This course is designed as a self-study online. To begin we recommend taking a few minutes to read the short manual to the course
Since there are variations in policy and guidelines by country, the course cannot reflect country- specific regulations. This course presents general principles, to complement, not replace, national and international guidelines.
Who is this course addressed to?
This course is to support prison doctors, contracted doctors, prison health care workers, prison administration, NGOs and others in delivering or supporting substitution treatment to opioid dependent prisoners such as ministries responsible for health care in prison.
Drug dependence has to be treated as a severe disease and everyone has a part to play to ensure the best treatment for prisoners and also to ensure that drug related harm is kept as low as possible. Applying the recommendations in this guide will contribute to a healthier prison for prisoners with drug dependence with satisfying roles for staff members and a marked reduction in the harm that drug use in prisons can create.
This course is an updated version of the book “Opioid Substitution Treatment in Custodial Settings. A practical Guide” which has been published with the endorsement of the WHO and UNODC in 2008. Since then, it has been translated in several languages (Czech, Azeri, Polish, Russian, and German) and adapted to the respective conditions. In some countries this manual has already been published in several editions. However, the English original has been unchanged for many years and needs an update to integrate new developments in medication-assisted treatment.
Parts of the original text (by Andrej Kastelic) have been modified from a chapter of the WHO Regional Office for Europe publication “Health in Prisons. A WHO guide to the essentials in prison health”. Essential parts have been taken from Annette Verster: Training Manual: Key aspects of substitution treatment for opiate dependence. An early version of this guide has been elaborated by the University of Bremen (BISDRO) for the European Commission, DG SANCO, Project No. 2003308, European Network on Drugs and Infections Prevention in Prison (ENDIPP; coordinated by WIAD, Bonn in Germany).
Subjects of the course
1. What is substitution treatment? Part I
The goal of this topic is:
- presentation of the main goals of substitution treatment.
- the ability to distinguish agonists from antagonists.
- presentation of the benefits of substitution treatment.
2. What is substitution treatment? Part II
The goal of this topic is:
- showing different substitution treatment regimens
- showing the risks and limitations of substitution therapy
- showing how to use methadone in substitution therapy
- show how to use buprenorphine and sustained-release morphine in substitution therapy
- showing how to use naltrexone as a prevent to addiction.
3. Substitution treatment in prisons
The goal of this topic is:
- showing how to implement substitution treatment in a prison.
- describing the role of psychological and social care.
- presentation of the ethical basis of substitution.
4. Basic information about treatment
The goal of this topic is:
- presentation of basic information for the patient on substitution treatment.
- describe how a patient can continue treatment after commencement or termination of prison sentence.
- describing the links between substitution therapy and treatment of blood-borne infections (eg HIV / AIDS, HBV, HCV) and others (eg tuberculosis or sexually transmitted diseases).
5. Medical ethics aspects of opiate substitution treatment programmes in prisons
The aim of this topic is to provide guidelines for substitution treatment under isolation conditions.
In many parts of the world, Europe, Asia, and North America opioid dependent or at least experienced people are over-represented in prisons. In these regions they represent about one third of the prison population and up to 80% in some countries such as in Central Asia. In sub-Saharan Africa, the problem is emerging, while in Latin America the main dependency is to cocaine.
Prisons are not the right place for treating drug using and dependent men and women, and countries should develop policies for alternatives to imprisonment (UNODC/WHO 2018). As long as these alternatives have not been developed and implemented, prison authorities are faced with this specific population, in need of treatment, care and support. Research has shown that medication-assisted treatment is the most effective way to treat opioid dependence, to reduce the risk of HIV and hepatitis C transmission, and to reduce the risk of overdose during imprisonment and after release.
Like all persons, prisoners are entitled to enjoy the highest attainable standard of health. This right is guaranteed under international law in Article 25 of the United Nations Universal Declaration of Human Rights and Article 12 of the International Covenant on Economic, Social, and Cultural Rights. The international community has generally accepted that prisoners retain all rights that are not taken away as a fact of incarceration, including the right to the highest attainable standard of physical and mental health. Loss of liberty alone is the punishment, not the deprivation of fundamental human rights. States therefore have an obligation to implement legislation, policies, and programmes consistent with international human rights norms and to ensure that prisoners are provided a standard of health care equivalent to that available in the outside community. (United Nations Office on Drugs and Crime, UNAIDS and WHO: HIV/AIDS prevention, care, treatment and support in prison settings: a framework for an effective national response (2006)
The need for access to treatment for opioid dependence in prison was internationally recognised almost thirty years ago. In 1993 WHO issued guidelines on HIV infection and AIDS in prisons, stating that “Drug-dependent prisoners should be encouraged to enrol in drug treatment programmes while in prison, with adequate protection of their confidentiality. Such programmes should include information on the treatment of drug dependency and on the risks associated with different methods of drug use. Prisoners on methadone maintenance prior to imprisonment should be able to continue this treatment while in prison. In countries in which methadone maintenance is available to opiate dependent individuals in the community, this treatment should also be available in prisons”.
