21 November 2006
Dr Gilbert Whitton began by giving us an overview of the prison population in Australia, currently at 24,000 and rising by 5% per year, 50% of prisoners being recidivist and 20% aboriginal. Based on the 2001 Inmate Health Survey, there are high rates of intellectual disability, and mental illness especially depression. Histories of sexual abuse and of head injury are common. Specific figures are not available for ADHD or personality disorders in NSW prisons, but these are prevalent as are substance use disorders. Eighty percent of prisoners are smokers (though 80% of them report that they are interested in stopping); one third of women and half of men have used alcohol at hazardous levels. Cannabis is the most common illicit substance of dependence, followed by amphetamines and then heroin. Hepatitis C prevalence rose from 34% to 40% between 1996 and 2001.
Among police detainees, 20% are affected by amphetamines, 20% by benzodiazepines and 10% by heroin at the time of arrest. Three quarters of prison sentences are linked to drugs in some way, and 60% had offended while under the influence of drugs and/or alcohol.
Between arrest and reaching the facilities of the Department of Correctional Services (after sentencing or on remand) the responsibility for a prisoner's health rests with the NSW Police. This applies in the holding cells of a police station, court cells (such as Sydney Central Court or in the Sydney Police Centre).
Justice Health is actually part of the NSW Health Department, not the Department of Correctional Services. A prisoner's medical records are therefore protected by the same confidentiality provisions as any one else's, and do not form a part of the prison records.
Seven percent of the methadone population in NSW are in prison at any one time, though the turnover is higher, about 100/month. The risk of overdose is much higher on release from prison: 15 times higher if the person is released not on MMT, three times higher if released on MMT. Unfortunately, the Department of Correctional Services cannot offer methadone or buprenorphine at every prison in NSW, often for logistical reasons such as the legal requirement need to have two people present for dosing, one of whom must be a nurse.
The Department of Juvenile Justice has its counterpart in Adolescent Health, part of Justice Health. Dr Whitton described the increasing activities of the Adolescent Health service, covering smoking is a high priority. There is a black market in cigarettes as these are prohibited in Juvenile Justice facilities. Methadone or buprenorphine treatment requires a second medical opinion for those under 18 years.
An old saw about people in prisons is: "If the drugs came before the crime, there is hope, but if the crime came first there's little hope". Dr Whitton gave evidence of very early histories of alcohol and cannabis use in the teenage prison population.
Sue Jefferies, who previously worked in the prison medical service joined the Drug Court in 1999. She informed us of how Drug Court operates under the Drug Court Act which allows convicted offenders to be diverted into programmes to reduce substance dependency and related crime. The aims are to reduce incarceration and the need to use substances, and to increase involvement in treatment.
Eligibility criteria are:
1. DSM IV for opioid dependency.
2. a prison sentence must be likely.
3. non violent crimes only considered.
4. if there is a previous history of violence, especially driving related, a risk assessment is required.
5. the person must live in a designated area - currently western Sydney.
6. no current serious mental illness.
A typical programme involves parole, attendance at groups, counselling, substitution treatment, for a minimum of a year.
People can be breached for non-compliance, being sent back to prison for a period of time - for practical reasons a 3 day spell may be stored up and added to other 'penalities' all to be served in one episode. Urine toxicology is performed 3 times a week. Actual titres of cannabinoids are used, and in consultation with a toxicologist conclusions are drawn about recent cannabis use. Some leniency is shown at first, but abstinence may be required. This fascinating area of differential or quantitative urine toxicology will be looked at in a Concord seminar next year.
Since 1999 there have been 1200 people inrolled in the programme. There are 270 out of prison having completed the programme successfully, and another 370 returned to serve their sentence.
The Drug Court is distinct from the MERIT programme, which is a pre-sentence programme for 'bailable' offences, administered by parole officers. It is a 3 month programme, but the same principles are used, including participation in groups, counselling and goals monitored by strict urine testing.
Health professionals do not refer people to the Drug Court, but Sue Jefferies is keen that GPs and addiction specialists are involved to ensure a smooth transition at the end of the programme.
A compulsory drug treatment programme has also commenced in NSW.
Several case studies were presented in the second half:
A seventeen year old was given symptomatic withdrawal management and eventually started on methadone. The rate of induction reflected both the need for a safe protocol which the doctor may have to write up without medical review being feasible for a week or two, and the low risk of illicit opiate access in prison. A sad observation was that this person was arrested after spending many weeks trying unsuccessfully to get onto buprenorphine maintenance. With early treatment perhaps he could have been kept out of gaol.
The case entitled "I had a liver autopsy in gaol but they stopped the interferon, dunno why" raised the question about how to get medical records (such as liver biopsy and hepatitis treatment results) from a person's time in prison. Stephanie Smith, Public Health Nurse at Mulawa Correctional Centre and a regular Concord participant, advised us of the contact numbers to obtain medical records of people released from custody: Phone 9289 5011/5012/5013; Fax 9289 5014. "It usually takes a few days for the files to get to records, which is located at Silverwater, so if they are recently released you are best off contacting the clinic directly."
"I don't want to go to gaol, they'll make me the pretty boy for sure". The issue of male rape in prison is a real one. Apparently one judge responded to a pre-sentence plea for the risk of rape to be considered with the comment: "Show me the evidence" (books and official reports have since been written on the subject). We heard about an ex-prisoner's advice to threats of rape when arriving in prison. A young cell-mate who had yelled out defiantly in response to threats of rape was the only one who got targeted. The usual advice is "keep your mouth shut". Many rapists are actually homophobic, and the rape is all about power.
Men who have been raped are often afraid or ashamed to report it. They may present to the clinic with complaints about their bowels instead.
"In gaol they used to punch me in the gut to spew my methadone so they could shoot it up". We were advised that this sort of thing is quite real. Another graphic example of the need to 'get stoned' in prison: woman may strap a tampon to their back of teeth and swallow it before dosing to absorb the methadone from the stomach. The product can be filtered through a kitchen scour. Diversion of buprenorphine is likewise a big problem, and sometimes requires a transfer to methadone.
One question showed some ignorance about typical prison conditions: Do people get a cell to themselves? The answer given was a definite "NO".
Summary compiled by Gilbert Whitton, Sue Jefferies and Richard Hallinan.
Sent from Byrne Surgery http://www.redfernclinic.com/
Next year's program is being finalised presently. It will start with a talk on stimulant problems by Dr Alex Wodak of St Vincent's Hospital on Tuesday Jan 30th 2007.
On this web site, Dr Byrne and colleagues have written summaries of many research articles, conferences and other events. These have been written largely to draw attention to peer-reviewed studies which may be relevant to clinical practice and public policy. While all care has been taken to be fair and accurate, readers are strongly advised to read the original publications before acting upon the information for clinical decisions.
Due to this brief form of communication, no responsibility can be taken for errors, mistakes or omissions.
Reputable sources of health information for the general public:
- http://www.healthinsite.gov.au/ (opens in a new window)
HealthInsite, a search site for reliable health information, Australian Department of Health.
- http://www.nlm.nih.gov/medlineplus/ (opens in a new window)
MedlinePlus, a search site for reliable health information, US National Library of Medicine.