Peripeteia of Opioid Substitution Therapy (OST) in the Penitentiary System of Georgia

Drug use, including the use of problematic drugs, is one of the most common problems in prisons in European countries. An analysis of various studies has shown that in EU countries, about half of the prison population has consumed any illicit drugs during their lifetime (Zurhold et al., 2005). An analysis of international studies, mostly conducted in the US, shows that 10-48% of men and 30-60% of women have used drugs or depending on them for a month before their arrest (Fazel, et al., 2006). Other data showing the problematic drug use^[1] in prisoners is limited. According to an international review of one study on prisoners, 25-50% of inmates were classified as clinically serious, more often because of opioid dependence (Prison and Health, WHO Regional Office for Europe, 2014).

The Georgian data is not much different from that of European countries. Unfortunately, there are not many pieces of research conducted in the Georgian penitentiary system that study the characteristics of drug use. Nevertheless, scarce data of studies still provide some insight into this issue. According to one study, 71% of the prison population reported illicit drug use in their lifetime (“Study on the Harm Reduction Needs Causing by Drug Abuse in Georgian Penitentiary Institutions”, TANADGOMA, Alternative Georgia, Mainline Foundation, 2012.)  According to this study, 46% report the consumption of drugs by injecting during their lifetime. In 2015, according to the survey on HIV / AIDS Surveillance, the cases of drug use (both injecting and non-injecting drug use) were recorded during imprisonment (“Risk and Safety Behaviors regarding HIV among Prisoners in Georgia”, International Curatio Foundation, 2015). Despite the scarcity of data, based on the trends existing in the general population, some assumptions can be made on prisons. In 2016, according to a recent study determining the size of injecting drug users’ population in Georgia and based on expert consensus, the estimated number of injecting drug users was 52,000 (50,000 – 56,000), the prevalence rate is 2.24% (2.13-2.34%) per population aged 18-64 whereas 1.41% (1.34-1.51%) per general population (International Fund Curatio and Public Union BEMONI, 2017.) In the same year, 31% of injecting drug users in Georgia depended on opioids, according to a conducted study on HIV risk and prevention behaviors among People Who Inject Drugs (International Foundation Curatio, 2017). According to the report of Council of Europe, as of January 31, 2018, approximately 34.1% of those placed in penitentiary institutions were serving sentences for drug-related offenses (Drug Development in Georgia, Annual Report, 2018). Based on the report data, we can assume that an essential part of the imprisoned drug users is opioid users or dependent on them.

What factors contribute to the “gathering” of drug users in penitentiary institutions?

Drug users enter the prison, on the one hand, because of the drug-related behaviors leading to criminal liability (consumption, purchase, storage, cultivation, shipping, and more of the illicit drugs), and because illicit drugs are quite popular with people who engage in criminal behaviors.

Because of health, mental and behavioral problems related to drug use, drug-users belong to the prison population who require specific help and services. Health and care services involve both treatment and rehabilitation, and harm reduction. Distinct drug users need varied services, but the essence of service delivery is generally common and focuses on improving health and quality of life, reducing the harm of drug use. Finally, the goal of treatment of the drug-related disorders is to:

• Discontinue or reduce drug use;
• Improving the quality and functioning of life;

• Minimization of future damage, avoidance of complications, and prevention of failure (pre-consumption). (WHO, UNODC, 2020).

According to the World Health Organization, drug services in prisons can be divided into the following categories: assessment, prevention, counseling, abstinence oriented and medication-assisted treatment, self-help groups, and peer-driven interventions, harm-reduction measures and pre-release and aftercare programmes. It also states that drug dependence is not criminal or hedonistic behavior but a chronic disease, which consequently requires a continuing care and support. It should be treated in the same way as other chronic conditions, and a prison drug strategy should be part of and in line with the national drug strategy (Prison and Health, WHO Regional Office for Europe, 2014).From the above services, recommended by various competent international organizations (WHO, UNODC, EMCDDA), of course, all are essential and the effectiveness of the treatment depends on their complex use. However, this time we will concentrate on opioid-supported treatment and discuss the issues and challenges in the Georgian penitentiary system.

“Opioid Substitution maintenance therapy is one of the most effective treatment options for opioid dependence. It can decrease the high cost of opioid dependence on individuals, their families, and society at large by reducing heroin use, the spread of HIV infection, minimizing the risk of overdose, and in general, eliminating the criminal activity.” (WHO, UNAIDS, UNODC, 2004).

In 1993 WHO guideline on HIV infection and AIDS in prisons we read:

“Drug-dependent prisoners should be encouraged to enroll in drug treatment programs while in prison, with adequate protection of their confidentiality.  Prisoners on methadone substitution prior to imprisonment should be able to continue this treatment while in prison. In countries in which methadone maintenance is available to opiate-dependent individuals in the community, this treatment should also be available in prisons.”

