Media release

Prisons: The next frontier

In releasing the report “Supply, demand and harm reduction strategies in Australian prisons: Implementation, cost and evaluation” the Australian National Council on Drugs (ANCD) has identified prisons as needing a far greater level of attention if Australia is to maintain and further reduce levels of drug use, HIV and hepatitis C.

The Chairman of the ANCD, Major Brian Watters, said “The Council is very aware that we are making inroads into the levels of both drug use and blood borne viruses such as HIV and hepatitis C in the community; and whilst we recognise that prisons have contributed in some part to this national effort there is clearly room for a greater commitment. The majority of prisoners serve sentences of less than 1 year before returning to the community which means there is an obligation on the prisons in this country to ensure that the potential for the spread of infections to the community is reduced and that our efforts to reduce the uptake, use and harms from drug use are not undermined.”

Some of the findings in the report include:

The number of prisoners in Australia has increased from over 15,000 in 1992 to more than 22,000 in 2002 (an increase of over 44%)
On average it costs between $50,000 – $73,000 per year for each prisoner — the ANCD notes that a bed in a residential rehabilitation costs less than $27,000 per year on average
A history of drug use is far more common amongst prisoners than in the general population
A high level of criminal activity is associated with prisoners with a history of drug use
The level of hepatitis C in prisons is estimated to be up to 17 times greater than in the general community
There is a diverse range of programs currently in place across all Australian prisons but very few evaluations on effectiveness and cost benefits have been undertaken
Access to information on program outcomes and costs is generally limited and poor in quality

Prof Margaret Hamilton (an Executive member of the ANCD) added “Prisons will always remain a less than ideal place to have effective therapeutic interventions for drug use. Indeed reports like this add further weight to the importance of the National Illicit Drug Diversion Initiative which attempts to divert drug users from the criminal justice system, particularly prisons, into community based treatment options.”

Mr Gino Vumbaca, the ANCD Executive Officer added “The prison authorities in all states and territories need to reflect on both the findings and recommendations of this report. There are some tough decisions, such as the introduction of needle exchange programs that need to be made, and we cannot afford to wait until an outbreak of HIV infection actually happens before we act.”

A list of the recommendations from the report is attached.

The report was prepared by the National Drug & Alcohol Research Centre (NDARC) on behalf of the ANCD.

16 November 2004

The ANCD is the principal advisory body to Government on drug and alcohol issues.

For further information, please contact:

Major Brian Watters (Chairman)
0400 780 509

Prof Margaret Hamilton (Executive Member)
0408 302 815

Mr Gino Vumbaca (Executive Officer)
0408 244 552

Recommendations

Prisons are an important part of policy responses to illicit drug use because

Many injecting drug users spend considerable periods behind bars
High prevalence of injecting drug use during incarceration has been reported
High proportions of prison inmates report injecting drug use in the community once released
Prisons are expensive institutions to establish and operate
There is limited evidence of the effectiveness of prisons in either rehabilitation of illicit drug use and decreasing drug use in prison or subsequent recidivism.

This study found a diverse array of supply, demand and harm reduction strategies in prison settings in Australia. However, the level of documentation of all three strategies is poor, particularly in regard to supply reduction, and should be improved. Indeed, a great deal of basic research and evaluation is required before cost-effectiveness and cost-benefits can be calculated. Drug use within Australian prisons poses a considerable health risk to prisoners and the broader community, as well as an obstacle to the correctional efforts of prison authorities. It is therefore appropriate that this issue is addressed by the most effective strategies available, and that the implementation of any strategy occurs in an accountable manner.

The following recommendations are based on the recognition of the importance of establishing strategies and programs in prisons that are as near as possible close to the standards and levels achieved in the community.

General Recommendations

As few strategies have been evaluated, there is limited information about the benefits, costs and unintended consequences of these strategies. Therefore, rigorous and comprehensive evaluation of supply, demand and harm reduction strategies is required.

Recognising the importance of all three strategies, and the imperative to optimise the relative allocation of scarce resources for supply, demand and harm reduction programs, regular and independent estimation should be made into the effectiveness, unintended consequences and cost-effectiveness of these programs. Successful programs should be implemented on the basis of these estimations. This information should be made available to key stakeholders.
Prison supply, demand and harm reduction strategies and data on their costs and benefits should be independently and regularly evaluated in line with the National Drug Strategy.
The population of IDU who enter and leave prisons repeatedly is disproportionately responsible for crime and other costs in the community. The nature and extent of this distribution of risks and harms in this sub population requires more accurate estimation.

