Asian Journal of Psychiatry 5 (2012) 114–115
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to the Editor Providing drug abuse treatment in prison: A call for action Drug abuse problems are over-represented in prison and it has been estimated that in some countries around three quarters of people in prison have alcohol or other drug-related problems, and more than one-third may be opioid dependent (WHO/UNODC/ UNAIDS, 2004). The link between drug abuse and crime is complex and economic, pharmacological and lifestyle mechanisms are some of the various factors which contribute to the development of these problems. Imprisonment of drug users for crimes they commit – often to support their addiction – contributes to prisoners’ high prevalence of drug dependence (European Commission, 2008). Prevalence of HIV infection among prisoners in many countries is substantially higher than in the general population (Dolan et al., 2007a; WHO, 2007). Many prisoners continue to use drugs while they are in prison, despite attempts to prevent the entry of illicit substances (Dolan et al., 2007b). Worldwide evidence shows that injecting drugs and sharing equipment, sexual activities, tattooing and body piercing and physical assault are the main risk factors for HIV transmission in prison (Dolan and Wodak, 1999; Hellard and Aitken, 2004). The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV (Ju¨rgens et al., 2009). These prisoners may continue with their risk behaviors upon release in the community (UNAIDS, 2006; Estebanez et al., 2002), thus posing a grave threat to public health. The consequences of drug use in prison also include drugrelated deaths, suicide attempts and self harm (Sto¨ver, 2010) Drug use in prison is also connected to bullying, assaults, corruption of prison staff and other threats to security (Penfold et al., 2005). Hence providing drug abuse treatment and HIV services in prison is imperative. Incarcerated individuals with substance abuse histories are at higher risk for relapse and return to criminal behavior if their need for treatment goes unmet (Fletcher and Chandler, 2006). These drug users often represent a marginalized section of society and prison is often the first time they come in contact with health services. There is a potential to provide a range of drug abuse treatment services like drug education; pharmacotherapies – detoxification and maintenance treatments; risk reduction programmes; therapeutic communities; drug free wings etc. A substantial body of research documents that treatment is, on the whole, more effective than incarceration alone in reducing drug abuse and criminal behavior among substance abusers and in increasing the likelihood that they will remain drug- and crimefree. (Fletcher and Chandler, 2006) and that effective prison-based substance abuse treatment reduces the likelihood of relapse and recidivism for participants (CSAT, 2005). A number of studies indicate that inmates who do not participate in substance abuse
treatment are significantly more likely to be rearrested than those who do (Andrews et al., 1990). Referral to community based services for drug abuse may be made on discharge from prison. Studies have also shown that effective aftercare is essential if the investment made in prisonbased treatment is to pay long-term dividends. Aftercare should not be limited to facilitating continuation of drug treatment, but needs to include social support services (WHO, 2007). Successful substance abuse treatment programs can lead to increased safety for inmates and prison staff by decreasing prison violence associated with inmate drug use and trafficking, and can foster positive attitudes and behaviors that frequently result in increased participation in educational, vocational and other prisonbased programming (Correctional Association of New York, 2011). However, despite increasing evidence of the benefits of treatment there still exists a huge gap between prisoners who require treatment and those who get it, worldwide. In low and middle income countries, even the extent of the problem is not known and minimal data exists about the pattern and prevalence of substance use disorders in correctional settings. There are other barriers to provision of treatment like negative attitudes towards drug users, perception of drug abuse as a moral rather than medical problem, low prioritization and poor funding for treatment. Further, provision of harm or risk reduction treatment may run in opposition to abstinence oriented approaches and established punishment/control culture in correctional settings. Nevertheless, several international recommendations and guidelines have flagged this is as a priority area and many countries are now taking up opportunities to provide harm reduction and drug abuse treatment services in prison. At the very minimum services should include procedures for identification and assessment, detoxification services, drug abuse education, risk reduction counseling, and information on available treatment services in the community. It is also desirable to include provision of motivational and relapse prevention counselling, tobacco cessation services, urine drug screening and long term medication including opioid substitution therapy for opioid dependent prisoners. Appropriate referrals for comorbid medical problems including to VCTC’S (Voluntary counselling and testing centres) may be done as indicated. Thus, the prison systems may provide a unique window of opportunity to intervene and initiate treatment in drug using offenders resulting in substantial gains in both individual as well as public health. Disclosure None. Role of funding None.
