 Welcome to our new EMCDA webinar. This time, we will talk about prisons and drugs. And I will give directly the floor to our director, Alexis Guzdi, for his opening remarks. Thank you. Thank you, Marika. Good morning, everybody, or hello, everybody. It's a real pleasure to be with you today for this very important topic. Actually, as some of you probably have heard me saying a few times, I think not only that is an extremely important topic. It's also sometimes I hear from the colleagues, the professionals working in that field in the last 20, 30 years, that unfortunately, there have been no major changes in the way we, as European countries, we address those issues. And for instance, we know, I think, one of the first seminars I have attended 30 or 35 years ago when I started working on the drugs field was about drugs and prisons, and about how important and critical and dangerous was the time of release and the potential risk of dying from overdose. And honestly speaking, those changes in the last 30 years, there have not been so many. And clearly, we can say it's not the question of lack of scientific evidence. So we need to find different ways to raise the awareness and to push for change, to push for better and more appropriated responses. I think still some element that can give us hope. First, our contribution to celebrate our contribution to the World Day on Drugs last week was the launch of the publication that you see just behind me, Prison and Drugs in Europe. And I would like to thank and congratulate Linda, all the colleagues of EMCDD, but also all the external partners of EMCDD who support us in this work. And we also try to support them. So I have a first question for you to send us all the suggestions, all the ideas you have. All the EMCDD could be more useful for you in the future. That's part of our mission. And that's part of what we are trying to change and to further improve our EMCDD in providing even better service to our customers. But certainly to manage, to publish, to finish, to prepare the insight. I think it was a lot of headaches for Linda and the colleagues. But Linda, she never abandons. And that's another good example. And that's a fantastic result for EMCDD. So I think that's a very important achievement for all of us. But now we need to find a way to make use of it and to make it now and to see how to make it even more useful. So this webinar, it's a very good opportunity. And it's only the first one, the first opportunity. The second very recent and very positive development is that the last 21st of June was adopted the European Action Plan on drugs and thanks to the efforts of the Portuguese presidency of the EU. In fact, the action plan is translating into actions and concrete activities, the objectives that have been defined in the European Drug Strategy that was adopted under the German presidency in December. And this process was initiated by the presentation by the European Commission and the Commissioner Johansson of what was presented as the European Agenda on drugs that was presented last year. One thing very positive for those like you and us who work in this field is the fact that for the European Union already from the European Agenda presented by Commissioner Johansson, two special issues were highlighted. The first is prisons and the other is the stigma, especially on the women using drugs. And I think those are challenges that are as old and even older than EMCDDA. We modestly try to contribute. We need and we want to do more, but certainly to have such an emphasis presented by the strategy, the action plan and the European Agenda are very important because now the priority will be put for all the EU member states for the implementation of the action plan. And we at EMCDDA will contribute in terms not only of monitoring but providing better services to practitioners and decision makers. The work in prisons and in the penal system and the high number of participants today illustrates that is very challenging work. And I would like to pay tribute to all the professionals working in that area. I had the privilege to be invited one week ago virtually to Sevilla for the seminar organized by UNAS in Spain on treatment of addictions in the penal process. There are so many courageous people who are trying to provide the best possible service. And I think that their working conditions are sometimes becoming even more challenging than before. So we really need to pay attention to that. And why is it so important? But also why is it maybe so complex? I think that what some people may forget is that basically when we speak about prisons and drugs, it's a much broader issue than just drugs and drug use. I think it has to do with what is the society vision? What is the role of the prison and the penal system in our vision of society, in our vision of the human beings and in the project that we have for society? And here compared with other countries or regions in the world, we have the chains that we have the European values as they are stated in the Lisbon Treaty with the fundamental rights that are explicitly applying to all citizens in the EU, including those who are using drugs. And whether is it enough or not? Probably not, we need to implement. But certainly we have a set of core values in Europe that are the ultimate reference for all of us without discrimination or hopefully without discrimination. So the challenge for us I think is based on the knowledge on the ideas you are going to discuss today to see how in the coming months, in the coming years, we can, thanks to the information, thanks to the evidence, but also to your own experience, how can we raise the awareness that we should stop maybe looking too specifically to some small parts or small policies and to go back to what's one of the strengths and good results of building a European Union for so many years, which is contributing to a space of freedom, justice and security. But we should don't forget that citizenship is a much broader project for all the society. And I think with all the risks and all the