Substance Abuse Substance Abuse TreatmentTreatment

Prevention and Policy Prevention and Policy in Correctional Servicesin Correctional Services

Dr. Myo Kyaw OoDr. Myo Kyaw OoConsultant PsychiatristConsultant Psychiatrist

Department of CorrectionsDepartment of CorrectionsJamaicaJamaica

Substance Abuse Substance Abuse Treatment & Treatment &

Rehabilitation must be Rehabilitation must be the Priority National the Priority National

AgendaAgenda

Treatment ModelsTreatment Models Many treatment modalities exist, based on Many treatment modalities exist, based on

wide range of factors within the context of wide range of factors within the context of a countrya country

Modalities are designed based on common Modalities are designed based on common problem of addiction and major economic, problem of addiction and major economic, cultural, religious and political dimensions.cultural, religious and political dimensions.

Resources available in countries vary Resources available in countries vary widelywidely

Important to remember hidden cost and Important to remember hidden cost and significant burden ( health care costs, significant burden ( health care costs, productivity loss, criminal justice costs..)productivity loss, criminal justice costs..)

Goal of TreatmentGoal of Treatment

Ultimate goal is ..to achieve “A Ultimate goal is ..to achieve “A Substance Free Quality life” Substance Free Quality life”

Programmatic GoalsProgrammatic Goals

Fiscal and political realitiesFiscal and political realities Appropriate use of resourcesAppropriate use of resources Philosophy of the program clearly Philosophy of the program clearly

defineddefined No single approach is effective for No single approach is effective for

everyoneeveryone Evaluation & ResearchEvaluation & Research

Objectives to provide a Objectives to provide a substance free quality lifesubstance free quality life

-harm reduction and motivation for -harm reduction and motivation for abstinenceabstinence

-bio-psycho-social level of functioning-bio-psycho-social level of functioning

-marital and family issues-marital and family issues

-job and financial management-job and financial management

-spiritual issues-spiritual issues

-relapse prevention-relapse prevention

Approach to Drug ProblemApproach to Drug Problem

Supply reductionSupply reduction Demand reductionDemand reduction

There should be a BALANCE between There should be a BALANCE between the two principlesthe two principles

Supply ReductionSupply Reduction

How to reduce supply reduction ?How to reduce supply reduction ? Cultivation, Manufacturing, Cultivation, Manufacturing,

EradicationEradication Trafficking & ExportTrafficking & Export EradicationEradication Precursors controlPrecursors control Money laundering and legislationMoney laundering and legislation

PreventionPrevention

No drugs …No abusersNo drugs …No abusers No precursors…No manufacturing No precursors…No manufacturing

processprocess How are you going to make prisons How are you going to make prisons

safe?safe? How do inmates receive their How do inmates receive their

supply?supply? Zero Tolerance Policy?Zero Tolerance Policy?

Demand ReductionDemand Reduction

Educational Approach, school Educational Approach, school education, public education, sport & education, public education, sport & cultureculture

Health & medical Measure, treatment Health & medical Measure, treatment and rehabilitation programsand rehabilitation programs

Community involvementCommunity involvement Economic empowermentEconomic empowerment Regional & International Cooperations Regional & International Cooperations

Caribbean & OAS Caribbean & OAS

Causes of Drug AddictionCauses of Drug Addiction

Moral/SpiritualMoral/Spiritual BiologicalBiological PsychodynamicPsychodynamic BehaviouralBehavioural Socio-culturalSocio-cultural Individual-drug-environmentIndividual-drug-environment INTEGRATIVEINTEGRATIVE

IntegrativeIntegrative

No single causeNo single cause Interaction of range of causesInteraction of range of causes Bio-Psycho-SocialBio-Psycho-Social Bio-Psycho-Socio-CulturalBio-Psycho-Socio-Cultural

Bio-Psycho-Socio-Bio-Psycho-Socio-CulturalCultural

No single causeNo single cause Interaction of the causesInteraction of the causes

General outline of demand General outline of demand reductionreduction

Treatment & RehabilitationTreatment & Rehabilitation Prevention & follow-upPrevention & follow-up

Models of Treatment Models of Treatment facilitiesfacilities

Residential basedResidential based Hospital or centresHospital or centres Short, medium, Short, medium,

long termlong term

Outpatient basedOutpatient based Drug Court Drug Court

TreatmentTreatment Prison basedPrison based

Treatment ApproachesTreatment Approaches

Individual therapyIndividual therapy Group therapyGroup therapy Family therapyFamily therapy Special program ( juvenile, Drug Special program ( juvenile, Drug

court, prison based, combined court, prison based, combined HIV,STI, TB, therapeutic HIV,STI, TB, therapeutic communities, cultural)communities, cultural)

