risk reduction for drug users in prisons

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RISK REDUCTION FOR DRUG USERS IN PRISONS ' ENCOURAGING HEALTH PROMOTION FOR DRUG USERS WITHIN THE CRIMINAL JUSTICE SYSTEM'

Editors: Heino Stover Franz Trautmann

Bremen Institute for Drug Research (BISDRO), Bremen / Germany Unit International Affairs, Trimbos Institute Utrecht /The Netherlands

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"This project is supported by the EC Program of Community Action on the Prevention of Drug Dependence." "Neither the European Commission nor anyone acting on its behalf is liable for any use made of the information in this publication"

Copywright © 2001 by Trimbos Institute , The Netherlands

Reina Regente , 5-bajo Apdo. 667

20603 -SAN SEBASTIAN

© 2001 by Trimbos Institute , The Netherlands ISBN:

90-5253-367-9

This publication may be copied for non-profit educational purposes only, under the condition that the source is quoted. The editors request the user of the manual to inform them of any publication of (parts of) the manual. Editors

Franz Trautmann & Heino Stover

Translation and text editing : Peter McDermott & Jeanette Roberts dEsiGn and dtp:,

www.ullcy.com Bob Karhof & Remko den Besten

Postal address :

Trimbos Institute - Netherlands Institute of Mental Health and Addiction Unit International Affairs PO. Box 725 3500 AS Utrecht The Netherlands +31 (0)30 297 1100 +31 (0)30 297 1111 [email protected] www.trimbos.nl

Phone : Fax: E-mail: Website :

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Contributing authors: Cas Barendregt Institute for Addiction Research Rotterdam / The Netherlands

Murdo Bijl MSF Moscow/ The Netherlands

Saskia de Bruine Service for Penitentiary Institutions /The Netherlands

Jon Derricott Writer and Training Consultant, Liverpool / England

Maarten van Doorninck Trimbos Institute / The Netherlands

Neil Hunt RMN, BSc, MSc, Lecturer in Addictive Behaviours, University of Kent at Canterbury, Maidstone / UK

Jan Hendrik Heudtlass CLEANOK, Lengerich / Germany

Jutta Jacob

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Carl von Ossietzky University of Oldenburg / Germany

Barbel Knorr Deutsche AIDS-Hilfe, Berlin / Germany

John Peter Kools Mainline, Amsterdam/ The Netherlands

Michael Levy Director Population Health, Corrections Health Service, New South Wales, Australia

Sheila R. McNerney

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Liason Health Adviser, Leeds Centre for Sexual Health, General Infirmary / England

Lucie van Mens Dutch Foundation for STD Control, Utrecht / The Netherlands Andrew Preston Freelance Harm Reduction Writer and Trainer, Dorchester / England .::V

Nick Ro le Scottish Prison Service / Scotland

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Petra Winkler Waldklinik Jesteburg, Hamburg / Germany

TABLE OF CONTENTS INTRODUCTION Production of the manual I. Prisons, medical care and drug use 2. 3. Drug use in prison: - Substances, patterns and frequency of use, routes of administration

1 3 5 11

SUBJECTS OF MESSAGE General health tips for men and women in prison Mental stability 1.1. t --^ 1.2. Taking care of your body 1.3. If an inmate is HIV or hepatitis B/C positive 1.4. Protecting yourself from illnesses 2. The effects and risks of drugs 2.1. The effects of drugs - what we ought to know - Uppers, downers and hallucinogens - Hashish and marijuana (cannabis) -Tobacco - Alcohol - Cocaine, freebase cocaine and crack - Heroin and methadone - Hallucinogens - Ecstasy (XTC) - Sleeping medication and tranquillizers - Self made drugs - the'prison high' - Quiz -'What do you know about drugs' 2 .2. T he risks of using drugs - Introduction - Methods of drug use - The risks of cannabis - The risks of tobacco - The risks of alcohol - The risks of cocaine - The risks of heroin - The risks of hallucinogens - The risks of speed - The risks of Ecstasy - The risks of sleeping medicines and tranquillizers - Quiz -'What do you know about an overdose?' 3. Transmission of virus , bacteria and parasites: HIV; hepatitis; TB and STD's 3.1. The prison as breeding ground for infections? Infectious diseases 3.2. - The 'flu' - Tuberculosis (TB) - Hepatitis A

17 17 17 17 18 19 21 21 21 23 24 25 26 27 29 32 33 34 37 43 43 46 50 51 52 54 55 57 58 59 60 63

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69 73 74 74 75 77

3.3.

4. 4.1. 4.2. 4.3. 4.4. 5. 5.1. 5.2. 5.3. 5.4 6. 6.1.

6.2.

6.3. 6.4. 6.5.

6.6. 6.7. 6.8.

- Hepatitis B (including vaccination) - Hepatitis C - HIV/AIDS - HIV and hepatitis Testing - Pre- and post-test counselling Sexually Transmitted Infections (STIs) - Chlamydia - Gonorrhoea - Genital warts - Genital Herpes - Trichomonas Vaginalis (TV) - Pubic Lice (Crabs) - Syphilis Safer Sex in prisons Condom availability in prisons General information about condoms Instruction condom use Quiz'What do you know about infectious diseases?' To sum it up: How to protect oneself! Daily contact Sexual contact (Other forms of) blood-to-blood contact Specifics of safer sex Safer drug use in prisons Syringes - boiling out injection equipment - the bleach procedure - the iodine procedure - the alcohol procedure Injecting paraphernalia - Spoons - Water / water container - Filter - Alcohol swabs - Surfaces - Acidifiers - Tourniquets - Environment Preparing a shot Self-injecting Alternative routes of administration - Chasing the dragon Snorting and smoking Syringe distribution in prison Quiz -'Play it safe' High risk situations in a high risk environment

78 79 82 84 86 90 91 92 93 94 94 95 95 97 98 99 100 101 107 107 107 107 108 113 114 115 116 117 118 119 121 121 122 124 124 125 125 126 126 127 129 129 129 131 133 139

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TABLE OF CONTENTS

- Overdosing heroin or other sedativa - Fatal dilutions, mixing drugs and choking

6.9.

6.10. 7. 7.1. 7.2.

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7.3. 7.4.

7.5. 7.6. 7.7.

139 140 First aid 141 aid - First in drug emergency 141 - Heart massage 146 - Quiz -'What do you know about an overdose?' 147 Drug use. after release - health warning 153 Skin penetration: acupuncture , tattooing and ear piercing155 What is a skin penetration procedure? 155 -The back g ro u nd 155 General 156 - Hand washing 156 - Single use equipment 157 - Gl oves for s ki n penetrat i on procedures 158 - Gloves for cleaning 158 - Best practices 158 Skin preparation 159 Cleaning 159 - Cleaning the equipment 160 - Care of cleaning equipment 160 Disinfection 160 Sterilisation in "emergency cases" 161 Questions left and alternatives 161

METHODS AND ORGANISATION 1. 2. 1

1

3.1. 3.2. 3.3.

3.4. 3.5.

3.6.

4. 4.1. 4.2. 4.3. 4.4.

Risk reduction strategies in prisons - why and how? Problems in transferring risk reduction measures into the prison setting Organisational aspects Needs assessment / collecting information Setting priorities and aims Defining the target group(s) Choosing an approach Preparing activities Monitoring and evaluation - Evaluating / monitoring individual counselling - Evaluating / monitoring training seminars - Evaluating / monitoring services / supportive measures - Monitoring cycle Main concepts for assisting drug users in prisons External variables Attitude Social influence Self-efficacy

163 167 169 169 170 171 172 173 178 179 182 184 184 187 188 189 190 191

Intention Barriers (Lack of) Skills How to make contacts to drug - using inmates 5. 5.1. The first steps Getting in touch 5.2. - Making a new contact on your own - G e tti ng i n t ro d uc ed by someone Counselling 6. How to raise the subject of safe(r) behaviour 6.1. How to discuss the subject of safe(r) behaviour 6.2. - Attitude and behaviour - Practical rules Training seminars 7. Needs assessment 7.1 Setting priorities and aims 7.2 Defining the target group(s) 7.3. Planning and designing a seminar program 7.4 - General considerations when organising a risk reduction seminar - The opening session - Methods to be used - Taking into account specific target groups / specific issues Training seminars for inmates 7.5. - Working with groups or individual inmates? Training seminars for prison / drug service staff 7.6. - Identification with the goal of preventing infections - Acquiring basic medical knowledge - Accepting and meeting individual and collective needs for safety 7.7. Training seminars for mixed groups Exercises for training seminars 8. Exercises on safer use (primarily for inmates) 8.1. - Introducing the safer use subject - Assessment of disadvantages of injection techniques of disadvantages of Assessment [copy sheet] injection techniques - Alternative route of administration -'In case of...'- How to respond effectively to unfavourable circumstances -'In case of...' [Copy sheet] -'In case of ..:some alternatives - Negotiation skills 4.5. 4.6. 4.7.

192 192 192 195 196 198 198 199 201 201 202 203 204 207 208 208 209 210 211 212 212 214 214 215 216 216 217 217 218 219 220 222 223 225 227 228 229 231 234

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TABLE O F CONTENTS

8.2.

- Prison drug-using situations how and when to intervene? - Simulation of a stressful situation: "Imagine....." - Needle sharing and drug sharing - Work sharing Exercises on safer sex (primarily for inmates) -'Dirty words' - Sexual or not - Sexual or not - Example list of words

[Copy Sheet]

[Copy Sheet] [Copy Sheet]

[Copy Sheet page 1] [Copy Sheet page 2]

[Copy Sheet page 1] [Copy Sheet page 2] [Copy Sheet page 3]

[Copy Sheet]



- Sexual or not

- Sex education - Safe or not? - Merry go round - Merry go round - Instruction condom use - Instruction condom use - Condom relay race - The safer sex debate - The safer sex debate - The safer sex debate - Exploring different value systems - Exploring different value systems - Statements - Exploring different value systems - Exploring different value systems - Exploring different value systems - Safer Sex in relationships, sex work as risk exposure - Safer sex in relationships - scenario - Respond to persuasion in a positive way - Exploring the facts about HIV/AIDS - Respond to persuasion in a positive way "Beep Beep" statements - Statements on HIV/AIDS

- Answer sheet to exploring the facts Exercises for prison staff only 8.3. - Legal and illegal drugs - Cannabis use of inmates what do you think about it? - Abstinence and/or risk reduction what are the goals? - Health risks for staff - Prevention of communicable diseases in prison 8.4. Exercises for prison staff and inmates - Talking about drugs [Copy Sheet page 1] - Talking about drugs [Copy Sheet page 2] - Talking about drugs

235 237 239 240 241 244 245 245 247 249 250 251 253 265 267 269 270 271 273 275 276 277 279 281 283 285 287 288 289 291 293 295 296 297 299 300 301 302 302 303 305

307 309 Services 309 Services to support safer use 312 Needle exchange programs 313 - Recommendations 314 - Different approaches 316 - Examples from practice 318 Provision of condoms or prescription not), doctor (either by medical - By the 319 or by the medical service/unit through nurses 319 - From the prisonshop - By prison social and health workers, or by the 319 staff of community AIDS and drugs services 319 inmates -Through 320 - Anonymous access 321 Supporting measures 10. 321 10.1. Collecting information - Describing the prison drug scene 322 with focus on health risks involved 323 - Assessing the needs of drug users in prisons - Identifying shortfalls in health and 324 drug services in prison and community 325 10.2. An inquiry by means of a questionnaire 326 material brochures 10.3. Development of information 10.4. Issuing a newsletter and collaborating with prison magazines 327 329 10.5. Organising activities 329 - Interest related 330 - Leisure 331 Peer Support in prisons 11. - A matter of Hygiene

3. 4. 5.

References Examples of evaluation questionnaires for training semimars Acronyms and Abbreviations Usefull websites Usefull Addresses

335 341 359 360 362

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INTRO D UCTION

Our interest in the issue of the criminal justice system and health promotion for drug users stems from our involvement in prisons in the framework of the European Peer Support Project (EPSP), a project which began in 1993. The focus of this project has been on developing peer support as a means to risk reduction in intravenous drug user (IDU) communities in the different EU Member States. The objective of this project, which was financially supported by the drug prevention program of the European Commission, was to stimulate professional and voluntary drug services as well as inmates and drug user self-organisations to use peer support as part of a strategy to reduce drug use related harm (Trautmann 1995). In November 1996 the EPSP entered its third phase. In its last phase, the project included the development of peer support among injecting drug users as part of a risk reduction strategy in prisons in Germany, Ireland, Italy and Portugal (Verpalen and Trautmann 1997a and 1997b). This pilot project confirmed our impression that there is a need for risk reduction interventions and health promotion for drug users in prison and that prisons can play a significant role in organising such activities (Stover and Trautmann 1998, Stichting Mainline 1997). The activities that were organised in prisons in the course of this project were an eye-opener to us in regard to the potential of the legal system in the field of health promotion for drug users. Hence we developed a new project - 'Encouraging Health Promotion for Drug Users within the Criminal Justice System' - which, in addition to writing this manual, also entailed the creation of an inventory of existing good practice in the different parts of the criminal justice system and the organisation of an international conference titled 'Encouraging Health Promotion for Drug Users within the Criminal Justice System' which was held from 22-25 November 2000 in Hamburg/Germany, this conference has been held in comjunction with the 4th European Conference of Drug and HIV/AIDS Services in Prison of Cranstoun Drug Services (London / UK). This as other inventories have demonstrated, there is a range of possible options for health promotion within the prison setting. Different professions can play an important role here: general prisons staff, prison health care workers and probation officers. Furthermore, community services and drug users can also contribute. Staff from drug treatment services can play a role in training prison staff. Drug users themselves may also play an important role, supporting their peers to help them realise safer behaviour.



From the many possible options for health promotion in prisons, we include the following measures: ^ Drug free treatment might be the most common health program for drug users in prisons. It is also the program that has been evaluated most thoroughly. However, the measured effects in terms of helping prisoners attain and sustain drug free status have been shown to range widely, from being 'quite effective' (Inciardi 1993) to'more or less ineffective' (Schippers and van der Hurk 1998). In general, expertise and sometimes even staff from existing treatment programs outside the prison are'imported' into prisons. ^ There are more general health education programs, one example being the Dutch program 'Everything under control', a training program for inmates with drug-using experience that is not focused primarily on the need to achieve abstinence from drug use. In this program, participants are taught ways to reduce the risks involved in drug use, and strategies to help them to control their drug use after release. In 11 sessions, people learn to make decisions about their drug use (what drugs do I want to use and in what way?), and learn how to set goals and limits and how to devise strategies to help them reach their goals. The program also covers a broader field of health education including psychosocial aspects, social skills, etc. (Blekman and van Ernst 1997). ^ Substitute drug programs (for example, methadone programs) have been implemented in various countries either as detoxification or as maintenance schemes (Dolan and Wodak 1996; Keppler/Stover 1998). ^ Harm reduction programs aim to limit as far as possible drug-use related health risks. The theme of these harm reduction programs is: 'If you use drugs in prisons, do it as `safely as possible!' The practical support for users matches the individual needs and resources of the drug users. These programs can include the following aspects: D Distribution of syringes has been implemented in a number of prisons in Switzerland, Germany and Spain, initially as an experiment (Stover 2001) and later as a regular service. D Distribution of bleach to clean syringes is allowed in a number of prisons in various countries (Dolan 1995). D Peer support (see above).

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^ `Information or training before release to prepare inmates with eperience of drug use for the risks faced after release (information about enhanced overdose risk after release, safer injecting, etc.) is a service available in a number of countries. This manual describes what can be done to reduce drug-related health risks in prisons. In this manual we integrate the results of various projects done in this field. Besides basic information on drugs, drug use, infectious diseases and risk reduction strategies the manual contains modules of training seminars for staff and inmates.

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PRODUCTION OF THE MANUAL

The manual is primarily addressed to professionals in health services working either within the prison or outside. They may be employed as civil servants within state agencies or in NonGovernmental Organisations. These groups have the advantage of confidentiality when working with prisoners. Moreover, social workers, prison officers, peer leaders or inmates can use this book as a source of practical information. It has been written as a curriculum, focusing on the question: what information should be provided at any given time? How and by whom? Answering these questions means that - when working in prisons - not only are the form and content important, but organisational and methodological issues must also be kept in mind. Our central subject matter is risk situations for prisoners and staff members. These vary from country to country, sometimes even from prison to prison within a particular country or even a region or city. So we have tried to write a manual that can be used for developing health promotion activities and can be adapted to the specific needs and circumstances of prisons in different countries. We are sure that a lot of useful information may be added when integrating the experiences of inmates and staff members working in health promotion projects.

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The major objectives of this manual are: ^ To raise awareness of health problems connected to drug use and drug-related infectious diseases To initiate and support a discussion about risk reduction as ^ response to these health problems ^ To contribute to knowledge, skills and insight into the problems and encourage a positive attitude towards risk reduction activities by both inmates and personnel



^ ^

To disseminate information relevant for health promotion by a range of means To stimulate and support the realisation of risk reduction activities for inmates as well as for staff members

In order to realise these objectives , the manual also contains information for prison staff about health and safety at work , drugs, addiction, infectious diseases and the services needed. For inmates, we have included information about risk situations and risky conditions within the prison setting . We give technical and organisational advice on how to raise certain topics and how to initiate risk reduction activities in a prison context. We introduce specific methods showing how to reach and work with the target groups . We have also included sheets listing central topics and questions, which may serve as a basis for group work or for individual counselling. Finally we have included an overview of relevant literature and a list of addresses of important institutions in various countries. However, a manual like this cannot cover all issues related to risk reduction. We have inevitably had to make choices . We have limited the scope of the manual to risk reduction as such. This means for instance that we do not cover some important psychosocial issues , such as dealing with the consequences of having been exposed to violence , including sexual violence like abuse and rape. The fact that we consider these issues to be beyond the scope of risk reduction does not, of course , mean that one should not care about them . If and when one does come across them , one should try to find appropriate support and care for the inmates in question. One should also, however, bear in mind that a prison is in no way a therapeutic institution. The opportunities and facilities for psychosocial support and care in prisons are usually quite limited. This is especially true for staff from community services whose task is to contribute to risk reduction . Such staff generally will not have enough time, adequate training or the right to get involved in this type of specialist issue. Another caveat is that this manual inevitably focuses primarily on individual behaviour change . However, it is evident to us that structural and institutional changes are a prerequisite to building a healthy environment and to supporting individual health behaviour. So we would contend that this level should always be considered at the same time. In spring 2001 , we 'tested ' parts of the manual in Turin ( Italy) and Dublin ( Ireland), discussing the draft version with prison governors, prison staff and community health staff. This was done in co-ope-

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ration With partner organisations involved in the prison part of the European Peer Support Project. Furthermore, different experts have commented on and contributed to different parts of the manual (see the list of contributing authors). The many helpful insights and critical remarks of all these people have been integrated into this final version of the manual. Finally, a Russian version of this manual is under preparation in co-operation with AIDS Foundation East West in Moscow, the successor of Medecins sans Frontieres - Holland (Moscow).



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PRISONS , MEDICAL CARE AND DRUG USE

In a European study of health problems arising in prison, Tomasevski (1992) pointed out three main problem areas: substance abuse, mental health and communicable diseases. These problem areas are closely interrelated. In most prisons in Europe drug use has become a substantial problem. Drug use related health problems have to do with a threefold ban on drugs in prison. Drugs are forbidden, drug use is forbidden (urine testing to prove drug use is common practice in many prisons in Europe and a positive test frequently results in additional punishment) and there are no special facilities where inmates can go and use drugs (in growing contrast with the situation outside prison, in countries like Germany, Switzerland and Holland, though this situation does not apply in other countries such as the UK, France, Ireland, etc.).This last point means that there is hardly any 'private' space in prison. In most countries, a cell has to be shared with other inmates, the 'public' space is intended for use by all prisoners. This inevitably leads to stress, particularly when drugs are being prepared. Hygienic precautions are neglected, with the possible risk of infections with HIV or hepatitis. The risks of overdoses when starting to inject drugs again after release are extremely high (Seaman/Brettle/Gore 1998).

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Injecting drug use in detention contributes to the risk of spreading communicable diseases like HIV/AIDS, hepatitis, Sexually Transmitted Diseases (STD's) or Tuberculosis (TB). A spread of these diseases from drug users into the wider community is likely and poses a serious threat to public health as prisons are not an isolated reality. The high, and in some countries, rapidly rising levels of communicable diseases among prisoners clearly show that the health of prisoners (and prison staff) is becoming a matter of growing concern for the general public health. The high turnover



rate of prisoners who often serve short-term sentences plays an important role here. In addition, the following factors serve to enhance the spread of the aforementioned communicable diseases in prisons: Overcrowding, malnutrition and poor hygiene conditions. ^ ^ The fact that prisoners often belong to poor, deprived and marginalized population groups, which are particularly vulnerable to HIV and TB infection. ^ The fact that imprisonment in many countries limits access to the means of prevention and medical care compared to the general standards in the community. ^ The fact that risk behaviours such as injecting drug use and sex among prisoners do occur and that injecting drug users in many countries constitute a large proportion of the prisoners (see also Joint WHO/UNAIDS European Seminar 1997). Drug users when entering the prison system frequently suffer from multiple drug dependencies and from severe health problems, i.e. withdrawal symptoms, abscesses, infectious diseases and mental health problems. The prevalence of infectious diseases like HIV/ AIDS and/or hepatitis A, B and C in prisons is often higher than in the general population. A relatively high percentage of inmates first began to use drugs while in prison. According to a recently published study in Ireland, more than one prisoner in five began to inject drugs while in prison (Houston 2000). Prison medical and security staff have to deal with these drugrelated problems, while the causes of the problems usually remain far beyond their reach. Furthermore an adequate response to the health problems encountered within the prison is often beyond the responsibility (and capacity) of the prison staff and administration - prisons are in no way therapeutic institutions.

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But both inmates and prison staff are exposed to similar health risks (i.e. accidental needle stick injury when searching the cells) and thus have vital common interests in health and security measures in the prison (see 11 8.3.). There are also significant differences between the countries medical care provision in prisons. In all but two of the EU Member States, medical care is provided by the administration of the Ministry of Justice. France and Italy are the only countries in which the community health services are responsible for providing health care in prison. Moreover, there are substantial differences in the approach

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towards drug use in prisons. In most of the countries the emphasis WAN is on supply reduction. Demand reduction is generally limited to drug free treatment. This approach fits in with an understanding of the prisons' job as being to prepare prisoners for a life without offending, as in many countries the use of illegal substances remains a criminal offence. While in the past decade risk reduction measures have been applied successfully in the community, in prisons, drug free orientation still is the predominant perspective. Risk reduction strategies, which are used outside prison, are often regarded as undermining the measures taken inside prison to reduce the supply of drugs. Such measures are also often regarded as a challenge to the policy of drug free orientation in penitentiaries and as a threat to prison security. The health risks connected with drug use are generally seen as of secondary importance. However, it would be more appropriate to view drug use as something that should be avoided, but when it does occur - and that seems to be a fairly frequent occurrence in most European prisons - then damage to the user's health and to that of other inmates and personnel should be avoided. Inmates should not leave prison with health problems in excess of those that they had when entering prison - a point of view that is clearly supported by the World Health Organisation (WHO).



According to estimates by WHO and information provided by EMCDDA, drug users form a substantial group among inmates throughout Europe. Although the figures given by various European countries widely differ, it can be assumed that approximately 15 50% of the 350,000 prison inmates in Europe currently use drugs or have used drugs in the past. There is a high turnover rate, with 180,000 - 600,000 drug users passing through the system annually. This fact inevitably affects life in European penal institutions. "There is probably no institution in society that has felt the influx of drugs has become a central theme, a dominating factor in the relationships between prisoners, as well as between prisoners and staff. Many of the security measures are aimed at controlling drug use and drug trafficking within the prison system" (Kingma/Goos 1997, p. 5). The spread of communicable diseases, especially HIV/AIDS within the prison system has led to efforts on the part of the WHO to develop guidelines aimed at dealing with HIV/AIDS in prisons. Since the guidelines were issued in 1993, they serve as a basis for assisting policy developments on the subject. The guidelines on preventive measures point out that the same measures which are generally applied in the community should also be applied in



prisons : " In countries where bleach is available to injecting drug users in the community, diluted bleach (e.g., sodium hypochlorite solution ) or another effective viricidal agent , together with specific detailed instructions on cleaning injection equipment, should be made available in prisons housing injecting drug users , or where tattooing or skin-piercing takes place. In countries where clean syringes and needles are made available to injecting drug users in the community, considerations should be given towards providing clean injecting equipment during detention and on release to those prisoners who request this" (WHO 1993). Proceeding from this internationally acknowledged principle of equivalence , namely the idea that the health care measures successfully applied outside prison should also be applied inside prison, it seems necessary here to take an inside/outside perspective. This means that the prison drug services should be perceived in the context of community drug services based on the standards of a regional or national drug policy. This is the main approach applied at all levels of our manual. It should , however, be kept in mind that full equivalence to the situation outside prison is not possible . The infrastructure of services in the community is much more differentiated . Outside, anonymity is guaranteed and easily manageable (e.g. concerning HIV testing), participation is voluntary and users have ( relative) freedom of choice between drug services in the community - qualities that are hardly realisable within the conditions of the ' total institution' prison. Here , such basic prerequisites ( i.e. confidentiality) are often hard to realise , although officially efforts might have been taken. Many aspects of HIV testing and prevention are therefore not equivalent to those available in the community ( O' Brien/Stevens 1997). Thus it still seems we are a long way from implementing the WHO guidelines, although the necessity of doing so becomes more and more apparent : " Governments and prison authorities have a moral and legal responsibility to prevent the spread of HIV infection among prisoners and prison staff and to care for those infected . They also have a responsibility to prevent the spread of HIV among communities . Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities " ( Kingma/Goos 1997, p. 7). This principle of equivalence has been the point of reference for the risk reduction activities underlying this manual . There are va-rious risk reduction activities outside prisons in most of the EU Member States: methadone detoxification and maintenance, needle exchange programs, training seminars on safer sex, safer

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druguse and safer work, support of drug user self-organisations, VANK integration of drug users into the work of information units etc. This kind of support towards reducing drug-related harm should also be available in prison as part of a broader health promotion approach. The problems around sex in prison are very similar to the aforementioned problems around drug use. Sex is taboo, especially among male inmates. But just as penitentiaries are not drug free areas , they are also not free of sex. Sexual contacts occur in different ways among inmates . Condoms are theoretically available in most of the prisons as a protection for sexually transmitted diseases, sometimes even free of charge . However, in practice they are not easily accessible, at least not without the risk that the person involved is getting stigmatised as potentially ' homosexual' (a characteristic that reduces one's status within the prisoner's subculture and hierarchy). In some of the prisons condoms have to be ordered at the prison shop. In others, a doctor's visit or a visit from the social worker has to be arranged in order to be supplied with condoms . Finally, there are still countries where prisoners do not have any access to condoms . Therefore it is fair to conclude that the capability of inmates to protect themselves against sexually transmittable infections is very limited, meaning that the risk of becoming infected through sexual contact is particularly high.

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DRUG USE IN PRISON: SUBSTANCES, PATTERNS AND FREQUENCY OF USE, ROUTES OF ADMINISTRATION



The extent of our knowledge about drug use in prisons is fragmented. There has been some research about the substances used in prisons about the patterns and frequency of substance use and the routes of administration. Needle sharing is evidently the riskiest mode of dividing a quantity of drugs between several users. However, a considerable number of drug-users continue to use this technique with varying degrees of regularity. Drug sharing, a process in which one quantity of heroin or cocaine provides the drug for several different syringes is also a source of infection, particularly if one or more of the needles or syringes used is not sterile. If one brings together the available information and research findings about drug use in EU prisons, we are faced with the following picture (Stover 2001): ^ The use of illegal drugs in prisons seems to be a longstanding phenomenon dating back to the mid or late seventies; needle sharing at that time was extremely widespread. Some studies state that the same substances available ^ outside are to be found inside prisons, with the same regional variations in patterns of use; some studies state that these drugs are often of a poor quality compared to that in the community.



The prevalence of drug consumption varies , depending on ^ the institution . The phenomenon is more significant in large institutions and in short-stay prisons, more in women's prison than in men's prison, more in prisons located close to a major city than in prisons in the countryside. There are also indications that there is a lower prevalence of drug use in remand prisons due to the lack of organised trafficking networks. ^ The most commonly used drug in prison besides tobacco is certainly cannabis, used primarily for relaxation purposes. Studies revealed that out of those using drugs during detention, 45% to 78% reported cannabis use in prison, 18% reported using injectable drugs in prison. Heroin use does seem to play an important role among prisoners: results following the introduction of Mandatory Drug Testing in England and Wales revealed that in 1998 18,9% of the inmates tested used illegal drugs (opiates about 4%; higher prevalences reported by other studies).

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^ The basic question of whether prison influences the motivation to stop drug use can be answered as follows: "... prison on the whole does not motivate individuals to stop drug use ... in the ... countries reporting a reduced drug use within prison, this would appear to be unrelated to the motivation of the drug user to stop per se but rather is a consequence of reduced availability, lack of resources to procure drugs or the fear of detection". Whether these factors finally create a sustainable motivation to stop drug use is unclear. Relapse into the drug-using patterns before imprisonment is widespread (and dangerous). Many drug users seem to stop the habit mostly in the fourth decade of life by the processes that have been described in the literature as `maturing out' (Muscat 2000). ^ There might also be further reasons for inmates to use drugs while in prison: Some users describe their constant search for drugs as a strategy for fighting boredom and enduring imprisonment, i.e. dealing with the hardships of prison life, to overcome a crisis (bad news, conviction and sentencing, violence, etc.). It seems that imprisonment sometimes provides even more reasons for taking drugs or continuing the habit, or may even cause relapse after a period of withdrawal. ^ Lifetime prevalence of the use of illegal drugs (any) prior to imprisonment is relatively high: i.e. 62% for men and 54% for women in Portugal. A study of 1009 prisoners in 13 prisons in England and Wales revealed that three quarters had used cannabis at sometime during their life. More than half had used opiates (mainly heroin) and/or stimulant drugs (amphetamines, cocaine and crack), while 40% of them had injected the drug(s). In some countries (France, Belgium, Finland) alcohol seems ^ to be the first or the second most commonly used drug (after cannabis, apart from nicotine) among people either admitted to prison or being already in prison. Recent figures (from France) show that 33.5% of newly admitted inmates claim excessive use of alcohol (more than 5 glasses per day and or 5 glasses consecutively at least once in a month). ^ Due to the scarcity of the preferred drug changes in patterns of drug use (volume and type of drug) are reported from many countries. The frequency of drug use decreases in relation to levels in the community. Those who continued to inject did it on irregular intervals and a reduced level. In a study in the UK, it turned out that those who do manage to inject on a daily basis are more likely to be imprisoned for a shorter period of time, often

on' reand and were held in a prison in, or close to their home town. mOther studies and observations by prison officers indicate that switching to alternative drugs is widespread (for example, from opiates to cannabis) or to any substitute drugs with psychotropic effects, no matter how damaging this might be (illegal drugs and/or medicine). Due to lack of access to the preferred drug of choice, or to strict controls (like mandatory drug testing), some prisoners seem to switch from cannabis use to heroin or at least experiment with heroin, because cannabis is deposited within the body's fatty tissues and therefore may still be detected up to 30 days after consumption. ^ •



Drug use in prison may be characterised as follows: D Highly sporadic availability of drugs , resulting in dramatic periods of change between consumption and withdrawal D Quality, purity and concentration is even harder to calculate than outside D Widespread poly-drug use used to bridge periods of inability to finance drugs

^ Despite the difficult circumstances some prisoners use prison as an opportunity 'to take a break , to recover physically' (Trabut 2000, 26), or to stop using drugs in prison because of the threat of detection via drug testing (especially for those using cannabis). Often this period of abstinence is accompanied by a stabilisation or improvement of the general health status (increases in weight etc.). Furthermore, many drug users in prisons come from the more disadvantaged groups in society with low educational attainment, unemployment, experience of physical and sexual abuse, relationship breakdown or mental disorder. Many of these prisoners never have had, or perhaps never have chosen to take up, access to health care and health promotion services prior to their imprisonment. Consequently, the medical services may offer an opportunity to improve their health and personal well-being. ^

With respect to cessation of injecting several reasons have been identified: D Personal choice (including an assessment of the risks associated with injecting) D Practical (including the problem of acquiring drugs, needles and syringes) D Economic (the cost of drugs) D Decreases in overall drug consumption



^ The percentage of those prisoners continuing their use of injectable drugs in prison is around 16% - 60% according to different studies in Europe. A survey was carried out at local level in seven European countries in 1997 using a common methodology. It showed proportions of active intravenous drug users (i.e. drug users who have injected drugs within the 12 month period prior to imprisonment) among prisoners in 21 prisons ranging from 9% in France to 59% in Sweden, and 16 to 46% in Belgium, Germany, Spain, Italy and Portugal. Needle sharing and drug sharing is widespread among ^ prisoners who continue their injecting drug use. Although injecting drug users are less likely to inject whilst in prison, those who do inject in prison are more likely to share injecting equipment, and with a greater number of people. In Greek penitentiaries, examinations have found that 50% of those who reported injecting in prison admitted shared their equipment with other prisoners. The EMCDDA (2000) also reports a high prevalence of sharing injecting equipment within prison, which may reach 70% of the injectors in some prisons. The majority of inmates who continue their injecting drug use do this with used equipment. That means for many drug-using inmates that they experience a relapse in hygienic . injecting technique, because they were mostly used to having easy and anonymous access to sterile injection equipment outside prison. These findings conform to prison studies throughout. world describing injecting and the sharing of injecting the equip=ment within prisons. Turnbull et al. (1996) found that when considering other injecting equipment, more sharing occurred than was actually reported. Much re-use of equipment was viewed simply as "using old works". The sharing of "cookers" and "filters", and drug sharing by "backloading" and "frontloading" were common. The concept of "sharing" tended to be understood by respondents as relating to the tool of injection (needles and syringes rather than other equipment); the use of tools in the art of injection (rather than for mixing drugs); proximity (multiple use of needles and syringes in the presence of others); temporality (shorter time elapse between consecutive use of needles and syringes previously used by another) and source (hired rather than borrowed or bought).They conclude that syringe sharing is an integral part of drug use and drug injecting in prison. Many of those interviewed displayed a restricted understanding of what actually constitutes syringe sharing. ^ Figures from a European study and some national and single prison-based surveys indicate that the number of those starting to inject while in prison ranges from 7% to 24%.

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^ -''"According to a French study, some prisoners discover new substances while in prison (medicines, Subutex®) or develop habits of mixing certain drugs they didn't take in that combination outside prison.

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^ Due to a study that included data on treated drug users in 23 European cities (Pompidou Group 1999, 12) the classic picture of the injecting drug user is vanishing and smoking heroin ('chasing the dragon') now plays a significant role all over Europe. In countries where injecting is not widespread outside prison (i.e. Netherlands), this route of administration is also not widespread within the prisons. There has also been some indication that users of injectable drugs turn to alternative (and risk reduced) routes of administration namely inhaling, smoking or sniffing (Greece, Spain). However, in those countries where injecting is the predominant route of administration outside, alternative ways are not applied in prisons, because they seem to be less effective and more expensive than injecting which is regarded as the best method of getting the maximum effect out of a minimal dosage of the drug. There is a high risk of acquiring communicable diseases ^ (esp. HIV/AIDS and hepatitis) in prison for those who continue their injecting drug use and obviously those sharing needles and drugs. Several studies conducted outside penal institutions reveal.. that a strong correlation exists between previous detention and the spread of the aforementioned infectious diseases. Although injecting drug use in prison seems to be less frequent than outside, each episode of injecting drug use is far more dangerous due to the combined factors of a lack of sterile injecting equipment, a high prevalence of sharing and an already widespread of level of infectious disease. ^ The attitude towards drug use in prison indicates that certain drugs (in particular cannabis and benzodiazepines) are often regarded as serving a useful function or helping to alleviate the experience of incarceration: "Many inmates seem to regard cannabis as essentially harmless. Alongside these attitudes, inmates recognise a need for treatment among those with serious drug problems and were aware of some of the health implications of injecting. They also displayed a concern, possibly exaggerated, about the problems of drug withdrawal. In the same study, prison officer staff shared many of these attitudes, with some commenting on the uses of drugs as palliatives and the relative harmlessness of benzodiazepines and cannabis. Others were concerned about the development of a black market in drugs. In general,



staff were acutely aware that the problem of drug misuse in prisons reflected a similar problem in the community" (Marshall et al. 1998, 62). Some prison managers confirm the view that the use of some drugs in prison doesn't vary considerably from that outside. "We do still accept that prisoners who use cannabis are breaking the law and they will be treated accordingly, but we are reflecting the way the world is outside prisons" (The Scotsman 13/5/98). In the UK, The Howard League for Penal Reform recommends in its 'Submission to the Home Affairs Select Committee' the 'depenalisation' of cannabis within prisons and makes a plea for cannabis to be treated in the same way as alcohol, in that it should be primarily considered a health issue rather than a punishment issue. ^ Many of the drug users in prison had had no previous contact with drug services prior to their imprisonment despite some having severe drug problems. After release , many drug injectors continue with their ^ habit . Studies showed that 63% of those who had injected before entering prison, injected again in the first three months after release. "Prison therefore cannot be seen as providing a short or longer term solution to individuals' problems with drugs".

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;SUBJECTS OF THIS PROJECT'S MESSAGE

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GENERAL HEALTH TIPS FOR MEN AND WOMEN IN PRISON

Prison and health hardly seem an ideal combination, and yet it is precisely the place where health - of inmates and of staff - is so important. Body and psyche of inmates, particularly when imprisoned for longer periods, are placed under a great strain, which can lead to illness. Here are some tips to show how to take care of your body in prison. 1.1

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Mental stability

Long-term imprisonment can have an effect on psychological well-being. Loneliness, separation from loved ones, significant infringements upon personal freedom as well as boredom, fainting fits, conflict with fellow prisoners, officers, guards, even the prison governor can all cause stress. Strain of this nature can weaken the immune system and lead to frequent illness. Admittedly, many of the causes of strain faced by people in prison are difficult to tackle, and so some stress will be inevitable. However, there are ways of coping with it. To tackle these problems inmates can look to fellow inmates with whom they spend their free time and share their problems with. They can also contact employees from the prison's psychological and/or social service, the prison chaplain or professionals from outside if they have problems that they feel cannot deal with themselves. Prisoners can also make use of the leisure amenities offered by the prison establishment. Sport, for example, is a good way of offloading strain, anger and aggression. If such facilities are not currently offered by the prison, inmates can see if it is possible to initiate something along these lines. 1.2

Taking care of your body

Although the Ministries of Justice in nearly all EU Member States have laid down nutritional guidelines for use in prison establishments, prisoners still have to check to see if they are being supplied with enough vitamins and minerals, and so should be warned to watch out for their nutrition. Vegetables and fresh fruit supply the body with vitamins, minerals and trace elements. If prison meals do not provide a sufficient amount of vitamins and minerals, then perhaps they can go shopping to stock up on them or receive additional food from visiting family or friends. It is also sensible to take

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extra magnesium, zinc and selenium in the form of chewing or lemonade tablets. Sport can help to keep the body firm; it stimulates the circulation and promotes perfusion. If there are not any sport facilities in the prison then inmates can keep fit by doing simple gymnastics. The desire for bodily warmth and tenderness does not cease as soon as a person is imprisoned. That is why sex plays an important role in prison. Having sex with someone of the same gender might be frowned upon but it is part of everyday life behind bars. In doing so, one should be careful and do all that one can to protect themselves and their partner from sexually transmitted diseases. The condom, for example, protects two men having sex, likewise the dental dam for lesbian women. A dental dam is a piece of latex cloth which is placed over the vagina. In an emergency situation, one can cut up a condom or disposable glove or even use clingfilm. If one cannot and does not want to stop taking drugs, then one should at least try to reduce the risks involved: by not injecting but sniffing or smoking from foil instead, in order to avoid infections spread by unclean injecting equipment. If someone is unable to making this "switch" then they should always use their own injecting equipment ("works") or unused disposables when having a fix. If this is not possible, you can clean the injecting equipment thoroughly (plastic syringes included) with cold water and rinse; then take the pieces apart and place each one of them in boiling water for 15 minutes (see 6.1). People should be informed that simply washing needles with water is not enough to kill the germs which might be contained within. 1.3

If an inmate is HIV or hepatitis B/C positive

Even if someone finds it hard to take care of their health and promote their sense of personal well-being in prison, there are a lot of people who want to and who can help with this. If necessary, prisoners can defend themselves. Inmates should be supported to refuse to allow themselves become a victim, and to refuse to be prepared to simply accept their fate passively. There are actually some things which inmates can do for themselves. In their present situation , prisoners might feel all alone and tormented by questions for which they have no answers: What am I supposed to do now? What is the rest of my life going to be like? What does it actually mean to be HIV positive? Will the disease

l // "brea kout?-What are the symptoms of HIVrelated sickness? Which

--doctor is` specialised to deal with it? Where can I get advice? Who can I speak to about my situation and who would it be best not to tell? What about sex? And what about the use of drugs , especially here in prison? Medically speaking, being HIV positive only means that one's organism has developed antibodies against the HIV virus. It does not mean that one has AIDS. Even a positive result of the HIV test does not necessarily mean that one will become sick tomorrow, or in the following month, year or even the next ten years. is

Of course, at times one is bound to feel better. At other times, you'll feel worse. People have to find out for themselves how best to deal with such changes. A person will also have to decide if their situation is best handled on their own, with the help of friends or if they need to seek professional help. If one does have problems or needs information , then they should try to get in contact with one of the specialist support services for HIV positive people . Their employees will be able to help with most questions . They might be able to inform people about selfhelp groups and social and legal queries . Inmates can talk to them about issues like sexuality, the use of drugs and health. 1.4

Protecting yourself from illnesses

Germs such as viruses, bacteria and fungus can be very easily spread in places where many people are living together. That is why one should be aware of what the risks of infection are and how one can protect themselves and others against them. Just another word on the subject of sexually transmitted diseases: these play a very large role in male prisons where men have sex with men and in female prisons where women may have sex with women. Try and remember that there is another side to it all: Periods of home leave, holidays and a life after - life after prison.





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THE EFFECTS AND RISKS OF DRUGS *' *1

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The effects of drugs - what we ought to know

Whether we're talking about heroin, cannabis or Ecstasy, most illegal drugs provoke debate. But they also raise questions as few people have any real knowledge of drugs. The half-truths and myths make many people afraid of drugs but have precisely the opposite effect on others. The drug user enjoys the 'rush' and will never forget their first trip into paradise with a mellow 'high' or at full overdrive. Their parents would much rather remember the child cutting it's first tooth, a period when their child was not addicted to drugs but merely hooked on Barbie dolls or Dinky Toys. Question: If drugs are so dangerous and reprehensible, why do people start using them? No one wants to risk an overdose or enjoys being addicted. Only a few people use drugs because they want to protest against the prohibitive law. People do not take their first shot or their first line because they are tired of life, but more usually because they are curious, bored, or simply want to feel they belong to their peer-group. But they also use - and sometimes this is forgotten - because the drug makes them feel good. Or, as the character Renton said about the effects of heroin in Irvine Welsh's book, 'Trainspotting': "multiply your best orgasm by 1000 and you're still nowhere near."



This chapter deals with various kinds of drugs without examining the health risks. (These will be dealt with extensively in the following chapter). Here, we will restrict ourselves to the drugs themselves. What do they look like? Where do they come from? How are they used? And how do they work? From a 'bag of smack' to a 'line of coke' - let's talk about drugs. Uppers, downers and hallucinogens Drugs affect the central nervous system. They do this in several ways. The so-called'uppers' like cocaine and speed have a stimulating effect. The user feels that he has lots of energy and is much more talkative and 'loose' than usual. Heroin, alcohol and benzodiazepines, (sedatives and tranquillizers), on the other hand, create a mellow'high', have a calming effect and are therefore referred to as 'downers'. Hallucinogens, such as LSD and mushrooms have a mind-altering effect: Under the influence of these, the world can look very different.

Based on 'RateYour Risks', Mainline Amsterdam (see References)



The difference between stimulating, sedating/depressing and mind-altering or hallucinogenic substances is not always clearly defined. Most substances have a double effect. Ecstasy, for instance, stimulates and at the same time, alters the mind. Depending on the situation and the quantity used, cannabis can have both a hallucinatory and a sedative effect. And we know that the first few glasses of alcohol are stimulating but that with increasing consumption, the sedative effects can take over. The effects of drugs are perceived in a different way according to the pattern of use, depending on whether the use is: ^ ^ ^ ^ ^

experimental recreational habitual circumstantial or dependent

It is important to be aware that the effects of a particular drug can depend on many factors and many different contexts (like prison). These factors include: the type of drug the duration of use the experience and tolerance of the user the health status of the user the use with other drugs the setting the purity and quality of the drug how it is taken the amount taken the situation in which is it taken (taken in a hurry in prison or relaxed at home) ^ sex, age and body type of user

^ ^ ^ ^ ^ ^ ^ ^ ^ ^

As well as categorising by effects, drugs can also be categorised according to origin. LSD, Ecstasy and benzodiazepines are synthetic or semi-synthetic substances, produced in a laboratory. Hashish, cocaine, mushrooms and the opiates are derived from plants and come from natural sources. Hashish and marijuana, for example, are derived from the plant cannabis sativa, cocaine from the coca plant, and opium, the basis of morphine, methadone and heroin, is made from the plant papaver somniferum.

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he problem with urine tests Drugs can be detected in the hair and also leave metabolites behind in the urine. Urine tests are therefore widely utilised to control the drug use of prison inmates. It is important to keep in mind that some results can produce a false negative or a false positive. Someone who has just eaten a poppy seed muffin (or any other foods containing poppy seeds) and has to take a urine test, may unfairly be accused of having used an opiate. Hashish and marijuana (cannabis) •

"Hashish has nothing in common with the crude drunkenness generated by the citizen from the Northern countries with wine and strong drink: Hashish produces an intellectual high." - Th. Gautier, 1844. Hashish and marijuana are derived from the cannabis sativa plant. The female tops supply the raw material for marijuana, and hashish is produced from the plant's resin. After tobacco and alcohol, cannabis is the most commonly used drug. Marijuana has a greenish-brown colour; hashish is light-brown to black, but much more characteristic than the colour is its smell. If you have smelled cannabis once, you will be able pick out that smell from among thousands of others. How is cannabis used? Hashish and marijuana are smoked with cigarette tobacco or smoked pure in special pipes: chillums and water pipes. When smoked with tobacco, the hashish or marijuana is crumbled onto a small bed of tobacco inside a fold of rice paper and then rolled into a cylinder, i.e., joint. This joint is then smoked like a normal cigarette. Incidentally, mixing cannabis with tobacco is somewhat illogical because tobacco suppresses the effect of cannabis. To be precise: tobacco constricts the blood vessels, while cannabis expands the blood vessels along with the mind. Smoked pure then, cannabis and hashish have a stronger effect. Sometimes, cannabis may be baked into a `space cake', (hash brownies), and eaten. In this case, the effect only kicks in after one hour. Consequently, there is a danger that the ingested dose might be too high (see'Freaking out' below).

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How does cannabis work? A hashish or marijuana user gets 'high' or 'stoned'. The word 'stoned' refers to the arms and legs feeling heavy. This relaxation of the muscles is caused by the major active substance THC. But tetrahydrocannabinol also does more: it intensifies one's mood, (including bad moods!), reduces concentration, slows reflexes and influences perceptions. Colour and music may be experienced very intensely. Beginners are known to get 'the giggles', while others, (even old-timers), can get a sudden attack of 'the munchies' (craving for food). "Freaking out" When the dose is too high, cannabis use can produce negative effects like anxiety and panic attacks. One also can become dizzy, nauseous or feel faint. When hash is taken in combination with speed, temporary paranoia might set in. If this happens to you, the best thing to do is: wait until the sensation passes by itself. However, if this happens to someone else, you can try to calm that person down with reassurance about how the effects are only temporary.

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Alcohol- cannabis Smoking cannabis and drinking at the same time is pointless because alcohol breaks down the effects of cannabis. How can you tell cannabis use in prison? In general, people who use only cannabis may seem slow and lethargic to outsiders. Cannabis products very rarely cause aggression in a user. More often the opposite is seen, where cannabis users amicably sit around and chat. Extracts of Cannabis Sativa have been used since ancient times as painkillers, medication for exhaustion, asthma, cough attacks, rheumatism, migraine, cramps and other symptoms. John F. Kennedy, for example, regularly smoked joints to relieve his chronic back pains and Queen Victoria used marijuana seeds for monthly period cramps. Tobacco Tobacco is ingested through smoking cigarettes and pipes. It can be sniffed as snuff or chewed. It can also be ingested through passive smoking (other words for cigarettes include 'smokes, `gaspers', 'fags' and 'bifters'). Tobacco smoke is a mixture of almost 4,000 different chemical compounds, including tar, nicotine, carbon monoxide, acetone, ammonia and hydrogen cyanide. Nicotine as a pure substance is a poison. Swallowing a relatively small amount of nicotine can kill an adult.

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___How_do.es tobacco work? Tobacco is a stimulant that restricts the flow of blood and causes blood pressure to rise. It causes a decreased blood flow to body extremities (cold finger tops). Brain and central nervous system activity is first stimulated and then reduced. For an experienced smoker, the effects are manifold and depend on the purpose and setting in which tobacco is used. Inexperienced smokers, in contrast, may identify the effects of tobacco as dizziness, nausea and watery eyes.



The vast majority of the population in most countries has at least some experience with tobacco. Some stop, others continue, and the percentage of regular smokers varies from 40-60%, depending on age group, social level, education and sex. Alcohol "Good Lord, if our civilisation would sober up for a couple of days, it would die on the third day from remorse." - Malcolm Lowry, `Under the Volcano", 1947.

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Alcohol is derived from the fermentation of grains or fruit sugar, (most notably grapes, but other fruits are also used), and is processed into three categories: beers (ca. 5% alcohol), wines (ca. 11 % alcohol), and spirits (ca. 35% alcohol). Sherry and port have a higher alcohol percentage (ca. 20%) and fall under the category of 'fortified wines'. In spite of the differences in alcohol percentage, the amount of alcohol ingested per glass is still the same. Wine and beer glasses are always larger than whisky glasses. How does alcohol work? One or two glasses of alcohol make you loose, euphoric and alert. Continue to drink though, and you will become careless and make mistakes in most normal daily activities, such as driving. Drink still more and you might become depressed or aggressive. With increasing amounts of alcohol, the sedative effects will take over. Walking in a straight line becomes impossible and you will talk with a'thick tongue'. If drinking continues, sleep or confusion sets in, which with more alcohol still, might lead to unconsciousness or coma.