crisis that we have seen around us, there may be a risk or potential risk to forget that this is our ultimate goal. And this is what makes our society a living democracy. We need to protect it and we need to see how we can contribute. So this webinar I think is a first new contribution from EMCDDA. I need to apologize. I used to stay and to share reflections at the end of the meeting. This is why today I've been a bit longer in my introduction, but today it's a great day for me. I'm going to get my second vaccination in half an hour. And I love you very much, but I don't want to sacrifice another 16 months of my life because I don't go to the vaccination. So I will go to the vaccination and I will be informed by Marika, Linda and the colleagues about the possible follow-up. And I thank all those at EMCDDA, Marika, the other colleagues who have taken the challenge to organize the webinars, to invent them at EMCDDA because we have every time fantastic events and you make the difference. So thank you very much. Thank you, Alexis. Thank you also for the good example with the vaccination. Of course, the webinars were your idea. We just followed. But I want to waste more minutes just to say Linda will share the webinar and she will also give an introduction. Towards the end of the webinar, you will be able to ask questions in the questions and answer button. So use it already someone has started using them. So I will shut my camera and leave the floor to Linda. Thank you very much. Thank you, Marika and thank you, Alexis, for this introduction. I'm very glad to be here to introduce the webinar and to chair this webinar on prison and drugs. The webinar, I will present you some selected finding from the insights and then we will discuss with important expert on the prison and drugs, the findings around the sum of the key question. I will share now my screen. So the title of today webinars is the title of the insight publication that was published on the 26th of June. And I would like to acknowledge the EMCDDA project group. So my colleague, Luis Royela, Ines Hasselberg who worked with me in this insight, but as Alexis was saying, also several other colleagues at the EMCDDA and external expert contributed in several and important way to the insight. The insight has eight chapter, introductory chapter setting the scene on prison and drugs in Europe. Two chapter on the epidemiology of drug use before, during and after incarceration and one on drug related health problems among people in prison with drug problems. The fourth and fifth chapter map and describe the available intervention for drug related problems in the prison population including hand reduction interventions. Then a sixth chapter discuss the evidence available for the implementation of those intervention and seventh describes the drug supply and supply reduction in prison. And finally, the concluding chapter where we present the main issues, the challenges, implication for policy and practice. The report is referring to 2019 in term of year and concern 30 reporting countries. So 27 European member state, Norway, Turkey and United Kingdom. Just to give you some contextual information on the 31st of January, 2019, there were 856,000 people in prison in the 30 reporting countries with the prison population rate of 142 people per 100,000 inhabitants, which is lower than the prison population rate reported in Russia and much lower than those that reported in the United States. However, there are also variations across the European countries with the prison population rate of 50 reporting in Finland and 330 in Turkey. Another, it's important also to have the characteristic of this population and to know that the large proportion of the prison population have centers of five years or less and the recidivist rate is high. How drugs and prison are interconnected? They are closely interconnected and it's possible to identify three groups of people, those that are in prison for drug law offenses, including use, possession and trafficking. Not all of them necessarily are drug users. In Europe in the last available data, 18% of the prison population are in prison for drug law offenses. Then there are people who are in prison for crime committed to support the drug use. And finally, people with drug related problem were using drugs who are in prison for different type of crime. So as you can see, there is a closed link between the two issues. And in this graph, you have the data on the prevalence of drug use before imprisonment in 15 reporting countries. And as you can see the level of prevalence is high for all substances and for all countries. Also there are variations between countries. This variation depends on several factors including differences in the prevalence, in the community, in prison, differences in the drug legislation, in the enforcement of the drug legislation, but also differences in the methodology which the data collected. This is one of the reason why we have defined with the group of experts around Europe that I would like to acknowledge and thanks a European model questionnaire to collect comparable data across the country. In this graph, just shortly you have this in six reporting country using similar, the same questionnaire, the comparison between the lifetime prevalence in among the prison population before imprisonment and in the community. And as you can see the dots are all on the left part of the square indicating an excess of drug use in this population. The excess is the highest for cocaine and lowest for cannabis and is higher for women. So, but if many people in prison, a large portion have experience with drugs, many people when they enter prison, they stop using drugs, but some continue to use some change the drug use patterns in terms of substances or route of administration. And some also start using drug. An emerging phenomenon in the last years is the appearance of new psychotic substances, particularly synthetic cannabinoids in prison reported in several European countries. So, drugs enter prison and the main trafficking routes