Associate Professor Mark Stoové - Burnet Institute - SESSION 3: Exploiting Incarceration as an...

Exploiting incarceration as an opportunity to change the health and criminogenic trajectories of people who inject drugs Associate Professor Mark Stoové Head, Justice Health Research Program Head, HIV Research Program Burnet Institute

Overview

• Characterise the trajectories of justice involved people who inject drugs (PWID)

• Outcomes of strategies to intervene and implications for policy and practice

• Case study of new hepatitis C treatments

… and some informed opinion

Drug Use is Inextricably Linked to Crime and Incarceration

Drug use among arrestees and prisoners:

• 2/3 police detainees test positive to at least 1 drug1

• About 50% of prison entrants report lifetime history of IDU2 – ~25% injected in past month (most commonly ATS and heroin)

• Generally higher prevalence of drug use among female detainees/prisoners

1 Drug Use Monitoring in Australia Report 2009–10

2 National Prison Entrants’ BBV & Risk Behaviour Report, 2004, 2006 & 2010


Self-reported crime and arrest among PWID:

• Injecting Drug Reporting System (IDRS) 20111 – 39% reported any crime in the past month

– 36% arrested in past month

• Melbourne Injecting Cohort Study (MIX)2 – 28% reported crime in the past month

• 58% reported weekly or more often property crime

– 54% arrested in past 12 months

– 60% lifetime incarceration

• Crime overwhelming categorised as drug-related or property crime

1 Stafford & Burns, NDARC, 2012

2 Horyniak et al, (2013). Harm Reduction Journal, 10:11


• 45% of offenders attribute their crime to drugs

• Commonly injected or IDU-associated drug types1 • Heroin – 54%

• Amphetamine – 33%

• Opiates – 27%

• Benzodiazepines – 27%

Correlates of property crime in sample of PWID in Melbourne2

1 AIC Trends & Issues Report # 439 2012

2 Kirwan et al (submitted). Drug and Alcohol Dependence

Variable Adjusted

OR

95% CI

Daily injecting 4.36 1.45-13.07

Used illicit benzodiazepines 2.59 1.02-6.57

Contact with mental health services 4.27 1.45-12.60

Drug & property-related offences generally attract shorter sentences

OST trial of 375 male heroin users recruited in NSW prisons1

• Median of 4 prior custodial sentences at baseline

During follow-up (1997 -2006):

• 88% reconvicted (median 15 times)

• 90% re-incarcerated

• 84% re-incarcerated within 2 years

1 Larney, Toson, Burns, Dolan, NDARC, 2011

People Who Inject Drugs Over-Represented Among Those Transitioning

Prevention of poor health and criminogenic outcomes = preventing a return to problematic patterns of drug use

• Retention in effective treatment pre-to-post release

• Supportive post-release social environments

In general, incarceration does little to prevent a return to drug use and crime and incarceration

Evidence of effective programs where opportunities begin pre-release and continue

through transition and beyond!

Prevention of Return to Problematic IDU

Numerous studies support effectiveness of opioid substitution therapy (OST) for reducing:

• drug use

• mortality

• crime/recidivism

• incarceration/re-incarceration

• blood borne virus transmission

But provision is not enough – retention is vital

Prevention of Return to Problematic IDU Opioid Substitution Therapy

Larney et al (2011)1:

• OST at release from prison reduced re-incarceration (on average by 20%), but only when controlling for program retention

Dolan et al (2005)2:

• Re-incarceration lowest among those retained in OST for ≥8mths; highest among those retained ≤2mths

Dolan et al (2003)3:

• reductions in heroin use, self-reported injecting, frequency of heroin injecting and sharing of syringes compared to wait list controls


1 Larney, Toson, Burns, Dolan, NDARC, 2011

2 Dolan et al Addiction, vol. 100, no. 6, pp. 820 – 828

3 Dolan et al Drug and Alcohol Dependence, vol. 72, no. 1, pp. 59 - 65

Degenhardt et al (2014):

• Impact of opioid substitution therapy OST during/after incarceration on post-release mortality

• Prisoner on OST between 1985-2010 in NSW; released from custody b/w 2000-2012

– 16,453 prisoners; 60,161 discharges

Prevention of Mortality Opioid Substitution Therapy


• Again, program retention is key …


1 MONTH

~4-fold decrease

CRUDE MORTALITY RATE

Retained in OST Partial OST No OST

1st week post-release 5.1 per 1000 PY 48.8 per 1000 PY

1st 4 weeks post release 3.5 per 1000 PY 10.4 per 1000 PY 26.5 per 1000 PY

1st year post-release 2.4 per 1000 PY 14.9 per 1000 PY 9.4 per 1000 PY




1 MONTH

~7.5-fold decrease









1 MONTH

~10-fold decrease









Spending time in and out of OST

• Enhanced mortality relative to ongoing OST

• Actually riskier than no OST over 12 months







• 1 in 5 participants had their first experience of OST in prison!