Supply Reduction Programs

It could be argued that supply reduction is effective in the correctional environment because levels of drug use (as documented in urinalysis and numbers of drug seizures) remain relatively low. However, other evidence, such as self reported drug use and demand for methadone and other treatments within prison, suggests that drug use are much higher than those detected. Prisoners are still using drugs, albeit less frequently than in the community.

Given the substantial investment into supply reduction programs, in addition to the relatively poor documentation, it is imperative that improving the documentation and evaluation of SR strategies takes the highest priority. Methods of measuring drug use other than urinalysis require further investigation and, if more cost-effective, should be implemented.
The benefits and possible unintended negative consequences of differential sanctions for different drugs detected in prison inmates should be independently evaluated. Greater use of incentives for drug-free status should be implemented.

Demand Reduction Programs

Demand reduction strategies were in evidence across jurisdictions, but were poorly documented and were often of restricted availability. Programs should reflect services available in the community as far as is practicable.

Given the high proportion of drug injectors and the limited number of places available in most jurisdictions, jurisdictions should regularly estimate and meet demand for all forms of drug treatment, particularly methadone and buprenorphine treatment.
Considering the increasing trend for the implementation of drug-free units, independent evaluation of these programs is required to determine their effectiveness in addressing problems associated with drug use.
Given the evidence of harms from interrupted drug treatment, it is imperative that continuity of treatment be ensured before, during and after incarceration.

Harm Reduction Programs

High levels of reported drug use and blood-borne viral infection among prisoners have been documented. It is imperative that the harms associated with continuing use, whether in prison or upon release into the community, be reduced where possible.

Efforts must be made to ensure prisoners have access to information regarding illicit drug use and related harms. Education programs, including peer-based education, on illicit drug use and related harms should be rigorously and independently evaluated. If effective, should be introduced in all prisons.
Based on the high levels of drug use and blood-borne viral infection among prisoners, all suitable prisoners should be provided with free hepatitis B vaccination.
As in the community, all testing for HIV and other blood-borne viral infections should be available and voluntary in all jurisdictions.
Given the evidence that some individuals continue to inject drugs during incarceration, bleach should be readily available and accessible in all prisons without repercussion.
In response to reports of injecting drug use still occurring during incarceration despite the best efforts of prison authorities, the introduction and rigorous evaluation of a trial needle and syringe exchange program in an Australian prison is warranted.
Documentation of the use, benefits and any unintended consequences of naloxone availability and use in prison is poor and should be improved in all jurisdictions. Data on fatal and non-fatal drug overdoses within prison should be documented.
Condoms and dental dams should be readily available and accessible in all prisons without repercussion.

Pre- and Post-release Programs

It has been well documented that the first few weeks post-release are a particularly high-risk period for injecting drug users.

Given the well-known increased risk of overdose post-release from prison, continuity of care should be improved for at-risk prisoners. This should be achieved through the implementation of post-release treatment plans including increased collaboration between prison authorities and the relevant community service providers.

Related Recommendations

Western Australia has taken the remarkable step of replacing prison sentences of six months or less with non-custodial sentences. This will reduce the size of the prison population and the number of prisoner movements into, out of and around the system, thereby enabling increased emphasis on correction and rehabilitation. Many prisoners spend only days or weeks incarcerated and the system incurs a substantial cost processing them. Another effect is likely to be a reduction in the number of drug using inmates who typically spend very short, but repeated periods in prison. The NSW prison system is currently considering a similar approach.

The high financial and social costs of incarceration should be recognised, with continuing consideration of alternative, more effective ways of reducing the size of the prison population in all jurisdictions, including the use of non-custodial sentences. In addition, the replacement of sentences of less than six months’ duration should be evaluated and, if found successful, should be implemented in other jurisdictions.

Male to male unprotected anal sex is the main route of HIV transmission in the Australian community. Male to male sex occurs in Australian prisons. Conjugal visits may also provide an incentive for prisoners to improve their behaviour in prison.

There is limited data on the potential benefits of conjugal visits and a trial is warranted in Australian prison.

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