are the similar to the routes used for other goods. So, external visit, people movement, but also increasingly the use of new technology like drones. These, many of these routes were disrupted during the COVID pandemic because of the introduction of containment measures. And some have been used more often than others like the drones. The people in prison with drug problems have also poorer health, mental and physical health and report high prevalence of several type of diseases. Here is just one of the information included in the insight on the high prevalence of drug related infectious diseases in the total prison population. And the reason for these high prevalence is also because a large proportion of those people are injecting or had experience with the drug injection and also the high prevalence of psychotic morbidity. Mental health disorder, particularly the COVID pandemic were increasing in the community, in among the people who use drugs and among the prison population. So then the mortality, Alexis was mentioning before the risk of mortality of the prison release, but in general, the prison population report high mortality rates with suicide inside prison being the leading cause of deaths. But then there is a specific drug risk when people leave prison. So there is a very high risk of overdose deaths in the first period after prison release, particularly in the first two weeks. And women report a particularly high risk more than men. Women are a small group in the prison population, represent 5% of the European prison population with variation between country. There is a higher proportion of women in prison for drug law offenses. And also the impact of imprisonment on women is more damaging, is very severe because their condition, for instance, in prison, usually they are more isolated, they are the primary care of children who are often then put in institution or foster care when they are imprisoned and is more difficult for them to be socially reintegrated when they leave prison because of several factors, including the fact that they are reporting double stigma as ex-offenders, triple extracuse, but also they don't fulfill the social expectation for their gender role. So what is done in prison? We have in the inside, we try to describe the different type of existing intervention according to the phase of imprisonment from prison entry, health assessment, detoxification. In prison stay, there are pharmacological intervention, psychosocial intervention and heart reduction intervention and in prison release where there are several heart reduction intervention to reduce the risk of overdose but also important intervention in terms of social reintegration and linkage to health and social care. The most of these interventions have an evidence in the community but the evidence in prison is scarce. It's scarce because there is little research that's being conducted. Although there are some intervention that have been proven to be effective and they are used in prison like COST or the intervention for infectious diseases. On the right, you have the publication, the important publication that was based on scientific evidence and also the opinion of experts in the field. Here in one of the chapter, as I say, we map the interventions that are officially available in the different European countries. And this is just the number of countries where those interventions are available. As you can see, we go from intervention of infectious diseases and information that are available in all countries. OST continued from the community is available in 29 out of 30 countries but there are some interventions that are widely available in the community that are available only in few countries in prison like needle and syringe programs or take home naloxone. What we have seen is that with the scarce data we have, there is no coverage of this intervention and also the intervention were introduced much later in prison than in the community. Here is an example of OST where you can see that the first obvious institution treatment were introduced in Sweden in 65 and the first in prison in 85, 20 years later. To conclude, some key issues that I think is important to highlight. So prison is a place where the population is, there is a large proportion of social vulnerable population. So they may require not only the implementation of the principle of equivalence of care but equity of care. So additional intervention to reach the equivalence. Prison and community are not separated. There are two worlds that are in continuous connection where the continuity of care then it's really important to ensure with coordination across different services. Prison are always places where the professional leave this tension between two objective, the care and control. And this should be addressed in some country and approach of all of government responsibility has be adopted. As I say before, there are key intervention proven to be effective in the community that are working in prison that they should be implemented and scaled up in prison. In the insight, in the report, we don't talk about alternatives approach because it's focusing on the situation inside prison but it's important to assess and to balance the cost and benefits for the prison population, the prison system. A recent Norwegian research tried to model what would be the reduction of imprisonment episode if you abolish the drug law offenses that it will be 18% with all drug related crimes. It would be 60% reduction in the prison episode. Finally, and this is really important for the MCDDA and all the agency working on data collection and monitoring. I think it's necessary really to improve the, to increase the information available and improve the evidence, the research and monitoring on drugs and prison. But you will find more information and more detailed information in the prison and drugs insight. And I think it would be nice now to go and move on to the discussion. Thank you to all for listening. So today we have four guest speakers with us, Blanka Shulak. Blanka is the head of drug