Drug use and opioid substitution treatment for prisoners

Re-examining mandatory drug testing in Australian prisons

Mandatory drug testing is commonly used in Australian prisons to detect and deter drug use. In this commentary, we review the limited evidence for mandatory drug testing programs, highlight potential harms associated with their implementation and provide recommendations for drug surveillance in prisons concordant with a harm minimisation framework.

Law enforcement-led, pre-arrest diversion-to-treatment may reduce crime recidivism, incarceration, and overdose deaths: Program evaluation outcomes

INTRODUCTION

Substance use disorder (SUD), overdose, and drug use-related crime continue to increase in the U.S. Pre-arrest diversion-to-treatment programs may decrease crime recidivism and overdose deaths. We assessed the impact of a community-wide diversion-to-treatment initiative on crime, incarceration, and overdose.

METHODS

This article reports on the prospective evaluation of a law enforcement-led, pre-arrest diversion-to-treatment program on crime, incarceration, and overdose deaths compared between participants who did not engage (non-engaged; n = 103), engaged but did not complete (non-completers; n = 60) and completed (completers; n = 100) the program. Participants included 263 adults apprehended by police officers for low-level, drug use-related crimes between September 1, 2017 and August 31, 2020. The program offered eligible persons participation in a six-month program consisting of a clinical assessment, referral to addiction treatment services based on each individual's needs, connection to recovery peer support, and treatment engagement monitoring. Completers had their initial criminal charges 'voided,' while non-engaged and non-Completer participants had their original charges filed with local prosecutors. The project collected participant-level data on arrests and incarceration within 12 months before and 12 months after program enrollment and data on fatal overdose within 12 months after program enrollment. Logistic regression predicted outcomes using baseline demographics (sex, age, race, housing status) and pre-index crime arrest and incarceration indices as covariates.

RESULTS

After accounting for baseline demographics and pre-enrollment arrest/incarceration history, logistic regression models found that the non-engaged and the non-Completer groups were more likely than completers to be arrested (odds ratios [ORs]: 3.9 [95 % CI, 2.0-7.7] and 3.6 [95 % CI, 1.7-7.5], respectively) and incarcerated (ORs: 10.3 [95 % CI, 5.0-20.8] and 21.0 [95 % CI, 7.9-55.7], respectively) during the 12-month follow-up. Rates of overdose deaths during the 12-month follow-up were greatest in non-engaged (6/103, 5.8 %) and non-Completer (2/60, 3.3 %) groups; completers had the lowest rate (2/100, 2.0 %), with all deaths occurring after completion of the six-month treatment/monitoring program.

CONCLUSIONS

Collaboration between law enforcement, clinicians, researchers, and the broader community to divert adults who commit a low-level, drug use-related crime from criminal prosecution to addiction treatment may effectively reduce crime recidivism, incarceration, and overdose deaths.

Accessing opioid agonist treatment in prison in England and Scotland remains problematic - the views of people with lived experience

PURPOSE

The purpose of this paper is to examine lived experiences of opioid agonist treatment (OAT) during and immediately following release from detention in prisons in England and Scotland.

DESIGN/METHODOLOGY/APPROACH

Surveys were completed by serving prisoners in both countries and by those recently released from prison (England only). The survey findings were discussed in focus groups of people with lived experience. The combined findings from the surveys and focus groups were shared with an expert group of prison OAT providers and people with lived experience with the purpose of making recommendations for more accessible and effective OAT in custodial environments and continuity of OAT on release.

FINDINGS

The quality and accessibility of OAT varied considerably between establishments. It was reported to be harder to access OAT in Scottish prisons. It was often hard for people in prison to get the dosage of OAT they felt they needed and it was generally harder to access buprenorphine than methadone in English prisons. Only Scottish people in prison were aware of long-lasting forms of buprenorphine. People in English prisons had mixed experiences of the help available in prison, with no improvement recorded since a 2016 study. People in Scottish prisons were more likely to rate the help available as poor.

RESEARCH LIMITATIONS/IMPLICATIONS

The number of people accessed while actually in prison (73) was reduced by the impact of the pandemic, making it more difficult to access people in prison and because some were resistant to participating on the basis that they had already been consulted for a wide variety of research projects focused on the impact of COVID. The Scottish cohort (a total of 19 individuals comprising 14 survey respondents and five focus group members) is clearly too small a number on which to base robust claims about differences in OAT provision between the English and Scottish prison systems..

PRACTICAL IMPLICATIONS

The study identifies key barriers to accessing OAT in prisons and suggests key components of more user-friendly approaches.

SOCIAL IMPLICATIONS

This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release and offers valuable recommendations on how to make service provision more effective and consistent.

ORIGINALITY/VALUE

This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release in England and Scotland and offers valuable recommendations on how to make service provision more effective and consistent.

Long-Acting Buprenorphine Formulations as a New Strategy for the Treatment of Opioid Use Disorder

Long-acting buprenorphine formulations have been recently marketed for the Opioid Agonist Treatment (OAT) of opioid use disorder (OUD) associated with medical, social, and psychological support. Their duration of action ranges from one week up to 6 months. The non-medical use of opioids is increasing with a parallel rise in lethal overdoses. Methadone and buprenorphine are the standard treatment for opioid dependence. Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing the risks of overdose, crime, and transmission of HIV (Human Immunodeficiency Virus) in people who use opioids; however, its effectiveness has been hindered by low rates of uptake and retention in treatment. Furthermore, both methadone and buprenorphine are widely diverted and misused. Thus, a crucial aspect of treating OUD is facilitating patients' access to treatment while minimizing substance-related harm and improving quality of life. The newly developed long-acting buprenorphine formulations represent a significant change in the paradigm of OUD treatment, allowing an approach individualized to patients' needs. Strengths of this individualized approach are improved adherence (lack of peaks and troughs in blood concentrations) and a reduced stigma since the patient doesn't need to attend their clinic daily or nearly daily, thus facilitating social and occupational integrations as the quality of life. However, less frequent attendance at the clinic should not affect the patient-physician relationship. Therefore, teleconsulting or digital therapeutic services should be developed in parallel. In addition, diversion and intravenous misuse of buprenorphine are unlikely due to the characteristics of these formulations. These features make this approach of interest for treating OUD in particular settings, such as subjects staying or when released from prison or those receiving long-term residential treatment for OUD in the therapeutic communities. The long-lasting formulations of buprenorphine can positively impact the OUD treatment and suggest future medical and logistic developments to maximize their personalized management and impact.