Treatment ProcessTreatment Process

Crisis Management (overdose, Crisis Management (overdose, withdrawal, medical & psychiatric withdrawal, medical & psychiatric emergencies)emergencies)

Assessment & DetoxificationAssessment & Detoxification Rehabilitation with or without Rehabilitation with or without

Skilled trainingSkilled training Relapse prevention & follow-upRelapse prevention & follow-up Special servicesSpecial services

Networking & Supportive Networking & Supportive ServicesServices

AA, NAAA, NA FBO, NGO, PSOFBO, NGO, PSO EAPEAP Government MinistriesGovernment Ministries Family support groupsFamily support groups

Important thing to Important thing to rememberremember

Drug abuse recovery is a process, not Drug abuse recovery is a process, not an eventan event

Treatment modalities must be Treatment modalities must be designed based on multidimensional designed based on multidimensional approach to meet the individual needsapproach to meet the individual needs

Success is measured not on absolute Success is measured not on absolute figures of statistical value but quality figures of statistical value but quality of life change of individualof life change of individual

Constitutional rights of individual must Constitutional rights of individual must be protected at all timesbe protected at all times

Changing Model of CareChanging Model of Care

Recovery is not an event but the Recovery is not an event but the processprocess

Incarceration by itself does little to Incarceration by itself does little to break the cycle of illegal drug use break the cycle of illegal drug use and crimeand crime

Offenders sentenced to Offenders sentenced to Incarceration exhibit high rate of Incarceration exhibit high rate of RECIDIVISM once they are releasedRECIDIVISM once they are released

HARM HARM REDUCTIONREDUCTIONWidely accepted Model of Widely accepted Model of

CareCare

What is Harm What is Harm Reduction?Reduction?

Physical – death, illness, addiction, Physical – death, illness, addiction, HIV, Hepatitis, Injuries related to HIV, Hepatitis, Injuries related to accidents and violenceaccidents and violence

Psychological – fear of Psychological – fear of crime/violence and effect on familycrime/violence and effect on family

Social – breakdown of social systemSocial – breakdown of social system Economic – drug trade, productivity Economic – drug trade, productivity

loss, workplace accidentsloss, workplace accidents

Drug Abuse Prevalence Drug Abuse Prevalence in prisonsin prisons

Drug Abuse in prison is very Drug Abuse in prison is very commoncommon

Estimated 22% - 86%Estimated 22% - 86% Most frequently used illicit drug “ Most frequently used illicit drug “

Cannabis” 8% - 60%Cannabis” 8% - 60% British Study 60% heroin user British Study 60% heroin user

reported use in prison, more than reported use in prison, more than 25% initiated use in prison25% initiated use in prison

Factors associated with Factors associated with substance abuse in prisonsubstance abuse in prison

Age, Ethnicity, Conduct disorder, Age, Ethnicity, Conduct disorder, abuses, school difficultiesabuses, school difficulties

Psychiatric disordersPsychiatric disorders Antisocial personalityAntisocial personality Support systemSupport system Length of sentenceLength of sentence

Drug Abuse Drug Abuse Survey in Survey in

Jamaican PrisonsJamaican Prisons20052005

MethodologyMethodology

4 maximum security prisons 4 maximum security prisons Sampling Frame of 3434 inmatesSampling Frame of 3434 inmates Stratified sampling method usedStratified sampling method used Estimated prevalence rate 45% ± Estimated prevalence rate 45% ±

5%5% A total of 440 inmatesA total of 440 inmates 42 items, 4 sections Questionnaire 42 items, 4 sections Questionnaire

usedused

Results - AgeResults - Age

A Total of 440 inmatesA Total of 440 inmates Male 82% (360), Female 18% (80)Male 82% (360), Female 18% (80) Age range – 18 to 73 yearsAge range – 18 to 73 years Majority 53% (Age range 23-34)Majority 53% (Age range 23-34)

Results – Age group by Results – Age group by GenderGender

Age groupAge group MaleMale FemaleFemale TotalTotal

17-2217-22 2525 88 33 (8%)33 (8%)

23-2823-28 9999 2121 120 (27%)120 (27%)

29-3429-34 9898 1515 113 (26%)113 (26%)

35-4035-40 7171 1212 83 (19%)83 (19%)

41-4641-46 3535 1212 47 (11%)47 (11%)

47-5247-52 2020 99 29 (6%)29 (6%)

53 & over53 & over 1212 33 15 (3%)15 (3%)

Results – Education by Results – Education by gendergender

LevelLevel MaleMale FemaleFemale TotalTotal

PrimaryPrimary 224224 2525 249 (57%)249 (57%)

