HIV/AIDS Services in Prison. Cranstoun Drug Services: London, 1997, at 68-70.
The first European methadone maintenance program in prison was in the male prison in Barcelona (Centro Penitenciario de Hombres de Barcelona (La Modelo)). This program was initiated as a pilot program in October 1992 for 6 months, but was maintained indefinitely because of the satisfactory results obtained. Because it was the first such program, very rigid admission criteria were established, allowing people from the following three categories into the program: anyone already on methadone maintenance, anyone with a history of mental illness who is also a heroin user, and anyone suffering from an incurable disease such as AIDS who is a heroin user. An evaluation at six months resulted in the following findings: a reduction in the sharing of injecting equipment; a high rate of relapse among those on doses of less than 50mgs/24h of methadone; a low percentage of prisoners who were HIV negative on the program; a statistically relevant change in the use of condoms in sexual relationships; and a significant reduction in the number of overdoses. Due to the positive results, it was decided to continue the program and extend the admission criteria, in particular to include more prisoners who were HIV negative.
Boucher R (2003). The case for methadone maintenance in prisons. Vermont Law Review, 27(2): 453-482.
www.drugpolicy.org/docUploads/ boucher_prison_methadone.pdf
Argues that "denying methadone to inmates can no longer pass constitutional muster because it offends the evolving standard of decency that marks the progress of a maturing society, in which scientists have declared opioid dependence a medical disorder treatable with methadone" and that denying methadone to prisoners who need it is cruel and unusual punishment.
Byrne A, Dolan K (1998). Methadone treatment is widely accepted in prisons in New South Wales [letter]. British Medical Journal, 316(7146): 1744-1745.
Reports that methadone treatment was introduced into prisons in New South Wales in 1987 as a pre-release measure. Treatment has since been expanded to become more widely available. Despite some initial misgivings, there has been almost universal acceptance of this treatment by prisoners, staff, and medical authorities.
Cornish JW et al. (1997). Naltrexone pharmacotherapy for opioid dependent federal probationers. J Subst Abuse Treat, 14(6): 529-534.
Federal probationers or parolees with a history of opioid addiction were referred by themselves or their probation/parole officer for a naltrexone treatment study. Participation was voluntary and subjects could drop out of the study at any time without adverse consequences. Following orientation and informed consent, 51 volunteers were randomly assigned in a 2:1 ratio to a 6-month program of probation plus naltrexone and brief drug counseling, or probation plus counseling alone. Naltrexone subjects received medication and counseling twice a week; controls received counseling at similar intervals. All therapy and medication were administered in an office located adjacent to the federal probation department. 52% of subjects in the naltrexone group continued for 6 months and 33% remained in the control group. Opioid use was significantly lower in the naltrexone group. The overall mean percent of opioid positive urine tests among the naltrexone subjects was 8%, versus 30% for control subjects (p < .05). 56% of the controls and 26% of the naltrexone group (p < .05) had their probation status revoked within the 6-month study period and returned to prison. The study concluded that treatment with naltrexone and brief drug counseling can be integrated into the Federal Probation/Parole system with favourable results on both opioid use and re-arrest rates.
Crowley D (1999). The drug detox unit at Mountjoy prison - a review. Journal of Health Gain, 3(3).
Cropsey KL, Villalobos GC, Clair CL (2005). Pharmacotherapy treatment in substance-dependent correctional populations: a review. Subst Use Misuse, 40(13): 1983-1999.
The number of drug or alcohol dependent inmates has increased dramatically in recent years. About half of all inmates in the US meet DSM-IV criteria for dependence at the time of their arrest and require substance use treatment or detoxification. Few inmates receive treatment while in prison, increasing the likelihood that they will continue to use substances in prison and after release. This article says that, while pharmacotherapy interventions have been shown to be effective with substance users in the community, few studies have investigated these treatments with a prison population. It concludes that "further research is needed to better understand the feasibility and efficacy of providing pharmacotherapies for substance dependence disorders within this population."
