DRUG PREVENTION OUTSIDE AND INSIDE PRISON WALLS
Ambros Uchtenhagen, Institute of Addiction Research, University of Zurich, Switzerland
The risk for developing substance dependence is increased in the prison milieu, due to stress factors, to the availability of drugs and to an over-representation of persons dependent on drugs among the prison population. Recent overviews on projects for primary prevention against substance abuse in European countries are summarised and some evaluation results are discussed (especially prevention programs in the school milieu and in community settings). The main messages are that knowledge and attitudes can be improved, but with unreliable impact on consumption behaviour, that short programs are not effective and that most programs cannot adequately reach those who are most in need for them. These messages have to be considered when it comes to prevention in the prison milieu. The specific prevention goals for Prison Populations are identified, and selected strategies mentioned (including control measures, therapeutic and harm reduction measures). Evaluation of such prevention strategies and programs is rare; a few examples are given. More pilot projects are recommended, focusing on relapse prevention of those already dependent, adequate networking with after-care and other agencies outside, and active participation by inmates in order to improve compliance with the programme.
Efforts to reduce the consumption of intoxicating and habit-forming substances in the prison milieu are not well documented and even less evaluated. This is in contrast with the increased risk for drug consumption in prison inmates, due to a number of factors, such as an increased demand for psychoactive medication and the overrepresentation of drug use in delinquent populations.
This paper therefore tries to summarise first what can be learned from drug prevention in general, focusing then on prevention issues relevant for the prison milieu and pointing out some perspectives for future activities.
SOME ESSENTIALS OF DRUG PREVENTION
Prevention has to start by designing its objectives.
Objectives may be:
· to prevent first use
· to reduce the number of users
· to reduce the overall extent of use
· to prevent abuse and dependence
· to minimalise harmful use
Prevention strategies have to be selected according to objectives.
Main strategies are
· Information through mass campaigns or targeting specific groups
· Education (health education, social skills training)
· Counselling (e.g. for individuals at risk, for parents and peers community activities) Improving quality of life at the workplace or improving living conditions in general
· Supply control (by interdiction, taxation, product control or privileged access)
As an example, Table I shows the range of strategies which can be used if the objective is to reduce the number of users. The various strategies are based on theoretical assumptions about the nature and predictors of human behaviour. The range of theories includes the following:
· Rationalistic theories: People act according to their knowledge
· Utilitarian theories: People act in order to maximise gains
· Learning theories: People act according to previous experience
· Voluntaristic theories: People act according to drives and needs
· Deterministic theories: People act according to preestablished patterns of behaviour (genetically or socially determined)
Drug prevention, aiming at preventing specific types of behaviour or aiming at behaviour change, has to be explicit concerning its theoretical bases. Some of the theoretical models used in drug prevention are
· Communication / persuasion model (MC Guire)
· Social learning model (Bandura)
· Life skills approach (Botvin)
· Healthy lifestyles approach (WHO)
· Functional equivalents to drug use (Silbereisen)
RECENT DRUG PREVENTION ACTIVITIES IN EUROPE
Two recent publications document prevention activities in a number of European countries, based on specific surveys.
The first isacatalogueof 75 projectsfrom 14countries, published in 1993 in Spain (Zaccagnini et al., 1993). Table 2 summarises the nature of information provided and the main topics covered in the projects.
The second publication is a report made on behalf of the council of Europe and published 1994 (NegreirosCarvalho). It focuses on'the most significant prevention projects'in the participation countries (defined as being innovative, and/or evaluated, andlor successful). The questionnaire during the pilot face asked for information about scope and objectives, target groups, planning, implementation, evaluation and funding. In total, 47 projects from 18 countries are included (overview in Table 3)
Both overviews demonstrate that most activities focus on information and education for non-users, especially in schools. A minority only is directed towards behaviour change. Half of the activities are performed on the national level, practically none on the international level. Monitoring and process evaluation is more frequent than impact assessment.
EVALUATION OF PREVENTION ACTIVITIES
Controlled studies from USA have demonstrateda number of essential findings concerning drug education and health education. Controlled studies onprimary prevention in schools from European countries have been collected recently by a working group of a COSTproject (Cost A-6 'Evaluation of action against drug abuse in Europe'), confirming some of the main findings (Table 4). From USA, we also have evaluation studies on secondary prevention for highrisks-groups in community settings. The findings may be summarised as follows:
· Secondary prevention for high-risk-groups in community settings
· short term effects: decreased use, less dangerous drugs and use patterns
· mid/long-term effects unknown
· involvement of parents: better results
· social support and training in social relationships better than information caveats
· inadequate strategies how to reach those who are most in need
· negative stigmatising effects for those labelled 'high-risk'
The main messages are that knowledge and attitudes can be improved, but with unreliable impact on consumption behaviour, that short programmes are not effective and that most programmes cannot adequately reach those who are most in need of them. Such findings confirmed a necessity to implement drug prevention programmes in prisons with their high-risk-populations.