SecondarySecondary 128128 3737 165 (38%)165 (38%)

TertiaryTertiary 88 1818 26 (5%)26 (5%)

Results – Literacy levelResults – Literacy level

LevelLevel MaleMale FemalFemalee

TotalTotal

ExcellentExcellent 5757 4040 97 (22%)97 (22%)

GoodGood 8989 2424 113 (25%)113 (25%)

Can help selfCan help self 120120 99 129 (29%)129 (29%)

Just a littleJust a little 6666 66 72 (16%)72 (16%)

Can not Can not read/writeread/write

2828 11 29 (8%)29 (8%)

KnowledgeKnowledge

Ganja is a drugGanja is a drug 72%72% Ganja smoking is harmfulGanja smoking is harmful 61%61% Alcohol, tobacco & beady are drugsAlcohol, tobacco & beady are drugs 78%78% Ganja improves sexual performanceGanja improves sexual performance 33%33% Alcohol improves sexual performanceAlcohol improves sexual performance 38%38% Addiction is drug dependencyAddiction is drug dependency 85%85% A link between drug abuse & STIA link between drug abuse & STI 73%73%

PrevalencePrevalence

PrevalencePrevalence NoNo YesYes

Drug abuse before Drug abuse before incarcerationincarceration

163163 273 ( 62% 273 ( 62% ))

Drug abuse during Drug abuse during incarcerationincarceration

233233 201 ( 201 ( 46%46% ))

PrevalencePrevalence

Drug abuse before incarceratedDrug abuse before incarcerated 62%62%

Drug abuse during incarcerationDrug abuse during incarceration 46%46%

Type of Substances abusedType of Substances abused(N=305)(N=305)

TypeType NumberNumber

GanjaGanja 172 (39%)172 (39%)

TobaccTobaccoo

98 (22%)98 (22%)

AlcoholAlcohol 21 (5%)21 (5%)

CrackCrack 6 (1%)6 (1%)

ValiumValium 5 (1%)5 (1%)

InhalanInhalantt

3 (0.7%)3 (0.7%)

Pattern of AbusePattern of Abuse

TypeType DailyDaily WeeklyWeekly OccasionallOccasionallyy

GanjaGanja 98 (22%)98 (22%) 1313 62 (14%)62 (14%)

TobaccoTobacco 75 (17%)75 (17%) 77 42 (10%)42 (10%)

AlcoholAlcohol 9 (2%)9 (2%) 11 32 (7%)32 (7%)

ValiumValium 6 (1%)6 (1%) 00 6 (1%)6 (1%)

CrackCrack 4 (0.9%)4 (0.9%) 00 3 (0.7%)3 (0.7%)

InhalantInhalantss

1 (0.2%)1 (0.2%) 00 2 (0.5%)2 (0.5%)

Factors affecting Factors affecting frequencyfrequency

FactorsFactors StatisticsStatistics

MoneyMoney 122 (28%)122 (28%)

AvailabilityAvailability 63 (14%)63 (14%)

Afraid of Disciplinary Afraid of Disciplinary actionaction

11 (3%)11 (3%)

Afraid of being seenAfraid of being seen 6 (1%)6 (1%)

Reason for Drug useReason for Drug use To feel more relaxedTo feel more relaxed 119119 27%27% To meditateTo meditate 9999 23%23% To cope with prisonTo cope with prison 8484 19%19% To sleepTo sleep 6565 15%15% CuriosityCuriosity 4646 11%11% LonelyLonely 3636 8%8% Peer pressurePeer pressure 2626 6%6% AddictionAddiction 2222 5%5% ReligionReligion 88 2%2%

Source of supply in Source of supply in prisonprison

Fellow inmatesFellow inmates 189189 43%43% Correctional officersCorrectional officers 13 13 3% 3% Over prison wall/fenceOver prison wall/fence 8 8 2% 2% Family/friendsFamily/friends 5 5 1% 1%

Motivation for changeMotivation for change

Want to stop drug abuseWant to stop drug abuse 150150 34%34%

Request assistance to stopRequest assistance to stop 113113 26%26%

Interest to participate in program 348Interest to participate in program 348 79%79%

Best group to sensitize Best group to sensitize drug abuse programdrug abuse program

GroupGroup StatisticsStatistics

Recovering addictsRecovering addicts 233 233 (53%)(53%)

ChurchChurch 108 108 (25%)(25%)

FamilyFamily 34 34 (8%)(8%)

Fellow inmateFellow inmate 29 29 (7%)(7%)

OthersOthers 22 22 (5%)(5%)

Correctional officersCorrectional officers 14 14 (2%)(2%)

SummarySummary

Prevalence of drug abusePrevalence of drug abuse 46%46% Ganja is most commonly abusedGanja is most commonly abused

39%39% 34%34% of inmates are motivated to of inmates are motivated to

quit and quit and 26%26% requested assistance. requested assistance. 79%79% showed interest to participate showed interest to participate

in the drug abuse program in prison.in the drug abuse program in prison.