Darke S, Kaye S, Finlay-Jones R (1998). Drug use and injection risk-taking among prison methadone maintenance patients. Addiction, 93(8): 1169-75.
This study aimed to examine the drug use and injection risk-taking among incarcerated methadone maintenance (MM) patients; to determine the impact of a diagnosis of antisocial personality disorder (ASPD) on prison-based MM treatment; and to compare incarcerated patients with community patients. Structured interviews were undertaken in New South Wales (NSW) prisons and community MM units. 100 incarcerated MM patients and 183 community MM patients participated. Subjects were interviewed about drug use and needle risk-taking in the previous 6 months, and assessed for a diagnosis of ASPD. Heroin had been used by 38% of prison MM patients in the 6 months prior to interview, on a median of 4.5 days. 44% of prison patients had injected a drug in the preceding 6 months. 32% of prison subjects had borrowed used injecting equipment within the preceding 6 months, and 35% had lent used injecting equipment to others. Community patients were more likely to have injected a drug in the preceding 6 months (84% vs. 44%), to have used heroin (72% vs. 38%) and to have done so more frequently (20 vs. 4.5 days). Prisoners, however, were more likely to have borrowed (32% vs. 15%) and lent (35% vs. 21%) injecting equipment in that time. While injecting at lower rates than their community counterparts, the injecting occasions of prisoners were of much higher levels of risk. A diagnosis of ASPD was unrelated to both drug use and needle risk-taking. The study concluded that incarcerated patients injected less frequently than community patients, but had higher levels of needle risk-taking.
Devaud C, Gravier B (1999). Methadone prescription in prisons: between realities and coercions. Médecine et Hygične, 57, (2274): 2045-2049.
Dolan, K et al. (1996). Methadone maintenance reduces injecting in prison. British Medical Journal, 312: 1162.
Dolan et al interviewed 185 ex-prisoners with a history of injecting drug use in New South Wales (Australia) in 1993, of whom 64 reported receiving methadone maintenance treatment (MMT) before, during, and after their period in prison; 80 reported receiving no treatment. Injecting drug users who reported receiving MMT in the three months before prison were significantly less likely to report daily injecting (42% v 60%, odds ratio=0.4 (95% confidence interval 0.2 to 0.9); P=0.03) and syringe sharing (13% v 26%, 0.4 (0.2 to 0.9); P=0.04) than those not receiving the treatment. Injecting drug users who received MMT during imprisonment reported significantly fewer injections per week (mean 0.16 v 0.35; P=0.03 Mann-Whitney test) than those not receiving the treatment but only when the maximum methadone dose exceeded 60 mg and if MMT had been provided for the entire duration of imprisonment. These results suggest that the reduction of injecting and syringe sharing that occur with MMT in community settings also occur in prisons. However, prisoners need a daily dose of at least 60 mg of methadone and treatment is required for the duration of incarceration for these benefits to be realized in prison. The authors conclude that MMT has an important role to reduce the spread of HIV and hepatitis in prison.
Dolan K, Hall W, Wodak A (1998). The provision of methadone in prison settings. In: Ward J, Mattick RP, Hall W (eds). Methadone Maintenance Treatment and Other Opioid Replacement Therapies. Amsterdam: Harwood Academic Publishers, 379-396.
Dolan K, Wodak A, Hall W (1998). Methadone maintenance treatment reduces heroin injection in NSW prisons. Drug and Alcohol Review, 17(2): 153-158.
Durand E (2001). Changes in high-dose buprenorphine maintenance therapy at the Fleury-Merogis (France) prison since 1996 [article in French]. Ann Med Interne, 152(Suppl 7): 9-14.
Since January 1994, the ministry of Health is responsible for inmate health in France. A few months after the authorization of buprenorphine in France (March 1996), the ministry of Health decided to give access to this treatment to incarcerated IV drug users. The aim of this study was to present the implementation of maintenance medication by high dose buprenorphine in a big prison, to explain the challenges faced, and to present how this treatment can contribute to reducing the risks of transmission of infectious diseases.
