Tá tú anseo:   Baile > Nuacht agus Imeachtaí > Seminar

Need for and availability of harm reduction in Irish prisons

Presentation By Jean Long

Introduction

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

The State of the Prisons in England and Wales (Ruck 1929)

Ar ais go Barr

What is known?…Reseach to date…

Commissioned by the Department of Justice, Equality and Law Reform

• Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C and HIV and risk factors in Irish prisoners: results of a national cross sectional survey (British Medical Journal 2000;321:78-82)
• Long J, Allwright S, Barry J, Reaper-Reynolds S, Thornton L, Bradley F, Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey (British Medical Journal 2001;323:1-6)
• Hannon, F., Kelleher, C., and Friel, S. General Healthcare Study of the Irish Prisoner Population. (Dublin: The Stationery Office 2000)

Independent research

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

Incidence of hepatitis C

• Incidence of hepatitis C was 66 per 100 person years
• 30 per cent higher than estimates in other countries
• History of imprisonment and frequent injecting were associated with testing positive for hepatitis C

Smyth B, O'Connor JJ, Barry J, Keenan E. (2003) Retrospective cohort study examining incidence of HIV and hepatitis C infection among injecting drug users in Dublin. Journal of Epidemiology and Community Health, 57, 310-311.

Prevalence of blood-borne viruses among prisoners in Ireland

Ar ais go Barr

Injecting drug use

Inmates

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

Entrants

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

Prevalence of blood-borne viruses among injector prisoners in the Republic of Ireland

Risk factors for hepatitis C among injectors

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

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

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

Ar ais go Barr

Why do we need harm reduction

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

United Nations Charter for prisoners

• “While prisoners are deprived of their liberty they should have full access to medical care ”.
• “Prisoners are sent to prison as punishment, not for punishment”.

Standard minimum rules for the treatment of prisoners (1977)

What do prisoners want?

Both injectors and non injectors want and will support programmes to address drug misuse.

Long J, Allwright S, and Begley C. Prisoners’ views of injecting drug use and harm reduction in Irish prisons (International Journal of Drug Policy 2004, 15: 139-149)

Regular routine

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

Ar ais go Barr

Individual counselling for self-selected prisoners is useful

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

Drug free units

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

Methadone maintenance and detoxification

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

Needle exchange

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

Prisoners’ wishes

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

What has happened since these studies?

• During 2000 and 2001, the Irish Prison Service along with other agencies developed both drug treatment service plans and health care plans
• Introduced, Evidence based methadone treatment services; expansion of drug free units; provision of hepatitis B vaccine; and employment of registered nurses

There is, of course, much more to do….

• Comprehensive harm reduction,
• Hepatitis C and STI treatment, drug free treatment and mental health care
• Need for routine health care and drug treatment information

Ar ais go Barr

Reports to date

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

In general, what works

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

Disinfectants

• Cleaning injecting equipment with bleach has not been shown to be effective in reducing the spread of hepatitis C
• Hepatitis C is our most common virus
• Do not recommend bleach in Ireland as you may give false hope

Kapadia F, Vlahov D, Des Jarlais D, Strathdee S, Ouellet L, Kerndt P et al. (2002) Does bleach disinfection of syringes protect against hepatitis C infection among young adult injection drug users? Epidemiology, 13, 738-741
Hagan H and Thiede H. (2003) Does bleach disinfection of syringes help prevent hepatitis C transmission? Epidemiology, 14, 628-629.

Needle and syringe exchange

• Needle exchange in prisons is feasible and creates a safer atmosphere
• Consider a limited needleand syringe exchange programme

Dolan K, Rutter S and Wodak A. (2003) Prison-based syringe-exchange programmes: a review of international research and development. Addiction, 98, 153-158.

Hepatitis B vaccine

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

Ar ais go Barr

Overdose

• Incidence of non-fatal overdoses in Irish prisons is unknown
• Management of overdose must be delegated to health rpofessionals and ambulance crews
• A combination of interventions are required and naloxone is only one small part
• Current interventions to prevent and manage overdose need to be documented
• Comprehensive and consistent response is required Sporer KA

(2003) Strategies for preventing heroin overdose. British Medical Journal, 326: 442-444. National Medicines Information Centre. (2003) Use of Naloxone in the Management of Opiate Dependence Syndrome. Dublin, National Advisory Committee on Drugs.

Recommendations for harm reduction

Do not:
Promote the use of disinfectants

Do:
Introduce a broad range of formal treatment
Expand hepatitis B vaccination
Introduce overdose prevention and management
Commence needle exchange programmes
Introduce health information systems

Consider in the future:
Outreach workers and safer injecting techniques

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

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

Acknowledgements

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

Ar ais go Barr

<< Back to Seminar on Harm Reduction Approaches.

Baile | Teagmhálacha | Mapa suímh | Cuardach | Faoin gCCND | Nuacht agus Imeachtaí | Foilseacháin | Gníomhaíochtaí Taighde| Clár Oibre | Maoiniú Taighde | Naisc