Drug treatment and rehabilitation in prison settings




  • A. H. Berman, U. Lundberg, A. L. Krook & C. Gyllenhammar (2004)  Treating drug using prison inmates with auricular acupuncture: a randomized controlled trial. Journal of Substance Abuse Treatment , Volume (Issue): 26(2) pp. 95-102. 


This study tested the viability of auricular acupuncture in prisons for alleviating inmates' symptoms of psychological and physical discomfort and reducing their drug use. The experimental NADA-Acudetox protocol was compared with a non-specific helix control protocol in a randomised trial. Over a period of 18 months, a 4-week, 14-session auricular acupuncture treatment programme was offered in two prisons to 163 men and women with self-reported drug use. Among treatment completers, no differences by method were found in self-reported symptoms of discomfort. Drug use occurred in the NADA group but not in the helix group. In contrast, confidence in the NADA treatment increased over time while it decreased for the helix treatment. No significant negative side effects were observed for either method. Participants in both groups reported reduced symptoms of discomfort and improved nighttime sleep. Future research should compare auricular acupuncture to a non-invasive control in order to attempt to disentangle active effects from placebo.


  • Belenko, Steven; Peugh, Jordon (2005) Estimating drug treatment needs among state prison inmates. Drug And Alcohol Dependence, Volume 77, Issue 3 , March 7, 2005, Pages 269-281.


Growing prison populations in the U.S. are largely due to drug-related crime and drug abuse. Yet, relatively few inmates receive treatment, existing interventions tend to be short-term or non-clinical, and better methods are needed to match drug-involved inmates to level of care. Using data from the 1997 Survey of Inmates in State Correctional Facilities, a nationally representative sample of 14,285 inmates from 275 state prisons, we present a framework for estimating their levels of treatment need. The framework is drawn partly from the American Society of Addiction Medicine Patient Placement Criteria and other client matching protocols, incorporating drug use severity, drug-related behavioral consequences, and other social and health problems. The results indicate high levels of drug involvement, but considerable variation in severity/recency of use and health and social consequences. We estimate that one-third of male and half of female inmates need residential treatment, but that half of male and one-third of female inmates may need no treatment or short-term interventions. Treatment capacity in state prisons is quite inadequate relative to need, and improvements in assessment, treatment matching, and inmate incentives are needed to conserve scarce treatment resources and facilitate inmate access to different levels of care.


  • B. Pelissier, S. Wallace, J. A. O'Neil, G. G. Gaes, S. Camp, W. Rhodes & W. Saylor, (2001) Federal prison residential drug treatment reduces substance use and arrests after release. American Journal of Drug and Alcohol Abuse, Volume (Issue):  27(2) pp. 315-337.


The effectiveness of federal prison-based residential drug and alcohol treatment programmes was evaluated using event history procedures that addressed the problem of selection bias and included a wide range of control variables. The sample comprised 760 treatment subjects and 809 comparison subjects. Treatment subjects were from 20 different prisons of medium, low, and minimum security levels. Comparison subjects were drawn from over 30 prisons. The results indicated that individuals who entered and completed in-prison residential treatment were less likely to experience the critical post release outcomes of new arrests and substance use during the first six months following release. Without controlling for selection bias, the effects of treatment would most likely have been attenuated. The results have greater generalisability than other studies of prison-based treatment. This study occurred with a multisite context of 20 programmes servicing both male and female inmates and operating within different security levels and different geographic regions. 


  • Brown, Barry S; O'Grady, Kevin E; Battjes, Robert J; Katz, Elizabeth C. (2004) The Community Assessment Inventory--client views of supports to drug abuse treatment. Journal Of Substance Abuse Treatment, Volume 27, Issue 3 , October, Pages 241-251


A measure assessing client views of the community supports available to them was developed and tested with entrants to outpatient drug free treatment. Items for a Community Assessment Inventory (CAI) fell into four areas of potential social support for treatment entry and engagement: (1) partner and/or family with whom living; (2) family living outside the home; (3) friends; and (4) the community itself. Based on 241 study participants, it was found that internal consistency alphas for the four scales ranged between .79 and .88. Both total CAI score and individual scales assessing support from friends and from partner/spouse were found capable of predicting treatment readiness as assessed using the TCU Motivation Scale. Evidence of construct validity was suggested by differences in CAI total score between participants reporting and not reporting involvement in discussions with others regarding crime and regarding drugs. Findings are also provided regarding leisure time activities and social relations of treatment entrants.


  • C. Chanhatasilpa, D. L. MacKenzie & L. J. Hickman (2000) The effectiveness of community-based programs for chemically dependent offenders: a review and assessment of the research. Journal of Substance Abuse Treatment,  Volume (Issue):  19(4) pp. 383-393.


An assessment of 15 community-based outpatient treatment programmes for chemically dependent adult offenders was undertaken using the format of the University of Maryland's 1997 report to the US Congress. The review finds less optimism about the effectiveness of this type of drug treatment than previous reviews. The assessment of these studies indicated that programmes that increase the supervision, monitoring, or control over offenders in the community are not effective in reducing recidivism. There is insufficient evidence to determine whether outpatient treatment alone, specific components of the treatment (such as acupuncture), or aspects of the treatment (intensity) are effective in reducing criminal activity. Outpatient treatment designed as aftercare to prison-based therapeutic communities (TCs) is shown to be effective. However, it is unclear whether this is the effect of the TC, the length of treatment, or the combination of the TC and the aftercare. 


  • C. Howells, S. Allen, J. Gupta, G. Stillwell, J. Marsden & M. Farrell (2002) Prison based detoxification for opioid dependence: a randomised double blind controlled trial of lofexidine and methadone.  Drug and Alcohol Dependence, Volume (Issue):  67(2) pp. 169-176.