Fiscella K et al. (2004). Jail Management of Arrestees/Inmates Enrolled in Community Methadone Maintenance Programs. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 81(4): 645-654.
Anecdotal evidence suggests that many jails fail to adequately detoxify arrestees/inmates who are enrolled in methadone programs, but there are few empirical data. The objective of this study was to assess how jails manage arrestees/inmates enrolled in methadone programs. A national survey of 500 jails in the United States was conducted. Surveys were mailed to the 200 largest jails in the country in addition to a random sample of 300 of the remaining jails (10% sample). Jails were specifically asked about management of opiate dependency among arrestees/inmates enrolled in methadone programs. Weighted logistic regression analyses were conducted to assess predictors of continuing methadone during incarceration and use of recommended detoxification protocols. Among the 245 (49%) jails that responded, only 1 in 4 (27%) reported they contacted the methadone programs regarding dose, and only 1 in 8 (12%) continued methadone during the incarceration. Very few (2%) jails used methadone or other opiates for detoxification. Most used clonidine. However, half (48%) of jails failed to use clonidine, methadone, or other opiates to detoxify inmates from methadone. The study concluded that these practices jeopardize the health and well-being of persons enrolled in methadone programs and underscore the need for uniform national policies within jails.
Gore SM, Seaman S. (1996). Drug use in prison. Methadone maintenance in prison needs to be evaluated. British Medical Journal, 313(7054): 429.
States that Kate Dolan and colleagues, supra, "claim, on the basis of inadequate data, that methadone maintenance reduces injecting in prison. This claim is based on recall of the number of injections in prison per week by a subgroup (number not stated) of ex-prisoners who--inside prison--both had received a maximum methadone dose exceeding 60 mg and had not defaulted from the program." Argues that the efficacy of methadone maintenance in prison should be evaluated prospectively in randomized controlled trials analyzed on an intention to treat basis.
Gorta A (1992). Monitoring the NSW prison methadone program: a review of research 1986-1991. Sydney: Research and Statistics Division: NSW Department of Corrective Services, Publication No. 25.
http://www.dcs.nsw.gov.au/information/research_and_statistics/research_publication/rp020.pdf
Gruer L, Macleod J (1997). Interruption of methadone treatment by imprisonment [letter].
British Medical Journal, 314: 1691.
The authors sent a questionnaire to general practitioners prescribing methadone. A majority (42 of 68) respondents reported adverse consequences of imprisonment for several patients, including severe symptoms of withdrawal, resumption of heroin injecting, needle sharing, and chaotic drug use both in prison and on release. The authors conclude that "[t]his survey has shown unacceptable discontinuity between clinical practice in the community and in prison, which seriously undermines the benefits to individual people and to the community of controlled methadone prescribing. There is an urgent need to improve communication between doctors in the prison and in the community. Procedures should be established to enable at least short term prisoners to continue successful treatment with methadone if this has the prescribing doctor's support."
Hall W, Ward J, Mattick R (1993). Methadone maintenance treatment in prisons: the New South Wales experience. Drug and Alcohol Review, 12: 193-203.
Hannafin J (1997). Treatment programmes in prison. Alcohol & Drug Issues Ltd, Department of Corrections: New Zealand.
The Department of Corrections evaluated the Protocol for Methadone Treatment Programmes in Prison to see how well it operated and identify possible improvements. The Department had some concerns about the safe provision of methadone in prisons, but also acknowledged that there were concerns from the methadone providers and patients in regard to the effectiveness of the prison protocol. The prison protocol allowed most inmates to stay on the methadone program for up to 21 days. The result of this policy was that most sentenced inmates were withdrawn from methadone treatment. Methadone program providers and patients expressed that they would like to see inmates kept on the program so that they can continue with their methadone treatment. The Department said that it would use this evaluation as a starting point for a review of the prison protocol.
Heimer R et al. (2005). A pilot program of methadone maintenance treatment in a men's prison in San Juan, Puerto Rico. Journal of Correctional Healthcare, 11(3).
