Prisons, Drugs, Death Why do we care

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Prisons, Drugs, DeathWhy do we care?
Victorian Alcohol Drug Conference 14 February
2007

• Dr Richard Matthews
• Deputy Director General Strategic Development NSW
  Health
• Chief Executive Justice Health

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Reasons for incarceration

• Retribution
• Rehabilitation
• Deterrence
• Incapacitation

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Prisoner Health Care in NSW

• 1787 - First Fleet sailed
• 750 convicts
• 4 naval surgeons
• January 1788 - First Convict Hospital
• 200 in care (March) dysentery and scurvy
• 44 deaths (March to June)
• 1790 onwards - Establishment of 26 convict
  hospitals

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Annual Reports of New HIV/AIDS Cases by Mode of
Transmission (Taiwanese), 2003-2005
The percentage of IDUs among HIV infection 2003
10 2004 41 2005 72
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Annual Reports of New HIV/AIDS Cases by Mode of
Transmission (Taiwanese), 1984-2006
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Chicken pox in a correctional system
PRISON C 250 female prisoners
PRISON D 300 male prisoners
PRISON A 45O male prisoners
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2
2
6
10
PRISON B Reception and transit centre
PRISON B Reception and distribution prison 800
male inmates
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9
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2
RELEASED TO FREEDOM
COURT CELLS
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Models for Health Care Delivery

• Funded and provided by the Justice arm directly
• Funded by Justice but provided by contracted
  external provider
• Funded by Health in-reach by local community
  health services
• 4. Funded and provided by specific Health entity

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Legislative Framework

• Statutory Corporation constituted under the
  Health Services Act 1997
• Role defined in the Justice legislation Crimes
  (Administration of Sentences) Act 1999
• Responsibility of Medical Officers (Section 236C)
• CEO Access (Section 236B)
• Responsibility to advise Commissioner of
  Corrective Services (Section 236A)

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Comprehensive Forensic Service

• At the interface between Health and the Criminal
  Justice System
• Seamless service between community, police cells,
  courts, custody (adult and juvenile) and forensic
  hospitals.
• Independent Board appointed by the Minister for
  Health

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Our Service - 2007

• Census - Adult 9500 Juvenile 340
• Throughput - Adult 18000 Juvenile 2000
• 29 adult correctional centres
• 1 juvenile correctional centre
• 11 periodic detention centres
• 8 police cell complexes
• 14 court complexes
• 8 juvenile detention centres
• adult and youth drug courts
• correctional centre release treatment scheme
• maximum secure forensic hospital

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Service DelineationNeed to inform with Data

• Traditional prison data (numbers and
  demographics)
• 27 less than 8 days
• 17 8 to 30 days
• 56 longer than 30 days
• 10 longer than 6 months
• 250, 000 movements p.a.

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Service DelineationNeed to inform with Data
Health socioeconomic data Inmate Health Survey
(1996 and 2001) National Mental Health
Interview Young People in Custody Survey Young
People on Community Order Survey Mortality
Study Socioeconomic Deficit Health Deficit
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Socioeconomic status

• Aboriginal
• 20 male 33 female (2 general community)
• 41 juvenile detainees
• Cultural and linguistic diversity
• 23 NESB
• Unemployment
• 45 male 64 female (unemployed 6 months prior
  to incarceration)
• Education
• 46 female 53 male have no school qualification
• 2 have not attended school
• EDOCC score 790

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Generational Incarceration

• Juvenile offenders (YPiCHS 2002)
• 43 past parental incarceration
• 11 current parental incarceration
• 28 history of care
• 10 have one or more children
• 19 live with someone with mental or physical
  health problem affecting daily life

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NMHI Mental HealthReceptions (n 756m/165f)
Community (n6,627m/6,837f)
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Screening for Intellectual Disability 2
Low HASI Score 227/882 (26)
WAIS Assessments 158/227 (70)
Lost to follow-up69 (30)
Not ID (IQ gt 79) 91 (58)
Borderline ID (IQ 75-79) 26 (17)
ID (IQ lt75) 40 (25)
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NMHI Drug Alcohol12 month prevalence
dependence/abuse (DSM-IV)Receptions (n
756m/165f) Community (n6,627m/6,837f)
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Serology

• Blood-borne viruses
• Adults
• 28 male 31 female exposed to Hepatitis B
• 11 male 6 female are currently infected
• 40 males 66 females Hepatitis C positive
• Juveniles
• 11 male 18 female exposed to Hepatitis B
• 3 male 12 female are currently infected
• 8 males 18 females Hepatitis C positive

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General Health

• Smoking 78 male 83 female adults
• 76 male 78 female juveniles
• Asthma 21 males 44 females adults
• 28 males 56 females juveniles
• Diabetes 3 adults reported diagnosis
• PAP smear 43 females have abnormal results
  (12 - 23 in general population)
• Hearing 32 male 30 female juveniles found
  to have mild hearing loss
• A further 3 males had moderate to profound
  hearing loss

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So what do we do?