This paper reports results from the first controlled trial of opioid withdrawal treatment in the UK using lofexidine in a prison setting. Seventy-four opioid dependent male inmates at a Southern England prison were randomised to receive either methadone (the standard prison treatment) or lofexidine using a randomised double-blind design. No significant statistical difference between the treatment groups was found in relation to the primary variable of severity of withdrawal symptoms (effect size = 0.12). No discernible difference was found in the sitting blood pressure or heart rate of the two groups during the trial. These results provide support for the use of lofexidine for the management of opioid detoxification in the prison setting. 


  • D. Farabee, M. Prendergast & J. Cartier (2002) Methamphetamine use and HIV risk among substance-abusing offenders in California. Journal of Psychoactive Drugs, Volume (Issue): 34(3) pp. 295-300.


Recent epidemiological surveys of illicit substance use show a particularly high prevalence of methamphetamine use in the western and south-western United States-most notably California. Moreover, in their analysis of 1995 Drug Use Forecasting data, Anglin and colleagues (1998) found that methamphetamine was a preferred substance among California arrestees. The present study uses data from 807 state prison inmates in California (32% of whom reported using methamphetamine prior to incarceration) to examine the associations between methamphetamine use and HIV risk behaviours. Methamphetamine users in this sample were significantly more likely than nonusers to have injected drugs during the six months prior to their current incarceration. Among injectors, however, injection-related risks (such as dirty needles and needle sharing, etc) were not significantly associated with methamphetamine use. However, past six-month sex-related risks were dramatically higher for methamphetamine users. These patterns persisted even after controlling for background differences between the two groups. The results of this study underscore the importance of addressing the higher sex-related HIV/AIDS risk among methamphetamine users undergoing prison-based drug treatment. 


  • D. Brooke, C. Taylor, J. Gunn & A. Maden (1998 ). Substance misusers remanded to prison - a treatment opportunity? Addiction, Volume (Issue): 93(1) pp. 12-13 


The aim of this study was to describe self-reported levels of substance misuse before arrest among remanded prisoners (unconvicted prisoners awaiting trial), to assess their degree of dependency on opiates and stimulants and to record their experiences of treatment in prison. The study design was random selection of subjects from prisons chosen to give a geographical spread across England and Wales; self-report at semi-structured interview, plus examination of the prison medical record. The settings were 13 male prisons, three Young Offenders' Institutions and three women's' prisons. Participants were 995 consenting, unconvicted prisoners, randomly selected from all locations within the prisons: 750 men (9.4 percent sample) and 245 women (82.2 percent of all remanded women). The CAGE Questionnaire, Severity of Dependence Scales (SDS) for daily users of opiates and/or stimulants were used as measurements. Before arrest, 145 (19.3 percent) men and 72 (29.4 percent) women had been dependent on street drugs; 91 (12.1 percent) men and 16 (6.5 percent) women were solely dependent on alcohol. Seventeen (2.3 percent) men and four (1.6 percent) women reported injecting drugs during this imprisonment. Mean SDS scores were 10.6 for opiate and 7.7 for stimulant users. Two hundred and forty-four (25 percent) of all subjects described withdrawal symptoms on reception into custody; 157 (16 percent) reported being prescribed some symptomatic relief; 235 (24 percent) requested treatment at interview. By extrapolation, 1,905 people - 23 percent of all unconvicted prisoners - want treatment for substance misuse. This apparent shortfall in provision must be addressed; the rapidity with which remanded prisoners return to the community dictates that prison and community services should be closely linked.


  • D. Mason, L. Birmingham & D. Grubin (1997) Substance use in remand prisoners: a consecutive case study. British Medical Journal, Volume (Issue):  315(7099) pp. 18-21.


The study looks at the prevalence of drug and alcohol use among newly remanded prisoners, assesses the effectiveness of prison reception screening, and examines the clinical management of substance misusers among remand prisoners. A consecutive case study of remand prisoners screened at reception for substance misuse and treatment needs and comparison of findings with those of prison reception screening and treatment provision. Subjects were 548 men aged 21 and over awaiting trial. Before remand 312 (57 percent) men were using illicit drugs and 181 (33 percent) met DSM-IV drug misuse or dependence criteria; 177 (32 percent) men met misuse or dependence criteria for alcohol. Some 391 (71 percent) men were judged to require help directed at their drug or alcohol use and 197 (36 percent) were judged to require a detoxification programme. The prison reception screen identified recent illicit drug use in 131 (24 percent) of 536 men and problem drinking in 103 (19 percent). Drug use was more likely to be identified by prison screening if an inmate was using multiple substances, using opiates, or had a diagnosis of abuse or dependence. Forty-seven (nine percent) of 536 inmates were prescribed treatment to ease the symptoms of substance withdrawal. The prevalence of substance misuse in newly remanded prisoners is high. Prison reception health screening consistently underestimates drug and alcohol use. In many cases in which substance use is identified the quantities and numbers of different substances being used are underestimated. Initial management of inmates indentified by prison screening as having problems with dependence producing substances is poor. Few receive a detoxification programme, so that many are left with the option of continuing to use drugs in prison or facing untreated withdrawal. 


  • E. Odegard & A. Amundsen (1998). About the effects of treatment provided for convicted drug addicts.(in Norwegian). Nordisk Alkohol & Narkotikatidskrift, Volume (Issue):  15(1)  pp. 21-33.


Section 12 of the Norwegian Prisons Act provides for convicted persons to be transferred to a treatment institution as part of the serving of their sentence. In recent years with a growing drugs problem this provision of section 12 of the Prisons Act has been applied to an even greater extent in the case of inmates with a drug abuse problem. One purpose of transferring inmates to a treatment institution has been to prevent recidivism. The aim of this study was to analyse the effect of serving under section 12 with respect to criminal relapse. The authors find no preventive effect from serving under section 12 with respect to recidivism.