Howells A et al. (2002). Prison-based detoxification for opioid dependence: a randomised double blind controlled trial of lofexidine and methadone. Drug and Alcohol Dependence, 67(2): 169-176.
Reports results from the first controlled trial of opioid withdrawal treatment in the UK using lofexidine in a prison setting. 74 opioid dependent male prisoners at a Southern England prison were randomised to receive either methadone (the standard prison treatment) or lofexidine using a randomised double-blind design. No significant statistical difference between the treatment groups was found in relation to the primary variable of severity of withdrawal symptoms (effect size=0.12). No discernible difference was found in the sitting blood pressure or heart rate of the two groups during the trial. These results provide support for the use of lofexidine for the management of opioid detoxification in the prison setting.
Hughes RA (2000). "It's like having half a sugar when you were used to three" - Drug injectors' views and experiences of substitute prescribing inside English prisons. International Journal of Drug Policy, 10(6): 455-466.
Hume S, Gorta A (1988). View of key personnel involved with the administration of the prison methadone program. Process evaluation of NSW Department of Corrective Services Prison Methadone Program. Sydney: Research and Statistics Division, New South Wales Department of Corrective Services.
Hume S, Gorta A (1989). The effects of the NSW prison methadone program on criminal recidivism and retention in methadone treatment. Evaluation of the NSW Department of Corrective Services Prison Methadone Program. Study No 7. Sydney: Research and Statistics Division, New South Wales Department of Corrective Services.
Keen J et al. (2000). Can methadone maintenance for heroin-dependent patients retained in general practice reduce criminal conviction rates and time spent in prison? Br J Gen Pract, 50(450): 48-49.
A retrospective analysis was made of the criminal records of 57 patients successfully retained in methadone maintenance at two general practices in Sheffield. Their criminal conviction rates and time spent in prison per year were compared for the periods before and after the start of their methadone program. Overall, patients retained on methadone programs in the general practices studied had significantly fewer convictions and cautions, and spent significantly less time in prison than they had before the start of treatment.
Kinlock T et al. (2002). A novel opioid maintenance programme for prisoners: preliminary findings. Journal of Substance Abuse Treatment, 22: 141-147.
Effective postincarceration treatment for individuals with preincarceration heroin dependence is urgently needed because relapse typically follows release. This article presents first-year findings from a unique 2-year pilot study of opioid agonist maintenance treatment initiated in prison and continued in the community. Incarcerated males with preincarceration heroin dependence were randomly assigned to Levo-alpha-acetylmethadol (LAAM) maintenance or control conditions 3 months before release. Approximately 92% of eligible inmates volunteered to participate; 36 of 58 subjects who were eligible and randomly assigned to LAAM maintenance successfully initiated treatment. Twenty-eight of these continued on LAAM until release; 22 (78.6%) entered community-based maintenance treatment; and 11 (50%) remained in treatment at least 6 months postrelease. Changes in LAAM's labeling because of its association with cardiac arrhythmias now makes it a second-line treatment for heroin dependence, unsuitable for treatment initiation. Nonetheless, study findings may also be applicable to methadone maintenance treatment, suggesting such treatment may be a promising means of engaging prisoners with preincarceration heroin dependence into continuing treatment.
Levasseur et al. (2002). Frequency of re-incarceration in the same detention centre: role of substitution therapy. A preliminary retrospective analysis. Annales de Médecine Interne, 153 (Suppl 3): 1S14-19.
Magura S, Rosenblum A, Joseph H (1992). Evaluation of in-jail methadone maintenance: preliminary results. In: Leukefeld C, Tims F (eds). Drug Abuse Treatment in Prisons and Jails, NIDA Research Monograph 118. Rockville: Maryland.
Magura S et al. (1993) The effectiveness of in-jail methadone maintenance. Journal of Drugs Issues, 23(1): 75-99.