Evaluation of fentanyl immunoassay test strips for rapid in-situ detection of fentanyl and fentanyl analogs in seized samples and alternative matrices

BACKGROUND

Ion mobility spectrometry is used for the rapid detection of drugs at points of security but are unable to differentiate some drugs leading to the instrument alarming for a drug not present in the sample. This can be particularly problematic for samples that alarm for fentanyl. In this study, fentanyl immunoassay strips were evaluated for use as a secondary test for fentanyl, including for the testing of alternative matrices, such as powders, e-liquids, and infused papers and textiles.

METHODS

The limit of detection of fentanyl immunoassay strips was examined along with their selectivity to 18 fentanyl analogsand 72 other drugs and cutting agents. The effectiveness of the test strips at the detection of fentanyl in the presence of other drugs was examined by testing a series of concentrations of fentanyl in solution in combination with other drugs. The testing of alternative matrices was explored with laboratory prepared samples through sampling with cotton buds and extraction in water.

RESULTS

The fentanyl immunoassay strips detected fentanyl at concentrations of 45 ng/mL and reacted with 16 of 18 tested fentanyl analogs with carfentanil and norfentanyl being the only analogs to not react. There was no reactivity with other drugs or cutting agents. The effectiveness of the fentanyl test strips was not reduced when fentanyl was mixed with other drugs. Fentanyl was successfully detected with high sensitivity in all alternative matrices.

CONCLUSION

The fentanyl immunoassay strips were found to be an effective secondary test for fentanyl and at least 16 fentanyl analogs in seized drug samples, including when mixed with other drugs. The effectiveness of the sampling methods for alternative matrices should be further evaluated using fentanyl and fentanyl analog casework samples. The use of this method by law enforcement and other agencies should be examined to assess its effectiveness and ease of use in operational settings.

The relationship between police contacts for drug use-related crime and future arrests, incarceration, and overdoses: a retrospective observational study highlighting the need to break the vicious cycle

BACKGROUND

Individuals with substance use disorder often encounter law enforcement due to drug use-related criminal activity. Traditional policing approaches may not be effective for reducing recidivism and improving outcomes in this population. Here, we describe the impact of traditional policing approach to drug use-related crime on future recidivism, incarceration, and overdoses.

METHODS

Using a local Police Department (PD) database, we identified individuals with a police contact with probable cause to arrest for a drug use-related crime ("index contact"), including for an opioid-related overdose, between September 1, 2015, and August 31, 2016 (Group 1, N = 52). Data on police contacts, arrests, and incarceration 12 months before and after the index contact were extracted and compared using Fisher's exact or Wilcoxon signed-rank tests. County-level data on fatal overdoses and estimates of time spent by PD officers in index contact-related responses were also collected. To determine whether crime-related outcomes changed over time, we identified a second group (Group 2, N = 263) whose index contact occurred between September 1, 2017, and August 31, 2020, and extracted data on police contacts, arrests, and incarceration during the 12 months prior to their index contact. Pre-index contact data between Groups 1 and 2 were compared with Fisher's exact or Mann-Whitney U tests.

RESULTS

Comparison of data during 12 months before and 12 months after the index contact showed Group 1 increased their total number of overdose-related police contacts (6 versus 18; p = 0.024), incarceration rate (51.9% versus 84.6%; p = 0.001), and average incarceration duration per person (16.2 [SD = 38.6] to 50 days [SD = 72]; p < 0.001). In the six years following the index contact, 9.6% sustained a fatal opioid-related overdose. For Group 1, an average of 4.7 officers were involved, devoting an average total of 7.2 h per index contact. Comparison of pre-index contact data between Groups 1 and 2 showed similar rates of overdose-related police contacts and arrests.

CONCLUSIONS

The results indicated that the traditional policing approach to drug use-related crime did not reduce arrests or incarceration and was associated with a risk of future overdose fatalities. Alternative law enforcement-led strategies, e.g., pre-arrest diversion-to-treatment programs, are urgently needed.

Development and use of a checklist for the implementation of medication for opioid use disorder in jails

Background

In light of short lengths of stay and proximity to communities of release, jails are well-positioned to intervene in opioid use disorder (OUD). However, a number of barriers have resulted in a slow and limited implementation.

Methods

This paper describes the development and testing of a Medication for Opioid Use Disorder (MOUD) Implementation Checklist developed as part of a Building Bridges project, a two-year planning grant which supported 16 US jail systems as they prepared to implement or expand MOUD services.

Results

Although initially developed to track changes within sites participating in the initiative, participants noted its utility for identifying evidence-based benchmarks through which the successful implementation of MOUDs could be tracked by correctional administrators.

Conclusions

The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports.

Plain Language Summary

People incarcerated in jails are more likely to have opioid use disorder than the general population. Despite this, jails in the United States (U.S.) often offer limited or no access to Medication for Opioid Use Disorder (MOUD). The Building Bridges project was designed to address this gap in 16 U.S. jail systems as they prepared to implement or expand MOUD services. This article addresses the use of a MOUD checklist that was initially designed to help the jails track changes toward evidence-based benchmarks. The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports.

'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK

BACKGROUND

The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings.

METHODS

Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons.

RESULTS

Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services.

CONCLUSION

The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.

The contribution of methamphetamine use to crime: Evidence from Australian longitudinal data

BACKGROUND

To quantify the extent to which methamphetamine use is associated with increases in crime net of any premorbid risk of criminality among people who use the drug.

