Opiate Substitution Treatment and
Harm Reduction in prisons:
the Geneva model
PD Dr Hans Wolff
University Hospitals Geneva
Hans.wolff@hcuge.ch
Plan
• Prisons in Switzerland
• Switzerland:
Examples of realizations at the prison medicine unit in Geneva
• Opiate substitution treatment (OST)
• and harm reduction in prison
• Needle and syringe exchange
Switzerland
Language regions & bordering
countries
3
Switzerland
1 country – 26 cantons
4
Incarceration in Switzerland
• General Population: 7 Mio
• 113 Prisons: 6065 detainees in 2011
– 78 detainees/100’000 inhabitants
World (2008): 10.1 Mio detainees: ¼ in the US (2.3 Mio, 9 Mio/year ), ¼ in Russia and China
USA (costs) $49 Billion/year, 70’000,-$/inmate/year
Prevention in Prison
The Comprehensive Package (UNOCD):
15 Key interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Information, education and communication
HIV testing and counselling
Treatment, care and support
Prevention, diagnosis and treatment of tuberculosis
Prevention of mother-to-child transmission of HIV
Condom programmes
Prevention and treatment of sexually transmitted infections
Prevention of sexual violence
Drug dependence treatment including Opioid Substitution
Therapy
Needle and syringe programmes
Vaccination, diagnosis and treatment of viral hepatitis
Post-exposure prophylaxis
Prevention of transmission through medical or dental services
Prevention of transmission through tattooing, piercing and other
forms of skin penetration
Protecting staff from occupational hazards
Opiate Substitution Treatment (OST)
delivered appropriately will:
• Reduce or stop illegal drug use
• Improve physical, mental and social well-being of the patient
• Prevent and reduce infectious diseases, including HIV and
hepatitis
• Reduce mortality, in particular through overdose
• Reduce morbidity
• Improve the quality of life of the patient and his family
• Reduce public spending in health care
• Reduce public spending in the criminal justice system
Guidelines Euromethwork
http://www.q4q.nl/euromethwork/
Reduce mortality by overdose
n
600
90000
80000
500
400
60000
50000
300
40000
Heroin Overdoses
200
30000
Buprenorphine Patients
20000
Methadone Patients
100
10000
0
0
1988
1990
Carrieri & al 2006
1992
1994
1996
1998
2000
2002
2004
Patients Treated
Heroin Overdoses
70000
Reduction of criminality
Two interviews (85 patients )
First interview before MMT (methadone maintenance treatment)
The second, after a mean MMT of 57 months
7
6
Number of days with criminal act per week
4,9
5
p<0,001
4
n
3
2
0,7
1
0
Avant MMT
MMT
I Sheerin & al. Reduction in crime by drug users on a methadone maintenance therapy in New Zealand. The New Zealand medical Journal; 12
March 2004 vol117, n°1190 ISSN 11758716
Cost-effective
$38
1 $ invested in OST,
Saves 38 $
(cost related to criminal activity, further
incarcerations, unemployment,
hospitalizations, medical follow-up)
$1
Cost
Savings
MMT
Gary A. Zarkin, Laura J. Dunlap, Katherine A. Hicks and Daniel Mamo Additional contact information Health Economics, 2005, vol. 14,
issue 11, p 1133-1150
Access to OST in the community and in prison
Harm Reduction International, The global state of harm reduction 2012
Time gaps in the official introduction of OST
in prisons: ~7-8y (Source: EMCDDA, Statistical Bulletin 2011,
HSR tables)
TR
30
CY
CZ, RO,
NO
no. countries providing
25
FI, RO,
BG, EE
SK
LV, LT,
BG
TR
FR, HU
20
HR
BE
PL, UK E&W,
CZ, SE
PL,GR
DE, IE
15
UK Scot
SI, ES,
HR
LU, IE,
NO
BE
HU
MT, AT LU
10
PT
IT
FI
NL, UK
ES
DE
DK
5
PT
FR, SI
DK
IT
AT
NL
SE
0
1965
1970
1975
1980
OST in the community
1985
1990
OST in prison
1995
2000
2005
2010
