Spanish Survey on Health and Drug use among Prisoners Drug research and drug monitoring in prison Spanish Survey on Health and Drug use among Prisoners http://www.pnsd.msssi.gob.es/ Management and funding : Spanish Ministry of Health, Social Services and Equality Spanish Observatory on Drugs and Addictions Government Delegation for the National Plan on Drugs Room 5b Tengo 15 minutos. Partners: Ministry of Interior. Secretaría General de Instituciones Penitenciarias Generalitat de Cataluña. Dirección General de Servicios Penitenciarios del Departamento de Justicia

INTERVENTIONS evidence-based SPAIN 60 172 inmates (46 528 966 inhabitants) “IMPROVE HEALTH IN PRISONS” OBJETIVE IMPLEMENT EVALUATE INTERVENTIONS evidence-based SPAIN 79 prisons Diagnosis of situation SURVEY Useful tool Foto prisión de granada La población penitenciaria en el momento de la elaboración de la muestra (31 octubre 2016) era de 60.172 internos. La población sobre la que se hace la muestra es de 50.671 internos, en la que se incluyen hombres y mujeres de más de 18 años internos en centros penitenciarios de SGIIPP y DGSP, con conocimiento de castellano, árabe o rumano suficiente para comprender y contestar el cuestionario, de acuerdo a su clasificación penal se incluyen preventivos y penados en 2º grado, penados con preventivas y penados sin clasificar (se excluyen penados en primer y tercer grado y medidas de seguridad). 80 centros penitenciarios en total, 70 de IIPP + 10 de Cataluña (después de estudio cerraron la modelo de Cataluña) CIS o Secciones abiertas (no entran en estudio) hay 13 en IIPP y 4 en Cataluña, 1st STEP

OBJECTIVE SURVEY To obtain information on health, drug use, risk behaviours and drug treatment from prisoners in Spain, aiming at providing useful information to develop and evaluate, evidence-based, programs and intervention to prevent and reduce drug use and associated harms in inmate population. METHODOLOGY Inmates in Spanish prisons Women &men > 18 years old Speaking Spanish, Arabic or Romanian National coverage Sample 2016: 5024 Periodic survey 2006-2011-2016 Work field 2 Nov-2 Dec 2016 Questionnaire face to face (40 min) Comparable to the “European Questionnaire on Drug Use in Prison“

Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment

Spanish male 39 years old with low level education Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Stopped studying at 16 years old Employed before imprisonment Used to live in a house/flat whit his partner (35% whit sons) 32% foreigners (10% Morocco, 7% Rumania, 3% Colombia) For half of them it is the first time in prison Average time in prison in the current imprisonment: 3 years. The most frequent offenses are against properties, people or public health (1 out of 4 related whit drugs) Ofensas public health (tienen q ver con drogas son 1 out of 4) Encuesta Europea de Salud en España 2014 (encuesta a personas de 15 y más años residentes en viviendas familiares en España Personas de 15 y más años residentes en viviendas familiares principales en España). https://www.msssi.gob.es/estadEstudios/estadisticas/EncuestaEuropea/Enc_Eur_Salud_en_Esp_2014.htm 66% of inmates think their health situation is good or very good (71% among the general population) Health Perception Sources: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions. General population data from European Health Survey in Spain 2014.

30% of inmates have been diagnosed of a mental disease ever MENTAL HEALTH Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment 30% of inmates have been diagnosed of a mental disease ever 28% of inmates are currently taken psychiatric medication 21% of inmates have attempted suicide ever 10%-freedom 6%-prison 5%-both places 11% of the inmates are currently taken psychiatric medication and have used an illegal drug in the last 30 days Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

INFECTIOUS DISEASES % of ALL inmates Tested Infected* HIV 77% 6% Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment % of ALL inmates Tested Infected* HIV 77% 6% Hepatitis C 80% 16% % of INJECTORS (ever) Tested Infected* HIV 95% 27% Hepatitis C 71% * % of infection among those who know the test results. Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

7 have used an illicit drug* EVER (71%) For every 10 inmates Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment 7 have used an illicit drug* EVER (71%) 6/5 have used an illicit drug* last YEAR in FREEDOM (54%) 5 have used an illicit drug* last MONTH in FREEDOM (49%) 95% of drug users (ever used illicit drug*) started drug use in FREEDOM 2 have used an illicit drug* last month in PRISON (21%) * Illicit drug: cannabis, opioids, cocaine, ecstasy, amphetamines, hallucinogens, inhalants. Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

INMATE population vs GENERAL population Percentage* of users Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Higher % of drug users among inmates (in freedom) than in general population Age of onset Inmates vs G.population Inmate population starts drug use at a younger age Prevalencia de cocainapolvo. *Prevalence's for tobacco in last month other drugs in last year. Cocaine is cocaine powder. Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

frequency of heroin use* Inmate population in FREEDOM vs in PRISON Percentages of drug users* Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment After imprisonment percentage of drug users decreases frequency of heroin use* Freedom vs Prison ≥10 days/ month < 10 days/ month After imprisonment frequency of drug use decreases 23% imprisonment COCAINA POLVO 81% ≥10 days/month < 10 days/month ↑ Frequency ↓ Frequency *prevalence and frequency in last 30 days users. Powder cocaine Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

