experiential account experience in the prison

Dr Sonali Jhanjee, Additional ProfessorNational Drug Dependence Treatment Centre,

AIIMS

National CME: OST , 19.04.15

Experiential account: Experience in the prison

Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Why should we think about OST in

Prison?


Why should we think about it?...

Strong connection between criminal activity and substance abuse.

Chaiken 1986; Inciardi 1979; Johnsonet al. 1985

Percentage of people with a drug problem in prison ranges from 40 to 80%

Dolan K,, Brentari, C, and Stevens A 2008

Problematic substance misuse is overrepresented in prison as compared to the community.


There are drugs in prison…

Prisons are ‘secure’ establishments

However drugs are available in prisons throughout the world.

Presence of drugs can be a difficult issue for prison authorities to officially acknowledge.


Prisoners experience drug problems before, during and after imprisonment…

Pure criminal justice interventions, without associated drug treatment: Have very limited impact on drug-using behaviour Between 70 and 98 % of those imprisoned for drug-related crimes

and not treated relapsed within the year following release re-offending

(WHO, Status Paper on Prisons,2005) The risk of a fatal overdose in the first few days following

release from prison: In a UK study of 51,590 releases from prison, approx 35% of all male

and 12% of all female drug related deaths are from prisoners recently released.

(Farrell & Marsden 2005) Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Prisons and prisoners are part of our community…

A large percentage of prisoners serve short prison terms of lessthan one year.

Prisoner health is community health- rapid turnover, sharing, unprotected sex, both inside prison and back in the community

A significant number of these will reoffend and return to prison, creating a “revolving door” between prison and the community.

Prison health challenges do not ‘stay behind bars’…


A unique opportunity

Unique opportunity for health promotion, intervention anddisease prevention providing access to ‘hard to reach’ groups.

In the absence of effective treatment -high proportion of drugdependent prisoners will continue using drugs and persist incrime.

Drug dependence treatment works…


Introduction

Criminal justice system

Drug abuse treatment system


Attitudinal barriers

Denial of drug abuse problem in prison Common perception that prisons should be drug-free zones Moral failing of individual vs chronic relapsing disorder Treatment programs often encounter opposition because they run counter to the established punishment/ control

culture in correctional settings OST undermines their efforts to reduce the drug supply in

their institutions (ie, a black market for drugs)


AIIMS-UNODC-TIHAR project


Background

UNODC-ROSA (funding agency)

Project: “Prevention of Spread of HIV amongst vulnerable groups in South Asia(RAS/H71)”

Component: Advocating for and Provision of Oral Substitution Treatment (OST) in Prisons of South Asia


Advocacy

Breaking Denial

Training &Sensitization

Peer networking &

peer led intervention-

involving Prison staff,

inmates, NGOs

Building partnerships-

prison officials, civil

society,prisoners

Breaking the “Us”

and “Them” Divide

Hand Holding for acceptance of a comprehensive

packageof services for HIV prevention


Study Intervention site (Tihar Prisons)

Delhi Prisons has two Prison Complexes Tihar one of the largest prison complex in the world comprising

of nine central prisons District Prison at Rohini Prison Complex

Houses 12000 prisoners against sanctioned capacity of 6250 prisoners

First intervention In a South Asian Prison


Objectives

To test the feasibility and effectiveness of buprenorphine asmedication for long term treatment for opioid dependence inTihar prisons

To develop a manual/ protocol of guidelines for implementingOST in prisons settings


Training


Agenda

Overview of OST (opioid substitution therapy) Minimum standards of practice and best practices in OST

delivery Safeguards overdose prevention and management prevention and minimization of diversion

Issues related to implementation in prison setting Participative group session Drafting road map for implementation of OST in Tihar prison


Human Resources and Training


Human Resources and TrainingExisting health structure and human resources of the Tiharprison was utilized for training. Doctors and nurses already working in prison were deputed

for the programme and trained in the delivery of OST. Existing lab personnel of Tihar were trained to carry out urine

screening for morphine. Counselors to deliver psychosocial interventions were trained

from NGOs working in Tihar prisons. Personnel from the prison administration were sensitized to

address organizational issues and provide administrativesupport for the programme.


Training

The trainings were provided by psychiatrists and faculty ofClinical chemistry from NDDTC, who had technical expertiseand wide experience in administration of OST in thecommunity setting in India.

The training was participatory and multi-modality and on-siteexposure to patients receiving Buprenorphine in thecommunity was provided.


