Heino Stöver

Drug use and opioid substitution treatment for prisoners

Drug use is prevalent throughout prison populations, and, despite advances in drug treatment programmes for inmates, access to and the quality of these programmes remain substantially poorer than those available for non-incarcerated drug users. Because prisoners may be at greater risk for some of the harms associated with drug use, they deserve therapeutic modalities and attitudes that are at least equal to those available for drug users outside prison. This article discusses drug use by inmates and its associated harms. In addition, this article provides a survey of studies conducted in prisons of opioid substitution therapy (OST), a clinically effective and cost-effective drug treatment strategy. The findings from this overview indicate why treatment efforts for drug users in prison are often poorer than those available for drug users in the non-prison community and demonstrate how the implementation of OST programmes benefits not only prisoners but also prison staff and the community at large. Finally, the article outlines strategies that have been found effective for implementing OST in prisons and offers suggestions for applying these strategies more broadly.

Substitution treatment for opioid addicts in Germany.

BackgroundAfter a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987. The number of patients in MMT – first low because of strict admission criteria – increased considerably since the 1990s up to some 65,000 at the end of 2006. In Germany each general practitioner (GP), who has completed an additional training in addiction medicine, is allowed to prescribe substitution drugs to opioid dependent patients. Currently 2,700 GPs prescribe substitution drugs. Psychosocial care should be made available to all MMT patients.ResultsThe results of research studies and practical experiences clearly indicate that patients benefit substantially from MMT with improvements in physical and psychological health. MMT proves successful in attaining high retention rates (65 % to 85 % in the first years, up to 50 % after more than seven years) and plays a major role in accessing and maintaining ongoing medical treatment for HIV and hepatitis. MMT is also seen as a vital factor in the process of social re-integration and it contributes to the reduction of drug related harms such as mortality and morbidity and to the prevention of infectious diseases. Some 10 % of MMT patients become drug-free in the long run. Methadone is the most commonly prescribed substitution medication in Germany, although buprenorphine is attaining rising importance. Access to MMT in rural areas is very patchy and still constitutes a problem. There are only few employment opportunities for patients participating in MMT, although regular employment is considered unanimously as a positive factor of treatment success. Substitution treatment in German prisons is heterogeneous in access and treatment modalities. Access is very patchy and the number of inmates in treatment is limited. Nevertheless, substitution treatment plays a substantial part in the health care system provided to drug users in Germany.ConclusionIn Germany, a history of substitution treatment spanning 20 years has meanwhile accumulated a wealth of experience, e.g. in the development of research on health care services, guidelines and the implementation of quality assurance measures. Implementing substitution treatment with concomitant effects and treatment elements such as drug history-taking, dosage setting, co-use of other psychoactive substances (alcohol, benzodiazepines, cocaine), management of difficult patient populations, and integration into the social environment has been arranged successfully. Also psychosocial counseling programmes adjuvant to substitution treatment have been established and, in the framework of a pilot project on heroin-based treatment, standardised manuals were developed. Research on allocating opioid users to the right form of therapy at the right point in time is still a challenge, though the pilot project heroin-based treatment brought experience with patients who do not benefit from methadone treatment. There is also expertise in the treatment of specific co-morbidity such as HIV/AIDS, hepatitis and psychiatric disorders. The promotion and involvement of self-help groups plays an important part in the process of successful substitution treatment.

Taking action to reduce injecting drug‐related harms in prisons: The evidence of effectiveness of prison needle exchange in six countries

This article examines the issue of prison needle‐exchange programmes (PNEP) based upon the international experience and evidence in six countries. A review of existing literature was undertaken together with original research comprising site visits to prison needle‐exchange programmes in four countries operating such initiatives in October 2002. During the course of the research, prison needle exchange programmes were initiated in two other countries, Kyrgyzstan and Belarus. Site visits were not possible in respect of these two countries, and data was gathered via conversations with staff and funding organisations involved and by the examination of documentary evidence. The paper presents an overview of the PNEP initiated and a commentry on the outcomes. Based upon the evidence emerging from the investigation, the paper concludes that while prison syringe‐exchange programmes have been implemented in diverse environments and under differing circumstances, the results of the programmes have been remarkably ...