Process and outcome evaluation results are reported for the in-jail methadone maintenance program in New York City with three thousand admissions annually. The Key Extended Entry Programme (KEEP) enables addicts charged with misdemeanours to be maintained on a stable dose of methadone during their stay at Rikers Island (average 45 days) and to be referred at release to dedicated slots in participating community methadone programs. The main study examined inmates who were not enrolled in methadone at arrest. 88% were drug injectors (usually both heroin and cocaine) who admitted committing an average of 117 property crimes and nineteen violent crimes in the six months before jail. Methadone program participants' post-release outcomes were compared with outcomes for similar addicts who received seven-day heroin detoxification in jail. Multivariate analysis indicated that the program participants were more likely than controls to apply for methadone or other drug abuse treatment after release and to be in treatment at a 6.5 month follow-up. Moreover, being in treatment at follow-up was associated with lower drug use and crime, but rates of retention in community treatment after release were modest. The in-jail program was most effective in maintaining post-release continuity of methadone treatment for inmates already enrolled in methadone at arrest. Experience with KEEP at Rikes has eased the anxieties corrections personnel have about providing methadone to inmates. Diversions of medication has not been a problem; the few patients who have attempted "spitbacks" have been detected and dropped from the program. There have been no conflicts between inmates who have access to methadone and those who do not. In fact, corrections staff perceived that addicts receiving methadone are less irritable and easier to manage than other inmates. KEEP is now viewed as an integral part of the administration of the jail, and accepted by the wardens as an important program for the treatment of heroin addiction and an AIDS prevention measure among the jail population. See also Tomasino V et al., 2001, and Bellin et al., 1999.
McGuigan K (1995). Methadone maintenance in Parkhurst Prison. Report of the 2nd Seminar of the European Network of Services for Drug Users in Prison. Prison Resource Service: London, 10-11.
Research has shown that prisoners in Parkhurst are more subversive and difficult to manage than prisoners in other maximum security prisons in England and Wales. And those who seek methadone treatment are, before they receive treatment, more subversive than the rest of the Parkhurst population. While they receive treatment the measure of their subversiveness drops back to the average for the other prisoners. There is evidence that addicts who are engaged by addiction services and involved in maintenance programs whilst in prison are more likely to take up help from addiction services on release. Where there is a good relationship between patient and doctor, it is also more likely that the patient will begin to use other aspects of healthcare services. Short course treatment, however politically or economically appealing, risks the patient only turning up for "treatment" when opiates are difficult to access and reverting back to opiates when supplies can be re-established. The end result is a situation in which doctor and patient collude in a game where the real issues of drug misuse are never on the agenda for discussion.
The prescription of methadone over a longer period to this group allows them time to build up a working relationship with the Medical Officer and to reorganize their lifestyles. Patients prescribed methadone over a longer time, on a realistic dosage, have less need to have recourse to illicit drugs with all of the associated risks related to methods of administration, impurities and uncertain strength. Equally those engaged in tackling their substance misuse should begin to lead more stable lifestyles, and become better members of the prison communities. The development of a more positive working relationship with the population of substance users has had many benefits, not the least of which is that a significant number of the patients treated so far have decreased and come off methadone of their own volition (60% at the last count). Despite concerns at the start of the project, there has not been an overwhelming demand for methadone and numbers coming forward have after the first couple of weeks remained manageable.
McLeod F (1991). Methadone, Prisons and AIDS. In: Norberry J et al. (eds), HIV/AIDS and Prisons. Canberra: Australian Institute of Criminology.
McLeod C (1996). Is there a right to methadone maintenance treatment in prison? Canadian HIV/AIDS Policy & Law Newsletter, 2(4): 22-23.
(see also infra, section on "Legal, Ethical, and Human Rights Issues)
Michel L, Maguet O (2003). L'organisation des soins en matičre de traitements de substitution en milieu carcéral. Rapport pour la Commisssion nationale consultative des traitements de substitution. Paris: Centre Régional d'Information et de Prévention du Sida Ile-de-France.
Provides an overview of methadone and buprenorphine treatment in prisons in France, and presents the results of a study undertaken with health professionals, prison staff, and prisoners about the experience with such treatment. Makes recommendations for improvements to treatment provision.
