Experiential account experience in the prison

Dr Sonali Jhanjee, Additional Professor
National 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 less
than 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 and
disease prevention providing access to ‘hard to reach’ groups.
 In the absence of effective treatment -high proportion of drug
dependent prisoners will continue using drugs and persist in
crime.
 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
package
of 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 as
medication for long term treatment for opioid dependence in
Tihar prisons
 To develop a manual/ protocol of guidelines for implementing
OST 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 andTraining

Human Resources and Training
Existing health structure and human resources of the Tihar
prison 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 administrative
support for the programme.

Training
 The trainings were provided by psychiatrists and faculty of
Clinical chemistry from NDDTC, who had technical expertise
and wide experience in administration of OST in the
community setting in India.
 The training was participatory and multi-modality and on-site
exposure to patients receiving Buprenorphine in the
community was provided.

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
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 center
located in the premises of the Tihar Jail Complex of Delhi
Prisons.
 The deaddcition centre is a 120 bedded hospital. Prisoners on
OST were housed exclusively in one ward of the hospital.
 This was done with a view to make it easier for prison
administration to coordinate and deliver OST services from
one single point

Service Delivery
 Three common situations where it is appropriate to initiate
users on to opiate maintenance in the prison setting are
immediately
 upon admission to prison
 during the sentence
 a period of time before release.
 In this study, opioid dependent prisoners were identified at
the initial medical examination upon admission into prisons
and eligible opioid dependent inmates from Tihar prisons
were offered pharmacotherapy with buprenorphine and
psychosocial 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 OST

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 NA

Daily Dispensing
 Buprenorphine was given as daily Directly Observed Treatment
(DOT) sublingually.
 The medication was dispensed early in the morning to
minimize disruption of their daily activities of the prisoners
including 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 those
who 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 use
Prior 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=133

7.7
1.3
0.8 0.9
0.0
0
1
2
3
4
5
6
7
8
9
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
8.5
3.1
0.3 1.4
0
5
10
15
20
25
30
35
40
45
A highly significant
decrease(F=182.19, df=4,
p<.001) was observed over time
5.0
2.2
0.6
1.2
0.0
0
1
2
3
4
5
6
Baseline 3
months
6
months
9
months
12
months
A highly significant
decrease(F=22.97, df=4, p<.001)
was observed over time

7.5
0.8
0.6
0.0 0.0
0.0
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 were
minimal 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 of
medication was stored in the head office of the prison and a
stock of few days medication was maintained at the site of
dispensing.
 Mechanisms were put in place to ensure that the supply chain
of buprenorphine is well maintained.

Monitoring of provision
 Intensive mentoring inputs were provided from the technical
experts from NDDTC during this period who made weekly site
visits to hand hold the provision of OST and monitor the
difficulties encountered/solve operational problems during the
first 6-8 months.
 Once mechanisms of delivery were established, these visits
were made fortnightly and later monthly.
 Further, telephonic contact with technical agency was always
made 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 days
take away dose of the buprenorphine naloxone combination
on release from prison may be provided to the prisoners upon
their release to offset the risk of relapse.
 This allowed the released prisoner some time to locate his
follow up center in the community and also provided cover for
holidays.

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”

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 was
the unpredictable duration of stay (mostly short) and
unplanned release of these inmates as overwhelming majority
was pretrial remand prisoners and not convicts.
 The available time for therapeutic intervention was often
short.
 Therefore the designated follow up community center was
communicated to the inmate at the time at the time of
induction itself and a referral slip to the community center was
provided 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 counseling
Coordination of prison health staff and administration essential

Conclusion
 This collaborative project was implemented in Tihar prisons
from 2008-12.
 Overall, this project was a significant regional advance as it
demonstrated that it is feasible to implement OST in prisons
and support from both, prison administration and health
services is critical to implement this programme.
 This project has also helped to develop the Standard
Operating Procedures to be followed for OST within prison
settings.
 The effectiveness of OST was demonstrated in prison settings
and this OST model was also “presented” (through study visits)
to Government counterparts from other countries of South
Asia.

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, RMOTihar prisons
 Project team at NDDTC AIIMS
 UNODC-ROSA

 Needle and Syringe Programmes (NSP)
 Opioid SubstitutionTherapy (OST)
 Voluntary HIV Counselling andTesting (VCT)
 Anti-RetroviralTherapy (ART)
 SexuallyTransmitted 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 PSYCHOTROPIC
SUBSTANCES (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 PSYCHOTROPIC
SUBSTANCES (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 CY O N NA R C OT I C
 D R U G S A N D P SY C H OT 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

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