treatment department in the prison hospital in Zagreb. Blanka is a social pedagogue and she has large experience in the field of prevention and treatment of substance abuse among offenders and contributed to developments and implementation of rehabilitation programs. Heino Stover is a well-known international prison and drugs expert, is a professor of social scientific addiction research at the Frankfurt University of Applied Science in Germany. And he has been working for many years since the eighties in the field of addiction, particularly in the health promotion for vulnerable and marginalized groups, including people in prison, is consultant for several international organizations. Mark Johnson is the founder of User Voices. User Voices is a UK NGO aiming to foster the dialogue between service users, service providers and aid rehabilitation and recovery of people with prison experience. Mark is an expert from his own personal experience and his story is documented in his best-selling autobiography, Wasted. He is also consultant for governments and charities. Finally, last but not least, Theano Mavrumastaki, he's the head of department civil litigation of the law office of the Republic of Cyprus. She's a senior legal counsel for the government at Attorney General's office in the country. She's also legal advisor for the National Cyprus Authority Against Addiction and she's nominated legal correspondent expert for the MCBDA since 2002. So thank you to all the speakers for participating and we will organize the discussion around few questions. The first one is why it's important to address the issue of drugs and prison for policymakers, practitioners and people with lived experience. I would like to ask Heino to start commenting on this question and I will stop sharing my screen. Many thanks, Linda, for the introduction and for your presentation of the new insight of prison and drugs. So I think it's very important for the groups you mentioned, policymakers, practitioners to address the problem of drugs and prison because prisoners come from the community and they return to it. And so prison health is always public health. So we are highly looking on the treatment during imprisonment, which is very important. We do have revolving door effects among prisoners. Many of the prisoners incarcerated are there for several times, have been there for several times already. And so far we especially look at people who are using drugs before, during and after imprisonment and it's very important that we look for a continuous care and counseling for those people who were put to prison because they're taking drugs or they were financing drugs or they were smuggling or producing drugs because it is a highly marginalized and vulnerable group which needs a lot of treatment. You mentioned already in your graphs, the hepatitis C and HIV prevalence in prisons that indicates that the people in prison are manyfold higher infected than in the community and we should take a special eye on this group. So imprisonment is associated with increased levels of health risks including overdose and infectious diseases transmission. You mentioned that already. And it does not only affect people in the prison but also prison people afterwards in the community. Let me shortly mention the EU drug strategy which has been mentioned by Alexis already. I think in this drug strategy, the spirit of this insight has gone in already because they identified there for priority areas to be in this strategy. One is to assure equivalence and continuity of healthcare provision in prison and by probationary services. The second is to implement interventions that are evidence-based measures to prevent and reduce drug use and its health consequences including measures to address the risk of drug related deaths and the transmission of blood-borne viruses. Third is to provide overdose prevention and referral services to ensure continuity of care on release. And fourth is the availability of drugs and prison should be restricted. So I think in these four priority areas, the spirit of this insight has already gone in and so far I think it delivers a very good and solid database for all policymakers for stakeholders and decision makers in order to plan national strategies which are focusing on the group of drug users in prison. Thank you, Alina. Thank you also for highlighting this link with the community, the continuity of care which was a big issue also during the pandemic and reporting on the importance of using this information for policymakers. As you mentioned the intervention and treatment I would like to give the floor to Blanka Shulak to try to provide from the perspective of as professional in prison her view on this first question on why it's important to address this issue. Blanka, please. Thank you, Linda. And thank you also for the introduction part. Well, I can only firmly agree with Hino in several points. The statement that present health, the health of the prisoners is also an issue of public health is more than true and that this effect, this COVID situation that has happened around the world did prove us that because what we did inside with our prisoners during the pandemic situation reflected to the outside world. So all our intervention in prisons and penitentiaries were aimed to contain the COVID spreading and to keep the prisoners safe. So that's the situation that we I think most prisons in European countries handled that well. It was the living proof that prisoners inside and all actions and all treatment rehabilitation programs and everything that we do with prisoners inside has a big impact on the civil society that welcomes that prisoner outside. So what I wanted also to say that there has been an increase of pharmacological therapy inside prison administration because due to COVID situation we had restrained visits from the outside and that had an impact on our prisoner's organization of life inside. So that was something that was also a new dimension for us because we do not have that much problem in Croatia with drugs inside prisons. We