  • G. M. Schippers, A. A. van den Hurk, M. H. M. Breteler & G.-J. Meerkerk (1998)  Effectiveness of a drug-free detention treatment program in a Dutch prisonSubstance Use & Misuse, Volume (Issue):  33(4) pp. 1027-1046.


Several Dutch penitentiaries, which have relatively severe drug-use related problems, experimented with drug-free detention treatment programmes (DVA). These programmes aim at controlling drug use by offering a therapeutic atmosphere and serve as linkage to detention post-treatment. In a Rotterdam jail (335 cells), ca. 10 percent were the DVA. Information was gathered from 86 male inmates who volunteered to enter the programme and 42 from other wings. After one year the drug-free detention group more actively searched and accepted treatment. No differences were found in drug use, recidivism or physical, social and psychological problems. 


  • H. Stöver & J. Nelles (2003) Ten years of experience with needle and syringe exchange programmes in European prisons.   International Journal of Drug Policy, Volume (Issue):  14(5-6) pp. 437-444.


Results of needle and syringe exchange programmes (SEPs) in prisons based on 10 years experience in Switzerland, Germany, Spain and Moldova are presented. SEPs have been introduced in 46 European prisons, predominantly as pilot projects. Forty-three of these projects were still operating at the time of writing. In 11 prisons, SEPs were evaluated to assess feasibility and efficacy. Results did not support fears that commonly arise in the start-up of implementation of SEPs. Syringe distribution was not followed by an increase in drug use or injection drug use. Syringes were not misused, and disposal of used syringes was uncomplicated. Sharing of syringes among drug users reduced. Based on these experiences, it can be concluded that in these settings harm reduction measures, including syringe exchange, were not only feasible but efficient. Despite these positive results, syringe exchange in prison is far from general acceptance. However, a governmental decree released in Spain in 2001 that all prisons in the country are required to provide drug users with sterile injection equipment may lead to a breakthrough of this harm reduction measure in the future. The discrepancy concerning the success of SEPs in prisons on the one hand and its low acceptance on the other hand is striking. Suggestings for the installation of SEPs in prison are given to assist a more objective discussion.


  • J. A. Inciardi, S. S. Martin, C. A. Butzin, R. M. Hooper & L. D. Harrison  (1997) An effective model of prison-based treatment for drug-involved offenders. Journal of Drug Issues,   Volume (Issue):  27(2) pp. 261-278.


A multistage therapeutic community treatment system has been instituted in the Delaware correctional system and its effectiveness has captured the attention of the National Institutes of Health, the Department of Justice, members of Congress and the White House. Treatment occurs in a three-stage system, with each phase corresponding to the client's changing correctional status - incarceration, work release and parole. In this paper, 18 month follow-up data are analysed for those who received treatment in: (1) a prison-based therapeutic community only; (2) a work release therapeutic community followed by aftercare; and (3) the prison-based therapeutic community followed by the work release therapeutic community and aftercare. These groups are compared with a no-treatment group. Those receiving treatment in the two-stage (work release and aftercare) and three-stage (prison, work release and aftercare) models had significantly lower rates of drug relapse and criminal recidivism, even when adjusted for other risk factors. The results support the effectiveness of a multistage therapeutic community model for drug-involved offenders and the importance of a work release transitional therapeutic community as a component of this model. 


  • J. Keen, G. Rowse, N. Mathers, M. Campbell & N. Seivewright (2000) Can methadone maintenance for heroin-dependent patients retained in general practice reduce criminal conviction rates and time spent in prison ?   British Journal of General Practice, Volume (Issue):  50(4) pp. 48-49.


A retrospective analysis was made of criminal records of 57 patients successfully retained in methadone maintenance at two general practices in Sheffield. Their criminal conviction rates and time spent in prison per year were compared for the periods before and after the start of their methadone programme. Overall, patients retained on methadone programmes in the general practices studied had significantly fewer convictions and cautions, and spent significantly less time in prison than they had before the start of the treatment. 


  • J. A. Inciardi, S. S. Martin, C. A. Butzin, R. M. Hooper & L. D. Harrison  (1997) An effective model of prison-based treatment for drug-involved offendersJournal of Drug Issues,  Volume (Issue):  27(2) pp. 261-278.


A multistage therapeutic community treatment system has been instituted in the Delaware correctional system and its effectiveness has captured the attention of the National Institutes of Health, the Department of Justice, members of Congress and the White House. Treatment occurs in a three-stage system, with each phase corresponding to the client's changing correctional status - incarceration, work release and parole. In this paper, 18 month follow-up data are analysed for those who received treatment in: (1) a prison-based therapeutic community only; (2) a work release therapeutic community followed by aftercare; and (3) the prison-based therapeutic community followed by the work release therapeutic community and aftercare. These groups are compared with a no-treatment group. Those receiving treatment in the two-stage (work release and aftercare) and three-stage (prison, work release and aftercare) models had significantly lower rates of drug relapse and criminal recidivism, even when adjusted for other risk factors. The results support the effectiveness of a multistage therapeutic community model for drug-involved offenders and the importance of a work release transitional therapeutic community as a component of this model.


  • K. A. Dolan, J. Shearer, M. MacDonald, R. P. Mattick, W. Hall & A. D. Wodak(2003) A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug and Alcohol Dependence, Volume (Issue): 72(1) pp. 59-65.


The aim was to determine whether methadone maintenance treatment reduced heroin use, syringe sharing and HIV or hepatitis C incidence among prisoners. All eligible prisoners seeking drug treatment were randomised to methadone or a wait list control group from 1997 to 1998 and followed up after 4 months. Heroin use was measured by hair analysis and self-report; drugs used and injected and syringe sharing were measured by self-report. Hepatitis C and HIV incidence was measured by serology. Of 593 eligible prisoners, 382 (64%) were randomised to MMT (n = 191) or control (n = 191), 129 treated and 124 control subjects were followed up at 5 months. Heroin use was significantly lower among treated than control subjects at follow up. Treated subjects reported lower levels of drug injection and syringe sharing at follow up. There was no difference in HIV or hepatitis C incidence. Consideration should be given to the introduction of prison methadone programmes particular where community based programmes exist. 


