Health and Social responses
Last week (21 April 2022), the European Monitoring Centre for Drug and Drug Addiction (EMCDDA) published its latest version of its miniguide to delivering health and social responses to drugs in prison. The guide reviews the available interventions and their effectiveness and considers implications for policy and practice.
Evidence and responses
The guide concludes that, in general, interventions that are effective in tackling drug problems in the community are also found to be effective in prisons, although there tend to be fewer studies to support this. In particular, the availability of opioid agonist treatment for people with opioid dependence is recommended.
Two important principles for health interventions in prison are equivalence of care to that provided in the community and continuity of care between the community and prison on admission and after release. This implies that all appropriate prevention, harm reduction and treatment services should be available within prisons, and also that particular attention should be paid to service provision around admission and release.
Encouraging drug-using offenders to engage with treatment can offer an appropriate alternative to imprisonment, with this approach having a number of potential positive effects, such as reducing drug-related harms for individuals, preventing the damaging effects of detention and contributing to reducing the costs of the prison system. More and better evaluations of the different models of interventions are needed.
Interventions at prison entry
The EMCDDA recommends that to meet these basic requirements in relation to the continuity and quality of care, prison reception routines need to include systems for identifying individuals with high treatment needs immediately on arrival. Health assessment on entry to prison is a core practice in prison healthcare regimes. The aim is to diagnose any physical or mental illnesses, provide the required treatment and ensure the continuation of community medical care. In addition, a proper needs assessment and review must be undertaken to ensure that treatment is matched to each individual’s needs.
Where detoxification is appropriate this should be properly managed. Acute detoxification management may include symptomatic treatment of the effects of withdrawal, and may benefit from the use of clinical tools to monitor symptoms. The medical consultation upon entry to prison is also an opportunity to give the individual information about treatment and prevention, raise their awareness of risk and distribute harm reduction materials.
Interventions during the prison stay
I was particularly interested in the contents of the guide on opioid agonist treatment (OAT) which we tend to call OST with the S standing for Substitution. The guide says that methadone and buprenorphine are the two most commonly available substitute medications available in Europe.
It summarises that there is evidence to suggest that providing OAT with methadone during incarceration reduces injecting risks and increases engagement with community treatment after release from prison. Continuity of care when entering and leaving prison is a critical issue for those undergoing OAT because there is a high risk of overdose and or transmission of hepatitis C virus (HCV) infection when treatment is disrupted. Although the available evidence is limited, providing OAT in prison, particularly if continued in the community, may reduce mortality after prison release.
I am currently researching the recent experiences of over 150 people who use heroin (or other opiates) and have been to prison. Interestingly, approximately half of people find accessing OAT very straightforward while the other half experience difficulties and complain about having no choice in the form of substitute medication and not getting sufficient dosage. Some opt to conceal their heroin use and source heroin or OST illegally in prison.
The guide also discusses naltrexone (not to be confused with naloxone which can reverse opioid overdoses) and a substance rarely used in the UK for prison leavers. Naltrexone is used to prevent relapse in opioid-dependent individuals, and extended-release naltrexone is a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist. The EMCDDA concludes that providing extended-release naltrexone may be beneficial in reducing relapse to opioid use among offenders, but more evidence is needed.
Interventions on release
The EMCDDA highlights two key interlinked components in interventions for release from prison: connections to services in the community in order to ensure that ongoing treatment for substance use disorder and infectious diseases continues; and prevention of overdose deaths in the period immediately following release from prison. The provision of take-home naloxone is a key intervention here.
Continuity of care in prison remains a major challenge for us with just 38.1% of people who engage in treatment in prison continuing that treatment in the community within three weeks of release.
Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here.