Motiuk L, Dowden C, Nafekh M (1999). Methadone Maintenance Treatment (MMT) programming for federal prisoners: A preliminary investigation. Ottawa, ON: Correctional Service Canada.
Pont J, Resinger E, Spitzer B (2005). Substitutions-Richtlinien für Justizanstalten. Vienna: Ministry of Justice.
Unpublished guidelines on substitution treatment in prisons
Reynaud-Maurupt C et al. (2005). High-dose buprenorphine substitution during incarceration. Management of opiate addicts. Presse Med, 34(7): 487-490.
The objective was to assess the impact of high-dose buprenorphine substitution therapy on the health of prisoners and the course of their incarceration. A prospective study was conducted on opiate dependent people on admission to prison and after 2 months of incarceration, in 6 prisons in the South East of France. During incarceration, no significant difference (other than in medical follow-up) appeared between the prisoners receiving substitution treatment and those who went through withdrawal on arrival. The first group, however, diffeered from the second in several respects: their occupational history before incarceration was less stable, their history of drug addiction and incarceration was more serious. The study concluded that the impact of buprenorphine substitution therapy during incarceration could not be demonstrated, but that prisoners receiving this treatment had a substantially different profile than those who were not receiving treatment when they arrived in prison.
Rich JD et al. (2005). Attitudes and practices regarding the use of methadone in US state and federal prisons. Journal of Urban Health,
The authors conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, 48% use methadone, predominantly for pregnant prisoners or for short-term detoxification. Only 8% of respondents refer opiate-dependent prisoners to methadone programs upon release. According to the authors, the results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.
Ross M et al. (1994). Prison: shield from threat, or threat to survival? British Medical Journal, 308: 1092-1095.
Reports that there is unequivocal evidence from published and unpublished Home Office statistics that the philosophy and pattern of provision to opiate dependent subjects by the British prison medical service diverges considerably from the consensus position adopted by drug dependency clinics in the NHS. For example, although in 1992 NHS treatment centres provided treatment with a notifiable drug (usually methadone) in 90% of renotified drug addicts, the corresponding figure for the prison medical service was only 29%. Furthermore, it is likely that those cases where methadone was offered, the usual methadone regimen provided by the prison medical service was, at most, an accelerated seven day regimen, which does not concur with the physiological rate for the withdrawal process. Recommends that the prison medical service implement the sort of treatment program that is standard practice in NHS drugs dependency treatment centres and certain general practices.
Rothon D (1997/98). Methadone in provincial prisons in British Columbia. Canadian HIV/AIDS Policy & Law Newsletter, 3(4)/4(1): 27-29.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Winter9798/23ROTHONE.html.
British Columbia's experience with MMT in prisons.
Rotily et al. (2000) HIV risk behavior in prison and factors associated with reincarceration of injection drug users. La Presse Médicale 29(28): 1549-1556.
The aim of this study was to estimate the frequency of risk behaviour for HIV transmission in prison and to identify the factors associated with reincarceration. Multivariate analysis showed that reincarceration was significantly more frequent among prisoners not receiving opiate substitutes at the time of their imprisonment.
Shearer J, Wodak A, Dolan K (2004). The Prison Opiate Dependence Treatment Trial. Technical Report No 199. Sydney: National Drug and Alcohol Research Centre.
The Prison Opiate Dependence Treatment Trial examined the treatment history and treatment outcomes for 204 heroin users in prisons in New South Wales, Australia, between January 2002 and January 2004. The trial was commissioned by the New South Wales Corrections Health Service to evaluate the introduction of naltrexone, a long-acting opioid antagonist, through a controlled comparison with the two existing treatments for heroin users: methadone maintenance treatment and drug-free counselling. The study found very poor induction and retention rates for oral naltrexon. Six-month retention was significantly lower in the subjects that started naltrexon (7%) compared to the subjects that started methadone (58%). The study did not replicate the success observed among prison parolees in the US or work release programs in Singapore. According to its authors, the "most likely reason for this was that inmates were not subject to coercion or incentives to enter and stay on naltrexone maintenance. In the absence of such incentives, opioid dependent inmates showed a preference for agonist treatment including methadone maintenance and buprenorphine maintenance."