  • K. Dolan, S. Rutter & A. D. Wodak  (2003)  Prison-based syringe exchange programmes: a review of international research and development. Addiction, Volume (Issue):  98(2) pp. 153-158.


Journal publications and conference presentations on prison-based syringe exchange (PSE) programmes were identified by a comprehensive search of electronic databases. Experts involved with development and evaluation of current PSE programmes or policy were contacted for reports, documents and unpublished material. Spanish information on PSE was translated for this review. The first PSE programme started in 1992 in Switzerland. As of December 2000, seven PSEs were operating in Switzerland, seven in Germany and give in Spain. There have been six evaluations of prison syringe exchange programmes and all have been favourable. Reports of drug use decreased or remained stable over time. Reports of syringe sharing declined dramatically. No new cases of HIV, hepatitis B or hepatitis C transmission were reported. The evaluations found no reports of serious unintended negative events, such as initiation of injection or of the use of needles as weapons. Staff attitudes were generally positive but response rates to these surveys varied. Overall, this review indicated that prison syringe exchange programmes are feasible and do provide benefit in the reduction of risk behaviour and the transmission of blood-borne infection without any unintended negative consequences.


  • k. A. Dolan, A. D. Wodak & W. D. Hall  (1998) Methadone maintenance treatment reduces heroin injection in New South Wales prisonsDrug and Alcohol Review,  Volume (Issue):  17(2) pp. 153-158.


The purpose of this study was to examine whether methadone maintenance treatment reduces injecting risk behaviour (and therefore transmission of blood-borne viral infections) among prisoners in New South Wales (NSW), using comparison of retrospective reports of drug use in prisons for people who received standard drug treatment, time-limited methadone treatment and methadone maintenance treatment. The setting for the study was the NSW prison system. One hundred and eighty-five injecting drug users who had been recently released from NSW prisons were recruited in 1993. Self-reported drug use and injecting risk behaviour were compared in inmates who received standard drug treatment (counselling), time-limited methadone treatment and methadone maintenance treatment. HIV status was determined by serology. Intervention comprised high and low dose methadone treatment and counselling. The groups were similar in terms of most basic demographic characteristics but subjects who had been maintained on methadone reported a significantly lower prevalence of heroin injection, syringe sharing and scored lower on an HIV Risk-taking Behavioural Scale than subjects who received standard drug treatment and time-limited methadone treatment. This study suggests that methadone treatment is associated with reduced injecting risk behaviour in prison with adequate (greater than 60 mg) dose and duration in treatment. These treatment conditions are known to increase effectiveness in community-based methadone programmes. Prospective studies are required to evaluate the effectiveness of methadone programmes in the prevention of HIV and other blood-borne viral infections among IDU prisoners. 


  • K. Stark, R. M ller, U. Bienzle & I. Guggenmoos-Holzmann (1996) Methadone maintenance treatment and HIV risk-taking behaviour among injecting drug users in Berlin. Journal of Epidemiology and Community Health, Volume (Issue): 50(5) pp. 534-537.


The study objective was to determine whether methadone maintenance treatment (MMT) is effective in reducing the levels of HIV risk-taking behaviour (borrowing and lending of injection equipment, irregular condom use) among injecting drug users (IDUs) and to identify independent predictors of the borrowing of used syringes. The 612 IDUs were recruited at different services for drug users such as treatment centres, walk in agencies, a hospital and on the streets. Of all IDUs, 41 percent had borrowed and 34 percent had passed on used injection equipment in the previous six months. In univariate analysis, IDUs receiving MMT had injected less frequently and were significantly less likely to borrow and lend syringes. In logistic regression analysis, MMT was protective against the borrowing of syringes (adjusted odds ratio 0.36, 95 percent confidence interval 0.2, 0.8), but not against syringe lending nor against sexual risk behaviour (i.e. numbers of sex partners, lack of condom use). Important independent predictors of the borrowing of syringes were injecting drug use in prison, use of sedatives and sex with another IDU in the previous six months. MMT may play a significant role in reducing the levels of borrowing of syringes among IDUs. However, additional prevention measures are needed which should specifically address sexual risk behaviour and target subgroups of IDUs with high levels of needle sharing, such as IDUs who have been in prison and those who are sedative users. 


  • K. Knight, D. D. Simpson & M. L. Hiller (1999). Three-year reincarceration outcomes for in-prison therapeutic community treatment in Texas. Prison Journal, Volume (Issue):  79(3) pp. 337-351.


Longer term in-prison therapeutic community (ITC) outcome studies are needed along with more attention on who benefits most from these programs. This study examined reincarceration records for 394 non-violent offenders during three years following prison. Those who completed both ITC and aftercare were the least likely to be re-incarcerated (25 percent), compared to 64 percent of the aftercare dropouts and 42 percent of the untreated comparison groups. Furthermore, high severity aftercare completers were re-incarcerated only half as often as those in the aftercare dropout and comparison groups (25 percent vs. 66 percent and 52 percent). The findings support the effectiveness of intensive treatment when it is integrated with aftercare, and the benefits are most apparent for offenders with more serious crime and drug-related problems. 


  • K. G. Power, I. Markova, K. J. McKee & C. Kilfedder (1996)  Correlates of HIV/AIDS knowledge in a Scottish prison sampleHealth Education Research, Volume (Issue):  11(3) pp. 287-297.