The same document emphasizes that the quality and continuity of services must be ensured between the civil sector and prisons. Herein, all international documents emphasize that continuity must be guaranteed both during and after release from prison.

According to the World Health Organization’s program “Health in Prisons,” and the Council of Europe’s Pompidou Group Guide on “Delivery of health services to prisons,” (2001), “health services in prisons should be equivalent to the services provided outside prisons. ” (principle of equivalence).

How do the principles of equivalence and continuity maintain in the context of opioid substitution therapy in Georgia between the civil sector and prisons?

In our country, the launch of Opioid Substitution Therapy is related to the programs of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The first program was introduced to the civil sector in 2005. Since the programs expanded, over the years the program has been funded on a co-payment basis, since July 1, 2017, Methadone substitution therapy programs have shifted entirely to state funding, increasing their accessibility. In the civil sector, besides Methadone substitution programs, there is Suboxone substitution therapy, concentrating in the private sector. During 2018, 12,179 people were involved in OST (Methadone and Suboxone) programs.

The first OST program in Georgian prisons was launched in 2008 in the penitentiary establishment N8, which is designed for 80 people; then the program was expanded to western Georgia, and it was opened in the penitentiary establishment N2 (designed for 50 people). During this time the treatment involved detoxification with Methadone. In 2018, 763 people were involved in the program.

The OST program in penitentiary institutions is regulated by a joint order №92 №01-26/n of the Minister of Corrections and Probation of Georgia and the Minister of Labor, Health and Social Affairs of Georgia from July 14, 2016. According to this document, the substitution program in prisons provides for a) short-term detoxification – treatment with decreasing Methadone doses not exceeding one month; B) long-term detoxification – treatment with decreasing Methadone doses for over one month; C) short-term substitution therapy – which involves treatment with stable doses of Methadone for no longer than 6 months; D) long-term substitution therapy – treatment with stable Methadone doses for over 6 months.  The same document (Article 2) states that by the beginning of 2018, the Ministry of Justice should ensure all the necessary measures to start short-term and long-term substitution treatment. On December 29, 2017, this order was amended (Order №148/№01-74/N) and the second article was edited stipulating that all necessary measures should be taken before January 1, 2020, to implement short-term and long-term substitution therapy, envisaged by the program.

As seen from the above, from the start of OST programs there are still certain barriers in the penitentiary system. In particular:

• Only detoxification with Methadone is available;
• The programs are running only in two establishments (N2 and N8);
• There is a limitation for female prisoners addicted to opioids–OST does not. function in establishment N5.

It is interesting to see the issues that these barriers form for opioid-dependent prisoners in the practice.

We can find the answers to this in a 2019 joint study “Access to Opioid Substitution Therapy in Georgian Prisons” conducted by the Institute of Adaptology of Ilia State University and the non-governmental organization “Alternative Georgia.”

We will glance at some key aspects of the study:

• About 2 to 15 beneficiaries involved in the OST in the civil sector enter the penitentiary system per year. Their majority is state beneficiaries of the methadone substitution program of the civil sector, which has contributed to their inclusion into the OST program in the prison since their arrest. Pre-trial detention isolators also provide daily doses with no delay; the beneficiaries stated that before 2013, the detox course lasted only for 2 months with a very rapid dose reduction, but after 2013, the course duration exceeded 5 months. Yet, the respondents note that the methadone-assisted detox course was not sufficient to relieve the abstinence syndrome. The vast majority of them state that this is “mandatory detoxification.”
• Regarding the post-detoxification period, respondents note that until 2013, program staff did not pay any attention to them after they had completed treatment. Respondents in custody between 2014 and 2015 said they were prescribed sedatives and sleeping pills to relieve discomfort after detoxication.
• Detainees who were not involved in the OST in the civil sector and used drugs at the time of their arrest had some challenges with their involvement in the prison’s OST program. “One respondent said that prison staff did not believe he used drugs, and they refused him to receive the detoxication service.”
• There is no OST program in the women’s facility that creates big problems for female prisoners who are beneficiaries of the OST program in the civil sector. In some cases, as an exception, female prisoners are transferred to a Gldani facility (presumably to a medical facility) to participate in the OST program;• Continuation of treatment in the OST programs in the civil sector after the release depends on the stage when the beneficiaries involved in the prison OST programs are released from prison. If the release takes place at the detoxification stage, then returning to the OST program in the civil sector is not a problem. In case a prisoner has undergone a detoxification course in OST in the prison and is trying to return to OST of the civil sector, the prisoner will have to go through the same procedures as when he/she first joined OST. In particular, to take a urine test for determination of the use of psychoactive substances, and submit a health certificate. This barrier pushes a person to use illicit drugs for the urine test to show a positive response to drug use needed to return to the program;
• After release, within the first days, the civil sector OST programs often have to increase the dose for the beneficiaries returning from prisons based on their complaints. According to the civil sector OST staff, the dose in prisons is declining rapidly and the period of detoxification is insufficient. For many beneficiaries, detoxification was not beneficial at all and was done against their will. ;
• •           The staff of the Suboxone program often note that communication with the prison OST programs is challenging, which is essential to determine proper dosages for returnees into the program after their release. .
• No release plan is approved before release, which is tailored directly to the needs of drug users. .