Percentage of users (prison last month) Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment 69% Smoked/inhaled 14% Snorted. 11% injected 5% smoked. 1% oral Snorted- 69% Injected-14% Prison last month   2011 2016 Alcohol 3.8 2.2 Cannabis 21.3 19.4 Tobacco 75.1 74.9 Hypnosedatives* 4.1 6.2 Crack cocaine 1.0 1.4 Powder cocaine 1.3 Heroine 2.4 2.8 Trends Risk groups Tendencias: El resto de drogas tienen valores inferiores a 1%. Tendencia poco valorabl Policonsumo: Consumidores de drogas legales e ilegales en prisión últimos 30 días incluye alcohol, tranquilizantes sin receta, cannabis, heroína sola, metadona no recetada, otros opiáceos, cocaína base, cocaína polvo, heroína mezclada con cocaína, anfetaminas, éxtasis, alucinógenos, inhalables. EN PRISON FUMA 92,2% DE LOS QUE TIENEN 20 O MENOS AÑOS Men < 25 years old Spanish *Hypnosedatives without prescription Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

Percentage of injectors Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Availability: Syringe exchange programs and OST are present in Spanish prisons. Knowledge: 95% of inmates know that AIDS can be transmitted by shared syringes/needles. 83% knows this transmission route for Hepatitis C. Percentage of injectors Injection trend En prisión últimos 30 días de todas las droga se inyectan : heroína (66%) cocaína polvo (21,5%) heroína+cocaína (11%) coca base 9,2% Profile: Spanish men between 25 and 44 years old who inject heroin or cocaine, he start injection whit 20 years. injection % injectors in prison last month % of injectors is higher in freedom Decreasing trends Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

6 out of 10 inmates who had sex in the last year did NOT use condom Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Availability: 98% of inmates know that free condoms are available in prison if needed. Knowledge: 95% of inmates know that AIDS can be transmitted by not protected sex. 78% knows this transmission route for Hepatitis C. 6 out of 10 inmates who had sex in the last year did NOT use condom 6 de cada 10 intenso han tenido relaciones sexuales en último año unsafe sex 61% among those infected by hepatitis C 41% among those infected by HIV *% among inmates who had sexual relationship in the year. 6 out of 10 of inmates have had sexual relations in the last year Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

for drug abuse in prison Access to health services and drug treatment in prisons is similar than in the general population. It is universal and free of charge. Sociodemographic & criminal profile Mental health Infectious diseases Drug use Risk behaviours Drug treatment Inmate currently in treatment for drug abuse in prison Type of drug and treatment ** 13% of all inmates 53% of inmates who consume drugs* 41% Opioid Substitution Treatment 59% others therapies *Consume illegal/legal drug in prisons in the last month: tobacco, alcohol, Hypnosedatives without prescription, methadone without prescription, cannabis, opioids, cocaine, amphetamines, ecstasy, hallucinogenic, inhalants . ** information from inmates currently in treatment in prison. Source: Spanish Survey on Health and Drug use among Prisoners. Spanish Observatory on Drugs and Addictions.

3 CONCLUSIONS & RECOMENDATIONS Standardization of definitions and methodologies for data collection and analysis is necessary, in order to improve the comparability between regions and countries. (Ex: “European Questionnaire”). Adapting methodologies and sources of information to the changing phenomena of drugs will help to detect new patterns of drug use. The inmate population has special characteristics: sociodemographic, health, mental and infectious diseases & drug use. - Maintain/improve HIV and Hepatitis C diagnosis. - Increment knowledge on risk factors. - Reassure inmates on the need of condoms use and drug users on the need of sterile syringes. - Mental health!! Prevention, harm reduction, treatment services, social reintegration, etc. must be designed and implemented, taking into account the available data and the characteristics of this population, with a multidisciplinary approach and with the collaboration/coordination of all the actors involved. Prisons have an crucial role, they can reach drug users who had no previous contact with the drug care system, help to start (or continue) drug treatment and contribute to treatment adherence.

INTERVENTIONS evidence-based FINAL GOAL “IMPROVE HEALTH IN PRISONS” IMPLEMENT EVALUATE INTERVENTIONS evidence-based “Providing periodically and update information is useful to develop and evaluate interventions and is good for inmates, their families and in the end for society” Diagnosis of situation SURVEY 1ST step useful tool Foto prisión de granada La población penitenciaria en el momento de la elaboración de la muestra (31 octubre 2016) era de 60.172 internos. La población sobre la que se hace la muestra es de 50.671 internos, en la que se incluyen hombres y mujeres de más de 18 años internos en centros penitenciarios de SGIIPP y DGSP, con conocimiento de castellano, árabe o rumano suficiente para comprender y contestar el cuestionario, de acuerdo a su clasificación penal se incluyen preventivos y penados en 2º grado, penados con preventivas y penados sin clasificar (se excluyen penados en primer y tercer grado y medidas de seguridad). 71 centros total, 61 de IIPP + 10 de Cataluña

Spanish Survey on Health and Drug use among Prisoners http://www.pnsd.msssi.gob.es/ Obrigado Thank you Management and funding: Spanish Ministry of Health, Social Services and Equality Spanish Observatory on Drugs and Addictions Government Delegation for the National Plan on Drugs Partners: Ministry of Interior. Secretaría General de Instituciones Penitenciarias Generalitat de Cataluña. Dirección General de Servicios Penitenciarios del Departamento de Justicia