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oozing and soaps On average, an American soap opera contains three to four scenes per show, in which drinking alcohol is presented as a relaxing pastime. This was found in a 1985 study carried out by the American researchers, Wallack, Breed and DeFoe. Cheers! How can you tell alcohol use in prison? Alcohol users get drunk. They have problems standing straight and may fall easily. Wounds and other injuries do not seem to bother the alcohol drinker. When drunk, alcohol users are easily annoyed and may be quick to react aggressively. Others, on the other hand, are overcome by an irresistible urge to sleep. Cocaine , freebase cocaine and crack "A brain loaded with cocaine is like a crazy pinball machine, whose blue and red lamps flash on and off in an electric orgasm." - William Burroughs, `Naked Lunch', 1959. Cocaine comes from the coca plant which grows in the SouthAmerican Andes mountains . Chewing coca leaves is an ancient custom of the Incas and a long-accepted local remedy in that region, used against fatigue and altitude sickness. It only turns into cocaine after a chemical process. The white crystalline powder can also be turned into freebase cocaine and crack. Crack is cooked cocaine cut with baking soda. Freebase cocaine is cooked pure cocaine. How is cocaine used? Cocaine is primarily sniffed but can also be injected. When sniffing, the cocaine is laid out in a little line and inhaled into the nostrils through a snorting straw or tube. Crack and freebase cocaine are 'chased', freebased or smoked. When `chasing the dragon', the drug is placed on a piece of aluminium foil and heated. The vapour is then inhaled into the mouth through a pipe. When freebased, the converted cocaine is smoked in a crack pipe or a water pipe. Smoking has the advantage that all of the active substances are inhaled with several deep breaths. A water pipe compensates for the heat of the vaporised material. The flash derived from smoking on foil is less intense than that from freebasing.

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• L-__-How-does cocaine work? When sniffed, cocaine takes effect within several minutes. The effects last for approximately 30 minutes. Cocaine gives energy, makes people talkative and alert and may be sexually stimulating. The effects of crack and freebase cocaine are much more explosive. The `rush' (an intensely stimulating effect) only lasts for several minutes.



How can you tell cocaine use in prison? Users react energetically and speedy. Speed of movement often is increased and in a discussion, coke users often argue more intensely than usual. Although cocaine does not create aggression as such, feelings of aggression can be intensified.

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rystal clear psychoanalysis Cocaine is coupled with a strong urge to analyse things. Coincidence or not, the founder of psychoanalysis - the psychiatrist, Sigmund Freud from Vienna, Austria - was a fervent f user of the white crystalline powder.

Heroin and methadone "Brown sugar - how come you taste so good." - Rolling Stones, 1971. •

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Heroin belongs to the opiate family of drugs. These are substances derived from the plant, papaver somniferum. After making an incision in the unripe seed pod of the poppy plant and drying the released milky juice, crude opium, the mildest of the opiates is produced. Crude opium has been used for centuries. From crude opium, morphine can be isolated, and by putting morphine through additional chemical processes, producers end up with heroin: the strongest of the natural opiates. Pure heroin is rarely, if ever, sold in Europe. The coarse-grained white powder or the tiny yellow 'rocks' are generally cut with caffeine, aspirin or milk sugar.



How is heroin used? Heroin can be 'chased', injected, sniffed and smoked. 'Chasing the dragon' is becoming increasingly popular: the drug is placed on a piece of aluminium foil and heated. The vapour is inhaled into the mouth via a pipe or tube and directly enters the lungs. How do opiates work? All opiates have a strong sedative effect, but this is particularly true of heroin. Pain, sorrow, fear, hunger and cold are all banished. There is a short euphoric effect, (the rush), which may be followed by feeling of indifference: the outside world no longer matters. On average, the effects last from three to five hours. Methadone Methadone, (invented in Germany before the Second World War), is an opioid, a synthetic opiate which, just as with heroin, .has powerful sedative and pain-killing effects. The major difference between heroin and methadone is that the effects of methadone last longer: instead of just four to six hours, methadone lasts for 12 to 24 hours. The drug is not excreted as rapidly from the body of a methadone user, which enables them to lead life with a normal rhythm, both day and night. Another advantage is that methadone is not usually injected and so no syringes are involved - therefore, the risk from dirty needles is avoided! Methadone can simply be drunk as a liquid, or swallowed in tablet form, and in rare circumstances, methadone can also be used intravenously. All this makes methadone very suitable for people wishing to quit heroin. However, methadone is not without its own risks. It is just as addictive as heroin, and many users feel that methadone is even more addictive.

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eroin as a cure for morphine addiction Heroin was once the methadone of today. It was first produced in 1898 and, among others, sold as a medicine to treat morphine addiction. When it became apparent that heroin was even more addictive than morphine, most countries gradually discontinued the medical use of heroin. How can you tell heroin use in prison? Heroin/methadone users appear sluggish and sleepy. They are difficult to approach and slow in their reflexes. Heroin and methadone if taken alone are unlikely to cause aggression in a user. Users in withdrawal, however, might well be irritable.

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"In a dream-like state with closed eyes, (the daylight appeared unpleasantly bright), I noticed a continuous stream of fantastic images, bizarre shapes with an intense kaleidoscopic play of colours." - Albert Hofmann, 1943.

Hallucinogens Hallucinogens are naturally or synthetically derived substances, which have a strong effect on people's senses , consciousness and perception. The combination of hallucinogens with other drugs or alcohol has unpredictable effects and is therefore dangerous. LSD On April 16, 1943, the Swiss chemist, Albert Hofmann, was forced to finish work in his laboratory early and go home. In his own words, he suddenly became "very uneasy and dizzy". The reason: By coincidence, Hofmann had ingested his own discovery: LSD. LSD (lysergic acid diethylamide) is a semi -synthetic substance, derived from a natural fungus. LSD is odourless, colourless, and tasteless.



How is LSD used? LSD is mostly sold as a paper 'trip': An edible piece of paper about half a square centimetre, containing extremely small quantities of liquid LSD. A standard trip contains just 50 to 100 micrograms of LSD, (a microgram is 1/1000th milligram). How does LSD work? LSD takes 30 minutes to one hour before it starts working. After that, the user is completely submerged in their own world. A world in which the user spontaneously sees objects changing form, in which music can be seen and colours can be smelled. The room may appear as large as a dance hall. You sit and think you're standing. You stand and think you're flying. The trip progresses in waves with a peak after two to six hours. After 12 to 24 hours, the effects of LSD taper off. 'Flashbacks' There have been reports that flashbacks may occur months or even years after a trip. During a flashback, the user relives a part of the trip, without actually having taken LSD. A flashback can last from only a few minutes to several hours. However, there is no hard proof that these flashbacks are attributable to LSD,

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and some researchers believe that they represent psychotic episodes in people suffering from various forms of mental illness, who then attribute the episode to an earlier experience of having taken acid. How can you tell LSD use in prison? LSD users can seem detached from the outside world. LSD may sometimes lead to severe anxiety attacks, which are coupled with heavy sweating and fear of impending death, (bad trip). Individuals rarely become aggressive after using LSD, they tend to become friendly and amicable.

Dubious CIA methods Hofmann's invention of LSD quickly aroused the interest of the CIA. During interrogations, individuals were given LSD without their knowledge in the hope that the trip would evoke a confession. Mushrooms Mushrooms are among the oldest 'tripping' substances known to man. The Indians of Central and South America have been using them for centuries, where they play a role in helping religious shamans make contact with the gods. The mushroom's 'magical' effect is caused by psilocybin, an active substance which is found in more than twenty different mushroom types. The best known are the 'Mexican ', 'Balinese' or 'Hawaiian' mushrooms and the pointed 'Liberty Cap', which grows in Northern temperate zones throughout the world. In Europe, certain types are found in the wild; others are cultivated. How are mushrooms used? Mushrooms are eaten fresh or dried. The effect is stronger when the mushrooms are dried. It is also possible to make tea from mushrooms. Four to twelve milligrams are sufficient for one 'trip'. How do mushrooms work? A'mushroom trip' is similar to an'LSD trip' but milder.'Bad trips' occur less frequently with mushrooms than with LSD. The effects can be felt for three to five hours with a peak in the first two hours.

• How; can you tell mushroom use in prison? n general, the effects of mushroom use are barely noticeably to outsiders. The use does not lead to aggressive behaviour. Mushroom users are harder to identify by their behaviour. Speed

S

"You are simply unstoppable. You just keep going endlessly. Where the energy comes from? You're bound to find out. After a few days, you're completely out of steam. And don't ever think that you're being productive, that you're creating something useful. You're only busy with idiotic things. Freaking on the square inch - boy, it kills your nerves."

In comparison with most other drugs, speed has existed for a relatively short period. At the end of the 19th century, amphetamines (one of the various types of uppers) were produced in a laboratory for the first time. Amphetamines were originally prescribed as slimming pills and were used as stimulants by soldiers during the Second World War. The health risks of excessive speed use only revealed themselves after a number of episodes when amphetamines became popular among young people in the early 60's in the UK as part of `mod culture' and later, between 1969 and 1972 in Holland. After this, most countries made the possession or use of amphetamines illegal.

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How is speed used? Speed is available as a tablet or in powder form and is mostly taken orally. Speed is the street name for `uppers', substances of which we have heard in connection with doping checks in sport. Use of uppers in sports is not really surprising as they increase one's stamina. "In Trainspotting, no more drugs were used than during the Olympic Games", film director Danny Boyle said sharply, when asked whether his movie was in favour of drugs. How does speed work? When taken orally, speed takes effect after 15 to 20 minutes. When sniffed, the effect sets in after several minutes and when injected, more or less immediately. In all cases, speed tapers off after around eight hours. Speed has a stimulating effect on the central nervous system and is exhilarating. Speed gives energy, and sleepiness, fatigue



and hunger disappear. The body temperature and blood pressure rise, and the pulse quickens. The pupils dilate, and the muscles tense up, resulting in a stiff jaw and grinding teeth. Speed use can also lead to accelerated heartbeat, headache and dizziness. At the same time, speed can make you very active, cheerful, alert and self-assured. How can you tell speed use in prison? Speed users appear nervous, rushed and speedy. As with cocaine, speed users become hyperactive and self-assured. In conflict situations, speed users are more likely to let go of their inhibitions, which can result in aggressive behaviour 10

H

itler's `blitzkrieg' His soldiers took it at the front. And Adolf Hitler himself used it too. He was given speed injections five times per day. But in spite of all those amphetamines, the Allies turned out stronger in the end. Ecstasy (XTC) "Ecstasy makes its user as soft as butter. Even the toughest, most aggressive macho will turn into a softie." - Gerben Hellinga and Hans Plomp, 'Uitje bol' (Freaking out), 1994. The'love drug' of the nineties is sold in tablet form. The pills have different colours and often have pictures on them. Its image as a love drug derives from the effects of the substance MDMA, which creates an atmosphere of confidentiality and intimacy. But Ecstasy also has the reputation of being a `party drug', which enables you to dance night after night without getting tired. This is due to the fact that MDMA, like many of the other drugs discussed, is a substance with a double effect. How does Ecstasy work? Ecstasy is an amphetamine derivative. As well as stimulating, Ecstasy also has a mild psychotomimetic (mind-altering) effect. With excessive use, (several pills in one night or taken several days after each other), the speed effects take over. A single tablet or capsule takes effect after about 20 to 60 minutes after being ingested. The effect is strongest during the first hour and then gradually ebbs away. Ecstasy wears off after four to six hours.

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owcan you tell Ecstasy use in prison? Ecstasy users appear active and cheerful. Many Ecstasy users will feel the urge to be nice to each other. The use of Ecstasy does not lead to aggression. 1

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little `talking pill' Ecstasy makes you talkative. This is why in America in the seventies, it was sometimes used experimentally in the fields of counselling and psychotherapy to help patients to communicate with each other. 0



Sleeping medication and tranquillizers 1"In the world of drug addicts, sleeping pill users are looked down upon: Goof ball bums don't have any class" William Burroughs. In 1965, the effects of benzodiazepines were discovered. These include drugs such as the sleeping medicines and tranquillizers Librium®, Valium® (also known as Diazepam), Rohypnol®, Oxazepam®, Normison®, Temazepam® and Prothiaden®. How are benzodiazepines used? Sleeping medicines and tranquillizers are usually taken orally but can also be injected. Here, the gel-like benzodiazepine is removed from the capsule with a hypodermic needle, drawn into the syringe and injected into the vein. How do they work? Benzodiazepines have an inhibiting effect on the brain functions. Physicians prescribe them to patients who suffer from sleep disorders, stress, anxiety, nervous conditions and exhaustion. How can you tell benzodiazepine use in prison? Benzodiazepine users become sluggish and sleepy. In addition, the motor functions are slowed which can result in people hurting themselves more easily. The use of benzodiazepines alone does not usually lead to aggressive behaviour.



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0 Wall bangers Certain sleeping medicines (the so-called barbiturates) are also called'wall bangers' because the user, in a sort of drunken state, `bangs' into everything in their way. The following day the user won't remember a thing and will be highly surprised about their collection of bruises. Home made drugs - the `prison high' In prisons home-made drugs have a long tradition. A variety of substances are made and used for their psychoactive effects, such as alcohol made with fruit, smoking dried banana peels, etc. Also, legally purchased substances such as tablets received on a doctor's prescription are used for their psychoactive effects, rather than for their medical purposes. The production of drugs in prisons requires knowledge about the precursors one needs to make them, their psychoactive effects, etc. Although reported in a Bulgarian study (Nesheva/Lazarov 1999) the use of over-boiled tea and over-pressed coffee seems to be quite common in prisons. The effect of these products is stimulating, caused mainly by the caffeine extracted from them. Some sorts of tea contain up to 2-3 times more caffeine then the average coffee sample. The caffeine affects some brain structures responsible for the metabolism and directly stimulates the formatio reticularis accendent, an area of the brain which is responsible for the increasing tonus and vigility. The large quantity of caffeine consumed also affects the vegetative neuro system. Other components of tea and coffee, such as theobromine (3,7 dimethylxanthin) and theophylline (1,3 dimethylxanthin) are alkaloids, and affect the cardiovascular and respiratory system by stimulating the central nervous system. Taking into account the pharmaco-dynamic aspects of the caffeine, theophylline and theobromine, some level of biological dependence is expected to develop. Nesheval and Lazarov write: "Coffee and tea were available in the shops located in every prison: any prisoner could buy a certain quantity. Relatives visiting prisoners and sending them packages could give them coffee and tea. These two sources were 'legal,' permitted by the prisons' rules. The study revealed that there was also an illicit market for coffee and tea in the prisons. Those who used over-boiled tea and over-pressed coffee bought the ingredients at inflated prices from other prisoners. This exchange introduces a new element into the general picture of inter-prison relations. A user could, for example, collect tea and coffee from the other prisoners as a payment for protec-ting

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I them. The usual ways of preparing these two drugs were as folL lows:-50) 100, or 200g (or more) of tea was put in boiling water and boiling continued until there was a significant reduction of the liquid . The result was a dark brown , concentrated liquid above the tea leaves . Users usually drank this liquid, although it was suspected that some administered it intravenously. Fresh coffee , again 50, 100, 200g or more, was pressed several times or boiled as above. It was then drunk, although once again, some may have been injecting it. The aforementioned quantities usually comprised one dose . There were two main ways of drinking : either all at once, or over 15 - 20 minutes. Although none of the interviewees reported injecting these substances, there was some anecdotal information that others did. The use of over- boiled tea was more common than the use of over-pressed coffee . The substances were usually used in the late afternoon or evening . There were cases of group use, but usually the users used these products alone.

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Quiz

Brown Sugar, Golden Sunshine, Purple Haze, White Lady, Pink Floyd, Red Lebanese - in the 'colourful' world of drugs one could easily get lost. What do you know about drugs? Test your knowledge with this quiz.



1

When using heroin , one might be overcome by an irresistible craving for sweets? A. Correct B. Incorrect

2.

When used together, cannabis reduces the effects of alcohol? A. Correct B. Incorrect

3.

A glass of spirits is more damaging to the health than a glass of wine? A. Correct B. Incorrect

4.

When cocaine is sniffed , the effects will last for approximately 30 minutes? A. Correct B. Incorrect

5.

Methadone is just as addictive as heroin? A. Correct B. Incorrect

6.

LSD has a distinct odour? A. Correct B. Incorrect

7.

Fresh mushrooms have a stronger effect than dried mushrooms? A. Correct B. Incorrect

8.

The effects of speed last for approximately eight hours? A. Correct B. Incorrect

9.

When taking Ecstasy, the user never knows exactly what they are taking? A. Correct B. Incorrect

10.

i •

Some sleeping medicines are taken orally they but may also be injected? A. Correct B. Incorrect



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Quiz •

Add up the figures behind the answers you gave. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

A-1 A-0 A-0 A-1 A-1 A-0 A-0 A-1 A-1 A-1

B-0 B-1 B-1 B-0 B-0 B-1 B-1 B-0 B-0 B-0

• 0-5 points Your knowledge on drugs is inadequate. 6-8 points You are pretty well informed. 9-10 points You are well informed. The correct answers are as follows: 1. A -

When using heroin, one might be overcome by an irresistible craving for sweets? Correct. All opiates cause a craving for sweets.

2. B-

When used together, cannabis reduces the effects of alcohol? Incorrect . Exactly the opposite applies. When used together, alcohol reduces the effects of cannabis.

3. B-

A glass of spirits is more damaging to the health than a glass of wine. Incorrect . In spite of the differences in the percentage of alcohol, the amount of alcohol per glass one drinks is still the same. A wine glass will always be larger than, for example, a whisky glass.

4.

When cocaine is sniffed, the effects will last for approximately 30 minutes? Correct.



A-

is

5. A-

Methadone is just as addictive as heroin? Correct. Methadone is indeed as addictive as ' heroin, except that methadone is longer acting: 12 to 24 hours for methadone, as opposed to 4 to 6 hours for heroin.

6. B-

LSD has a distinct odour? Incorrect . LSD is completely odourless.





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Quiz

B-

Fresh mushrooms have a stronger effect than dried mushrooms? Incorrect . The opposite applies: Dried mushrooms have a stronger effect than fresh mushrooms, when eaten.

8. A-

The effects of speed last for approximately eight hours? Correct.

9. A-

When taking Ecstasy, the user never knows exactly what he is taking? Correct.

10.

Some sleeping medicines are taken orally but they may also be injected? Correct . Sleeping medication and tranquillizers are usually taken orally but they can be injected . Then, the gel-like benzodiazepine is removed from the capsule , drawn into the needle and injected into the vein.

A•

Brown Sugar is another name for heroin. Golden Sunshine, Purple Haze and Pink Floyd are slang names for LSD trips. White Lady is a synonym for cocaine and Red Lebanese is a type of hash.



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2.2

The risks of using drugs

Introduction One single shot of heroin and you're hooked for life. A life which won't last long anyway Fall for smack and you can count on an early grave. Look at Sid Vicious from the punk band 'Sex Pistols'. •

But it does not have to be like that. Keith Richards, the guitar player of the Rolling Stones bought his heroin by the kilogram. He sniffed and shot up for 25 years but kept going all the time. Strange? Not really. A person who uses safely or injects with clean needles and doesn't use too much at any one time can get very old on heroin. The most notorious drug of all is, in reality, far less harmful than the most commonly accepted drug: alcohol. Pure heroin does not damage tissue or organs. It does not cause cirrhosis of the liver, nor Korsakow's syndrome (a serious brain disorder resulting from long and excessive alcohol use). Heroin's reputation as a 'killer' has other reasons. The drug's danger lies in its heavily sedating effect, the manner it is used and the real risk of an overdose - especially with combined use. A person who takes Valium® and heroin together risks a 'knock-out' in slow motion. A cold might not be noticed because of the numbing effect of the drug, which can lead to neglect of health - or worse: pneumonia. And finally, someone who uses other people's equipment for shooting up risks an infection with the deadly HIV virus. All are indirect health risks which are not necessarily connected to the substance itself. Addiction consists of multiple factors Yet it is heroin, above all drugs, which is loathed by many people. Not because it regularly causes victims (so does road traffic) but because the opiate is highly addictive. One fix of smack and you're lost: first the gutter, then the grave. In stark contrast to this notion is the user who can easily postpone their 'rush' to the following weekend and so can't really be called 'heavily addicted'. Furthermore, there are accounts of people who tried withdrawal several times without luck, but the moment they fell in love with someone from outside the 'scene' had no problem at all stopping their heroin use.



Question: when does drug use turn into addiction - or to use a less normative phrase, dependence? Is it the drug itself or are other factors involved? An addiction consists of multiple factors. Individuals are rarely addicted to the substance alone but also to the `scene' and the manner in which the drug is used. The world of a real 'needle freak', for instance, revolves to a great extent around the practice of preparing the fix. The injection ritual finds its way even into their dreams - especially during withdrawal. Though 'main liners' also enjoy discussing the 'rush' of injecting with others, the same applies to people who snort, to'pot heads' and'acid freaks'. In the drug world everyone likes to mingle with their own group and exchange drug stories or talk about drug experiences. Someone who does not use any longer will soon feel excluded. Moreover, ex-users often are not welcomed back with open arms. They tend to be approached with scepticism and suspicion. A person who finds this hard to deal with and has no social contacts outside of the'drug world' can easily relapse. There is an additional factor: the social status of a user is also important. Statistically speaking, children from working-class families are more likely to turn into addicts than the honour student son or daughter of a lawyer. Still, the number of users with both a degree and a bag of smack in their pocket should not be underestimated. The big difference is that these'classy users' do not have to dirty their hands to get their drug. They have all the money they need and consequently are not on a collision course with society. Nor do they get into trouble with the law as often. Next question: just when is someone addicted? If they light up the ceremonial 'after dinner cigarette' every evening or only after everything - including their own self-esteem - takes second place to the drug? In short : How do we define addiction? In the theory of addiction, we roughly differentiate between three diverse views. The 'moralistic' view sees addiction as something reprehensible and blames the addict primarily for a lack of willpower. The second view, which regards addiction as an illness, is more likely to be sympathetic towards the addict. As viruses destroy their host, so drugs destroy their users. But who's to blame?

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The-question then , is to what extent does the user lose all control of ttaernself when 'on drugs'? In the modern view of addiction, is no longer reviled or patronised but addressed as a right-minded individual who cares about their own health. In practice, it appears that users do manage to do much better for themselves than the other two standpoints might suggest. So, despite the initiation into drug use, it seems the situation often isn't that hopeless after all. In the Netherlands, where these matters have been studied extensively, it was found that after ten years, two-thirds of the individuals whose drug use was once problematic had not come into contact with the law and to all intents and purposes were properly integrated in society. Half of them, or one-third of the total group had stopped using drugs altogether. (Cramer / Schippers 1994). This chapter deals with the risks of drug use. We shall discuss the health risks of each substance for the short, medium and long-term. Short-term effects arise immediately after use, such as an overdose or a'shake', (sudden high fever attack). Medium effects only occur after frequent use and often are temporary. Examples would include weight loss in cocaine use. Long-term effects like lung cancer in heavy smokers and Korsakow's syndrome in alcoholics are mostly irreversible. We also address the addiction potential of the different substances because an acute addiction can result in an unhealthy life-style, (bad eating habits, little sleep, social isolation, etc.). •

The manner in which drugs are used carries certain health risks. So prolonged sniffing (snorting) can lead to infections of the nasal membranes. Injecting can lead to abscesses and freebasing can damage the airways. What is addiction? There is a difference between physical and psychological addiction. Someone who simply craves for a substance and does not feel 'normal' without it is psychologically dependant. Someone who displays withdrawal symptoms (sweating, cold shivers, diarrhoea, etc.) after having stopped drug use, is physically dependant. We speak of 'tolerance' (also called habituation) when the body needs more and more of a certain substance to maintain the same effect. The body quickly adapts to heroin, sleeping medicines and alcohol. With these substances, a steadily increasing dose is needed. Certain drugs produce both a physical and psy-

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chological addiction. If, in addition, withdrawal symptoms occur when the drug is stopped, the way back from addiction can be very difficult. Drug use and aggression Drugs which induce a 'high' like heroin will rarely cause aggressive behaviour. More dangerous are 'uppers' (cocaine and speed), combined drug use, and certain pills. If you find a box of Rohypnol®, then watch out. This sleeping pill is notorious for temporarily 'incapacitating' someone's consciousness when large amounts are used. It can lead to uncontrolled aggression while the user does not remember a thing afterwards. Alcohol can also cause aggression, particularly after excessive use and in combination with other drugs. The 'high' turns into a row. The row into a fight. Drugs and pregnancy Just as with alcohol and tobacco it is advisable to stop using drugs during pregnancy. This also applies to the period in which the baby is breast-fed. The active substances can be passed on to the baby. This is why the babies of `heroin mothers' may display withdrawal symptoms. Methods of drug use In general, drug users are pretty flexible in the way they use drugs - especially in times of emergency. If no syringes can be found they smoke on foil. Is the foil finished, the drug is sniffed or smoked. Each method has its advantages and disadvantages. Shooting up intensifies the 'rush' but also increases the risk of HIV infection. 'Chasing the dragon' is healthier than injecting but requires the necessary know-how: Beginners often see their precious drug literally go up in smoke. Moreover, smoking on foil is damaging to the lungs. Here is a summary of the various advantages and disadvantages: -4 Sniffing (snorting) Method used for: cocaine, speed, (less commonly: heroin). The powder (cocaine for example) is laid out in a 'line' and inhaled into the nostrils through a straw pipe. Advantages: > When cocaine is sniffed or snorted the effects are felt within minutes. When injected or freebased the effects of the (freebase) cocaine are felt even faster but also wear off faster

[ Snorting takes little time and preparation Snorting requires very little specialist paraphernalia Disadvantages: D When used excessively the mucous membranes of the nose can become infected. This is very painful and may cause perforation of the nasal septum. D Sniffing can lead to a chronic infection of the airways, a chronic cold, nose bleeds, headache and decreased sense of smell and taste. D Sharing a straw pipe can spread hepatitis C. -4 Freebasing Method used for: crack, freebase cocaine. The crack or freebase cocaine is smoked in a water pipe or special crack pipe. Advantages: D Freebasing takes little time D It gives an intense `rush' (without the risks associated with needle use!) Disadvantages: D Freebasing can damage the lungs. Most lung problems are caused by freebasing D Freebasing can cause irregular heartbeat D Sharing a base pipe can spread TB and hepatitis A •

-+ `Chasing the dragon ' (smoking on foil) Method used for: heroin, cocaine, crack, freebase cocaine, and `speedballs' (a combination of cocaine and heroin). The drug is placed on a piece of aluminium foil and heated. The vapour is inhaled into the mouth through a pipe and directly enters the lungs. Advantages: 'Chasing the dragon' is a safe alternative for injecting. It prevents abscesses and reduces the risk of getting infected with HIV and hepatitis. D 'Chasing the dragon' takes little time. Disadvantages: D When a plastic pipe is used, the user might inhale damaging chemical vapours into the lungs. D 'Chasing the dragon' irritates the airways and increases

mucous production . Most lung problems are caused by ammonia-based freebase cocaine . Freebase cocaine made with sodium bicarbonate is less damaging. Injecting Method used for: Heroin, speed, cocaine, (less commonly: certain benzodiazepines). A little heroin is placed on a spoon or the torn off bottom of a (soda) can, dissolved in water and (in case of heroine base) acid, (citric or ascorbic acid or lemon juice) and heated. The solution is sucked into a syringe and injected into the vein. Cocaine is dissolved in water. Advantages: D The ' rush ' is more intense than with any other method, although long-term users are less likely to experience this short , euphoric feeling D The user believes they are getting the most out of the drug Disadvantages: D Injecting with non-sterile equipment and failure to disinfect the injection site can cause abscesses D Injecting can cause a 'shake' (also known as a 'dirty hit' or'cotton fever'). A shake is a fever attack caused by bacteria which enters the blood during injecting. The dirtier and blunter the needle, the greater the chance of getting a shake D Injecting with other people's equipment (syringe, needle, filter, spoon, water) can spread hepatitis and HIV D Cocaine, if improperly dissolved in the water, leaves little lumps. After injecting, these lumps can cause blood clots and blocked veins (thrombosis) D 'Sterile infections' can occur after cocaine injections. These are infections which are not caused by bacteria but by dying dermis (true skin) D After prolonged intravenous drug use, veins can 'disappear'. When a user has 'run out' of veins on the arm the alternatives are grim: Injecting into hands and feet is painful and shooting into groin and neck can be fatal due to the arteries in the immediate vicinity of these veins. If an artery is hit, the needle must be withdrawn immediately and firm pressure applied to the vein for five to ten minutes. Medical help is essential D Subcutaneous injection (for example in the lower abdomen) or injection into a muscle can only be done

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,.with heroin. If this is done with cocaine or speed, the `tissue will die D Sometimes the sleeping medicines temazepam® (Normison®), tuinal® or ketamine are injected. Then, the gel-like substance is removed from the (eggshaped) capsule with a large-gauge needle, sucked into the syringe and injected into the vein. The oil might clot and coagulate the veins which can lead to infections of the heart valves. D If oral methadone preparations are injected, the sugar may damage the vascular walls or may cause infections on the injection site Smoking Method used for: cannabis, crack, freebase cocaine (less commonly: heroin). Advantages: D Socially more acceptable D Sharing a joint is good fun Disadvantages: D Smoking tobacco, crack orfreebase cocaine can damage the lungs D When smoking hash, the cannabis is crumbled onto a bed of tobacco and in the fold of a cigarette rolling paper, rolled into a joint. The joint is smoked like a normal cigarette. Smoking hash or marijuana can damage the lungs just like smoking tobacco but cannabis smoke contains more carcinogenic substances than tobacco smoke. Also, the way the smoke is inhaled is a factor. When smoking hash or marijuana, the smoke is usually inhaled very deeply and held in the lungs as long as possible Eating Method used for: cannabis ('space cake', brownies), mushrooms. Advantages: D Eating cannabis is better for the lungs than smoking

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Disadvantages: D There is a risk of taking too high a dose. Due to the slow absorption by the blood, the effects only set in after a while. An impatient individual can easily take too much 649 ; stir



D With mushrooms, it is not possible to tell how potent the active substance is, which increases the risk of experiencing a 'bad trip' -+ Swallowing ( pills/paper trips) Method used for: speed, Ecstasy, LSD, sleeping medicines and tranquillizers, methadone. Advantages: D Easy to take Disadvantages: D Without actual testing, one never knows which substances a pill really contains (with the exception of pharmaceuticals such as sleeping medicines or tranquillizers)

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Drinking Method used for: Alcohol, methadone, mushrooms (tea). Advantages: D Methadone dose can be measured easily > Drinking alcohol is socially accepted Disadvantages: D Excessive alcohol use can cause cancer of the mouth, larynx, throat and oesophagus D Liquid methadone contains a lot of sugar and therefore - when dental hygiene is poor may be bad for the teeth

The risks of cannabis For thousands of years, hashish and marijuana have been praised for their medicinal healing qualities but like any other drug, cannabis also has its side effects. There is, for example, a reduction in concentration as well as a slowing of reflexes. Driving in a straight line also can become a difficult undertaking. Furthermore, in the middle of a conversation the cannabis user might suddenly lose their train of thought. Much more of a worry is 'freaking out'. Then, the mellow hash experience can turn into an anxiety or panic attack, dizziness, nausea and sometimes fainting, (this often is due to an excessive dose, for example through oral intake, e.g. by eating space cake).

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theT;medium term , cannabis use may lead to reduced fertility in men, and women, but if cannabis use is discontinued, fertility returns to normal. Airways and lungs, however, may suffer irreversible damage. Cannabis smoke contains more carcinogenic substances and often is inhaled deeper than tobacco smoke. This increases the risk of lung cancer.

^ Short-term: Increased appetite, particularly for sweets, and dryness of the mouth and throat D Reduced concentration and slower reflexes D 'Freaking out' •

^ Medium term: D Reduced fertility ^ Long-term: D Lung cancer (when smoked) Is cannabis addictive? Not physically, but it may cause psychological dependence especially when used excessively or to escape reality. Problems are then 'smoked away'. Can cannabis use lead to aggression? In theory this is unlikely, because THC (the active chemical in cannabis) slows down the reflexes and relaxes the muscles.



The risks of tobacco Tobacco is probably the most widespread drug in the world and the drug with the most severe health consequences. Tar is released when a cigarette burns. This is the main cause of lung and throat cancer in smokers and also aggravates bronchial and respiratory disease. A smoker who smokes one packet a day, inhales more than half a cup of tar from cigarettes each year.

^ Short-term: D Increased pulse rate D Temporary rise in blood pressure D Acid in the stomach Brain and central nervous system activity are stimulated then reduced D Decreased blood flow to body extremities •

^ Long-term: D Diminished or extinguished sense of smell and taste



D D D D D

Increased risk of colds and chronic bronchitis Increased risk of emphysema Increased risk of heart disease Premature and more abundant face wrinkles Increased risk of cancer of the mouth, larynx, pharynx, oesophagus, lungs, pancreas, cervix, uterus and bladder

Is tobacco addictive? Nicotine is a highly addictive drug. Smokers who quit have great difficulties with withdrawal symptoms. However, nicotine withdrawal is usually not as problematic as severe alcohol or heroin withdrawal. Nicotine withdrawal usually involves intense cravings and psychological symptoms such as mood swings and lack of concentration. The physical effects of withdrawal are in contrast to alcohol and heroin mild but may also involve symptoms such as diarrhoea and tremors during the first days.

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1+1=3 Tobacco is a stimulant, although many smokers believe smoking calms their nerves. However, smoking releases epinephrine, a hormone which creates physiological stress in the smoker, rather than relaxation. The addictive quality of the nicotine contained in the cigarette causes the user to smoke more to calm down, when in fact the smoking itself is causing the agitation. The risks of alcohol Alcohol is the most widely accepted drug but when used in excess (more than 6 to 8 glasses per day) also one of the most harmful. In particular, the liver suffers serious damage. The liver needs 90 minutes to metabolise a single glass of alcohol. When drinking large amounts for several years, the liver gets no chance to `rest' and the alcohol user runs a high risk of contracting cirrhosis of the liver. It could take another 10 to 15 years but eventually one might die from cirrhosis of the liver. A connection has been found between alcohol use and cancer of the mouth, throat, larynx and oesophagus. In addition, excessive drinking promotes cardiovascular diseases and can inflict serious damage to stomach, pancreas and brain (Korsakow's syndrome). ^ Short-term: D Adverse effect on judgement and reflexes D Aggression D Overestimation of one's own abilities D Adverse effect on motor functions

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^ stong-term: >< Liver cirrhosis Cancer of mouth, throat , larynx, and oesophagus Cardiovascular diseases D Korsakow's syndrome

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Is alcohol addictive? Rarely, when used in moderation. However, when used excessively and prolonged, alcohol can be addictive both psychologically as well as physically. The numbing effect of alcohol can become very attractive because it is relaxing and can obscure problems. The body can also develop a tolerance to alcohol. Whereas beginners already get drunk after a few glasses of beer, an experienced drinker can put away a few litres without the user appearing intoxicated. This phenomena is called tolerance: greater quantities of a drug are needed to maintain the desired effect. Aside from tolerance, alcohol users may also experience withdrawal symptoms if alcohol use is discontinued abruptly after a long and heavy period of drinking. These can vary from sleeping badly and 'the shakes' to - in severe cases - seizures or delirium tremens. During delirium tremens, high fever and hallucinations occur and one may see things, such as animals , that are not really there. 1+1=3 As with sleeping medicines and tranquillizers, alcohol is a'depressant'. Together the effects are multiplied which can lead to cardiac arrest. In combination with cocaine and heroin the risk of an overdose is increased. Can alcohol use lead to aggression? Yes, the 'high' can suddenly turn into aggressive behaviour and a fighting mood. Alcohol can lead to aggression, especially after excessive use and in combination with other drugs. Drug users and alcohol Drug users and HIV-infected individuals are particularly at risk from alcohol. In combination with cocaine or heroin, the risk of an overdose is increased. If someone has gastrointestinal (stomach) problems and/or liver damage (often a consequence of excessive alcohol use), methadone can irritate and hepatitis C can have an even greater impact. In the case of liver damage, AIDS inhibitors can be less effective.



The risks of cocaine Occasional use of cocaine makes the user euphoric and alert; regular cocaine use makes the user restless and irritable. Selfconfidence can turn into overconfidence. Heavy cocaine users might also live in a world of make-believe: they think that they have a fabulous life, amassing social contacts and virtually feeling like God himself. In reality, this fabulous life may not be all that it seems. Chronic cocaine use can make the user selfish, arrogant, delusional and aggressive, character traits which do not really attract friends. "Coke distorts everything and everybody - friends seem like vampires, sex turns into sadomasochism, dialogues into monologues, concern into hypocrisy." (From: `Los' 1997).

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But cocaine also takes a physical toll. Prolonged loss of appetite leads to serious weight loss and reduced resistance against infections. Combine this with sleeping disorders, (a well-known problem caused by cocaine use), and the year- long assault on the body results in exhaustion which may also be accompanied by disturbances of the heart rhythm. Then there is the 'creepy crawlies' phenomenon. Long-term users suddenly might feel as though an army of bugs is mercilessly gnawing away at their flesh. ^ Short-term: D Restlessness > Insomnia D 'The shakes' (a sudden fever attack when cocaine is injected) D Overdose D HIV infection and hepatitis ^ Medium term: D Weight loss > Reduced resistance > Nose bleeds D Infection of the nasal membranes D Heart rhythm disturbances D Exhaustion D Paranoia Delusions D Abscesses from injecting

go

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Long-term: Perforation of nasal septum. Is cocaine addictive? Cocaine is not physically addictive but can lead to psychological dependence, particularly when it is used in order to boost selfconfidence. The addiction potential of crack and freebase cocaine is many times higher than that of pure cocaine. This is due to the 'rush' wearing off much quicker. Without this short, extreme feeling of bliss the world all too soon seems cold and empty to the user. And in a short period they return to using again and again and again. Can cocaine use lead to aggression? Yes, especially after prolonged cocaine use, suspicion or mistrust may turn into aggression.

A

lcohol and cocaine The combination of alcohol and cocaine seems ideal: one stimulates, the other calms you down. A person can keep going for hours without feeling drunk. In reality, the user ruins their body. Prolonged use of both cocaine and alcohol leads to exhaustion and insomnia. This `ideal combination' also increases the risk of an overdose.

0 The risks of heroin As already mentioned in the introduction, heroin is far less harmful to the health than its image leads us to believe. The health risks from heroin use mainly consist of indirect problems: infection risks (HIV and hepatitis) when injecting, the danger of taking an overdose, and the health neglect factor. Because heroin numbs pain, a cold could turn into pneumonia unnoticed. Heroin use can also cause malnourishment and so reduce immunity to infection. Vitamins and fibres are usually not a priority in the life of a heroin user; the'bag of smack' is their'daily bread'.

^ Short-term: D Overdose 0

D Abscesses if injecting > 'The shakes' (fever attack after heroin is injected) D HIV infection and hepatitis



^ Medium term: D Malnourishment D Constipation D Abscesses, if injecting ^ Long-term: D Discontinuation of menstrual bleeding D Reduced resistance to infection Is heroin addictive? Contrary to popular belief, no one turns into an addict immediately after taking a single dose but the body gets used to heroin remarkably quickly. When heroin is injected intravenously, then tolerance develops quickly. A steadily increasing dose is needed to maintain the same effects. If the heroin wears off or its use is discontinued, a variety of withdrawal symptoms occur (cold shivers, diarrhoea, sweating, cramps). This so-called `cold turkey' can become so unbearable that after a while individuals may only keep on using so as to avoid the sickness. As well as physical pain, heroin also numbs mental pain. This makes heroin twice as attractive to individuals with personal problems. 1+1=3 Alcohol, methadone, sleeping medicines and tranquillizers all have the same effect as heroin: they sedate. Combined use intensifies this effect which can lead to respiratory failure. Heroin and cocaine Combined use of heroin and cocaine can also be dangerous. Because both substances partly neutralise each other's effect, (one sedates, the other stimulates), too much can be used unnoticed.

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Can heroin use lead to aggression? In theory this is unlikely, because heroin, like all other opiates is extremely sedating. The heroin user is very calm and may not feel like much action.

S

r :.Th:e risks of hallucinogens LSD "A demon had taken over my body, my senses and my soul. A terrible fear of becoming insane kept me in its grip." Albert Hofmann's words after his second experience with his discovery, LSD.

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Because LSD intensifies moods, the user might experience a `bad trip- especially if they do not feel good to begin with. During a bad trip, fear can turn into panic. Everyday objects can seem threatening, music may sound like an artillery attack or a room appear as small as a shoe box. On rare occasions, individuals with a predisposition can become psychotic. Others may lose control and, for example, believe they actually can fly. ^ Short-term: D 'Bad trip' (anxiety and panic attacks) D Loss of sense of reality ^ Medium term: D Psychosis ^ Long-term: D 'Flashbacks'

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Is LSD addictive? No, not physically and very rarely psychologically. The effects of a trip often are so intense that only very few individuals desire another dose of LSD quickly following their last. In addition, a pause of at least three days is necessary for being able to feel the effects of LSD again. After repeated use within a short period of time, the effects of LSD are no longer felt. Mushrooms As the effects of mushrooms are not as strong as those of LSD, the risks are not as alarming either. Are mushrooms addictive? No. When mushroom use is stopped abruptly, the user does not experience any withdrawal symptoms. Nor is there any psychological addiction to mushrooms. Using several doses in quick succession during a short period of time is pointless, since the effects of the mushrooms can no longer be felt.



Can mushroom use lead to aggression? Theoretically, a user could behave recklessly during an LSD or mushroom trip. In addition, the panic attacks during a 'bad trip' could provoke aggressive behaviour. The risks of speed The risks of speed are similar to those of cocaine. The `speed freak' also ruins their body as speed suppresses sleep and hunger. Common problems are: heart palpitations, headache, dizziness, insomnia and compulsive movements such as grinding teeth. The speed user is also 'acquainted' with the 'creepy crawler' phenomena (see chapter'The risks of cocaine'). One of the short-term risks is the rise in body temperature. In warm rooms like overcrowded dance clubs with bad ventilation this can lead to overheating, which can be life-threatening. Symptoms include high fever (40 degrees Celsius or more), seizures and massive internal bleeding from all organs. Medical help is a must. ^ Short-term: D Overheating D Reckless behaviour D Tense muscles

D Insomnia D 'The shakes' (fever attack, after speed is injected) D Overdose D HIV infection and hepatitis ^ Medium term: D Restlessness D Compulsive movements such as teeth grinding D Heart palpitations D Headache D Dizziness D Weight loss D Exhaustion D Abscesses (when injecting)

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^ Long-term: D Suspicion/mistrust D Delusions D Aggression

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s peed addictive? Speed is not physically addictive. When speed use is stopped abruptly, there are no withdrawal symptoms except perhaps an overwhelming feeling of tiredness. However, speed can be psychologically addictive. With speed rushing through your veins, you believe you can do anything. Without it, you feel insecure and depressed. To get rid of these feelings an individual is easily tempted to use again , and in increased amounts because tolerance builds up fast.



Alcohol and speed The combination of alcohol and speed seems ideal: as with cocaine, one stimulates, the other calms down. A person can keep going for hours without feeling drunk but in reality ruins their body. Prolonged use of speed and alcohol together causes exhaustion and insomnia. This `ideal combination' also increases the risk of an overdose. A fatal mistake In powder form, speed and cocaine pretty much look alike. Pure speed, however, is much stronger than pure cocaine. In other words, much less of it is needed. An individual who sniffs speed thinking that they are using coke might take an overdose of amphetamines, which can cause a heart attack. Can speed use lead to aggression? Yes. Just like cocaine, speed makes one suspicious which could easily lead to erratic and aggressive behaviour. The risks of Ecstasy Ecstasy is a relatively new drug. Long-term risks are therefore not yet known. People with cardiovascular diseases, diabetes and epilepsy are advised not to use Ecstasy. Particularly since the `love drug' is often found to contain substances which have nothing to do with Ecstasy. Sometimes a pill might contain pure speed or DOB - a strong hallucinogen whose effects last for up to 24 hours. When taking Ecstasy, a user can never be sure what he is swallowing, so naturally this is one of its biggest dangers. Another health risk is dehydration. As with speed, the Ecstasy user can become overheated in warm and badly ventilated rooms, which again can be life-threatening. (See chapter 'The risks of speed').



^ Short-term: D Overestimation of one's own capabilities D Overheating and dehydration ^ Medium term: D Sleeping disorders D Anxieties D Hallucinations D Depression D Reduced resistance ^ Long-term: D Not yet fully known 0 Is Ecstasy addictive? The psychological dependence can be considerable because many people today feel'what's a party without a pill'? With regard to the physical dependence, Ecstasy does not produce withdrawal symptoms but tolerance does develop. Rapidly repeated intake of Ecstasy pills is also pointless in terms of the hallucinogenic effect. The mind-altering effect will only reoccur after a 30-60 day pause. Dubious combinations The effect of combining Ecstasy with other drugs is unpredictable and therefore risky. Can Ecstasy use lead to aggression? No. Pure Ecstasy does not cause aggression; the adulterants, however, might.

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The risks of sleeping medicines and tranquillizers Benzodiazepines have a sedating effect but because of their potential for producing agitation and tantrums can also cause a great deal of unrest. However, the greatest danger with these drugs lies in fatal combinations: 1+1=3 Certain benzodiazepines - particularly the fast-acting kind - are popular in the drug world because of the mellow'high'they give. Used together with other drugs, though, they can be life-threatening . The effects of heroin and other opiates are intensified with benzodiazepines, creating the usual 1 + 1 = 3 effect. With a little bad luck the 1 + 1 = 4 effect is induced, or the user may die from respiratory failure.

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'Alcohol Combined with alcohol, benzodiazepines can be fatal. One might well survive a high dose of Valium® but taken in combination with alcohol one can fall into a coma.

^ Short-term: D Drowsiness; Weak muscles; Indifference; Overestimation; D Reduction in concentration and reflexes. 0

^ Medium term: D Weight increase. Are benzodiazepines addictive? Yes. Particularly in psychological terms, there is a potential for a quick and heavy dependence. Regular use of benzodiazepines also leads to tolerance: an increasing amount being needed to maintain the same effect. Can the use of benzodiazepines lead to aggression? Yes. Particularly in combination with alcohol or when the substance is discontinued after prolonged use.

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Of all the benzodiazepines, Rohypnol has the worst reputation. This substance can induce aggressive and seemingly unscrupulous behaviour when taken in high doses. The individual loses their inhibitions and much of the time cannot remember anything afterwards.



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Quiz •

WHAT DO YOU KNOW ABOUT OVERDOSE?'

This chapter regularly mentions the word'overdose'. What is an overdose? And what must be done in case of a heroin or cocaine overdose (see also 6.9 in this chapter) ? Test your knowledge with this quiz.



1.

A heroin overdose is always fatal within minutes? A. Correct B. Incorrect

2.

Giving a shot of salt water helps to combat a heroin overdose? A. Correct B. Incorrect

3.

For someone not used to heroin , 0.2 gram of heroin can be deadly. A. Correct B. Incorrect

4.

In case of a cocaine overdose , the user should swallow sleeping pills or tranquillizers as quickly as possible? A. Correct B. Incorrect

5.

When dying from a heroin overdose, the user eventually dies from suffocation? A. Correct B. Incorrect

6.

Swallowing sleeping pills or tranquillizers can increase the risk of a heroin overdose? A. Correct B. Incorrect

7.

A heroin overdose does not lead to death as often as a cocaine overdose? A. Correct B. Incorrect

8.

A cocaine overdose can cause a heart attack? A. Correct B. Incorrect

9.

During an epileptic seizure due to a cocaine overdose, you must try to keep the mouth open by inserting an object? A. Correct B. Incorrect

10.

The combination of heroin and benzodiazepines increases the chance of a cocaine overdose? A. Correct B. Incorrect



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0

Quiz 0

Add up the numbers to the answers you gave. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. •

A-0 A-0 A-1 A-0 A-1 A-1 A-0 A-1 A-0 A-1

B-1 B-1 B-0 B-1 B-0 B-0 B-1 B-0 B-1 B-0

0-5 points When an overdose occurs, swift and accurate action is important. Knowing what to do can be a matter of life and death. Unfortunately, your knowledge is inadequate. 6-8 points You are pretty well informed but not quite well enough. 9-10 You are well informed. Here are the correct answers to the'What do you know about overdose?' quiz: 1. B-

A heroin overdose is always fatal within minutes. Incorrect. A heroin overdose can be fatal quite quickly (within a few minutes) but most of the time it takes longer for death to set in. In any case, action needs to be taken quickly.

2. B-

Giving a shot of salt water helps to combat a heroin overdose? Incorrect. The idea that administering a shot of salt water helps is a myth. Individuals suffering from an overdose must be woken up and kept awake. This might be achieved by slapping them in the face, pinching them hard below the collar bone or throwing cold water in their face. If you do not succeed in your wake-up attempts, call an ambulance as quickly as possible.

3.

For someone not used to heroin, already 0.2 gram of heroin can be deadly? Correct. 0.2 gram can indeed be deadly for someone who does not normally use heroin. Also, in individuals who have been'clean' for awhile, a small amount of heroin can induce an overdose.



A-

0



B-

5. A-

After a heroin overdose, the user eventually dies from suffocation? Correct. During a heroin overdose the brain almost stops functioning. This suppresses breathing and lets moisture enter the lungs, resulting in an even smaller supply of oxygen. Suffocation therefore is the greatest danger with a heroin overdose.

6.

Swallowing sleeping medicines or tranquillizers can increase the risk of a heroin overdose? Correct. If taken together with benzodiazepines and tranquillizers, one can fall into a coma more easily.

A-

7. B-

A heroin overdose does not lead to death as often as a cocaine overdose? Incorrect. It is precisely the other way round: A cocaine overdose is less likely to be fatal than a heroin overdose. This does not mean though, that in case of a cocaine overdose, speedy action is not necessary.

8. A-

A cocaine overdose can cause a heart attack? Correct. An overdose of cocaine can manifest itself in two ways: 1. chest pains and 2. epileptic attacks. In the first case, heartbeat and blood pressure rise rapidly, which can lead to a heart attack.

9.