A sample of 559 inmates in Scottish prisons were administered a 48-item HIV/AIDS knowledge questionnaire. High levels of HIV-related knowledge were associated with: a history of drug offences, having had an HIV test, knowing someone who has had an HIV test, knowing someone who is HIV seropositive, a history of injecting drug use and having a sexual partner who is also an injecting drug user. Inmates who are objectively at high risk of contracting HIV by virtue of their drug injecting and sexual behaviour are also amongst the most knowledgeable inmates, with regard to HIV/AIDS. Unfortunately, such knowledge does not result in the adoption of risk reduction behaviours. Results are discussed in relation to the heterogeneity of inmate populations and the diversity of their educational needs. 


  • M. A. Lang & S. Belenko (2000). Predicting retention in a residential drug treatment alternative to prison program. Journal of Substance Abuse Treatment. Volume (Issue):  19(2) pp. 145-160.


One hundred and fifty felony drug offenders diverted from prison to community-based, residential drug treatment alternative to prison programme completed a comprehensive interview as part of a longitudinal study. Treatment completion predictors were sought examining intake data (demographics, family, social, employment, medical, psychological, criminal, sexual behaviour, drug use and treatment histories). Logistic regression results found completers had more social conformity and close friends, and less need for employment counselling, felony drug convictions, drug dealing income, and unprotected sex than dropouts. Completers were also less likely to encounter recent problems with significant other, have a psychiatric history, experience gunshot or stabbing, and commenced heroin use at older ages than dropouts. However, completers reported higher alcohol use than counterparts. Further analyses explored subcategory models: "life choice' (substance use, criminal and sexual behaviour), static (background and dispositional), and dynamic situational influences (employment, psychological state, recent and past encounters). Treatment implications considering findings are discussed. 


  • M. Rotily, C. Weilandt, S. M. Bird, K. K ll, H. J. A. van Haastrecht, E. Iandolo & S. Rousseau (2001). Surveillance of HIV infection and related risk behaviour in European prisons. A multicentre pilot study. European Journal of Public Health, Volume (Issue):  11(3) pp. 243-250.


In order to demonstrate the feasibility of human immunodeficiency virus (HIV) infection and related risk behaviour surveillance in European prisons, a multicentre pilot study was undertaken. A cross-sectional survey was carried out in six European prisons (France, Germany, Italy, The Netherlands, Scotland and Sweden). Inmates were invited to complete a self-administered and anonymous questionnaire and to give a saliva sample in order to test for HIV antibodies. Eight hundred and forty-seven out of 1124 inmates participated in the survey (response rate 75%). Saliva from 817 inmates (73%) was collected and processed for HIV antibodies. Twenty-seven percent reported that they had ever injected drugs and 49% of these reported they had injected whilst in prison. Eighteen percent of inmates reported that they had been tattooed whilst in prison, which was found to be higher among injecting drug users (IDUs). One and sixteen percent reported that they had ever had homosexual and heterosexual intercourse in prison respectively. The HIV prevalence among IDUs was 4% (versus 1% among non-IDUs). The proportions of inmates previously tested for hepatitis C and vaccinated against hepatitis B were 24 and 16% respectively. This survey demonstrates the feasibility of cross-sectional surveys in European prison inmates and highlights the importance of surveillance of HIV prevalence and related risk behaviour among inmates. The continuing high HIV prevalence and potential for HIV spread in prisons should encourage decision makers in implementing or enhancing harm reduction and education programmes and substance abuse treatment services in prison. 


  • M. Malliori, V. Sypsa, M. Psichogiou, G. Touloumi, A. Skoutelis, N. Tassopoulos, A. Hatzakis & C. Stefanis (1998). A survey of bloodborne viruses and associated risk behaviours in Greek prisons .   Addiction, Volume (Issue): 93(2)  pp. 243-251.


The aim of the study was to determine HIV and hepatitis infection prevalence and correlates with risk behaviour in Greek prisons. Some 544 drug users imprisoned for drug related offences, all completed the questionnaire and 533 blood samples were collected. Of the 544 drug users, 375 (68.9 percent) had injected drugs (IDUs) at some time, 35 percent of whom had injected whilst in that prison. Of the 533 blood samples tested, one was positive for anti-HIV-1 (0.19 percent), 310 for anti-HCV (58.2 percent), 306/531 (57.6 percent) for anti-HBc, 34/527 (6.5 percent) for HBsAg and 12/527 (2.3 percent) for anti-HDV. Prevalence rates for IDUs only were 0.27 percent for HIV-1, 80.6 percent for hepatitis C, 62.7 percent for hepatitis B and 3.3 percent for hepatitis D. Ninety-two percent of IDUs injecting in prison shared needles, indicating that IDUs inject less but share more during incarceration. Multiple logistic regression revealed needle-sharing as the most important risk factor for HCV infection in IDUs. Prior knowledge of a positive hepatitis result did not appear to inhibit IDUs from practising risky behaviours in prison. The epidemic of hepatitis B and C among imprisoned IDUs identified by this study constitutes a major public health problem. Prevention programmes, such as counselling, HBV vaccination, community-based methadone maintenance treatment and syringe exchange schemes, are necessary in order to prevent a further spread.


  • P. J. Turnbull & R. Webster, 1998. Demand reduction activities in the criminal justice system in the European Union. Drugs: education, prevention and policy, Volume (Issue):  5(2)  pp. 177-184.


With increased prisoner numbers, many European Union member states have begun to consider the possibility of drug demand reduction interventions within the criminal justice system. In this paper the results of a six month study of drug demand reduction activity within the criminal justice system (CJS) of the member states of the European Union are presented. The extent of activity at the arrest stage varies widely between states. The two most common objectives of interventions aimed at drug using arrestees are to provide information and to encourage contact with treatment services. The extent of activity at the court stage was difficult to establish, however, in many countries legislation exists which extends the possibility of drug treatment as an alternative to a legal sanction. There is a considerable and increasing range of interventions focused on drug users in prison. All countries provide some form of demand reduction activity within this context. Many respondents indicated a very low level of drug demand reduction activity targeted at released prisoners. Despite the existence of many interventions, no member state has an extensive programme of demand reduction activities at every stage of the criminal justice system. Further, activities are rarely available throughout all geographical areas of a country. 