METHODS

Four one-month data panels from 469 participants dependent on methamphetamine were drawn from the MATES cohort (N = 501). Odds ratios for within-person effects were extracted from a random intercept logistic regression model for crime during periods of methamphetamine use compared to no use. Effects were adjusted for time-varying measures of age, other substance use, and socio-economic disadvantage (income, unemployment and unstable accommodation). Involvement in crime (property crime, drug dealing, fraud, violent crime) and days of methamphetamine in the past month were assessed using the Opiate Treatment Index.

RESULTS

Crime was more likely during months when participants used methamphetamine compared to when they did not (OR 13.2 95% CI 8.5-20.6; AOR 4.7 95% CI 2.8-8.0), this reflecting more property crime (OR 10.6 95% CI 6.3-18.0; AOR 5.5 95% CI 2.8-10.8), violent crime (OR 8.2 95% CI 4.2-15.9; AOR 3.4 95% CI 1.5-8.0), fraud (OR 3.4, 95% CI 2.0-5.8; AOR 1.7 95% CI 0.8-3.3) and dealing drugs (OR 18.2 95% CI 10.2-32.5; AOR 5.9 95% CI 3.0-11.9), although the adjusted relationship for fraud was not significant. Effects were dose related.

CONCLUSIONS

The use of methamphetamine was associated with significant increases in crime beyond premorbid risk for criminality. Crime is a likely social consequence of methamphetamine use and efforts are needed to reduce this impact.

Pharmacological Approaches to Managing Violence and Aggression in Prison Populations: Clinical and Ethical Issues

Violence and aggression are common problems encountered in prison, which frequently require clinical intervention. This increased prevalence is partially attributable to the high morbidity of psychiatric and personality disorders in prison inmates. As prisons are non-therapeutic environments, the provision of clinical care becomes more complex. This article examines the general principles of management of violence and aggression in prison settings, with a particular focus on the clinical and ethical considerations that guide pharmacological approaches. Use of psychotropic medication to address these problems is reserved for situations where there is (i) a diagnosable psychiatric disorder, or (ii) a significant risk of harm to an individual without urgent intervention. Initial focus should be on environmental and behavioural de-escalation strategies. Clear assessment for the presence of major mental illness is crucial, with appropriate pharmacological interventions being targeted and time-limited. Optimising management of any underlying psychiatric conditions is an important preventative measure. In the acute setting, rapid tranquilisation should be performed according to local guidelines with a focus on oral prior to parenteral administration. Clinicians must be mindful of capacity and consent issues amongst prisoners to protect patient rights and guide setting of care.

OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis

BACKGROUND

In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB.

METHODS

A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting.

RESULTS

For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction.

CONCLUSION

PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.

Implementation of opioid maintenance treatment in prisons in North Rhine-Westphalia, Germany - a top down approach

BACKGROUND

Opioid Maintenance Treatment (OMT) is a well-evaluated treatment of opioid use disorder (OUD). Especially, under the condition of imprisonment, OMT is a preventive measure regarding infectious diseases such as hepatitis C. However, only a minority of prisoners with OUD are currently in OMT in numerous countries. In 2009, the Ministry of Justice of the federal state of North Rhine-Westphalia (NRW), Germany, launched the process of implementing OMT in prisons with various elements (e.g. development of recommendations regarding the treatment of prisoners with OUD, monitoring the number of prisoners in OMT, education of prison doctors). In the recommendations OMT was defined as the gold standard of treatment of OUD.

METHODS

To assess the effectiveness of the implementation strategy a survey on the prevalence of OMT in prisons in NRW was carried out twice a year by the Ministry of Justice between 2008 and 2016. Participants were prisoners in NRW, Germany. The diagnosis of OUD at admission to prison and the treatment state on survey dates was measured.

RESULTS

The number of prisoners in NRW dropped from 17,301 in 2008 to 16,432 in 2016. In the same period, the number of prisoners with OUD (mainly males) dropped from 4201 persons to 3650 persons and the number of prisoners in OMT increased from 139 persons (3.3%) to 1415 (38.7%) persons.

DISCUSSION

Currently, the percentage of prisoners with OUD in OMT in NRW is almost reaching the treatment rate outside prisons in Germany (45-50%). However, after release from prison there is still a high risk for a discontinuation of OMT.

CONCLUSIONS

Overall, the top-down approach of implementing OMT in prisons in the federal state of NRW was effective.

Prevalence of Opioid Dependence and Opioid Agonist Treatment in the Berlin Custodial Setting: A Cross-Sectional Study

BACKGROUND

Among people living in detention, substance use is highly prevalent, including opioid dependence. Opioid agonist treatment (OAT) has been established as an evidence-based, first-line treatment for opioid dependence. Despite high prevalence of opioid dependence, conclusive data regarding its prevalence and the OAT practice in German prisons is scarce; rather, the existing data widely diverges concerning the rates of people in detention receiving OAT.

MATERIALS AND METHODS

We conducted a cross-sectional survey of all detention facilities in Berlin. On the date of data collection, a full census of the routine records was completed based on the medical documentation system. For each opioid dependent individual, we extracted sociodemographic data (i.e., age, sex, and non-/German nationality, whether people experienced language-related communication barriers), information about OAT, comorbidities (HIV, hepatitis C, schizophrenia), and the detention center, as well as the anticipated imprisonment duration and sentence type. The data was first analyzed descriptively and secondly in an evaluative-analytical manner by analyzing factors that influence the access to OAT of people living in detention.

RESULTS

Among the 4,038 people in detention in the Berlin custodial setting under investigation, we identified a 16% prevalence of opioid dependence. Of the opioid-dependent individuals, 42% received OAT; 31% were treated with methadone, 55% were treated with levomethadone, and 14% were treated with buprenorphine. Access to OAT seemed mainly dependent upon initial receipt of OAT at the time of imprisonment, detention duration, the prisons in which individuals were detained, German nationality, and sex. The overall prevalence of HIV was 4-8%, hepatitis C was 31-42%, and schizophrenia was 5%.

CONCLUSIONS

The prevalence of opioid dependence and access to OAT remains a major health issue in the custodial setting. OAT implementation must be especially intensified among male, non-German, opioid-dependent individuals with a short detention period. Treatment itself must be diversified regarding the substances used for OAT, and institutional treatment differences suggest the need for a consistent treatment approach and the standardized implementation of treatment guidelines within local prison's standard operating procedures. Testing for infectious diseases should be intensified among opioid-dependent people living in detention to address scarcely known infection statuses and high infection rates.