The same study shows that representatives of the Penitentiary Department although approving the initiative on a level of rhetoric, stating that the system was not ready to provide long-term treatment in all prisons. ‘’The named reasons were insufficient physical infrastructure and lack of qualified medical personnel. They also stated that the initiative could have been implemented starting from 2020 under the overall reform of the penitentiary system.’’

Indeed, according to the Order of the Minister of Justice of Georgia from February 22, 2019 “On adopting 2019-2020 Strategy and Action Plan on the Development of Penitentiary and Crime Prevention Systems” (Order #385), in 2019 various activities were planned aiming at improving access on rehabilitative and treatment programs for drug and alcohol-dependents. .

In particular, in the strategic plan: Result E2. By identifying drug and alcohol dependants and introducing harm reduction approaches through the provision of medical and rehabilitation services for April 2019 was planned to draft the transitional management concept, and by May 2019 – to draft the Report on assessing the needs of long-term substitution therapy for drug-dependants in penitentiary establishments.

Being one of the stakeholders (the organization has been working in the system for almost 20 years for promoting the development of drug treatment and rehabilitation interventions for drug users), on February 3, 2020, we submitted a letter to the Ministry of Justice on behalf of our organization, the Medical-Psychological Information Center “Tanadgoma”, asking the Ministry to share the documents on the “transitional management concept” and the “Report on assessing the needs of long-term substitution therapy for drug-dependants in penitentiary establishments.” On 18-19 February 2020, the international conference ‘’Rehabilitation of drug-dependent inmates–Why should you care?’’ was organized by the Pompidou Group and the Ministry of Justice of Georgia in Tbilisi. Representatives of local government agencies and non-governmental organizations and experts in various fields from various countries attended the conference. At the conference, I asked the representative of the Ministry of Justice if the documents mentioned in our letter were ready and if they would share it. The representative of the Ministry replied that these two documents were ready and as soon as he would receive our letter, they would answer us.

Indeed, on March 9 this year, we received a response from the Ministry stating that “these documents are a guide for employees and not available to other interested parties.”

Also, I would like to note that at the conference I had a communication with one of those people directly involved in the preparation of the “Report on assessing the needs of long-term substitution therapy for drug-dependants in penitentiary establishments.” According to the remark of this person, the study report includes nothing to prevent it from sharing with the public.

“The leadership of the health system of the Penitentiary Department stated multiple times that they perceived detoxification and (forced) abstinence as a cure from addiction. This suggests that apart from possible infrastructural barriers, the principal obstacle for introducing longterm OST in Georgian prisons can be insufficient knowledge of the nature of drug dependence and treatment principles and approaches by the leadership of the prison health system.” – this is the extract from the study ”Access to the Opioid Substitution Therapy in Georgian Prisons” (Institute of Adaptology of Ilia State University and “Alternative Georgia,’’ 2019.)

Apparently, the suspicion expressed in the report was not groundless!Finally, there is a precedent – the litigation “Wenner v. Germany” https://www.hr-dp.org/files/2016/09/05/CASE_OF_WENNER_v._GERMANY_.pdf. The dispute concerned the Bavarian court’s decision to restrict the right of a prison inmate on OST treatment in prison. Upon his arrival in prison, Wenner, who was addicted to opioids, was offered only detoxification treatment, and he had been refused opioid-supported therapy. After his release from prison, Wenner appealed to the European Court of Human Rights. On September 1, 2016, the European Court of Human Rights delivered a judgment, recognizing actions of the Bavarian court as a breach of Article 31 – Prohibition of Torture (“No one shall be subjected to torture or to inhuman or degrading treatment or punishment”). This precedent may be regarded as a warning to any country where people in detention are denied access to health services, including those with the problem of drug dependence (Ilia State University Institute of Adaptology and Alternative Georgia, 2019.)

We hope that soon, in prisons, there will be available long-term substitution therapy with opioids and other drug treatment services. Until then, we will try our best to obtain the “Report on assessing the needs of long-term substitution therapy for drug-dependants in penitentiary establishments” and continue advocating for the process with partner organizations.

[1] The European Monitoring Center for Drugs and Drug Addiction considers injecting drug use or long-term use of opioids, cocaine, and amphetamines as problematic drug use.