Implementation of Implementation of Substance Abuse Substance Abuse

Treatment & Prevention Treatment & Prevention in Prisons is well in Prisons is well

justifiedjustified

Models of Treatment Models of Treatment facilitiesfacilities

Residential basedResidential based Hospital or centresHospital or centres Short, medium, Short, medium,

long termlong term

Outpatient basedOutpatient based Drug Court Drug Court

TreatmentTreatment Prison basedPrison based

Principle of Principle of Therapeutic Therapeutic

JurisprudenceJurisprudence

Prof. Bruce WinnickProf. Bruce Winnick

Prof. David WexlerProf. David Wexler

Application of TJApplication of TJ

Offenders with underlying drug abuse Offenders with underlying drug abuse problems problems

Incarceration alone does not help or Incarceration alone does not help or reduce recidivismreduce recidivism

Therapeutic principle is applied in Therapeutic principle is applied in Judicial processJudicial process

Diversion ProgrammeDiversion Programme Prison Based ProgrammePrison Based Programme Parallel ModelParallel Model

Diversion ProgrammeDiversion Programme

Drug Court Treatment & RehabilitationDrug Court Treatment & Rehabilitation May 2001 Kingston, July 2001 Montego May 2001 Kingston, July 2001 Montego

BayBay Drug Court Act 1999Drug Court Act 1999 Offenders with Minor Offences who meet Offenders with Minor Offences who meet

eligible criteriaeligible criteria Bail offeredBail offered Six months outpatient programme under Six months outpatient programme under

court supervision and weekly urine testingcourt supervision and weekly urine testing

Jamaica Drug CourtJamaica Drug CourtMay 2001 – March 2009May 2001 – March 2009

Treatment CenterTreatment Center Total referred by Total referred by CourtCourt

AdmissioAdmissionn

Drop outDrop out GraduateGraduatedd

KingstonKingston 295295 149149 9999 5050

Montego Montego BayBay

284284 262262 153153 109109

579579 411411 252252 159159

Jamaica Drug CourtJamaica Drug CourtMay 2001 – March 2009May 2001 – March 2009

EligibilityEligibility 71%71%

Drop OutDrop Out 61%61%

GraduationGraduation 39%39%

Monthly saving on one Monthly saving on one graduategraduate

J$ 58,333.33 J$ 58,333.33

Total saving on graduatesTotal saving on graduates J$ J$ 9,274,978.809,274,978.80

What about those What about those ineligible ineligible

Offenders?Offenders?

Prison Based ProgrammePrison Based Programme

Prison based Prison based ProgramProgram

? Legislation? Legislation Political willPolitical will Budget Budget

commitmentcommitment

Outpatient Drug Outpatient Drug CourtCourt

LegislationLegislation Court supervisionCourt supervision Probation period Probation period

after graduationafter graduation Criminal offence Criminal offence

not recordednot recorded

Jamaica DCS Pilot Jamaica DCS Pilot ProjectProject

Situational AnalysisSituational Analysis TrainingTraining Project Design and ImplementationProject Design and Implementation EvaluationEvaluation

Things to rememberThings to remember

Two pillars approach supply and Two pillars approach supply and demand reductiondemand reduction

Integrative model of causesIntegrative model of causes Recovery is a process, not an eventRecovery is a process, not an event Harm Reduction modelHarm Reduction model Therapeutic Jurisprudence Therapeutic Jurisprudence

principles in judicial processprinciples in judicial process Legislation to assist rehabilitationLegislation to assist rehabilitation

Things to rememberThings to remember

Interagency Cooperation & Interagency Cooperation & CoordinationCoordination

Regional & International Regional & International CooperationCooperation

Research and PublicationResearch and Publication

Insanity is doing the Insanity is doing the same thing over and same thing over and over and expecting over and expecting

different resultsdifferent results

Punitive Model without Punitive Model without Rehabilitation does not solve Rehabilitation does not solve

underlying issuesunderlying issues

Try innovative methods and Try innovative methods and programsprograms

Thank YouThank You

Dr. Myo Kyaw OoDr. Myo Kyaw OoMBBS,DPM, DM Psych.MBBS,DPM, DM Psych.

Acting Senior Medical OfficerActing Senior Medical OfficerBellevue HospitalBellevue Hospital

June 10, 2009June 10, 2009