  • Rao, Sandhya R; Broome, Kirk M; Simpson, D Dwayne (2004) Depression and hostility as predictors of long-term outcomes among opiate users. Addiction (Abingdon, England), Volume 99, Issue 5 , May, Pages 579-589


AIMS: This study used data from the national Drug Abuse Treatment Outcome Studies (DATOS) to investigate the associations that pre-treatment depression and hostility have with drug use and criminal behaviour at 1 year and 5 year follow-up in patients with and without additional treatment involvement in the year prior to each follow-up. DESIGN: Following a naturalistic, non-experimental evaluation design, admissions to methadone treatment were followed up approximately 1 and 5 years later. Data analysis was conducted using multiple logistic regression. SETTING: Eighteen programs from DATOS were included. PARTICIPANTS: An analytic sample consisting of 727 patients at 1 year follow-up and 432 patients at 5 year follow-up was included. FINDINGS: Multiple logistic regression analyses revealed that greater depression predicted less drug use in the year preceding each follow-up, whereas greater hostility predicted increased drug use and more arrests at each follow-up. Furthermore, these predictive relationships appeared only among individuals not involved in additional treatment. CONCLUSIONS: Depression and hostility showed opposite associations with outcomes, underscoring the need to assess these psychological conditions separately and tailor treatment plans appropriately.


  • R. L. Bauserman, D. Richardson, M. Ward, M. Shea, C. Bowlin, N. Tomoyasu & L. Solomon ( 2003) HIV prevention with jail and prison inmates: Maryland's Prevention Case Management program. AIDS Education and Prevention , Volume (Issue) 15(5) pp. 465-480.


Prevalence of HIV infection and AIDS cases is higher among inmates of correctional facilities than among the general population, especially for female inmates. This creates a strong need for effective HIV prevention with this population. Maryland's Prevention Case Management (PCM) programme provides individual or group counselling to inmates nearing release to promote changes in risk behaviour. Pretest and post test surveys assess changes in perceived risk, condom attitudes, condom use self-efficacy, self-efficacy to reduce injection drug risk and other substance use risk and behavioural intentions during participation in the programme. Client contact logs, kept by counsellors, document the number and duration of sessions, and the specific modules, completed by participants. Over a 4-year period, PCM records identified 2,610 participants in the programme. Pre-intervention and post-intervention data were available for 745 participants, with client contact log records available for 529 (71%) of these individuals. Significant, positive changes were found in self-reported condom attitudes, self-efficacy for condom use, self-efficacy for injection drug use risk, self-efficacy for other substance use risk and intentions to practice safer sex post-release. Inmate populations are a crucial audience for HIV/AIDS testing, treatment and prevention efforts. The Maryland PCM programme has documented positive changes in participants' attitudes, self-efficacy and intentions related to HIV risk, over a 4-year period.


  • Rhidian Hughes (2000)  Lost Opportunities? Prison needle and syringe exchange schemes.  Drugs: education, prevention and policy, Volume (Issue):  7(1) pp. 75-86.


Community needle and syringe exchange schemes (CNSES) have become an established part of harm reduction strategies in the UK. However, prison needle and syringe exchange schemes (PNSES) have not been afforded the same attention. This article explores some of the pertinent issues that surround PNSES debates. The focus is on the UK, although it draws on international sources as the issues presented transcend international borders. To represent the range of considerations that surround PNSES debates the following six questions will be addressed: Are PNSES unrealistic and unpopular? Do PNSES conflict with the duties and principles of the prison service and its staff? Do PNSES affect levels of drug use and drug injection in prison? Would PNSES affect levels of infections? Will drug injectors use PNSES? Will PNSES affect safety and security? This article concludes with a call for a much fuller debate on the issue of PNSES. 


  • R. H. Peters, A. L. Strozier, M. R. Murrin & W. D. Kearns (1997). Treatment of substance-abusing jail inmates: examination of gender differences. Journal of Substance Abuse Treatment, Volume (Issue): 14(4) pp. 339-349.


Females incarcerated for drug-related offences represent one of the fastest growing populations within jails and prisons. The few studies of female offenders with substance abuse disorders depict a population with multiple psychosocial problems and treatment needs and one that is characterised by frequent exposure to sexual abuse and other violence. The current study examined intake assessment results from a sample of 1,655 substance-involved jail inmates referred to a jail treatment programme in Tampa, Florida, including 26 percent female and 74 percent male inmates. The study was designed to identify gender differences in psychosocial characteristics and substance abuse treatment needs among jail inmates. Results indicate that female inmates more frequently experienced employment problems, had lower incomes, more frequently reported cocaine as the primary drug of choice and were more likely to report depression, anxiety, suicidal behaviour and a history of physical and sexual abuse. Implications for developing specialised treatment approaches for female offenders are discussed, including use of integrated treatment strategies. 


  • S. Brochu, L. Guyon & L. Desjardins, 1999. Comparative profiles of addicted adult populations in rehabilitation and correctional services. Journal of Substance Abuse Treatment, Volume (Issue):  16(2) pp. 173-182 


For many years, clinicians, especially those working in rehabilitation centres for alcohol and drug users, have been preoccupied with clients presenting with dual diagnosis: substance abuse and legal problems. Comparative analyses of three groups of addicted men, 553 offenders and 499 non-offenders in treatment for addiction problems and 103 addicted inmates were made to ascertain the bio psychosocial profile of these persons. Results showed that dual diagnosis clients experienced more severe bio psychosocial problems than the non-offending group of subjects. Offenders in prison experienced more social maladjustment than offenders in drug addiction treatment, they were less preoccupied by their drug consumption and less motivated to change. Implications for treatment are discussed. 