The study also found relatively poor retention in subjects who started buprenorphine due to the high proportion (20%) who were discontinued due to diversion, leading the authors of the study to recommend that "alternate dose formulations may be warranted." The authors finished by saying: "We conclude from this study that treatment of heroin dependence in correctional settings using oral naltrexone is relatively ineffective because of limited attraction and poor compliance and that compliance is superior for oral methadone which is also more attractive and more effective." To order a copy of the report: ndarc.med.unsw.edu.au/ndarc.nsf/website/Publications.reports
Sibbald B (2002). Methadone maintenance expands inside federal prisons. Canadian Medical Association Journal, 167(10): 1154.
Stöver H, Keppler K (1998). Methadone treatment in the German penal system. Sucht - Zeitschrift für Wissenschaft und Praxis, 44(2): 104-119.
Provides an overview of the practice of methadone treatment in prisons in the different states of Germany.
Tomasino V et al. (2001). The Key Extended Entry Program (KKEP): a methadone treatment program for opiate-dependent inmates. The Mount Sinai Journal of Medicine, 68(1): 14-20.
The article describes the features of the methadone treatment program at the Correctional Facility on Rikers Island, New York. See also Bellin et al., 1999; and Magura, Rosenblum, Joseph, 1992, and Magura et al., 1993.
Tracqui A, Kintz P, Ludes B (1998). Drug and death in custody: two fatal overdoses. Journal de Médecine Légale et de Droit Médical, 41(3-4): 185-192.
Two overdoses related to substitution drugs (methadone, buprenorphine) and benzodiazepines in prisons are discussed.
Wale S, Gorta A (1987). Views of inmates participating in the pilot pre-release Methadone Program, Study No. 2. Sydney: Research and Statistics Division: NSW Department of Corrective Services.
Warren E, Viney R (2004). An Economic Evaluation of the Prison Methadone Program in New South Wales (Project Report 22). Sydney: Centre for Health Economics Research and Evaluation, University of Technology Sydney.
This is the first published study about the cost-effectiveness of prison methadone programs. It suggests that, irrespective of whether avoided cases of HCV are included, approximately 20 days of re-incarceration must be avoided to offset the annual cost of methadone treatment in New South Wales prisons.
Whitling N (2003). New policy on methadone maintenance treatment in prisons established in Alberta. Canadian HIV/AIDS Policy & Law Review, 8(3): 45-47.
Available in English and French at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/vol8no32003/prisons.htm#p1.
The right of a prisoner to access methadone maintenance treatment (MMT) while incarcerated in a correctional institution was raised and examined in the Alberta Court of Queen's Bench case of Milton Cardinal v The Director of the Edmonton Remand Centre and the Director of the Fort Saskatchewan Correctional Centre. This is a significant, precedent-setting case. For the first time, a Canadian court has ordered that a prisoner be provided with MMT during his or her period of incarceration. As a result of the case, and just before it was to proceed to trial, Alberta changed its policy and is now providing MMT to its provincial prisoners - at least when they had been receiving MMT prior to their incarceration.
Heroin Prescription
Kaufmann B, Dreifuss R, Dobler-Mikola A (1997/98). Prescribing narcotics to drug-dependent people in prison: some preliminary results. Canadian HIV/AIDS Policy & Law Newsletter, 3(4)/4(1): 38-40.
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Winter9798/28BEATE.html
Based on a series of federal measures dated 20 February 1991 and designed to reduce problems relating to drug use, Switzerland started testing the prescription of narcotics under medical control to drug-dependent people in January 1994. The Project for the prescription of narcotics under medical control in prisons (PSTEP) undertaken at Oberschöngrün penitentiary was a component of a broader research plan involving these scientific trials. The authors review preliminary results of the project and conclude that prescribing heroin under medical control in prisons is feasible: "All the medical and social problems could be resolved in a satisfactory way. Participants experienced an improvement in their quality of life. After a few start-up problems, adapting to the requirements of the prison sentence was considered to be satisfactory by the prison staff. For the prison itself, this pilot project was a major challenge that, thanks to the extra efforts of motivated and available staff, could be carried out successfully."