1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.11.012
Letter to the Editor / Asian Journal of Psychiatry 5 (2012) 114–115
Contributor Sonali Jhanjee. Conflict of interest None. Acknowledgement None. References Andrews, D.A., Zinger, I., Hoge, R.D., Bonta, J., Gendreau, P., Cullen, F.T., 1990. Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology 28, 369–404. Center for Substance Abuse Treatment (CSAT), 2005. Substance abuse treatment for adults in the criminal justice system. In: Treatment Improvement Protocol (TIP) series 44 (DHHS Pub. No. (SMA) 05-4056), Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Rockville, MD, U.S. Correctional Association of New York, 2011. Treatment Behind Bars: Substance Abuse Treatment in New York Prisons, 2007–2010. Dolan, J., Kite, B., Aceijas, C., Stimson, G.V., 2007a. HIV in prison in low income and middle-income countries. Lancet Infect. Dis. 7, 32–43. Dolan, K., Wodak, A., 1999. HIV transmission in a prison system in an Australian State. Med. J. Aust. 171 (1), 14–17. Dolan, K., Merghati, K.E., Brentari, C., Stevens, A., 2007b. Prisons and Drugs: A Global Review of Incarceration, Drug Use and Drug Services. Beckley Foundation Drug Policy Programme, Report Twelve.
115
Estebanez, P., Zunzunegui, M.V., Aguilar, M.D., Russell, N., Cifuentes, I., Hankins, C., 2002. The role of prisons in the HIV epidemic among female injecting drug users. AIDS Care 14 (1), 95–104. European Commission, 2008. Final report on prevention, treatment, and harm reduction services in prison, on reintegration services on release from prison and methods to monitor/analyse drug use among prisoners. Bonn, Germany. Fletcher, B., Chandler, R.K., 2006. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-based Guide. U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, Bethesda, MD. Hellard, M.E., Aitken, C.K., 2004. HIV in prison: what are the risks and what can be done? Sex. Health 1 (2), 107–113. Ju¨rgens, R., Ball, A., Verster, A., 2009. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect. Dis. 9, 57–66. Penfold, C., Turnbull, P.J., Webster, R., 2005. Tackling Prison Drug Markets: An Exploratory Qualitative Study. Home Office Online Report 39/05. Home Office, London. Sto¨ver H., 2010. OST for prisoners: practices, problems and perspectives. Acceptance-Oriented Drug Work. 7, 20–32. UNAIDS, 2006. Report on the Global AIDS Epidemic. UNAIDS, Geneva. WHO/UNODC/UNAIDS, 2004. Position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. World Health Organization, 2007. Evidence for action technical papers. Effectiveness of interventions to address HIV in prisons – drug dependence treatments. Geneva.
Sonali Jhanjee All India Institute of Medical Sciences, New Delhi, India E-mail address: [email protected] 22 July 2011
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to the Editor Providing drug abuse treatment in prison: A call for action Drug abuse problems are over-represented in prison and it has been estimated that in some countries around three quarters of people in prison have alcohol or other drug-related problems, and more than one-third may be opioid dependent (WHO/UNODC/ UNAIDS, 2004). The link between drug abuse and crime is complex and economic, pharmacological and lifestyle mechanisms are some of the various factors which contribute to the development of these problems. Imprisonment of drug users for crimes they commit – often to support their addiction – contributes to prisoners’ high prevalence of drug dependence (European Commission, 2008). Prevalence of HIV infection among prisoners in many countries is substantially higher than in the general population (Dolan et al., 2007a; WHO, 2007). Many prisoners continue to use drugs while they are in prison, despite attempts to prevent the entry of illicit substances (Dolan et al., 2007b). Worldwide evidence shows that injecting drugs and sharing equipment, sexual activities, tattooing and body piercing and physical assault are the main risk factors for HIV transmission in prison (Dolan and Wodak, 1999; Hellard and Aitken, 2004). The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV (Ju¨rgens et al., 2009). These prisoners may continue with their risk behaviors upon release in the community (UNAIDS, 2006; Estebanez et al., 2002), thus posing a grave threat to public health. The consequences of drug use in prison also include drugrelated deaths, suicide attempts and self harm (Sto¨ver, 2010) Drug use in prison is also connected to bullying, assaults, corruption of prison staff and other threats to security (Penfold et al., 2005). Hence providing drug abuse treatment and HIV services in prison is imperative. Incarcerated individuals with substance abuse histories are at higher risk for relapse and return to criminal behavior if their need for treatment goes unmet (Fletcher and Chandler, 2006). These drug users often represent a marginalized section of society and prison is often the first time they come in contact with health services. There is a potential to provide a range of drug abuse treatment services like drug education; pharmacotherapies – detoxification and maintenance treatments; risk reduction programmes; therapeutic communities; drug free wings etc. A substantial body of research documents that treatment is, on the whole, more effective than incarceration alone in reducing drug abuse and criminal behavior among substance abusers and in increasing the likelihood that they will remain drug- and crimefree. (Fletcher and Chandler, 2006) and that effective prison-based substance abuse treatment reduces the likelihood of relapse and recidivism for participants (CSAT, 2005). A number of studies indicate that inmates who do not participate in substance abuse