do have a larger issue with all points of view to therapy because that's what they usually happen when an addict enters the prison system. The usual benefit of all points of therapy seems to lose some sense because of this increase that happened due to the pandemic situation. What has proven to be a good recipe for various successful treatment for addicts in prison administration is a combination of pharmaceutical approach and a combination of CBT approach programs, cognitive behavior programs in working with addicts. So that is also one of the recommendation of the European Council of the European Council that are involved in giving some good references and guidelines to the prison administration upon this treatment of prisoners inside and after release. We had a good cooperation with our probation system and it is so to speak, they are our prolonged friends outside who work with us in this continuous treatment. But what also was shown to be effective is the NGOs. Probation system sometimes is overloaded with lots of alternative sanctions that they have to continue. And what has been a good third part in our process of how to maintain the continuance of the treatment that was started in prison administration. The third part seems to be in several NGOs who have approached us with good programs which we often start within our prisoners while they're inside and then the treatment continues while they go outside. The question of why is important for policymakers to be addressed of this issue because of a common situation when the legislative is being made or developed about how to handle this problem in prison situation. There are not a lot of practical experts from the prison administration who are directly involved in this treatment. So usually we have laws and bar laws which predict a large amount of deaths but many of those things are not so practically useful for us. Okay, thanks very much Blanca and you give me the opportunity to give the floor to Teano. Mavrumostaki, as you mentioned the policymaker and how the policymaker can support the implementation of important interventions in prison. Please Teano. Hello to everybody, thank you Linda. Well, I think we all understand and we agree that prison and community as you said cannot be separated. So this is why it is so important to address this issue and realize that population in prison yesterdays and tomorrows is the same population of the community plus there are special problems that can develop in prisons. In that environment, of course we all understand that things can get worse but control can also be facilitated because they are in a controlled environment. I found very interesting reading the publication that in prisons there are people that have access to therapy for the first time but there are also people who have access to drugs for the first time. So you have these opportunities to work with these people and they are in a controlled environment so maybe access to them to their therapy or education is easier. There is any to address these issues of course because people need to get ready to be prepared for their early release, for their release. And we did have a problem with early releases recently in Cyprus as I mentioned to you earlier that when in COVID times people were released earlier not prepared, there was no such chance for their continuation of their therapy and there were some problems there. However, there was a strange finding that crime rates were reduced. Of course we had a strict lockdown then so maybe criminologists need to look at this and it's not for this webinar to discuss. So people need to be ready to integrate there are health issues, criminal justice issues, social issues. So this is why it is important to address this issue when people are in the controlled environment that also civil justice issues, civil law, civil lawyer. So I know that from that side we very often need to defend the government in cases involving prisons. So there are civil justice issues as well. Now, the understanding needs to be that people need to be ready to be released. The understanding is that drugs circulating prisons and this is a great understanding for everybody and that should be a priority to control this circulation. If we cannot control it completely and then I'm sure with every prison there are efforts done in that respect then facing and regulating these issues must be a priority for everybody. So good understanding is needed of the population you are dealing with and prioritizing the issues to face when entering, during and after release. I hope I answered your question. Yes, and we also make a nice bridge talking about the population and I would like now to give the floor to Mark Johnson and to have the user perspective on these questions on how it's important to address the drugs and prison issue. Mark. Yeah, hi there. Thanks, thanks. So I mean, why it's important to address drugs in prison is really like kind of the saddest and sort of the end of the very sad situation for a lot of lives of drug users. It shows a failure from societal systems from prevention in childhood and addressing early childhood trauma to all of society's constructs to address like human health. It shows a failure in how police are the default mental health service in our society, how the courts have a skills deficit into not criminalizing and being able to filter and assess criminogenic factors to drug use to sort of sociobiological factors. It shows a skills deficit within the probation services in the community and ultimately people end up in prison, you know? And so in this issue, it's basically down to policy makers and I'm going to make a quite challenging statement. Policy makers and practitioners do not understand the living reality of somebody that is literally drug addicted and in prison. And, you know, that's pretty much why I started the organization which I founded and I was in the privileged position to be able to do that and speak quite loudly. Alexi started by saying, we've got the science. You know, there's a historical sort of record of lots