The transfer of harm-reduction strategies into prisons: needle exchange programmes in two German prisons

In Autumn 1995, the Minister of Justice of Lower Saxony (a northern state of Germany) gave the green light for the implementation of a 2-year pilot project. This project provided for the distribution of sterile injection equipment and provision of communicative methods of prevention to drug addicted inmates in a womens prison with 170 inmates (Vechta) and a mens prison with 230 inmates (Lingen). The decision to go ahead with the project was based on positive experiences in Swiss prisons and the supporting recommendations of a panel of experts. The pilot project in Vechta started on 15 April 1996, using five dispensing machines which allow a needle exchange to guarantee an anonymous access. The project in the mens prison started on 15 July 1996. Here the staff of the drug counselling service and of the health care unit hand out sterile syringes to inmates. The social scientific evaluation was carried out by the Carl von Ossietzky University in Oldenburg. The study focused on the aim of the project which is to assess the feasibility, usefulness and efficacy of the measures undertaken. Of special interest was whether and how changes occured in the prison system itself (i.e. acceptance of the measures by staff, medical service and management), and in the drug users behaviour and knowledge (i.e. development of needle sharing, change in drug use patterns). The study used a multi-methodological approach: documentation of the project practice, half standardized, longitudinal examination of inmates (n=224) and staff (n=153), qualitative examination of management, selected groups of prisoners, staff and external organisations (AIDS-Help-Groups; n=75) for at least two times. The evaluation intended to be dynamic, process accompanying, in order to communicate the empirical data and developments with the practice already during the pilot phase. Results of the final report of the study are presented here. Finally this paper discusses shortly what is known so far about the impact of needle exchange programmes in prisons in Germany and Switzerland.

Substitution treatment in European prisons: A study of policies and practices in 18 European countries

The objective of this study was to examine practices and policies in place for the provision of substitution treatment in prison in 18 European countries. Methodology. Across the 15 European member states (prior to 1 May 2004) and Czech Republic, Poland and Slovenia, interviews with ministerial representatives, professionals (i.e. service providers and security officials) working in prisons, and a total of 33 focus groups with a total of 132 male and 52 female prisoners were conducted. Results. Although constraints of access to substitution treatment for specific target groups only (e.g. HIV‐positive opiate users) have largely vanished, substitution treatment is now offered to a broad cross‐section of prisoners. The provision of this treatment still lags behind the standards of substitution treatment in the community (regarding access and continuity). In most countries, this form of therapy is most likely to be discontinued when entering prison. A treatment gap persists between prisoners requiring substitution maintenance treatment and those receiving it. Heterogeneous and inconsistent regulations and treatment modalities appear throughout Europe, sometimes within the same country or region. The concrete provision practice of substitution treatment in prison varies from one country to the other, from one prison to the other, within a medical team, and evennfrom one doctor to another. Although psychosocial care was seen as a valuable additional and necessary part of the treatment to support the medical part of the substitution treatment in prison, it was found that such support was rarely provided. Compared to previous research, this study illustrates that the scope of substitution treatment has extended considerably across Europe. Across the board, a consensus surrounding the need to continue substitution treatment that had already been started in the community was apparent.

Substitution treatment and HCV/HIV‐infection in a sample of 31 German prisons for sentenced inmates

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners worldwide. However, little is known about the prevalence of IDUs, HCV/HIV and the availability of respective treatment options in German prisons. Data provided by prison physicians of 31 prisons, representing 14,537 inmates, were included in this analysis. The proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in three out of four prisons (74.2%). Overall, 1137 substitution treatments were provided annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and 1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment annually, 86.5% of all HIV-positive inmates in antiretroviral HIV-treatment. Generally, substitution treatment, and HCV and HIV testing and treatment are available. However, due to abstinence-orientated treatment aims, substitution treatment is rarely available as maintenance treatment, and HCV/HIV-treatment is mainly provided for patients with an existing treatment before imprisonment. The inconsistent data quality necessitates changes in prison-related policy to improve surveillance and to generate aggregated data in German prisons. The selection process in this analysis might lead to overestimating the provision of substitution and antiviral HCV-treatment.

