Lars Moller

The effectiveness of opioid maintenance treatment in prison settings: a systematic review.

AIMS To review evidence on the effectiveness of opioid maintenance treatment (OMT) in prison and post-release. METHODS Systematic review of experimental and observational studies of prisoners receiving OMT regarding treatment retention, opioid use, risk behaviours, human immunodeficiency virus (HIV)/hepatitis C virus (HCV) incidence, criminality, re-incarceration and mortality. We searched electronic research databases, specialist journals and the EMCDDA library for relevant studies until January 2011. Review conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Twenty-one studies were identified: six experimental and 15 observational. OMT was associated significantly with reduced heroin use, injecting and syringe-sharing in prison if doses were adequate. Pre-release OMT was associated significantly with increased treatment entry and retention after release if arrangements existed to continue treatment. For other outcomes, associations with pre-release OMT were weaker. Four of five studies found post-release reductions in heroin use. Evidence regarding crime and re-incarceration was equivocal. There was insufficient evidence concerning HIV/HCV incidence. There was limited evidence that pre-release OMT reduces post-release mortality. Disruption of OMT continuity, especially due to brief periods of imprisonment, was associated with very significant increases in HCV incidence. CONCLUSIONS Benefits of prison OMT are similar to those in community settings. OMT presents an opportunity to recruit problem opioid users into treatment, to reduce illicit opioid use and risk behaviours in prison and potentially minimize overdose risks on release. If liaison with community-based programmes exists, prison OMT facilitates continuity of treatment and longer-term benefits can be achieved. For prisoners in OMT before imprisonment, prison OMT provides treatment continuity.

Women in prison: The central issues of gender characteristics and trauma history

Insufficient attention is being paid to two key issues which are critical to a better understanding of what can be done to improve present services for women in prison. Firstly, the demographics, determinants and profiles of imprisoned women clearly show factors that should be central to any prison policy for women. Secondly, an analysis of the role of trauma history shows its strong influence on offending behaviour. Any modern approach to providing a more acceptable criminal justice policy for women must pay much greater attention to these two important issues.

The World Health Organization European Health in Prisons Project after 10 years: persistent barriers and achievements.

The recognition that good prison health is important to general public health has led 28 countries in the European Region of the World Health Organization (WHO) to join a WHO network dedicated to improving health within prisons. Within the 10 years since that time, vital actions have been taken and important policy documents have been produced. A key factor in making progress is breaking down the isolation of prison health services and bringing them into closer collaboration with the countrys public health services.However, barriers to progress remain. A continuing challenge is how best to move from policy recommendations to implementation, so that the networks fundamental aim of noticeable improvements in the health and care of prisoners is further achieved.

Imprisonment and women's health: concerns about gender sensitivity, human rights and public health

The health of prisoners is among the poorest of any population group and the apparent inequalities pose both a challenge and an opportunity for country health systems. The high rates of imprisonment in many countries, the resulting overcrowding, characteristics of prison populations and the disproportionate prevalence of health problems in prison should make prison health a matter of public health importance.Women prisoners constitute a minority within all prison systems and their special health needs are frequently neglected. The urgent need to review current services is clear from research, expert opinion and experience from countries worldwide. Current provision of health care to imprisoned women fails to meet their needs and is, in too many cases, far short of what is required by human rights and international recommendations. The evidence includes a lack of gender sensitivity in policies and practices in prisons, violations of womens human rights and failure to accept that imprisoned women have more and different health-care needs compared with male prisoners, often related to reproductive health issues, mental health problems, drug dependencies and histories of violence and abuse. Additional needs stem from their frequent status as a mother and usually the primary carer for her children.National governments, policy-makers and prison management need to address gender insensitivity and social injustice in prisons. There are immediate steps which could be taken to deal with public health neglect, abuses of human rights and failures in gender sensitivity.

Women's health in prison: urgent need for improvement in gender equity and social justice

The needs of women held in detention have received little attention and con-tinue to be neglected by health systems and prison authorities. One reason for this, too readily accepted until now, is that women prisoners are a clear minor-ity group within prisons all over the world. It is only recently that attention has been drawn to the fact that a minor-ity status does not justify the widespread ignorance of women’s basic rights and the considerable gender insensitivity still dominating criminal justice systems.In Europe alone, there are about 100 000 women and girls in prison.