The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids

BACKGROUND

Opioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.

AIMS

The present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.

METHODS

Using a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.

RESULTS

Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.

Optimising opioid substitution therapy in the prison environment

PURPOSE

The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales.

DESIGN/METHODOLOGY/APPROACH

A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017).

FINDINGS

Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison.

ORIGINALITY/VALUE

Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Utilization of opioid agonist therapy among incarcerated persons with opioid use disorder in Vancouver, Canada

BACKGROUND

Inability to access opioid agonist therapy (OAT) in correctional settings has previously been reported in Vancouver, Canada, and is associated with harms among people with opioid use disorder (OUD), including overdose death. We investigated the prevalence and correlates of OAT utilization within correctional settings among incarcerated persons with OUD in Vancouver.

METHODS

Data were derived from three prospective cohorts of people who use drugs in Vancouver between 2005 and 2016. Using multivariable generalized estimating equations, we examined factors associated with OAT utilization among participants with OUD reporting incarceration in the past six months.

RESULTS

Among 597 eligible participants, 207 (34.7%) contributed 325 reports of having utilized OAT while incarcerated. Of those, 295 (90.8%) were continuations and 30 (9.2%) were new initiations of OAT while incarcerated. For those currently on OAT (at the time of interview), in multivariable analyses, non-fatal overdose (adjusted odds ratio [AOR] = 0.49, 95% confidence interval [CI]: 0.29-0.82) and daily prescription opioid use (AOR = 0.42, 95% CI: 0.20-0.85) remained independently and negatively associated with having utilized OAT while incarcerated. For those not currently on OAT, none of the variables considered had significant associations with utilization of OAT while incarcerated.

CONCLUSIONS

Utilization of OAT in correctional settings was low in our sample. Utilization of OAT was significantly and negatively associated with overdose and ongoing prescription opioid misuse if OAT was continued upon release from correctional settings. Findings underscore the urgent need for improved utilization of OAT in correctional settings, and linkage to community care to prevent harms such as overdose.

The furthest left behind: the urgent need to scale up harm reduction in prisons

Purpose Raise awareness about the disproportionate impact of HIV and hepatitis C (HCV) on prisoners worldwide and the need for key harm reduction services such as needle and syringe programmes and opioid substitution therapy in prisons offer practical recommendations to assist policy makers in implementing or scaling up these services. The paper aims to discuss these issues. Design/methodology/approach This study is a desk review of existing data and evidence on HIV, HCV and harm reduction in prisons, analysis of political barriers and formulation of key policy recommendations. Findings Harm reduction works, yet service provision in prisons remains extremely limited. There is an urgent need for governments to enhance political leadership and funding for harm reduction in prisons. Authorities must also work to remove obstacles to the implementation of harm reduction services in prisons, enhance the monitoring and evaluation of laws, policies and programmes relating to HIV, HCV and drugs in prison settings, and recognise access to harm reduction in prisons as a fundamental human right. Until these obstacles are addressed, the world will not meet the Sustainable Development Goal of eradicating HIV and HCV by 2030. Originality/value More than just a desk review, this policy brief provides a political analysis of the harm reduction crisis in prisons and offers clear-cut recommendations for policy makers.

“I Lost Me Visits”

Utilizing Bacchi’s poststructuralist approach, “What’s the problem represented to be?,” we critically examine how the “problem” of drug use in prison is represented within a key initiative—the Identified Drug User program (IDUP)—of prison drug policy in one Australian jurisdiction. We use two data sources for our analysis: interview transcripts of recently incarcerated young men (aged 19–24) with histories of injecting drug use and selected prison drug policy and program documents. We examine how the “problem” of drug use in prison is problematized within the IDUP and question commonly accepted ways of thinking that underpin the program. We explore the discursive and subjectification effects of problem representations which produce young men as “rational” and “choosing” and, at the same time, as “untrustworthy” and “deserving of punishment.” We highlight how these effects have consequences for young men’s connections to family while incarcerated which can work against the very issues the IDUP is trying to address. We make two claims in particular: that the IDUP produces harmful effects for young men and their families and that the harmful effects produced are, paradoxically, those the IDUP aims to avoid. Our analysis offers insights into how drug use in prison could be thought about differently, including suggestions that might reduce at least some of its adverse effects.

Drug use in prisons: strategies for harm reduction (ANRS-PRIDE Program)

The existence of risky practices related to drug use inside prisons is a reality everywhere and is a major issue for the community as a whole. The level of implementation of harm reduction (HR) measures recommended by the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) is very often poor and reveals inadequate concern about public health issues in the prison environment, without any respect for the principle of equivalence for prevention and health assistance with the general community. In 2009, the French National Agency for Research on AIDS and Viral Hepatitis (ANRS) developed a comprehensive research program focusing on the prevention of infectious risks in prison settings. Different steps were defined and scheduled, and included i) an inventory of harm reduction (HR) measures, ii) a qualitative survey on the reality of risky practices, iii) an assessment of the social acceptability of HR measures, and iv) an intervention trial exploring the feasibility of upgrading existing HR strategies. A progressive implementation of this program has shown it is feasible, but in France, it requires tenacity, simple long-term objectives, support from a scientific authority, pedagogical interventions for all involved, as well as constant discussion with the authorities. The implementation of this program in other countries is equally simple to manage.