THE ESSENTIALS AND IMPORTANT FIRST STEPS
Although individuals committed to particular parts of the prison service can do much, we strongly believe that a healthier prison for drug dependent prisoners can only be achieved if all staff are involved, including senior staff members who determine the ethos of the prison as a whole.
Changes should be introduced with continuity in mind. Although single-issue and often externally funded initiatives and pilot projects can achieve much, projects will be more effective in the longer term if the prison health system is based on the principles of a sustainable approach, if sound policies are in place based on explicit principles that lead to effective practice by well-supported and trained staff.
Sustainability can best be achieved if strong links are created between prison health care services and the health services of the local community and if they work in close cooperation. Such collaboration will help to prevent prisons from being used as default health care services. Many essential components are required to achieve a healthier prison for drug and especially opioid dependence, including political leadership, management leadership and leadership by each staff member. Health care staff members have a special role to play, but prisoners also have a role, and community support is very important.
Experience in several countries of Europe has drawn attention to the problems that often arise if prison health services are provided separately from the country’s public health services. These include difficulty in recruiting professional staff and inadequate continuing education and training. It is now strongly recommended that prison health services work closely with national health services and health ministries, so that the prisons can provide the same standard of care as local hospitals and communities. Indeed, as the WHO Moscow Declaration on Prison Health as a Part of Public Health acknowledged, the government ministry responsible for prison health should, where possible, be the ministry responsible for public health services (see also UNODC/WHO 2013: https://bit.ly/3erR1F8).
LEADERSHIP BY EACH MEMBER OF THE STAFF
A healthier prison for drug dependence cannot be created without the contribution of each member of its staff. Given the current health problems in prisons, staff members need to know and understand what the health problems are for drug/opioid users, how infections can spread, how they can be better controlled to decrease harm and how health and well-being can be promoted. Physicians, nurses and other professionals working in prisons have a unique leadership role in producing a healthier environment for drug dependent prisoners. They should start from a sound basis of professional training in which issues such as confidentiality, patient rights and human rights have been fully covered and discussed. They should also have some knowledge of epidemiology, of how diseases spread and of how lifestyles and socioeconomic background factors can influence ill health. They should also be aware of human nutrition and of the importance of exercise and fresh air in promoting health. They should be alert to potential threats to health and able to detect early signs of mental and physical health problems as co-morbidity is an often-related condition for drug/opioid dependence.
PARTNERSHIPS FOR HEALTH
One of the central pillars of health promotion is the concept of empowerment: the individual has to be able to make healthier choices and has to be allowed to do so. In health promotion in prisons, this approach is difficult to implement in prisons. It is therefore important that as much empowerment as possible be built into the prison regime.
One area that has been found to be important is providing health information to prisoners. Fact sheets should be made available for prisoners with drug dependence, explaining what the prison health service can provide and providing advice as to how the prisoner can best cope with such an illness while in prison. If written fact sheets will not be effective, because of language barriers or poor literacy, alternative ways of sharing information should be used, such as the use of videos and other visual aids or health discussion groups with a trained health worker. It is most important to encourage peer-based HIV prevention, education, counselling, and care initiatives. Increasing the role of prisoners in developing and providing health programmes and services increases the capacity of prisons to respond to HIV. The support to the development of peer-based education initiatives and educational materials designed and delivered by prisoners themselves is particularly crucial for populations with low literacy levels, where face-to-face educational interventions are critical. The development and support of self-help and peer-support groups that raise the issues of HIV, hepatitis C, TB etc. from the perspective of prisoners and drug users themselves should be encouraged.
Apart from availability of medication-assisted treatment a number of harm reduction measures should be available such as clean syringes and needles and equipment for disinfection especially to avoid spread of blood borne disease from piercing and tattooing. A system for tattooing by professional tattooist should be considered.
Regular contact with local community services and the involvement of voluntary agencies can assist greatly in promoting health and well-being in prisons as well in ensuring the continuity of care, both when entering prison and upon release from prison. Where possible, prisoners should be connected to key community services before leaving prison, such as probation or parole, social services and the provision by a doctor of ongoing opiate substitute prescribing. For previous drug dependent prisoners this can avoid overdose related deaths after release.