Acute drug-related mortality of people recently released from prisons.

The rate of acute drug-related mortality, or overdose deaths, among prisoners in the immediate post-release period is unacceptably high. Such incidents result from many factors, including decreased tolerance after a period of relative abstinence during imprisonment and the concurrent use of multiple drugs which, with every additional illicit drug consumed in combination with opioids, nearly doubles the risk of death from opioids. Other important factors are the lack of pre-release counselling, post-release follow-up and failure to identify those at risk. Substance dependence is a chronic disorder with high relapse rates and often requires long-term continuous treatment. The deaths are preventable and a number of interventions including opioid substitution treatment reduces the risk of overdose among opioid users after release.

Women’s health in prisons: It is time to correct gender insensitivity and social injustice

Women form a minority group within the prisons of Europe. Prisons have been built and they are run with the needs of the majority of prisoners in mind, namely men. Evidence collected throughout Europe about womens health in prisons showed that the services provided in some countries failed to meet even basic needs of women and provided examples of considerable gender insentivity and failures to observe their human rights. Along with UNODC, a joint report was issued called the WHO/UNODC Declaration which presented the evidence and made recommendations for urgently required improvements.

Drug use in prisons in Kyrgyzstan: a study about the effect of health promotion among prisoners

In Kyrgyzstan the prevalence of injecting drug behaviour is among the highest found throughout the world. Health promotion training, improved health care and needle/syringe exchange (NSE) programmes have been shown to decrease risk behaviour among injecting drug users. In Kyrgyzstan, an intervention study with training of prison staff and prisoners was performed in one prison. Before and after the training, a random selection of the prisoners answered a questionnaire about drug use, risk behaviour and health care. The survey was carried out in both the intervention prison and in a reference prison. The number of drug users, the use of drugs and risk behaviour were improved significantly within half a year and, especially, the injection and use of drugs decreased in the intervention group. The study clearly shows that increased focus, improved healthcare and training of prisoners and staff on drug use and harm reduction can reduce both use of drugs and risk behaviour.

Health protection in prisons: the Madrid Recommendation

At an international conference held in October 2009 in Madrid, experts in harm reduction and in the control of communicable diseases generally and in prisons agreed the Madrid Recommendation. This paper outlines the recommendations for health protection in prisons and draws attention to its call for action.

Public health leadership, social justice and the socially marginalised

Arrogant Confident Visionary Poor communicator Good communicator Inspirational Stubborn Flexible Adaptable Indecisive Decisive Future focused Etc. According to Dilbert, ‘leadership is the art of trading imaginary things in the future for real things today’. Does this rather cynical comment apply to public health? A case of ‘Do this today for health for all in the future’? A recent paper asks the question, where is the future in public health? It points to a tension at the heart of ‘the public health enterprise’ in that it is engaged about the future while its methods for gathering evidence lock it into the present. We need public health research and practices that represent the interests of both tomorrow’s and today’s populations. We are on firmer ground as regards today’s population needs. There has been in fact a resurgence of public visibility for public health due to the reminder that infectious disease has not been conquered and the recognition that the health of populations is a function of good public health and socioeconomic conditions and not just the advances in medical technology. Health protection locally, nationally and globally remains a key feature of public health practice. It requires skills, experience and vigilance as well as a proactive public health approach. One study concluded that key factors in creating such a proactive organisation were a strong public health ethos and effective management and leadership skills. The first article in thisminisymposium relates to the discussion on a public health ethos. Here, we want to consider what is involved in effective public health leadership. One of us (AG) had two learning experiences early in his career. The first was from being involved in a pilot study that was carried out in Reading in Berkshire, England, by McKinsey as part of their advisory role for the 1974 reorganisation of the National Health Service (NHS). They pointed out that managers in the NHS tended to spend too much time on problems; as they put it, to sort out a problem simply got you back to where you should have been anyway. The skill in effective management was to look for opportunities and to make full use of them. Theotherwas talking toGeoffreyVickers at the timehewas drawing attention to his systems thinking and ‘appreciative