Exploiting incarceration as an opportunity to 
change the health and criminogenic 
trajectories of people who inject drugs...
Overview 
• Characterise the trajectories of justice involved people who inject drugs (PWID) 
• Outcomes of strategies to ...
Drug Use is Inextricably Linked to Crime and Incarceration 
Drug use among arrestees and prisoners: 
•2/3 police detainees...
Drug Use is Inextricably Linked to Crime and Incarceration 
Self-reported crime and arrest among PWID: 
•Injecting Drug Re...
Drug Use is Inextricably Linked to Crime and Incarceration 
•45% of offenders attribute their crime to drugs 
•Commonly in...
Drug & property-related offences generally attract shorter sentences 
OST trial of 375 male heroin users recruited in NSW ...
Prevention of poor health and criminogenic outcomes = preventing a return to problematic patterns of drug use 
•Retention ...
Numerous studies support effectiveness of opioid substitution therapy (OST) for reducing: 
•drug use 
•mortality 
•crime/r...
Larney et al (2011)1: 
•OST at release from prison reduced re-incarceration (on average by 20%), but only when controlling...
Degenhardt et al (2014): 
•Impact of opioid substitution therapy OST during/after incarceration on post-release mortality ...
Degenhardt et al (2014): 
•Again, program retention is key … 
Prevention of Return to Problematic IDU 
Opioid Substitution...
Degenhardt et al (2014): 
•Again, program retention is key … 
Prevention of Return to Problematic IDU Opioid Substitution ...
Degenhardt et al (2014): 
•Again, program retention is key … 
Prevention of Return to Problematic IDU 
Opioid Substitution...
Degenhardt et al (2014): 
•Again, program retention is key … 
Prevention of Return to Problematic IDU 
Opioid Substitution...
Degenhardt et al (2014): 
•1 in 5 participants had their first experience of OST in prison! 
•Incarceration as an “opportu...
National Treatment Agency (NHS) in UK (2012)1 
•~20,000 people ≥1 conviction in previous 2 years who started a new drug co...
Presenting Drug 
% Reduction in Convictions 
Opiates only 
25% 
Opiates & crack 
20% 
Crack only 
39% 
Opiates & crack - d...
1 National Treatment Agency for Substance Misuse. NHS. 2012 
Prevention of Return to Problematic IDU
Sweden’s Prison Therapeutic Community System – 2005 onwards 
Specific prisons and units designed as therapeutic communitie...
Baldry (20031, 20062) cohort study of 238 NSW/Vic prisoners followed to 9 months post-release. 
•Re-incarceration associat...
The Future of Hepatitis C Treatment A role for Correctional Health Care
•Single-pill combination therapy (no injections) 
•97% cure rate at 12 weeks: 
•Only mild adverse events 
•Ongoing phase 3...
We estimate that approximately 5-6% of those chronically infected with hepatitis C pass through prisons annually 
EXCELLEN...
Prison and Transition Health Cohort Study (PaTH) 
NHMRC – Stoove, Kinner, Butler, Ogloff, Aitken, Dietze; ~$1 million; 4.5...
Summary 
1.PWID vastly over-represented in prison and among ex-prisoners 
–overwhelming proportion of the economic, social...
Summary 
3.Primary responsibility must be borne by Justice Health and Correctional programs to: 
•Deliver effective progra...
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Associate Professor Mark Stoové - Burnet Institute - SESSION 3: Exploiting Incarceration as an Opportunity to Change the Health and Criminogenic Trajectories of People who Inject Drugs

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Mark Stoové delivered the presentation at the 2014 Correctional Services Healthcare Conference.

The 2014 Correctional Services Healthcare Conference - addressing the gaps, promoting multidisciplinary care and improving the continuum of care into the community.