During an epileptic seizure following a cocaine overdose, you must try to keep open the mouth by inserting an object? Incorrect . Putting something in the mouth does not help and might cost the helper a few fingers. It is also not good for the teeth of the victim. Better to call an emergency number and protect the heavily convulsing victim by laying him somewhere on the ground where they cannot get hurt. Put a pillow or jacket under their head. When the convulsions have stopped, put them in a side position with the upper leg bent and the lower leg straight, and the head straight or slightly bent backward.

B-

10. A-

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lnc se of a cocaine overdose, the user should quickly swallow sleeping medicines or tranquillizers? Incorrect. The agitation that comes with an overdose of cocaine could indeed be combated with benzodiazepines but the situation is extremely dangerous and the individual should not self-medicate. Due to the slow absorption by the blood, the effect of sleeping medicines and tranquillizers is delayed. In a panic situation, the person might easily take too many pills and suppress their breathing.

The combination of heroin and benzodiazepines increases the chance of a cocaine overdose? Correct. With heroin and benzodiazepines in the blood, the cocaine user feels very relaxed, which makes a second helping of cocaine seem very tempting. This relaxation, however, is only a pretence. In reality, the heart is doing overtime and the next 'line' could be the last.





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TRANSMISSION OF VIRUS, BACTERIA AND PARASITES: HIV; HEPATITIS; TB AND STD's

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`All dragons are dead. The only real challenge that more or less was not eliminated by the relentless domestication of the once wild roaming human species is the fight against our untamed small fellow creatures, lying in ambush in dark corners and creeping up on us from the bodies of rats, mice and various pets which fly and crawl around together with insects and await us in our food, drink and even invade our love life.' From: 'Rats, Lice and History' (1935) by Hans Zinsser (American bacteriologist).

This manual regularly deals with viruses but what actually is a virus? And how does a virus differ from a bacterium? Next, we put the world of microbes under the looking glass.



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Micro-organisms Living organisms , too small to detect with the naked eye, were first discovered by the Dutch scientist , Antoni van Leeuwenhoek (1632-1723). Van Leeuwenhoek dedicated much of his time to the grinding of magnifying lenses . He produced the best lenses available at that time , with a magnification of approximately 300 times. Van Leeuwenhoeks amazement while observing the world of microbes could be sensed from one of his letters to the Royal Society regarding a rotten tooth:'I removed this stuff from the root cavities , mixed it with clear water and placed it under a microscope. I have to admit that the stuff looks like it is living. But even so, the volume of those tiny creatures was so extraordinarily large that around a billion would be needed to make up a grain of sand: Viruses A virus is a piece of DNA and is much smaller than the smallest known bacterium. Viruses cannot multiply by themselves and do not stay alive outside of the host body. The most important weapon of man against viruses is the immune system. This system functions in two ways: It helps us to recover from a virus disease and protects us from a following infection. Some viruses, like HIV, destroy their host's immune system. Others have learned to 'hide' in cells, specially selected for this purpose and sporadically appear at'convenient' moments. Herpes Simplex, for example - this virus lives in the nervous system of as many as 90% of all adults. If your resistance gets weaker or you have had



too much sun, this virus causes cold sores on the lips. The third virus category has developed a mechanism which treats every contact with the immune system as a new encounter, like the flu virus, for example.

T

he virus as secret weapon In the history of mankind, virus diseases are important events. It is highly unlikely that in 1520, a small group of Spanish soldiers could have defeated the Indians in Mexico without the smallpox epidemic, which the soldiers unknowingly carried with them into the New World themselves.

• Bacteria Bacteria are single-celled organisms which, in contrast to viruses, can multiply without needing a host. One can differentiate between bacteria by the shape; these include spherical bacterium or coccus, rod-shaped bacterium or bacillus and spiral bacterium or spirillum. Under a microscope, bacteria look rather strange. They form little balls, flakes, or worm-like squiggles. Yet bacteria are a normal phenomena. More than 600 million bacteria live on our skin alone. Under our armpits, 800 bacteria per square millimetre may exist, while drier spots such as the forearm may be occupied by around 20 bacteria per square millimetre. There are both harmless and harmful bacteria like the streptococci which causes dental caries. Staphylococci types include those that cause conditions as diverse as boils and pneumonia. Also the most common venereal disease - chlamydia - is also caused by a bacterium, and this is also true of gonorrhoea and syphilis.



Generally the body reacts in a similar fashion to both a bacterium or a virus: it starts to create antibodies. Bacterial diseases and disorders can usually be treated effectively with antibiotics.

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._Penicillin_discovered by accident After a vacation in 1928, the Scottish scientist Alexander Fleming (1888-1955) returned to his London laboratory. On his worktop, he noticed that the lid of a culture dish containing staphylococci had come loose, which resulted in the contamination of the culture with yeast and fungi. Fleming found that all staphylococci on the spot where Penicillum notatum (one of the fungi) had developed, were dead. After further investigation, he succeeded in reducing this occurrence to the presence of an active substance in the fungus. In 1929, he gave this substance the name penicillin, which is derived from the name of the fungus. In 1940, the researchers Howard Florey and E. B. Chain succeeded in isolating penicillin and confirming its bacteria-killing ability: As the cure for several infectious diseases, including syphilis, this magical fungus turned out to be one of the most important discoveries in modern medicine, which - astonishingly - was purely due to chance. Fleming: "There are thousands of different fungi and a thousand types of bacteria, so that the chance of combining these two atjust the right moment was just as small as winning the major prize in a lottery."



Infectious diseases are diseases you can catch from other people. These infections may be minor, such as a cold, or more serious infections like AIDS and hepatitis. Fortunately, infection is easy to avoid for most infectious diseases. Some infectious diseases can be transmitted through normal daily contact. By normal daily contact we mean the usual daily interaction with others, such as talking, eating together, touching people, engaging in sports activities or taking communal showers. Influenza and TB are major infectious diseases that can be transmitted through this sort of daily contact. Some risky situations may arise in the course of daily contact, such as sharing toothbrushes, shaving equipment (esp. razors) and trimming scissors. Blood particles can stick to these items, and when shared with others, these blood particles can be transmitted from one person to another. See in this chapter 5.1 for hints on avoiding infection through daily contact or blood-to-blood contact. 71JI



Blood -to-blood contact Other viruses may only be transmitted via blood-to-blood contact, by which we mean that the blood particles of one individual enter somebody else's bloodstream. This can happen in various ways: Pricking the skin with a needle or syringe with somebody ^ else's blood on it ^ Blood can also be transmitted through equipment, such as cotton balls ^ Blood entering an open wound or skin with sores and scratches (such as bites) ^ Blood entering the eyes, mouth or nose These blood particles may not be visible to the naked eye. The most common risks stemming from blood-to blood contact concern different ways of using drugs. In order to distribute the small quantities of heroin bought in a fair manner between two or more consumers, two different methods are used. The most dangerous form is needle sharing, i.e. injection equipment (consisting of a syringe and/or a needle) is used by two or more consumers. The heroin powder is dissolved in a spoon, then the whole quantity of liquid heroin is drawn up into a single syringe which is then used by the drug consumers in succession. The contents of the syringe can be divided equally by using the scale lines marked on the syringe (a rarely used technique). This practice is still common among drug users, particularly in prisons.

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The other way of sharing drugs is by dividing the heroin between several different syringes. The dissolved powder is divided between different syringes to distribute the quantity in equal amounts. This can be done in either of two ways: ^

Front loading The solution is squirted via the tip of the needle into the second syringe in the opening at the front and then it is injected.

^

Back loading The plunger of the second syringe is removed and the solution of dissolved heroin is passed to the next syringe via the opening at the back. This technique is mostly applied with insulin syringes where the barrel and the needle form a single unit.

These forms of drugs sharing are only completely safe if all of the equipment used is brand new or has been cleaned and sterilized thoroughly (see 6 .1 in this chapter)





3.1 Theprison as breeding ground for infections? AIDS, hepatitis and tuberculosis can be caught anywhere but as various statistics show, this possibility is greater within prison than it is outside. For several reasons, prisons are a high risk environment for infectious diseases:



^ Lack of hygiene In many European prisons, sanitary conditions are inadequate. This results in an increased risk of hepatitis A, infections, abscesses, and parasite infestations such as lice, fleas and scabies. ^ Overcrowding In a large prison in Eastern Europe, as many as 35 prisoners may share a single cell. However, other European prisons also have problems with overcrowding. Overcrowding creates containment problems and promotes unhygienic conditions and the spread of infectious diseases. ^ Violence According to a prisoner of an old prison in Dublin, Ireland: 'There is a lot of tension, we are just waiting for another riot: Violence creates extra dangers in terms of direct blood contact and therefore is a risk of infections with HIV, or hepatitis B and C.



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Unsafe drug use ^ Injecting drug use is widespread in prison. About half of the inmates who have used injectable drugs outside prison continue with different use patterns when they are incarcerated. Injecting in the prison setting usually means sharing needles and syringes and other injecting equipment. Alternative routes of administration are often much more expensive. Unsafe sex ^ In prison, sex between men is not uncommon. However, many men involved will not openly admit to the practice and so research statistics tend to give a distorted picture. Research findings from prisons in Zambia, Australia, Canada and England show that between 6 and 12% of the male prison population engage in sex with other men. A 1993 study from Rio de Janeiro (Brazil), however, showed that 73% of the men had sex with each other. Sex in prisons usually means anal intercourse, whereby men penetrate the partner's anus. Rapes also take place from time to time. Anal sex without condoms and anal rape creates additional infection risks because both semen and blood contact is involved.



Blood brotherhood ^ In spite of the risks from HIV and AIDS, life-threatening rituals surrounding blood brotherhood are still very popular in some prisons. ^ Tattooing and piercing Tattooing and piercing have become increasingly popular in recent years. In prison especially, tattooing can be a symbol of solidarity and belonging. Both tattooing and piercing involve health risks, including the potential for transmission of infectious diseases. There are many reports on wound infections, as well as on the transmission of hepatitis and HIV. Tattooing is institutionalised in prisons but it is also usually regarded as illegal, and so the likelihood of unsterile equipment being used is very high. Tattooing is a social activity and tends to involve sharing needles and other tattooing equipment. Male prisoners seem more likely than female prisoners to engage in tattooing.

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3.2 Infectious diseases The following information is about those infectious diseases that form a considerable risk for both inmates and prison staff. For each disease, we will list the symptoms, the ways that they are transmitted and any possible ways to avoid them. We also describe the measures that can be taken by the institution to try and prevent each infectious disease. The flu What is the flu? The flu (influenza) is caused by a virus. Every year, new strains of flu are emerging. Common 'flu symptoms include: high fever, aching muscles and headaches. Sometimes people with the 'flu can also have a dry cough or a sore throat.

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How do people get the flu? The flu virus is spread through the air. Somebody who becomes ill may have infected others during the period preceding the emergence of symptoms without the person knowing anything about it. Not everybody who is infected gets sick. What happens when somebody has the flu? About 1 out of every 20 Dutch people catch the flu each winter. Most people recover on their own within a week. All they need is rest. Medication can relieve some of the symptoms. The flu can be very serious among people in poor health, such as those with chronic illnesses or the elderly.

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• ___--Avoiding infection Becoming infected with the `flu virus is hard to prevent, daily contact included. You can, however, help avoid passing on the flu virus. If you put your hand in front of your mouth and turn away from others when coughing or sneezing, you can avoid spreading the virus unnecessarily. Using disposable tissues when suffering from colds or flu is also a good idea. People with poor health can also have themselves vaccinated against the flu for the winter. Doing so will protect them from the types of the flu going around that year. In the institution In some prisons there are flu shots available from the prison medical service for everybody who needs them. Inmates can see the doctor or nurse about getting one. Tuberculosis (TB) What is TB? TB is an infectious disease caused by a bacterium. While these bacteria can attack different organs, lung tuberculosis (consumption) is the most common form. TB symptoms include tiredness, lack of appetite and coughing. How do people get TB? The bacteria are released into the air by patients with lung TB. People with lung TB are only capable of infecting others during the contagious stage. These patients cough up bacteria from their lungs which are then transmitted through the air. An individual inhaling the same air may then become infected with TB. What happens when somebody has TB? Not everybody infected with TB gets sick right away. People in poor health are likely to get sick. Others may feel fine for years. Some people never get sick at all, even though they are infected. As soon as somebody is diagnosed with lung TB, everybody with whom he or she has been in touch needs to be contacted and examined for TB. Everybody infected with TB needs to be treated with medication. People who are not ill (but have been infected) are treated as a precaution against becoming ill later on.



TB medication needs to be taken for an extended period. People who stop taking the medication before finishing the treatment may go on to develop the disease after all.



Further treatment then becomes far more complicated in such cases. In the early stages of their treatment, people with lung TB must be isolated to avoid infecting others. After a few weeks they are no longer contagious and can interact with others once again. Avoiding infection Because TB is spread by coughing and sneezing, putting your hand in front of your mouth and turning away from others is important. You should also turn the other way when others cough in your direction. In the institution In some prisons, everybody is tested for TB by the medical service upon entering the institution. Any TB infections are identified to avoid spreading them throughout the institution.

S

The TB examination generally involves a Mantoux test , where a small amount of liquid is injected in the lower arm. After a few days , the skin 's reaction to the liquid is checked . Sometimes the TB examination consists of a lung X-ray. If a person is transferred to a different institution , the results might be sent to the medical service at the new institution. Anybody with TB in an institution should be treated immediately. People with lung TB should be isolated for a few weeks during the contagious stage Symptoms of Tuberculosis The main symptoms of TB are: ^ Protracted coughing ^ Loss of appetite ^ Loss of weight ^ Night sweats and fever ^ Coughing up blood ^ Pain in the chest that lasts longer than three weeks.

9

If you or a cellmate has similar symptoms, an urgent doctors consultation is necessary. It will usually consist of giving a sputum sample, which is then examined under the microscope. The availability of mycobacteria in the sputum means that the person has an active form of TB, and therefore will need anti-tuberculosis medication for at least six months. In order to avoid catching TB or infecting others: ^ Cough in your hand or a handkerchief 76

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^ ^ ^ ^

0

Don't spit the sputum everywhere - use a handkerchief or napkin Air your cell regularly - particularly if it is overcrowded Try to eat well, and if possible consume plenty of vitamins, fresh fruit and vegetables to improve your immunity If these symptoms appear, contact a doctor immediately. The sooner treatment begins, the better the outcome will be

Hepatitis A What is hepatitis A? 'Hepar' is Greek for liver; 'itis' means inflammation. hepatitis, therefore, is an inflammation of the liver. There are different types of hepatitis. hepatitis A is the most harmless variety but it is also very contagious. Each year, over 10 million people world-wide are infected with the hepatitis A virus. How do people get hepatitis A? People become infected through contaminated food and water. The dazzling blue ocean water near a five-star hotel could be contaminated due to an open sewer nearby. The exquisite dinner in the same hotel could be contaminated because the cook has not washed their hands after visiting the toilet. The virus can also be transmitted through sexual contact, particularly oral-anal sex. When licking the anus, small particles of faeces can get into the mouth.



Risk factors ^ sharing unhygienic sanitary facilities ^ oral-anal sex Does one always get sick when infected with hepatitis A? No. What happens if somebody does get sick from hepatitis A? The symptoms can vary, but include fatigue, fever, muscle and joint pains to nausea and abdominal pains. The illness can also produce colour changes in eyes, skin, urine, (tea colour) and faeces (pale colour). How long is the incubation period? After the initial infection, it normally takes two to six weeks before one gets sick.

Is hepatitis A curable? Yes, but not with medicine. After a few months, hepatitis A eventually disappears by itself. If someone has been sick with hepatitis A once, they are immune to the virus for the rest of their life. How can contracting hepatitis A be prevented? The golden rule is good personal hygiene. Always wash your hands after visits to the toilet, or before eating or preparing food. There are also vaccinations against hepatitis A infection. A safe and effective vaccine against hepatitis A (+B in combination) has now been available for many years. In the institution If an inmate thinks that they might be infected with the hepatitis A virus, they should be able to see the medical service to decide whether they need to be tested. Determining whether one is infected involves taking a blood sample for examination. A positive result indicates either a recent infection or that you have developed an immunity to the virus due to prior infection. Hepatitis B (including vaccination) What is hepatitis B? Hepatitis B is a virus that affects the liver. It is very infectious, and can result in serious long-term health problems. Hepatitis B can cause different symptoms, including jaundice, tiredness, listlessness, fever, dark urine and pale coloured stools (faeces). However, many people may experience no symptoms at all. How is the virus transmitted? ^ Sexual contact ^ Blood to blood contact, i.e. sharing of injecting equipment, sharing razors, needle stick injuries, contaminated blood products ^ Mother to baby (vertical transmission) The virus can be found in all body fluids, but is much more concentrated in blood, semen and vaginal secretions.



What happens if somebody has hepatitis B? In 90-95% of cases, the infection will resolve spontaneously and the person infected will be left with a "natural immunity" to further Hep. B infection. In 5 to 10 percent of all cases, the virus remains active. This is known as "chronic carrier status", and this group may develop long-term health problems. They also remain infectious to others

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Via-the-routes already described. Long-term health risks ^ Liver cirrhosis ^ Liver cancer ^ Liver failure In recent years some people with chronic hepatitis B have been receiving a new medication. Although the treatment can cause side effects, it does cure some patients of the disease. A specialist can decide whether a course of medical treatment is likely to help.





How can you avoid infection? ^ Safer injecting techniques ^ Practising "safer sex" ^ Use of "universal precautions" when handling body fluids ^ Vaccination against hepatitis B Vaccination against hepatitis B (and A) is offered in many prisons. It makes a great difference whether the service promotes take-up of the vaccine in a proactive way, or if the service is only available 'on demand'. Sometimes, prisoners are not informed about the availability of the Hep. B. (or the Hep. A+B combination) vaccination. People in certain professions, such as prison officers, can have their employer pay for the vaccination. Daily social contact presents no risk of infection. In the institution If an inmate thinks that they might be infected with the hepatitis B virus, they should be able to see the medical service to decide whether they need to be tested. Determining whether one is infected involves taking a blood sample for analysis. The prison medical service should also provide condoms or should inform the inmates where they can get them inside the institution. Hepatitis C What is hepatitis C? Hepatitis C is a virus that affects the liver. The long-term health risks can be very serious, due to the prospect of liver damage. Symptoms, when present, are similar to those of hepatitis B infection, but in many cases, the person will be unaware they are infected. How is hepatitis C transmitted? ^ Blood-to-blood contact, i.e. sharing of contaminated drug injecting equipment

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^ Contaminated blood products What happens if somebody has hepatitis C? Eighty percent of people with this liver disease will develop chronic hepatitis C. They carry the virus and can infect others. After 15 to 20 years, people with chronic hepatitis C can develop liver cirrhosis. Liver cirrhosis involves damage to the liver caused by scar tissue which prevents the liver from functioning. In extreme cases, people may die. Hepatitis C carriers also run a higher risk of developing liver cancer. People infected with hepatitis C can take medication. Some can never be fully cured and the treatment can cause serious side effects. A specialist usually decides whether such medication will be helpful. 0 How can you avoid infection? ^ Safer injecting techniques ^ Use of "universal precautions" when handling body fluids ^ There is currently no vaccine available to prevent hep. C You cannot become infected with hepatitis C through normal daily social contact. In the institution If an inmate thinks that that they might be infected with hepatitis C, they should have the opportunity to see the prison medical service to find out whether they have been at risk. Counselling on the advantages and disadvantages of getting tested for hepatitis C should also be offered (see page 81). The hepatitis C test involves taking a blood sample for analysis. Testing should only be done on a voluntary basis, and after an inmate has been made aware of the hepatitis C test's advantages and disadvantages. Consequently, an individual should have the opportunity to think about the test for a few days before taking it. Any positive test result should be delivered within the framework of post-test counselling (see below) •2 Based on Mainline Magazine 1997 (see references)

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The Top 12 Questions about hepatitis C *2 1. How likely is it that I have hepatitis C? In blood-to-blood transmission, the hepatitis C virus (HCV) is three times as infectious as HIV. Seventy to eighty percent of injecting users have it. Anyone who has ever had an unsafe injection has run the risk of infection, and someone who has become infected with HIV through a dirty needle is highly likely to have HCV as well.

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Could I have hepatitis C even if there doesn 't appear to be anything wrong with me? Yes, it's possible. Many people are HCV+ without being aware of it. Most of them start suffering from vague symptoms such as tiredness and listlessness only many years later.



3. Can I die from hepatitis C? Sometimes hepatitis C gets better of its own accord, and many people who have it live to a ripe old age. No-one dies of the virus itself, but a small proportion of infected people develop cirrhosis of the liver some fifteen to twenty years after infection. In these cases, more and more liver functions begin to fail until ultimately the patient starts getting serious haemorrhages and infections, then goes into a coma and dies. Cirrhosis can also turn into liver cancer. 4.

Is there more risk of getting hepatitis C if I have already had another type of hepatitis? The seven kinds of viral hepatitis now known are all distinct liver diseases. One type does not change into another. Having once been infected with one of the other six types does not increase your chance of getting hepatitis C, but it does not afford you any protection against it either. Thus if you do get hepatitis B through an unsafe injection, there is a real chance you could become infected with HCV at the same time.



Is there a link between HCV and HIV? 5. Both viruses can be transmitted by dirty needles. That is why many HIV+ drug users are also HCV+. A double infection of this kind can also cause earlier and more severe liver disease. The chances of curing it with interferon are relatively small and a liver transplant is not possible. There is also greater risk of crossinfection from mother to baby. What can I do to look after myself if I believe or know I have hepatitis C? Be kind to your liver. Giving up alcohol is a major step in the right direction. Take care with medicines and other drugs too. Eat a healthy diet, get plenty of sleep, avoid stress and try to lead a stable, regular life. 6.

7. Am I eligible for treatment with interferon? Your GP can refer you to a specialist for interferon treatment. National health insurance might pay for it. The fact that you are a drug user is not supposed to debar you from treatment.



How can I avoid a hepatitis C infection? 8. contact in which blood could be exchanged. Inject any Avoid safely: never share needles, barrels, filters, rinsing water or spoons. Any used injecting equipment could carry traces of blood. Always make sure you have your own equipment with you. If I am already HCV+, can I get infected again? 9. Even if you are HCV+ you can still get infected by another variant of hepatitis C. This will cause a resurgence of the hepatitis and your health will deteriorate more rapidly. So do be sure to avoid new infections. 0 Can I get hepatitis C by kissing? 10. No, touching or kissing a HCV+ person is perfectly safe. It's also safe to share anything other than razors, toothbrushes or anything else which could become contaminated with blood. Can I get hepatitis C through unsafe sex? 11. Research shows that Hep C is not currently believed to be sexually transmitted. If I am pregnant and have hepatitis C, am I likely to infect the baby? The chance of transmitting HCV to your baby is probably very low. But if you have both HCV and HIV, the chance of your baby becoming infected with hepatitis C is greater. 12.

HIV/AIDS HIV stands for "Human Immunodeficiency Virus". It is the presence of this virus that can eventually develop into AIDS, or HIV related illness, as a result of damage to the immune system. AIDS stands for "Acquired Immune Deficiency Syndrome", and is defined as an illness characterised by one or more particular diseases. HIV attacks the immune system. Our immune system protects our body from illnesses. The symptoms may not appear for many years. The first signs may be one or more of the following symptoms: severe tiredness, night sweats, fever, weight loss, swollen lymph glands, persistent diarrhoea. How is HIV transmitted? ^ Blood to blood contact i.e. sharing of contaminated injecting equipment ^ Sexual contact ^ Mother to baby (vertical transmission)

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HIV-ca be found in all body fluids , but is much more concentrated in: ^ Blood ^ Semen ^ Vaginal fluid The only way of knowing if you have HIV is to have a blood test. Without visible symptoms, nobody can see that these people are HIV positive. They can infect others through unsafe sexual contact and blood-to-blood contact. Mothers with HIV can also pass the virus on to their babies while pregnant, during the delivery and by nursing. •

What happens if somebody has HIV? He or she will not have any symptoms in the beginning. Over time, the virus attacks the immune system, which becomes less effective at fighting infection. Diseases of the immune system occur, defined as HIV related illness, or AIDS. Left untreated, these illnesses will ultimately cause death. However, while there is no vaccine or cure for HIV infection, symptoms can be successfully treated in many cases with the right combination of medication. Drugs are also available to suppress the activity of HIV on the immune system, known as "combination therapy". How can you avoid infection? ^ Practice "safer sex" ^ Safer injecting techniques ^ Use of universal precautions (when handling body fluids, avoiding needle stick injuries by wearing gloves, using sharp save boxes) In the institution If an inmate thinks that they might be infected, they should have the opportunity to see the medical service to find out whether they have been at risk. Counselling about the advantages and disadvantages of getting tested for HIV should be offered. The HIV test involves taking blood for examination. Testing should only be done on a voluntary basis. Once an inmate is aware of the HIV test's advantages and disadvantages, the inmate should have the opportunity to think about the test for a few days before taking it. A positive test result should be delivered within the framework of post-test counselling (see below)



Infecting your baby While pregnant, a mother can pass infectious diseases on to her unborn child. Women who want to become pregnant and may be infected can have themselves tested for HIV. Use of combination therapy during pregnancy greatly reduces the risk of passing on the virus to the baby. Checking for other infectious diseases, such as STI's (Sexually Transmitted Infections) and hepatitis is also a good idea.

HIV and hepatitis Testing Getting an HIV or hepatitis test can be an important service for inmates who want to know if they are infected or not. Furthermore, getting tested is the basis for receiving timely, adequate treatment. In many prisons HIV and hepatitis testing is offered at the first medical check on a voluntary basis, acknowledging confidentiality and informed consent. However, in some countries forced, mass testing of those groups considered to be at higher risk of HIV is still considered an appropriate tool for controlling the epidemic. This is especially true for countries where HIV is a relative new phenomenon and fears of a spread of the disease leads to compulsory mass testing and segregation of infected prisoners in single cells. A mandatory HIV test for all inmates in such cases is perceived as both a prevention and a security measure. Knowing who is infected in prison is believed to have a preventive effect for the infected person, and also for staff and other inmates. But simply knowing about one's serostatus does not necessarily result in behavioural change, nor does it prevent transmission - either sexual, drug-related, or perinatal.

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Segregation of HIV positive inmates may also be seen as an adequate prevention and security measure. It is believed to protect the HIV positive inmate from attacks from fellow inmates and to protect others from the possible transmission of HIV. However, there are good arguments against mandatory testing and segregation: ^ Mandatory testing and segregation create a false sense of safety for those not separated , possibly leading to higher risk behaviour. One should keep in mind that a negative test is no guarantee of negative serostatus . With an HIV

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^

^

^

^

;test there is always the risk of false negative test results, articularly during the `window' period . The term refers to the period of 3 months after the actual infection, where a test result might be negative but a person is actually infected. Segregation also contributes to discrimination of the HIV infected , possibly resulting in psychological stress , possible alienation from family and friends, etc. Segregation can be perceived as a form of additional punishment and might lead to a negative attitude by prison staff (due to fear and prejudice). Mandatory testing generally leaves the person unprepared for dealing with a positive test result , possibly leading to emotional and psychological problems . Even , if pre-test counselling (see below) were to be offered, it is questionable how useful it would be in such circumstances . Mandatory testing conflicts with the atmosphere of trust necessary for effective counselling. Mandatory testing and segregation conflict with accepted ethics defined in the internationally accepted human rights code . Mandatory testing violates the integrity of the body as guaranteed by the human rights code, which states that any invasive action needs informed consent.

r ! The safest and most realistic prevention approach for both staff and inmates is for everybody to act as if everybody is infected.





Thus it is everybody's personal responsibility to protect themselves from being infected. It is the responsibility of the prison administration to create the conditions that allow safe behaviour for staff and inmates , i.e. providing information about and the means to facilitate safe behaviour. However, testing - on a voluntary basis - is a valuable contribution to any prison health service. The Committee of Ministers '3 to Member States of Europe state that "emphasis should be put on explaining the advantages of voluntary and anonymous screening for transmissible diseases and the possible negative consequences of hepatitis , sexually transmitted diseases , tuberculosis or infection with HIV. Those who undergo a test must benefit from follow-up medical consultation...". The WHO guidelines on HIV and AIDS in prison (1993) state: "...Since segregation , isolation and restrictions on occupational activities, sports and recreation are not considered useful or re-

*3 Council Of Europe, Committee Of Ministers, Recommendation No. R (98) 71 Of The Committee Of Ministers To Member States Concerning The Ethical And Organisational Aspects Of Health Care In Prison.

levant in the case of HIV infected people in the community, the same attitude should be adopted towards HIV infected prisoners. Decisions regarding isolation for health conditions should be taken by medical staff only, on the same grounds as are used for the general public, in accordance with public health standards and regulations. Prisoners' rights should not be restricted further than is absolutely necessary on medical grounds, and as provided for by public health standards and regulations. HIV infected prisoners should have equal access to workshops and to work in kitchens, farms and other work areas, and to all programs available to the general prison population..." Pre- and post-test counselling When it comes to HIV or hepatitis testing, pre and post-test counselling are of vital importance. The focus of pre-test counselling is to weigh the advantages and disadvantages of getting tested to allow a properly considered decision. Post-test counselling will concentrate on dealing with emotional problems in the case of a positive test result, and reinforcing messages about safer sex and injecting in the case of a negative result. These are the requirements for HIV test counselling: ^ Having trained counsellors available who are trusted by the inmates (see further under counselling in chapter 3,6) ^ Having available counselling facilities, a room where people can talk in private with a counsellor and feel at ease ^ Having guaranteed confidentiality by the medical service carrying out the HIV test counselling and the actual test, e.g. allowing anonymous testing ^ Being able to provide inmates with the necessary services, care and treatment

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Pre-test counselling These are the important elements of pre-test counselling: ^ Determining the level to which an inmate is aware and informed (or in denial) of their risk of HIV infection and facilitating an accurate self-perception of risk; ^ Ensuring the individual understands the nature of HIV infection; ^ Providing information about HIV transmission and risk reduction; ^ Discussing risk activities the individual may have been involved in with respect to HIV infection, including the date of the last risk activity engaged in, and the perception of a need for a test.

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^

^ ^ ^ ^ •

^

Exploring the reasons why an inmate wants a test; Discussing whether the test is the way to get what the inmate wants; Discussing the benefits and difficulties a test brings to the individual , their family and associates , and knowing the result whether positive or negative Discussing whether a person thinks they will be able to cope with a possible positive test result; Providing details of the test and how the result will be provided , including information about post-test counselling. Making a plan for when the actual test will be done; Explaining the issue of the `window period' (the period of time following infection before any antibodies can be reliably examined); Obtaining an informed decision about whether or not to proceed with the test.

An additional element can be to negotiate and reinforce a plan to reduce or eliminate risk behaviour. To help inmates considering whether to get tested , the following information could be passed to them . This can be done orally - in a group information session or in an individual counselling session, or in writing via a leaflet (see chapter 3, 10.4 and 10.5). Different people will be thinking about having the test for different reasons . It is impossible to give hard-and-fast rules . Here are some points to consider =4:



^ If you are ill and a doctor feels that this could be due to HIV, being tested will be an important part of finding out what's going wrong. ^ Do not use the test simply to try and find out whether you should have safer sex. Safer sex is important for everyone, to ensure that if you are uninfected you stay uninfected, and if you are positive you avoid infecting other people. ^ If you are in a relationship, discuss with your partner how getting tested might affect you both. In the past, some relationships have been destroyed by the knowledge that one person is positive and the other negative. ^ Being tested may help if worries about being infected are affecting the quality of your life. But think carefully about whether you would be able to cope with a positive result, and would a negative result really stop you worrying?

*4 Based on a leaflet publishhed and distributed by the Scottish Prison Service



^ It may make sense to be tested if you are or intend to become pregnant. If you wish to become pregnant, or are in the early stages of pregnancy, there may be considerable pressure for you to have an HIV antibody test. Careful pre-test counselling is essential so that you understand all the advantages and disadvantages of knowing if you have HIV, and can make your own informed decisions about whether you should continue with your pregnancy. ^ There is still ignorant and cruel prejudice against people with HIV, and against people who are misguidedly seen as being at `high risk' of having HIV: People with HIV are sometimes not allowed to work in certain units (kitchen, barber etc.) People with HIV are sometimes placed in single cells or the cellmate is informed about their sero-status

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^ Think through your decision carefully before going to be tested and don't be pressurised into having a test unless you have had enough time to decide whether it is the best thing for you. Remember that the test is there for your benefit alone, not for anything or anyone else. ^ Get advice from your clinic about early intervention treatment options and support for people who have positive results. Recent advances in medical treatment of HIV mean that some doctors now think that it is worth knowing if you have HIV infection. ^ For example, it is possible for doctors to monitor how well you are through measurement of viral load, so that if your health deteriorates to a point at which you may be at risk from infections like PCP (a virulent pneumonia) drugs can be prescribed which prevent or significantly delay their onset. If your doctor knows that you are at risk from such conditions, they will be prepared to diagnose and treat any infection more promptly. ^ Some healthy people with HIV who have HIV induced damage to their immune systems may benefit from antiviral drugs. However, others who only discover that they are HIV positive when they get ill do not have the option of early treatment. All effective medicine should also be accessible in prison.

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For those with a negative test result it is inevitable to give prevention advice and to discuss the impact of that result. A positive test result should be followed by post-test counselling to offer psychological support where needed and serve relevant information. In a session in which enough time is allowed to digest information and to ask questions, it is important to sort out and discuss possible emotional and psychological problems in case of a positive test result.





There are important elements of post-test counselling: ^ If necessary make a plan for and/or refer to on-going psychological support ^ Explain further tests (i.e . for hepatitis C - PCR, liver biopsy) ^ Help obtain referrals to receive additional medical care and treatment and other necessary services (such as drug treatment) ^ Allow such people to receive prevention counselling to help initiate behaviour change aimed at preventing the transmission or acquisition of HIV and hepatitis ^ Provide prevention services and referrals for sex and needle sharing partners of HIV infected people ^ Provide information about the risk of infecting others and ways to prevent this ^ Provide family planning information and referrals for women of childbearing age ^ Suggest local support groups ^ Give accurate literature to take away

3.3 Sexually Transmitted Infections (STIs) What are STIs? They are increasingly common infections spread via sexual contact with an infected partner. Sexually transmitted infections can be caused by: Bacteria ^ ^ Viruses Parasites ^ The most common are: Chlamydia ^ Gonorrhoea ^ Genital warts ^ ^ Herpes Trichomonas vaginalis ^ Pubic lice ^ Less ^ ^ ^

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common are: Syphilis Hepatitis B (more common among injecting drug users) HIV

STI's often have no visible symptoms. Sometimes people can tell they are infected, for example by the appearance of an unusual discharge from the penis, vagina or anus, a burning sensation while urinating, sores or blisters on the penis, vagina, anus or mouth or an itch around the genitals or private parts. How do people get a STI? STI's are spread through unprotected vaginal , oral or anal sexual contactwith somebody who is infected. As you might have noticed, the inside of the mouth, vagina, anus , and penis is lined with a special skin. This lining is called the mucous membrane . Bacteria and viruses that cause diseases live on this lining. When you have unprotected sex they can move from one person's mucous membrane to the other person's. And that's all you need for infection to take place. A mother infected with a STI can pass the disease on to her baby during the pregnancy or delivery. People who are infected may not have any symptoms. They can still pass a STI on to others. What happens when somebody has a STI? Most STI's are completely treatable, and the individual will suffer no long-term effects. However, the consequences of untreated STI's can cause serious health problems, and presents a significant

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health problem. Chlamydia is a well established cause of peluicainflammatory disease, ectopic pregnancy and infertility. The presence of a STI can also increase the risk of HIV infection. Some sexually transmitted infections can recur spontaneously. For example, herpes and genital warts will disappear after treatment but may come back later. How can you avoid infection? ^ Practice "safer sex" (see under 4 in this chapter) ^ Attend a sexual health clinic/prison medical service for regular check-ups



Normal daily social contact presents no risk of infection. In the institution If you have any symptoms or think you have been infected with a STI, you can see the prison medical service to have yourself tested and possibly treated. Chlam, This is the most common bacterial sexually transmitted infection. It infects the cervix (neck of the womb) in women and the urethra, rectum and eyes in both men and women. Transmission: ^ Having sex with an infected partner ^ Mother to baby during childbirth ^ Transfer of the infection from genitals to eyes by fingers



Signs and symptoms: Women Most women experience no symptoms at all. Possible symptoms include: ^ Increased vaginal discharge ^ Lower abdominal pain ^ A need to pass urine more often ^ Pain on passing urine ^ Irregular menstrual bleeding ^ Painful sexual intercourse ^ Pain and swelling of the eyes if infected



Men Men are more likely to experience symptoms, but many don't. These include: ^ Discharge from the penis



^ Pain and/or a burning sensation when passing urine ^ Pain and swelling of the eyes if infected Treatment Chlamydia is easily treated with antibiotics. Any sexual partner(s) will also need to be treated. It is advisable to avoid sexual contact until treatment of youself and any partner(s) is completed. Complications in women ^ Pelvic inflammatory disease (PID), which in turn can cause infertility. ^ Ectopic pregnancy (pregnancy outside the womb) ^ Premature birth or miscarriage of pregnancy ^ Can also lead to chronic (long-term) pelvic pain Complications in men ^ Inflammation of the testicles, which can cause infertility



In men and women ^ Reiters syndrome can be due to chlamydial infection, causing inflammation of the eyes and joints and sometimes a rash on the genitals and soles of the feet. Prevention : Using a condom or dental dam (or equivalences) reduces the risk of infection. Gonorrhoea Gonorrhoea is a bacterial infection infecting the cervix in women, and the urethra, rectum, anus and throat in both men and women. Transmission Sexual contact with an infected partner. Signs and symptoms Women These might include: ^ Vaginal discharge that may be yellow or greenish in colour, and with a strong smell ^ Pain or burning sensation when passing urine ^ Irritation and/or discharge from the anus Men These might include: ^ Yellow or white discharge from the penis ^ Irritation and/or discharge from the anus 0

Treatment Gonordabea is easily treated with antibiotics. Any sexual partner(s) will also need to be treated . It is advisable to avoid sexual contact until treatment of yourself and any partner(s) is completed.

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Complications in women ^ Pelvic inflammatory disease (PID) if left untreated, which can cause infertility ^ Ectopic pregnancy (pregnancy outside the womb) ^ Painful sexual intercourse ^ Infection of baby during childbirth. This can result in an eye infection causing blindness Complications in men ^ Inflammation of the testicles and prostate gland, which could cause infertility. Prevention : Using a condom or dental dam reduces the risk of infection. Genital warts Genital warts are a sexually transmitted infection that can appear anywhere in the genital area . They are caused by a virus - the Human Papilloma Virus (HPV). There are more than 60 types of HPV, some of which cause genital warts, others cause warts on different parts of the body. Transmission Sexual contact with an infected partner

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Signs and symptoms Symptoms can take several months to develop but may include: ^ Small pinkish/white lumps or large cauliflower-shaped lumps on the genital area ^ Itching ^ If present on the cervix (neck of the womb) in a woman, she may notice slight bleeding, or more rarely an unusual vaginal discharge Treatment Use of a brown liquid - Podophylin - painted onto the warts and washed off after 4 hours. Freezing the wart or laser treatment is also common. Any sexual partner(s) should also attend a clinic for a sexual health check and treatment if necessary.

i Prevention Using condoms will offer some protection, but only if they cover the affected area. Genital Herpes Herpes is caused by the herpes simplex virus (HSV). It can affect the mouth, the genital area, and the fingers. The virus lives in the nerve fibres, often causing no symptoms at all. There are 2 types of HSV ^ Type 1 usually infects the mouth or nose, and is referred to as oral or facial herpes. It increasingly infects the genital area as a result of oral sex ^ Type 2 usually infects the genital and anal area 0 Transmission ^ Skin contact ^ Kissing ^ Vaginal, anal and oral sex Signs and symptoms ^ Itching and tingling sensation in the genital or anal area ^ Painful ulceration (blisters) of the affected area ^ Pain when passing urine ^ Flu-like illness, swollen glands, fever, backache Treatment If left untreated, herpes will clear up by itself, although the symptoms can be very uncomfortable and distressing. There is an anti-viral treatment available which can alleviate the symptoms of herpes, but this needs to be taken within 72 hours of the onset of symptoms. Any sexual partner(s) experiencing symptoms should also have a sexual health check up. Trichomonas Vaginalis (TV) TV is a sexually transmitted infection caused by a parasite. It infects the vagina in women, and sometimes the urethra in men. Transmission ^ Vaginal, anal or oral sex ^ Through rare, sharing of wet towels, jacuzzis or hot baths Signs and symptoms Women Symptoms, though not always present, may include ^ Soreness, inflammation and itching of the vagina ^ Pain when passing urine



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frothy, yellow/green vaginal discharge, which may have am"usty/fishy smell ^ Painful sexual intercourse Treatment TV is easily treated with antibiotics. Any sexual partner(s) should also be treated. It is advisable to avoid sexual contact until treatment is completed. Complications Complications with TV are rare



Prevention Using a condom reduces the risk of infection Pubic Lice (Crabs) These are small parasitic insects that live in hair of the pubic area, abdomen, chest, underarms and legs. Transmission ^ Sexual contact with an infected partner ^ Close physical contact ^ Sharing bedding and towels Signs and Symptoms ^ Itching ^ Sometimes the lice are visible on the skin ^ Lice droppings in underwear that looks like black powder ^ Nits (eggs) on the hair



Treatment They are easily treated using a special lotion prescribed by a doctor, or available from a pharmacy. Any sexual partner(s) should also be treated. It is advisable to avoid any sexual contact until treatment is completed. Syphilis Syphilis is caused by a bacteria. Transmission ^ Sexual contact with an infected partner ^ Infected mother to her unborn child Signs and Symptoms These are the same for men and women. They very often go unnoticed and can take up to 3 months to show. There are se-

veral stages, but the primary and secondary stages are the most infectious. Primary stage: painless ulcers around the genital area mainly, but can appear anywhere on the body. They usually appear around three weeks after infection, and are very infectious. Secondary stage: if untreated, this stage occurs 3-6 weeks after the appearance of the ulcers. A rash covering the whole body or in patches: ^ Hair loss ^ Flu-like symptoms, swollen glands, loss of appetite Latent stage This is untreated syphilis. Symptoms have disappeared and the infection can remain undetected for several years. A blood test can diagnose infection. If it remains untreated, syphilis can cause damage to the heart and nervous system, which may be irreversible. Treatment Syphilis can be treated with antibiotics at any stage. Current and former sexual partners will need to be tested and receive treatment if appropriate. Children born to women who have syphilis may also need to be tested.

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SAFER SEX IN PRISONS

Sexual activities occur inside prisons , just as they do outside. Sexual experiences and pleasure are part of being human. In the same way that prisons are not drug free, neither are they sex free. In addition, prison life produces conditions that encourage the establishment of homosexual or lesbian relationships within the institution. The prevalence of sexual activity in prison is based on such factors as whether the accommodation is single-cell or dormitory, the duration of the sentence, the security classification, and the extent to which conjugal visits are permitted. Several studies have provided evidence that significant rates of risky sexual behaviour occur in correctional settings. Despite the availability of condoms in prisons, knowledge of sexual risk behaviour and individual risk prevention is poor. Todts et al. (1997) reports that none of a group of Belgian prisoners who were having sexual contacts while in prison used condoms. Prevention offers have not been accepted. The reason might be that men having sex with men is not generally accepted by most of the prison population and prisons do not offer enough privacy where this behaviour does occur.



Sexual transmission of HIV, hepatitis B or other sexually transmitted diseases in prisons is a complex phenomenon , with taboos for all concerned : prison authorities , health personnel, and prisoners as well . Penetrative sex between male prisoners can take place in a whole range of situations , and not just between 'gay' inmates: ^ ^

Self-identified heterosexual men having sex with men True homosexual sex

^

Consensual sex

^ ^ ^ ^

Circumstantial sex (prisoners pay with what they have) Coercive sex Rape and gang rape Male sex work

There are many misrepresentations about the nature of sexual coercion inside prisons, and a lack of awareness of the problem. Making condoms accessible to inmates may be useful for some cases, but will certainly not prevent the sexual transmission of HIV in most cases of so-called "consensual" prison sex (see also Reyes 2000).



4.1 Condom availability in prisons The WHO guidelines on HIV infection and AIDS in prisons (1993) recommend: "...Since penetrative sexual intercourse occurs in prison, even when prohibited, condoms should be made available to prisoners throughout their period of detention. They should also be made available prior to any form of leave or release." It should be added that condoms should also be made available at conjugal visits (both official and unofficial).

(Perkins 1998, 33; Laporte 1997)

The availability of condoms in European prisons differs widely in practice regarding the provision of and access to condoms. Perkins (1998) examined the accessibility of condoms in European prisons and found a wide range of different policies "...on a continuum spanning endorsement of free distribution within prison to total prohibition. Nine of the fifteen EU countries had clear policies allowing access to condoms for prisoners, in line with the WHO Guidelines. The other six took different positions on access, from the extreme In of prohibition based on lack of recognition of the problem." in prison prohibited activities are Ireland, sexual and Italy Scotland, and condoms as well as lubricants are not available for prisoners. They are handed out for home leavers and/or as part of the release pack.

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Different policies are applied in European prisons. Access via Social workers ^ Medical unit ^ ^ Priests Prison shops ^ On prescription, where the prison doctor believes that there ^ is a risk of STD transmission. (England/Wales)

Throughout the world, condom availability is a controversial issue due to the the fact that sexuality is the second major taboo in prison (after drug use). In 1995 in Australia, 50 prisoners launched a legal action against the state of New South Wales (NSW) for non-provision of condoms, arguing that "it is no proper part of the punishment of prisoners that their access to preventative means to protect their health is impeded." Since then, at least in part because of the legal action, the NSW government has decided to make condoms available. Other Australian systems have also made condoms available. Others (South and Western Australia) sanction the provision of condoms but don't actually provide them. 0

General information about condoms 'Cond'oms, if used properly, are a good way to have sex safely or make love in a safe way. Although not 100% safe, condoms can prevent most STIs and unwanted babies. Different types of condoms are generally available (but rarely in prisons):



^ With and without lubricant Many people prefer to use a condoms in combination with a lubricant as the chance of tearing or slipping off is reduced. Often, a water-based lubricant is already put on the condom. With condoms suitable for anal sex, extra water-based lubricant is sometimes packaged separately. ^ Flavoured condoms Most of the flavoured condoms marketed are not designed for vaginal use. Flavoured condoms are not lubricated and are most suitable for use in 'blow jobs'. (fellatio). ^ Female condoms and dental dams These condoms are not available in all European Union member states and not at all in prisons. They are expensive everywhere. Nevertheless, the female condom can be convenient for several reasons. It is inserted in the vagina, and a rubber ring inside the condom helps to keep the condom in the right position. The major advantage of the "Femidom" is that it can be inserted long before actual intercourse takes place. Extra strong condoms ^ Extra-strong condoms are often referred to as'gay condoms', which is actually incorrect because anal sex is also common among heterosexuals. Extra strong condoms are specially designed for anal sex. This type of condom is not considered 100% safe. The possibility of an'accident', such as tearing of the condom, is considerable if it is not used properly. This type of condom is best used with extra lubricant.

0



4.3 Instruction on condom use ^

^ ^

^

^

^

^

^ ^

Check if you have the right condom: D Is it intended for vaginal or anal use? For anal use, only special, thicker condoms are suitable. D Is it big enough? D Is it an approved brand? > Check the expiry date Open the package carefully in the middle: D Do not use teeth or scissors to avoid tearing the condom Take out the condom: D Be extra careful if you have long fingernails D Make sure that you don't hold the condom inside out Pinch ( squeeze) the semen reservoir at the tip of the condom, so that there is no air left. We do this because: D The chance that it will tear is smaller because the reservoir does not come under pressure D If the condom has no reservoir you can make one yourself by squeezing the air out of the top of the condom (1-3 cm). Put the condom on top of the penis and unroll it carefully to the base of the penis D Wait until the penis is completely hard before putting the condom on. D When fully unrolled, there is less chance that the condom will slip off D Again, be careful with long nails Be sure to use water-based lubricants D Always use lubricant for anal penetration D A non-water-based lubricant will dissolve the condom. So do not use hand cream, body lotion, vaseline, oil or butter. If none of these things are available, use saliva instead! Withdraw the penis carefully immediately after ejaculating D While withdrawing, hold the condom at the opening to avoid it slipping off D If you wait too long the penis becomes flabby, the condom slips off and semen drips out Dispose the condom by putting it in a bin D Avoid using the toilet because condoms can stop up the drain Wash hands 1

• Use a new condom each time you start fucking . Never use two condoms on top of each other as this can cause the condoms to tear.



Quiz •

WHAT DO YOU KNOW ABOUT INFECTIOUS DISEASES?' '6 •6

Can you get AIDS from eating from somebody else's plate? Is it dangerous if you prick yourself with a used syringe? What has the hepatitis C virus to do with AIDS? In short, what do you know about health risks? Test your knowledge with this quiz.



1.

Water and soap kill the hepatitis B virus when cleaning a syringe? A. Correct B. Incorrect

2.

More than half of all injecting drug users are infected with the hepatitis C virus? A. Correct B. Incorrect

3.

Accidentally pricking yourself on a used needle is not dangerous? A. Correct B. Incorrect

4.

HIV is more infectious than the hepatitis B virus. A. Correct B. Incorrect

5.

By using the knife and fork of an AIDS patient , you can catch HIV yourself? A. Correct B. Incorrect

6.

Breathing-in someone else's cough is enough to get infected with tuberculosis? A. Correct B. Incorrect

7.

Only someone with active hepatitis B can infect others with the hepatitis B virus? A. Correct B. Incorrect

8.

After having been bitten by someone else, you could be infected with the hepatitis B virus? A. Correct B. Incorrect

9.

Most drug users with HIV are also infected with the hepatitis C virus? A. Correct B. Incorrect

10.

The risks of catching an infectious disease are greater for people who work in prisons? A. Correct B. Incorrect

Based on 'RateYour Risks', Mainline Amsterdam (see References)







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Quiz



Add up the figures behind the answers you gave. B-1 1. A-0 A-1 B-0 2. B-1 A-0 3. A-0 B-1 4. A-0 B-1 5. A-1 B-0 6. A-0 B-1 7. A-1 B-0 8. A-1 B-0 9. B-0 A-1 10. 0-5 Points Your knowledge of health risks is inadequate. This is a dangerous situation. Your lack of awareness could result in your becoming infected by a dangerous, even life-threatening virus. 6-8 Points Your knowledge of health risks is pretty good but not quite good enough. 9-10 Points You are well informed about health risks. If you combine your know-how with safe behaviour, the risk of infection due to personal wrongdoing or negligence on your part is very small. The correct answers to'Rate your risks' quiz: 1. Water and soap kill the hepatitis B virus? BIncorrect. Water and soap will not kill the hepatitis B virus. 2. A-

3. B-

Accidentally pricking yourself on a used needle is not dangerous? Incorrect. The AIDS virus does not survive outside of the human body, except in a used syringe and in blood residue. In a syringe, the AIDS virus stays alive for periods longer than three weeks. hepatitis can also be spread through a contaminated needle. Accidentally pricking your self on an old needle is most definitely dangerous.