Trials and tribulations of conducting bio-behavioral surveys in prisons: implementation science and lessons from Ukraine

Purpose - Ukraine is home to Europe's worst HIV epidemic, overwhelmingly fueled by people who inject drugs who face harsh prison sentences. In Ukraine, HIV and other infectious diseases are concentrated in prisons, yet the magnitude of this problem had not been quantified. The purpose of this paper is to evaluate the systematic health survey of prisoners in the former Soviet Union (FSU). Design/methodology/approach - Qualitative interviews were carried out with research and prison administrative staff to assess the barriers and facilitators to conducting a bio-behavioral survey in Ukrainian prisons. Findings - Crucial barriers at the institutional, staff, and participant level require addressing by: first, ensuring Prison Department involvement at every stage; second, tackling pre-conceived attitudes about drug addiction and treatment among staff; and third, guaranteeing confidentiality for participants. Originality/value - The burden of many diseases is higher than expected and much higher than in the community. Notwithstanding the challenges, scientifically rigorous bio-behavioral surveys are attainable in criminal justice systems in the FSU with collaboration and careful consideration of this specific context.

Are we ready to treat hepatitis C virus in individuals with opioid use disorder: assessment of readiness in European countries on the basis of an expert-generated model

Individuals with a history of injecting drugs have a high prevalence of chronic hepatitis C (HCV) infection. Many have a history of opioid use disorder (OUD). Despite novel treatments with improved efficacy and tolerability, treatment is limited in the group. A faculty of experts shared insights from clinical practice to develop an HCV care-readiness model. Evidence and expert knowledge was collected. Ten experts developed a model of three factors (with measures): 'healthcare engagement', 'guidance' and 'place'. Overall, 40-90% of individuals with OUD engage with drug treatment services. Ten of 12 HCV guidelines provided specific advice for the OUD population. Ten of 12 OUD care guidelines provided useful HCV care advice. In 11 of 12 cases, location of HCV/drug treatment care was in different places. This readiness assessment shows that there are important limitations to successful HCV care in OUD. Specific actions should be taken: maintain/increase access to OUD treatment services/opioid agonist therapy, updating HCV guidance, locate care in the same place and allow wider prescribing of anti HCV medicines.

A randomized clinical trial of buprenorphine for prisoners: Findings at 12-months post-release

BACKGROUND

This study examined whether starting buprenorphine treatment prior to prison and after release from prison would be associated with better drug treatment outcomes and whether males and females responded differently to the combination of in-prison treatment and post-release service setting.

METHODS

Study design was a 2 (In-Prison Treatment: Condition: Buprenorphine Treatment: vs. Counseling Only)×2 [Post-Release Service Setting Condition: Opioid Treatment: Program (OTP) vs. Community Health Center (CHC)]×2 (Gender) factorial design. The trial was conducted between September 2008 and July 2012. Follow-up assessments were completed in 2014. Participants were recruited from two Baltimore pre-release prisons (one for men and one for women). Adult pre-release prisoners who were heroin-dependent during the year prior to incarceration were eligible. Post-release assessments were conducted at 1, 3, 6, and 12-month following prison release.

RESULTS

Participants (N=211) in the in-prison treatment condition effect had a higher mean number of days of community buprenorphine treatment compared to the condition in which participants initiated medication after release (P=0.005). However, there were no statistically significant hypothesized effects for the in-prison treatment condition in terms of: days of heroin use and crime, and opioid and cocaine positive urine screening test results (all Ps>0.14) and no statistically significant hypothesized gender effects (all Ps>0.18).

CONCLUSIONS

Although initiating buprenorphine treatment in prison compared to after-release was associated with more days receiving buprenorphine treatment in the designated community treatment program during the 12-months post-release assessment, it was not associated with superior outcomes in terms of heroin and cocaine use and criminal behavior.

Extended-release naltrexone for pre-release prisoners: A randomized trial of medical mobile treatment

BACKGROUND

Extended-release naltrexone (XR-NTX), is an effective treatment for opioid use disorder but is rarely initiated in US prisons or with criminal justice populations. Mobile treatment for chronic diseases has been implemented in a variety of settings. Mobile treatment may provide an opportunity to expand outreach to parolees to surmount barriers to traditional clinic treatment.

METHODS

Male and female prisoners (240) with pre-incarceration histories of opioid use disorder who are within one month of release from prison will be enrolled in this randomized clinical trial. Participants are randomized to one of two study arms: 1) [XR-NTX-OTx] One injection of long-acting naltrexone in prison, followed by 6 monthly injections post-release at a community opioid treatment program; or 2) [XR-NTX+ MMTx] One injection of long-acting naltrexone in prison followed by 6 monthly injections post-release at the patient's place of residence utilizing mobile medical treatment. The primary outcomes are: treatment adherence; opioid use; criminal activity; re-arrest; reincarceration; and HIV risk-behaviors.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

The use of long-acting injectable naltrexone may be a promising form of treatment for pre-release prisoners. Finally, as many individuals in the criminal justice system drop out of treatment, this study will assess whether treatment at their place of residence will improve adherence and positively affect treatment outcomes. ClinicalTrials.gov: NCT02867124.

HIV, Hepatitis C, TB, Harm Reduction, and Persons Deprived of Liberty: What Standards Does International Human Rights Law Establish?

HIV, hepatitis C virus (HCV), and TB in prisons and other places of detention are serious public health concerns, with prevalence and incidence considerably higher than in the general community because of the overrepresentation of risky behavior, substandard conditions, overcrowding, people who inject drugs, and the wholly inadequate prevention, care, and treatment of these conditions, including the denial of harm reduction services. This is not only a severe public health crisis but also a serious human rights concern. This article works to clarify the standards established by human rights law with regards to HIV, HCV, TB, and harm reduction in prisons by examining international and regional case law, minimum standards on the treatment of prisoners and public health, as well as the work of UN treaty bodies, Special Rapporteurs, and prison monitoring bodies. It is imperative that urgent steps are taken to close the gap between human rights and public health standards on the one hand, and effective implementation in prison settings on the other.

Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions

Purpose

The World Health Organization recommends the initiation of opioid agonists prior to release from incarceration to prevent relapse or overdose. Many countries in the world employ these strategies. This paper considers the evidence to support these recommendations and the factors that have slowed their adoption in the US.

Methods

We reviewed randomized controlled trials (RCTs) and longitudinal/observational studies that examine participant outcomes associated with the initiation or continuation of opioid agonists (methadone, buprenorphine) or antagonists (naltrexone) during incarceration. Papers were identified through a literature search of PubMed with an examination of their references and were included if they reported outcomes for methadone, buprenorphine, or naltrexone continued during incarceration or initiated prior to release in a correctional institution.