For more information about the event, please visit: http://bit.ly/correctionalsvs14

Published in: Health & Medicine
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Associate Professor Mark Stoové - Burnet Institute - SESSION 3: Exploiting Incarceration as an Opportunity to Change the Health and Criminogenic Trajectories of People who Inject Drugs

  1. 1. Exploiting incarceration as an opportunity to change the health and criminogenic trajectories of people who inject drugs Associate Professor Mark Stoové Head, Justice Health Research Program Head, HIV Research Program Burnet Institute
  2. 2. Overview • Characterise the trajectories of justice involved people who inject drugs (PWID) • Outcomes of strategies to intervene and implications for policy and practice • Case study of new hepatitis C treatments … and some informed opinion
  3. 3. Drug Use is Inextricably Linked to Crime and Incarceration Drug use among arrestees and prisoners: •2/3 police detainees test positive to at least 1 drug1 •About 50% of prison entrants report lifetime history of IDU2 –~25% injected in past month (most commonly ATS and heroin) •Generally higher prevalence of drug use among female detainees/prisoners 1 Drug Use Monitoring in Australia Report 2009–10 2 National Prison Entrants’ BBV & Risk Behaviour Report, 2004, 2006 & 2010
  4. 4. Drug Use is Inextricably Linked to Crime and Incarceration Self-reported crime and arrest among PWID: •Injecting Drug Reporting System (IDRS) 20111 –39% reported any crime in the past month –36% arrested in past month •Melbourne Injecting Cohort Study (MIX)2 –28% reported crime in the past month •58% reported weekly or more often property crime –54% arrested in past 12 months –60% lifetime incarceration •Crime overwhelming categorised as drug-related or property crime 1 Stafford & Burns, NDARC, 2012 2 Horyniak et al, (2013). Harm Reduction Journal, 10:11
  5. 5. Drug Use is Inextricably Linked to Crime and Incarceration •45% of offenders attribute their crime to drugs •Commonly injected or IDU-associated drug types1 •Heroin – 54% •Amphetamine – 33% •Opiates – 27% •Benzodiazepines – 27% Correlates of property crime in sample of PWID in Melbourne2 1 AIC Trends & Issues Report # 439 2012 2 Kirwan et al (submitted). Drug and Alcohol Dependence Variable Adjusted OR 95% CI Daily injecting 4.36 1.45-13.07 Used illicit benzodiazepines 2.59 1.02-6.57 Contact with mental health services 4.27 1.45-12.60
  6. 6. Drug & property-related offences generally attract shorter sentences OST trial of 375 male heroin users recruited in NSW prisons1 •Median of 4 prior custodial sentences at baseline During follow-up (1997 -2006): •88% reconvicted (median 15 times) •90% re-incarcerated •84% re-incarcerated within 2 years 1 Larney, Toson, Burns, Dolan, NDARC, 2011 People Who Inject Drugs Over-Represented Among Those Transitioning
  7. 7. Prevention of poor health and criminogenic outcomes = preventing a return to problematic patterns of drug use •Retention in effective treatment pre-to-post release •Supportive post-release social environments In general, incarceration does little to prevent a return to drug use and crime and incarceration Evidence of effective programs where opportunities begin pre-release and continue through transition and beyond! Prevention of Return to Problematic IDU
  8. 8. Numerous studies support effectiveness of opioid substitution therapy (OST) for reducing: •drug use •mortality •crime/recidivism •incarceration/re-incarceration •blood borne virus transmission But provision is not enough – retention is vital Prevention of Return to Problematic IDU Opioid Substitution Therapy