4. B-

HIV is more infectious than the hepatitis B virus? Incorrect. The hepatitis B virus is a hundred times more contagious than HIV.

5.

By using the knife and fork of an AIDS-patient, you can catch HIV your self? Incorrect . Although the HIV virus has been found in the saliva of HIV positive individuals, the concentration is too low to infect another person. In addition, the virus does not stay alive outside of the human body, or on glasses, cups, plates and cutlery.

B-



More than half of all injecting drug users are infected with the hepatitis C virus? Correct . 70% to 80 % of all injecting drug users are infected with the hepatitis C virus.



0

Quiz •

You-can therefore use the knife and fork of an AIDS patient without any danger to yourself whatsoever. 6. A-

7. B-

8. •

A-

0

Only someone with active hepatitis B can infect others with the hepatitis B virus? Incorrect . Not only people with acute hepatitis B but also people with chronic hepatitis B can spread the virus. After having been bitten by someone else, you could be infected with the hepatitis B virus? Correct. The hepatitis B virus is found in blood and saliva. Therefore being bitten is dangerous.

9. A-

Most drug users with HIV are also infected with the hepatitis C virus? Correct. Most drug users are infected with the hepatitis C virus.

10.

The risk of catching an infectious disease is greater for people who work in prisons? Correct . The average number of people infected with a viral disease is larger in prison than on the outside . This is why prison staff members are considered a high- risk group.

A-



Breathing in someone else's cough is enough to get infected with tuberculosis? Correct. TB is spread through cough droplets. Turn away your face when someone coughs or sneezes in your direction.





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TO SUM IT up: How TO PROTECT ONESELF!

5.1 Daily contact Of the infectious diseases described above, only the 'flu and TB can be transmitted through daily contact. Testing new arrivals with a chronic cough for TB has greatly reduced the risk of infection with TB. Protecting yourself from the 'flu (influenza) is virtually impossible. Fortunately, the'flu is not serious. Only people in poor health should have themselves vaccinated. To avoid spreading bacteria or viruses through the air, always cover your mouth and turn away from others when coughing. Use disposable tissues for colds. 5.2 Sexual contact In sexual contact sperm, menstrual or other blood, pre-come or vaginal secretions can enter another person's bloodstream and cause infections. The use of a condom during vaginal and anal sexual intercourse provides an effective protection. For anal sex use an extra-strong condom with additional water-based lubricant. Oil-based lubricants (such as vaseline) will damage the condom's rubber and may cause rips. Prevent any sperm, pre-come or vaginal secretions from entering your mouth. When giving blow-jobs (having oral sex), use a condom. For cunnilingus, you can cut open the condom. French kissing, petting and masturbating yourself or others are also safe. Condoms don't protect against pubic lice. 5.3 Other forms of blood-to-blood contact Blood particles can enter the bloodstream through wounds and sores or via the mouth, nose and eyes. Although the chances of infection are small, prevention is better. Preventing somebody else's blood from entering your bloodstream is important. Blood may be infected with HIV, hepatitis B or hepatitis C. Fortunately, there are simple measures people can take to prevent another person's blood entering their bloodstream. During some activities in a penal institution one should wear protection. For example, when having sex or doing certain types of cleaning, people should wear condoms and rubber gloves respectively. Precautions are necessary in the following situations: Accidents or other situations where blood may flow ^ If somebody else's blood accidentally enters a wound or sore (including inflamed skin, e.g. gums and eyes) on somebody else's body, one can reduce the small risk by:



^ ^ ^

allowing the wound to keep bleeding rinsing with water disinfecting the wound with iodine

If a person gets blood in the mouth, nose or eyes, they should rinse the affected areas thoroughly with water and ask the medical service about additional procedures. One should then describe exactly what happened. The risk may be minimal. The doctor or nurse might recommend a vaccination against hepatitis B or postexposure (anti-viral) prophylaxis. ^

Tattooing, piercing, taking intravenous drugs and blood brotherhood

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These activities all involve piercing or cutting the skin. One person's blood may enter another person's bloodstream in the process. Often tattooing and piercing are done with needles and other sharp objects used by someone else previously. Small quantities of blood may remain. Ideally, one should not re-use, but if you must, make sure you cleanse the items thoroughly before reusing them. Syringes and injecting accessories are in short supply within the penal institution because they generally are always removed by the staff whenever they are discovered. Drug use is not allowed. Any available syringe within a prison has almost certainly been used by somebody else. Consequently, it is likely to contain blood particles that may be contaminated with HIV or hepatitis. Shooting drugs is therefore very risky. If you must inject in prison, make sure you cleanse the syringe and equipment thoroughly. The ritual of blood brotherhood cannot be accomplished safely. One person's blood will always enter the other person's wound. Try to find a different way to bond. 5.4 Specifics of safer sex Based on Trautmann / Barendregt'European Peer Support Manual' (see References)

"'

Anal sex (butt-fucking) and vaginal sex (intercourse) are both risky activities implicated in HIV transmission. However, a good condom, used correctly, can greatly reduce your chances of infection, and not only from HIV but also from other sexual transmitted diseases. Unprotected anal sex (butt-fucking without a condom). ^ This is the most risky type of intercourse for HIV and other STIs. The lining of the anus is very fragile. Anal intercourse causes damage to the lining, allowing sperm that is infected with HIV

0



or -the--hepatitis virus to enter the bloodstream. Other STIs, like gonorrhoea and chlamydia can also be transmitted through the mucous membrane. A lot of people believe that only the person is being penetrated (the one who is being fucked) can be infected . This is not true. The man who is doing the penetrating can also get infected with HIV or another STI if the head of his penis comes into contact with a virus or a bacteria from the other person 's body. Never have unprotected anal sex. You can make it safer by using an extra-strong condom together with a water-based lubricant. But even with a condom, anal sex is never completely safe, because the condoms can break or slide off. 0 ^ Unprotected vaginal sex (fucking without a condom). Fucking without a condom puts you at a high risk for getting infected with HIV or other STIs. If you already have venereal disease, the chances of becoming infected are even greater. What's more, HIV survives in menstrual blood, so if you already have HIV (if you are seropositive), the possibility of passing it on to someone else is much higher while having your period. So our advice is pretty clear. you should always use a condom when fucking. ^ Blow jobs (oral sex on a man , fellatio , giving head). Many people have questions about whether oral sex is safe. The general advice is: if you don't get sperm in your mouth, you won't come in contact with HIV and other blood-borne virusses. The problem is that it is difficult to know exactly when a man is going to come. That's why you should use a condom even for oral sex. This is especially important if you have sores in your mouth or if your gums bleed. Using a condom will also protect you from other venereal diseases like gonorrhoea, chlamydia, and syphilis. It is almost impossible to get infected with HIV or any other blood-borne virusses from licking a man's balls or around the anus. Just look out for scratches or sores (to avoid blood contact), and try to avoid contact with faeces (shit). You won't get AIDS from it (unless it contains blood), but you can get nasty intestinal infections and diseases.



^ Cunnilingus (oral sex on a woman , licking) Even if a women is infected with HIV or hepatitis C, there is only a tiny amount of the virus in her vaginal fluid. Therefore the chances of getting infected by'going down' on a woman are'very slight. If

S



she is having her period, oral sex becomes riskier, because contact with her menstrual blood can pass on HIV or other bloodborne virusses. We recommend against going down on a woman just before, during, or just after her period. Herpes and pubic lice can also be transmitted by oral sex. If a woman has blisters, sores or scabs on or around her vagina or her mouth (like cold sores), you should avoid going down on her or letting someone go down on you. If you want to be completely safe, use a barrier material that is similar to a `dental dam', which should be held over the lips of the vagina during oral sex. ^ Hand jobs (jacking off, beating off) You can't get infected with HIV or other blood-borne virusses from giving a hand job, because the virus cannot pass through healthy skin. If you have an open sore or blister on your hand, just put a plaster or band-aid over it and you will be safe.

0

Finger-fucking ( in the anus or vagina) ^ Similarly, you can't get a blood-borne virus from finger-fucking (in the vagina) or'fisting' (in the anus), not even if the whole hand is put in. As we have already said before, the virus cannot enter the body through healthy skin. Nevertheless, fisting is more hygienic if you use a thin rubber glove. And be sure to use enough waterbased lubricant to keep from damaging the inner lining of the anus while fisting. ^ Golden showers and defecation (piss and shit) Urine (piss) and faeces (shit, poop) do not contain HIV and other blood-borne virusses. But urine or faeces can contain tiny amounts of blood from liver or kidney infections or from haemorrhoids. Those invisible drops of blood can expose you to HIV. Urine and faeces can also transmit sexually transmitted diseases, like gonorrhoea and they can produce severe intestinal infections such as hepatitis A if ingested.

0

You don't have to worry if you get piss or shit on your hands or your skin, but avoid getting them in your nose, eyes, mouth, vagina or anus. All of these areas are lined with delicate skin (the mucous membrane). And don't drink anyone else's piss. Wash your hands and other contaminated skin with soap and water.

0



^ -SIM (Sadomasochism). Aswith-:everything else, S/M can be safe or risky depending on what you do. Make sure that you don't cause bleeding, because infected blood and sperm can enter the body more easily. If you get blood on any equipment, wash it with soap and water and then soak for 10 minutes with a 70% alcohol solution (this is sold in pharmacies). If bleach is available, this will also do.



Sex toys (dildos , vibrators etc.). ^ There is a minimal chance that sex toys can transmit blood-borne virusses if you use them with several different partners. Try to use only your own personal sex toys, and clean them well with water and soap after use. If you do share your toys with others, use them with a condom. If you are using a dildo for anal sex, then don't put it in your vagina after it has been in your anus. This can transfer bacteria from the anus to the vagina and cause nasty infections.

^

Massage

There is no problem if limited to external massage. Touching and rubbing are completely safe. If massage is combined with penetration, then the penetration is no safer than it would be without massage so you must wear a condom.

0

^ French kissing (tongue kissing) There are only tiny amounts of HIV and other blood-borne virusses in saliva (spit), so French kissing will not give you the AIDS virus. Kissing can give you herpes if your partner has cold sores, blisters or scabs on the mouth or lips. Group sex (menage ?? trois , trios , orgies) ^ Is group sex risky? That depends on what you do and who is in the group. If you plan on engaging in this, then do read this list over again to be sure of what's safe and what's not. Be sure to use a NEW condom each time you have intercourse, and for each different partner. Make sure everybody agrees on the ground rules in advance and watch out for cheats!

40





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SAFER DRUG USE IN PRISONS

Because of the scarcity of injecting equipment, those inmates who continue to inject while in custody are likely to engage in very high-risk behaviours for transmission of blood-borne viruses, many of which they would not countenance outside prison. Because they have easy access to sterile syringes outside prison from drug services in most EU countries, many inmates experience a 'hygiene relapse' while in prison.



Injecting equipment may be obtained in prison by: ^ Bringing in `sawn off' syringes, often anally or vaginally ^ Borrowing previously used equipment ^ Hiring previously used equipment ^ Stealing equipment from prison hospitals or clinics ^ Smuggling by visitors Manufacturing injecting equipment from available ^ materials It is evident that using these devices can involve various health risks. Anecdotal evidence shows that this equipment sometimes may serve all drug-using inmates on a whole wing or even a whole prison. Injection equipment is sometimes used as currency and has a high price when in short supply. So why do prisoners use them? Because they are addicted and lack control, ignoring any precautionary measures for the time being.



Two additional answers may be: To many prisoners the term 'sharing' is not clear. Many ^ prison injectors only class using previously used equipment as sharing if it has been used very recently, or at the same time as they use it. ^ Inmates trust each other in reporting the status of their infections. HIV-infected prisoners use the syringe at last. There is a need to reduce the incidence of sharing of injecting equipment in prison. Current and past policies to control drug use in prisons clash with the new public health imperative of preventing the spread of blood-borne viruses.

The World Health Organisation guidelines for prison HIV services (WHO 1993) say: "All prisoners have the right to receive health care, including preventive measures, equivalent to those available in the community, without discrimination and in particular with respect to legal status or nationality." The guidelines go on to say: "Preventive measures for HIV/AIDS in prison should be complementary to and compatible with those in the community. Preventive measures should also be based on risk behaviours actually occurring in prisons, notably needle sharing among injecting drug users and unprotected sexual intercourse."

6.1 Based on Trautmann / Barendregt'European Peer Support Manual' (see References)

Syringes

0

.s

Most heroin users in Europe take their drug by means of injection. There are also other drugs (e.g. cocaine, amphetamines, methadone) which are taken by injection. The HIV epidemic has stressed the importance of using clean injecting equipment. The best option therefore is: Always use a new needle and syringe for each injection. As the best option of prevention - always using a new needle and syringe - is generally not a realistic option in prisons, the next best or `better than nothing' options will have to be applied. In the following procedures for cleaning needles and syringes are described that can be applied in these circumstances. Besides this, prison adopted procedures are also described, as there is limited access to cleaning materials or heater and boiling water in the prison setting.



Cleaning does not guarantee 100% safety. Syringes are especially difficult to clean so take your time. The second best option that one can use is boiling the works. Other alternatives are: ^ The bleach procedure ^ The iodine procedure

0



The alcohol procedure Finally: even rinsing with cold water is better than doing nothing Boiling injection equipment This is the most time-consuming procedure but the safest as well. As a hotplate is available and use is allowed in many prisons this is a realistic procedure: Material required : Duration :

Hotplate, a pan, water. If all equipment is at hand, boiling injection equipment takes around 15 - 20 minutes.

Procedure: ^ First rinse the needle with syringe with cold water twice by pulling up water through the needle and flushing it into the gutter or the toilet. ^ Detach (if possible) the needle from barrel, and pull out the plunger. Make sure no air bubbles are left. Put needle and syringe into boiling water for at least 15 minutes. ^ Let the parts cool down and put them back together again. ^ Before using, rinse the complete syringe again with cold water. Advantages: ^ Required equipment is simple and harmless. ^ This is the only way of cleaning which protects against most infections (HIV, hepatitis B and C but also bacteria and moulds. Whether it also kills the hepatitis C virus is yet not clear.) A spoon can also be disinfected by boiling it together ^ with the syringe. Disadvantages: ^ People think that putting the syringe in hot water for a minute is good enough. This is not true. ^ In Europe most drug users inject using disposable syringes. These syringes can only be boiled between one and three times. After that, the vacuum-seal of the syringe becomes deficient. Some syringes will not stand being boiled for 15 to 20 ^ minutes.

••



The bleach procedure Only in a few countries do national recommendations and provisions exist regarding the use of disinfectants. Whilst the introduction of bleaching agents would be welcome in all prisons - since proper bleaching is better than doing nothing at all - experience of bleaching practices outside prison shows that they are idiosyncratic even when optimum conditions exist. The nature of the prison environment means that cleaning and bleaching of injecting equipment will often be unsatisfactory, simply because the resources and opportunity will not be available. It is recommended not to use `Natriumhypochlorit' (NaHCIO) because of its chemical instability, so jodophore disinfectants are more effective (see next chapter). But using Natriumhypochlorit seems to be better than nothing at all. Dispensing bleach should also be accompanied with specific information during the reception phase of admission to the prison.

0

In Scotland, sterilising tablets are given to prisoners with instructions on how to use them for sterilising mugs, cutlery, razors, chamber pots and injecting equipment. Material required :

Duration :

Use bleach (Natriumhypochlorid in household bleach) in the highest available concentration, cup or bowl. If all equipment is at hand the bleach procedure takes about 5 minutes.

Procedure : 2 x water- 2 x bleach "2 x water. ^ Pre-rinsing: draw up cold clean water through the needle until the syringe is completely filled and then squirt it out in the gutter or toilet. Repeat this. ^ Draw up bleach through the needle into the syringe, add some air and shake for 30 seconds, then squirt it out. Repeat this and don't forget to shake again for 30 seconds. Rinsing: draw up cold clean water through the needle ^ until the syringe is completely filled and squirt it out in the gutter or toilet. Repeat this. Splashes: If your eyes or face are splashed with the ^ liquid, rinse it off with fresh tap water to minimise irritation Mixing: Mixing the liquid or tablets with other cleaning ^ products may reduce their effectiveness 40

• i

Advantage: The bleach procedure is inexpensive and quick (about 5 min.).



Disadvantage: ^ The larger the amount of blood in the syringe, the greater the chance that the bleach procedure will not be safe. So pre-rinse well with water and do not forget to shake the syringe filled with bleach, thoroughly. ^ The limited tenability of bleach. As it reacts with oxygen, bleach loses its disinfecting quality after three to four weeks. ^ Bleach is not accessible in all European prisons and is not accepted as a substance for disinfection in all European countries. This is an indication that bleaching is not 100% safe. ^ Bleach can damage some types of syringes. For maximum safety: Take the syringe into parts after the disinfection and rinsing, and put it in a bath of bleach for one hour. Shaking a syringe for 30 seconds does not seem very long, but in fact it is, especially when one is withdrawing and in need of drugs. It is instructive to shake a syringe for 30 seconds when one is not in need to get a sense of the timescale involved. The iodine procedure Material required : Iodine dilution. This is used medically for the disinfection of hands, surgical materials and disinfection in surgery treatment. A suitable 100 gram ilu tion contains: 7.5g poly (1- vinyl-2 pyrro lidine) iodine complex with 10% available iodine (Mw 40000). A cup or bowl. Duration :

If all the equipment is at hand, the iodine procedure takes about 6 minutes.

2 x water " 2 x bleach "2 x water. Procedure : Pre-rinsing: draw up cold clean water through the needle ^ until the syringe is completely filled and then squirt it out in the gutter or toilet. Repeat this. ^ Draw up the iodine/alcohol dilution through the needle and let it work for at least 2 minutes and then shake well before squirting it out. Repeat this.



^

Rinsing: draw up cold clean water through the needle until the syringe is completely filled and then squirt it out in the gutter or toilet. Repeat this.

Advantages: Relatively cheap and quick procedure ^ Iodine is a well-known and accepted substance for dis^ infection in surgical treatment ^ Little loss of quality of the syringe Disadvantages: ^ The more blood that rests in the syringe the greater the chance that the iodine procedure will not be save. People suffering from iodine allergy or malfunctioning of ^ the thyroid (gland), should use this method only after additional thorough rinsing when disinfection is carried out. Iodine produces yellow stains on skin and clothes. ^

The iodine procedure is not as commonly used as the bleach procedure. The iodine solution mentioned above is approved in Germany as an appropriate substance to disinfect surgical material. A Dutch literature study by the RIVM (National Institute of Public Health and Environmental Hygiene) shows that there is no research data opposing the use of iodine. Iodine is handed out in some Austrian and Swiss prisons as part of a first aid kit and used to clean syringes.

0

i

For maximum safety: Take the syringe to pieces after the disinfection and rinsing, and put it in a bath of iodine for one hour. The alcohol procedure Material required : Medical alcohol (ethanol, isopropanol or n-propanol). Alcohol for consumption is not suitable. Alcohol should at least be 70 to 80% strong (preferably clear spirits). A cup or bowl. Duration :

If all equipment is at hand, the alcohol procedure takes about 6 minutes. 0



_-Procedure: ^ Pre-rinsing: draw up the cold clean water through the needle until the syringe is completely filled and then squirt it out in the gutter or toilet. Repeat this. ^ Draw up the alcohol through the needle and let it work for at least 2 minutes. Shake it well before squirting it out in the gutter or toilet. Repeat this. ^ Rinsing: draw up cold clean water through the needle until the syringe is completely filled and then squirt it out into the gutter or toilet. Repeat this.



Advantages: Quick procedure. Alcohol is tenable for a very long time. ^ Disadvantages: ^ Alcohol doesn't completely disinfect everything 100%. ^ Alcohol severely affects the protection layer on the inside of the syringe. The plunger will therefore begin to stick and run less smoothly. For maximum safety: Take the syringe to pieces after the disinfection and rinsing, and put it in a bath of alcohol for one hour. .9

6.2 Injecting paraphernalia `9





The preparation and sharing of drugs tend to be overlooked as potential points of transmission for blood-borne disease. The exclusive focus on needles and syringes in the messages given to drug injectors has also encouraged the erroneous belief amongst users that, as long as needles and syringes are not directly shared, then they are safe. The infective amount of blood for getting infected with hepatitis B for instance may be 0.00004m1 of blood, i.e. less than one five hundredth of a drop of blood. hepatitis B+C and HIV can potentially be passed on by any equipment which has been in contact with an infected person's blood. Due to the high risk of getting infected with hepatitis, all prison workers who are in contact with drug injectors should know about the details of the injecting process, in order to enable inmates to make changes to protect themselves. There is also a need to understand the ease with which any of the equipment involved in the preparation of an injection (including lighters, knives, etc.) may transmit for instance hepatitis C. Simple changes to the practice of preparation , such as using a personal area and washing hands

Based on `The Safer Injecting Briefing', (see Useful Websites, chapter 5.1)



before and after injecting, will significantly lower the risk of bacterial and viral infection. Drug workers and prison health staff need to discuss all types of paraphernalia and the environment in which they are used, with injectors. Many of these are dealt with in detail in the following pages. This section describes in detail the injecting equipment used, and infection risks through these injecting paraphernalia and cleaning processes. It also addresses the risks that are specific to particular substances. In detention the paraphernalia needed to consume drugs are frequently in short supply because these items are seized during searches of cells as potential drug-consuming material. In general two or more prisoners consume drugs jointly so that there is a high risk of using - unintentionally or deliberately - materials that have already been used by one or several other persons and so may therefore be infected with bacteria or viruses. The trainings that have been held in prisons so far revealed that most of the participants have been unaware of this potential chain of infections and therefore have not taken any precautions. In the following section, the use of various materials and the risks involved are outlined: Paraphernalia regularly used for injecting drugs include: ^ Spoons or other containers (for mixing drugs with water, etc.) ^ Water ^ Water containers Alcohol swabs ^ ^ Filters The preparation surface ^ Acidifiers ^ ^ Tourniquets ^ Other utensils, such as lighters, knives, etc.

0



All these paraphernalia are associated with the transmission of blood-borne viruses, most notably hepatitis B and C, although HIV transmission is a possibility. The risk of infection from one separate injecting event is likely to be low, but repeated exposure to low-risk events may result in infection. 0

_.Spoons Spoons are often used as a receptacle in which drugs are mixed (e.g. dissolved in water) prior to injection. Lending and borrowing of spoons amongst injectors appears to be a common behaviour. Contact of the spoon with a needle previously used by another person (e.g. by drawing up the substance from the spoon together), may be enough to transmit some infections, such as hepatitis C.



Injectors should be encouraged to mark their spoons for easier identification and keep them for their sole personal use in a place to which other injectors do not have access. For cleaning, spoons should be boiled, or cleaned with bleach, iodine or alcohol and rinsed thoroughly before use (see cleaning procedure for syringes). Similar precautions should be taken with other receptacles used for drug preparation, such as the base of emptied and dried soft drink cans.



Water/water container In many cases water is used to prepare heroin for consumption and frequently the same water is used that was previously used for tentatively cleaning or rinsing syringes and needles to remove any blood residues, pollutants or obstructions. If the water used for dissolving the heroin was previously used to clean the viruscontaminated (due to protein residues) equipment of a drug consumer, the circle of infection is unintentionally closed. Drawing up from a common pot of water represents a risk for the transmission of hepatitis and HIV as another person's used needle and syringe might have come into contact with the water source. Very small amounts of blood which will not be visible can transmit infection. Sterile water for injection is the ideal option where it is available. This should be for personal use only and discarded afterwards. The bottle or container, once it has been opened, should not be kept for subsequent injection, as it will contain bacteria from the air, and may have been used by another person.



Water drawn straight from the tap is better than bottled water, distilled water or'pure bottled water' which may have been exposed to bacteria in the air and kept warm for some time , and so are therefore likely to contain far more organisms.

0^^



If in the context of intravenous drug use a common water pot e.g. for cleaning - is used and the water shall be disinfected, the water has to be boiled for fifteen minutes. HIV is killed sooner, but with 15 minutes you are on the safe side for hepatitis B and/or C. Filter Filters are generally used by injecting drug users to minimise the risks associated with injecting undissolved particles which may be contained in the drug solution. In practice filters represent a considerable risk. In most cases, small pieces of (sometimes used ) cigarette filter tips are used (or more rarely: cotton fabric, bandaging material, cotton wool, toilet paper, tampons, paper handkerchiefs). By means of these provisional filters the dissolved heroin is drawn up from the spoon into a syringe . In this way drug consumers want to avoid the risk from dirt particles, which become visible when the drug was boiled up but which are unrelated to the heroin , getting into the veins. Using a filter is meaningful considering that the heroin offered is generally diluted, a process which involves great risks. If no filters were used , the number of abscesses and damage to veins would rise significantly as would the number of cases of bacterially-induced endocarditis , a disease which - if untreated rapidly develops into a life-threatening inflammation of the heart and which is supposed to cause early invalidity among injecting drug users. Analyses carried out in Dutch institutes have shown that the residue that `sticks ' to each of these provisional filters , i.e. does not reach the syringe, amounts to about 0,0046 grams of heroin. Most of the drug consumers are aware of these residues and when the drug is in short supply, the more sparingly it must be used . Hence some drug consumers save the filters for further use. If they have run out of heroin, 10 or more of these filters the emergency supply - may once again be boiled up in a spoon so that most of the drug residue contained in the filters can be used. Health risks related to filters include: ^ The filters might be saved after injecting as they will contain a small amount of drug residue and then be reused later by the original injector or by others. This might spread bloodborne viruses and/or serious bacterial infection. This is especially true when filters are stored in a moist place as then they are - in a negative sense - an excellent breeding ground

0

0

0



--for-bacteria : within 6 hours up to 8 million bacteria will'grow' which later on contaminate the consumer 's veins , tissue, heart, etc. . ^ The reused filters are carriers of viruses if only one of the filters stored was contaminated by blood residues containing viruses . In moist conditions particularly hepatitis viruses survive for some time . Hence , if a prisoner reuses their own filters along with those of others to consume the heroin residues , they could unintentionally start a chain of (hepatitis) infections. ^ Filters may also have been in contact with needles used by different persons if more than one injector draws up from the same spoon ^ Loose fibres can be drawn up into the syringe, causing circulatory problems if injected. This is most likely to happen when cotton wool or clothing fibres are used.

Clean , unused cigarette filters , especially those intended for hand rolling , are probably the best option for provisional filters , but even these can cause problems if broken apart. The worst option is readily soluble filters, sometimes made out of toilet paper, paper handkerchiefs or tampons. The only possibility for minimizing health hazards in the use of these provisional filters (e.g. cotton wool) is to dry the used filters for several days before boiling them up again . In this way the possibility of viral contamination can be reduced. •

There are different types of commercial syringe filters on the market. Some of these are designed to filter out the bacteria which may cause skin infections and abscesses. Although these filters may prove to be valuable , they should be viewed and employed with caution as they may: ^ Create a false sense of safety among injectors , wrongly believing that they will filter out all blood -borne infections - they won 't: viruses cannot be filtered out as they are inside blood cells ^ Be reused or shared in a similar way to home-made filters ^ Be so 'fine-meshed ' that injectors consider them to be either too slow or so effective that they are removing too much of the drug from the solution ^ Block and burst under pressure because of the very small pore size.



Since 1997 a new kind of syringe is available on the market: the Swiss company Compet AG developed a new filter and prepared it for series production together with Braun. A membrane in the filter optimally filters all dirt particles bigger than 15 micron . The filter material is hard , i.e. it cannot dissolve and get into the veins. Its most important benefit, however, is that the filter is completely permeable by heroin. Therefore there is no reason for any drug users to collect ( used) cigarette filters, boil them up and pass them on to others for drug consumption. By using the new filters at least one of several possible chains of infection can be eliminated. Alcohol swabs Alcohol swabs are used to clean the skin at the spot where drugs will be injected. Frequently drug users are careless about the use of swabs and several drug consumers use the same swab to clean the puncture spot before injecting the drug. Frequently the swabs are contaminated with blood from a previous user so that an open wound is easily infected. Whether or not the swabs' alcohol content is sufficient to disinfect the blood material absorbed cannot always be clearly determined. This is particularly doubtful if the swab's vacuum wrapping was opened a long time before use so that the swab dried out. There is no sterilising effect anymore because the alcohol in the swab volatilised. This means alcohol swabs should only be used by one person, cleaning the skin spot in one go. Another important issue is whether alcohol swabs are used accurately. This means that the skin is disinfected for at least 30 seconds . Even nurses and doctors often use them for less than 30 sec. In order to kill bacteria and virus on the skin it is absolutely necessary to disinfect the skin adequately. Alcohol swabs used to clean the spoons mean they are just cleaned rather than disinfected - but this is better than nothing! Surfaces If a surface on which substances are prepared for injection is contaminated with blood or with water from flushing out syringes, there is a risk of transmission of infection. Ideally, surfaces should be cleaned with bleach or detergent before injecting . If this is impossible under prison circumstances it would still be better than nothing to prepare an injection on something disposable, such as a newspaper or magazine. This will also serve to mark out a'personal area ' for injecting. 124



-Acidifiers -Acidifiers' are used to enable heroin base - which is manufactured principally for smoking , as opposed to heroin salt which is made for injecting - to be more easily dissolved into a solution for injecting. They do not need to be used with the more refined hydrochloride form of heroin, i.e. heroin salt, as it is highly soluble in water. Nor need they be used in the preparation of other drugs such as cocaine hydrochloride, i.e. cocaine salt (although not in the form of crack , i.e. base cocaine ) or amphetamine for injection. Various acids such as lemon juice and vinegar are used for heroin preparation. Any acid already in liquid form may contain bacteria or become contaminated with hepatitis or HIV viruses. Lemon juice , whether fresh or bottled, has been associated with thrush and other fungal infections within the body, which have been reported to cause loss of vision and blindness due to retinal damage (candidal endophthalmitis ). It has also been associated with endocarditis and other conditions. Powders such as ascorbic acid (vitamin C) or citric acid are thought to be the safest options . These however can cause irritation to veins and tissues , so the smallest amount possible should be used . The more acid the solution, the more irritant it will be. Ascorbic acid is probably less caustic than citric acid and may therefore cause less irritation Tourniquets Tourniquets should only be used if they are really needed. Many injectors, at least early in their injecting careers , will be able to easily access superficial veins without using tourniquets. If left in place for too long they can cause a limb to be deprived of its blood supply not loosening the tourniquet before injecting can also lead to dying off (through necrosis or gangrene ) of the part of the body which is tied off in cases where the user loses consciousness due to overdosing. If a tourniquet is not loosened prior to injection, excess pressure has to be used to get the solution into the vein , which can lead to leakage of the drug into the tissues or to rupture of the vein. If an injector is frequently complaining of `missed hits', check that they are releasing the tourniquet before injecting.

0



If tourniquets are contaminated with blood and subsequently shared, they represent a hepatitis C transmission risk. Various techniques can be used to help superficial veins become more accessible, including: ^ Clenching and re-clenching the fist ^ 'Windmilling' the arm ^ Any vigorous exercise ^ Letting the limb hang down ^ Bathing the arm in warm water. Environment The environment in which injecting takes place can be a factor in the transmission of blood-borne viruses. The risks associated with injecting will be reduced if there is adequate: ^ Privacy ^ Time ^ Lighting ^ Running water ^ Sterile injecting equipment. For inmate injectors, few, if any of these may be available. For these injectors at least , some of the points mentioned can be obtained (in the cell, toilet or another room). Injecting with another person present lowers the risks of an undetected overdose, but will increase the risk of viral transmission if any equipment is shared. One basic piece of advice is to wash your hands over an empty sink before starting to prepare a shot.

6.3 Preparing a shot given (Based L instructions The next instruction is written from the perspective of the ideal situby L. Synn Stern.) ation. The conditions in prisons are far from that, so where possible alternatives are given.

^ ^

Clean the spoon (or the bottom of a coke can) following the instructions under 6.1, with water. Use clean water. Cold water from the tap is cleaner than warm water and running water is cleaner than still (dead) water. Cold water from the tap does basically have the same qualities as water taken out of a bottle (this is not true when the tap is giving water with particular qualities,

126;-'

0

0

^

^

^

--e-.g-.high degree of iron or nitrate in it). Water in a bottle may .have already been used and it should not be carbonated. Make a new filter (from a cigarette filter, tampax etc.) with clean material and with clean hands for every shot. The most suitable filters are the specially manufactured type for infusion. Ensure that the liquid in the syringe is transparent and without `dirt'. If not, cook, shake and filter once again. Dirt can cause serious problems, such as 'the shakes', cardiac diseases, abscesses and embolisms. Check that there are no air bubbles in the syringe. For heroin base injectors, ascorbic acid (Vitamin C) is preferable to lemon juice.

6.4 Self-injecting '10 ^

^

^

^

^ •

^

^

^



Use a new needle and syringe each time. At least use a new needle to avoid clogged or broken needles and infections (hepatitis B/C, HIV, bacteria) Choose a different injection site each time, to avoid scars, bruises, abscesses, swellings, sunken veins or problems with blood circulation. Find the biggest veins and switch veins each time. If this is impossible, find a new spot a least 2.5 cm (1 inch) from the spot you used last. Clean the injection site with an alcohol swab and wait till the alcohol has evaporated. Then it is effective and doesn't hurt when the needle is being inserted. A tourniquet helps the veins to dilate. Use an elastic band which is easy to loosen e.g. knicker elastic. If you inject in your arm, first let it hang down to fill with blood and then tie off. Don't tie off too tight or for too long. If you do not succeed in finding a vein, untie the tourniquet, do some physical exercise and tie off once again. Make sure you can open the tourniquet before pulling the needle out. For instance: keep the pulled end of the tourniquet in your mouth. If you become too stoned your mouth will fall open and automatically the tourniquet unties. Do not forget to remove the air from the syringe. Keep the syringe upright, if necessary flick any air bubbles out and push the piston carefully until no air is left). It is safer to untie the tourniquet before pushing the plunger, because if you overdose (lose consciousness) with a tight tourniquet you will almost certainly lose that part of the body which is tied off. For many people this is not possible because if they untie the tourniquet they also `lose'

*10

(Based on instructions given by L. Synn Stern.)

0

^

their vein. It is always useful to have someone with you, just in case. Insert the needle at an angle of 15° - 35° in the direction of your heart with the point of the needle pointing down. In this way the needle slides easily into the vein.

0

^

^

^

^

^

Veins don't roll away if you pull them tight with a finger or the side of your hand: the needle is now between the tourniquet and the finger that holds your vein tight. If you see dark red blood when you pull back the plunger, you are in a vein. If the blood is pink or the plunger is pushed back by itself, you have hit an artery. When this happens immediately untie the tourniquet and pull out the needle. Press on the spot with a bandage for at least 5 minutes until you are sure it has stopped bleeding. Hitting an artery can cause serious problems, so medical help is advicable. When you know you are in a vein push the plunger home slowly. Check several times if you are still in the vein by pulling back the plunger a little. With cocaine you may not notice if you are next to a vein. If the needle slips out of the vein during injecting, untie the tourniquet and choose another spot. The needle won't clog easy if you draw up a little extra cold water. Don't forget to remove the air. When you are finished, and you did not yet, do it now, untie the tourniquet and remove the syringe in the oppo site direction to the way you have inserted it. Apply pressure to keep the injection site closed for a short while (for most people till the rush has finished), preferably with your arm or leg held up to prevent possible bleeding underneath the skin. If you miss the vein or have subcutaneous bleeding, put on some ointment, (heparin/herodoid) or salted water and cover it with pressure bandages. Missed hits and subcutaneous bleeding can lead to abscesses.

[,;128

40

0



Don't forget to dispose of your used syringe in a safe way or exchange it for a clean one.

6.5. Alternative routes of administration `"

0

Chasing the dragon In some countries this route of administration has become more and more popular for using heroin. At first sight it seems a simple technique, but in fact it requires some practice to do it effectively. ^ Some heroin base is put on a strip of aluminium foil ^ The foil is heated under the heroin with a modest flame from a lighter ^ The heroin melts and the vapours which come off are inhaled through a little tube in the mouth Advantages: ^ Material required is cheap and easy to obtain ^ Minimal risk of overdose ^ No risk for HIV infection. Small risks of other infection (only by sharing the tube one risks a hepatitis infection) Disadvantages: ^ Requires good quality heroin ^ Only brown heroin, i.e. heroin base is suitable ^ Needs some practice to learn to use effectively. Errors can be expensive ^ Some adulterants of heroin can cause irritation of the air passages The effectiveness of chasing the dragon works best when the heroin is diluted with caffeine.

0

Snorting and smoking Due to bad quality of heroin (generally between 2 and 20% purity) and due to the relatively isolated position of the drug culture, chasing the dragon is not widespread in most European countries. In these countries the most common alternative to injecting heroin is snorting. ^ Prepare a tube of strong paper or take a straw ^ Chop the substance to a fine powder (using a razor blade on a mirror) ^ Make a fine line of the powder

Based on Trautmann7" Bare nd regt 'European Peer Support Manual' (see References)



^ Sniff it through the tube into the nose Advantages: ^ Only requires cheap and easy to obtain materials ^ Less risky than injecting in terms of infections and overdoses Disadvantages: ^ The drugs and possible adulterants can cause irritation of the nose Also smoking heroin in cigarettes is not uncommon in several countries. The big disadvantage with this mode is the serious loss of heroin while smoking. Again, adulteration of the drug can cause health problems.

0

0

130

9

6.6._Syringe distribution in prison Many objections have been put forward against the development of prison syringe exchange. These include arguments that: ^ It is condoning an activity that the prison does not allow ^ Needles could be used as weapons against either staff or other inmates ^ That it will increase the incidence of injecting ^ That those not currently injecting or using drugs at all will start to inject Pilot prison syringe exchange programs operating in Switzerland, Germany and Spain demonstrated these projects to be successful: no threatening scenarios occurred , and the rate of needle sharing and the number of abscesses dropped significantly. Similar concerns about needle exchange were voiced initially about community projects yet were overcome. However, in talking about the prison population , politicians are usually very keen on being seen to be `tough on crime ' and relaxing the prison rules would, no doubt , be seized upon by sections of the media as 'going soft on crime'. It is clear that even many of the second-best solutions listed above are probably not realistic or pragmatic . The commonly voiced view that if injecting equipment was supplied , then needles would be used as weapons ignores the fact that many potentially infected syringes and needles are already circulating in most, if not all prisons. Many individual prisons and prison workers are committed to helping to limit the spread of blood-borne viruses . This work should be supported and assisted by the introduction of realistic resources and policies to help control the spread of viruses within prisons.

0







0

Quiz •

'Safe sex' and 'safe drug use' are inevitable in the prevention of HIV and other infections. What do you know about safe condom use and the cleaning of syringes ? What do you know about accidents with used needles ? Test your knowledge with this quiz. 1.

Cleaning syringes with bleach and iodine is one hundred percent safe? A. Correct B. Incorrect

2.

If you are afraid that the condom might tear, it is better to use two condoms over each other? A. Correct B. Incorrect

3.

Bleach that is older than two years is no longer safe for cleaning syringes? A. Correct B. Incorrect

4.

When cleaning syringes with bleach , the syringe must be shaken once and the bleach squeezed out through the needle? A. Correct B. Incorrect

5.

If you accidentally prick yourself on a used needle , the wound must be sucked out? A. Correct B. Incorrect

6.

When boiling syringes , only the needle needs to be boiled? A. Correct B. Incorrect

7.

During foreplay, the use of a condom is not necessary? A. Correct B. Incorrect

8.

When boiling syringes, the water must boil for at least 15 minutes? A. Correct B. Incorrect

9.

When a condom is used , the penis must be withdrawn immediately after ejaculation? A. Correct B. Incorrect

10.

With anal sex, where the penis penetrates the anus, an extra -strong condom is necessary? A. Correct B. Incorrect







Quiz

0

Add up the figures from the answers that you gave. 1. A-0 B-1 2. A-0 B-1 3. A-1 B-0 4. A-0 B-1 5. A-0 B-1 6. B-1 A-0 7. B-1 A-0 8. A-1 B-0 9. A-1 B-0 10. A-1 B-0 •

0-5 points Your knowledge is inadequate. 6-8 points Your knowledge is pretty good but still needs improving. 9-10 points You are well informed. The correct answers to'Play it safe' quiz: 1. Cleaning syringes with bleach and iodine is one hundred percent safe? BIncorrect . Just as with boiling, the cleaning of syringes with bleach and iodine is not one hundred percent safe. The only really safe way of injecting, is fixing with brand new equipment. 2. B-



3. A-

4. B-

5. B-



If you are afraid that the condom might tear, best use two condoms over each other? Incorrect . Do not do this! The use of two condoms on top of each other increases the chances of tearing as the two condoms rub against each other. Bleach which is older than two years is no longer safe for cleaning syringes? Correct. When cleaning syringes with bleach the concentration must be at least five percent . After two years , the concentration will have decreased too much to be viable. When cleaning syringes with bleach, the syringe must be shaken once and the bleach squeezed out through the needle? Incorrect . The syringe should be filled with bleach two times, shaken, and the bleach then squirted out through the needle. Both times it is important that the syringe is shaken for at least thirty seconds. If you accidentally prick yourself on a used needle, the wound must be sucked out? Incorrect . Don't ever do this! Do not suck out the wound but thoroughly let it bleed out. Afterwards, rinse with plenty of water and then disinfect with 70% alcohol. Contact the medical service after a 'needle stick accident' and also if an open wound has been in contact with blood, semen or vaginal secretion: an injection with antibodies within 48 hours can prevent an infection with hepatitis.

L1i



I0

Quiz S chance of infection is very small, (less than 1 percent). However, consult a doctor if an AIDS test or treatment is necessary. Tips: when picking up stray syringes, wear heavy gloves, and do not touch the needle. 6. B-

When boiling syringes, only the needle needs to be boiled? Incorrect. Not just the needle but also the syringe barrel and plunger could contain blood residue. Therefore, rinse everything first with cold water. In addition, everything has to be boiled. The best way is to place needle, syringe and plunger separately in a pan with boiling water. Make sure that no air bubbles are left behind.

7. B-

During foreplay, the use of a condom is not necessary? Incorrect. A condom is also essential during foreplay, since the HIV virus, together with semen, can also be transmitted by pre-ejaculate.

8. A-

When boiling syringes, the water must boil for at least 15 minutes? Correct.

9.

When a condom is used, the penis must be withdrawn immediately after 'coming'? Correct. When the penis gets soft, the condom may slide off. While withdrawing the penis, always hold on to the base of the condom and after use , tie a knot in it.



A-

10. A-

10

With anal sex, where the penis penetrates the anus, an extra-strong condom is necessary? Correct. Because condoms tear faster with anal sex , extra-strong condoms with extra water-based lubricant are a 'must'. Oil-based lubricants can damage the rubber of the condom and so lead to tearing.

0

0 High risk situations in a high risk environment

Overdosing on heroin or other sedatives The most widespread drug in prison after tobacco and cannabis is heroin or other opiates. These are sedatives that effect the central nervous system (brain). The central nervous system regulates breathing and pulse. When overdosing on opiates the central nervous system reduces or stops the breathing functions and eventually the heart functions. Other sedatives, such as barbiturates, benzodiazepines and alcohol, produce similar symptoms. 0 High risk situations are: ^ The use of drugs when quality and purity are unknown. First try a small dose. ^ Purchasing drugs from unknown inmates. ^ The use of heroin after having taken excessive quantities of alcohol and/or tranquillisers. In these circumstances, one may easily lose consciousness and throw up. If this happens, the vomit can block the throat (see above). ^ Using the amount you were used to in the period before incarceration, after a clean period, or a period of reduced drug use in prison. ^ Using drugs alone. Nobody can give first aid in this situation. ^ Using heroin after treatment with an opiate antagonist (see below). The ^ ^ ^

0

following symptoms of overdosing on downers are: Unconsciousness Slow breathing Slow pulse

What can you do? ^ Check if someone is really unconscious by screaming and shaking the person. ^ If not, try to wake them up any way you can. ^ The moment the person shows first signs of consciousness, keep them awake by forcing them to walk, talking, squeezing etc. ^ If the person does not regain consciousness or slips back into unconsciousness again , keep him alive with the kiss of life and, if necessary, heart massage (see following chapter). Have someone call a doctor or a (trustfworthy)

ET911

prison officer. A doctor will probably give the person an injection with an opiate antagonist (Narcanti etc). Fatal dilutions , mixing drugs and choking Here are some additional risk factors: ^ Fatal dilutions In order to maximize profits, illegal drugs are often cut with other substances. This is particularly true in prisonconditions. Sometimes the cut can be more dangerous than the drug itself and may leads to casualties. ^ Mixing drugs Mixing drugs can be dangerous. A mix of opiates, tranquillisers and alcohol is common on the prison opiates scene. This combination frequently leads to dangerous situations such as overdosing. ^ Choking Choking can be one of the consequences of mixings drugs as mentioned above. If people fall unconscious they will sometimes throw up. To avoid choking, clear the mouth and throat (with a handkerchief, for example) and when their breathing and pulse is stable, put them into the recovery position.



Keeping people awake If someone starts dozing off after having used drugs, you should try to keep that person awake to prevent unconsciousness. What can help is fresh air, making the person walk around, putting wet, cold towels on the neck and talking to the person. A good 'fellow user' should also protect his buddy from getting robbed to boot.

0

Keeping things calm The proverb "too many cooks spoil the broth" also applies here. No more than two people should take care of the person in distress. In an emergency it is not important what substance and/or precisely how much of it was used, as first aid is always aimed at the symptoms. In other words, it doesn't matter if it was an overdose from heroin, cocaine, or tablets, the emergency procedure is always the same.

The ^ ^ ^



Check vital functions vital functions are: Breathing Heart beat / blood circulation and Consciousness

The other vital functions such as regulating the body's metabolism or temperature cannot be influenced without medical help.

---- ----Check breathing Hold your hand over the nose and mouth of the `patient' and see if you can feel his breath, (maybe moisten your hand first), place your other hand on the chest and feel if it rises. An adult has to breathe 12 - 17 times per minute. Blue lips or strange sounds while breathing, similar to snoring, are cause for alarm.

0

Clear the airways First of all, tilt the person's head back as far as possible (see illustration). This prevents that the tongue blocks the windpipe. Then check for any foreign objects (dentures), blood or vomit inside the mouth. If there is something inside the mouth, turn the person's head sideways and clean mouth and mouth cavity with a handkerchief as well as you possibly can. Afterwards, immediately reposition the head to the position shown in the illustration. Artificial respiration If the person still does not breathe, breathe into him 3 times. Tilt the person's head back even further, cover his mouth, take a deep breath and slowly breathe the air into his nose. If the nose is bloody or blocked in any other way, breathe your air into the person's mouth. Check the pulse You can feel the pulse on the wrist, but more efficiently on the neck (at the side of the neck, next to the thyroid gland). An adult has an average pulse rate of 60 to 80 beats per minute.

0 Alternate between artificial respiration and heart massage (CPR If you can't detect breathing or pulse, artificial respiration and heart massage will have to be administered in turn. Always begin with artificial respiration (to get oxygen into the blood) and then alternately breathe into the person's mouth twice and administer heart massage (chest compression) 15 times. Emergency drill In an emergency, everybody tends to be excited. Therefore it is useful to practice your first aids skills every now and then, based on the following routine.

Check breathing Breathing is adequate ?

4

yes

4

stable side position

40 no

y Clear airways Place body in flat position. Remove any objects from mouth (cavity), tilt head back as far as possible, lift lower jaw. Breathing is adequate ?

4

yes

4

stable side position

4

yes

4

stable side position

4, no

Breathe into him 3 -5 times Breathing adequate now? 4,

0

no

+ Check pulse Yes

4

continue art. respiration

Continue artificial respiration and external heart massage (CPR)

0

Single -helper method

• 1a

3

To begin, always breathe into person 3-5 times

lb

15 short and powerful chest compressions

after 4 repetitions , check 4a pulse on both sides of neck

if no pulse , breathe into person 2 times

2a

breathe into person 2 times

4b 15 short and powerful chest compressions

2b

15 chest compressions

5

pulse can be felt continue artificial respiration until emergency doctor arrives

Two-helper method

0

ja

3

0

First helper: 2a lb Second helper : Begin with always breathing 5 short and powerful into person 3-5 times chest compressions

After 4 repetitions , 4a first helper checks pulse on both sides of neck

If no pulse , first helper breathes into person once

4b

First helper : 2b Second helper: 5 chest compressions breathe into person once

5 short and powerful chest compressions by second helper

5

Pulse is noticeable continue artificial respiration until emergency doctor arrives

0

Heart massage ^ Lay the overdose victim on their back on a hard surface. ^ Put the forefinger on the solar plexus and the other forefinger close above it. ^ Then put the ball of the first hand next to 'second' forefinger on the chest. This is the correct spot. Next, lay the 'second' hand over the first one.

0

^ Bend vertically over the victim with your arms stretched. The chest is now pushed in short, firm strokes (4cm) towards the spinal column. Release pressure on the chest immediately but the keep hands in the same position. ^ Repeat the pushes from 60 to 80 times per minute. If victim still has no pulse and is not breathing and you are alone: 0 ^ Start with 3 to 5 breaths into the victims lungs, ^ then, give 15 pushes on the chest, 2 more breaths, then 15 more pushes. ^ Check the pulse on the artery in the neck after 1 minute. Remember to check both sides! ^ If there is still no pulse, continue the heart massage. If there is a pulse, continue the breathing until help arrives. Tip: The kiss of life and heart massage should be practiced before doing it for real. This exercise could well be organised as part of a peer support initiative, for example by inviting somebody from the emergency room or a medical doctor from a drug service. 0

Quiz •

WHAT DO YOU KNOW ABOUT OVERDOSE?'

This chapter regularly mentions the word 'overdose'. What is an overdose? And what must be done in the case of a heroin or cocaine overdose? Test your knowledge with this quiz.



1.

A heroin overdose is always fatal within minutes? A. Correct B. Incorrect

2.

Giving a shot of salt water helps to combat a heroin overdose? A. Correct B. Incorrect

3.

For someone not used to heroin , 0.2 gram of heroin can be deadly. A. Correct B. Incorrect

4.