Results

Fourteen studies were identified, including eight RCTs and six observational studies. One RCT found that patients treated with methadone who were continued on versus tapered off methadone during brief incarceration were more likely to return to treatment upon release. A second RCT found that the group starting methadone treatment in prison versus a waiting list was less likely to report using heroin and sharing syringes during incarceration. A third RCT found no differences in postrelease heroin use or reincarceration between individuals initiating treatment with methadone versus those initiating treatment with buprenorphine during relatively brief incarcerations. Findings from four additional RCTs indicate that starting opioid agonist treatment during incarceration versus after release was associated with higher rates of entry into community treatment and reduced heroin use. Finally, one pilot RCT showed that providing extended-release naltrexone prior to discharge resulted in significantly lower rates of opioid relapse compared to no medication.

Conclusion

Reasons why uptake of these pharmacotherapies is limited in the US and relatively widespread in Europe are discussed. Recommendations for future research are outlined.

Opioid substitution therapy: Lowering the treatment thresholds

BACKGROUND

Opioid substitution therapy (OST) has been established as the gold standard in treating opioid use disorders. Nevertheless, there is still a debate regarding the qualitative characteristics that define the optimal OST intervention, namely the treatment threshold. The aim of this review is twofold: first, to provide a summary and definition of "treatment thresholds", and second, to outline these thresholds and describe how they related to low and high threshold treatment characteristics and outcomes.

METHOD

We searched the main databases of Medline, PubMed, PsycInfo, EMBASE, CINAHL and the Cochrane Library. Original published research papers, reviews, and meta-analyses, containing the eligible keywords: "opioid substitution", "OST", "low threshold", "high threshold" were searched alone and in combination, up to June, 2015.

RESULTS

Treatment thresholds were defined as barriers a patient may face prior to and during treatment. The variables of these barriers were classified into treatment accessibility barriers and treatment design barriers. There are increasing numbers of studies implementing low threshold designs with an increasing body of evidence suggesting better treatment outcomes compared to high threshold designs.

CONCLUSION

Clinical characteristics of low threshold treatments that were identified to increase the effectiveness of OST intervention include increasing accessibility so as to avoid waiting lists, using personalized treatment options regarding medication choice and dose titration, flexible treatment duration, a treatment design that focuses on maintenance and harm reduction with emphasis on the retention of low adherence patients.

Pattern of Substance Use and Related Factors in Male Prisoners

BACKGROUND

Prisoner's addiction is one of the major problems in many countries which imposes very high medical costs and social harm to communities. This study investigated the pattern of substance use and related factors in male prisoners in one of the prisons in southeastern Iran.

METHODS

This cross-sectional study was carried out in 2016. The study population was inmates of a prison in southeast Iran. Sampling was carried out randomly according to the list of prisoners. Data were collected using a form and were analyzed with statistics software SPSS.

FINDINGS

More than four-fifths (75.3%) of the subjects consumed at least one substance (alcohol, tobacco and other drugs), 74.4% were smoking, 73.2% used a narcotic substance, and about one-fifth (19.3%) reported drinking alcohol. With a frequency of 62.0%, opium was the most frequently utilized narcotic substance. Poppy juice (31.6%), cannabis (29.8%), crystal (16.9%) and tramadol (16.9%) were the next frequent substances used. A percentage of 41.5% subjects reported using two or more drugs. A percentage of 80.7% subjects reported substance use among their friends, 39.2% by siblings and 37.2% by father. Regression analysis showed predictor variables of substance use were education, substance use by prisoner before being imprisoned, substance use by father, friends and siblings.

CONCLUSION

This study showed a remarkable prevalence of substance use in prisons, which was more than general population. Therefore, it is necessary to consider alternative penalties of imprisonment due to the factors associated with substance use. Screening of people at high risk for substance use should be considered on admission to prison, and primary prevention measures should be focused on them.

Gender differences in recovery consequences among heroin dependent patients after compulsory treatment programs

Studies on recovery patterns and how baseline factors influence recovery consequences among heroin dependent patients have shown mixed results. This study is aimed at describing the gender differences in long-term recovery patterns and exploring the predictors of negative recovery consequences by gender among heroin dependent patients in Shanghai, China. At baseline, this study recruited 503 heroin dependent patients discharged from Shanghai compulsory rehabilitation facilities in 2007 and 2008. In this cohort study, the baseline data was then linked with participants’ 5-year follow-up data from official records. Generalized Estimating Equations (GEE) were used to compare males with females in terms of the presence of negative consequences (incarceration, or readmission to compulsory treatment, or both), in the subsequent 5-years after their discharge from compulsory treatment. Ordinary least squares (OLS) regression was used to explore factors associated to the time length of negative consequences in 5 years after the discharge for males and females separately. Our findings indicate that female heroin dependent patients tend to have less negative recovery outcomes than male patients. Male patients with a life-time history of poly drug use and female patients with borderline personality disorder are especially at risk of incarceration and readmission into compulsory treatment programs.

A cost-effectiveness analysis of opioid substitution therapy upon prison release in reducing mortality among people with a history of opioid dependence

AIM

Although opioid substitution therapy (OST) immediately after prison release reduces mortality, the cost-effectiveness of treatment has not been examined. Therefore, we undertook a cost-effectiveness analysis of OST treatment upon prison release and the prevention of death in the first 6 months post-release.

DESIGN

Population-based, retrospective data linkage study using records of OST entrants (1985-2010), charges and court appearances (1993-2011), prison episodes (2000-11) and death notifications (1985-2011).

SETTING

New South Wales, Australia.

PARTICIPANTS

A cohort of 16,073 people with a history of opioid dependence released from prison for the first time between 1 January 2000 and 30 June 2011.

INTERVENTION

OST treatment compared to no OST treatment at prison release.

MEASUREMENTS

Mortality and costs (treatment, criminal justice system-court, penalties, prison-and the social costs of crime) were evaluated at 6 months post-release. Analyses included propensity score matching, bootstrapping and regression.