  9. 9. Larney et al (2011)1: •OST at release from prison reduced re-incarceration (on average by 20%), but only when controlling for program retention Dolan et al (2005)2: •Re-incarceration lowest among those retained in OST for ≥8mths; highest among those retained ≤2mths Dolan et al (2003)3: •reductions in heroin use, self-reported injecting, frequency of heroin injecting and sharing of syringes compared to wait list controls Prevention of Return to Problematic IDU Opioid Substitution Therapy 1Larney, Toson, Burns, Dolan, NDARC, 2011 2Dolan et al Addiction, vol. 100, no. 6, pp. 820 – 828 3Dolan et al Drug and Alcohol Dependence, vol. 72, no. 1, pp. 59 - 65
  10. 10. Degenhardt et al (2014): •Impact of opioid substitution therapy OST during/after incarceration on post-release mortality •Prisoner on OST between 1985-2010 in NSW; released from custody b/w 2000-2012 –16,453 prisoners; 60,161 discharges Prevention of Mortality Opioid Substitution Therapy
  11. 11. Degenhardt et al (2014): •Again, program retention is key … Prevention of Return to Problematic IDU Opioid Substitution Therapy 1 MONTH ~4-fold decrease CRUDE MORTALITY RATE Retained in OST Partial OST No OST 1st week post-release 5.1 per 1000 PY 48.8 per 1000 PY 1st 4 weeks post release 3.5 per 1000 PY 10.4 per 1000 PY 26.5 per 1000 PY 1st year post-release 2.4 per 1000 PY 14.9 per 1000 PY 9.4 per 1000 PY
  12. 12. Degenhardt et al (2014): •Again, program retention is key … Prevention of Return to Problematic IDU Opioid Substitution Therapy 1 MONTH ~7.5-fold decrease CRUDE MORTALITY RATE Retained in OST Partial OST No OST 1st week post-release 5.1 per 1000 PY 48.8 per 1000 PY 1st 4 weeks post release 3.5 per 1000 PY 10.4 per 1000 PY 26.5 per 1000 PY 1st year post-release 2.4 per 1000 PY 14.9 per 1000 PY 9.4 per 1000 PY
  13. 13. Degenhardt et al (2014): •Again, program retention is key … Prevention of Return to Problematic IDU Opioid Substitution Therapy 1 MONTH ~10-fold decrease CRUDE MORTALITY RATE Retained in OST Partial OST No OST 1st week post-release 5.1 per 1000 PY 48.8 per 1000 PY 1st 4 weeks post release 3.5 per 1000 PY 10.4 per 1000 PY 26.5 per 1000 PY 1st year post-release 2.4 per 1000 PY 14.9 per 1000 PY 9.4 per 1000 PY
  14. 14. Degenhardt et al (2014): •Again, program retention is key … Prevention of Return to Problematic IDU Opioid Substitution Therapy Spending time in and out of OST •Enhanced mortality relative to ongoing OST •Actually riskier than no OST over 12 months CRUDE MORTALITY RATE Retained in OST Partial OST No OST 1st week post-release 5.1 per 1000 PY 48.8 per 1000 PY 1st 4 weeks post release 3.5 per 1000 PY 10.4 per 1000 PY 26.5 per 1000 PY 1st year post-release 2.4 per 1000 PY 14.9 per 1000 PY 9.4 per 1000 PY
  15. 15. Degenhardt et al (2014): •1 in 5 participants had their first experience of OST in prison! •Incarceration as an “opportunity” to initiation •Long-term impact reliant on effective transition and retention in community programs! •Somewhat effective transition programs •Inadequate post-release supports for OST retention Prevention of Return to Problematic IDU Opioid Substitution Therapy
  16. 16. National Treatment Agency (NHS) in UK (2012)1 •~20,000 people ≥1 conviction in previous 2 years who started a new drug course of treatment in 2006 and 2007 •Conviction rates were compared for 2-year retrospective and prospective period •~5000 retained in treatment for the entire 2 yrs showed an average 47% reduction in convictions –>3 times higher than the 15% reduction among those who dropped out 1 National Treatment Agency for Substance Misuse. NHS. 2012 Prevention of Return to Problematic IDU
  17. 17. Presenting Drug % Reduction in Convictions Opiates only 25% Opiates & crack 20% Crack only 39% Opiates & crack - duration of Rx > 3 months 13% 3-6 month 16% 6-12 months 15% 1-2 years 23% Continuing at 2 yrs 46% 1 National Treatment Agency for Substance Misuse. NHS. 2012 Prevention of Return to Problematic IDU
  18. 18. 1 National Treatment Agency for Substance Misuse. NHS. 2012 Prevention of Return to Problematic IDU