In case of a cocaine overdose, the best thing to do is to swallow sleeping pills or tranquillizers as quickly as possible? A. Correct B. Incorrect

5.

When dying from a heroin overdose , the user eventually dies from suffocation? A. Correct B. Incorrect

6.

Taking sleeping pills or tranquillizers can increase the risk of a heroin overdose? A. Correct B. Incorrect

7.

A heroin overdose does not lead to death as often as a cocaine overdose? A. Correct B. Incorrect

8.

A cocaine overdose can cause a heart attack? A. Correct B. Incorrect

9.

During an epileptic seizure due to a cocaine overdose, you must try to keep open the mouth by inserting an object? A. Correct B. Incorrect

10.

The combination of heroin and benzodiazepines increases the chance of a cocaine overdose? A. Correct B. Incorrect





.

Quiz

Add up the figures behind the answers you gave. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. •

A-0 A-0 A-1 A-0 A-1 A-1 A-0 A-1 A-0 A-1

B-1 B-1 B-0 B-1 B-0 B-0 B-1 B-0 B-1 B-0

0-5 points When an overdose occurs, quick, precise, correct action is important. Knowing what to do can be a matter of life and death. Unfortunately, your knowledge is inadequate. 6-8 points You are quite well informed but need further improvement. 9-10 points You are well informed. The correct answers to'What do you know about overdose?' quiz: 1. B-

A heroin overdose is always fatal within minutes? Incorrect. A heroin overdose can be fatal quite quickly (in a few minutes) but most of the time it takes longer for actual death to set in. In any case, action always needs to be taken quickly.

2. B-

Giving a shot of salt water helps to combat a heroin overdose? Incorrect . That administering a shot of salt water helps, is a myth. Individuals suffering from overdose must be woken up and kept awake. This might be achieved by slapping them in the face, pinching them hard below the collar bone or splashing cold water in their face. If you do not succeed in your wake-up attempts, call an emergency number as quickly as possible.

3.

For someone not used to heroin, just 0.2 gram of heroin can be deadly? Correct. 0.2 gram can indeed be deadly for someone who normally does not use heroin. This is also true in individuals who have been `clean' for a while, when a relatively small amount of heroin can induce an overdose.

A-

4. B-

In case of a cocaine overdose, the user should swallow sleeping medicines or tranquillizers as quickly as possible? Incorrect. The agitation that follows an overdose of cocaine could indeed be combated with benzodiazepines, but the individual should not self-medicate. Due to the slow absorption by the blood, the effect of sleeping medicines and tranquillizers is delayed. In a panic situation, the person could easily take too many pills and suppress their breathing.

11..._J





0

Quiz

5. A-

With a heroin overdose, the user eventually dies of suffocation? Correct . During a heroin overdose the brain gradually stops functioning. This suppresses breathing and allows moisture to enter and collect in the lungs, resulting in an even smaller supply of oxygen. As a result, suffocation is the greatest danger with a heroin overdose.

6.

Taking sleeping medicines or tranquillizers can increase the risk of a heroin overdose? Correct . When heroin is used together with benzodiazepines and tranquillizers, one can fall into a coma more rapidly.

A-

7. B-

8. A-

A cocaine overdose can cause a heart attack? Correct. An overdose of cocaine can manifest itself in two ways: 1. chest pains and 2 . epileptic seizures. In the first case , the heartbeat and blood pressure rise rapidly, which can lead to a heart attack.

9.

During an epileptic attack due to a cocaine overdose, you must try to keep open the mouth by inserting an object? Incorrect. Putting something in the mouth does not help and might cost the helper a few fingers. It is also not good for the teeth of the victim. Much better to call an emergency number and protect the heavily convulsing victim by laying them somewhere on the ground where they cannot get hurt. Put a pillow or jacket under their head. When the convulsions have stopped, put them onto their side in the recovery position with the upper leg bent and the lower leg straight, and the head straight or bent slightly backward.

B-

• 10. A-

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A heroin overdose does not lead to death as often as a cocaine overdose? Incorrect. It is precisely the other way round: A cocaine overdose is less likely to be fatal than a heroin overdose. This does not mean however, that in case of a cocaine overdose, speedy action is not necessary.

The combination of heroin and benzodiazepines increases the chance of a cocaine overdose? Correct. With heroin and benzodiaepines in the blood, the cocaine user feels very relaxed, which makes a second helping of cocaine seem very tempting. This sense of relaxation, however, is false. In reality, the heart is working overtime and the next 'line' could well be the last.



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--6AO Drug' use after release - health warning



An English study found out that 86% of interviewed drug users report some form of drug use within four months after release, so the impact of prison does not end at the time of release. The first two-weeks post-release is particularly dangerous, with death from drug overdose being eight to eighty times that of community levels (Seaman / brettle 1998). The reason is that drug users in prison use drugs less frequently and in smaller quantities than they do outside. Very few prisons respond to these health risks during their preparation for release. The reason is a fear of being too pro-active in talking about relapse after release. For many prisoners, however, we know that this is the case. There are some good examples of talking about this - and this example from Scotland shows one way to deal with it. Congratulations! Getting out of a jail probably feels like the best thing that's happened to you for a long time. You may be thinking about having a party. If so, for your own sake, and that of your family, read on.



Drugs In the last few years, users have been dying shortly after release from jail. The chances are that drugs outside are available in greater quantity and better purity than any that you may have had recently. Reducing drug use, even for a short time, means your body can't cope so well with drugs anymore. This means that if you use drugs after release you may be in danger of overdosing, losing control, suffering brain damage or even death. You must use less on release What should I do? Ideally, get a life and stop using drugs, but if you must use drugs then: Use less: which will also save your money ^ Use carefully and take care of your health and safety ^ Use with a friend who can watch out for you if things go ^ bad tell them what this leaflet says What if I overdose? Before it is too late and you slip into a coma: Get to a phone, ask for an ambulance. Tell them were you ^ are and what you have taken ^ If you are with a friend, make sure they know what to do



^

Get yourself into the recovery position

Drugs from a doctor If you are taking prescription drugs such as methadone or Valium®, your GP should give you less than before to reduce the risk of overdosing. Remember, prescribed drugs can be just as dangerous as street drugs if used incorrectly. Don't `top up' other drugs the mixture could kill you. Alcohol If you haven't had a drink for a while, it is like having your first ever drink again, so take care. Mixing drugs and alcohol could be fatal, so leave the cocktails to James Bond!

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Injecting If you stopped injecting inside, do yourself a favour and don't start again. If you can't stop, seek advice from your GP or a drugs information service. Remember: sharing works can kill you, so: ^ Do get clean needles from a needle exchange ^ Don't share works ^ Don't share cleaning water, filters, spoons, mixing liquids, etc. ^ Don't share by back or front loading ^ Do remember other users may be infected, so avoid unprotected sex, blood spills, razors, etc. ^ Do use a smaller amount if you must start again

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SKIN PENETRATION : ACUPUNCTURE , TATTOOING AND EAR PIERCING

In prison tattooing and piercing are usually done with needles and other sharp objects that are often used by someone else before. Small blood particles may remain on the equipment. The infection risks with tattooing and piercing can easily be prevented by using bleach disinfection procedures for sterilizing the needles, or by providing facilities for boiling the syringes (see chapter 6.1 in this chapter). Some basic advice is given here in order to avoid getting infected via skin penetration. •

7.1 What is a skin penetration procedure? The following recommendations for safer skin penetration are based on the Australian New South Wales Code of Best Practice '12. These skin penetration procedures are adopted to the prison setting and include commonly applied techniques for: ^ ^ ^

Acupuncture Tattooing and Ear piercing

Even if not all recommendations can be followed in the prison, due to a lack of access to cleaning or sterilisation equipments or because of time pressure as tattooing and ear piercing are generally not allowed in most prisons, the recommendations might help to reduce the transmission of blood borne and other infectious diseases to inmates. The background Skin that is intact, without cuts, abrasions or lesions, is a natural protective barrier against infection. Penetrating the skin can introduce infective micro-organisms into the body. Infection can occur if equipment that pierces, punctures or penetrates the skin is contaminated, or from direct person to person contact with blood or other body substances. The use of infection control techniques for skin penetration procedures eliminates the introduction of infective micro-organisms into the body.



Unhygienic practices and procedures may affect the health of both prison staff and inmate. Where procedures involving skin penetration are not managed correctly, they have the potential to transmit bacterial and fungal infections, as well as viral infections

•12

Source: www.health.nsw. gov.au/ public-health/ ehb/publications

such as HIV, hepatitis B and hepatitis C. Skin infections can also occur without breaking the skin. For this reason all equipment must be cleaned between each inmate to eliminate the potential to spread infection. Equipment used in a procedure that does not penetrate the skin, but comes in contact with the skin can spread staphylococcal, streptococcal and pseudomonal infections, all of which are bacterial infections. Other types of skin infections can include herpes (a viral infection), ringworm or tinea (fungal infections), scabies (a form of mite infection). Head lice can also be transferred through contact with contaminated hair. Micro-organisms are everywhere; they live on skin, in food and dirt. They are easily spread between inmates and operators and are easily transferred by contact with unwashed hands, soiled equipment, or contact with blood and body substances. Micro-organisms can be present even after cleaning has removed all visible soil and stains. Cleaning can reduce the numbers of micro-organisms, however an invisible trace of blood on equipment that penetrates the skin can spread diseases such as HIV, hepatitis B and hepatitis C. Inmates must be aware that all blood and other body substances are potential sources of infection.To prevent the transfer of microorganisms, operators must perform procedures in a safe and hygienic manner that include the use of tongs, disposable single use gloves, maintaining clean premises, clean equipment and safe methods of work.

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7.2 General To achieve the highest standard of safety the following advice should be kept in mind: Hand Washing Hand washing and hand care are the first steps in any infection control program to prevent the transfer of micro-organisms. Cuts and abrasions on exposed skin should be covered by a waterproof dressing which should be changed as necessary and when soiled. The surface of hands and nails must be cleaned immediately before and after skin penetration. All surfaces can contain micro-organisms. When surfaces are touched, the micro-organisms can be transferred to the hands.





The more surfaces or items touched the greater the microbial

load-on-the hands. Hands should be washed immediately before and after skin penetration procedures!



To protect both the operating inmate and inmate from microorganisms , hands must be cleaned: ^ Before and after treatment ^ After contact with any blood or body substance ^ Immediately prior to putting on a new pair of gloves ^ Immediately after removing gloves ^ After touching the nose or mouth ^ Before and after smoking , eating and drinking ^ Ater going to the toilet ^ Before and after treating wounds or handling soiled wound dressings following is the recommended method to clean hands: Wet hands Use soap with warm running water Rub hands vigorously Wash hands all over, including backs of hands, wrists, thumbs and between fingers for 15-20 seconds ^ Rinse hands well ^ Thoroughly dry hands with a single use paper towel

The ^ ^ ^ ^

! Do not use nailbrushes for scrubbing hands as they may damage the skin!

Single use equipment Pre-sterilised single use items are recommended for use in skin penetration procedures. Using pre-sterilised single use equipment with the correct infection control techniques will ensure microorganisms are not being transferred from person to person. Items that are identified as single use , are not necessarily sterilised.

! It is recommended that single use items are used on each inmate J

F L



Gloves for skin penetration procedures Gloves are worn as a physical barrier to protect the wearer's hands from contamination and to prevent the transmission of micro-organisms. Single use gloves must be worn at all times during a skin penetration procedure to protect both. This will be problematic to follow in the prison setting, if not possible careful hand washing procedures should be done at least.

! All persons carrying out skin penetration must wear single use gloves during the procedure and dispose of them when finished. 0 Gloves for cleaning General purpose utility gloves, e.g. rubber gloves, should be used for: ^ Equipment cleaning ^ Decontamination procedures ^ Handling chemicals General purpose utility gloves should be washed in detergent, rinsed and left inverted to dry after each use. Gloves should be inspected before each use and discarded if damaged or in a state not able to provide protection. Hands should be washed after using general purpose gloves. Best practices The following best practices are recommendations for skin penetration procedures:

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Equipment set up: ^ Unopened bags of sterilised equipment should be set up just prior to the procedure to ensure the skin penetration procedures can be undertaken without interruption. Interruptions increase the chance of transferring microorganisms. ^ When sterilised equipment is set up for use on an inmate, it should not be removed from its sterile packaging until the procedure is ready to occur. ^ All equipment set up for use on an inmate is assumed to be soiled after the procedure even if the equipment is not used. All equipment must be disposed, or cleaned and sterilised (if required) before re-use. 0



Liquids; creams and gels: liquids or gels (eg. lotions , creams , oils and pigments) should be measured and decanted into single use containers for each inmate. Excess or unused liquids and gels must be discarded after completion of treatment. ^ If liquids or gels can not be decanted separately for each inmate , then single use applicators or spatulas are to be used , and they are not to be re-dipped. ^ If re-useable containers are used they must be cleaned and sterilised ( if required) after each use. ^ Use collapsible squeeze tubes/bottles or pump packs to dispense liquids and gels. ^ Liquids and gels should be removed with a clean unused spatula or spoon each time, even when it is for the same inmate. ^ Never return decanted stock to original containers. ^ It is recommended that a skin penetration procedure is not performed if the operating inmate has a cut or wound that is not able to be covered sufficiently, and there is the likelihood of the area being exposed to blood or other body substance from the procedure. 7.3 Skin preparation Before commencing a skin penetration procedure, skin should be wiped with a suitable antiseptic and allowed to air dry. Suitable antiseptic solutions include ethyl or isopropyl alcohol (70-80%) or aqueous or alcoholic formulations of povidine iodine (1 % WN available iodine). •

7.4 Cleaning Cleaning is the physical removal of dirt from equipment surfaces by washing in detergent and warm water to reduce the number of micro-organisms. All equipment must be cleaned before it is reused . Cleaning greatly reduces the microbial load on the dirty item. It is essential to clean before disinfection or sterilisation to remove all visible organic matter and other residue . Accumulation of organic matter, detergents or other material on the equipment can inhibit the disinfection or sterilisation process.



All surfaces must be cleaned and rinsed thoroughly and regularly. Surfaces should be cleaned immediately after soiling or spills occur. Effective cleaning ensures that equipment and surfaces are clean to the naked eye and free from any residues.



Cleaning the Equipment Cleaning involves the use of water, detergent or cleaning agent, and physical or mechanical action. The manufacturer's instructions should be checked before cleaning. A good cleaning process includes: ^ Moving equipment directly to an area set aside and designed for cleaning ^ Pulling equipment apart and disposing of all non re-useable pieces ^ Immersing the equipment in warm water and detergent to remove visible soil ^ Holding the equipment under the surface of the water and scrubbing carefully with a clean brush ^ Rinsing the equipment with warm to hot water ^ Allowing the equipment to air dry or using a clean lint free cloth ^ Storing equipment in sealed containers or in a location that ensures it remains clean, dry and dust free Care of cleaning equipment Brushes, utility gloves and other items used to clean equipment must be maintained in a clean and serviceable condition. All cleaning items should be stored clean and dry. Damaged cleaning equipment does not clean effectively and can transfer micro-organisms to the equipment being cleaned, and to other surfaces. Cleaning items should themselves be cleaned regularly and stored clean and dry. 7.5 Disinfection Disinfection is the killing of disease-causing micro-organisms except bacterial spores. All equipment must be cleaned. Cleaning is a critical step in the control of micro-organisms because dirt protects micro-organisms from disinfection. After thoroughly cleaning the equipment will be thermally or chemically disinfected (for the different procedures please look at 6.1 in this chapter).

i

Disinfection will reduce the microbial load on equipment and sur,facesssevenfurther but it will not remove all of them. For that reason, all equipment that penetrates the skin must be sterilised and not just disinfected.



Disinfection can be used as an optional best practice technique to help remove micro-organisms. Disinfection will not be effective unless the equipment has been thoroughly cleaned to remove dirt. If equipment that is not designed to penetrate the skin becomes contaminated , it must be thoroughly cleaned prior to being re-used as a best practice method . After the process of disinfection equipment should be left to air dry after the disinfection process . It should be stored in a clean , dry, dust free environment.

! Disinfection is not a substitute for cleaning or sterilisation The next best solutions to disinfect needles, colour containers and other relevant materials is to use iodine or alcohol solutions. (The procedure is described under 6.1 in this chapter) 7.6 Sterilisation in "emergency cases"

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Tattoo needles can be sterilised in emergency cases by cleaning, disinfecting and afterwards putting into an oven (best placed in .a home made box of aluminium). The temperature is 200 C for 20-30 minutes. This only works when there are no plastic parts to the needle, because they would melt. 7.7 Questions left and alternatives Beware that the following problems may arise: ^ Where to dispose the needles? ^ How to take care of the new tattoo? ^ How to avoid medical problems such-as contact dermatitis, infections of the wounds? ^ How to solve problems with regard to piercings in special parts of the body (breast, tongue, earlobe)? Alternatively, different forms of tattoos may be supported . In Italy (Venice) a group of external HIV/AIDS drug services tries to promote henna as an alternative to traditional tattooing . Of course this is a different culture ; tattoos don't last as long on the body (months rather than permanent), but it does seem to be worth trying (see Emilian/Kampwerth 1998)

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METHODS & ORGANISATION



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RISK REDUCTION STRATEGIES IN PRISONS - WHY AND HOW?

It is evident that strategies have to be developed for the prison setting, to address problems such as the use of injectable drugs, unprotected sexual contacts and tattooing with non-sterile equipment, lack of knowledge about transmission of viral hepatitis, HIV/ AIDS and the dynamics of addiction.



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The limited possibilities in prison call for creativity and unconventional solutions. `Second best' or'better-than nothing'-strategies which are effectively pragmatic solutions to these problems have to be considered. Sometimes, prison-based rules and traditions can be followed. We know for instance, that, if it comes to injecting drugs without having a syringe available for all those involved in the act, in some prisons the inmates will stick to the rule that HIV positive inmates inject last. Another example is that a used syringe is cleaned by simply drawing up several times with cold water because of a lack of effective means of either thermal or chemical disinfecting. To reduce health risks, inmates tend to develop their own forms of risk assessment, sometimes based on far from scientifically proven facts. For example, fatal errors can occur when inmates select their needle sharing partners by looking into their eyes in order to try and see whether the partner is hepatitis positive or not. Trust plays an important role among inmates and their culture and hierarchy. These onsets of risk reduction may serve as a starting point for risk reduction activities, such as discussing drug use, prison conditions and the spread of viral infections. Risk reduction should integrate the existing knowledge and practices of the target groups: drug users will often already know more than any trainer from outside, and staff have already developed their strategies for tackling intoxicated prisoners. This starting point should form the basis for further discussions. When developing information material on risk reduction in prisons one has to keep in mind the specifics of the prison situation. Medical staff require different information than guards (prison officers). Inmates have their own specific background, subculture and language. Prevention material designed for target groups in the community cannot simply be transferred to the prison setting. The relevant target groups require prison-adopted versions. This makes it necessary to get input from each of the different groups concerned. This information can be collected through interviews or focus-group discussions. Initial drafts and design need to be tested and approved. The WHO states that: "it is important to recognise



that any prison environment is greatly influenced by both prison staff and prisoners. Both groups should therefore actively participate in developing and applying effective preventive measures, in disseminating relevant information..." (WHO 1993) Developing a network of key persons can be a helpful strategy. This can serve as a valuable background support. Key persons should be selected on the basis of their role in their specific networks (e.g. services for drug-using inmates). It is their task to provide crucial information about the situation in their working area (specific needs, where to organise activities, identifying partner organisations to collaborate with, pointing out other key persons, etc.), in the process of developing and realising modules of any risk reduction approach in prisons. In many European countries community drug teams, AIDS projects or other health services are included in the care of drug-using inmates. Some prisons even have their own advisory board on drug issues. Sometimes, social and health workers from the community are involved in health promotion and risk reduction activities in prisons. In contrast to prison staff, these workers are more widely accepted and trusted by prisoners as they are not part of the prison system. In some countries, these 'outsiders' even have a duty to maintain confidentiality and have the right to refuse to give evidence. Moreover, they generally have a lot of valuable expertise, e.g. about the content of and requirements for the various services offered. They can provide this information on services in and outside prison to inmates. They also can contribute to the process of motivating drug-using inmates to overcome their drug use, e.g. through enrolling in prison or community therapy programs. However, they also can play an important role in delivering a prevention and risk reduction message. Including staff from community services facilitates the development of a chain of treatment, linking prevention and treatment in the community to prevention and treatment in prisons. Thus using such people generally contributes to continuity of health care, avoiding inefficient interruptions in services provided. It underlines the link between prison and community and promotes the advantages and need for prisons to be oriented towards the community. To sum up, it can be said that when developing risk reduction measures in a prison, the chosen strategies should focus on the specific needs and beliefs, on the myths and the living and working conditions of the target groups. Strategies successfully applied outside cannot necessarily be applied inside without adaptations.

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l In the following we distinguish between three major approaches to risk reduction in prison: an individual approach , aiming at personal behaviour change of inmates , i.e. individual counselling (see 6) a group-oriented approach aiming at personal behaviour ^ change, acquiring knowledge and skills and changing attitudes - both for inmates and prison staff, mainly via training seminars (7 and 8) services and supportive measures; By services , we mean ^ distributing condoms, bleach or even syringes (9). Supportive measures could be producing and distributing a newspaper, magazine or leaflets for inmates (10). •

However, before being able to raise the issue of safer behaviour, first one has to reach, get in contact with drug users in prison. This sounds easier than it often is. Therefore we will deal with this issue separately (5). One basic problem in reaching drug users in prison is the fact that in one way or another they have to `out' themselves as former or current drug user in an institution that generally imposes severe sanctions on this behaviour (in the form of loss of privileges, etc.). All three approaches will be dealt with in detail below.

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PROBLEMS IN TRANSFERRING RISK REDUCTION MEASURES INTO THE PRISON SETTING

Risk reduction strategies commonly applied outside prison are often regarded as undermining the measures taken inside prison to reduce the supply of drugs. To support, on the one hand, the hygienic use of illegal drugs (by means of bleach and syringe/ needle provision) and then, on the other hand, confiscate them when they come to light is a fundamental contradiction. Risk reduction strategies are regarded as a challenge to the prison policy of drug free orientation in general, and may be seen by some as not taking the risks connected with drug use seriously enough. These risks are the focus of risk reduction strategies which should be seen as an additional strategy to drug free-oriented measures. Drug use itself should be avoided, but when it does occur - which seems to be the case in most prisons - irreversible damage to the user's health and to that of other inmates, prison personnel and inmates partners and families in the community - should be avoided. Inmates should not leave prison with more damage to health than they had when entering prison. This point of view is clearly supported by the World Health Organisation (WHO 1993).

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Additionally, most drug-using prisoners seek to hide their drug use in order to avoid losing privileges (such as home leave, segregation, higher levels of control, frequency of visits, etc.) or being subjected to intensive controls, such as body search (both of themselves and also their visitors), cell searches, discrimination by non-drug-using prisoners (due to fear of transmission of infectious diseases), etc. This background makes it difficult for the prison authorities to cope adequately with the health risks of drug users in prison. Due to a lack of anonymity and confidentiality even making contact with the target group on this issue might pose a problem.



Other problems are: Difficulties talking about sex, drugs and infectious diseases ^ Lack of confidentiality and anonymity when talking frankly ^ about drug use and sex. Gender specific taboos (men having sex with men without ^ homosexual identity). Utilising the knowledge and status of the doctor and person ^ nel of the medical department.

^ ^ ^ ^

Inside/outside: integrating people from the community Self-help groups or self-organisations? Any knowledge acquired is not just for application during the time spent in prison. Looking at the specific prison conditions: overcrowding, infrastructure, `Healthy Prisons', structures of communication and co-operation?

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ORGANISATIONAL ASPECTS

The aim of risk reduction activities in prison is to achieve a level-headed approach to the health care matters that concern drug addicted inmates and the health risks of the prison personnel. Therefore the organisation of risk reduction activities must be prepared carefully. One should approach this task via the following steps: ^ Needs assessment ^ Setting priorities and aims Defining the target group(s) ^ ^ Choosing an approach Evaluation ^ 3.1 Needs assessment / collecting information The initial point of departure is a needs assessment, which should be based on a general understanding of the aims and target group(s). Therefore, the first step will be to collect information on the following issues: What are the needs/problems of inmates when it comes to ^ health risks? ^ What are the needs/problems of prison staff concerning health risks? What services are available? ^ How are these services functioning? (quality, accessibility, ^ etc.) ^ What services are lacking? •



This information is necessary in order to verify any prior assumptions. It also provides the basis for establishing priorities regarding the specification of aims and target group(s). Important steps in this process are: Collecting and reading written information such as: ^ statistical material about the characteristics of the target ^ group(s) (age, gender, ethnic background, health risks faced, awareness, knowledge, etc.). ^ Studies of drug users in prison. ^ Reports of prison and community services (number and types of drug users, information on health services avail able, information on health problems, etc.). Identifying key persons (staff of prison and community ^ sevices, drug users, etc.) and collecting information from them. Getting information inside prisons, exploring the situation ^

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(when, where and what drugs are used, what healt problems and safety risks are encountered by inmates and prison staff, etc.). It is worth bearing in mind that all these sources of course have their limitations and biases. Therefore, it is important to check and compare information to get a relatively accurate picture of the situation. When collecting this information it is helpful to begin by making a rough plan: ^ What data is relevant? (e.g. how many drug users are HIVpositive, how many inject, how many are homeless, etc.) ^ Where to find this data? (at which organisations, on the street, etc.) ^ who is collecting such information? 3.2 Setting priorities and aims Based on this initial information, priorities for risk reduction activities should then be formulated. First of all, it has to be clear what one wants to achieve via these activities. Making the goals of such a project clear is important for different reasons, e.g. ^ To create common ground for the people (both staff and inmates) involved ^ To explain to the 'outside' world what you are aiming at.This is not only important to convince policy makers of the urgency of financial support but also for public relations rea sons. ^ To have a standard by which you can measure the results. This is not only important because one will have to prove the results of one's work to external agencies, such as policy makers, funding organisations, etc. Similarly, it is important for one's own organisation to gain a clear insight into the results of any work. This provides a basis from which one can learn from one's successes and mistakes and subse quently improve one's approach. The aims therefore should be smart, i.e.: D Specific, describing as exactly as possible what one wants to reach through the activities. Global aims like reducing risk behaviour within the target population are not enough. D Measurable , allowing a final evaluation to determine whether one has reached the goals that one wanted to reach.

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D Acce p table , for both inmates and p rison mana g ement and staff (everyone involved should be fully informed about the aims and content of your work, otherwise it might cause suspicion or be perceived as threatening). D Realistic, meaning that they should be achievable. It is important here to establish priorities (what aims are most important and what is less important), and to get a picture of what could realistically be achieved in the actual situation . It does not make sense, for example, to state that activities are aimed at getting all inmates drugfree. D Time specific, meaning that one should produce a plan identifying how much time it will take to realise these aims.

is

Risk reduction activities in prison could, for example, aim at: ^ Improving knowledge of infection risks and safer behaviour among prison staff and inmates (this can be measured by using the information in the following chapter about the con tent of the message). ^ Increasing general health awareness in the drug-using com munity (taking care of injuries, nutrition, etc.). ^ Changing social norms, attitude and behaviour of prison staff and inmates. 3.3 Defining the target group(s)

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Selecting the target group(s) is closely linked to setting the aims of the project. The selection of a target group(s) could be made upon ^ Priorities within a problem area , e.g. based on an epidemic profile ^ Identifying the limits of the reach of existing prevention programs, and/or

^

Pragmatic criteria

Priorities within a problem area In the field of risk reduction activities, the target group(s) with a high incidence of health risks - both for prison staff and inmates will generally take priority. Thus, an epidemic profile can be very useful. In order to establish priorities one has to collect information on the current state of the epidemic (e.g. an estimate on how many drug users are HIV-positive or already have AIDS) and on the expected future development. Different sources can be used to obtain this information, such as: Sero-prevalence studies ^ ^ HIV counselling and testing programs,.



^ ^ ^

AIDS service programs Knowledge, attitudes, beliefs and behaviour surveys Prison medical services, etc.

The limits of the reach of existing services In combination with an epidemic profile, data can be collected on which inmates or groups are not successfully being reached by current risk reduction activities. To be more precise, these could be: ^ Inmates who literally are not reached by risk reduction activ ities, e.g. because the main part of HIV/AIDS prevention measures are aimed at drug users, or focus more or less exclusively on dependent opiate injectors. Thus, the socalled recreational, non-dependent drug users - people who are using or injecting substances other than opiates and people who are starting or experimenting with injecting or other types of drug use - are more or less systematically neglected. Other groups who sometimes tend to be over looked are women, homosexuals and ethnic minorities. ^

Inmates who have got information about HIV/AIDS, safer use and safer sex, but don't appear to have achieved rea sonable results. This might be due to: D Incomplete or inadequate information D An inadequate approach, e.g. getting information during a methadone intake assessment, Factors or problems on the user's side, such as feelings of distrust, lack of motivation, negative attitude, social norms, lacking resources, etc.

Pragmatic criteria Experiences with risk reduction activities in prison have shown that pragmatic considerations can be very useful in selecting the target group(s). In general one should consider starting by informing prison staff, as their support will be needed to work with drugusing inmates successfully. 3.4 Choosing an approach In general , among the various risk reduction activities in prison, certain approaches currently dominate. As we stated above, in this chapter we distinguish between three major approaches to risk reduction in prison: An individual approach (individual counselling) ^ Agroup oriented approach (training seminars) ^ Services and supportive measures ^

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\Thechoice of approach depends on a number of different issues, such as ^ The target group(s); e.g. if one is focusing on prison staff or on inmates , or trying to get new people involved in risk reduction activities then an individual approach will be pref erable. Alternatively, if targeting people who are not yet involved then a seminar might be an adequate option. ^

The aims ; what is the best way to reach your aims? For example, if a snowball effect is a key aim then a train ing seminar for drug-using inmates ('how to pass on the message effectively', for instance) can be of great value.

^

The specifics of the situation one is working in; again, pragmatic considerations play a major role here. Which approaches are acceptable for those in the criminal justice system , prison management and staff?

^

The available human resources ; the qualifications of the drug users and/or professionals involved, and the availability of professional support are decisive factors in determining what can be done.

^

The available resources ; this is especially important where there is not enough money to do both outreach work and training seminars . As outreach work by peers generally is seen as less expensive and time-consuming (due to the limited involvement of professionals ) than organising train ing seminars , often the decision to use outreach work will be made on this pragmatic consideration.





3.5 Preparing activities When preparing activities the following things should be considered: It is of vital importance to obtain permission from the prison ^ governor and any national or regional criminal justice author ities prior to anything else. These people should be con suited about the activities planned in plenty of time, inviting them to give their opinions and have input into the plans. Having them involved in the planning of the activities is nec essary to get them both convinced and committed. A useful strategy could be: D To identify the people one would have to address D To send these people information about the extent



and range of health problems, on your plans for risk reduction activities and on your organisation, acknowledging in the accompanying letter that you need their support and would like to discuss your plans with them, and finally, informing them that you will call to make an appointment. To make an appointment for a personal meeting by phone, Discussing the plans at this meeting, trying to convince them to co-operate. ^

Organising a seminar or meeting on this issue and inviting prison governors and criminal justice authorities; involving as speakers governmental and inter-governmental officials (e.g. from WHO) might be another initial step.

^

As already stated, the support and commitment of prison staff is a vital prerequisite. Once again, a seminar can be an appropriate format to give information about the relevance of risk reduction activities for both inmates and prison staff; both to provide information about your plans and as a means of getting people involved in a discussion on how to realise risk reduction in their prison - while taking into account that particular prison's specific circumstances.

^

The value of co-operation between prison services and community health (drug) services in the creation of riskreduction services should be given careful consideration. Using the expertise and support of the latter has proved highly effective in numerous countries. These organisations can contribute to the knowledge and skills of prison staff and inmates, on issues such as infection risks and how to avoid them. It is also efficient to use such services as it avoids the necessity for prison staff to're-invent the wheel'. Finally, such co-operation can also contribute to better coordination between health services, facilitating continuation of treatment when drug users enter prison and referral to community health services when they leave.

^

Providing information about the activities you are planning to these community services can be seen as the first step in developing co-operation with them. At this stage, suggestions about ways of working together can be pro posed. Here again, a seminar involving representatives from prisons and community services can be an appropriate choice for kick-starting a project of this nature, as it facili-

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esa discussion between prison and community services. The contribution of community services to risk reduction activities in prison can vary widely. Some organisations can offer professional support, e.g. the development of working methods, training and supervision of the prison staffin volved, etc. With other organisations, regular consultations over issues such as fine tuning the policies and creating a basis for satisfactory referral might be a better approach. These consultations should not be limited to the formal level - informal talks between individual workers can be valuable and effective as well. Through this process, a local network can be developed or maintained. •



^

Clear arrangements between prison administrations and community health services should be made, defining and dividing the tasks between the various organisations and individuals involved. The specific conditions of the prison will have to be accepted, meaning that the structure of decision-making, communication and co-operation in the prison system has to be acknowledged. There might be considerable differences between different countries and regions. Every prison has its own policy, its own population of inmates and its own way of communication and co-oper ation with external drug and AIDS services. Careful prepa ration is necessary to target the specific needs of the inmates, as well as the staff members.

^

Due to the fact that drug use, sex and tattooing are forbidden in prison, there is a desire for anonymity and a need to protect the privacy of inmates. This canbe a significant obstacle to organising risk reduction activities in prisons. Admitting drug use, or even showing interest in information about safer use might be avoided due to the fear of being treated differently. These fears range from being identified by the guards as an active or current drug user and being the target of intensified checks such as cell searches or searching visitors, intensified urine testing and losing privileges such as home leave, things that are all very impor tant in the everyday life of a prisoner. This is a particular problem for those inmates who so far have been success ful in hiding their drug use. For these inmates, participation in risk reduction seminars would be comparable to a coming out as drug user. Their interests might be different from the interests of those inmates who believe that they have noth ing to lose and whose drug use is common knowledge.



Talking openly about drugs, drug use and risk reduction in prison might also be interpreted by staff members as not taking the problems connected with intravenous drug use seriously. However, this could be used as a starting point for a thorough discussion of the issues. Another problem, also linked to privacy, might be that inter est in participating in a safer sex training seminar might be interpreted by other (male) inmates as a sign of either having sexual problems, or being a homosexual. The will ing ness to participate in the safer use/safer sex program always reflects the climate of confidence, acceptance and policy in that specific penitentiary system. ^

It is also worth considering ways to introduce and discuss risk reduction activities in prison with other relevant organi sations and with the general public. This should only be done with the agreement and co-operation of the prison and criminal justice authorities. By other organisations, we mean not only drugs and HIV/AIDS services but also gen eral social and medical services, politicians, policy makers, police and criminal justice officials. This is one basis on which tuning in and co-operation can be realised.

^

With regard to public relations, one possible strategy could be the following: Begin by considering if representatives of the most rel evant organisations should be informed, even before the actual start of any activities. Collecting information on the local and regional specifics will provide the infor mation on which organisations should be contacted. Generally, an informal personal conversation is more effective than sending written information. In this first meeting, the aims and the approach of the activities can be explained and discussed. In addition, first plans for attuning the services can be made at this meeting. D Directly before the ^ start of the activities, all relevant organisations could get a letter with ample information on the project, covering its aims, approach, starting date, contact person, etc. D In the starting phase, additional meetings for the teams of these organisations can be organised, in order to inform the workers about your activities in greater detail.

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Informing the general public generally means informing the media. As with the drugs and AIDS service organisations, a written general announcement can be sent to the media. In addition, a press conference can also be organised. This shows the press and public alike that one has nothing to hide and satisfies any curiosity about what risk reduction activities in prison might look like. Finally, if one has particu lar media contacts who you know from experience will sym pathise with this sort of initiative, they should be invited for an exclusive interview or story. In some cases, it might be better not to go public at the very beginning. There might be good reasons for initially establishing the activities and being able to present some results prior to announcing the project. This is especially true when your activities might be expected to meet some resistance.

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However, not going public involves the risk of losing control over the information process. A single inaccurate or nega tive article in a newspaper - based on rumour or secondhand information - can cause major problems. Once out there, correcting this false picture is invariably very difficult. Moreover, by not informing the public voluntarily, one can give the impression that one has something to hide. Any discovery by accident may well result in negative publicity. ^

Public relations on these different levels - can also be very important in the later stages of a project. Consider whether to provide the media and other relevant organisations with information on the project's activities on a regular basis. This can be done through things like an annual report, but also through other strategies for disseminating news about the project. News, in this context, can mean organising a seminar on the public health implications of infectious diseases in prison, or starting a new activity, having new people appointed, new collaborative working arrangements with other organisations, etc.

^

Throughout all of this, one should take good care to create and maintain a positive image of the project's activities. Gaining public acceptance can be an extremely important means of support. To facilitate this, it generally is very effec tive to have good contacts with one or two journalists who sympathise with one's work. This can be helpful not only during possible conflicts, but can also offer the possibility

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i of press coverage of one's activities on a regular basis. This sort of press coverage can be helpful in convincing the public of the value of one's work. ^

Besides the internal need for evaluation, necessary to be able to adapt and improve the work (see below) there is also a demand to prove to the outside world (politicians, other organisations, etc.) that risk reduction activities are having a very real positive impact on the target groups. When designing evaluation strategies for internal and exter nal purposes, it is useful to seek professional assistence, particularly when the evaluation is for external use. This is especially true if one is aiming at getting statistical informa tion from the evaluation. Undoubtedly, the best option is to employ an experienced researcher to take care of this aspect of the work. However, the available financial and human resources might not allow this. In this case, support could also come from a volunteer expert at a university or from a social science student in his practical training, etc.

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One workable and very efficient solution to this problem is to develop and use the evaluation measures and results we describe below, both for internal use and also for exter nal purposes. 3.6 Monitoring and evaluation At any given time, there is always a need to see what has been accomplished, who has been reached, what the result has been, which step has to be taken next, and if and how the chosen approach can or should be developed or modified, etc. This process requires relevant and accurate information, both for internal and external purposes. Therefore, it is important to collect data and monitor and evaluate risk reduction activities. There are a number of different ways to do this. First of all, one should consider a process evaluation. This is a detailed description of the development and realisation of the risk reduction activities undertaken. A process evaluation should cover a description of all of the steps that we've mentioned above, i.e. Needs assessment ^ Setting priorities and aims ^ Defining the target groups ^ Choosing an approach ^ Preparation of activities ^ Realisation of activities ^

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The first five points can be covered by writing a report that describes wha( hasbeen done , which decisions have been taken and why these- decisions have been taken. To evaluate and monitor the risk activities undertaken , one can use a more standardised form of collecting information ( see below). Always keep in mind that the effect of risk reduction activities in prison might be hard to measure in quantitative terms. Many experts doubt whether a solely quantitative approach to research would make sense when investigating this issue. This is particularly true when considering the effects of peer support by snowballing' i.e. drug users who are reached by the project and then pass on the information they have learned to their peers), as it is difficult to establish a representative statistical sample that can measure such an effect. When dealing with these effects, more qualitative research (field observation, interviews with drug users, etc.) tends to provide the most useful material, both for evaluation and also for those authorities who are interested in new ways of HIV/AIDS prevention as for drugs services and drug user self-organisations. However, quantitative data tends to be most highly regarded, and is often insisted upon by funding organisations, policy makers, etc. Evaluating and monitoring individual counselling To evaluate and monitor the results of individual counselling, registration forms are a useful instrument for getting the necessary information about the reach and results of one's project. Important issues to record can be: ^ ^ ^ ^ ^ ^

^

Date of counselling session Gender Age Ethnicity Is this a new or repeat contact? Risk assessment, including: D Modes of drug use, levels of sharing drugs and drug use equipment (syringe and needle , spoon, filter, water; frontloading , backloading, etc) D Sexual risks (forms of sexual behaviour, different partners , sex work, etc.) D Knowledge D Attitude D Social norms Who initiated the contact? (staff or inmate) 179,



^ ^ ^

^

How has the contact been made? (accidental talk or appoint ment) Where was the contact made? (In a cell, at medical ward, in the corridor etc.) What did the contact consist of?, e.g. D Introduction D Advice giving D Counselling D Handing out condoms, syringes and needles, other paraphernalia > Referral What role can the contact play in the development of a network? ('chain' referral to other inmates, etc.) 0

It is evident that, for reasons of privacy, no personal information (name, date of birth, exact address) should be collected, where possible. The inmates who participate in these programs should receive full information on who has access to what information, what will be done with the information, etc. To avoid or minimize the problems with sorting data where there are several different forms on the same person , a list of those people who have been contacted that is separate from the registration forms can be made . On this list , each person will correspond to a certain code (a number, nickname, whatever). On the registration form only the code is filled in . However, the latter should only be done if one can guarantee that this list , linking the code to an actual person , is absolutely secure and no negative ramifications for the individual are likely to result from their participation.

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One problem tends to be that collecting all of the data of potential interest is just too much work. If filling in the form takes more than five minutes, then it might not work. Though having someone to remind the counsellors to fill in the forms can be helpful, it still is important to develop a form which can be easily and quickly filled in. One good suggestion here is to split the registration form into two, with one part focusing on general information about the contacts made, followed by a second part that concentrates on one specific issue. The first part has to be filled in for all contacts, comprising the first five points listed above plus the section on `what did the contact mean'. This approach allows the collection of good, albeit primarily quantitative, information on the reach of a project. 0



`The second part of the registration form can then be on different specific issues , for example , on modes of drug use and how they change, on (changes in) sexual behaviour, etc. After having monitored one issue in this manner for a period , (say two or three months ) one can then change to another issue. Using this process of registration at least some indicators , albeit qualitative, can be discovered on certain issues . This two-part design of the registration form , then , results in relatively short forms that are easy for workers to complete. We have suggested that it may be useful to seek some professional support for the design of the registration form, the evaluation, etc. This support can come from a sympathetic or interested expert from a local university, who may have a social science student seeking practical research experience, etc. Having somebody from outside the prison system ( i.e. somebody from a university or a community health service ) doing the actual evaluation , particularly the interviewing , might also help to gain trust and therefore more truthful answers from the inmates . In addition, it might be worthwhile to consider using inmates themselves as evaluation interviewers . An approach that mixes a number of these strategies could also be considered, as it is one way to reduce possible biases by making them visible.



This sort of data collection has a severe limitation , insofar as it is restricted to the active period of the project . It does not tell you anything about the effect of your interventions . In case of a project of short duration (some months) this is a significant disadvantage. It is impossible to assess the longer term effects of one's work on issues like changes in attitude and behaviour of the target group. In such a case a combination of an evaluation during the course of the project and a small outcome evaluation (e.g. some interviews with people from the target group) following the project is advisable. An additional evaluative instrument could be focus groups, i.e. meetings of a selected group of participants (such as prison staff or inmates) to discuss with them their impression of the results of the risk reduction measures , and any necessary adaptations they may consider desirable or feasible in the light of their additional experience in this area. The collection of additional data on issues like the prevalence of health problems of the inmates can provide us with some indications of the impact the project is having . For instance, the reduction in the number of abscesses, number of new infections (number

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of people who prove positive in a test on HIV, Hep C, etc. while having been tested negative before), etc. can serve as an indicator - although not as a proof - that people are less frequently engaged in risk behaviour. Evaluating / monitoring training seminars An evaluation of a training seminar can provide relevant information for the organisation responsible for the seminar, for the trainers and the participants. The responsible organisation and the trainers can learn about the following: Has the content been relevant for the participants? What issues do participants regard as a priority for future training, seminars, etc. ^ Were the format and didactics adequately chosen to pass on the content effectively? (Was it a well matched mix of presentations, discussions and exercises? Were there enough breaks, etc.?) ^ Has the seminar been well organised? (Adequate accom modation, etc) ^ Has the seminar been well performed? (Clear, understand able presentations, friendly, open attitude of presenters, trainers, etc.) ^ What are the participant's further training needs? For the participants, an evaluation can help them to reflect on their level of knowledge, skills, etc. and on further training needs. ^

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An evaluation of a training seminar can cover a number of different elements. It can be: ^ A reaction evaluation, eliciting information about the general response of the participants to the seminar. Did they enjoy the seminar? Did they like the atmosphere in the group? Did they like the presentation style? This will tell you something about the choice of the trainers, the choice of composition of didactic tools, the balance of the program, the logical composition of contents, the choice of the target group, the composition of the group, etc. ^ A learning evaluation eliciting information about the extent to which the participants learned what they were intended to learn . This type of evaluation covers skills, insight in problems and attitude in addition to knowledge. Again, this will tell you something about the choice of the trainers, the choice of didactic tools , the balance of the program , logical composition of contents, the choice of the target group , the comU18

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position of the group, etc. It can also provide insights about the learning, aims , about the question of whether participants could relate-to the subject and about their needs for further training. ^ A performance evaluation, eliciting information about whether the trainers performed well. Were they well prepared ? Did they present well? (Understandable and well structured .) Did they behave well? (Friendly attitude , etc.).



^ An outcome evaluation, eliciting information about whether the training seminar has had or will have an impact on risk reduction. This type of evaluation will tell you something about the adequacy of the learning aims, and the choice of the target group, but also about the question of whether the participants could relate to the subject, about possible barriers to realising risk reduction (E.g. people know and want to change behaviour but don't have the necessary means to do so), and again, about potential needs for further training. A training seminar can best be evaluated by an evaluation form. As annex 4 we have included examples of an evaluation form for use by trainers and participants, both staff and inmates. However, instead of using forms, one could also opt for a discussion at the end of a course, which would be structured by a series of questions taken from the evaluation forms. This could be achieved in a focus group like set-up, discussing issues such as further training needs.

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Another option might be an exam format, using a quiz format similar to those we offer in earlier sections. One can also use observation. A good format here can be a role play or demonstration where participants are requested to show what they learned (see exercises under 8 in this chapter). This is especially usefull in skills training. Finally, for the long-term effects of a training seminar, assignments can be used, requesting participants to work on certain issues after the seminar. In a follow-up meeting the results of the assignments can be discussed. This format has been used successfully in the aforementioned program `Everything under control'(see chapter 1).

Evaluating and monitoring services : supportive measures By services here, we mean things like condom or bleach distribution. Supportive measures could be producing and distributing a newspaper or magazine or leaflets for inmates. Both - services and supportive measures - will be discussed later on in this chapter. Both services and supportive measures can, in general , be evaluated in a quantitative way. One can count how many people have requested bleach or condoms or how many condoms or bleach tubes have been taken from an anonymous distribution service. The same measures apply to leaflets and newspapers or magazines. In addition to this quantitative data, you can also choose additional `qualitative' information. This can be done through individual talks or through group meetings. Individually, this can be an element of a counselling session or through an evaluation interview using a questionnaire. Questions about the use of services and supportive measures can also be answered anonymously, e.g. by depositing short questionnaires at an anonymous distribution service.This latter, of course, might suffer from a serious bias as you cannot check if people are serious when giving the answers. Furthermore, only some people will fill in the questionnaire and this selection will be far from a representative sample. Monitoring cycle Evaluation is not a static thing which can be done once, e.g. after a training seminar or at the end of a risk reduction project, and then forgotten. It is much more effective to use evaluation at a certain stage , e.g. after a seminar as an element in an ongoing monitoring process. Another option is to have evaluations on a regular basis, e.g. every three months.

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Each evaluation step can provide relevant information that necessitates the adaptation of the program of risk reduction activities. This will lead to a process of ongoing evaluation identifying what is going on and resulting in a monitoring cycle that will allow you to adapt risk reduction activities to the actual needs and problems as and when they are discovered and identified.

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Monitoring circle assessment I decisions about the kinds of interventions that should be implemented I implementation of interventions 1 evaluation of interventions 1 further assessment I modification of interventions or development of new ones

This monitoring process can focus on all the organisational elements mentioned above, on: ^ Needs assessment - have the needs changed?For example through a change in the inmate population (target group) or through the outbreak of a new epidemic( an outbreak of TB might lead to the urgent need for a general TB test andsubsequent prevention measures). Additional questions might be: Is the picture one has of the situation concern ing health risks still accurate?ls he definition of the prob lem still accurate? ^ Priorities and aims - do the priorities and aims have to change? For example through the results of earlier riskre duction activities (e.g. the introduction of condom distribution may make other needs a priority). Besides a check on whether the aims and priorities are still up-to-date, a reg ular check might be considered if the aims could or should be more specific, better measurable, acceptable enough for the target group(s), still realistic and adequately speci fled in time (smart, see 3.2 above) ^ Target group(s) - have they changed? (Through the growing influx of a particular ethnic group with specific risk patterns of drug use). ^ Approach and activities - does the approach have to be adapted to a new target group? (Counselling about sex risks will have to take into account the cultural, religious background of inmates) or would other activities be more appropriate? (Individual counselling instead of group meetings to discuss delicate issues).





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MAIN CONCEPTS FOR ASSISTING DRUG USERS IN PRISONS





How can health risks related to drug use, sex or tattooing be avoided? We all know that individual habits, social rituals, norms and external factors and lack of information often form obstacles to changing behaviour that is perceived as risky or even damaging. From prevention theory we know that inside information, knowledge from personal experience and trust are important factors in the take up and cessation of a certain behaviour. In the fields of illegal drug use and risk behaviour, trust is a basic requirement. The peer group and the norms of the prison subculture are very important with regard to influencing the attitude of drug users towards safer behaviour. Self-efficacy by role modelling is another highly important feature. This means that providing social information plays a much more important role than simply providing mere facts. This is even more important in settings like prisons, where anonymity and confidentiality is hard to achieve and to realise. Quite often, the level of factual knowledge may be quite high. Elements of factual knowledge which have proved to be important generally refer to specific details (e.g. infection risk by sharing the spoon or the filter). Being familiar with the group norms and being trustworthy for drug users also serves as a basis for getting reliable information on risk behaviour. Drug use, sexual contacts, tattooing have also to be understood as part of the inmates' subculture. Being involved in this behaviour always includes an element of resistance against the prison system. 'Dissonance-Shaping' is a term from health psychology used to describe the notion that the gap between objectives (of risk reduction) and coping abilities should not be too big. If this gap is too big, then the health objectives we want to be achieved can be rejected easily and will not be integrated into the user's sense of identity in everyday life. The strength of this 'dissonance' should remain `acceptable' as a confrontation with the user's fundamental goals is not fruitful. This means: Changes should be realised step by step. This generally ^ means setting goals below the maximum objectives Objectives should be acceptable and achievable, i.e. ^ realistic

^ ^

The credibility of message and messengers are vital The initial point of departure is the user's individual resources and living conditions.