Dobler-Mikola A, Kaufmann B (1997). In O'Brien O (ed.). Report of the 3rd
European Conference on Drug and HIV/AIDS Services in Prison. Cranstoun Drug Services: London, 71-72.
Another summary of the experience with the Swiss prison heroin prescription trial.
Mortality upon Release
In recent years extensive research has focused on the mortality of people released from prisons, noting a large number of deaths during the first weeks after discharge that are attributed to drug overdose. As noted in the literature, this phenomenon probably can be explained by the reduced tolerance to opiates during the imprisonment with the resumption of drug injecting upon release. This highlights the importance of substitution treatment not only as an HIV prevention strategy in prisons, but as a strategy to reduce overdose deaths upon release.
Bird SM, Hutchinson SJ (2003). Male drugs-related deaths in the fortnight after release from prison: Scotland, 1996-1999. Addiction, 98: 185-190.
Found that drugs-related mortality in 1996-99 was seven times higher (95% CI: 3.3-16.3) in the 2 weeks after release than at other times at liberty and 2.8 times higher than prison suicides (95% CI: 1.5-3.5) by males aged 15-35 years who had been incarcerated for 14+ days. The authors estimated one drugs-related death in the 2 weeks after release per 200 adult male injectors released from 14 + days' incarceration.
Harding-Pink D (1990). Mortality following release from prison. Med Sci Law, 30(1): 12-16.
Joukamaa M (1998). The mortality of released Finnish prisoners: a 7 year follow-up study of the WATTU project. Forensic Sci Int, 96(1): 11-19.
Seaman SR, Brettle RP, Gore SM (1998). Mortality from overdose among injecting drug users recently released from prison: database linkage study. British Medical Journal, 316: 426-428.
The study showed that, overall, imprisonment does not seem to increase IDUs risk of dying from overdose. However, the risk of death from overdose was 8 times higher within 2 weeks after release from prison than it was during the next 10 weeks after release.
Seymour A, Oliver JS, Black M (2000). Drug-related deaths among recently released prisoners in the Strathclyde Region of Scotland. J Forensic Sci, 45(3): 649-654.
Shewan D et al. (2001). Injecting risk behaviour among recently released prisoners in Edinburgh (Scotland): The impact of in-prison and community drug treatment services. Legal and Criminological Psychology, 6: 19-28.
Singleton N et al. (2003). Drug-related mortality among newly released offenders. London: Home Office, Findings 187.
This study provides estimates of the rates of mortality amongst recently released prisoners in England and Wales and provides some evidence of the risk factors associated with this group. From a sample of 12,438 prisoners discharged in June or December 1999, 79 drug-related deaths and 58 deaths from other causes were recorded in the study period up to 31 January 2001. There was a high rate of death from all causes in the immediate post-release period: 13 deaths in the first week after release (55 deaths per thousand per annum); 6 in the second week (25 deaths per thousand per annum); 3-4 per week in the third and fourth weeks (15 deaths per thousand per annum). After this, the rate of death declined to a steady rate of about two deaths per week
(between 5 and 10 deaths per thousand per annum). In the week following release, prisoners in the sample were about 40 times more likely to die than the general population. In this period, immediately post-release, most of these deaths (over 90%) were associated with drug - related causes.
Verger P et al. (2003). High mortality rates among inmates during the year following their discharge from a French prison. J Forensic Sci, 48(3): 614-616.
The authors studied the mortality of 1305 prisoners released during 1997 from a French prison. Compared with the general population, ex-prisoners' non-natural mortality rates were significantly increased both in the 15-34 and 35-54 age categories (3.5-fold and 10.6-fold respectively) and the risk of death due to overdose was 124 and 274 times higher in the same categories respectively. The study concluded that prevention and care should be reinforced in the pre-release period.
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