Clinical Management of Substance Clinical Management of Substance MisuseMisuse

Dave MarteauDave Marteau

Prison HealthPrison HealthDavid.marteau@dh.gsi.gov.ukDavid.marteau@dh.gsi.gov.uk

Drug-motivated offences are estimated to comprise Drug-motivated offences are estimated to comprise around a third of the total cost of crimearound a third of the total cost of crime

* Includes: security expenditure, property stolen, emotional impact on victim, lost output and expenditure on criminal justice system** This is an estimate within a range of £14-20bnSource: Team analysis, based on NEW ADAM survey of arrestees 1999-2002, ‘Economic and social costs of crime’

Cost of drug-motivated crimes*

Cost of all crime Cost of drug-motivated crime

£58bn

£19bn**

Many high harm causing users enter prison Many high harm causing users enter prison each year, and most leave again within a yeareach year, and most leave again within a year

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

In prison Jan 2001 Enter prison during year Released from prison In prison Jan 2002

Source: Team analysis, based on Prison statistics 2001, NEW ADAM, ONS Psychiatric Morbidity of Prisoners 1998, Criminality Survey 2000

• Nearly a quarter of high harm causing users are in prison at one point during any year

• Their average sentence length is around 4 months

15,000

50,000 49,000

16,000

High harm causing users in prison, entering prison and leaving prison during a year

Characteristics of Injecting Drug Characteristics of Injecting Drug UsersUsers (Matthews 2005) (Matthews 2005)

Entrenched (in their habits)Entrenched (in their habits)

Treatment resistantTreatment resistant

Poor physical & mental healthPoor physical & mental health

Challenging behavioursChallenging behaviours

High suicide and self-harm riskHigh suicide and self-harm risk

Very high post-release mortality Very high post-release mortality riskrisk

StigmaStigma

Rewards for successRewards for success

A 33 year follow-up of narcotic addictsA 33 year follow-up of narcotic addicts(Hser et al., 2001)(Hser et al., 2001)

0

20

40

60

80

100

56 60 64 68 72 76 80 84 88 92 96

Unknown Dead Incarcerated Daily use MMT Occasional use Abstinence

N 581 439 354 242Age 24.5 (3.9) 36.8 (5.4) 47.6 (5.1) 57.4 (4.0)

National Confidential Inquiry National Confidential Inquiry study of 172 prison suicides 1999/2000study of 172 prison suicides 1999/2000

Death Rates in First Year of LibertyDeath Rates in First Year of Liberty (v national mean average)(v national mean average)

Figure 3: Excess mortality ratio for different time periods post-release by cause of death

05

1015202530354045

Time since release (w eeks)

Exce

ss m

orta

lity ra

tio Drug-related deaths Not drug-related

MMT

non-MMT

Follow-up study of mortalityFollow-up study of mortality (Dole et al 2003)(Dole et al 2003)

0.95

0.96

0.97

0.98

0.99

1

0 3 6 9 12 15 18 21 24 27 30 33 36

Probability of survival

months

Re- incarceration up to May Re- incarceration up to May 20022002

ContinuousContinuous

MethadoneMethadone n=45n=45

Non- ContinuousNon- Continuous

MethadoneMethadonen= 216n= 216

pp

Mean total Mean total weeks in prison weeks in prison (sd)(sd)

41 41 67 67 .007.007

Source: Dolan, K

Methadone maintenance treatment [MMT] at 12 Methadone maintenance treatment [MMT] at 12 months after release from prison months after release from prison [Johnson van de Ven [Johnson van de Ven

& Grant 2001]& Grant 2001]

% of released prisoners returning to same % of released prisoners returning to same

prison over 3.5 yearsprison over 3.5 years [n = 3,606][n = 3,606](Levasseur et al, 1997)(Levasseur et al, 1997)

0

10

20

30

40

50

1 2

Released on Subst Released Detoxified

Number of prisoners on methadone Number of prisoners on methadone maintenance programmes in Spainmaintenance programmes in Spain

90 135 6962,041

6,606

10,577

16,283

18,89920,214

21,642 21,81921,223

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

11.7

9.3

11.3

18.6

16.7

14.1

9.2

5.2 5 4.7 3.9

3

0

2

4

6

8

10

12

14

16

18

20

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Incidence of AIDS cases per thousand Incidence of AIDS cases per thousand prisoners in Spain (Pallas 2004)prisoners in Spain (Pallas 2004)

Clinical Management of Drug Clinical Management of Drug DependenceDependence

PlanPlanIndividual assessmentsIndividual assessmentsCare plans based on needCare plans based on needCloser Integration of clinical & CARAT [DIP] teamsCloser Integration of clinical & CARAT [DIP] teamsIncreased maintenance prescribingIncreased maintenance prescribing

Aiming to ReduceAiming to ReduceEarly suicides in prisonEarly suicides in prisonDeaths on releaseDeaths on releaseBlood-borne virus transmissionBlood-borne virus transmissionRe-OffendingRe-Offending

Projected Clinical InterventionsProjected Clinical InterventionsTotal (Total (redred) and maintenance () and maintenance (blueblue))

0

20000

40000

60000

80000

100000