DRUG PREVENTION ISSUES AN STRATEGIES IN PRISONS
There are at least five categories of populations at risk:
1. inmates who never used: exposure to first views while in prison,
2. inmates who are non-dependent users: risk for developing dependence during stay in prison,
3. inmates dependent on drugs: risk for secondary infections, increased management problems,
4. inmates who are ex-users: relapse risk while in prison,
5. inmates with specific delinquency risks: relapse after discharge (e.g. driving while intoxicated).
Drug prevention therefore has many issues to cope with, such as the following:
· how to prevent non-users to start drug use while in prison,
· how to prevent development of abuse and dependence in persons with controlled users,
· how to prevent relapse during stay in prison,
· how to prevent relapse in specific delinquency after release from prison.
A range of strategies therefore has to be considered, some of which are applicable for all groups at risk, whereas others are more specific:
· Supply control (cheeks)
· User control (urinanalysis, separating heavy users from non-users)
· Medical and psychosocial assessment and counselling/care for users and non-users
· User treatment and management (drug-free, substitution, psychopharmacological, medical and psychosocial care, family/spouse counselling)
· Hygienic measures to avoid harmful use (Bleach, syringe exchange)
· Nutrition (alternative source of satisfaction and wellbeing)
· Options for leisure activities and initiatives
· Information/education (drug specific and/or general health education)
· Pharmacological relapse prevention (Antabus, Naltrexone)
· Psychosocial relapse prevention (release preparation, after-care)
A starting point for identifying risk groups and appropriate strategies in a given prison are: detailed knowledge on user categories, psychiatric and health status of inmates, length of stay in prison and milieus where inmates are returning to. A good example is the implementation of specialised teams in French prisons (antenne- toxicomanie) which have to screen all inmates at entry for drug use and social problems which provides anonymised data, centrally evaluated at INSERM and providing individual care, sports, cultural activities, preparing release and establishing contacts with agencies outside prisons for follow up. Some of the data are especially relevant for prevention purposes: such as the high rates of drug using partners (25%), drug using siblings (22%) and children at risk (27 %) (Facy 0.j.).
EVALUATION OF DRUG PREVENTION IN PRISONS
Evaluation studies are extremely rare. The abovementioned overviews include only one project from Sweden, and a comprehensive literature search resulted in two recent US studies.
The national Swedish Board of Health and Welfare implemented in 1987 an individual learning course on drug related issues for staff working in correctional centres fordelinquent use. This course used an information package developed for staff working for drunken drivers. Evaluation is planned, results are not available yet.
A study by Peyrotetal. (1994), using a cognitivebehavioural approach, found evidence of improvement of knowledge and attitudes but no behaviour change. Barbour 1993 evaluated a programme aiming at interactive coping skills for highrisk situations (relapse prevention) and found in the shortterm improved self-efficacy, at in mid-term no difference in a control group regarding consumption and self-efficacy.
There are a number of reasons which account for the scarcity of systematic drug prevention programmes in prisons and especially for evaluations. Nevertheless, with increasing numbers of drug users in prisons, with increased health and management problems and with high relapse rates documented, additional efforts are asked for.
PERSPECTIVES FOR THE FUTURE
Not knowing what strategies and programmes are feasible and effective, well-designed pilot projects are recommended, including independent evaluation. In the preparation ofprojects, the results from drug education programmes outside the prison milieu and from other approaches have to be taken into account.
As a basis for more systematic implementation of drug prevention in prisons, a systematic collection of relevant information on inmates is essential. Available data are in favour of
· combined care prevention projects for those who are already involved in drug use,
· a special focus on relapse prevention,
· adequate networking with after-care and agencies outside,
· active participation by inmates, in order to improve projects and to improve compliance.
Arribros Uchtenhagen, Instiyte fuer Suchtforschung, Konradstrasse 32, Zurich 8005, Switzerland.
BarberjG (1993). An application of microcomputer technology to the drug education of prisoners. Journal of Alcohol & Drug Education 38(2) 14-22.
Facy F. Toxicomanes incarc6r6s vus dans les antennes-toxicomanie, enquete 6pid6miologique 1989-1990. Convention entre le minist~re des affaires sociales, le minist~re de la justice et l'institut national de la sant6 et de la recherche m6dicale
Negreiros J. Drug misuse prevention projects in Europe. University of Porto (Portugal), P-PG (94) 25, Cooperation group to combat drug abuse and illicit trafficking in drugs (Pompidou Group) Council of Europe.
Peyrot M et al 0 994). Shortterm substance abuse prevention in jail: A cognitive behavioral approach.joumalofDrugEducation 240) 33-47.
World Health Organization (199 1). Programme on substance abuse. Guidelines for assessing alcohol and drug prevention programmes, WHO/PSA/91.4
Zaccagnini JL et al (1993). Catalogo de programas de prevencion de la drogadiccion. Promolibro Valencia.