  19. 19. Sweden’s Prison Therapeutic Community System – 2005 onwards Specific prisons and units designed as therapeutic communities - employing 12-step and cognitive therapy programs •7 institutions with 500 places •Rx units at other prisons 300 places. •Provides access to Rx for ~1/3 drug using prisoners In 12 months post-release, compared to matched controls:1 •Significantly reduced proportion with new convictions •Significantly reduced proportion re-incarcerated •No difference these outcomes between drop out and non-Rx controls 1 Journal of Scandinavian Studies in Criminology & Crime Prevention, 13:1, 44-63. 2012 Prevention of Return to Problematic IDU
  20. 20. Baldry (20031, 20062) cohort study of 238 NSW/Vic prisoners followed to 9 months post-release. •Re-incarceration associated with: –‘worsening’ of heroin use, AOD problems – frequently moving, no/unhelpful accommodation support •Avoiding re-incarceration associated with: –Not moving or moving only once in first 3 months –Living with significant other (partner, parent, close family member) Binswanger et al (2012)3: •relapse to AOD use occurred when those released from prison were ubiquitously exposed to drugs in their living environments (family using, street drug markets in neighbourhood) Supportive Post-Release Social and Living Environment 1 AHURI Final Report No. 46, 2003 2 Baldry et al. ANZJC, 2006 3 Binswanger et al. Addiction Science & Clinical Practice 2012, 7:3
  21. 21. The Future of Hepatitis C Treatment A role for Correctional Health Care
  22. 22. •Single-pill combination therapy (no injections) •97% cure rate at 12 weeks: •Only mild adverse events •Ongoing phase 3 studies with ~2000 individuals HCV treatment delivery could substantially shift away from hospital-based to community settings The Future of Hepatitis C Treatment A role for Correctional Health Care
  23. 23. We estimate that approximately 5-6% of those chronically infected with hepatitis C pass through prisons annually EXCELLENT SETTING FOR NEW THERAPIES •Highly effective •Highly tolerable •Short duration •Simple to administer •Nurse-led models of care with cost savings The Future of Hepatitis C Treatment A role for Correctional Health Care
  24. 24. Prison and Transition Health Cohort Study (PaTH) NHMRC – Stoove, Kinner, Butler, Ogloff, Aitken, Dietze; ~$1 million; 4.5 years Study aims: 1.Identify typical trajectories of people with a history of IDU following release from prison –patterns of health service utilisation, drug use, BBV infection, physical and mental health, criminal justice; 2.Identify crucial intervention opportunities •500 male prisoners with IDU histories •In-depth interview, blood specimen (HCV antibody/PCR/phylogenetics) •Baseline at 4-6 weeks prior to release; follow-up at 3, 12, 24-mth post-release •Extensive record linkage: –Medicare, PBS, mental health, hospital service, ambulance, police (LEAP)
  25. 25. Summary 1.PWID vastly over-represented in prison and among ex-prisoners –overwhelming proportion of the economic, social, health, individual and community burden associated with incarceration –Investing transition programs is therefore likely to be highly cost effective –Advocacy within government to enhance or re-allocate transition program funding •Prison infrastructure to accommodate increased demand Vs prevention of re- incarceration to alleviate demand? 2.Opportunity begin pre-release and MUST be supported post-release –To some extent we know the types services/program that work –Need research to inform their refinement to enhance effectiveness
  26. 26. Summary 3.Primary responsibility must be borne by Justice Health and Correctional programs to: •Deliver effective programs •Facilitate others to deliver effective programs (e.g., in-reach) •Coordinate pre/post release services •Refine governance structures in collaboration with other relevant government departments and community services •Advocate within government •Support research and evaluation (and make publically accessible)

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