SMOKE IT! Promoting a change of opiate consumption pattern - from injecting to inhaling

BackgroundIntravenous drug use has been predominantly practised since illegal heroin use became known in Germany in the early 1970s. The available data suggest that the risk of accidental overdose when smoking heroin is substantially reduced compared to injecting a substance of unknown purity and quality. Moreover, the risk of transmitting HIV, Hepatitis B or C via blood contact is considerably reduced when smoking heroin rather than when injecting it intravenously. In spite of the significant strain on the lungs and the respiratory tract caused by smoking, it can be concluded that inhalative use - measured by the indicators ‘overdose’ and ‘viral infections’ is considerably less dangerous than intravenous use. Despite these harm-reducing effects of inhalative use, there is only very limited scientific survey on this subject. The project ‘SMOKE IT!’ studied to what extent a change of the consumption method can be supported by making new equipment for drug use available.Method‘SMOKE IT!’ was carried out as a multi-centre survey in drug consumption rooms (DCRs) in five German cities. Participants received ‘SMOKE-IT!’ packs that contained new heroin smoking foils, as well as information about inhalative drug use. The quantitative data collection was aided by a written questionnaire filled out at three different stages in 2012.ResultsThe vast majority of the 165 respondents favoured using the foils from the ‘SMOKE-IT!’ packs (82.5%). The survey shows that two-thirds of the sample used the SMOKE-IT foils for inhaling instead of injecting. Almost six out of ten said that smoking was healthier than injecting. Thirty-five percent of the participants named the reduced risk of a hepatitis or HIV infection as a particularly important factor. A third of the respondents used the smoking foils to avoid the danger of an overdose.ConclusionsTargeted media and personal intervention in association with the dispensation of attractive drug use equipment can motivate opiate users to change their method of drug use. The main reason for inhalative use is that it is significantly less dangerous, measured by the indicators ‘overdose’ and ‘viral infections’. All drop-in centres should expand their syringe-exchange services to include the dispensation of smoking foils.

[Prison health is public health! Problems in adapting and implementing health services for prisoners in Germany. A review].

ZusammenfassungAuf Basis internationaler Standards orientiert sich die Gesundheitsversorgung Gefangener auch in Deutschland am „Äquivalenzprinzip“ (Gleichwertigkeit der medizinischen Versorgung innerhalb der Gefängnisse mit der im jeweiligen Land vorgehaltenen medizinischen Versorgung). Vor diesem Hintergrund werden anhand ausgewählter Gesundheitsprobleme nicht nur vereinzelte Angleichungs- und Umsetzungsprobleme in der Gesundheitsversorgung Gefangener verdeutlicht, sondern auch strukturelle Probleme benannt, die aus dem von der GKV entkoppelten Parallelsystem der gefängniseigenen „Gesundheitsfürsorge“ resultieren. Die vorliegende Übersichtsarbeit dient als Grundlage für Vorschläge zum Umdenken und zur Reorganisation der intramuralen Gesundheitsdienste.AbstractOn the basis of international standards, health care in German prisons has been oriented along the principle of equivalence (equity of health care delivery for inmates compared with the health care delivery in the community). Against this background, selected health problems demonstrate not only isolated problems in adaptation and implementation of health care delivery, but also structural problems resulting from the parallel system of prison health care, which is separated from the general German health care insurance system. This review serves as a basis to present suggestions to rethink and reorganize prison-based health care services.On the basis of international standards, health care in German prisons has been oriented along the principle of equivalence (equity of health care delivery for inmates compared with the health care delivery in the community). Against this background, selected health problems demonstrate not only isolated problems in adaptation and implementation of health care delivery, but also structural problems resulting from the parallel system of prison health care, which is separated from the general German health care insurance system. This review serves as a basis to present suggestions to rethink and reorganize prison-based health care services.