  • S. M. Gore & A. G. Bird, 1996. Cost implications of random mandatory drugs tests in prisons. Lancet . Volume (Issue): 348(9035) pp. 1124-1127.


Compulsory urine testing of prisoners for drugs, a control initiative, was introduced in eight prisons in England and Wales early in 1995. Despite no evidence of effectiveness, testing was extended to all prisons in England and Wales by March 1996. The authors consider the cost of testing. They combined the costs of refusals, confirmatory tests, punishment of confirmed positives for cannabis or for class A drugs to estimate the average costs of random compulsory drugs testing. These costs were then compared to: (1) the healthcare budget for a prison; and (2) the cost of putting in place a credible prisons' drugs reduction programme. They then used Scottish data on incarceration and regional prevalence of injecting drug users to estimate the extent of the injecting drug use problem that prisoners face. Costs per 28 days of the random mandatory drugs testing control initiative in an establishment for 500 inmates where refusal rate is ten percent or nil; and 35 percent of urine samples test positive, one tenth of them for class A drugs were estimated at between UK22,800 and UK16,000 per 28 days ($US35,100 and $US24,600). This cost was equivalent to twice the cost of running a credible drugs reduction and rehabilitation programme and around half the total healthcare expenditure for a prison of 500 which averaged UK41,114 per 28 days ($US64,860). Major cost-generating events were the punishment of refusals and testing positive for cannabis. In Scotland, around five percent of injecting drug users (IDUs) are incarcerated at any time: five percent of Lothian's drugs care, treatment and prevention costs and 2.5 percent of its HIV/AIDS prevention budget in 1993-1994 amounted to UK101,300 per annum - or UK7,770 per 28 days ($US11,970) - and about 35 percent of monthly MDT costs. The authors suggest that five percent of current resources for drugs prevention and treatment and for IDU-targeted HIV/AIDS prevention should be directed towards the prisons because in the prisons, where five percent of the clients are at any time, injectors have less access to harm reduction measures than on the outside. 


  • S. Darke, S. Kaye & R. Finlay-Jones (1998) Drug use and injection risk-taking among prison methadone maintenance patientsAddiction,  Volume (Issue):  93(8) pp. 1169-1175.


To examine the drug use and injection risk-taking among incarcerated methadone maintenance (MM) patients; to determine the impact of a diagnosis of antisocial personality disorder (ASPD) on prison-based MM treatment; to compare incarcerated patients with community patients. The design was a structured interview. Setting was New South Wales (NSW) prisons and community methadone maintenance (MM) units. One hundred incarcerated MM patients and 183 community MM patients participated. Subjects were interviewed about drug use and needle risk-taking in the previous six months and assessed for a diagnosis of ASPD. Heroin had been used by 38 percent of prison MM patients in the six months prior to interview, on a median of 4.5 days. Forty-four percent of prison patients had injected a drug in the preceding six months. A third (32 percent) of prison subjects had borrowed using injecting equipment within the preceding six months and 35 percent had lent used injecting equipment to others. Community patients were more likely to have injected a drug in the preceding six months (84 percent vs. 44 percent), to have used heroin (72 percent vs. 38 percent) and to have done so more frequently (20 vs. 4.5 days). Prisoners, however, were more likely to have borrowed (32 percent vs. 15 percent) and lent (35 percent vs. 21 percent) injecting equipment in that time. While injecting at lower rates than their community counterparts, the injecting occasions of prisoners were of much higher levels of risk. A diagnosis of ASPD was unrelated to both drug use and needle risk-taking. Incarcerated patients injected less frequently than community patients, but had higher levels of needle risk-taking. 


  • S. S. Martin, C. A. Butzin, C. A. Saum & J. A. Inciardi  (1999) Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: from prison to work release to aftercare. Prison Journal, Volume (Issue):  79(3) pp. 294-320.


Delaware researchers have argued for a continuum of primary (in prison), secondary (work release), and tertiary (aftercare) therapeutic community (TC) treatment for drug-involved offenders. Previous work has demonstrated significant reductions in relapse and recidivism for offenders who received primary and secondary TC treatment one year after leaving work release. However, much of the effect declines significantly when the time at risk moves to three years after release. Further analyses reveal that program effects remain significant when the model takes into account not simply exposure to the TC program, but, more importantly, program participation, program completion, and aftercare. Clients who complete secondary treatment do better than those with no treatment or program dropouts, and those who receive aftercare do even better in remaining drug- and arrest-free. 


  • T. Newburn (1998) Young offenders, drugs and prevention. Drugs: education, prevention and policy, Volume (Issue):  5(3) pp. 233-243.


There is evidence that drug use by young people is on the increase. As concern about youthful drug use has heightened, so increased attention has been paid to providing education and treatment with the aim of preventing or reducing use, or reducing harm. Although targeting interventions is problematic it is important and, consequently, the focus on "high risk' groups has intensified. As research confirms the link between drug use and delinquency, it is therefore felt that the criminal justice system provides one possible means of identifying a very significant target population: young offenders. This paper looks at what is known about the levels and types of drug use among young offenders, examines drug-related interventions within the youth justice system and concludes by looking at two developing programmes in the East and West Midlands which are currently being evaluated by the author. 


  • Barbara Sibbald.  Methadone maintenance expands inside federal prisons. Editorial, CMAJ • November 12, 2002; 167 (10)

In an attempt to curb rising HIV and hepatitis C infection rates and to lower recidivism rates, federal prisons have begun offering methadone maintenance treatment (MMT) to any prisoner with an opiate addiction.

The Correctional Service of Canada (CSC) expanded access to MMT in federal prisons May 2. It estimates that up to 800 prisoners may enter the program within 3 years at an annual cost of more than $10 000 each, or a potential annual total of roughly $8 million.