But which factors do influence the user's behaviour and beliefs? These can be illustrated by means of a model for behaviour change. Like all models, this model is a simplification of reality. For instance 'attitude' is a complex phenomenon - it is a fair way from being a result of rational decisions. More aspects are relevant: emotional, motivational and environmental aspects may contribute to changes in behaviour as well. It is, however, useful for clarifying how peer support activities can be initiated and how they can be realised. We will briefly describe these factors by giving some examples and indicate how one can influence them by peer support activities.

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Attitude

Barriers External variables A

Social Influence

Intention I

v_ A

Behaviour

Skills vice vv vaavvvvvv . vvvv vvc

icac y :......................................................................

(Taken from: Kok/Sandfort 1991) 4.1 External variables." Based on Trautmann / Barendregt `European Peer Support Manual' (see References)

External variables include demographic factors which cannot be influenced (such as gender, age, race etc.) but also residential factors (serving a sentence in a prison) or the political reality (drug policy in prisons).

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Examples Elements of political reality are the drug law, drug policy, public opinion, prison reality, (e.g. no lobby or trade union for inmates etc.). These elements determine drug users' daily life. For instance, whether or not allowing substitution treatment, distribution of syringes, bleach, general hygienic improvement, gender- and migrant specific services, overcrowding, segregation of (HIV+) drug users, etc. -+

Risk reduction measures Proposing a survey of infectious diseases and the situa tion of drug-using inmates in prison to (local) health authorities

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Discussing and assessing the drug and infectious disease situation with the prison doctor, colleagues in the medical department, prison staff members. D Trying to influence public opinion in favour of measures like bleach or condom distribution by offering valid reasons (Public health risks) for a risk reduction policy. Developing a plan for a substitute drug program (detoxification and maintenance). D Attracting allies to support this policy, for example, journalists, scientists, politicians (i.e. local AIDS self-help groups or drug counselling agencies).

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4.2 Attitude Attitude says something about how a person values certain behaviour. Valuing behaviour is weighing advantages against disadvantages, which is not just a logical and rational process. Irrational habits, emotions and beliefs also influence the relative weight of advantages against disadvantages.

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Examples D Clean syringe for each injection is valued positively for being hygienic, safe and sharp. But licking a drop of heroin from the needle after the air is pushed out is both unhygienic and ineffective, yet it is valued as positive by some drug users. Not having a clean needle available in the prison does for many drug users not necessarily mean that they will stop using intravenously. Instead, they rely on trusting other inmates when they claim that they are HIV- or hepatitis negative. The attitude towards the use of condoms is tremen dous important. Condom use is valued negatively by many people, as they see more disadvantages than advantages associated with their use. It is difficult to mention advantages because most advantages do not give immediate benefit (it's all about avoiding some thing). The only benefits one could think of is that the sperm is instantly ready for disposal. Many of the prison staff members might have the attitude that drug users are not capable of changing their behaviour in order to follow precautionary rules or of controlling their drug use in order to comply with health warnings.



Risk reduction measures Discussing motives, ideas, beliefs towards safer behav lour. P Safer use: discussing with drug-using inmates their beliefs about effective disinfection practices. Which alternative routes of administration do they know? What are the reasons for not applying them? P Safer sex: discussing about the advantages and dis advantages of condom use in a partnership. It alsoshould be stressed that the chance of getting infected and re-infected among drug users and their partners is rel atively high. P Tattooing: discussing measures designed at preventing infections: which are known and applied by prisoners? P Discussing with staff the risks of becoming infected and their beliefs of how best to avoid a risky exposure (i.e. when searching the body or cell). What is their knowl edge of transmission of virus and bacteria?



4.3 Social influence Direct social influence means that all social surroundings, i.e. the peer group, the institution, partners, family and friends expect certain behaviour. Not behaving in accordance with these expectations can lead to sanctions. Indirect social influence means that norms are internalised; people behave according to the norms as if they are their own rules. Examples > Direct social influence: in many prisons it is common to share the syringe and needle of a trustworthy inmate simply by rinsing with clean cold water. Refusing a used needle needs to be justified. P Indirect social influence: smoking heroin by means of chasing the dragon was initiated in the Netherlands by people from Surinam, a former colony of the Netherlands. Meanwhile the majority of drug users in the Netherlands have adopted this behaviour. -+ Risk reduction measures From different so-called peer support projects - both in and outside prisons - we know that positive social influence by peers can contribute to risk reduction. If some skilled drug-using peer supporters offer a good example of safer behaviour (e.g. proper injecting or alternative routes of administration), then other drug users will tend to follow them. An important prerequisite is that drug users active j190

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a peer support initiative are so-called `peer leaders' meaning that they,are both influential and trustworthy, and that they serve as-a-role model. 4.4 Self-efficacy Self-efficacy is the assessment of a person's abilities to carry out certain behaviour. "Will I succeed in avoiding the use of injectable drugs during this prison sentence?", and if not, why not? Is my success due to myself, my experience, my intelligence, my persistence or the support of my partner? Do I have enough self-control to avoid simply taking any drug that happens to be available in prison (Including benzodiazapines and others)? Can I resist the various temptations? If a drug user is convinced that they will manage, they can be said to have a high level of self-efficacy. The opposite, however is extremely common. Many drug users regularly experience negative judgements from others in their environment. This influences not only their sense of self-efficacy but also their sense of self-esteem in a negative way. One example of limited self-efficacy is when people are acknowledging and complaining that things are not going well, but there is nothing they can do about it, because everything is the responsibility or product of other people's actions. -4

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Examples D Many drug users have tried several times to kick he habit. The failure to stay drug free has an influence on the decision to try it once again. Repeatedly relapsing results in low self-efficacy. D If a drug user in prison has some drugs but only has a used syringe, will they take the time to look for disinfectant and clean the syringe? If they are determined to do this and in the end actually manage to do so, then they have shown high self-efficacy. D Condom use depends, in part at least, on the self-effi cacy of the man: can he keep his penis stiff while put ting on a condom? If he doubts - due to disappointing experiences earlier on - he might not want to use a condom in order to avoid a failure.

-+ Risk reduction measures Successfully carrying out activities enhances one's self-efficacy. Consequently. when it comes to safer injecting, techniques should be discussed and practised. From so-called self-control projects we know that every drug user does have control techniques that they apply in different situations, such as drug use, drug purchase,



selection of other drug users etc. Sharing these control techniques to see if inmates can learn valuable things for their own situation from their peers can contribute to risk reduction. This can be done both intentionally and systematically in a training seminar setting but also on an individual basis. In the case of safer sex though, it is a little more complicated to practice proper techniques.

4.5 Intention The intention is the actual plan or desire to carry out a particular behaviour. All conditions (positive attitude, supporting social influence and self-efficacy) are - at least for an important part - fulfilled. Now, strictly speaking, there are only two things that can prevent the person from carrying out the behaviour: barriers and lack of skills.

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4.6 Barriers Even when people do wish to change behaviour, in prison people often lack the means to facilitate this behaviour change - which can result in them being unable to make the desired changes in their behaviour. Example In general, a drug user might be used to using a clean syringe for each injection. Unfortunately clean works are generally unavailable in the prison setting. 0 -, Risk reduction measures If new syringes are hard to find, or not available at all, then providing bleach or a hotplate, and giving out accurate information about cleaning and disinfecting syringes (see chapter 6.1 above) would be the next best solutions. Also, providing methadone is a measure to consider here.

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If .somebody wants to practice safer behaviour but does not know how, lacks experience or doesn 't have any routine to practice, then safer behaviour is much more difficult. People will need to acquire the necessary skills to enable them to engage in safer behaviour. Example Drug users who behave in a perfectly safe manner outside prison - using a new syringe for every fix - might run into problems inside prison. They might consider chasing the dragon but lack the necessary skills to do so. They might consider cleaning works but lack both the knowledge and the necessary skills to do so. Risk reduction measures Drug users often think of themselves as being experts in injecting, but analysing their injection procedure often reveals `hidden risks': either hygienic precautions are not taken or sharing the drug or injection equipment is exposing the drug user to risks. One issue that requires almost permanent attention is that of the injec- ting practices of drug-using in prison, because the prerequisites for safe practice enjoyed outside are not available and drug use takes place in hidden and often unhygienic places. Support for either alternative routes of administration or on proper injecting can be organised, as well as information on disinfection methods. With the support of the prison medical or community health service, staff can provide safer use instructions that can be followed effectively.





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HOW TO MAKE CONTACT WITH DRUG-USING INMATES

.2 *2

There is one basic problem in reaching drug users in prison. A prerequisite for discussing safer behaviour is that generally inmates would have to 'out' themselves as former, current, actual or potential drug users. The only exception to this is when distributing general information, e.g. on a leaflet handed out to all individuals on entering prison. Outing oneself as a drug user, however, is not easy in an institution that punishes this behaviour severely (through loss of privileges etc.). So methods of making contact have to be developed that protect drug users by making sure that no disadvantages result from participating in a training seminar or other risk reduction activity. One option might be to find - through discussion with the prison management - ways of allowing confidential counselling or less public ways of organising risk reduction seminars, e.g. by using rooms in the general education unit so that the purpose of the training is not apparent.



Aside from this basic problem, making contact can be regarded as a task on its own, even if it doesn't immediately result in other risk reduction activities. To reach the target group of drug-using inmates, one needs to have a network of contacts among the general inmate population in order to be able to reach those who are difficult-to-reach or'unreached'. One problem here is that while the'unreached' is a popular term, it is not very specific. Therefore, before going into detail about how to make contact it is worthwhile to define what is generally meant by the term. This can be helpful in the process of establishing the types of people who constitute the target group. Among those considered to be 'unreached' we would include: ^ Inmates who have never had any significant contact with an HIV or drug counselling service either outside or within the prison. ^ Inmates who have so far avoided any contact with prison health services about their drug use. ^ Inmates who do have contact with health services in prison but are not being reached by risk reduction measures. ^ Inmates who are not being successfully reached by risk reduction measures and drug counselling. D Either due to incomplete or inadequate information D Or due to an inadequate approach

Based on Trautmann / Barendregt 'European Peer Support Manual' (see References)

D Or due to factors or problems on the client's side: motivation , attitude , social norms, lack of resources, etc. In general, one can say that the more repressive the prison setting is, the more difficult it will be to approach drug-using inmates. Peer support, i.e. drug-using inmates contacting other drug-using inmates, can be helpful here, firstly as a first step to risk reduction by peer support, and secondly as a means of facilitating risk reduction activities by prison or community service staff. The latter might have an advantage over prison staff, by being independent from the prison system and thus possibly being more trusted by inmates. However, prison administration differs widely in every European country, as do the conditions under which `outsiders' are allowed access to prisons. There are countries where good co-operations between community drug and health services exist. However, in other countries this is far from being the case. Another factor that may impede the process of making contact might be that the drug-using population is not homogenous. There are differences regarding drugs of preference, methods of administrating drugs, ethnic backgrounds, sexual preferences, etc. These sort of differences can make developing contacts even more complex. This problem can, to some extent, be addressed by selecting peers or staff of the same gender or ethnic background as the people targeted when seeking to engage in risk reduction activities.

5.1 The first steps

i

Before actually making contact, one has to at least have a vague idea of who it is that one wants to reach and what one wants to achieve. Starting from our general notion of target groups and aims, we can then begin to take the first steps and start to explore the situation. Important things we need to know will be: ^ What is the situation of drug users in prison? ^ What are their specific needs? ^ What drugs are used, how are they used and what health risks are involved? ^ What is the situation concerning the spread of infectious diseases and drug-related diseases? What is the extent of sexual contacts and what health ^ risks do they imply? ^ How widespread is tattooing and what disinfection techniques are applied? ^ What are the risk reduction resources of the institution?

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Howl can risk reduction activities be implemented and insti tutionalised? Important sources of information for answering these questions will be found through discussions with key persons , staff members and colleagues and probably inmates or ex- inmates . Though one will generally only get rough estimates and anecdotal information about risk behaviour, combining and triangulating this information from different sources will provide some valuable indications of what is going on . Additionally it will be important to get a picture of how justice authorities , prison governor, middle management and prison medical service officials view the problem, what they want to do about it and what they expect from risk reduction activities. This information will serve as the basis for redefining and choosing the target group (criteria, priorities , etc.). Then making contact - the first step in any risk reduction activities - can be started. Of course, the process of collecting this information will have already resulted in us making some contacts.

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S

The process of making contact includes: ^ Visiting the prisons and getting in touch with inmates (the first step for community service workers); Communicating the aims of the risk reduction activities; ^ getting a conversation started; generally this start will tend ^ to be a casual chat , just to get on speaking terms and create a basis for further talks about risk reduction , and finally; Introducing oneself (again , this is especially important for ^ community service staff), i.e. D Explaining what one's task or aim is D Telling people what organisation /group you are working for (you can leave a business card) D Describing what you stand for D Explaining what you can do for the target group, etc. Establishing credibility and a trusted relationship with the ^ target group (s), for instance by D Proving that you are aiming at improvements in their situation D Always being honest (about what you are , what you can and cannot offer) D Offering support for those with problems, being care ful to only offer what you can actually deliver.



5.2 Getting in touch In the attempt to really make contact, the start of the process can be a long-term, frustrating enterprise, especially if one has to begin from scratch in a prison. One has to decide: Where to make contact (in a cell, in the corridor, in a com ^ munity room, etc.) When to make contact (which is the right moment, do people ^ have time, are they in the mood for a talk, etc.) ^ Which person to contact first (generally, one should con sider starting with informal leaders of the inmate commu nity) ^ What is the right way to handle it (a direct or less direct approach) ^ What can you offer When to stop (temporarily, at least), when is it time to take ^ a break and leave

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For clarity's sake, two ways of getting in contact can be distinguished: ^ Doing it on your own, or Getting introduced by someone ^ Making a new contact on your own When you intend to make a new contact on your own, you have the choice between: ^

An indirect approach , e.g. by starting some casual chat (about soccer, etc.). Such a chat often will develop into a more personal talk, at which point you can introduce your self, or may be asked to introduce yourself ('what the ... do you want from me?').

^

Or a direct introduction of yourself as (community) health worker, D explaining what your task is > what you stand for > what you can do for the target group, etc.

The most difficult approach, without doubt, is how to start on your own. For prison staff it is possible to just walk around in the prison, starting a casual conversation as a prelude for counselling or getting people involved in a training seminar. Moreover, they generally know or are known by the inmates. Inmates will be aware of their role as social or health workers. For people working in community

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service's though , this might be more difficult . However, there are useful tools that can make things easier. Risk reduction activities (counselling , seminars and services ) can be announced through: ^

^ ^

0 ^

^ ^

Prison staff, during educational and recreational activities and in working places . One also can consider whether to organise recreational activities , such as sport, music, etc. which are focused on paying attention to health issues. A poster. The poster should be presented in a `safe' place, where people can read it without being seen, e.g. in toilets. A leaflet. To avoid the problem that inmates receiving or having the leaflet are seen as admitting their drug use one can consider to hand out the leaflet to all inmates or to have it available at a `safe' place. A newsletter or magazine . In some prisons a prison news letter or magazine is produced . An announcement on risk reduction activities can easily be included in this. One also can consider the possibility of producing a risk reduction/health promotion magazine , and including an announcement of services available in this. An inquiry using a questionnaire , seeking to determine what the health needs and problems of the target groups are. Giving out condoms/bleach/syringes.

Using these devices as supportive measures for making contact has proved to be quite useful in the past . They can facilitate the start of a personal discussion or the participation in training seminars . All these options will be discussed in more detail below (9 and 10). Being introduced by someone As soon as prison or community service staff have some contact with people from the target group or groups, things begin to get easier. Making new contacts can then be achieved by being introduced by those people that one already knows. It may even be possible that the initiative for making contact is taken by one of these people. If people trust the staffmembers they might introduce their friends to them. This latter situation is, of course, the easy way, and is what many people employed in this function often dream of.



However, even making the first contacts can be a relatively easy job. If you , as a prison or community service worker, are in a community room with some members of the target group where you already know some people and want to make contact with others:



^

^

You can join a group with some people you know and start a conversation. By doing so, you will generally get introduced or get the chance to introduce yourself to those people you do not yet know. Alternatively, you can explicitly ask one of the people you know (do this beforehand) to introduce you to people you want to make contact with. You also can ask if people know others who could benefit from information on risk reduction activities, etc.

Here again , success depends on an appropriate assessment of the situation . It can be helpful to visit informal meeting places (the corridor, TV room, sports facilities) on a regular basis, on the same day, at the same time. This makes it easier for the target group to find the staff involved in risk reduction activities , either for their own sake or for introducing or referring a friend to them. 'If you go to this place on Friday at 10 o'clock you can meet them').

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As a community service worker involved in risk reduction activities in prison you can also consider getting introduced through people in positions of trust (such as the social worker, priest, medical personnel). However, you should also bear in mind the inmates' privacy. You should never ask for names of inmates to speak to. The only thing you can ask is that these trusted individuals inform inmates about your work, refer them to you. It is then up to them to turn to you. Here, too, the process of building up contacts can be facilitated by handing out some form of literature (see 5.2, 9 and 10 in this chapter).

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COUNSELLING `3

Counselling is a direct, personalised, and client-centred intervention designed to help initiate behaviour change, e.g. to keep people off drugs, avoid infections or, if already infected, to prevent transmission to other inmates or partners, and to obtain referral to additional medical care, preventive, psychosocial and other valuable services that are necessary in order to remain healthy. Counselling can consist of giving short advice and information, it can be referral, it can be the core of longer and more intensive assistance and, finally - of course - of prevention. In this manual, we concentrate on counselling as a, useful method of risk reduction, although the information that follows might also be useful for other tasks. Consequently, the following issues will be discussed here: ^ How to raise the subject of safer behaviour; ^ How to discuss the subject of safer behaviour. Either instead of, or in addition to individual counselling, you also might consider running group meetings to discuss safer behaviour. However, discussing touchy issues such as using drugs and having sex (especially true in prisons) requires mutual trust. You should make sure that people feel safe enough to do so in a group. 6.1 How to raise the subject of safer behaviour •

Getting into contact with drug users is one thing, starting a conversation about things like injecting behaviour, hepatitis or HIV/AIDS, another. Those who work in a prison and are responsible for risk reduction work often realise that accidental contacts and talks can be quite fruitful, though this often means working without a clear agenda and without a well defined structure. Nevertheless it is worthwhile to set an agenda for yourself. This can result in a guideline offering some structure for the work: Nonetheless, talking to prisoners in an unstructured setting has a lot of advantages: ^

^

It can be very effective because one is acting in close proximity to the target group's own environment. One can react directly to real life, spontaneous situations, to ques tions people have, etc. (trust building); Operating in the daily surroundings of the target groups generally facilitates an atmosphere of trust;

-3

Based on Trautmann / Barendregt'European Peer Support Manual' (see References)

^

One is getting valuable information about the actual living situation, the actual needs of the target groups;

If people know what one is doing, they will sometimes start talking about AIDS or other health-related subjects by themselves. Besides this, there are various other ways to raise the issue: One strategy is to look for openings in the contacts - whether ^ casual or planned - in order to raise the issue. One can give a short reminder about safer use when confronted by a drug user with an abscess. Other opportunities arise if someone has been kicked off the substitution program, if someone suffered an overdose, etc. Thus, making use of unexpected chances is very important. Exclusively focusing on HIV/AIDS, or only discussing safer ^ use and safer sex will soon be boring. It is not attractive to drug users. Thus, it is advisable to incorporate the risk reduction message in a broader framework of drug users subculture, e.g. focusing on health in general or hygiene conditions in the prison. ^ If you meet people you know but have not seen for a while, the questions 'How are you', 'How are things going', might be enough to get a conversation started in which health may be one subject. Here, too, some of the methods mentioned above that can ^ be useful: > A leaflet D A newsletter/magazine D An inquiry on what the needs and/or problems of the target group(s) are D Giving out condoms, bleach or syringes Handing out things and asking questions, addressing and acknowledging the expertise and knowledge of inmates can help to start a talk about the issue of risk reduction (see 9). It is vital to have a broad repertoire of means to raise the issue, especially because it is evidently not enough to just raise or discuss the issue once. Short reminders, repeating the message from a different angle or by a different approach can be very effective.

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6.2 How to discuss the subject of safer behaviour Whereas most papers on counselling refer to a structured, therapeutic setting, counselling in prison often lacks this clear structure of well-defined roles and setting. One has to create a setting for a confidential talk (finding rooms, etc.) and is therefore highly dependent on spontaneous opportunities. However, there are some rules for discussing the subject of safer behaviour.

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I

---Attitude and behaviour

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^

Do not be judgmental , e.g. simply judging or condemn ing risk behaviour as stupid, incredible, will not change someone's behaviour.

^

As a result of this principle, it is important, not to ask'why'. The question 'why' often simply shows that you don't understand 'why' and are therefore judging. Open questions inviting people to tell their story brings about more important information.

^

Do not patronise , and so avoid giving advice regard ing personal business like whether or not someone should get tested for HIV or how they should behave. ('If I were you I would ..: ). Instead, try to offer relevant, complete information and discuss alternatives. Making one's own decision is more effective than adopting some one else's view. However, in impersonal or objective mat ters advice can be very useful ('In this case you need a lawyer. You can refer to ...;' 'For getting an HIV test you can refer for further information to .... You first have to make an appointment by phone'; `You should boil a syringe for 15 minutes and not just flush it with boiling water'; etc.).

^

Do not take responsibility for someone's problems, try to motivate and support people to solve their problems by themselves.

^

Listen carefully. This means do not talk too much, do not interpret, but make sure that you understood well by recapitulating briefly what you believe someone has said and asking if this is what they meant.

^

Stick preferably to the ' here and now', what do people feel or think now, what do things/emotions mean to people now, what do they see as perspective, etc. This generally gives more relevant information to realising safe behaviour than discussing the past.

^

Pay attention to emotions . How and what do people feel? What do certain events mean to them, etc.? This can give insight into why people behave as they do.

^

Show that you understand and care , show interest. Ask people how they are, how things are going, where they were (if you have not seen them for a while).If you have not seen someone for a while, ask their mates where they are, what has happened to them, or if you know, you can visit the person in their cell, in the hospital wing, etc.

^

Treat people with respect . For example, thank people for their information and assistance, apologise when you are bothering someone, invite them for a cup of coffee, etc.

^

Do not play therapist or 'shrink'. Although carefully listening and paying attention are important one has to avoid playing the role of an uninvolved therapist. Questions like 'Tell me, how does it feel?', 'What does this mean to you?' can raise feelings of aversion, especially when given as a reply to questions for advice or help. Drug users might know this way of counselling by their attempts to kick the habit. These experiences with therapeutic treatment are frequently quite negative.

Most of these rules are closely linked to one's personality, and to one's attitude towards the target group. It is evident that one genuinely has to care, understand, etc. Simply pretending is not enough, nor is just adopting these rules. It is obviously nonsense to use the jargon or codes of the target group if you don't feel familiar or comfortable doing so. One has to integrate these rules and codes into your own, personal style of behaviour. To get a picture of how one is developing a personal style of working, regular feedback is necessary. This can be done by supervision through a colleague or preferably - an external expert. As supervision is not based on direct observation of how someone is working, immediate feedback is not possible. Practical rules Try to find a quiet place to talk where you have an ^ undisturbed conversation, e.g. a quiet room, where you can sit down. ^

Make sure that somebody has the time and feels like talking. Generally you can see at first sight if somebody





is in a hurry, feels restless, etc. If you are aiming at a /longer conversation you can ask explicitly if someone has time. You also can invite someone to have a cup of coffee. ^

Use appropriate language , i.e. language that is read ily understood and accepted. It is important to know or learn the jargon, the subcultural codes of the target groups.

^

Provide consistent, complete and neutral information, offering the chance for a well-considered decision. Informing people is not just telling but also listening. Particularly when asking personal questions, state clearly that people don't have to answer, that you don't want to be offensive. Explain the reason why you are asking this question, e.g. to get a picture what information some one needs.

^

s

Provide relevant information , i.e. information people need. This can be done by a formal risk assessment D Using a form to collect relevant information on level of knowledge (what do people know about routes of transmission of HIV/AIDS, hepatitis etc.), attitude (e.g. how do people view condom use) and risk behaviour of the target group members (do they share their injecting equipment, etc.). D Explaining the basics about the relevant infectious diseases (transmission of the virus, different forms (and levels) of risk behaviour, etc.) Asking and answering questions D D Discussing the possibilities for reducing risks, etc. A formal risk assessment enables both prevention worker and drug user to set risk reduction goals and structure outreach prevention. However, it generally will be not possible to reach all outreach contacts with this formal instrument. For people who cannot be reached by this instrument you have to have a less formal, appropriate variant. This means one has to be able to improvise. ^



Besides explicitly talking about HIV/AIDS and hepatitis related issues, a drug worker can also touch on or present safer behaviour information to be'read between the lines'. One can talk about other health subjects as how to stay healthy in prison, about drug user's life-style (not just the misery, but also having fun, how to enjoy life).

X05;



This approach can be effective in preventing people from getting tired of being confronted with yet another talk about HIV/AIDS, hepatitis and drug-related health risks. ^ Do not stick exclusively to AIDS prevention. Harm reduction work in prisons takes place in the environment of people. Therefore it will be impossible and inadequate to confine yourself to AIDS prevention. If you have people's confidence they will regularly contact you for matters other than AIDS prevention. Their first priority will probably not be getting information about safer use and safe sex. They might be more in need of other services. If you do insist on AIDS-prevention topics, you might lose your credibility. Therefore it is important to have knowledge of and contacts with other potentially relevant services. Support (positive) changes in behaviour and attitude to ^ reinforce these changes, even if they seem to be quite small. This support for changes towards safer behaviour is important to foster self-esteem and self-efficacy and thus is the basis for ongoing change. ^ Do not judge or reject a person for failure to change their behaviour Encourage and support snowballing ^ D By simply asking drug users to pass on the information to their peers, D By discussing how this can be done, D By involving drug users in the making and handing out of information material, etc. ^ Stop a talk in good time. Do not force people to go on, either implicitly -- by ignoring the unspoken signals that someone wants to stop, and thus maybe forcing some one to continue, or explicitly ('Wait a minute, I want to ask you one other question!). Indicators that suggest stopping (or not beginning) a conversation can be: D If the conversation is getting less intense, e.g. if people stop asking questions, stop talking by themselves and only react briefly to your questions D If people are getting restless D If people's attention gets diverted often, e.g. if they start talking with somebody else or change the subject D If people start looking around. If you want to talk with people again, you can try to make an appointment or just tell them that you will come around again to continue where you left off.

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TRAINING SEMINARS

Training seminars for both prison staff and inmates are an important means of transferring relevant information about risk reduction. However, training seminars as part of a risk reduction strategy in prisons are - in most countries - a relatively new phenomenon. This is especially true for seminars in which both prison staff and inmates participate. Training seminars on risk reduction - particularly the ones aimed at inmates - are often perceived as threatening to the traditional abstinence-oriented drug policy in prisons.



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Therefore risk reduction seminars must be prepared very carefully with clear arrangements between prison administration and other parties involved. Obtaining permission from criminal justice authorities and the prison governor is the primary prerequisite. The same goes for taking into account the specific conditions of the prison involved. Due to differences in policy, in inmate population, in health problems, in communication and co-operation with community drug and health services and in available human and financial resources, careful preparation is needed to successfully target the specific needs of both prison staff and inmates. If risk reduction activities are planned by prison staff, all relevant units should be informed or integrated. The medical health care unit should be asked for professional support, along with community health services and organisations (e.g. AIDS self-help groups). The venue of training seminars for staff members seems to be of great importance for the atmosphere and the readiness to talk. It is vital to find a place where people feel at ease. It can make a big difference whether a seminar for prison staff is carried out within the prison walls or outside the prison in training centres. Both options are possible. Carrying out seminars for the staff within the prison has the advantage that the number of participants will be higher, because the threshold for participation is low. Choosing a venue outside prison, on the other hand, has the advantage that it might be easier for the participants to address controversial topics more frankly. Bearing in mind what has been said above about general organisational matters, the following steps have to be taken: Needs assessment ^ ^ Setting priorities and aims ^ Defining the target group or groups ^ Planning and designing a seminar program ^ Evaluation



In the following section, we will discuss the basics of how to prepare and conduct training seminars. 7.1 Needs assessment Most of the things mentioned under section 3.1 also apply to a needs assessment for preparing training seminars. Training needs can be identified through directly asking prison staff and inmates what they need to know and what issues might be of special interest. This can be achieved through a group discussion, formally, through a group interview or focus group, or informally via an additional question. Besides this, an individual interview using a questionnaire should also be considered as this not only provides valuable information but is also an effective means to make contact with inmates (see 5 and 10.2).

is

The focus of this needs assessment should include knowledge about safer behaviour, skills, attitudinal aspects, social norms and self-efficacy. So, when interviewing drug-using inmates, you could include questions like: ^ "What does 'safer use' mean to you?" ^ "How do you manage to maintain your hygienic requirements?" ^ "What is most important to you in your current situation?" ^ "What have you found most interesting about this topic?" When having these discussions or interviews with staff and inmates, one should pay attention to information you get from 'reading between the lines'. Answers to questions about factual knowledge might also tell you something about people's attitude and their social and cultural norms.

i

Furthermore, information about factual risk behaviour can tell something about actual needs. Valuable information can be obtained here from the prison medical service and from community health services. For example, abscesses are an indication that people do not inject safely. 7.2 Setting priorities and aims Based on the needs assessment, the priorities and aims of the training activities can be defined. Important issues here include: ^ ^

Which steps have to be taken to realize the training seminars? In which order should these steps been taken? Which target group is the main priority? In general, staff training will be required prior to the training of inmates.

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^

^

One/ has to make sure that the prison staff is aware of the health risks and acknowledges the need for risk reduction 'activities. What content do you prioritize? Should the focus be on awareness, knowledge, skills, attitude, social norms or some specific combination of these things? Are the aims 'smart' (see 3.2)?

7.3 Defining the target groups Although there are issues that are of interest to both inmates and prison staff (e.g. the effects and risks of drugs (see in chapter 2.2) and the transmission of viruses, bacteria and parasites (see in chapter 2.3) there are issues that are only of interest to either the inmates ('What damage is caused by which drug?' or 'How can I avoid damage while continuing drug consumption?') or to staff ('How can I avoid a needle stick injury when searching cells?'). Possible target groups are ^ ^

^

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Prison staff, i.e. guards, health workers and/or management. Inmates. One can work with individual drug users, for example, to train them as peer tutors (group meetings could be seen as threatening for the system) or with a group. Depending on the issues to be dealt with in a seminar one can consider whether to differentiate the target group by gender, age or ethnic background. When dealing with sexual behaviour and safer sex, for example, women might feel safer discussing these issues when there are no men present (see below chapter 7.4). If training seminars for inmates are not possible, one can consider organising seminars on life and health risks in prison for drug users in the community, since many of them either have been in prison in the past or will end up there at some point in the future. Training drug users in the community can be a means of facilitating peer support in prison, as the trained drug users can then pass on the information gathered through training in the community to other inmates when in prison. Community health service staff. These can be an important target group as some of them work with drug users in prison. Moreover, since many drug users in the community have experienced or will experience imprisonment, the work of community drug and health service workers outside prison can be of importance. Finally, community drug and health



^

services can play a supportive role to prison staff in developing risk reduction activities in prisons. A mix of these target groups. Combining target groups can be quite powerful with regard to an exchange of information, change in attitude etc. It can facilitate mutual under standing. Possible target groups are prison staff, drug users and drug service or health service workers.

7.4 Planning and designing a seminar program As stated earlier, training seminars should not only focus on transfer of knowledge about risk reduction but also on transferring skills, influencing attitude and social norms, and enhancing selfefficacy. To ensure that more than only factual knowledge is transmitted the interactive character of the training session is important. Participants should not be taught but stimulated or even provoked to take part in the discussions. Therefore, it is important to limit lectures to what is strictly necessary to transfer relevant information and include as many interactive work forms as possible. One should also keep in mind that a transfer of knowledge also can be achieved through structured discussions on relevant issues, such as how to inject safely. The role of the trainer is then to guide the discussion and to make sure that no inaccurate information is provided and nothing is missed. The exercises included below (see chapter 8) are meant to facilitate this active learning.

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It is clear that inmates in different prisons in diverse countries will attend risk reduction seminars with different motivations and different interests. The motivation and interest of the participants should be reflected in the design and contents of seminars. It is also worthwhile checking if risk reduction is an appropriate issue to get people involved. In some cases embedding risk reduction in the broader framework of health promotion has proven beneficial, as it is less linked to taboos than a narrower focus on sexual behaviour and drug use. When preparing a seminar program, pay attention to the following things: ^ Define the size and composition of the group, keeping in mind the subject of the seminar, specific target groups, etc. Select the trainers. Trainers have to be experts, but they ^ also have to have a positive attitude towards the target groups, and they have to be flexible, i.e. being able to change the program if needed, etc.

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^ ^ ^ ^ ^ ^ ^

Define the course regulations , e.g. one person speaking atatime, giving respect to different opinions , letting people --fnish what they have to say, no aggression or violence, etc. Choose teaching methods (see chapter 7.4) Choose assessment and evaluation methods (see 7.1) Design a detailed seminar program and timetable Prepare visual aids (sheets, slides, flipchart, etc.) Prepare handouts and photocopies for exercises Choose and book the venue Plan and organise logistics (devices like overhead projectors, technical assistance, lunches and refreshments, etc.)



^

^

^ ^

^ ^

^

^ ^ ^

General considerations when organising a risk reduction seminar Invite potential participants well in advance. People, especially drug users, might have to get used to the idea of being invited to a training seminar. The background of the seminar should be talked over and explained. An official letter might underline that the presence of those invited is appreciated. In the meantime, it can be a good thing to keep people informed about the development of the training seminar and the planned risk reduction activities. Do not stop motivating people to attend the training course until they actually have arrived. One could consider inviting more people than one actually wants to train. Due to the taboo on sex and drugs in prison, some people might not show up despite their promises to participate. The number of people to be trained at any one time should not exceed 20 people. It might be better to organise a training course consisting of three afternoons rather than one that runs for an entire day. It is important to use methods of delivery that take the skills and experience of the participants as a starting point. Consider giving a small present to the participants after finishing the seminar as an appraisal for their presence. Consider giving people a diploma after the seminar. Always end a training course with an oral or written evaluation. What have you learned, what was lacking, suggestions for improvement, etc (for examples, see annex).

^

^

Choose a room for the course close to where people feel comfortable. The room will thus have a greater psychological accessibility. Organising a training course for drug users can be valuable, but it can become even more valuable if some kind of follow-up activity is organised.

The opening session A well-prepared beginning to a training seminar is crucial for its success. The opening session of the seminar should include the following: ^ A general welcome to everybody, e.g. thanking people for showing interest. ^ An introduction of the trainers (name, organisation, profession, experience, etc.). ^ An explanation of the reasons for and aims of the seminar. ^ A presentation of the program. ^ A round in which the participants introduce themselves (name, what is their main interest, what do they want to learn, etc.) Working with 'icebreakers' at the beginning (refer to a ^ recent newspaper headline on a relevant issue, connect the training topic to well-known persons, make a joke, etc.) Methods to be used Depending on the groups' experience in the prison, interests and needs, some of the following approaches may be useful elements in a training seminar '4 : Elements of this chapter have been adapted from Brian Murtagh: Peer education (book 2). Health Promotion Unit of the National Youth Federation Ireland

Group work: Start in small groups where all inmates feel more confident to speak and then to move to larger or plenary discussions. The size of the group may influence the level of discussion and selfdisclosure which takes place during exercises. Consider how a group could be divided up, e.g. participants could be invited to decide to choose who they want to work with or may be directed to work with a person they have not worked with before. Feel free to use and adapt the suggested outlines of exercises below (see chapter 8), according to your knowledge of your particular group, the prison circumstances and resources. 0



Brainstorming This is/a way of recording immediate thoughts on a subject. Everybody's contribution is written down as it is given . Only when everybody has finished contributing does discussion and analysis of the contributions begin. Drawing: Drawing and collage are a useful way to approach issues which are intimate or personal and are useful in stimulating discussion. Quiz or questionnaires: These are useful for establishing the information levels of a group but care must be taken not to create a sense of competition (see quizzes in chapter 2). Attitude continuum: This involves placing cards with the word agree-disagree, acceptable-unacceptable, at opposite ends of a room and inviting participants to express their views or values. It is a very useful way for enabling structured discussion of participants' different opinions. Video: Videos can be a useful catalyst for discussion or for giving information. TV programs popular amongst inmates can provide relevant material for discussing relationships , sex, personal development etc. •

Newspapers and magazines: Literature, articles, drug users' magazines, photographs, prison magazines/newsletter, and case studies can be used as the basis for an exercise, too. Drama , role play: Drama and role play can be used most effectively. Providing a case study and role playing it can help participants see a variety of angles on an issue. 'Freeze framing', where the action is `frozen' and the participants are asked to suggest what has happened or what is about to happen is also a good technique. It is important to use a variety of presentations and interactive methods to help concentration and make learning as interesting as possible. Finally one should not forget to include regular breaks in the program.

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Taking into account specific target groups / specific issues From experience we know that generally there are good arguments for having safer-sex seminars for male inmates be conducted by male trainers and a female trainer for female inmates. This is due to the gender specific experiences, habits and risk exposure of both groups (e.g. prostitution, abuse etc.) and gender specific attitudes. Women frequently do not feel safe to discuss issues of sexual behaviour in the presence of men. Men might feel the obligation to play the 'macho', boosting their sexual achievements. The ethnic, cultural and religious differences of inmates should also be considered, perhaps through running different training seminars with different approaches. In a predominantly Islamic culture it is not acceptable to talk as bluntly about sex as in Western countries. This point is important, as in most European prisons the percentage of foreigners is relatively high. This raises specific problems of culture and religion. Communication might also be hampered through language barriers. Having staff available who speak the language, or even better who come from the same country, culture or religious background can be very helpful.

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7.5 Training seminars for inmates Many inmates have not been reached successfully by health services before entering prison. So the time of imprisonment can be used effectively to inform them about risk reduction and other health issues. Here, one can contribute to making sure that the period of imprisonment is not simply'lost time'. Two types of training seminars for inmates can be distinguished: ^ ^

Training small groups of drug-using inmates in prison about risk reduction, possibly resulting in a snowball effect and Training drug- using inmates about risk reduction and as `peer supporters' involved in further risk reduction activities.

Both kind of training seminars have their own perspective . The first type is meant for drug users who do not have any advance intention of becoming active in peer support activities. Nevertheless, our training seminar experiences showed an impact on both the participant and his/her peers . It is not hard to imagine that the training seminar will be discussed with friends and peers . This is

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i t`where the 'snowball ' starts to roll . This type of training seminar can \be organised and conducted by both prison staff and community health-or drug workers. The second type of training seminar only makes sense in a broader peer support framework. It can be conducted as starting point for peer support activities in prison. In such a case it can be valuable for professionals to participate and bring along their knowledge and competence (e.g. nurses from the medical department). For example, when drug users are interested in contributing to a risk reduction strategy through a peer support initiative this kind of seminar can be fruitful. It is obvious that in these seminars attention is paid to organisational aspects and to the message, but also

to how to get the message across. When organising risk reduction seminars for inmates important things to keep in mind include: ^ The need to clarify in advance that inmates who want to participate in the seminars will get the opportunity to do so (getting time off from work, schooling etc.). This should be discussed with the prison governor. ^ Inmates should only participate on a voluntary basis to make sure that they are motivated to do so and to facilitate peer support, i.e. passing on the information to their peers. Drug using inmates, especially peer leaders prove to have ^ a lot of valuable information and can contribute in many ways to training seminars. •

Working with groups or individual inmates Training drug users should preferably be done as a group event. This is, of course, more efficient (less work, less money involved) than training on an individual basis. Moreover, it stimulates group discussion, facilitating group influences on attitude and social norms, making use of resources available among inmates. However, some prisons do not permit group work because it is regarded as a security risk. In that case it might be an option to train individual drug-using inmates to work as peer tutors. Working with individuals allows a very intensive and thus effective transfer of information.

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7.6 Training seminars for prison I drug service staff 1"What creates health? It is the interaction of environment and people in the course of everyday life that creates a pattern of health in the individual, the family, the community and the globe." (Ilona Kickbusch, 1997) Especially important issues for training seminars for prison staff include: Seminars that help prison staff to identify themselves with ^ and support the objective of preventing infections Seminars in which prison staff acquire basic knowledge ^ about drugs, drug use, infectious diseases and other drug use related health risks Seminars in which individual and collective needs for ^ safety are discussed and agreed upon

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Again the focus of these seminars cannot only be on knowledge but should also focus on: Skills, e.g. in the field of counselling; ^ Raising awareness about the staff's attitude towards drug ^ use, sexual behaviour, etc. The training seminars should focus on adequate behaviour patterns as part of measures initiated to prevent the spread of infections in prison. A single training on behaviour change, however, will not be efficient without accompanying structural changes in the prison setting. According to interviews with prison staff, the three aforementioned goals need to be met. Identification with the goal of preventing infections Prison staff and management can only personally identify with the objective of preventing infections if they accept that infections are a threat for everybody, both in and even outside prisons and therefore should be fought. They need to understand that they have a vital role in doing so successfully. Using print media as leaflets is not enough. These are only suited to complementing other preventive measures such as personal counselling and other services (see chapter 9) but they cannot replace such measures. Implementation of preventive measures is frequently jeopardized by individual attitudes and prejudice of prison staff ("Inmates know exactly what they are doing; they are grown-ups and they are responsible for themselves"). Moreover, prison staff often consider drug consumption a weak-

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,tness' of character ("Addiction can be overcome if the will is strong enough . Quitting is the only solution!") or religious reasons are-given for why earthly means are hardly suitable for combating risks of infection ("AIDS is the well-deserved punishment imposed by a higher power!"). Such attitudes and beliefs are deeply rooted in people. They cannot be changed easily. Hence training offered to prison staff should aim at familiarizing them cautiously with new attitudes and at sensitising staff towards the situation of drug-using inmates and of course, allaying the fears of colleagues.



Acquiring basic medical knowledge The use of illegal drugs and the use of medical services and medication are often related to each other. However, frequently, drug-using inmates are reluctant to seek help concerning their use of illegal drugs directly from medical services. The situation is getting more complicated by the taboo under which drug use (in prison) operates. Therefore it is crucial that prison staff learn basics of medical knowledge in order to: ^ Avoid infections, especially viral infections often associated with drug use, Allow prevention and early treatment of health damage ^ related to drug use.





Accepting and meeting individual and collective needs for safety This is an important issue when training prison staff, as it has been shown that fear, insecurity and the wish to separate oneself from others have a negative effect on the atmosphere and on interactions and relations between staff and inmates. Although separation from others can be considered a method of protecting oneself against supposed or real threats, it should be overcome in order to establish a closer relationship between prison staff and inmates. This is a prerequisite for successful risk reduction activities, such as discussing safer behaviour. A closer relationship can only be established if the prison staff's need for safety is accepted and met. Seminars should focus on supporting prison staff, helping them to feel more secure in handling drug-related problems. Besides extending their knowledge on drug and drug use related issues (see chapter 2), seminars should also answer questions related to the risk to prison staff of getting infected, and inform participants on things like PostExposure-Prophylaxis (PEP) after a needle stick injury, first aid

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in drug-related emergencies, adequate treatment of wounds and the availability of vaccinations. Often guidelines and protocols for avoiding risk exposure and adequate safety behaviour (such as wearing gloves when searching cells etc.) do already exist. These can be used, as basic material and problems in applying these recommendations then can be discussed. Besides taking up the staff's needs and fears as an initial point of departure for training, one can use major parts of this manual (the whole of chapter 2 and also elements from this chapter, e.g. chapter 7 on 'Methods and material to conduct risk reduction work' which contains lots of ideas for training seminars) for designing training seminars for prison staff.

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7.7 Training seminars for mixed groups Combining the target groups of prison staff and inmates can be quite powerful with regard to the exchange of information, changes of attitude, etc. Exercises from the European Peer Support Manual have proved to be useful in this respect (Trautmann / Barendregt 1994). Here, again, a needs assessment might be a good thing to start with. From our experiences working with peer support in prisons (Stover/ Trautmann 1998) we know that peer support can be an issue to deal with in seminars for mixed groups. Peer support and peer education can be useful approaches to contribute to risk reduction in prisons (see chapter 10.6). To work out a plan for peer support one could organise a mixed seminar to present and discuss options of peer support as part of a risk reduction strategy. How and what can drug users contribute, how can they be supported by prison staff, etc. could be issues of discussion. Using exercises on safer use (such as how to inject safely, etc.) can show prison staff that drug users do have valuable information and know-how. However, peer support in general should be first introduced to prison staff as part of an introduction of risk reduction strategies in prisons, for example, by seminars on drug use in general. It does not make sense to focus in a seminar or training seminar on peer support without having discussed first the basics of risk reduction. Our experience has also taught us that peer support initiatives are most successful when supported by professional or voluntary organisations (Trautmann/Barendregt 1994). In the closed setting of a prison, a risk reduction strategy would be impossible without the support of prison staff.

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EXERCISES FOR TRAINING SEMINARS

In the training seminars, the emphasis is not only on knowledge about safer behaviour but also on skills, attitude, social norms and self-efficacy. To ensure that more than just factual knowledge is transmitted, the interactive character of a seminar is important. Participants should not be taught but stimulated or even provoked to take part in the discussions. Therefore, we have made up and selected exercises based on active participation, which can be useful elements of a seminar program.

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Below we present exercises on the two major risk reduction subjects: safer use and safer sex, in addition to some other exercises. In general the following instruction applies to all of these exercises: Start off with short but clear instructions! D Explain why you want to use the exercise D Stimulate participants to ask the trianer questions, inplenary sessions as well as while working in small groups. D Make participants feel comfortable about asking questions. A statement like "Anyone can make mistakes regarding Safer Use!" may be helpful. D When working in small groups someone should keep minutes to be able to report on the group's discussion in the plenary session. Arrange for the right composition of the groups! Frequently, participants who get on well will sit next to each other or join the same group when small groups are formed. Try to move them into different groups by 'forming groups through counting off'. Establishing new contacts is a valuable side effect of seminars, so try and facilitate participants' exposure to new points of view.



Observe what is going on in small groups attentively! When splitting up the group of participants into small groups, you should keep in mind that you cannot supervise more than 3 or 4 small groups, meaning that 15-20 participants is the maximum number of participants. During a role-play, which will generally last 30-45 minutes, you should join each group for a few minutes, to find out how the participants are working together and participating, and whether the



group is failing to make progress due to an unfavorable composition of the group, etc. In this latter case, you can take up the role of a mediator and initiator of new problem-solving strategies. Keep a record of the most important things happened, the most relevant contributions by participants. Although a record is kept in each group, interesting suggestions or cross references are frequently missed, particularly if they have been expressed by participants who are less dominant. These suggestions can sometimes be very useful! -+ Immediately after the group work , summaries should be presented by those who kept the minutes. The results developed in the small groups should not be flogged to death by commenting on and discussing all the unimportant aspects! First, it is important to gain an overview all of the solutions expressed. Therefore a summary of the most relevant results of the groups should be presented back to the plenary by the participant who kept a record of the minutes. These should be noted on a flipchart so that all participants in the training program can see them. These recordings can also be used to structure further discussions after the conclusion of the program.

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8.1 Exercises on safer use (primarily for inmates)'5 Some of the exercises have been taken from Trautmann / Barendregt `European Peer Support Manual' (see References)

Applying precautions to avoid getting infected or proper injecting techniques are skills which are not learned overnight. A skill is learned and improved by practice. For injecting drug users, safe injecting is an important skill. Unfortunately some drug users have not learned this skill correctly or are not always capable often due to difficult situations in prisons - of avoiding risks. Sometimes they are not informed adequately about alternatives, `second best solutions' and 'better than nothing strategies'. For example, many drug users are used to have easy access to clean injection equipment in the community. To stay 'safe' in prison circumstances requires different approaches that are far removed from the daily routines in the community. The exercises in this manual aim at improving drug users' skills and risk awareness. The starting point is the experiences that drug users have themselves. Each exercise should be valued, whether it is suitable for the prison situation and the target group. For some users, talking about drug use may be too close to their personal situation with drugs. It should be clarified - especially to prison staff - that talking about the risks of drug use doesn't mean that exercises are intended to promote an acceptance of drug use.

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When necessary, one should adapt these exercises to the specific 7 needs of the group or prison conditions. One basic requirement for-all-these exercises is to carry them out in an 'interactive' way, integrating views, perspectives, questions and competence of the target group. They are meant as practical tools to allow'learning by doing'. Although the exercises in this chapter are primarily appropriate for seminars for inmates, most of them can also be valuable elements in mixed seminars (for both staff and inmates) as our experiences in the European Peer Support Manual have shown. You should, however, check beforehand if a certain exercise will be acceptable in a mixed seminar. An important issue here, for instance, is if there is enough mutual trust between those who are involved.



Introducing the subject of safer use This exercise uses a part of the manual (chapter 6.3 + 6.4). The trainer can choose whether to focus on: the preparation of a shot, or, the technique of self-injecting 1. Introducing the subject of safer use. 2. Showing the correct preparation and self injection sequence. 30 - 45 minutes Duration : Minimum 4, maximum 20 No. of participants : Preferably videotape on self-injecting, e.g. Material needed : the video included in the European Peer Support Manual

Objectives:

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Injecting equipment (see 6.2 in chapter 2) and a soluble powder that resembles heroin, e.g. sugar In case injecting equipment is not available or allowed to use you should use materials that can replace the equipment (such as a pen for a syringe, etc.) Exercise outline: Show the video ^ ^ Ask for comments afterwards. Focus on: D Different ways participants inject D What was your everyday routine before getting to prison? What are the obstacles to applying these routines D when using drugs in prison? ^ Focus on the differences and the possible hygienic mistakes. Variations: One can ask one of the participants to show how he ^ is used to preparing a shot and how he would inject it. This can best be done with real injecting equipment and all of the paraphernalia normally used (see 2.6.2.) ^ The other participants watch carefully and make comments afterwards, about things they do in a different way and about mistakes made in the presentation Correct mistakes and omissions in the discussion ^ Remarks: Use photocopies of 16.3. and 16.4. as background information If you are using the European Peer Support video or another '222'

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``safer use' video, please check the contents beforehand (is the information presented correct , relevant and acceptable ?). Also check if there is video equipment available for playing the tape.