treatment are significantly more likely to be rearrested than those who do (Andrews et al., 1990). Referral to community based services for drug abuse may be made on discharge from prison. Studies have also shown that effective aftercare is essential if the investment made in prisonbased treatment is to pay long-term dividends. Aftercare should not be limited to facilitating continuation of drug treatment, but needs to include social support services (WHO, 2007). Successful substance abuse treatment programs can lead to increased safety for inmates and prison staff by decreasing prison violence associated with inmate drug use and trafficking, and can foster positive attitudes and behaviors that frequently result in increased participation in educational, vocational and other prisonbased programming (Correctional Association of New York, 2011). However, despite increasing evidence of the benefits of treatment there still exists a huge gap between prisoners who require treatment and those who get it, worldwide. In low and middle income countries, even the extent of the problem is not known and minimal data exists about the pattern and prevalence of substance use disorders in correctional settings. There are other barriers to provision of treatment like negative attitudes towards drug users, perception of drug abuse as a moral rather than medical problem, low prioritization and poor funding for treatment. Further, provision of harm or risk reduction treatment may run in opposition to abstinence oriented approaches and established punishment/control culture in correctional settings. Nevertheless, several international recommendations and guidelines have flagged this is as a priority area and many countries are now taking up opportunities to provide harm reduction and drug abuse treatment services in prison. At the very minimum services should include procedures for identification and assessment, detoxification services, drug abuse education, risk reduction counseling, and information on available treatment services in the community. It is also desirable to include provision of motivational and relapse prevention counselling, tobacco cessation services, urine drug screening and long term medication including opioid substitution therapy for opioid dependent prisoners. Appropriate referrals for comorbid medical problems including to VCTC’S (Voluntary counselling and testing centres) may be done as indicated. Thus, the prison systems may provide a unique window of opportunity to intervene and initiate treatment in drug using offenders resulting in substantial gains in both individual as well as public health. Disclosure None. Role of funding None.
1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.11.012
Letter to the Editor / Asian Journal of Psychiatry 5 (2012) 114–115
Contributor Sonali Jhanjee. Conflict of interest None. Acknowledgement None. References Andrews, D.A., Zinger, I., Hoge, R.D., Bonta, J., Gendreau, P., Cullen, F.T., 1990. Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology 28, 369–404. Center for Substance Abuse Treatment (CSAT), 2005. Substance abuse treatment for adults in the criminal justice system. In: Treatment Improvement Protocol (TIP) series 44 (DHHS Pub. No. (SMA) 05-4056), Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Rockville, MD, U.S. Correctional Association of New York, 2011. Treatment Behind Bars: Substance Abuse Treatment in New York Prisons, 2007–2010. Dolan, J., Kite, B., Aceijas, C., Stimson, G.V., 2007a. HIV in prison in low income and middle-income countries. Lancet Infect. Dis. 7, 32–43. Dolan, K., Wodak, A., 1999. HIV transmission in a prison system in an Australian State. Med. J. Aust. 171 (1), 14–17. Dolan, K., Merghati, K.E., Brentari, C., Stevens, A., 2007b. Prisons and Drugs: A Global Review of Incarceration, Drug Use and Drug Services. Beckley Foundation Drug Policy Programme, Report Twelve.
115
Estebanez, P., Zunzunegui, M.V., Aguilar, M.D., Russell, N., Cifuentes, I., Hankins, C., 2002. The role of prisons in the HIV epidemic among female injecting drug users. AIDS Care 14 (1), 95–104. European Commission, 2008. Final report on prevention, treatment, and harm reduction services in prison, on reintegration services on release from prison and methods to monitor/analyse drug use among prisoners. Bonn, Germany. Fletcher, B., Chandler, R.K., 2006. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-based Guide. U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, Bethesda, MD. Hellard, M.E., Aitken, C.K., 2004. HIV in prison: what are the risks and what can be done? Sex. Health 1 (2), 107–113. Ju¨rgens, R., Ball, A., Verster, A., 2009. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect. Dis. 9, 57–66. Penfold, C., Turnbull, P.J., Webster, R., 2005. Tackling Prison Drug Markets: An Exploratory Qualitative Study. Home Office Online Report 39/05. Home Office, London. Sto¨ver H., 2010. OST for prisoners: practices, problems and perspectives. Acceptance-Oriented Drug Work. 7, 20–32. UNAIDS, 2006. Report on the Global AIDS Epidemic. UNAIDS, Geneva. WHO/UNODC/UNAIDS, 2004. Position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. World Health Organization, 2007. Evidence for action technical papers. Effectiveness of interventions to address HIV in prisons – drug dependence treatments. Geneva.
Sonali Jhanjee All India Institute of Medical Sciences, New Delhi, India E-mail address: [email protected] 22 July 2011