Training


Agenda

Role definition Detailed pharmacology of Buprenorphine Demonstration of Psychosocial interventions to be carried out Clarification of dispensing to doctors/nurses and prison

managers Explanation about maintenance of stock registers to nurs Interaction with patients already receiving OST in Trilokpuri

community clinic


Training


Training

Formally inaugurated by hon,ble Mr. Tejendra Khanna, Lt. Governor, Delhi

Hands on practical training as and when required Weekly visits to Tihar jailPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Site of Implementation

The site of implementation was the de-addiction centerlocated in the premises of the Tihar Jail Complex of DelhiPrisons.

The deaddcition centre is a 120 bedded hospital. Prisoners onOST were housed exclusively in one ward of the hospital.

This was done with a view to make it easier for prisonadministration to coordinate and deliver OST services fromone single point


Service Delivery

Three common situations where it is appropriate to initiateusers on to opiate maintenance in the prison setting areimmediately upon admission to prison during the sentence a period of time before release.

In this study, opioid dependent prisoners were identified atthe initial medical examination upon admission into prisonsand eligible opioid dependent inmates from Tihar prisonswere offered pharmacotherapy with buprenorphine andpsychosocial intervention.


Intervention

OST (Buprenorphine)

• Intiate daily dispensing in prison

• Continue post release in community at• NDDTC, Ghaziabad, AIIMS• Community clinic, Trilokpuri,

AIIMS• Mobile clinic, Sundarnagari,

AIIMS• Psychiatry OPD, AIIMS

Psychosocial intervention

• Administered in group sessions and individual sessions

• By trained NGO’s operating at Tihar prison regarding• Goals of maintenance

treatment• Treatment compliance• Relapse prevention• Coping and problem solving

skills• High risk behavior• Motivation enhancement• Lifestyle changes• Rehabilitation


Methodology

Design • Pre-post design with assessments (on predetermined

parameters) at• Baseline• 3 months• 6 months• 9 months and• 12 months

Post release • On release, patients assigned a designated follow up centre

(closest to their residence) to continue OSTPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Inclusion criteria Age > 18 years Likely to stay in prison for one year ICD-10 diagnosis for Opioid dependence (as per self

report) at the time of incarceration (Preference would be given to those IDU’s who are HIV/ hepatitis B/

hepatitis C +ve) History of opioid dependence for ≥ 5 years Staying near or willing to follow up in a community centre Willing to participate voluntarily and provide informed

consent Priority given to patients already receiving OST in the

community upon imprisonment


Source: International Centre for Prison Studies, London, 2005

Countries Remand prisoners and/or pre-trial detainees as % of all prisoners

India 70

Bangladesh 60

Sri Lanka 48

Nepal 60

Maldives NAPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Daily Dispensing

Buprenorphine was given as daily Directly Observed Treatment(DOT) sublingually.

The medication was dispensed early in the morning tominimize disruption of their daily activities of the prisonersincluding legal visits and allotted work.


Baseline


Socio-Demographic Profile Age: 83% in 18-35 years age group 40% in 18-25 years 43% in 26-35 years Mean age of the sample 29.2 ± 8.1 yrs

Marital status: 71% were single 56.4% unmarried 14.3 % were either divorced or separated due to drug use

Sizeable number were illiterate (47.4%) followed by thosewho were literate / educated up to only the middle level (33%)

65%: either presently unemployed or never employed 38%: either living alone or with friends


Crime record

96%: pretrial remandees 93%: repeat offenders Mean no. of times arrested before this crime was (6±4)

Mean age at first imprisonment 20±6 years Majority (81%) NOT arrested under NDPS act 98%: committed offences to support their drug use


Drug use profile Mean age of initiation of primary drug is 18 +5 yrs In 37%, age of onset, before 15 years

The mean duration of regular use 10+7 yrs

70.5% were currently (1month prior to imprisonment) IDUs Sharing of syringe/needle: 85% Sharing of paraphrenalia: 67%


0

20

40

60

80

100

Ever usePrior to imprisonment

Drug use among prisoners

Most were poly drug users with heroin being the primary drug in 97%


At follow-up


Treatment outcome at time of release Median duration of stay in the prison: 81 days (minimum=2,

maximum=715, s.d. =152)

95.5% retention rate in prison 100 % compliance among those retained in prison

3 months 6 months 9 months 12 months

Mean dose of Buprenorphine(in mg)

5.1± 2.4 4.8± 2.1 3.8 ±1.1 3.3± 1.4


Drug use 3 prisoners reported IDU at follow up Majority reported not using any illicit drugs on follow up 4% reported heroin use 5% reported Cannabis use

Objectively confirmed by urine screening 47% continued use of tobacco within prison setting although

not on a daily basis

Marked decline in drug use


Lab parameters: urine screening

•6% of sample tested positive at 3 months•None tested positive at 6, 9 and 12 months follow-up