FINDINGS

A total of 13,468 individuals were matched (6734 in each group). Twenty (0.3%) people released onto OST died, compared with 46 people (0.7%) not released onto OST. The final average costs were lower for the group that received OST post-release ($7206 versus $14,356). The incremental cost-effectiveness ratio showed that OST post-release was dominant, incurring lower costs and saving more lives. The probability that OST post-release is cost-effective per life-year saved is 96.7% at a willingness to pay of $500.

CONCLUSION

Opioid substitution treatment (compared with no such treatment), given on release from prison to people with a history of opioid dependence, is cost-effective in reducing mortality in the first 6 months of release.

Insufficient access to harm reduction measures in prisons in 5 countries (PRIDE Europe): a shared European public health concern

Background

Prisoners constitute a high-risk population, particularly for infectious diseases. The aim of this study was to estimate the level of infectious risk in the prisons of five different European countries by measuring to what extent the prison system adheres to WHO/UNODC recommendations.

Methods

Following the methodology used in a previous French survey, a postal/electronic questionnaire was sent to all prisons in Austria, Belgium, Denmark and Italy to collect data on the availability of several recommended HIV-HCV prevention interventions and HBV vaccination for prisoners. A score was built to compare adherence to WHO/UNODC recommendations (considered a proxy of environmental infectious risk) in those 4 countries. It ranged from 0 (no adherence) to 12 (full adherence). A second score (0 to 9) was built to include data from a previous French survey, thereby creating a 5-country comparison.

Results

A majority of prisons answered in Austria (100 %), France (66 %) and Denmark (58 %), half in Belgium (50 %) and few in Italy (17 %), representing 100, 74, 89, 47 and 23 % coverage of the prison populations, respectively. Availability of prevention measures was low, with median adherence scores ranging from 3.5 to 4.5 at the national level. These results were confirmed when using the second score which included France in the inter-country comparison. Overall, the adherence score was inversely associated with prison overpopulation rates (p = 0.08).

Conclusions

Using a score of adherence to WHO/UNODC recommendations, the estimated environmental infectious risk remains extremely high in the prisons of the 5 European countries assessed. Public health strategies should be adjusted to comply with the principle of equivalence of care and prevention with the general community.

A Phase 4, Pilot, Open-Label Study of VIVITROL® (Extended-Release Naltrexone XR-NTX) for Prisoners

This was a Phase 4, pilot, open-label feasibility study of extended-release injectable naltrexone (XR-NTX) administered to pre-release prisoners having a history of pre-incarceration opioid disorder. We evaluated the relationship between XR-NTX adherence and criminal recidivism (re-arrest and re-incarceration) and opioid and cocaine use. Twenty-seven pre-release male and female prisoners who had opioid disorders during the year prior to index incarceration were recruited and received one XR-NTX injection once each month for 7 months (1 injection pre-release from prison and 6 injections in the community) and of those 27, 10 (37%) were retained in treatment at 7-months post release. Results indicate those completing 6 compared to those completing <6 injections were less likely to test positive for opioids in the community (0% vs. 62.5%, respectively; p=0.003). Although not statistically significant, individuals who did not complete all 6 injections were more likely to be re-arrested compared to those completing all 6 community injections (31.3% vs. 0%, respectively; p=0.123). Contingent upon further study of a randomized controlled trial, XR-NTX may be a feasible option in the prison setting in view of the lack of potential for diversion. Furthermore, these data suggest that completing the entire course of treatment (6 injections) may reduce opioid use and, to a lesser degree, re-arrest and re-incarceration.

The paradox of control: An ethnographic analysis of opiate maintenance treatment in a Norwegian prison

BACKGROUND

Opiate maintenance treatment (OMT) is increasingly being offered in prisons throughout Europe. The benefits of OMT in prison have been found to be similar to those produced by OMT in community settings. However, prison-based OMT has been a controversial issue because of fear of the diversion of OMT medications and the development of black markets for prescription drugs such as buprenorphine and methadone. Prison-based OMT thus involves a delicate balance between the considerations of control and treatment.

METHODS

This article reports on an ethnographic study of a prison-based OMT programme in a closed Norwegian prison. The data include field notes from eight months of participant observation in the prison as well as qualitative interviews with 23 prisoners and 12 prison staff. Midway through the fieldwork, the prison authorities established a separate unit for OMT-enrolled prisoners to reduce the widespread diversion of buprenorphine. This "natural experiment" is explored in the analysis.

RESULTS

The prison-based OMT programme was characterised by strict and repressive control to prevent the diversion of buprenorphine, and the control became even stricter after the establishment of the OMT unit. However, the diversion of buprenorphine increased rather than decreased after the establishment of the OMT unit. To understand this "paradox of control", the article engages with theories of legitimacy, power and resistance. The excessive and repressive control was perceived as illegitimate and unfair by the majority of study participants. In various ways, many prisoners protested, confronted and subverted the OMT programme. The increase in buprenorphine diversion is interpreted as a form of collective resistance towards the perceived unfairness of the OMT programme.

CONCLUSION

The article demonstrates that an unbalanced and control-dominated approach to prison-based OMT may have the opposite effect of what is intended.

Long-term course of opioid addiction

Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.

A randomized controlled trial of prison-initiated buprenorphine: prison outcomes and community treatment entry

BACKGROUND

Buprenorphine is a promising treatment for heroin addiction. However, little is known regarding its provision to pre-release prisoners with heroin dependence histories who were not opioid-tolerant, the relative effectiveness of the post-release setting in which it is provided, and gender differences in treatment outcome in this population.

METHODS

This is the first randomized clinical trial of prison-initiated buprenorphine provided to male and female inmates in the US who were previously heroin-dependent prior to incarceration. A total of 211 participants with 3-9 months remaining in prison were randomized to one of four conditions formed by crossing In-Prison Treatment Condition (received buprenorphine vs. counseling only) and Post-release Service Setting (at an opioid treatment center vs. a community health center). Outcome measures were: entered prison treatment; completed prison treatment; and entered community treatment 10 days post-release.