Thanks to H. Stöver
Opioid users in Geneva’s prison
Epidemiology
•
•
•
•
•
•
Prevalence: 8%
Male : 95,3%
Mean age : 29,7
Previous incarceration : 74,7 %
Intravenous users : 39,9 %
Used other substances (legal or illegal) : 94,8%
–
–
–
–
Cocaine :70,8%
Tranquilizers : 63,5%
Alcohol :55,4%
Canabis : 44,2%
Opiate substitution therapy (OST) in
the prison of Champ-Dollon (Geneva)
• Start 1970 (formal authorization in 1996)
• Pragmatic approach
• Politics of 4 pillars (Prevention, Harm
reduction, treatment, repression)
• MTD/Buprenorphine:
– start or continue treatment
– 5-10% with OST
– 100% of those who wish or need substitution
receive OST
•14 0 overdose the last 10 years
Injecting & Syringe Sharing in Prison
Location
N
% injected
% shared
Reference
Australia
(NSW)
7 studies
31-74
70-94
Potter 1989; Wodak 1989;
Dolan 1996,1998, 1999;
MacDonald 1994; Dolan &
Wodak 1999
Canada
4,285
11
Correc. Services Canada
1995
Canada
105 (F)
19
Di Censo, Dias, Gahagan
2003
Canada
>1,200
27
80
Small et al. 2005
England
378
11.6
73
Edwards et al 1999
Europe*
871
13
Rotily et al 2001
0.2-34
EMCDD 2005
EU & Nor.
Greece
861
20.2
Mauritius
200
2-11
Russia
1,044
10
Russia
277
13
Thailand
689
25
USA
472
15%
83
Koulierakis et al 1999
RSA Mauritius 2005
66
Frost, Tscherkov 2002
Dolan et al 2004
78
Thaisri et al 2003
Clarke et al 2001
Needle and syringe exchange
Distribution machine:
Hindelbank, CH
Hand-to-hand
exchange: Geneva, CH
Hand-to hand distribution
Injection/prevention kit
Spain
Injection/prevention kit
Switzerland
Proof of efficacy
of needle exchange programs in prison
•
•
•
•
•
Prevents HIV infection
No negative consequences
No increase of drug use or drug injection
Needles not used as weapons
Facilitate referral of drug users to drug
dependence treatment programs
WHO 2007
Jürgens, Lancet Inf Dis 2009
Global availability of needle and syringe programs (NSP)
in the community and in prisons
Harm Reduction International, The global state of harm reduction 2012
Needle exchange
at the prison of Champ-Dollon, CH
• Start 1996: principle of equivalence → cantonal law
in 2000
• Pragmatic approach (consider the fact that drugs
enter each prison in the world)
• Support by prison authorities
• At entry: Information concerning the possibility to
obtain injection material for free and in a confidential
way
• Information at the medical unit (=confidentiality),
then
distribution at the cell door (=security)
Syringe exchange at the prison of Champ-Dollon, 2001-2011
Problems and solutions
• Initial mistrust, fear of the syringe as potential
weapon (detention officers)
– Frequent exchanges between stake holders
improved acceptance of all
– Improvement of the culture of dialogue
– Prison direction implicated in public health
strategies
• Proportion of needles returned to the health
team
– Trust building
– Ask the detainees (=experts)
Problems and solutions II
• Acceptance by the detainees? Fear of
denunciation?
– Importance of confidentiality
– Separation of the hierarchies (independence medical /
prison staff) helps
– Participative approach in the improvement process
– Initiate other ways of syringe distribution
• Syringe sharing still exists
– Evaluate situation properly
– Other distribution methods (automates)?
Conclusions
• Addiction and associated health problems is of
major concern in detention
• Effective harm reduction strategies exist
• OST, condom distribution and Needle
exchange in prison are
– Necessary and FEASABLE
– Effective and low cost measures
– Should be implemented in every prison –
worldwide!
• Opportunity to improve the health of the
entire community (improve public health!)