The new program builds on a 1998 initiative that allowed federal prisoners to continue receiving methadone if they had been in an MMT program in the community before their arrest. In March 1999 the program was temporarily modified to allow, under exceptional circumstances, MMT for severely addicted offenders. As of December 2001, 304 federal prisoners were receiving MMT through these programs, but there was no money for expansion. Of that total, 230 inmates had been receiving methadone in the community prior to their arrest. Another 74 inmates had started receiving it in 2001 under the "exceptional circumstances" provision, 47 of them in the Pacific region.

The problem, says Dr. Françoise Bouchard, CSC's director general, health services, is that the application of "exceptional circumstances" differed across the country. "It was up to individual judgements. We decided to make it more concrete."

The new program was announced shortly after inmate Barry Strykiwsky settled his court case alleging that Ottawa had violated his Charter rights by not providing him with MMT, a treatment available to other Canadians addicted to heroin. Strykiwsky asked prison officials for MMT in 1998. Even though he had the support of his physician, he was refused.

"I'm encouraged by the new program," said the head of the Canadian HIV/AIDS Legal Network, Ralf Jürgens, "but I'm dismayed that they waited until the case went to court."

Bouchard says the CSC was already moving in this direction, but "we needed to measure the impact of [the initial] program." A CSC study of the impact of the original MMT program found that after a year, 41% of inmates who were receiving MMT were readmitted to prison, compared with 58% of addicted inmates who were not on the program. In a study of 636 former inmates, injection drug users reported significantly more needle sharing (72.6% vs. 51.8%) than users who had not been in prison (Can J Infect Dis 2002; 13 [Suppl A] ).

The new program may also slow the spread of HIV and hepatitis C infections. Among those who agreed to be tested, 1.8% were HIV positive at the end of 2002. In 1989, there were 24 known HIV-positive federal inmates; in 2001, there were 223. (At the end of 2001, the rate of hepatitis C infection among federal inmates who have been tested was 23.6%.)

CSC says this "dramatic rise ... in the past decade is linked in large measure with the substance-abuse practices and associated lifestyles of many of these offenders" before they arrive in prison.

Despite CSC's "zero tolerance" for drug abuse in prisons, the problem is pervasive. The service estimates that 70% of inmates have drug or alcohol abuse problems when they enter prison. "It's logical that they would try to sustain [their habit] while in here," says Bouchard. "This [MMT] is not only a harm-reduction measure, but it is designed to stop drug substance abuse. It's the only effective medical treatment for opiate drug users."

According to a CSC study, 80% of inmates have abused alcohol or drugs and 34% used injection drugs prior to their incarceration; 11% reported using them while in custody, and 25% said they were under pressure to smuggle drugs into the institution.

Jürgens is pushing for needle-exchange programs in prisons - he says they have proven effective in Europe and do not increase drug use or threats to staff. "There's clearly a need for the federal prison system to do a pilot study."

Needle-exchange programs as a harm-reduction measure are being considered, says Bouchard, but their implementation is not imminent.

Provincial prisons

Addicted inmates at provincial prisons (where sentences under 2 years are served) have fewer harm-reduction options. Inmates who were in an MMT program outside prison are eligible for in-prison treatment (if available) in all provinces except PEI and Newfoundland. No provinces offer it to addicted inmates who were not previously on a program. - Barbara Sibbald, CMAJ

Prison optics

On any given day in Canada, our federal prisons house 13 000 inmates and provincial prisons another 18 700.1 Our incarceration rate of 118 per 100 000 population is roughly equivalent to Britain's and about one sixth of the US rate (the highest in the world).2 Each year, 5000 people are released from Canadian prisons to the community.

The Canadian Centre on Substance Abuse estimates that 54% of federal inmates and similar proportions of men and women in provincial custody abused alcohol or drugs on the day of their offence.1 The Correctional Service of Canada estimates that almost 7 out of 10 federal prison inmates have a substance abuse problem.3 Plainly, substance abuse exacerbates crime, but it is equally clear that a high proportion of people behind bars suffer from dependency problems and their associated health effects. HIV and hepatitis C infections are far more prevalent among prison inmates than in the general population, and the gap appears to be widening.

Imprisonment is an imperfect cure for addictions. As in the world outside prison walls, drugs are traded for money, goods and sex. Prison life presents impediments to drug use (70% of women surveyed in a BC prison used injection drugs before sentencing, but only 21% during their prison term), but it also creates inducements to unsafe practices (of those women who injected drugs, 82% shared needles).5

In spite of the fact that most prisoners have substance abuse problems, acceptance of harm reduction strategies has been slow. It took a Charter challenge (see News, page 1154) to instate methadone maintenance therapy (MMT) as the right of all federal prisoners who need it, but there is no such guarantee in provincial prisons. Provincial prisons in PEI and Newfoundland do not offer MMT, and in other provinces, inmates are eligible only if they were receiving MMT before their incarceration. Condoms have been available in federal prisons since 1992, but not in the provincial institutions of New Brunswick, Newfoundland and PEI.6 Distributing bleach is the only prison-sanctioned method of ensuring clean injection and tattooing equipment; in the culture of "corrections," needle exchange appears to be unthinkable.

In the Panopticon, the model prison proposed by Jeremy Bentham in 1791, inmates were to be controlled by the knowledge that anything they did might be observed. Panopticism is still a necessary aspiration of prison security, but the management of prison health issues has been characterized by blind spots just the same. Despite what is known (and surmised) about infectious disease and high-risk behaviours behind bars, prison harm reduction programs are repeatedly criticized for failing to achieve the accessibility and discretion required for them to be effective.

Security, surveillance and zero tolerance have not put an end to high-risk behaviours. What we need now is for federal and provinical correctional institutions to take a coordinated, synoptic view of the health problems and human rights of incarcerated people. Prison health must fall under the pragmatic and proactive gaze of public health. - CMAJ



© 2006 UNODC