• Incarceration as an “opportunity” to initiation

• Long-term impact reliant on effective transition and retention in community programs!

• Somewhat effective transition programs

• Inadequate post-release supports for OST retention


National Treatment Agency (NHS) in UK (2012)1 • ~20,000 people ≥1 conviction in previous 2 years who started a new drug

course of treatment in 2006 and 2007

• Conviction rates were compared for 2-year retrospective and prospective period

• ~5000 retained in treatment for the entire 2 yrs showed an average 47% reduction in convictions

– >3 times higher than the 15% reduction among those who dropped out

1 National Treatment Agency for Substance Misuse. NHS. 2012


Presenting Drug % Reduction in

Convictions Opiates only 25% Opiates & crack 20% Crack only 39%

Opiates & crack - duration of Rx > 3 months 13% 3-6 month 16% 6-12 months 15% 1-2 years 23% Continuing at 2 yrs 46%



Sweden’s Prison Therapeutic Community System – 2005 onwards

Specific prisons and units designed as therapeutic communities - employing 12-step and cognitive therapy programs

• 7 institutions with 500 places

• Rx units at other prisons 300 places.

• Provides access to Rx for ~1/3 drug using prisoners

In 12 months post-release, compared to matched controls:1 • Significantly reduced proportion with new convictions

• Significantly reduced proportion re-incarcerated

• No difference these outcomes between drop out and non-Rx controls

1 Journal of Scandinavian Studies in Criminology & Crime Prevention, 13:1,

44-63. 2012


Baldry (20031, 20062) cohort study of 238 NSW/Vic prisoners followed to 9 months post-release.

• Re-incarceration associated with:

– ‘worsening’ of heroin use, AOD problems

– frequently moving, no/unhelpful accommodation support

• Avoiding re-incarceration associated with:

– Not moving or moving only once in first 3 months

– Living with significant other (partner, parent, close family member)

Binswanger et al (2012)3: • relapse to AOD use occurred when those released from prison were

ubiquitously exposed to drugs in their living environments (family using, street drug markets in neighbourhood)

Supportive Post-Release Social and Living Environment

1 AHURI Final Report No. 46, 2003

2 Baldry et al. ANZJC, 2006

3 Binswanger et al. Addiction Science & Clinical Practice 2012, 7:3

The Future of Hepatitis C Treatment A role for Correctional Health Care

• Single-pill combination therapy (no injections)

• 97% cure rate at 12 weeks:

• Only mild adverse events

• Ongoing phase 3 studies with ~2000 individuals

HCV treatment delivery could substantially shift away from hospital-based to community settings


We estimate that approximately 5-6% of those chronically infected with hepatitis C pass through

prisons annually

EXCELLENT SETTING FOR NEW THERAPIES

• Highly effective

• Highly tolerable

• Short duration

• Simple to administer

• Nurse-led models of care with cost savings


Prison and Transition Health Cohort Study (PaTH)

NHMRC – Stoove, Kinner, Butler, Ogloff, Aitken, Dietze; ~$1 million; 4.5 years

Study aims:

1. Identify typical trajectories of people with a history of IDU following release from prison

– patterns of health service utilisation, drug use, BBV infection, physical and mental health, criminal justice;

2. Identify crucial intervention opportunities

• 500 male prisoners with IDU histories

• In-depth interview, blood specimen (HCV antibody/PCR/phylogenetics)

• Baseline at 4-6 weeks prior to release; follow-up at 3, 12, 24-mth post-release

• Extensive record linkage:

– Medicare, PBS, mental health, hospital service, ambulance, police (LEAP)

Summary

1. PWID vastly over-represented in prison and among ex-prisoners

– overwhelming proportion of the economic, social, health, individual and community burden associated with incarceration

– Investing transition programs is therefore likely to be highly cost effective

– Advocacy within government to enhance or re-allocate transition program funding

• Prison infrastructure to accommodate increased demand Vs prevention of re-incarceration to alleviate demand?

2. Opportunity begin pre-release and MUST be supported post-release

– To some extent we know the types services/program that work

– Need research to inform their refinement to enhance effectiveness

Summary

3. Primary responsibility must be borne by Justice Health and Correctional programs to:

• Deliver effective programs

• Facilitate others to deliver effective programs (e.g., in-reach)

• Coordinate pre/post release services

• Refine governance structures in collaboration with other relevant government departments and community services

• Advocate within government

• Support research and evaluation (and make publically accessible)

Associate Professor Mark Stoové - Burnet Institute - SESSION 3: Exploiting Incarceration as an...

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