RESULTS

There was a significant main effect (p=.006) for entering prison treatment favoring the In-Prison buprenorphine Treatment Condition (99.0% vs. 80.4%). Regarding completing prison treatment, the only significant effect was Gender, with women significantly (p<.001) more likely to complete than men (85.7% vs. 52.7%). There was a significant main effect (p=.012) for community treatment entry, favoring the In-Prison buprenorphine Treatment Condition (47.5% vs. 33.7%).

CONCLUSIONS

Buprenorphine appears feasible and acceptable to prisoners who were not opioid-tolerant and can facilitate community treatment entry. However, concerns remain with in-prison treatment termination due to attempted diversion of medication.

Rapid Assessment Response (RAR) study: drug use, health and systemic risks--Emthonjeni Correctional Centre, Pretoria, South Africa

BACKGROUND

Correctional centre populations are one of the populations most at risk of contracting HIV infection for many reasons, such as unprotected sex, violence, rape and tattooing with contaminated equipment. Specific data on drug users in correctional centres is not available for the majority of countries, including South Africa. The study aimed to identify the attitudes and knowledge of key informant (KI) offender and correctional centre staff regarding drug use, health and systemic-related problems so as to facilitate the long-term planning of activities in the field of drug-use prevention and systems strengthening in correctional centres, including suggestions for the development of appropriate intervention and rehabilitation programmes.

METHOD

A Rapid Assessment Response (RAR) methodology was adopted which included observation, mapping of service providers (SP), KI interviews (staff and offenders) and focus groups (FGs). The study was implemented in Emthonjeni Youth Correctional Centre, Pretoria, South Africa. Fifteen KI staff participants were interviewed and 45 KI offenders.

RESULTS

Drug use is fairly prevalent in the centre, with tobacco most commonly smoked, followed by cannabis and heroin. The banning of tobacco has also led to black-market features such as transactional sex, violence, gangsterism and smuggling in order to obtain mainly prohibited tobacco products, as well as illicit substances.

CONCLUSION

HIV, health and systemic-related risk reduction within the Correctional Service sector needs to focus on measures such as improvement of staff capacity and security measures, deregulation of tobacco products and the development and implementation of comprehensive health promotion programmes.

Selection of Variables that Influence Drug Injection in Prison: Comparison of Methods with Multiple Imputed Data Sets

BACKGROUND

Prisoners, compared to the general population, are at greater risk of infection. Drug injection is the main route of human immunodeficiency virus ý(HIV) transmission, in particular in Iran. What would be of interest is to determine variables that govern drug injection among prisoners. However, one of the issues that challenge model building is incomplete national data sets. In this paper, we addressed the process of model development when missing data exist.

METHODS

Complete data on 2720 prisoners was available. A logistic regression model was fitted and served as gold standard. We then randomly omitted 20%, and 50% of data. Missing date were imputed 10 times, applying multiple imputation by chained equations (MICE). Rubin's rule (RR) was applied to select candidate variables and to combine the results across imputed data sets. In S1, S2, and S3 methods, variables retained significant in one, five, and ten imputed data sets and were candidate for the multifactorial model. Two weighting approaches were also applied.

FINDINGS

Age of onset of drug use, recent use of drug before imprisonment, being single, and length of imprisonment were significantly associated with drug injection among prisoners. All variable selection schemes were able to detect significance of these variables.

CONCLUSION

We have seen that the performances of easier variable selection methods were comparable with RR. This indicates that the screening step can be used to select candidate variables for the multifactorial model.

Exploring motivations to stop injecting in English prisons: qualitative research with former male prisoners

Purpose

This paper aims to explore the cessation of injecting amongst male drug users when in prison in England and uncovers what influenced this behaviour and why.

Design/methodology/approach

Qualitative interviews were conducted with 30 male drug users on release from prison to explore what happened to their injecting drug use in prison. The research was conducted from a pragmatic harm reduction approach using grounded theory.

Findings

Not injecting in prison was identified as a pertinent finding and nine overarching themes accounted for this decline. The themes often overlapped with one another, highlighting how the decision not to inject when last in prison was multi‐factorial. Running throughout the themes were participants' concerns regarding the health and social risks attributed to injecting in prison, alongside an appreciation of some of the rehabilitative measures and opportunities offered to injecting drug users when in prison.

Originality/value

This qualitative research offers an updated perspective on illicit drug injecting in prison in England from the view of drug users since health and prison policy changes in prescribing and practice. It contributes to evidence suggesting that prisons can be used as a time of reprieve and recovery from injecting drug use.

The effectiveness of opioid maintenance treatment in prison settings: a systematic review

AIMS

To review evidence on the effectiveness of opioid maintenance treatment (OMT) in prison and post-release.

METHODS

Systematic review of experimental and observational studies of prisoners receiving OMT regarding treatment retention, opioid use, risk behaviours, human immunodeficiency virus (HIV)/hepatitis C virus (HCV) incidence, criminality, re-incarceration and mortality. We searched electronic research databases, specialist journals and the EMCDDA library for relevant studies until January 2011. Review conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-one studies were identified: six experimental and 15 observational. OMT was associated significantly with reduced heroin use, injecting and syringe-sharing in prison if doses were adequate. Pre-release OMT was associated significantly with increased treatment entry and retention after release if arrangements existed to continue treatment. For other outcomes, associations with pre-release OMT were weaker. Four of five studies found post-release reductions in heroin use. Evidence regarding crime and re-incarceration was equivocal. There was insufficient evidence concerning HIV/HCV incidence. There was limited evidence that pre-release OMT reduces post-release mortality. Disruption of OMT continuity, especially due to brief periods of imprisonment, was associated with very significant increases in HCV incidence.

CONCLUSIONS

Benefits of prison OMT are similar to those in community settings. OMT presents an opportunity to recruit problem opioid users into treatment, to reduce illicit opioid use and risk behaviours in prison and potentially minimize overdose risks on release. If liaison with community-based programmes exists, prison OMT facilitates continuity of treatment and longer-term benefits can be achieved. For prisoners in OMT before imprisonment, prison OMT provides treatment continuity.