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Assessment of disadvantages of injection techniques Continuous intravenous drug use under street or prison conditions often leads to severe damage to the tissue and blood-vessels (veins). In this exercise you try to identify possible damage and how to avoid it by improving injection techniques. Objectives : 1. Participants assess risks and potential for damage from their injecting technique 2. Participants learn how to avoid them by improving injecting technique Duration 30 to 60 minutes No. of participants : Minimum 4, maximum 20 Material needed : Work sheet of man and woman (attached), pens and flipchart Exercise outline: Split the group into smaller groups of two or four people ^ ^ Each group receives a copy of the work sheet (male participants use the sheet with a male, female participants with a female) ^ Ask participants to judge and mark possible injecting spots on the work sheet according to the following standards (allow 20 minutes): 1 = very suitable 2 = only in emergency, 3 = risky 4 = never ^ In a plenary session, the small groups present their work. Use a drawing of a human body on a flipchart to mark the correct standard.





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ASSESSMENT OF THE DISADVANTAGES OF •

INJECTION TECHNIQUES (WORKSHEET)



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Alternative routes of administration Choose whether to focus on: Chasing the dragon, or -+ Snorting and smoking Objectives :

1. Introducing'chasing the dragon' as an alternative way of taking heroin. 2. Discussing safer use techniques. Duration : 30 - 45 minutes No. of participants : Minimum 4, maximum 20 Material needed : Material used for chasing the dragon and snorting and smoking (see chapter 2, 6.5 ) (if available, videotape from European Peer Support Manual ,video equipment) Exercise outline: Show the 3rd part of the video or ask one of the ^ participants to demonstrate injecting and/or snorting; ^ Ask for comments on this method of taking drugs; ^ Discuss the advantages and disadvantages of alternative routes of administration ^ Is'chasing the dragon', 'snorting' or 'smoking' an alternative in prison? What makes it so difficult to apply alternative routes ^ of administration in prison? Remarks: Use 6.5 as background information. Make use of participant's experience of alternative routes of administrating drugs.

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`In case of..: - How to respond effectively to difficult circumstances Every injecting drug user is interested in injecting drugs quickly and efficiently. This is especially true of the prison setting, where nearly all areas are intensively controlled and common meetings generally have limited time. To be successful, certain conditions must be fulfilled, e.g.: All equipment should be at hand ^ ^ Veins should be easy to inject ^ A comfortable area where one won't be disturbed should be available ^ The drug user should have the knowledge and skill to inject safely. In prison, these conditions are rarely fulfilled. It often happens that the conditions are far from favourable at the moment that drugs are available.

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For drug users it is very handy to have a repertoire of alternatives available which can help to limit the risks related to unfavourable circumstances. 1. How to respond effectively to unfavourable circumstances regarding proper injecting. 2. Drug users share the improvising skills they have regarding proper injecting. 45 - 60 minutes Duration : No. of participants : Minimum 4, maximum 20 Copies of the 'in case of...' list (next page), Material needed : pen and flipchart

Objectives:

Exercise outline: ^ The trainer splits the group in two groups (A and B) or into couples. Each group is given some unfavourable circumstances ^ from the list on the next page (the A's from the list to group A, the B's to group B) to which they have to respond as if it was a real life situation. ^ After a set time (e.g. 15 - 30 minutes) the various responses are discussed in plenary. The trainer corrects mistakes and presents alternatives ^ not mentioned by participants, using page 3 of this exercise as checklist (see some possible alternatives in chapter (2.6.5.). Alternative: Make up your own list of unfavourable circumstances or add to or modify the attached list.



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CASE OF...' (WORK SHEET

A# B#

no clean needles and syringes are available no bleach is available

A# B#

no fresh tap water is available a shot of cocaine and the needle clogs

A# B#

a shot of heroin and the needle clogs the syringe lacks a good vacuum (piston/plunger leaks)

A# B#

the needle has a barb (burr) no drugs and 10 clean needles and syringes.

A# B#

no spoon is available no fresh cotton is available

A# B#

no alcohol swab is available the plunger cannot be pulled back any further

A# B#

you notice you missed the vein (bubble)? you have difficult veins; hard, rolling, lying deep

A# B#

you do not have a quiet place of your own you have an abscess

A# B#

you hit an artery no heater or cooking plate is available





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`In case of ..:some alternatives \-To be honest : it's a risky business , isn't it? You know that yourself If no clean syringes or disinfectant is available, you should avoid using drugs intravenously. What we recommend here in case you think you cannot avoid injeckting, are only second-best solutions. Be aware of that! ^

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No clean needles and syringes are available D Boil it out for 15 - 20 minutes (see chapter 2, 6.1) D Clean it with bleach (see chapter 2, 6.1) Use the drugs by chasing the dragon (see chapter 2, 6) D Snort the drugs (see chapter 2, 6.5) No bleach is available -^ D Boil out the syringe for 15 - 20 minutes Chase the dragon

D Snort the drugs Clean the syringe carefully with anything else (cola, alcohol, anything)

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^

No heater/cooking plate and no bleach is available D Try to clean the syringe and needle as often as you can with fresh water

^

No fresh tap water is available Use mineral water D Or boil water for 15 - 20 minutes

^

One portion of drugs, one clean syringe, one used syringe and two people willing to share the drugs equally. D Boil out the used syringe or clean it with bleach Both chase the dragon One person divides the drugs into two equal portions, the other chooses.

^

one portion of drugs, two people with one used syringe of their own each and willing to share the drugs equally. -^ D Boil out the used syringes or clean them with bleach Or second best: rinse your own syringe well D One person divides the drugs in two equal portions, the other chooses.



^

A shot of cocaine and the needle has clogged. D Stop injecting, put the liquid back in the spoon, remove the clot, add some cold water, put on a new needle or take a new syringe and needle, D To unblock the needle: warm the needle with a lighter to expand it. D Pull up some fresh cold water and shake the syringe.

^

A shot of heroin and the needle has clogged. D Stop injecting, put the liquid back in the spoon, put on a new needle or take a new syringe and needle.

^

The syringe lacks a good vacuum ( piston/plunger leaks) D Take a new syringe D Wet the rubber of the piston and try again

^

The needle has a barb ( burr). D Sharpen it on a glass or match-box and clean it with a (lighter) flame.

^

No drugs and 10 clean needles and syringes. -+ D Stupid question D Try to sell them to make money.

^

No spoon is available -, D Prepare the bottom of a can, cleaning it by flame

^

No fresh cotton is available D Use the filter of a cigarette D Use whatever is available, such as an alcohol swab, the lining of a coat etc. D Use no filter. Carefully tip the spoon and keep the residue at the other end from where you draw up

^

No alcohol swab is available D Clean the injection spot with water and soap D Clean it with water only D Do not clean it.

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The plunger cannot be pulled back any further. D Stop injecting, untie tourniquet, squirt half the contents of the barrel back on the spoon or into a second syringe then let your arm hang down, tie off again and look for another vein. D Take a second syringe ^

You notice you missed the vein ( bubble)? D Cover it with wet bandages D Massage the bubble gently and evenly

^

You have difficult veins; hard, rolling , deep- lying. D Learn to chase the dragon D Ask someone else to help you

^

You don 't have a quiet place of your own. D Find a friend with a quiet place D Use a public toilet (if door opens inward, you overdose and fall against the door, then nobody can open it to help you)

^

You have an abscess D Make a compress of wet bandages D See a doctor as soon as possible.

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Negotiation skills Apart from all kind of individual 'technical' problems (as covered in the last exercise), drug users can run into situations where problems have to be sorted out with other drug users. This exercise tries to raise this subject of solving problems together. Objective : Duration : No.of participants : Material needed :

Preparing drug users for high risk situations. 30 to 60 minutes Minimum 4, maximum 20 At choice: a flipchart to write down reactions/solutions

Exercise outline: ^ The trainer splits the group in smaller groups of about 5 people ^ Each group gets one or two high risk situations (giving different groups the same situation might lead to interesting comparisons). ^ The participants are asked to present and discuss possible solutions, and to decide on the safest solution. ^ In the plenary discussion the solutions found are compared and discussed The trainer corrects mistakes and presents alternatives ^ not mentioned by participants, High Risk situations: ^ Two people have 1 gram of cocaine. It is nearly time to go back your cell and you have only one syringe available. How do both get a 'hit' and not get infected? ^ One portion of drugs, two people each with a used syringe of their own and willing to share the drugs equally. ^ Two cell mates and 1 /2 gram of heroin. It is 06.00 am and both are getting sick. The medical unit will open at 08.00 am and you do not have any needles around. Three inmates take a good shot of heroin, all with ^ their own (clean) needle. They get really stoned for a while. Then they want to take another 'hit' but they are not sure whose syringe is who's. Let the participants introduce a high risk situation which ^ has been settled in a safe way. ^ Let the participants introduce a high risk situation which could not be settled in a 100% safe way.

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- ---'Prison drug-using situations - how and when to intervene? Drug using inmates regularly might run into situations where other inmates are talking about injecting drugs. They can use these situations to inform these inmates about safer behaviour. However, it is a question of careful timing to raise the issue of proper and safer injecting. In this exercise, we try to find out what a third person (a friend or inmate, for example) can do to improve injecting technique. By means of discussion and practical exercises, several situations regarding good injecting technique are reviewed.

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Objectives :

1. discuss the best timing to raise the subject of proper injecting in prison situations. 2. discuss how to support drug users with good injecting techniques. 3. exercising practical support Duration : 30 to 60 minutes No. of participants : Minimum 4, maximum 20 Material needed : A tourniquet. The European Peer Support or another 'safer use' video tape (if available). Exercise outline: ^ Show one of the injecting parts of the video (if video tape is available) ^ Ask participants: if you were in the same room as the drug user, when and how would you start a conversation about safer use. ^ If video tape is not available, ask participants to think of their last use of injectable drugs: when and how could a conversation about safer use best be started Questions to ad: ^ What kind of situations are most suitable for starting a conversation about safer use with drug users in prison? Or to put it differently: As a (former) drug user, when do you definitely not want to be disturbed with a talk about safer use? ^ What kind of introductions are appropriate for raising the subject of safer use (unavailability of needles, a recent case of an inmate overdosing, etc.)?

Additional elements of the exercise: An explicit peer support action is to help each other ^ finding good veins. Participants look for good injection veins on their neighbour's arms. Roll up the sleeves, take the arms and examine them carefully. The correct use of the tourniquet is essential for ^ many drug users. Participants practice the correct and incorrect use of the tourniquet. The results are watched closely (veins coming up, going down). This exercise is particularly interesting if done by people with difficult veins. Question: what can be done to help veins come up ^ D if there is no tourniquet available, D if it is cold and veins are deep down. (see chapter 2, 6.2)

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!Simulation of a Stressful Situation : "Imagine....." ln_this'exercise, a stressful situation in which different injecting equipment is used is simulated in a role play. The situation should be as realistic as possible. The given situation is always the same, no matter if prison staff is trained or if drug users are educated about drug-related risks.

Objectives:



1. To experience a stressful situation that is as realistic as possible and to feel its impact - to get an idea of the readiness to take bigger risks 2. To exhaust the participant's creative abilities to identify safer solutions 3. To prevent infections, despite continued drug consumption - to develop behavioral patterns which reduce the risks involved in drug consumption

Duration : 45 - 60 minutes No.of participants : Minimum 4, maximum 20, split up in groups of 4 people Material needed : Overhead projector Flipchart and pens Injecting equipment (see 6.2) and a soluble, heroin-like powder, e.g. sugar If injecting equipment is not available or allowed, you should use materials that can replace the equipment (a pen for a syringe, etc.)



Exercise outline: The participants are asked to imagine the following situation: Imagine... You are in jail. You have been provided with fresh stuff of the best quality - I gram for 4 people. Three of you have not consumed heroin for a long time, one of you is priggish. The score is his. You are running out of time because locking of the cell doors is imminent. You are determined to use the drug, however in the least damaging way.

The only items you have available to consume the heroin are: D D D D D D

1 1 3 1 1 1

unused syringe used syringe used needles small bottle of water lighter lemon, not entirely fresh

And now all of you start to consume the drug as quickly as possible because - as mentioned above - time is running out. Please try to think of realistic but meaningful ways in which the drug can be consumed in the least damaging way under the given conditions and put the solutions you have developed to the test, i.e. pretend to prepare a drug injection with the equipment available. One of your group keeps a record of all solutions suggested, those accepted and those rejected; these notes can then be used in the discussion to be held in the plenary session later

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on. ^ ^ ^

Divide the group into small groups of 4/5 participants Give 30 minutes time to `imagine' and discuss Give 20/30 minutes for short presentations of the results from the small groups and discussion of these results

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Needle-sharing and drug-sharing n_thisexercise , the risks of sharing drugs , needles , syringes and paraphernalia are tackled (see chapter 2, 6). Different techniques of sharing drugs - hazardous or non-hazardous ones are examined. Objectives :

1. Recording the various sharing practices applied 2. Identifying the risks involved in drug shar ing 3. Pointing out alternative modes of sharing drugs 4. Making needle sharing into a taboo and pointing out alternative ways of consuming drugs in a less hazardous manner.

Duration : 45 - 60 minutes No.of participants : Minimum 4, maximum 20, Material needed : Flipchart, markers Injecting equipment (see 2, 6.2) and a soluble, heroin-like powder, e.g. sugar If injecting equipment is not available or allowed you should use materials that can replace the equipment (a pen for a syringe, etc.) Exercise outline: The most important element of this exercise is a demonstration of the various distribution techniques: ^ The participants are given the task of demonstrating distribution techniques in which typical material is used (syringe, spoon, needle, imitation heroin) ^ They are asked to name the risks involved ^ The participants are asked to develop and demonstrate alternative techniques. Remarks Use chapter 2, 3 as background information

Work-sharing This exercise also focuses on health risks that may arise from paraphernalia (see chapter 2, 6.2) needed for drug injection that is commonly shared among drug users, i.e. materials like filters, water, spoons, swabs.

1. identification of drug consumption paraphernalia as potential carriers of infection 2. use of clean equipment to protect the user's tissue and blood-vessels. 45 - 60 minutes Duration : No.of participants : Minimum 4, maximum 15, Flipchart, Felt pen, Material needed :

Objectives :

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Injecting equipment including all possible paraphernalia and a soluble, heroin-likepowder, e.g. sugar If injecting equipment is not available or allowed begin with summing up paraphernalia Exercise outline: ^ Show or request that participants name possible injecting paraphernalia ^ Collect all items named on the flipchart ^ Ask individual participants to demonstrate or describe the use of certain paraphernalia. The other participants are asked to comment on this, identify possible 'mistakes' and risks they have witnessed. Correct statements where necessary.

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Remarks: Use the information from chapter 2, 6.2

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.2' Exercises on safer sex (primarily for inmates) '6

Some of the exercises have been't a k en from Trautmann Barendregtz`European Peer Support Manual' (see References)

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Aside from injecting, safer sex is the other important topic involved in the transmission of HIV and hepatitis B. There is evidence that safer sex is a rarely or poorly practised, particularly among heterosexuals. In many western European countries, the incidence of new infections with HIV is highest among heterosexuals. An additional problem is that it has proved harder to discuss safer sex than safer drug use with drug users. Sex in general is still a touchy topic to discuss. General considerations for safer sex seminars ^ Inform participants exactly what you want to focus on in presentations, discussions and exercises. When discussing or doing exercises on certain sensitive issues, allow people on beforehand to decide whether or not they will participate. Show respect if they decide not to do so. Emphasise that people are free to decide whether or not they answer certain questions. When presenting this rule use preferably positive formulations, e.g. "please feel free to decide whether or not to participate or answer" instead of negative ones "you have the right to refuse...". ^ In general, it might be better to work with participants of the same gender (see 3, 7.4). However some issues, e.g. relationship issues, sensitising participants for gender specific problems, emotions, etc. can be dealt with in mixed groups. Even in these cases you should check carefully if partici pants feel at ease in a mixed group. ^ In some cases, one might consider whether to involve - perhaps just in a part of a seminar - a second trainer of the opposite sex, for example, to bring in the point of view of the opposite gender. Secure agreement with the group over the need to be ^ respectful towards participants' sexual orientation. Interfere if people do not comply with this rule. ^ As a trainer, you should be able to talk freely about sex and sexuality, e.g. being able to respond openly to personal questions. In response, of course, you can state that some questions might be touching upon issues you consider to be strictly personal. When using sex tools, make sure that this is acceptable ^ to participants. When using a dildo, for example, consider whether the colour is adapted to the group. Do not offend dark-skinned people by using a white dildo. ^ It has been widely experienced that many people are reluctant to practice `condom technique' on a dildo. Our suggestion is to use other, less intimidating, 'penis shaped' objects 242

0

0

0

well. Using a banana, for example , generally makes people laugh . Laughing and humour can work as an 'ice breaker'. The exercises in this part of the manual deal with safer sex in various ways . It starts with some exercises which aim at making sex a subject of discussion. After this, the safer sex part can come in. Experience has shown that this is a suitable build up. As with the exercises about safer use, the exercises in this chapter are primarily appropriate for seminars for inmates . However, most of them can also be valuable elements in mixed seminars (for both staff and inmates) as our experiences in the European Peer Support Manual have shown. You should , however, check beforehand to see if a certain exercise will be acceptable in a mixed seminar. An important issue here for instance is whether there is enough mutual trust. In order to unite the group again, plenary tries to compose a list of words on which everybody agrees.

0

`Dirty words' 1. Participants discuss sex in order to make Objectives : them more comfortable with the subject. 2. Making clear that different language is used with different people. 15 to 30 minutes Duration : No. of participants : Minimum 4, maximum 20 Pens, paper, flipchart Material needed : Exercise outline: Give every participant pen and paper and ask to write ^ down as many words possible for the male genitals; medical words, dirty words, pet names etc. for 5 minutes. ^ Ask participants to name the different words and write down the results on the flipchart. The one who came up with the most words is the winner. ^ Repeat this procedure, but now with words for the female genitals. Discuss the results along with a question about which ^ words can be used for different categories of people: parents, your children, partner, peers.

is

0



Sexual or not Objective: 1. Make participants conscious of the different impact words can have for different people. Duration : 30 to 45 minutes No.of participants : Minimum 6, maximum 20 Material needed : List of words, participants sheet, pens.

40

Exercise outline: ^ Preparation: compose a list of words adapted to the group (see: example list) ^ Make copies of the participants sheet (see: next page). ^ Distribute participants sheets ^ Read aloud the words of the list and ask the participants to write them down, individually, in the column that they think is right (no discussion) Split up the group into two or more smaller groups, in ^ which the results are compared and discussed ^ In order to unite the group again , plenary tries to compose a list of words on which everybody agrees

Sexual or not - Example list of words



0

to hug

exciting

to lick

horny

sucking

to rub

security

sensitive

toys

kissing

tenderness

partner

warm

tickle

confidence

dick

fuck

dark

scratching

surrender

ecstasy

caressing

smell

sharing

safe

hold

tied







• 246

Sexual or not



down the words mentioned in one of the columns.

SEXUAL

NOT SEXUAL

0



247







I^!i5L1 1.k 'll.^.l I^W

11^!W'...,.IIIVii^l'Ni1PWl

Sex education Many people are not used to, or do not feel comfortable talking about sex or safer sex . They haven 't learned to speak freely about sex. However, when the risk of getting infected through sexual contact is the issue, it is of vital importance to talk about sex. This exercise makes clear to everyone that it is normal to feel a little embarrassed or shy about it, because we have never learned otherwise . In this exercise , the plenary discussion is limited in order to maintain privacy. Objectives

10

1. Introducing the safer sex issue in a nonthreatening way. 2. Making clear that most people's sex education was very limited, i.e. not including a lot of open talk.

Duration : 15 to 30 minutes No. of participants : Minimum 6, maximum 21 Material needed: None

0

Exercise outline: ^ Split the group into threes Each individual in these smaller groups gets a maximum ^ of 3 minutes to tell the other two about their sex education. Key words are: when did it happen, who did it, and what have you been told. After everybody has told their history, the general out^ come is briefly discussed in a plenary session. Remarks: useful as an icebreaker, or as the start of a discussion of a safersex issue.

9

Safe or not? Objectives :

1. Catalogue the extent to which participants have knowledge of safer sex techniques and supply lacking information. 2. Raise awareness regarding the fact that there are more safe than unsafe sexual techniques.

30 to 45 minutes Duration : No. of participants : Minimum 6, maximum 20 3M post-it notes (the little yellow selfMaterial needed : adhesive pads), pens, 4 flipchart sheets of a naked man and woman one flipchart with two columns titled 'safe' and 'unsafe' Exercise outline: Split the group in two or more smaller groups. ^ Supply each group with post-it notes, a pen and the ^ instruction to write down as many variations as possible on lovemaking (techniques, positions, acts). On each little sheet another technique. Sheets are stuck on the table for the time-being. (10 min.) ^ Put the 4 prepared flipchart sheets on the wall. On the flipchart, the naked front and back of man and woman are displayed. ^ The participants have 5 minutes to put the post-it sheets on those parts of the body where they think a certain variation belongs. ^ Then, put the 5th flipchart sheet against the wall. This flap-over sheet has two columns: one labelled `safe', the other `unsafe'. ^ Let each participant take some attached post-it notes and read aloud the variation written down. Then the participant puts the sheet in the right column. ^ To conclude, discuss the result and give additional information if necessary.



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Objectives:

1. Participants experience talking about intimate sexual subjects 2. Participants experience posing intimate questions.

Duration : 30 to 60 minutes No. of participants : Minimum 12, maximum 30. Material needed : Cards with questions.



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Exercise outline: ^ Preparation: copy the questions on the following pages onto heavy paper. ^ Cut them into cards. ^ Form an inner and outer circle. Place an equal number of people in each circle. Participants sit in pairs, face to face. Give the people in the outer circle a pile of cards. ^ ^ The participants in the outer circle ask a question from a card to the person opposite, but only if they would have answered the question themselves. Make clear in advance that participants may decide whether or not answer questions put to them . Five minutes. ^ The outer circle moves two places and the procedure is repeated. Five minutes. Depending on the available time and the number of par^ ticipants, the procedure can be repeated. The pairs change chairs and the inner circle becomes ^ the outer circle. ^ The new outer circle moves one place and the questioning starts again. ^ Afterwards, in the plenary some experiences can be exchanged.









252

MERRY GO ROUND

1. Do you think you are 'good' 12. Did you ever play 'doctor' in had or not? I or other forbad en g a mes. I

13. Do you think there is a difference between what men and women feel during making love?

I I 14. Do you talk occasionally about your sex experiences? I I

I I 15. Do tell what you like when you are making love?

I

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6. Have you ever been afraid of your sexual feelings? I

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1 8. For men/women:

I

17. What means promiscuity to you?

I

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do you think you have I male/female characteristics?

19. Do you feel that your ideas 10. Do you have sexual about sex are further deve dreams? loped than your behaviour? I

I

11. Have you ever wondered how your parents make love? And how your children make love?

112. In a movie you see, an extended scene of homosexual love making; I what does that do to you? I







x

a.

MERRY GO ROUND •

113. Do you sometimes punish 114. Do you like to be touched, your partner by not wanting caressed?

L

I

1•

I 16. Do you tell your children

I15. What do you prefer:

to tempt or to be tempted?

about your sexual feelings? I

H-

I 1 17. Do you know what makes you horny? What?

18. What do you feel after

masturbation?

I

9. WOUIU you consider it as 0 20. Have ever had a fight sign of weakness to look caused by sex? I for help for a sexual problem? F ' 21. What do you think about extra - marital relations? I

22. Should people stay together because of the kids?

T 123. What do pornographic photographs and films

I

do to you?

1

124.. Did you use to fall in love with somebody who felt in love with you?

1 255







0

MERRY GO ROUND



25. Have you ever been afraid 126. Have you had hole-andcorner sexual affairs that you were homosexual ? 1 ^ (for parents , partner)?

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I

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I

127. In what way do you like to be hugged most ?

1 28 • D o you d ay- d ream a l o t?

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130. Have you ever been afraid 129. Do you like body fragrance ? that you (your partner was) I I were pregnant?

II 131. What was your most un-

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132 . How do you think about pleasant sexual experience?I oral sex?



I

133. Why are naked women/men 1134. Are you satisfied with your on the wall in the cells sexual equipment? I always that good in shape ? I

I---------T--------I you like watching some-1 I 35. Do you know and do you 1 36. Do body from the same sex , like your partner's flavour ? I who is looking good? I •

21





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MERRY GO ROUND



1 38 . What does it do to you when somebody of your gender feels attracted to I

137. If your partner has somebody else, how do you react?

you?

L 1139. Were you hugged a lot by 140. Can you accept that your your parents? Do you hug I partner doesn't want sex i ren a I o t,> y our c h'Id I wi th ou t fee I'ing rejec t e d?

What do you think of the taste of your partners' genitals?



' 43. Can you show your affection as good with your body as with words?

42. How often do you masturbate?

44. Does somebody 's voice has a sexual impact

on you?

145. Do you anticipate your first) 46. Do you become easily sex after release? jealous?

(47. What does the size of your penis (breasts) mean

t

?

148. Do you see the need for independence of your partner as a rejection of the relationship with you?



9





0

MERRY GO ROUND



49. Do you ever go somewhere 1 50. Tell something about your to meet a sex partner? I homosexual experiences? L



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151. Which sexual position do you prefer and why?

152. Why do you fuck?

153. Do you think you are as sexy as other people?

1 54 . Were y o u d e si re d as a b a b y I and of the desired gender? 1 -I- -

155. Have you ever felt exploi1 ted in a sexual relationship 56. Have you ever had a sexual transmitted disease? and have you ever exploited

someone?

I

F 157. Did you ever fuck without 158. Have you ever pretended

contraception?

159. What fantasies do you have when you make love?

that you were coming?

60. Do you masturbate occasionally in your partner's presence?



- I 261''







0

MERRY GO ROUND



- T -

Special question for women:

Special question for women:

61.1. What would you think if 161.2. What do you think about 1 your par t ner v i s it e d a vibrators and other sexprostitute? t oys 03

I

11

a

Special question for women:

Special question for women:

161.3. If your partner wanted anal sex, would you do it?

I

I1 61.4. Do you fuck during your period?

Special question for men:

Special question for men:

162.1. Have you ever been with 162.2. Can you imagine yourself) being passive when maa prostitute? king love?

Special question for men:

Special question for men:

0

162.3. Do you think sex is over- 162.4. Do love and sex necesemphasised when talking 1 sarily belong togetherr about relations?

F

Special question for men:

62.5. What do you think about men having sex with men in prison?

T I •

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Objective:

1. Participants practice giving instruction in condom use and experience the obstacles they can be confronted with.

Duration : 30 to 45 minutes No. of participants : Minimum 4, maximum 20 Several dildos (or bananas/cucumbers etc), Material needed : different (types of) condoms. Instructions on condom use (see next page; in addition you can use the text from chapter 2, 4.2 + 4.3)



0

Exercise outline: ^ Preparation: copy the instructions on condom use on the next page. ^ Split up the group into pairs and give each pair a condom and a dildo (or a dildo look-alike). ^ One of the pairs teaches the other how to use a condom (5 minutes). ^ Make an inventory of reactions in the plenary. ^ Distribute the instructions on condom use and let participants read them carefully ^ The same pairs sit together again but now the exercise is done the other way around; the second person, with a new condom, gives condom instruction according to the instructions they have just read (5 minutes). ^ To conclude, let participants react to the instructions given and stress the obstacles one can face while demonstrating the use of condoms.

0

INSTRUCTION CONDOM USE •

/Check if you have the right condom: P' Is it for vaginal or anal use ?(Special , extra stong condoms are suitable for anal use only). D Is it big enough? D Is it an approved brand? D Check the expiry date ^

Open the wrapping carefully: D Do not use teeth or scissors, avoid tearing the condom

^

Take out the condom: D Be extra careful with long nails D Make sure that you don't hold the condom inside out

^

Pinch (squeeze ) the semen reservoir, so that there is no air left. D This reduces the chance that it will tear because the reservoir does not come under pressure D If the condom has no reservoir, make one yourself by squeezing the air out of the top of the condom (2-3 cm)

^

Put the condom on top of the penis and unroll it carefully to the base of the penis > When fully unrolled there is less chance that the condom will slip off D Again , be careful with long nails

^

Use only water- based lubricant D Always use lubricant for anal penetration D A non water- based lubricant will dissolve the condom

^

Withdraw the penis carefully shortly after ejaculating D While withdrawing , hold the condom at the opening to avoid it slipping off D If you wait too long, the penis can become flabby, the condom slips off and semen drips out

^

Make a knot in the condom and dispose of it D Not in the toilet because it can stop up the drain

0

Use a new condom each time you start fucking . Never use two condoms on top of each other, as this can cause the condoms to tear.

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Objective:

Participants practice the use of condoms by playing a game.

Duration : 10 to 20 minutes No. of participants : Minimum 6, maximum 12 Material needed : Dildos (or bananas, cucumbers, etc.), condoms, a written condom instruction (see copy sheet from exercise instruction condom use). •

Exercise outline: ^ Instruct participants on how to use a condom. ^ The written instruction is used as the `gold' standard (see copy sheet) Split the group into equal numbers. ^ ^ Give each member of the groups two condoms (one as a spare) ^ Participants stand in a line The first person of each group gets a dildo and has to ^ put on the condom in the proper way, then take it off again and make a knot. Then the second can start the same sequence The group who finishes first is the winner ^ Remarks: The trainer can decide to appoint referees who judge the ^ participants actions' If participants make a mistake they should start again ^ The winners should receive a small prize ^

40



The safer sex debate People use all kind of pretexts against condom use. The aim of this exercise is to bring those pretexts to the surface and find valid counter arguments. Objective : Duration : No. of participants : Material needed :

Discussing condom use, pros and cons. 30 to 45 minutes Minimum 6, maximum 20 Two different viewpoints

Exercise outline: ^ Split the group in two, one group pro condom use, one group opposing condom use Each group is handed the participants' worksheet, see: ^ next pages ^ The groups prepare their assignment for 10 minutes ^ The groups then come together and sit face to face. The group opposing condoms gives their first reason for not using them. The `pro' group is then given the opportunity to respond to that. The reasons for and against condoms are then exchanged, one by one, as many as possible.

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270

THE SAFER SEX DEBATE (1/2) •

A/Vr te.down the arguments for condom use one by one and keep in mind that your partner will probably not agree with you. Short stories PRO. "You have been watching this attractive person for a couple of weeks. Now you both have met and have fallen in love . After an exciting night out , you find you have both ended up in bed together, willing to make love. You want to use a condom but are not sure how to raise the subject . The last thing you want to say is that you are HIV positive. Convince your partner to use the condom". "You are having your period. It's the first day and it is a heavy flow. It is your last night on holiday, and your last chance for romance with the sexy man you have met in the bar at the harbour but he's told you he has a history of drug use and a regular partner with high risk behaviour. It's 01.30 in the morning and you have only one hour before he has to return home to his fiance. There are no condoms available. What do you do?" "After months of heavy quarrels about money and drug use with your partner, the situation has become unbearable and you leave the house. You are lucky to find a place to sleep at one of your friends' houses. After being his guest for a week, your friend wants to see some 'rent'. He wants you to have sex with him. When you are in bed with him it appears that he does not want to use a condom".

40





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THE SAFER SEX DEBATE (2/2)

=Writebelow the arguments against condom use one by one and keep in mind that your ' partner' probably will not agree with you. Short stories AGAINST. "You have been watching this attractive person for a couple of weeks. Now you both have met and have fallen in love. After an exciting night out, you find your have ended up in bed together, willing to make love. Because you hate condoms you are not going to use them. Besides, you are not HIV positive. Your partner proposes that you do use a condom. Explain why you don't want to use it". "You and your girlfriend have been using drugs for 10 years. Your girlfriend works on the street and is making enough money to supply you both with drugs. It is a long time since you were last dope sick. One night, she suddenly says that she wants to use condoms with you. You are surprised because you feel condoms are only for clients. You refuse."

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'-`_--,Exploring different value systems AlthoughHlV and hepatitis transmission routes are discussed quite frequently, uncertainties and doubts still remain (see chapter 2, 3.2). Objective:



1. Exploring different value systems 2. Enable participants to clarify what is acceptable and unacceptable for themselves 3. Providing a basis for negotiating safer sex Duration : 45 - 60 minutes No. of participants : Minimum 6, maximum 20 Material needed : Ccopies of the statement cards and 3 header cards (see following pages: 'This is OK for me', 'This is OK for others', 'This is not OK') Exercise outline: ^ Fix the three header cards on the wall/flipchart where everybody can see them and put the smaller cards with questions in a pile that everybody can reach. Ask participants to choose a card, one at a time, and place ^ it under the heading that best fits their views. Ask them to comment on their choice. ^ If a person picks a statement card which they do not want to declare their views on, they can place it back in the pile and either take another or return to their seat. Once all the statement cards have been placed in a line, ^ tell participants that they can move any card under another header card, if they disagree with where it is currently placed. Each person can only move a particular card once. ^ Participants may like to say why they are placing the statements cards under particular headers, or they may choose to do so silently. ^ Ask participants if they were surprised at any of their own responses or those of others. Ask participants what they learned from the exercise. ^

0

.,

This exercise has been adapted from Brian Murtagh: Peer education (book 3). See references.



Exploring different value systems - Statements Having more than one partner

Being paid to have sex

Working as a prostitute

-+

Always insisting on a condom when working as a prostitute 0

-•

Using a vibrator

Getting drugs for sex

Giving drugs for sex

Talking about other inmates having sexual contacts with each other

-+

Sex between two women

-^

Vaginal intercourse without a condom in private heterosexual relations

Women who drink

Pornography

Put pressure (bullying and intimidation) on others to have sex Have sex to prove you love someone

EXPLORING DIFFERENT VALUE SYSTEMS (1/3)

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EXPLORING DIFFERENT VALUE SYSTEMS (2/3)

0 279







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EXPLORING DIFFERENT VALUE SYSTEMS (3/3)

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• 2R1'







SaferSex in relationships , sex work as risk exposure HIV and STD's are frequently discussed in professional sex relations. Risks in private sexual relationships are often neglected. Risks are often connected. More awareness should be raised on the connections between risks. Objective:

i

1. Explore risks and everyday beliefs in heterosexual relationships. 2. Provide an opportunity to practice negotiation and decision making skills, so that the inmate is better able to make positive choices in social and ( hetero)sexual relationships. 3. Discuss the necessity of communication about risky behaviour.

Duration: 60 minutes No.of participants: Minimum 6, maximum 20 Material needed: Copies of the scenario (following page), flipchart Exercise outline: ^ Divide the group into couples and let them discuss the scenario (10-15 minutes) Collect the solutions (helping arguments) and ^ discuss them ^ Write down the list of possible solutions on the flipchart ^ Make it clear that this scenario is only one example of how to start with female sex work and that there are many other ways which often include violence, having no other choices etc.

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0

SAFER SEX IN RELATIONSHIPS

- SCENARIO





Maureen and Paul have been together for about six months, both have been using drugs for quite a while. Financing the drug for both is getting more and more difficult. After Paul was caught by the police, he is not allowed to enter certain supermarkets and warehouses anymore (to steal things). Seeing no other solution, Maureen started to work as a street prostitute. For both Paul and Maureen, it was clear that Maureen should insist on the use of condoms, but initially, she didn't always succeed in persuading her clients. It was often impossible, especially when she needed the money urgently because she was turkeying. Most of the clients wanted oral sex in their car but others wanted vaginal sex. The first time she did it, she thought that oral sex wasn't a cause of infections, but after having done it more often she felt depressed about her situation. Although her clients looked very clean and it seemed impossible to her they could be infected, she still felt highly uncomfortable with unprotected sex. The problem was that she couldn't find a way to discuss her problem with Paul. Although they hadn't had sex since she went out on the street, she didn't want to infect him.

Can you find some arguments to help Maureen?



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I L

__ Respond to persuasion in a positive wax `s In many situations, any suggestion of condom use is rejected by the male partner. A condom is often associated with mistrust, feeling uncomfortable, being too complicated to organise etc. Here are some statements in response to which challenging statements are requested. Objective :

1. To provide inmates with an opportunity to respond to persuasion in a positive way by challenging the persuader and asserting themselves and their own ideas. 2. To discuss different strategies for finding solutions in conflict situations based on individual experiences and knowledge

Duration : 60 minutes No. of participants : Minimum 6, maximum 20 Material needed : Beep Beep Suggestion Sheet (below) Exercise outline: ^ Clear the room of any chairs or objects; ^ Ask the group to form a line side by side at one side of the room; ^ Tell the group you will read out a statement from the sheet; ^ Each statement tries to persuade someone to have sex without condoms either in professional or in private relationships; ^ Anyone who can come up with a challenging statement in response must shout "Beep Beep"! The trainer calls this person's name, and they will then make their challenge and take a step forward. The rest of the group stays where they are; ^ This procedure is then repeated. When the end of the room is reached by one of the group, reposition everyone back in the starting place. Proceed until all statements are gone. ^ Discuss the participant's responses. Are they realistic? Are they being applied? What is the explicitly'positive'value here? Can participants think of applying these statements in the future?



1^ f \

This exercise has been adapted from Brian Mailagh: Peer education on (book 3), see references.



Exploring the facts about HIV/AIDS

9

Although HIV and hepatitis transmission routes are talked about quite frequently, people still have uncertainties and doubts especially about transmission in everyday life (see chapter 2.3.2.6.). This exercise has been adapted from Brian Murtagh: Peer education (book 3). See references.

Objective :

1. Explore the facts about HIV/AIDS and hepatitis

45 - 60 minutes Duration : Minimum 6, maximum 20 participants : of No. Pens, questionnaires and answer sheets for Material needed : clarification

40

Exercise outline: Circulate the questionnaire to participants ^ ^ Discuss answers on completion Variations: ^ Have three large sheets of paper. One marked AGREE, the second DISAGREE and the third UNSURE. ^ Place AGREE and DISAGREE on walls at opposite ends of the room, and UNSURE in the middle. ^ Read out a statement. If people agree with it they should go to the AGREE end or stand at whichever card they think best suits their viewpoint. Encourage discussion between participants on their sug^ gested answers. Some statements have clear correct answers, while others are deliberately ambiguous to generate discussion and to encourage participants to think about different situations. Clarify the correct information at the end of each section.

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RESPOND TO PERSUASION IN A POSITIVE WAY •

" BEEP BEEP"STATEMENTS -

If you really loved me you would do it 2.

Do you think I have a disease or something?

3.

It's because I love you that I want us to do it.

4.

I want to be very close to you - not even with latex between us

5.

I will withdraw before I come

6.

I won't tell anyone

7.

AIDS is a gay disease - people like us don't get it

8.

Condoms spoil my pleasure

9.

Look into my eyes - do they look yellow or something? I don't have hepatitis or AIDS, you would see it if I did.

10.

If you are using the pill, nothing will happen.

11.

If you get pregnant, you could use the 'morning-after' pill.

12.

I'd feel so rejected if we couldn't do it here and right now

13.

I will pay you 5 pounds more

14.

Look at this car, my suit - do you think I could have all this with an infectious disease?

15.

If you do it orally, nothing will happen at all!

16.

I'm not the one who is at risk but you. I should be scared of getting infected by you.

17.

I can't father a child - I've been sterilised!

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STATEMENTS ON HIV /AIDS •

1/2

r



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D'sa ree

Air? Blood? Food? Men's semen? Women's vaginal fluids? Breast milk? Saliva? Sweat? Tears? Urine? Skin contact?

an gef'F,1_iv rom ... Oral sex (women with women)? Insect or animal bites? Getting a tattoo? 0 Being sneezed on by somec Sharing a toothbrush? Mixing blood? Sharing needles? Wet kisses? Sharing a dildo? Ear Piercing? Mouth to mouth resuscitation? Cleaning up someone else's blood? Blood transfusion? Shaking hands?

0

Which,of t he o ioWg dyou think would help yu to

avoi_d;ge Not sharing a cell with an HIV- positive woman? Using the contraceptive pill? Stopping oral sex before the man comes? Stopping vaginal sex before the man comes? Not borrowing a toothbrush? Always using condoms during professional sex contacts? Not sharing cups and towels with your cell mate?

)=agreem

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9

ANSWERE SHEET TO EXPLORING THE FACTS 2/2



ov Air?

HIV is not an airborne virus . Therefore there is no risk from being in the same room or being near somebody who is Infected HIV is present In large quantities in the blood of an Infected person to allow transmission to occur HIV Is transmitted only via body fluids . There Is no danger from eating food which has been handled by someone who Is HIV positive. if the semen from an Infected person enters the body of another person, e.g. durin g un p rotected sexual Intercourse HIV can be found in vag inal fluid and transmission can occur The breast milk of an infected woman does contain HIV and it is possible for the mother to infect her baby during breastfeeding All the body fluids of an HIV Infected person contain the virus In varying quantities . Saliva does not contain enough of the virus to facilitate transmission See above IIIIWIII See above See above

Blood? Food Men's semen ? Women' s vaginal fluids Breast milk ?

i

Saliva?

Sweat? Tears? Urine? Skin contact?

Ca» Oral sex (women with women )? Insect or animal bites? Getting a tattoo?

HIV can be found in va g inal fluid and transmission can occur Mosq uitoes , for exam p le, cannot infect p eop le with HIV The risk associated with tattoos relates to the use of 'dirty' needles, which mi ht have been used on an HIV-infected person

Being sneezed on by someone who is infected with HIV? Sharin g a toothbrush ? Mixing blood ? Sharing needles ? Wet kisses? Sharing a dildo?



o

y,

yes

Ear Piercing? Mouth to mouth resuscitation Cleaning up someone else's blood ? Blood transfusion?

no

Shakn hands?

ttlih

he

of

o

ou to void

do you th

Ve ry low risk Ve low risk Very high risk Although theoretically possible It is highly improbable . The amount of virus p resent In the saliva is usually ve ry small. HIV can be found in vaginal fluid and transmission can occur through sharin g a dildo But ve ry low risk throug h contaminated needles Theoretically possible. If there is blood in the mouth of the person who Is dyi ng then there is a slig ht risk, but no sing le case of infection Is known. If the blood Is Infected and the person who is cleaning up has cuts or open wounds on the hands and Is not wearin g g loves An number of people have been infected this way in the past before testing of blood started No risk

woui

n

Not sharing a cell with an HIV-positive woman?

Infection will only occur through sex , shared needles and syringes , or bloodto-blood contact The pill offers no protection against HIV or other blood-borne diseases Often this method is not successfully applied within the dynamic of sexual

Using the contraceptive pill? Stopping oral sex before the man comes?--

intercourse Stopping vaginal sex before the man comes? Not borrowing a tooth brush ? Always using condoms during professional sex co ntacts? __ _ _ Not sharing cups and towels with your cell mate?

no

See above Although minimal r §sk4ee abovel_ Condoms are a successful means of preventing Infected semen from reaching your blood____,__ Infection will only occur through sex, shared needles and syringes , or bloodto-blood contact

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X8.3 N -



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Exercises for prison staff only

We suggest starting any training for staff members by talking about drugs in a more general and basic way: effects, patterns and prevalence of use, associated risks, and myths. It may be useful to begin with the quiz `What do you know about drugs?' (see chapter 2, 2.1). This form seems appropriate and helpful in initiating discussions about drugs and their impact in our society. Avoid making a competition out of the quiz, as participants might feel embarrassed when making mistakes. Use the questions as starters for further discussion. The quiz can be filled in by participants individually, without making the answers known to other participants. It then works as a check of the level of knowledge of individual participants, showing that people might need to have a more thorough knowledge of the issues.



Legal and illegal drugs Discussions with staff members about the topics 'drugs' and `infectious diseases' should start and be structured by the specific prison circumstances and the needs of the staff. The following exercise might be useful as a starting point: This exercise uses chapter 2, 2 of the manual. 1. Introducing the effects and risks of drugs. 2. Showing differences and similarities of legal and illegal drugs Duration : 60 - 80 minutes No.of participants : Minimum 4, maximum 20 Flipchart, (photocopies of chapter 2, 2 can Material needed : be used as 'give aways')

Objectives:

Exercise outline: ^ Participants are asked to list legal and illegal drugs; write these down on the flipchart in two columns (legal and illegal) Ask for the effects of the most widespread drugs and list them on the flipchart. Generally, the focus will be on negative effects. Ask explicitly what the positive effects might be ('Why do people feel attracted to or use this substance?', e.g. pleasure, pain relief). What are the differences and similarities between the different substances (legal, illegal and pharmaceutical drugs)? .

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Variation: ^ Ask the participants to split up in two groups, one will discuss the pros and one the cons of the prohibition of alcohol. Each group selects a speaker who will then present the arguments to the whole group after 30 minutes. ^ 'In Italy every prisoner is allowed to buy '/2 litre of wine every day' - discuss the impact of that: Would you agree/ disagree with this measure? Remarks: The trainer needs to be well-informed about drugs and drug use.

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Cannabis use by inmates - what do you think about it? The-attitude of society towards drugs, especially towards cannabis is changing in many countries. Cannabis use is seen as less problematic than in former days. In different countries the law's approach towards use, possession (and in some cases even small-scale selling) is changing towards less harsh measures. Cannabis seems to be the main drug used by inmates. Cannabis is often regarded as serving a useful function or helping to alleviate the experience of incarceration. Some directors of penal institutions have realised that they cannot avoid adapting to this new situation: in some prisons (for example, in North Germany) urine tests do not include testing for cannabis consumption anymore. Some prison managers in Scotland confirm the view that the use of some drugs in prison doesn't vary considerably from that outside. "We do still accept that prisoners who use cannabis are breaking the law and they will be treated accordingly, but we are reflecting the way the world is outside prisons" (The Scotsman 13/5/98). The Howard League for Penal Reform in the UK recently recommended depenalization of cannabis in prisons in its'Submission to the Home Affairs Select Committee'.

Objectives:

1. Introducing the purpose of drug use 2. Sensitisation to cultural changes, values and judgements about cannabis (use). Duration : 60 - 80 minutes No. of participants : Minimum 4, maximum 20 Material needed : Photocopy of the sheet below Exercise outline: ^ Ask participants to split up into groups of 4 and discuss the following questions alongside the photocopied text: Have you had any previous contact with cannabis use/ usage in prison? D How widespread do you think the use of cannabis is in prison? What do you think about cannabis use in general? D What do you think about cannabis use in prison? D Have there been any changes in your opinion toward cannabis since you started working in prison?

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^

Focus on changes in personal views, the meaning of drug use for inmates and the possible toleration by the prison system.

Points of attention in the discussion can be: ^ What effects of cannabis fit into the prison system, and which drugs are not suitable (stimulants)? Would there be more violence among inmates without ^ cannabis? Urine tests: is it still necessary to detect cannabis in drug ^ testing?

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0

Abstinence and/or risk reduction - what are the goals? Objectives :

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1. Identifying health objectives for drug-using inmates 2. Understanding the differences between drug services (abstinence, methadone maintenance, risk reduction) 3. Understanding the principle of equivalence of health care inside and outside the prison 4. Identifying prejudices against risk reduction ('Second hand service') or negative connotations 5. Raising awareness of risk reduction providing a bridge function

Duration : 80 - 100 minutes No. of participants : Minimum 4, maximum 20 Material needed : Flipchart, pens



Exercise outline: ^ Ask participants to split up into groups of 4 and discuss the following questions (every group should appoint a note taker to write down the results on the flipchart): D What are realistic short-term and long-term health objectives? D What drug and health services are needed to realise these objectives? D What drug and health services are available in the community? D Can these services be transferred into the prison setting? Discuss the different answers in the plenary, and try to ^ sort them from long-term, maximum objectives on top (e.g. abstinence) and the short-term objectives below (e.g. risk reduction). Discuss the hierarchy of goals. Variation: ^ Discuss abstinence vs. risk reduction in the context of sexuality in prisons.

Health risks for staff 1. Identifying health risks for staff members 2. Raise risk awareness for communicable diseases 3. Discussing prevention measures 60 - 80 minutes Duration : No. of participants : Minimum 4, maximum 20 Material needed : flipchart, pens

Objectives:

Exercise outline: Ask participants to recall situations in their everyday routine ^ when they thought they were 'at risk' D Note these reports of situation (e.g. cell/body/visitors search) Try to cluster these reports D D Let the participants identify the risks of communicable diseases: which ones constituted serious risk,which ones probable risk, which ones no risk? D Ask participants about their knowledge of and experience with vaccination (e.g. Hep. A+B) D Are the participants aware of post-exposure-prophylaxis? Do they know what to do immediately after a needle stick injury? Give information. Collect all the answers and risk situations and make an ^ assessment of what is needed in future in terms of training, provision of technical means of prevention, in-depth discussions with unions, prison doctor and governor.



Prevention of communicable diseases in prison

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In about 19 prisons in Switzerland, Germany and Spain, needle exchange programs have been introduced. Interesting findings from the evaluation of these interventions have included: a decrease in needle-sharing among the participants was found; the number of abscesses dropped dramatically; the amount of drugs found and seized did not rise. This can be seen as an indication that ears that an increase in the availability of clean needles would result in increased drug use have not been confirmed. No scenario of using a syringe to threaten someone has appeared in any of the 19 prisons running needle exchange schemes so far. None of these prison have witnessed attacks on staff or fellow inmates by prisoners using needles as a weapon. Objectives:

1. Raising awareness of effective measures of prevention of infectious diseases 2. Debating the pros and cons of needle exchange projects in prisons 3. Discussing a hierarchy with alternative measures for the prevention of communicable diseases Duration : 60 - 80 minutes No. of participants : Minimum 4, maximum 20 Material needed : Flipchart, pens, Exercise outline: Present reasons for models and the results of needle ^ exchange in prison Ask participants to split up in two groups ('Pro' and 'Con' ^ groups). Give all participants a photocopy of the text above. D For 30 minutes, the two groups should collect arguments on the pros and cons of a needle exchange project in their prison Collect the arguments on a flipchart in the plenary. Look at how the needs of the staff are addressed and what priority they gain in the arguments. D Discuss the backgrounds of arguments pro (advantages for inmates and staff, etc.) and con (contradiction of general prison policy, fears of needle sticks, etc.) of needle exchange in prisons. Variation: ^ Ask one of the two groups to write a proposal for a needle exchange project in their prison. The other group should 301:



develop a bleach project D Who should be participating in the planning phase? D What kind of mode of distribution should be preferred, and why? D Ask each group to react to the proposals of the other 8.4 Exercises for prison staff and inmates Talking about drugs In prison, most staff members and inmates smoke tobacco. Is tobacco a drug? 1. Raising awareness about the fact that drugs and drug use are a widespread phenomenon in our society (see 2.2.); 2. Raising awareness that tobacco is an addictive drug comparable to illegal substances like opiates. 3. Discussing tobacco as a common and widely accepted drug. 45 - 60 minutes Duration : No. of participants : Minimum 4, maximum 20 Copies of cards (see next pages) Material needed :

Objectives:

Exercise outline: Ask the participants which of them smokes ^ Discuss briefly the facts about tobacco (using the informa^ tion in chapter 2, 2.1 to be included) Split up in small groups of four (two staff members, two ^ inmates). Half of the couples get a copy of card A ('My first cigarette') and the other half a copy of card B ('Running out of cigarettes/stopping). ^ Couples with cards A are asked to recount the circumstances of 'My first cigarette', couples with cards B are asked for'Running out of cigarettes/stopping'? ^ After twenty minutes, the participants discuss their results: one member of each group will present the results. ^ When discussing the results, compare them to the general perception of illegal substances. Use terms and concepts that apply to the use of illegal drugs (cold turkey, seduction into drug use by peers, just say no, addiction, relapse, moral weakness, etc.) Ask questions that are usually asked with regard to the use of illegal drugs. (Weren't you strong enough to stop? Have you been motivated enough?)

i 302T

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TALKING ABOUT DRUGS (1/2)

CARDS A

`My first cigarette' and how it went on ...

