Opiate Substitution Treatment and Harm Reduction in prisons:

the Geneva model

PD Dr Hans WolffUniversity 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

3

Language regions & bordering countries

Switzerland

4

1 country – 26 cantons

Switzerland

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 ChinaUSA (costs) $49 Billion/year, 70’000,-$/inmate/year

1. Information, education and communication 2. HIV testing and counselling3. Treatment, care and support 4. Prevention, diagnosis and treatment of tuberculosis 5. Prevention of mother-to-child transmission of HIV6. Condom programmes7. Prevention and treatment of sexually transmitted infections8. Prevention of sexual violence9. Drug dependence treatment including Opioid Substitution

Therapy10. Needle and syringe programmes 11. Vaccination, diagnosis and treatment of viral hepatitis12. Post-exposure prophylaxis13. Prevention of transmission through medical or dental services14. Prevention of transmission through tattooing, piercing and other

forms of skin penetration 15. Protecting staff from occupational hazards

Prevention in PrisonThe Comprehensive Package (UNOCD):

15 Key interventions

• 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

Opiate Substitution Treatment (OST) delivered appropriately will:

Guidelines Euromethworkhttp://www.q4q.nl/euromethwork/

Reduce mortality by overdose

0

100

200

300

400

500

600

1988 1990 1992 1994 1996 1998 2000 2002 2004

Her

oin

Ove

rdos

es

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Patients TreatedHeroin Overdoses

Buprenorphine Patients

Methadone Patients

Carrieri & al 2006

n

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

Reduction of criminality

4,9

0,7

0

1

2

3

4

5

6

7

Avant MMT MMT

Number of days with criminal act per week

Two interviews (85 patients )

First interview before MMT (methadone maintenance treatment)The second, after a mean MMT of 57 months

p<0,001

n

Cost-effective

1 $ invested in OST, Saves 38 $

(cost related to criminal activity, further incarcerations, unemployment, hospitalizations, medical follow-up)

$1

$38

MMT

Cost Savings

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

Harm Reduction International, The global state of harm reduction 2012

Access to OST in the community and in prison

Time gaps in the official introduction of OST in prisons: ~7-8y (Source: EMCDDA, Statistical Bulletin 2011, HSR tables)

CYCZ, RO,

NO

SKLV, LT,

BG

FR, HU

BEPL,GR

DE, IE

SI, ES, HR

LU

SE

NL, UKDK

FI

IT

PTMT, AT

TR

LU, IE, NO

PT

ESFR, SI

NL AT

DKIT

DE

HU

UK Scot

FI, RO, BG, EE

BE

PL, UK E&W,CZ, SE

HR

TR

0

5

10

15

20

25

30

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

no. c

ount

ries

prov

idin

g

OST in the community OST in prisonThanks 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• 0 overdose the last 10 years

14

Injecting & Syringe Sharing in PrisonLocation 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

EU & Nor. 0.2-34 EMCDD 2005

Greece 861 20.2 83 Koulierakis et al 1999

Mauritius 200 2-11 RSA Mauritius 2005

Russia 1,044 10 66 Frost, Tscherkov 2002

Russia 277 13 Dolan et al 2004

Thailand 689 25 78 Thaisri et al 2003

USA 472 15% Clarke et al 2001

Distribution machine: Hindelbank, CH

Hand-to-hand exchange: Geneva, CH

Needle and syringe exchange

Hand-to hand distribution

Injection/prevention kitSpain

Injection/prevention kitSwitzerland

• 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

Proof of efficacy of needle exchange programs in prison

WHO 2007Jürgens, 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!)