• Divert
• Target
• Link health care to rehabilitation
• Provide continuity of care

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Court Liaison Service2002 - 2006
18,902 clients screened
18,059 clients screened
15,059 clients screened
77 (av.) referrals identified with mental
illness 14 (av.) diverted to hospital 49 (av.)
diverted to community care 36 (av.) referred to
custodial MH care
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Targeted Screening Program (TSP)Hepatitis B
Vaccination Profiles
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Hepatitis C infection
50
Juvenile Order 4
Male Custody 40
Female Custody 66
Juvenile Custody 9
Female
Adult 1
Male
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Relationship between health care and
rehabilitation

• Oral Health
• 44 never visited a dentist
• 66 lost at least one tooth to caries by the age
  of 20

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Insert photo to be emailed seperately
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Why Pharmacotherapy in the Community

• Death
• Seroconversion
• 3. Crime

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Death by Overdose in NSW Correctional Centres
Mortality In custody (1991 1998) 19 times
higher than in community Post release (Seaman)
63 / 1,000 in the first 12 weeks Untreated
heroin use 20 / 1,000 per year Naltrexone 80
/ 1,000 per year MMT 10 / 1,000 per year
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Causes of death among 85204 adult offenders in NSW
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Characteristics of Prison Injectors

• Entrenched (in their habits)
• Treatment resistant
• Poor health
• Challenging behaviours
• Stigma
• Rewards for success

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How entrenched?Injecting frequency last month
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Methadone maintenance for prisoners
Source NSW DCS Inmate Census, UK Home Office,
World Prison Population List 4th Ed, US
Department of Justice
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NDARC Methadone Study

• NSW prison methadone maintenance
• Randomised control trail of 384 IDUs in 1997 and
  re-interviewed in 1998.
• Heroin use was significantly less for those
  receiving methadone, as measured by hair analysis.

Source Dolan Wodak
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Entry Criteria

• Inclusion
• male (pilot- women had fast access)
• have a history of injecting heroin (JH
  assessment)
• have a prison sentence of at least four months
• agree to be randomised, provide samples, grow
  hair
• Exclusion
• being HIV positive or having a psychiatric
  illness

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Methodology

• 382 subjects randomised to methadone or wait
  list control
• Interview, hair blood samples
• Re interviewed re-sample after 4 months
• Controls enter MMT after 4 months
• Normal waiting time was 6 months

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Recruitment

• 933 consecutive applicants for PMP assessed
• 330 (35) applicants did not meet study criteria
• 221 (24) declined to participate
• 382 (63 of eligible applicants) randomly
  allocated to methadone maintenance treatment
  (n191) or control (n191)

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Continuous Sample
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RCT Results

• MMT Control
• HCV incidence 24.3 31.7
• Heroin (hair) 27 42
• Heroin (SR) 33 78
• No cases of HIV

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Methadone RCT results

• 382 subjects randomised to methadone / wait list
  control
• MMT significantly reduced
• heroin use (morphine hair analysis, self report)
• syringe sharing (self report)
• Trend towards reduced HCV incidence
• RCTs of prison methadone are feasible

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Results 4 year follow up

• No deaths among those in continuous methadone
• All 17 deaths in subjects not receiving
  methadone (i.e. mortality rate 2.0 per 100 ppy)
  (95 CI, 1.2-3.2)
• Re-incarceration risk lowest during methadone
  episodes gt 8 months
• (or 0.3 95 CI, 0.2-0.5 plt0.001)
• Short methadone treatment, brief sentence
  highest risk of hepatitis C
• (or 20 95 CI, 5-76 ltp0.001)

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Results F/U study Mortality
Probability of survival
months
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Methods

• 204 male heroin using prisoners, 13 prisons in
  NSW
• Subjects originally randomised to
• naltrexone (50mg/day)
• methadone/ burprenorphine
• drug free counselling
• Outcomes
• retention, compliance, side effects, changes in
  drug use, drug injecting, other health,
  psychosocial outcomes
• Poor uptake naltrexone, unsuccessful
  randomisation

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Results

• 7 inmates (n14) started naltrexone
• 6-month retention
• naltrexone (7) lt than methadone (58)
  (p0.0007) buprenorphine intermediate 30
• Mean days Rx /6 months (95 CI)
• naltrexone 59 (32-86)
• buprenorphine 100 (70-130)
• methadone 149 (117-181)
• No deaths, serious adverse events noted

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Conclusions

• Treatment heroin dependent prison inmates oral
  naltrexone
• limited attractiveness
• poor compliance
• relatively ineffective
• Oral methadone
• more attractive
• greater compliance
• more effective
• Depot preparations, implantable devices for
  naltrexone and buprenorphine may overcome poor
  treatment retention
• Oral naltrexone limited value for Rx heroin
  dependent prison inmates

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Methadone Maintenance Costs900 inmates in 21
Prisons

• Total Cost 2.9 million pa
• Cost per person 3,234 pa
• Threshold analysis cost offset by 20 days
  reincarceration
• Hepatitis C avoided incident cases cost offset
  by 20 days reincarceration

An Economic Evaluation of the Prison Methadone
Program in New South Wales, Centre for Health
Economics Research and Evaluation, University of
Technology, Sydney, In collaboration with
National Drug and Alcohol Research Centre
(NDARC), University of New South Wales,
Sydney Emma Warren and Rosalie Viney, CHERE
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Outcome of custodial MMT

• Evidence based
• 2. Cost effective
• 3. Continuity of care assured

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Summary
Governance Data define the service Post release
is more important
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Ode to Methadone
Canst thou not minister to a mind diseased Pluck
from the memory a rooted sorrow Raze out the
written troubles of the brain And with some sweet
oblivious antidote Cleanse the stuffd bosom of
that perilous stuff Which weights upon the heart?
W. Shakespeare Macbeth