N=133Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

7.7

1.30.8 0.9

0.00123456789

at Beginning 3 months 6 months 9 months 12 months

A significant decrease (F=39.94,df=4,p<.001) in severity of dependence of drug use was reported over time

Mean score of severity of dependence of the inmates over time


Withdrawal symptoms

Mean Subjective Opioid Withdrawal Scale score (SOWS)

Mean Objective Opioid Withdrawal Scale score(OOWS)

38.3

8.53.1 0.3 1.4

05

1015202530354045

A highly significant decrease(F=182.19, df=4, p<.001) was observed over time 5.0

2.2

0.61.2

0.00

1

2

3

4

5

6

Baseline 3months

6months

9months

12months

A highly significant decrease(F=22.97, df=4, p<.001) was observed over time


7.5

0.80.6

0.0 0.00.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Baseline 3 months 6 months 9 months 12 months

A highly significant decrease (F=121.73, df=4, p<.001) was observed over time.

Mean visual analog (VAS) score for craving


Side effects

OST with buprenorphine demonstrated to be safe No major adverse events reported during implementation

Buprenorphine well tolerated Minor side effects like headaches, light headedness,

drowsiness and weakness reported at 3 months and wereminimal at 6 months followup


Diversion

Diversion noted at the initial stages of the project No diversion reported in the past year

To prevent diversion Medications dispensed in small batches of 3-5 prisoners Supervision by doctors, nurse with one staff from the jail

administration Tablets were crushed before dispensing


Safe keeping of Buprenorphine

Safe keeping of Buprenorphine was ensured and bulk stock ofmedication was stored in the head office of the prison and astock of few days medication was maintained at the site ofdispensing.

Mechanisms were put in place to ensure that the supply chainof buprenorphine is well maintained.


Monitoring of provision

Intensive mentoring inputs were provided from the technicalexperts from NDDTC during this period who made weekly sitevisits to hand hold the provision of OST and monitor thedifficulties encountered/solve operational problems during thefirst 6-8 months.

Once mechanisms of delivery were established, these visitswere made fortnightly and later monthly.

Further, telephonic contact with technical agency was alwaysmade available


Pre-release planning

It is well known that the continuity of treatment for prisoners as they re-enter the community is of critical importance to prevent death by overdose and reduce relapse to heroin use,

community linkages were secured at the start of the study.

On release the prisoner was provided with referral slips for follow up to the appropriate community centre indicating that the date of commencement of opioid substitution therapy and current dose of Buprenorphine.


Pre-release planning

Midway through the project, it was realized that a two daystake away dose of the buprenorphine naloxone combinationon release from prison may be provided to the prisoners upontheir release to offset the risk of relapse.

This allowed the released prisoner some time to locate hisfollow up center in the community and also provided cover forholidays.


Qualitative data- Staff

Initial 3 months of the program were very difficult due to coordination problems both the staff and patient.

Perceived increased workload was causing difficulties.

It took an initial 3months for all of them to comfortable with each other and all procedures to fall in place

Duties of staff adjusted to accommodate increased responsibility

Rapport with patients is much better, they respect the staff members and listen to what they have to say.

“Insaan ban gaye”Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Changes noted in patients behaviour Marked improvement in personal hygiene

Take a bath, shave ,wash clothes

Marked improvement in irritability and disciplinary problems

Are amenable to counselling

More responsible Do the work alloted to them

Look after new OST prisoners

Listen to what the staff members are saying

EAT!A positive change in behavior reported by jail authorities.


Patients

Subjective report of patients being relieved, comfortable reporting no craving, withdrawl or irritability.

They can finally focus on other issues.

First ray of hope that treatment is possible.

Satisfied with treatment and attitude of staff

Were satisfied with the dosage of drug provided.


Issues and challenges

A major challenge in the implementation of this project wasthe unpredictable duration of stay (mostly short) andunplanned release of these inmates as overwhelming majoritywas pretrial remand prisoners and not convicts.

The available time for therapeutic intervention was oftenshort.

Therefore the designated follow up community center wascommunicated to the inmate at the time at the time ofinduction itself and a referral slip to the community center wasprovided on discharge.


Refresher trainings It was also realized that maintaining a trained workforce in

prison may require continuous effort as rotation of staff was a norm.

Provision of periodic refresher trainings were required which besides training new personnel, incorporated a review of internal coordinating mechanisms between health personnel, counselors and prison administration staff to ensure smooth delivery of OST intervention.

Provision of these trainings also helped to maintain momentum of OST intervention program and helped to keep the team motivated.