Praxis, Probleme und Perspektiven der Substitutionsbehandlung Opioidabhängiger in Deutschland

Opioid dependency is a complex and chronically relapsing disease with high risks of morbidity and mortality. Frequent relapses and in most of the cases a long process of maturing out characterize this disease. Opioid substitution programs with methadone, buprenorphine and other opioids are a suitable intervention and form the first choice in the treatment of this disease. In Germany, compared to its neighboring countries, this treatment was introduced relatively late. However, in the last five years, the number of patients in substitution treatment has increased significantly to more than 70,000 patients, which marks an increase of 50%, meaning that one third to one half of the estimated opiate users are being reached. Despite the widely acknowledged success with respect to the improvement of the quality of life, survival rates, and accessibility of the target groups for ongoing treatments of drug-related diseases (such as HIV/HCV infections), opioid substitution treatment is still discussed controversially. In this contribution, problems in the areas of service provision, juristic, social, health and research policies are discussed and possibilities of increasing the access and quality of this treatment are introduced.ZusammenfassungOpioidabhängigkeit ist eine komplexe, chronisch rezidivierende Erkrankung mit hohen Morbiditäts- und Mortalitätsrisiken, bei der häufige Rückfälle und ein in den meisten Fällen langer Prozess des Herauswachsens aus der Abhängigkeit das Krankheitsbild prägen. Die Substitutionsbehandlung mit Methadon, Buprenorphin und anderen Opioiden stellt ein probates Mittel der Behandlung Abhängiger dar: Sie ist heute die Methode der Wahl. In Deutschland ist diese Behandlungsform – verglichen mit den Nachbarländern – erst relativ spät eingeführt worden, allerdings mit erheblichen Steigerungsraten über die Jahre. Allein in den letzten 5 Jahren hat sich die Zahl der Patienten in Substitutionsbehandlung um 50% auf mehr als 70.000 erhöht. Damit wird etwa ein Drittel bis zur Hälfte aller angenommenen Opioidabhängigen erreicht. Trotz allgemein anerkannter Erfolge in Bezug auf die Steigerung der (Über-)Lebensqualität und die Erreichbarkeit der Zielgruppen für weitergehende Behandlungen drogenkonsumbedingter Erkrankungen (wie HIV/HCV-Behandlungen) wird diese Behandlungsform immer noch kontrovers diskutiert. Im vorliegenden Beitrag werden Probleme in den Bereichen Versorgungs-, Rechts-, Sozial-, Gesundheits- und Forschungspolitik analysiert und Möglichkeiten vorgestellt, um die Qualität und den Zugang zu dieser Behandlung zu verbessern.AbstractOpioid dependency is a complex and chronically relapsing disease with high risks of morbidity and mortality. Frequent relapses and in most of the cases a long process of maturing out characterize this disease. Opioid substitution programs with methadone, buprenorphine and other opioids are a suitable intervention and form the first choice in the treatment of this disease. In Germany, compared to its neighboring countries, this treatment was introduced relatively late. However, in the last five years, the number of patients in substitution treatment has increased significantly to more than 70,000 patients, which marks an increase of 50%, meaning that one third to one half of the estimated opiate users are being reached. Despite the widely acknowledged success with respect to the improvement of the quality of life, survival rates, and accessibility of the target groups for ongoing treatments of drug-related diseases (such as HIV/HCV infections), opioid substitution treatment is still discussed controversially. In this contribution, problems in the areas of service provision, juristic, social, health and research policies are discussed and possibilities of increasing the access and quality of this treatment are introduced.

Begleitende psychosoziale Unterstützung in der Substitutionsbehandlung

Substitutionstherapien fur Opiatabhangige sind gesundheitsstabilisierende und lebenserhaltende Behandlungsmoglichkeiten und bieten die Chance, den Betroffenen einen Weg aus dem Szeneleben zu eroffnen, sie sozial zu (re-)integrieren, psychisch und physisch zu stabilisieren und ihnen ein menschenwurdiges Leben zu ermoglichen (1). Jedoch befinden sich substituierte Menschen haufig, insbesondere in der Anfangsphase der Behandlung, in prekaren Lebenssituationen. Im Verlauf der individuellen Drogenkonsumgeschichte sind oftmals — meist in Folge der Substanzenillegalitat und damit verbunden der Kriminalisierung — die soziale und gesundheitliche Verelendung sowie vielfaltige psychosoziale Problemlagen weit vorangeschritten.