Give the reasons why you took your first cigarette? Were there peers or other people involved who invited you to smoke that first cigarette? What did you feel after your first cigarette? Why did you go on smoking? When did you feel you could not stop? How do you feel, now you are confronted with more and more areas where smoking is forbidden? Is stopping smoking a voluntary decision? What does smoking mean to you? 0









TALKING ABOUT DRUGS (2/2)

CARDS B

Running out of cigarettes/stopping

What do you think or do when it's late at night , you are at home (or on holiday abroad) and you have no cigarettes available because the shops have closed? Have you tried to stop and did you succeed? How did it feel when you stopped? Did you start again? What made you start again?

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Objectives:

1. Discussing hygiene in prison as a common topic 2. Speaking about fears of infections 3. Looking for ways to deal with these fears Duration : 90 minutes No. of participants : Minimum 4, maximum 20 Material needed :' flipchart Exercise outline: ^ Ask people about their fears of infection in prison (door handles, toilets, surfaces, kitchen, barber, cell changes, needles). Discuss (on the basis of chapter 2, 3) any possible genuine risks of infections and write the results in a flipchart (using the following structure)

^ •

^

^

^ ^

Split up into small groups of four (two staff members, two inmates) Divide the results on the flipchart and give an equal amount of places, situations and objects to each of the small groups Ask the groups to. discuss realistic and effective measures to reduce and prevent the infection risks involved in their part of the flipchart and work with a note taker; Ask the note takers to report back their plans for risk reduction measures Discuss the plans briefly

; htl,s ^t



SERVICES

Ofcourse , risk reduction activities are not limited to counselling and training . You have to create the conditions that allow prisoners to act according to the rules of risk reduction . One thing that is vital here is providing the tools and materials that people need to behave safely.



In addition to facilitating safer behaviour, handing out this material provides an opportunity to pass along the message of safer behaviour. As stated above (see this chapter 2, 2.4 - 2 . 6) making contact and talking about sensitive things like safer use and safer sex is not always easy. Services providing risk reduction materials to inmates can facilitate and support this work . They can be a catalyst to start a discussion about the issue. 9.1 Provision of disinfectants for cleaning injecting equipment



Disinfectants are key components in HIV prevention strategies. In prisons they have become a form of risk reduction that copes with the reality that syringes do exist in prison but avoid the problem of not wanting to provide new, sterile injection equipment. The use of bleach for cleaning injecting and tattoo equipment is an effective tool for preventing transmission of HIV and other blood-borne diseases (e.g. HCV). The method used for cleaning with full strength household bleach is both simple and effective when it is done properly (as described in chapter 2, 6.1). The widespread availability of bleach for household purposes gives intravenous drug users the opportunity to take preventive measures in a discrete manner. One of the first bleach programs in a prison was started by a prison officer in Ireland . He was confronted with a stark political reality, in which pragmatic preventive health or HIV prevention was prohibited . The officer saw to it that each toilet in his institution contained a bottle of bleach and trained the drug dependent inmates on proper cleaning techniques and safer behaviour. In Europe several different modes of official distribution exist: ^

^

On admission , a `pocket pharmacy' is handed out to all inmates in Switzerland , containing condoms , plaster, a small bottle of polyvidonum - iodum and a leaflet with instructions of how to use bleach ; (see Bolli 2001) Direct access to bleach in bathrooms or toilets (Denmark and Finland ). as in some places distribution in bathrooms, 309



^ ^ ^

etc., is not possible due to sabotage From medical departments From the penitentiary administration (1 small bottle of 120m1 at 12° for every prisoner, every 15 days; France). A 'health kit' including bleach and instructions on how to clean needles most effectively, given to every inmate on home leave or on exit from the institution.

If you choose a person-to-person method of distributing disinfectants, you can consider the following channels: Inmate HIV/AIDS peer counsellor Institutional stores Cleaning personnel Inmate clerks working on different units Social/health worker Doctor/nurse in a prison unit Community HIV/AIDS or drug services If you choose an anonymous distribution strategy, disinfectants can simply be made available from the following spots: ^ In inmate washrooms and shower areas on the ranges ^ In laundry rooms on the units (or in the residential houses) ^ In recreation areas, such as the gymnasium and TV room ^ In the washroom area of the gym ^ In the visiting and correspondence area ^ On corridors, where major inmate movement occurs ^ In the kitchen on each unit ^ In the inmate washroom in health care centres (compare also Haslam et al. 1999) The options you choose will depend on the specific institutional context. The following criteria may help to choose the most suitable method of disinfectant distribution in your situation: ^ The degree of anonymity and confidentiality necessary for distribution ^ How easily accessible the distribution point is (opening hours, informal access, sufficient quantity, etc.) ^ The reach and extent of distribution is related to D The available resources D Whether the main focus is on general hygiene needs or solely on disinfecting syringes D The need to realise a pragmatic, informal, 'unsensational' distribution D The level of acceptance, support and involvement of prison and medical staff

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^ ^ ^ ^

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The need to communicate information about the appropriatg'application of disinfectants, and the best way -of achieving that; Whether the inmates use disinfectant properly or whether there are risks involved , e.g. self-injury The desire to control the quantities given out; The desire to use the distribution as a means of contacting or counselling drug -using inmates on risk reduction; The need to monitor the inmate's use of disinfectants and any change in skills , attitudes and behaviour.

Instructions on the proper use of disinfectants is an inevitable prerequisite for distributing or accepting the distribution of disinfectants . This can be done by a leaflet or other written material, or by counselling or training (through prison or community service staff or peer educators). (The information on cleaning injecting equipment can be found in 2 , 6.1 and 6.2) When you choose an option where inmates can refill their private bottles from a dispenser bottle , you should keep in mind that experience has shown that prisoners sometimes do not refill their private bottles , because they fear being revealed as drug users. The mode of distribution can be improved by providing discreet access in a public space (for examples, see above). However, anonymous access to allow refilling private bottles might also include some risks. If a dispenser bottle is freely accessible (and can simply be opened by anybody) you cannot guarantee the quality of the disinfectant. Bleach exposed to air gradually loses its effectiveness. Additionally, in the worst case inmates could even tamper with the disinfectant. This can include serious risks if certain inmates have a negative attitude towards drug-using inmates. If you want to avoid stigmatisation or the involuntary ' coming-out' of drug users or where there is no clear policy on the distribution of disinfectants , you could make them accessible in a wider context (e.g. bleach for simply cleaning and washing purposes or iodine for the treatment of injuries or skin diseases). Distribution of disinfectants for cleaning syringes is then ' hidden ' in this broader context. This broader approach could be , for example , ` health promotion' or 'hygiene ' (cleaning surfaces, toilets , razors) and can be used to transmit ' hidden messages'. In Scotland , sterilising tablets are handed out to inmates with concrete instructions how to use them for sterilising mugs , cutlery, razors , chamber pots and injecting equipment.



One fear of many prison officials is what to do when inmates drink bleach or misuse it in some other way. There should be a first aid service provided by the prison doctor. First aid measures and other precautions: ^ If bleach has been ingested by a prisoner, that person should drink warm water or milk and seek medical attention immediately. Vomiting must not be induced. ^ In the event that bleach has been inhaled by an inmate, that person should be removed to an area with plenty of fresh air and medical attention should be sought. ^ In the event that bleach comes into contact with a person's eyes, rinse thoroughly with lukewarm water for at least 10 minutes while holding the eyelids open and seek medical attention to ensure there are no burns to the eyes. Where bleach has come into contact with a person's skin, ^ thoroughly wash the affected area as well as any contaminated clothing (adapted from Correctional Service Canada 1986).

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9.2 Needle exchange programs On the basis of a study on practice and policy concerning the provision of sterile syringes for drug users in the European Union, the World Health Organisation/Regional Office for Europe elaborated recommendations of HIV/AIDS prevention for drug users in prisons as long ago as 1991. According to these guidelines, the following measures should be taken: Measures to reduce the number of i.v. drug users ^ ^ Measures to prevent drug use ^ Information about the risks of intravenous routes of administration ^ Information about the risks of sharing used needles ^ Demonstration of disinfecting techniques, provision of disinfectants and equipment for hygienic drug use (alcohol swabs, plaster) Provision of sterile syringes ^ Two years later, the WHO guidelines on HIV/AIDS in prison (WHO 1993) stressed the principle of equivalence: "...in countries where clean syringes and needles are made available to injecting drug users in the community, considerations should be given to providing clean injecting equipment during detention and on release to prisoners who request this."

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Until now, pilot projects under which clean drug injection equipment s made available in prisons have been launched as trials in Switzerland , Germany and Spain . Currently, this measure is carried out in 19 prisons . The results of the evaluation of these programs are encouraging and all projects have been continued after the pilot phase.



What can be learned from the process of implementing and running these projects? First of all, there is no general recipe for how to introduce needle exchange programs into the prison system. Every prison has to find its own way. Some keywords in this context are ^ participation (of management, staff, outside agencies such as AIDS and drug services and inmates as well) anonymity and ^ confidentiality. ^ Recommendations The following general recommendations on needle exchange programs have been elaborated at the European Conference on Prison and Drugs, held 1998 in Oldenburg/Germany:





1. Prisons have the responsibility for providing prisoners with access to adequate measures to prevent infection and promote health. 2. Needle exchange is a sensitive area for prison services in many European countries. It is necessary to carry out surveys in prisons that are considering the introduction of needle exchange, to find out how much injecting drug use exists within the prison prior to implementation. 3. Needle exchange programs can be useful and integral parts of a general approach to drug and health services in prisons. They should be provided as part of a range of services that include health promotion measures, counselling, drug-free treatment and substitution treatment. 4. To protect all parties participating in infection prevention and health promoting measures (such as needle exchange), legal ramifications must be clarified in advance of introduction of the measures. Legal issues need to be clarified especially concerning special groups such as juveniles and inmates in substitution treatment. Clarification of these issues is the responsibility of the government department involved. The results of this clarification should be published. 5. The choice of distribution, either through machines or through personal contact, depends on the specific conditions within the respective prison settings. Continuity of availability of sterile

syringes should be guaranteed, whether distributed by prison or community staff. 6. The successful implementation of needle exchange programmes in prison requires the establishment and the maintenance of acceptance among the prison staff and inmates, among political and legal authorities, professionals and the public at large 7. Participation in needle exchange programs should be strictly confidential, so that the participants need not fear negative consequences during their remaining sentence. 8. The distribution facilities should be located in easily accessible areas. 9. Effective infection prevention can only be achieved if measures of instrumental prevention are supplemented by counselling and information. Mandatory education and voluntary training for inmates and prison staff at all participating levels should also be provided. The following issues are of particular rele vance: a) basic knowledge about drug consumption and infection risks, b) means of transmission and infection prevention, c) safer use and safer sex, d) drug-related first-aid. Different approaches The following three modes of distribution have proved to be successful: Needle exchange slot machines , discreetly located in different wards to allow anonymous access Advantages: Guarantee of easy access ^ High degree of anonymity ^ 1:1 exchange ^ Disadvantages: ^ No control over who is using the slot machines (inmates might use the syringe of program participants and get their own syringe). Machines can be damaged by inmates and staff who are ^ not in favour of this program, which can result in technical problems. is

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Hand-to-hand provision by staff of the medical unit or the `prison doctor Advantages: ^ Can serve as an opportunity for counselling and therapy ^ Facilitates making contact with formerly unknown drug users High control over access ^



Disadvantages: ^ Low degree of anonymity and confidentiality, possibly resulting in a relatively low participation rate Probability of `informal participation' by inmates who send ^ others instead of participating themselves officially, because they mistrust the staff. Hand -to-hand provision by community HIV/AIDS or drug counselling services Advantages: ^ Can serve as an opportunity for counselling and therapy ^ Facilitates making contact with formerly unknown drug users High control over access ^ Can offer some degree of anonymity and confidentiality ^



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Disadvantages: Syringes are only available at limited times during ^ the week ^ Anonymity and confidentiality might be limited as the involved community services might have to provide information on participation rate to prison management ^ Mistrust by prison staff of the 'intruding' community services staff providing syringes

Examples from practice Needle exchange via slot machines: women's prison Vechta/ Germany (since 15th of April 1996) Information: As part of the admission procedure, at the beginning of a term of imprisonment every inmate is informed in good time, by means of a multilingual information paper about the modalities of participation in the needle exchange project. Further relevant information (safer use, safer sex) is given in the admission unit by staff who have experience working with drug users. The information meetings for inmates that complement the exchange of syringes are designed to provide extensive information about the risks involved in injecting drug use, about how to reduce health-damaging forms of consumption and how to practise safer use techniques in the period after imprisonment. The drug users are also informed about the rules of the project: They should only have a syringe on them when it needs ^ to be exchanged Lending or selling syringes is prohibited ^ Each inmate may only possess one syringe ^ ^ The syringe must be left in the prison if the inmate is transferred to another prison Moreover, a "safer sex" and "safer use" training is offered once a week to all interested inmates. Access : Needles can be exchanged in 5 sections of the prison, excluding the "leave" section, the home for mothers and children and the admission unit. A dummy syringe, which must be inserted into the machine to obtain a sterile syringe, is only handed out to those drug-addicted inmates who have been examined by the prison doctor and whose addiction has been documented in their medical record. The machines were placed in five easily accessible places in the prisons. Besides syringes, the machines also dispense heat-sealed alcohol swabs and ascorbic acid in adequate portions, filters, plaster and ampoules holding a sodium chloride solution. Trained staff from the health care unit maintains the machines on a daily basis, i.e. refilling them with new equipment and discharging the used syringes. Exclusions : Inmates participating in a methadone program are excluded from the needle exchange because they signed a contract, renouncing any additional consumption of drugs. Minors require their parents' declaration of consent.

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Staff:Atthe beginning of the project, the prison staff were given `-the-opportunity to participate in a one-day information seminar. In addition to this, special information meetings are offered which the staff may attend during working hours, in order to keep them up-dated about first aid, prophylaxis of infection, pharmacology and the handling of drug addicts.



Remarks : Possession of drugs is still prosecuted. Therefore the project cannot be considered a liberalisation of drug consumption in detention but should be viewed as dealing with the reality of drug consumption in prison. Due to the legal context and the philosophy of the project, no increase in cell searches or extention in urine sampling has been conducted. Needle exchange via hand-to-hand provision: men's prison in Lingen I, Dept. at Grol -Hesepe/Germany-(since 15th of July 1996)

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Information : Different from the approach chosen in Vechta, no machines were set up in the prison of GroI Hesepe. Here, the staff of the drug counselling service and the health care unit of the prison hand out sterile syringes to inmates in exchange for used ones during fixed hours each day in a tea-room. In addition to the exchange of syringes, further support services are offered: ^ Individual counselling on HIV/AIDS provided by the staff of the health care unit, the drug counselling service and the regional AIDS support group ^ Handing out of multilingual information papers on HIV/ AIDS, safer sex and safer use ^ Information meetings on HIV/AIDS and hepatitis Support measures like training courses on first aid are also offered for the prison staff to brush up and deepen their existing knowledge. Information meetings are organised at irregular intervals by the drug counselling service and the AIDS support group.



Access : The tea-room is located next to the drug counselling service, a room that is difficult to see into. The inmates can reach it via the recreational ground. Prisoners intending to exchange syringes in the tea-room may also use the opportunity to obtain counselling if they wish. The participants in the exchange project are assured that the provision of syringes is anonymous. The staff who hand out the syringes have a duty to maintain confi-

3



dentiality. All drug-addicted inmates may participate in the project. Exclusion : Like in the prison in Vechta, inmates participating in a methadone program are excluded from the needle exchange because they signed a contract, renouncing any additional consumption of drugs. Staff : Extensive discussions prior to the implementation of the project which were designed to make the project transparent, which helped staff to develop a great deal of sensitivity towards the drug problem and its medical and psycho-social implications. This provided a solid basis and the levels of acceptance required for a successful realisation of the project. The readiness of the prison staff to actively participate in the project was also reflected in the large number of staff who co-operated with those scientists involved in compiling the data for the first evaluation of the project. 9.3 Provision of condoms There are substantial differences in the availability and the modes of provision of condoms in European prisons. A wide range of different policies can be found, ranging from free distribution to total prohibition. There are countries where sexual relations in prisons simply are prohibited and consequently, neither condoms nor lubricants are available for prisoners. In some countries, they can be obtained free of charge or are prescribed by the doctor as in England and Wales, while in others prisoners have to pay for them.



The key elements of an appropriate condom provision scheme are again, confidentiality and anonymity of access. Sex, especially men having sex with men and to some degree, women having sex with women, is a taboo that can lead to exclusion and stigmatisation. In the provision of condoms, issues such as the method of distribution, by whom and where they are distributed are crucial to the reach of this service. Several modes of distribution are already being applied in European prisons.

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By the medical doctor (either by prescription or not), or by the medical service/unit through nurses Eachlof these modes of condom provision does have advantages and disadvantages . The provision (or even prescription) via medical doctors means that inmates have to apply for a doctor's visit in the morning, simply to get hold of a condom. This may be perceived by inmates as being a high threshold to access. A side effect of this is that the doctor then is informed about inmates' (potential) sexual activities. This is also partly true for provision via a medical service or unit or through nurses. However, this is a reliable source of provision which is permanently in service and condoms may be obtained also when an inmate is visiting these services for other reasons. Finally, any condoms obtained through this modality are generally free of charge. From the prison shop The latter is not the case at the prison shop. Here, the inmates generally have to buy condoms. Another disadvantage is where there is no prison shop - which, in most cases is open every day except for the weekend - but a visiting merchant. This service is only available perhaps once a week, or even once a fortnight. Inmates might even have to order condoms in advance. However, sexual activities cannot always be planned in that way. Often, they just happen. Moreover, anonymity and confidentiality are hard to maintain with this service. Finally, condoms are quite expensive in relation to the moderate amount of money that most inmates have in prisons.

40

By prison social and health workers, or by the staff of community AIDS and drugs services This seems to be quite a suitable way to provide condoms. Social or health workers in prisons are generally easy to contact and often are better trusted than security staff. Condoms can be distributed on a confidential basis. Community social and health workers tend to have even more trust and credibility in the eyes of the inmates. Of course, the latter's success at distributing condoms will depend on how regular they visit a prison and how many condoms they hand out to each inmate. When including community social and health service staff in training seminars on safer sex, they can leave some condoms used for exercises (see above) and inform inmates where and how they can get condoms in the future.

Through inmates Other inmates might be most trusted as they are peers. Nevertheless inmates often also make moral judgements and hold resentments against sexual activities, especially in male prisons when it comes to sex between men. But if peers are regarded as credible and trustworthy persons, this can be an appropriate way of giving out condoms. Anonymous access Apart from having people provide condoms to prisoners, condoms can also be made available anonymously. This can be done by either including condoms in the provision of a package of material or without personal interaction. Approaches tried successfully have included the following measures: Include condoms in a release pack for inmates who go ^ on leave or are released. This measure expresses the need to protect oneself in both professional and private sexual relationships immediately after release. Dispense condoms at admission with different informa^ tion material, e.g. including condom instruction and information on safer sex Dispense a box of condoms in visiting rooms (conjugal ^ visit rooms) Dispense condoms in waiting areas (doctor, social ^ worker, library) Dispense condoms in counselling rooms, in an informal ^ way as 'leftovers', when community AIDS or drug services from inside or outside the prison are offering counselling. Making condoms available without personal interaction offers a good opportunity to allow prisoners to obtain condoms without being seen by other inmates or staff. Prohibition of condoms may be based on a lack of recognition of the problem but also on cultural and religious reservations. Often, availability is restricted because of single experiences when condoms were used for different purposes (such as hiding drugs in the body). These restrictions can be tackled in a debate, balancing the health interests (prevention of infectious diseases) and the cultural and religious boundaries and these occasional isolated cases of misuse.

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SUPPORTING MEASURES

As stated above (see chapter 3, 2.4 - 2.6) making contact and talking about sensitive things like safer use and safer sex is not always easy. However, there are means to facilitate and support this work. By handing out material and other risk reduction measures, the target group feels invited to speak about their problems and to express their views of the drug and infection problems in prison.



Prevention material can be anything used to get the attention of the target group. However, material is more effective when it can also be utilised by the target group. So, when choosing prevention material, consider whether it supports the objectives you are aiming at, e.g. stop injecting drugs, stop sharing injection equipment, disinfect contaminated needles. Prevention materials should also meet the needs of the people you are aiming at. So do not disseminate instructions for boiling syringes when heaters are not allowed. Risk reduction activities in prison can be facilitated and supported by a number of methods . Useful methods can include: Collecting information ^ ^ A survey by questionnaire ^ Development of information material ( leaflets) Newsletters or magazines ^ Organising activities ^ ^ Distribution of prevention material



When considering using one of these methods, make sure that you don't re-invent the wheel. Many useful materials have been already developed in the community. How can they be adapted? What can be added? Try to connect with community drug and health services for advice and assistance. 10.1 Collecting information A vital prerequisite for people working with drug-using inmates is collecting information for the following purposes: Describing the prison drug scene, with special focus on the ^ health risks involved Assessing ^ the needs of drug-using inmates Raising omissions in medical care and health promotion ^ for drug-using inmates (including general hygienic conditions, oral and written information, availability of bleach, methadone detoxification and maintenance, etc.)



This information can be collected by prison staff, community staff or inmates. Co-operation between these different groups can be very fruitful, helping to secure agreement and commitment from all parties involved in risk reduction activities. The conclusions of the information collected should be communicated to and discussed with prison management, governor and justice authorities in order to improve the health situation of drug-using inmates. Information can be collected in different ways: through observation and occasional talks with inmates and prison staff, but also via more structured, systematic interviews. We will discuss some examples of collecting information in the following section. Describing the prison drug scene with a focus on the health risks involved It is vital for prison staff, especially for staff responsible for health issues , to know what is going on in the prison drug scene. You should consider ways to describe the scene systematically. A filing system should be used to collect data systematically. This system - preferably supported by forms for staff to collect information - could be filled in step by step, with information from observations, occasional talks, etc. Subjects to be included in this system could include: ^ What drugs are used? How are they used? ^ Changes in drug use patterns in prison: routes of admin^ istration, frequency of use, quantities Are there specific groups using specific drugs (ethnic / ^ religious / gender backgrounds)? How do inmates finance their habit? ^ ^ Where do they inject drugs? Do people take drugs together with other inmates? ^ ^ How do they relate to each other? ^ Is there a social hierarchy in the drug-using network? What are the norms and values relating to high-risk ^ behaviour? How are inmates using various in-prison services like ^ drug counselling, medical staff, priest?

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:It is self-evident that this job has to be done with extreme care, because some of the data obtained may be dangerous or sensitive. Of course, the information recorded should never include personal data about individual inmates! The information should not be used against inmates! The purpose of the exercise is to conduct a risk assessment and to analyse positive factors supporting risk reduction. Trust is a key element of the whole process. One should consider having this work done only by medical staff or by staff from community services. A clear agreement with and support from prison management and staff is a prerequisite . They have to be convinced that risk reduction is a higher priority than some legal principles and prison rules . If one cannot guarantee that the information collected will not be used against inmates , one should refrain from any systematic data collection.

Assessing the needs of drug users in prisons A basic principle in assessing the needs of drug-using inmates is to listen to what they say. Prison and community staff should be open-minded to drug users' stories and complaints. A lot of these needs are easy to assess just by talking to drug users, observing them in their daily life, examining the data from the medical service, etc. The following things are important here: ^ Prison or community staff should list the problems they face in the prisons. Listing problems and needs should be done as systematically as possible (see above). What services are needed? Which are available? Which are missing or unsatisfactory? Using peer support (see chapter 3, 10.6). Having drug ^ users make an inventory of the needs of their peers can produce information that cannot be obtained by staff. Staff and inmates involved in a needs assessment should ^ also put some effort into ordering and prioritising the various needs and problems. ^ The needs of drug users can vary. Drug users in methadone treatment have different needs to drug users who inject. Different needs also require different types of action. Some needs require immediate action (medical treatment), other needs require a long-term policy (making substitution treatment available). 0



Identifying shortfalls in health and drug services in prison (and community) A needs assessment should preferably result in concrete action, by presenting and discussing the results to the services and organisations responsible for meeting these needs. Several things can be done here: Organise a seminar or workshop on the results of ^ the needs assessment or on specific topics for criminal justice authorities, prison management, prison staff or inmates. Topics can be the situation regarding infectious diseases in prison, the benefits to prison staff from risk reduction measures, presentation of adequate risk reduction measures, etc. Organise study visits for prison staff to prisons where ^ certain forms of treatment and risk reduction programs are currently being run, or invite people from these services for a seminar at your prison, to present their experiences and expertise. Organise a seminar or workshop for prison authorities ^ and staff and community services to discuss any needs and possible co-operation. Organise an exclusive meeting with the prison governor ^ and management to discuss risk reduction. Support from influential sources (WHO, supportive governor from another prison, etc.) - either in writing or by their actual presence - can be helpful here. Publish a report of the results of the needs assess^ ment. ^ Raise media attention through press releases and public action. ^ A combination of the things mentioned above. When a needs assessment is carried out systematically it is easier to raise these needs with people in charge (prison doctor, governor) and drug and AIDS agencies inside and outside prison (see: a survey by questionnaire). Raising omissions is one thing, but changing policy is another and far more difficult. One should be conscious of the fact that accomplishing real changes demands more than just a single action - it requires a long-term strategy. One should set realistic goals and be satisfied with small achievements and steps forward. Through these small achievements, one can contribute to the development of sustainable risk reduction activities in prison.

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10:2 A/survey by questionnaire An effective way to contact drug-using inmates is to use a questionnaire to conduct a survey. This will require the permission and support of the governor. Anonymity is the keyword here, as he or she will have no access to the data collected. Small-scale research can easily be carried out by using a questionnaire serving a twofold objective: ^ Gaining insight into the issues studied (see needs assessment) ^ Becoming known as a prison drug worker •

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Asking for information shows that you take people seriously, that you are dependent on their information. The results of the survey can provide the basis for a change in prison drug policy. A side effect can be an increased awareness of the subject dealt with. For example, if a study is done on the risk of infectious diseases, people will become more aware of this risk. Questionnaires should always contain some questions about basic demographic issues. These demographics could include: age, gender, nationality, level of education. Obviously, the questionnaires should be completed anonymously. If anonymity is not guaranteed, one can be sure of either getting false data or no co-operation at all. Inquiries can be done on a range of subjects. Issues of interest can be: A systematic needs assessment (see 3, 10.1) ^ Counselling on drug and AIDS issues ^ Risk reduction practices and possibilities ^ ^ Hepatitis A+B vaccination General hygienic conditions ^ Detoxification procedures and written protocols ^ Methadone maintenance treatment (in relation to commu^ nity prescription protocols and regimes) Syringe and needle exchange ^ Obviously, big issues are important and the results can have a political impact. However they also demand very precise preparation and a complex management of data. This requires an experienced organisation. Therefore, the examination of smaller issues should be done first, such as: ^ ^

The price and use of filters, needles and syringes Cleaning procedures of used equipment



^

Knowledge about the transmission of infections Access to condoms Tattoo procedures and the circumstances of tattooing

T

he design of the questionnaire should preferably be done in co-operation with a researcher or somebody else with compatible skills. All people involved in interviewing should be instructed on the structure and contents of the questionnaire, and any possible difficulties which might arise during the interview should be discussed. Limit the time for collecting data to a reasonable period. Take into consideration that the analysis of the data collected takes at least the same time as collecting it. Here again, the support of experienced people would be of great help.

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10.3 Development of information brochures material Leaflets can be used in risk reduction work to inform drug users about different issues. But they ought to have one thing in common. Leaflets should help you to make contact with drug users and to introduce yourself. In general, leaflets should be easy to read. Using pictures can make them easier to read. Obviously leaflets should always have the producer's name on them. If the information is useful and credible, leaflets can contribute to the credibility and trust of the person handing them out. Leaflets can be issued on many occasions: Announcing the aims and work of prison the drug worker ^ Informing inmates about a program of risk reduction activi^ ties ^ Informing them of activities or actions for and with drugusing inmates (film, sport, discussion, seminar) You also can consider developing information leaflets on different aspects of risk reduction. Chapter 2 of this manual can provide some ideas (and useful information) for producing leaflets of this type, for example, on: ^ The effects and risks of drugs Infectious diseases ^ Safer use ^ Safer sex ^ ^ Pre and post-test counselling

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Fist aid in case of overdose 1 - Etc.

The admission unit or phase can be of special value for making contact with all of the newly arrested: allowing tips, advice on possible problems etc. Prisoners with longer sentences can receive relevant advice'from prisoner to prisoner'. The latter can reflect on how they felt, being in prison for the first time and what the specific needs of those in the admission unit are. A leaflet could become a tool to support those prisoners who were arrested for the first time, and can be perceived as a friendly gesture to new prisoners. The leaflet creates a situation where the prisoners can be a source of support for others.

10.4 Issuing a newsletter and collaborating with prison magazines A magazine can be extra helpful if it becomes known by the target group. Distributing a new issue, having a bag full of new magazines visibly with you, helps you to make contact with people you don't know but who do know the magazine. Before producing a newsletter, one ought to be clear on the goals. Publishing a newsletter can include various objectives: To inform drug-using inmates about health related issues, ^ about risk reduction. Information is the key word As ^ a voice of drug-using inmates for drug-using prisoners. Keeping people updated on activities is an important topic As a voice of drug-using inmates seeking to inform prison ^ drug workers, policy makers and the public. Expressing drug- using prisoners' points of view is important In reality, newsletters will include more than one of the objectives mentioned , but it is worthwhile defining the core objective. This will help people to choose the right angle when writing an article or doing an interview.

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Informative material, especially if it is lifestyle oriented can be effective here, as the work of several agencies has demonstrated. One example is the Mainline Foundation in Amsterdam! Netherlands. Mainline produces a professionally designed magazine in which the AIDS prevention message and general information on health for drug users is incorporated in a 'life-style' format. In Mainline Magazine, one can find articles on street life, prostitution, falling in love, services for drug users, a comic, the different ways of using drugs, life stories, etc. Nearly all of the articles are based on or reflect the experiences of drug users. The magazine is given out person-to-person on the street. This provides a basis for contacts to be built up to enable people to talk about health (problems), or about confidential matters such as safer sex and safer use. In these conversations, an exchange of information takes place. The people from Mainline don't only give out information to drug users, they also get information from them. This information from the street is one of the key sources of the articles in the magazine.

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This example makes it clear that prison drug work is important for getting the message across, too. Discussing personal and sensitive business, such as using drugs and having sex, is often easier in one's own familiar surroundings than on someone else's territory, such as on the premises of a drug service. A newsletter or magazine can serve harm reduction work in various ways: ^ Making and maintaining contact by distributing the newsletter or magazine Collecting information for an article ^ ^ Raising a subject by referring to an article Conducting a readership survey ^

However, publishing a magazine on a regular basis is an enormous job. One should adapt the size and frequency of any newsletter or a magazine to the capacity of the (self) organisation. It is better to publish a small newsletter that is issued regularly, than a fancy magazine that is produced infrequently. In many European prisons, prison magazines are mainly run by inmates themselves and/or supporters from outside do exist. These prison magazines can be used for raising awareness of human rights and for the inmate's needs and views. A prison magazine is





an ideal forum to lead a credible dialogue with inmates . Risk reduc`\tion -issues can be embedded in general public health subjects (hygiene etc .). The situation of drug users in prison is looked at by different means : articles , photographs , drawings . One of the most elaborate examples in Italy is 'Ristretti ' from the prison in Padua, which has raised the topics of the living and health conditions of drug users in prisons many times. The magazine also connects the different groups among inmates and between prisoners and staff, because the magazine is read by staff as well. 'Ristretti' also is a gate to the outside world and advocates for the support of drug users (equipment , knowledge , advice , etc.). Lastly, ' Ristretti' disseminates questionnaires ( placed in a library) and is also engaged in radio broadcasting in prison. Using and stressing the possibilities of a prison journal for drug and health-related problems can result in a credible dialogue. 10.5 Organising activities Organising activities for and with drug-using inmates can be a tool in establishing risk reduction initiatives and can help contact possible inmates and key persons among them. Activities can be divided in two main areas: leisure and interest-related issues.



Interest-related Without a doubt , interest-related issues need ongoing attention. Organising special meetings to inform inmates about issues related to their everyday life in prison is important. However, the possibilities in prison are limited to certain times and circumstances . Security considerations and the rhythm of the everyday routine often determines life in prison . The ability to organise such meetings may depend on these factors . If possible , the invitation of outside experts should be considered ( medical doctor, lawyer, epidemiologist , policy maker etc.). Topics covered in such special meetings can include: ^ Medical subjects ( hepatitis C) Life after prison , e.g. focusing on social rehabilitation, ^ housing , job and educational options Presentation of self-help groups from the community ^ ^ Legal issues A successful meeting depends largely on the organisation. A meeting will only be well-attended by drug users if it is transparent to them , particularly with regard to exactly who is organising it. A strategy for reaching as many people as possible is important . Consider the use of leaflets in combination with snowballing, asking inmates to inform their peers.



Leisure In general, less attention is paid to leisure-like activities. Working on risk reduction issues sometimes makes people forget that making/having fun is also important. Think of sports, such as a football match against drug workers, films, music, tournaments: chess, table football, darts etc. Note: before putting energy into the organisation, make a small inquiry into the need for such events. Cultural activities can also include benefit gigs by bands who are engaged with the subject of AIDS and drug use. Because a lot of money will inevitably be involved in such events, consider cooperation with other organisations. 0 Drug users have different backgrounds and different preferences. It is possible that some people may want to put energy into the defence of their common interests, but not all will be interested in organising leisure activities. One should consider whether organising leisure activities are a means to an end, or are a goal in itself.

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11;"

PEER SUPPORT IN PRISONS

Peer support means mutual support among people who belong to the same group. Peers are people who share some specific characteristics. So, a peer group could be a group of soccer players, a group of politicians, or a group of school children. Here, we are focussing on the peer group of injecting drug users (IDU's). Since the end of the eighties of the last century there has been a growing acknowledgement that peer support can be effective in reducing risk behaviour in IDU communities. Peer support projects have been developed, in different European countries, both by professionals and drug-user interest organisations (National Committee on AIDS Control, 1993). Efforts have been made, too, to initiate and support drug-user self-organisations and drug-user organisations especially in the field of AIDS prevention in intravenous drug user (IDU) communities. One reason for this has been the finding that HIV prevention by regular drug and health services has not been an overall success. There are still drug users who lack information, who simply are not reached by drug aid programs or who are not reached because of - among other things - their feelings of distrust. These feelings are one reason why peer support is considered a worthwhile method of making contact with drug users who are not reached by professional drug services.





Experience confirms that peer education and peer support do contribute to risk reduction among drug users (Friedman et. al., 1987). Inside information, knowledge from personal experience and trust are important items in this respect. Risk reduction, in the sense of discussing personal business such as drug use and sex, requires trust. Experience underlines the fact that social influences on drug users' attitude towards safer behaviour and a growing selfefficacy through role modelling are the most important features of peer education and peer support. This implies that providing social information is more important than offering mere facts. The fact that peers are familiar with the group norms and that they are easier to trust for drug users also helps to collect reliable information about risk behaviour. Those elements of factual knowledge that have proved to be important, generally have to do with specific details (e.g. infection risk by sharing the spoon or the filter). The growing attention on peer support as a useful method within the framework of risk reduction strategies might suggest that peer support among drug users has been invented recently. However, nothing is less true. The invention of peer support can be com-

331



pared with Columbus' discovery of America. One has discovered something that has always been there. Peer support is something that has been occurring within drug-users' communities as long as there has been drug use. Mutual support within certain communities is a reality of everyday life. This is especially true in drug user communities which suffer from repression, marginalisation and exclusion, such as drug users in prisons and other closed institutions. Though it has undermining and disruptive effects on the community, tempting or forcing drug users to steal from each other, producing repression and marginalisation, the prison situation as such also creates mutual solidarity, hence the community's cohesion. A shared threat, a common enemy usually has a unifying effect, thus stimulating mutual support. Peer support as part of the reality of everyday life is generally non-institutionalised. It is often even non-intentional; a way that people act, without any conscious or explicit intention to support their peers, even though risk reduction might be the result of their action. After all, peer support as a means of risk reduction entails more than just explicit, verbal interference. It also includes the influence of peer pressure, of serving as a role model, etc. Just as in other communities, influencing and even actively supporting peers is part of an unconscious routine, conducted as if running on an automatic pilot. The findings of a small scale research carried out in the framework of our European Peer Support Project - on what we called non-intentional peer influences in IDU communities support this view (Barendregt/Trautmann 1996). The institutionalised forms of peer support communities that are initiated or supported by professional health services are, in fact, nothing more than attempts to use, support and strengthen the potential of this already existing peer support among drug users. Professionals can play an important role in peer support. They can, for example, take care of the collection of relevant and correct information, and in doing so, prevent false information from being disseminated. They can also contribute through training peer supporters, again, not just on knowledge about risk reduction but also on skills, on methods of transferring this knowledge and skills (e.g. by counselling and training seminars as described above) and by showing how to influence attitudes and social norms effectively. In addition, they can stimulate, support and influence the ongoing peer support in IDU communities, as our experiences with peer support show. This positive experience with peer support in the community has been the background for introducing peer support in prisons

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"(see c^h'apter 1). Peer support in prisons can play an important role to avoid risks being 'shared ', stopping inmates from copying risk behaviour without being aware of it . To manage so-called ' hidden risks' (e.g. sharing of water, filter and spoons), whether the risks are known or unknown , an exchange of information between peers can be very important . The specific relationships between drug users in prisons (such as economic dependencies , sexual relations etc .) should get special attention , as they can interfere - and not only in a negative way - with peer support. The advantages of peer support in prisons are: ^ Drug users , especially (informal ) peer leaders have credibility and trust from their fellow inmates. ^ Drug using inmates will be able to reach - and influence other drug - using inmates with risk reduction messages that are out of reach for prison staff, i.e. able to reach the unreached. ^ Peers have relevant first-hand information , e.g. on how to avoid certain substances or mixtures. ^ Peers know what they are talking about as they have generally experienced risk situations themselves, e.g. overdose, unsafe drug use or unsafe sex. although it might not always be obvious from their behav^ iour, drug users do have a personal interest in risk reduction. ^ peer support is a cost-effective snow-balling strategy (see also Engelhardt 2000).

Prison Peer Education ( PPE) was found to significantly contribute to changes in prejudices that inmates may have had towards HIV and people affected by it. For example, a study of a PPE program in Australia concluded that a large majority of inmates (71 %) felt that HIV positive inmates should not be segregated from the mainstream inmate population. Inmates had a relatively high level of understanding of the principles of HIV transmission, with over 98% of them knowing that they could not get HIV from activities involving everyday contact - sharing an apple or cigarettes, kissing, touching or using the same toilet. Furthermore 99.4% understood that you could get HIV if you undertook the high-risk activities of sharing needles and having sex without condoms (Taylor 1994).

In the chapters above, we have named different options for peer support in prisons. Of course, training these peer supporters is an essential prerequisite for successful peer support. This training



should focus both on the contents of risk reduction work, as we have presented in chapter 2 of this manual, and on the methods, as discussed in chapter 3. One can work with individual drug users, to train them as peer tutors (group meetings could be seen as threatening for the system) or with a group. When training groups of inmates you should, if possible, aim at achieving a multiplier or snowball effect - i.e. trained inmates pass what they have learnt on to their peers. A good starting point for peer support can be a mixed seminar - including both inmates and staff - to present and discuss options of peer support as part of a risk reduction strategy. However, peer support in general should first be introduced to and accepted by prison staff as part of a wider introduction of risk reduction strategies in prisons, e.g. by seminars on drug use in general. Peer support can be a helpful means of making contact with drug-using inmates who cannot be reached successfully by prison or community service staff. It can be both a first step to risk reduction, and a means of facilitating risk reduction activities by prison or community service staff. Peer supporters can play a role in counselling, training seminars, supportive measures and services. In addition to support by and for inmates, risk reduction activities could be conducted by municipal organisations operating outreach activities among injecting drug users. 'Mainline', a Dutch health and prevention organisation maintains contact with detained drug users by low threshold counselling in prison settings. In individual meetings with inmates, health issues, risk behaviour and risk of drug use are discussed. One important feature is that as an 'outside' organisation, they secure a sense of independence and trust. Evaluation reveals that there is: ^ A high level of acceptance among inmates, prison staff and administration ^ The activity enhances ongoing contact after release ^ Their work is perceived as a valuable addition in the social support structure for drug users Evaluations show this is a cost-effective activity ^

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ANNEXES •

REFERENCES



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Barendregt, C., Trautmann, F. (1996) With a little help from my friends. Utrecht (Trimbos-instituut)

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Blekman, J and van Emst, A (1997) Alles onder controle!?! Een programma op basis van motiverings- en zelf controletechnieken. Arnhem/Utrecht: Gelders Centrum voor verslavingszorg/Trimbos-instituut.

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Correctional Service Canada (1996): Correctional Service of Canada Educational Package National Bleach Kit Distribution Program

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Council Of Europe, Committee Of Ministers 1998: Recommendation No. R (98) 71 of the Committee of Ministers to Member States Concerning the Ethical and Organisational Aspects of Health Care in Prison

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Dolan, K. (1995): Bleach Availability and Risk Behaviours in Prison in New South Wales. Sydney: National Drug and Alcohol centre, Technical Report, No. 22

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Engelhardt, J. (2000): Two Models of Harm Reduction Activities within the prison walls: outreach work in the Netherlands vs. Peer support in Russia. Oral presentation at the conference 'Encouraging Health Promotion for Drug Users within the Criminal Justice System' from 22-25 November 2000 in Hamburg

^

Friedman, Samuel R., Don C. Des Jarlais , Jo L. Sotheran, Jonathan Garber, Henry Cohen and Donald Smith 1987 AIDS and Self? Organisation among Intravenous Drug Users. The International Journal of the Addictions 3: 201-219

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Keppler, K.; Stover, H. (1998): Die Substitutionsbehandlung im deutschen Justizvollzug. In: Sucht 44, H. 2/98, S. 104-119

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EVALUATION OF THE TRAINING COURSE TRAINERS ' SHEET)

Date: Where: ...................................................................................................................... When: ...................................................................................................................... Who (trainer): ......................................................................................................... Number of participants drug users professionals volunteers total If the group is mixed, have you noticed any friction between participants? ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ Program (please attach the program to the form) I was satisfied by this training.



agree 0 0 0 0 not agree

I felt well supported when preparing the training.

agree 0 0 0 0 not agree

I think that this training needs further follow- up.

agree 0 0 0 0 not agree

If agree, what kind of follow-up do you feel is necessary? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ I felt that the different backgrounds of the participants caused excessive friction

agree 0 0 0 0 not agree

The level of the participants connected well with

the content of the training .

agree 0 0 0 0 not agree



0



The methods of delivery were well-designed for the-type of participants

agree 0 0 0 0 not agree

The presence of observers hindered the ability of participants to express themselves frankly.

agree 0 0 0 0 not agree

The training dealt with the following issues: ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ What were the objectives of the training? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Which of the objectives did you feel were not achieved and why not? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



Give a brief description of the methods of delivery used: ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Which of the messages did you consider were received best by the participants? Why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................

S

Which of the messages did you feel were least well received by the participants? Why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................









Which of the methods of delivery did you feel was received best by the participants? Why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................

Which of the methods of delivery did you feel was least well received by the participants? Why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ •

If you have any remarks , please state them below.

Thank you very much for your co-operation.

0







346

9

-EVALUATION OF THE TRAINING COURSE (PARTICIPANTS SHEET - INMATES).

Date: General The course has stimulated me to work on risk reduction.

agree 0 0 0 0 not agree

I can use this course or parts of it in my personal situation.

agree 0 0 0 0 not agree

I think I am more capable of making proper decisions about risk reduction.

agree 0 0 0 0 not agree

I enjoyed the course.

agree 0 0 0 0 not agree

The place where the course was held made me feel uncomfortable.

agree 0 0 0 0 not agree

The course contained too much theory.

agree 0 0 0 0 not agree

The course contained too many exercises.

agree 0 0 0 0 not agree

The course contained too much discussion.

agree 0 0 D 0 not agree

It was sometimes difficult for me to concentrate on parts of the course.

agree 0 0 0 0 not agree

0

If agree, please mention why (lasted too long, bored, sleepy etc)

Safer use



The course increased my insight into the proper methods of preparing drugs for injection.

agree 0 0 0 0 not agree

Thanks to the course I can improve my injection technique.

agree 0 0 0 0 not agree

1 have learned new things regarding safer use .

agree 0 0 0 0 not agree







0



If agree , what did you learn about safer use? ........................................................................................................................................ ........................................................................................................................................ I feel more capable of dealing with obstacles which might hinder proper injecting.

agree 0 0 0 0 not agree

Safer sex Thanks to the course I have improved my ability to putting on a condom.

agree 0 0 0 0 not agree

I have learned new things regarding safer sex.

agree 0 0 0 0 not agree

If agree , what did you learn about safer sex? ........................................................................................................................................ ........................................................................................................................................

0

The course gave me insight into the application of different types of condoms.

agree 0 0 0 0 not agree

The course made me feel more comfortable about practicing safer sex in the future.

agree 0 0 0 0 not agree

Risk reduction in general I have learned new things regarding risk reduction.

agree 0 0 0 0 not agree

If agree , what did you learn about risk reduction? ........................................................................................................................................ ........................................................................................................................................ I feel more capable of dealing with the issue of risk reduction.

agree 0 0 0 0 not agree

Organisation I know how to involve other drug users in risk reduction activities

agree 0 0 0 0 not agree

I know where and how to seek support for risk reduction activities.

agree 0 0 0 0 not agree

03'





0



I have some concrete ideas for risk reduction activities.

agree 0 Q Q Q not agree

Prevention I think I can convew the safer sex issue to drug users in an efficient way.

agree 0 0 0 0 not agree

The course contained enough material to compose a relevant course for drug users.

agree 0 0 0 0 not agree

This course helped me to think about ways the safer use message can be passed on.

agree 0 0 0 0 not agree

The course gave me insight into the use of risk reduction / information material.

agree 0 0 0 0 not agree

The course improved my skills at raising risk reduction issues with drug users.

agree 0 0 0 0 not agree

Which part of the course did you like most and why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Which part of the course did you like the least and why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Do you have any remarks on the trainer? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ What information was lacking in this training course? ........................................................................................................................................ ........................................................................................................................................ ...................................................................................................................................... Do you have any suggestion and/or remarks? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Thank you very much for you co-operation.

.351

I! i.

S

EVALUATION OF THE TRAINING COURSE (PARTICIPANTS SHEET - STAFF)

Date: General The course has stimulated me to work on risk reduction.

agree 0 0 0 0 not agree

I can use this course or parts of it



in my personal situation.

agree a 0 0 0 not agree

I think I am more capable of making proper decisions about risk reduction.

agree 0 0

I enjoyed the course.

agree 0 0 0 0 not agree

The place where the course was held made me feel uncomfortable.

agree 0 0 0 0 not agree

The course contained too much theory.

agree 0 0 0 0 not agree

The course contained too many exercises.

agree 0 0 0 0 not agree

a 0 not agree

The course contained too much

discussion.

agree 0 0 0 0 not agree

It was sometimes difficult for me to concentrate on parts of the course.

agree 0 0 0 0 not agree

49

If agree , please mention why ( lasted too long, bored , sleepy etc.).

Safer use I have learned new things regarding safer use. If agree , what did you learn about safer use?

33'

agree 0 0 0 0 not agree



EL

0

I feel more capable of dealing with the issue of (safer) drug use.

agree 0 0 0 0 not agree

Safer sex I have learned new things regarding safer sex.

agree 0 0 0 0 not agree

If agree , what did you learn about safer sex?

I feel more capable of dealing with the

i

issue of (safer) sex.

agree 0 0 0 0 not agree

Risk reduction in general I have learned new things regarding risk reduction.

agree 0 0 0 0 not agree

if agree , what did you learn about risk reduction?



I feel more capable of dealing with the issue of risk reduction.

agree 0 0 0 0 not agree

Organisation I know how to involve colleagues in risk reduction activities.

agree 0 0 0 0 not agree

I know where and how to seek support for risk reduction activities.

agree 0000notagree

I have some concrete ideas for risk reduction activities.

agree 0 0 0 0 not agree

Prevention I think I can address the safer sex issue with drug users in an efficient way.

agree 0 0 0 0 not agree

The course contained enough material to compose a relevant course for drug users.

agree 0 0 0 0 not agree

This course helped me to think about ways the safer use message can be passed on.

agree 0 0 0 0 not agree





0



The course gave me insight into the use of risk reduction / information material.

agree 0 0 0 0 not agree

The course improved my skills at raising the risk reduction issue with drug users.

agree 0 0 0 0 not agree

Which part of the course did you like most and why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ •

Which part of the course did you like the least and why? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Do you have any remarks on the trainer? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ What information do you feel was lacking in this training course? ........................................................................................................................................ ........................................................................................................................................ ......................................................................................................................................



Do you have any suggestion and/or remarks? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................

Thank you very much for you co-operation.



0



ACRONYMS AND ABBREVIATIONS

0

AIDS CEE EMCDDA EPSP EPSM EU HIV IDU

Acquired Immune Deficiency Syndrome Central and Eastern Europe European Monitoring Centre for Drugs and Drug Addiction European Peer Support Project European Peer Support Manual European Union Human Immune-deficiency Virus Injecting Drug User

i.v.

intravenous

NGO STD STI UNAIDS WHO

Non-Governmental Organisation Sexually Transmitted Disease Sexually Transmitted Infection Joint UN Program on HIV/AIDS World Health Organization

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d

0

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s . umrucw

a. \3'.ir.