Adopt Harm Reduction Practices in Jails and Prisons

Introductory Paragraph

It is important to address harm reduction by offering treatment for HIV, Hepatitis and substance use disorder in prison. This is expected to reduce infectious diseases and lower SUD-related morbidity and mortality rates. Research has shown that the incarcerated are a high-risk population for potential medical issues and have barriers to access medical care. Syringes in prisons without an Needle Syringe Program (NSP) are sold on illicit markets and are very expensive, given high demand and scarcity. However, in prisons where NSPs operate, there has not been any illicit market reported where needles and syringes are accessible.

Key Information

The Harm Reduction Coalition defines harm reduction as "a range of widely accepted public health policies, practices, and programs that seek to reduce morbidity and mortality associated with drug use and sexual activity, while respecting the autonomy, rights, and dignity of people who use drugs or engage in sex work.”

The Harm Reduction Coalition, a “national advocacy and capacity-building organization that promotes the health and dignity of individuals and communities impacted by drug use” has developed the following eight principles for guidance to communities and agencies to assist with effective harm reduction policies and programs. These principles and guidance can help assist prisons and jails with adapting effective harm reduction programs and practices.

The below are the eight principles of harm reduction provided from the Harm Reduction Coalition

• Accepts, for better and/or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
• Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drug are clearly safer than others.
• Establishes quality of individual and community life and well-being—not necessarily cessation of all drug use—as the criteria for successful interventions and policies.
• Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.
• Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirms drug users themselves as the primary agents of reducing the harms of their drug use and seeks to empower users to share information and support each other in strategies that meet their actual conditions of use.
• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
• Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Harm reduction in prisons and jails requires partnerships among communities for a public health effort to prevent the spread of disease such ad HIV and hepatitis among groups as well as reduce mortality rates. Those partnerships include police, public health and community health experts and community groups and practices.

Hepatitis C

Hepatitis C is more than three times more prevalent among people who inject drugs than HIV. In most countries, more than half the people who inject drugs live with Hepatitis C. The level of Hepatitis C infection amongst US prisoners is substantially higher than the general population: between 12 and 35 percent of prison inmates are infected with hepatitis C, compared to between 1 and 2 percent of the general population. Global HIV prevalence is up to 50 times higher among the prison population than in the general public, while one in four detainees worldwide is living with Hepatitis C.

Preventing the Spread of Hepatitis C by Treating Infected Prisoners

WHO, the United Nations Office on Drugs and Crime and UNAIDS recommended in 2007 that "prison authorities in countries experiencing or threatened by an epidemic of HIV infections among people who inject drugs should introduce and scale up Needle and Syringe Programs (NSPs) urgently."

An analysis of studies of European Prison NSPs "Ten Year of Experience with Needle and Syringe Exchange Programs in European Prisons" concluded that prison NSPs are not only feasible but effective, especially when embedded within a comprehensive prison-based harm reduction and health-promotion strategy."

There is increasing evidence that experience of imprisonment is a strong predictor of HIV and Hep C transmission for the individual prisoners. Nor is this an issue confined to prison. A majority of prisoners serve short-term sentences, during which they are unable to access long term drug treatment, and return to the wider community having been at significantly higher risk of Blood Borne Virus transmission and subsequently more likely to pass on Blood Borne Viruses. For this reason prisons have been called HIV and Hep C incubators.

Relevant Research

These findings come from a Harm Reduction International study on HIV, Hep C, TB and Harm Reduction in Prisons. This 2016 study found that:

• Prison NSPs are feasible and affordable across a wide range of prison settings
• Prison NSP are effective in decreasing syringe sharing among people who inject drugs in prison, thereby decreasing the risk of blood borne virus transmission between prisoners and from prisoners to prison staff
• Prison NSP are not associated with increased attacks on prison staff or other prisoners
• Prison NSP do not lead to increased initiation of drug consumption or injection
• Prison NSP contribute to workplace safety
• Prison NSP facilitate referral to available drug-dependence treatment programs
• Prison NSP can be delivered successfully via a range of methods in response to staff and inmate needs
• Prison NSP are effective in a wide range of prison systems
• Prison NSP can successfully coexist with other drug prevention and drug dependence treatment programs

Important factors in the success of prison NSPs include:

• Easy and confidential access to the service
• Providing the right type of syringes
• Building trust with the prisoners accessing the program

Other research surrounding harm reductions practices in prison settings include:

• Harm reduction in prisons: a ‘rights based analysis’

• Integrating Harm Reduction Therapy and Traditional Substance Abuse Treatment

• The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases

• Examining the relationship between U.S. incarceration rates and population health at the county level.

Impactful Federal, State, and Local Policies

Using Medicaid Funding to expand jail diversion programs There is a potential use of funds for jail diversion programs including harm reduction programs. This includes use of Medicaid funding.

• New York State Medicaid Coverage for Harm Reduction Services – Injection Drug Users Health Alliance (IDUHA)

Available Tools & Resources

EU- Drug treatment and harm reduction in prisons

Harms of Incarceration- The evidence base and human rights framework for harm reduction in prisons

Facts on Harm Reduction and Prisons- Canadian Guide on Mitigating risk in prison populations

Promising Practices

There are four main models of prison needle exchange programs

1. Hand-to-hand distribution by prison health staff, social workers, physicians, or nurses. This method is used in several Spanish and Swiss prisons. The used syringes are either exchanged at the cell door or in the medical unit.
2. Hand-to-hand distribution by trained peers (i.e., prisoners) to ensure confidential contact with prisoners who use drugs as well as access at almost all times. This system is mostly used in Moldovan prisons.
3. Hand-to-hand distribution by external personnel or NGOs who also provide other harm reduction services.
4. Automated dispensing machines e.g., Germany and Hindelbank women's prison, Switzerland (one-for-one exchange, starting with a dummy syringe as the first device).

Germany, Switzerland, and Spain had 19 programs in total by 2000.

Evaluations of these pilot programs have shown that the aims of the programs have been achieved. These include:

• Reduction in syringe sharing
• Subsequent reduction in Blood borne Virus rates
• No increase in drug use
• No syringes used as weapons

The Police Assisted Addiction & Recovery Initiative

The Gloucester ANGEL Initiative Angel Program This program assures any addict who walks into the police station with the remainder of their drug equipment (needles, etc) or drugs and asks for help will not be charged. The program works to guide those who come to the program towards recovery.

Police and HIV Programs – Law Enforcement and HIV Network (LEAHN) This international network provides examples of partnerships among health and law enforcement agencies to reduce HIV in the communities they serve.

---