Periodic refresher trainings were found to be an important component of the overall programme.


Post release A further observation of the project was that despite having

successful in prison outcomes, there was high rate of attrition post release even though community linkages were secured.

This may imply that to prevent relapse into crime and drug use people additionally need adequate support with overall social integration(Mourino,1994)..

There was a strong expressed need for rehabilitation both in prison and on release by prisoners. Thus mechanisms of strengthening the post release arm of treatment needs to be explored and formulated.


High Rate of attrition post release

Although facilitated entry in treatment but retention rates were low Reasons

Transportation charges/financial/unemployment Follow up centres very far Peer pressure Involvement in criminal activities Lack of family support/family wants patient to continue criminal

activities as source of income/family involved in drug peddling/ Lack of residence Trilokpuri centre near police station


What did we achieve in the prisons? Demonstrated that the intervention if feasible Achievements in jail

• Abstinence from illicit drugs as confirmed by periodic urine screening• Decrease in craving and withdrawl of drugs• No drug seeking behaviour• Decreased high risk behaviour• Retention in treatment in prison• Positive changes in institutional behaviour including increased

productivity• Information, education and communication on HIV and related risk

behaviours• First exposure to maintainence treatment • Counseling regarding nature of OST and relapse prevention counselingCoordination of prison health staff and administration essential


Conclusion

This collaborative project was implemented in Tihar prisonsfrom 2008-12.

Overall, this project was a significant regional advance as itdemonstrated that it is feasible to implement OST in prisonsand support from both, prison administration and healthservices is critical to implement this programme.

This project has also helped to develop the StandardOperating Procedures to be followed for OST within prisonsettings.

The effectiveness of OST was demonstrated in prison settingsand this OST model was also “presented” (through study visits)to Government counterparts from other countries of SouthAsia.


Where do we go from here?

Scale up nationally and

regionally

SOP laid down for

implementation

Develop models of community

linkages


Future directions• Acknowledge problem in national policies• Assess extent of the problem• Implement comprehensive and standardized screening and

assessment process• Match inmates to appropriate treatment programs based on

their individual needs and severity of substance abuse• Develop policies and procedures for providing clinical

supervision to treatment and evaluation• Develop models of community integration

Do we need to send them to Prison at all???


Acknowledgements Mr. B.K Gupta (ex- DG prison) Mr. Neeraj kumar (DG prison) Dr. Girdhar, RMO Tihar prisons Project team at NDDTC AIIMS UNODC-ROSA


Needle and Syringe Programmes (NSP) Opioid Substitution Therapy (OST) Voluntary HIV Counselling and Testing (VCT) Anti-Retroviral Therapy (ART) Sexually Transmitted Infections (STI) prevention Condom programming for IDUs and partners Targeted Information, Education and Communication

(IEC) for IDUs and their sexual partners Hepatitis diagnosis, treatment (Hepatitis A, B and C) and

vaccination (Hepatitis A and B) Tuberculosis (TB) prevention, diagnosis and treatment.


THE NARCOTIC DRUGS AND PSYCHOTROPICSUBSTANCES (NDPS) ACT,1985-

Under section 64 A, any addict, who is charged with an offence punishable under section 27 or with offences involving small quantity of narcotic drugs or psychotropic substances, who voluntarily seeks to undergo medical treatment for de-addiction from a hospital or an institution maintained or recognized by the Government or a local authority and undergoes such treatment shall not be liable to prosecution under section 27 or any other section for offences involving small quantity of narcotic drugs and psychotropic substances. This immunity may be withdrawn if the addict does not undergo the complete treatment for deaddiction.


THE NARCOTIC DRUGS AND PSYCHOTROPICSUBSTANCES (NDPS) ACT,1985-

. Section 71 of this act, empowers government to establish centers for identification, treatment, education, after care, rehabilitation, social reintegration of addicts and for supply, of any narcotic drugs and psychotropic substance (as prescribed by concerned Government) to the addicts registered with government and to others where such supply is a medical necessity


N A T I O N A L P O L I C Y O N NA R C O T I C D R U G S A N D P S Y C H O T R O PI C S U B S T A N C E S The primary purpose of these [drug court] programs is

to use a court's authority to reduce crime by changing defendants’ substance abuse behavior. In exchange for the possibility of dismissed charges or reduced sentences, eligible defendants who agree to participate are diverted to drug court programs in various ways and at various stages in the judicial process. These programs are typically offered to defendants as an alternative to probation or short-term incarceration." - See more at: http://www.drugwarfacts.org/cms/Drug_Courts#overview


experiential account experience in the prison

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