of science around drugs misuse and prison. Yeah, we still have an absolute systemic failure to address it. And all of this science equates to kind of nothing if it doesn't change somebody that's in prison's life so they don't re-offend. And we as a society need to really look at how we get successful reintegration of those people. And that's why I've centered all of my efforts and work on peer-led approach, which some would say discredit through antidote or unscientific or not research, but actually what we've found over 16 years is it makes the difference on the ground because we're talking now at this conference that's EU-wide and I'll guarantee you we could go into any prison in any country that's here and speak to a group of people which would corroborate the most basic sort of narrative of what we're talking about. We, so yeah, so going into that, so we work in sort of one-fifth of a prison. There's a COVID situation I'm talking about now. So 2020, we engaged 23,000 people in prison in the community. We were the last ones out and the first ones back in. 83% felt more isolated, 87 more frustrated, 80% more stressed, 65 worried. This worrying factor is less than a third being seen by a mental health team. So we've had 17 months of 23 and a half hour banger and I'll say 23 and a half hour because statutory is 23. But if you go to a healthcare, and I'm talking primary healthcare in a British prison, they take half an hour off your time out yourself. But it's 23 hours over seven months and British prisons have just moved to stage three, which means one visit a month by an immediate family. We know that prisoners don't have, they don't have families or have broken relationships. So if you don't have immediate family, you don't have any visits. And I'm just started to lead on a research project which is the economic social research cancer funded with Professor Shad Maruna from Queens Belfast into a study impact of COVID by prisoners. So we're training as peer researchers about 60 prisoners and we'll be conducting the work over the last 12 months and I'm happy to report that. Thank you, thank you, Mark. We have only 10 minutes left. So maybe I suggest we go through some questions already. So there was one question regarding the treatment. So in prison, say we normally give methadone or pulprenary for the drug addicts, what should we do with other substances users like methamphetamine, cocaine or cannabis user, I don't know if Hino or Blanca want to reply, please Blanca, short reply so we can manage. I mean, what we can do is what we should do is to offer pharmacological services. And we're in the lucky position that for opioid use disorder we do have medication assisted treatment with either methadone or buprenorphine or even diacetumorphine or slow release morphine, whatever. We've got some options for that. And for the other, let's say addiction phenomena we do not have, we are not in the lucky position to have pharmacological responses. But what we do have and what has been mentioned already by Blanca is we've got cognitive behavioral therapy plus we've got self-help groups that could work and function in the same way as groups and as strategies outside. So the best thing would be to integrate NGOs, external people from outside in order, let's say, to benefit from the trust they're giving and let's say to install such groups and such self-help activities inside prison. Thank you, Aina. I want to just, since you talk about trust to give back the floor to Mark regarding this. So what is, how is important is the trust inside prison to implement health or social intervention? Can you repeat that again? Sorry, Aina. My, Aina was talking about the trust, the needs for the trust. And I think this is a key probably factors for the implementation of good intervention inside prison. Yes, I mean, I find it really hard to comment on prison 18 months ago and using that as a reference because COVID has literally been a game changer, right? So there is no trust. So Aina talked about pharmaceutical intervention. I'll tell you the number one, which is what we're finding. I've only just done the first bits of the group work is the use of antidepressant medication. So the prisoner state saying that prisons are stable and there's a dropping number of users and users are reporting that 60% they didn't use within the first five months of lockdown which is very convenient running a prison regime. But what we're gonna, I think the emerging trend will be is the sort of blasé prescriptions on antidepressant medication. And that's how we're dealing with this. The fact is in British prison like 17 months there's been no intervention. So you've had an actually more worrying the reporting structures from individuals to healthcare or prison regimes. I believe we're gonna have the emerging trend of under-reporting what the actual truth is by prisoners because the mechanisms have gone because outside agencies, including in spectra, oddies, et cetera, have actually been withdrawn from that. So it's a tricky one, but I think trust is at all time lows for prisoners in the state being to sell over that period of time and some of the harrowing stories. I've been doing this a while listening to people and consulting and I actually cried in the last group that I heard with a group of women talk about their experiences. So yeah. Thanks, Mark. So I give the floor to Blanca, maybe she want to comment on this intervention for other type of drugs. Well, there are. And maybe also the reference to the COVID situation as I see there was also some questions regarding this. There are several combinations, not only for the substitution therapy, Mark has mentioned the antidepressants. So they are adequate responses from our psychiatry to the individual need of each and every prisoner according to his opoid or perhaps cocaine. I'm sorry. Yeah, amphetamine. Yes, addiction. Addiction, okay. In my experience, the opoid substitution therapy is never only one pharmacological choice. There are always several which are targeting several prisoners needs. So they are not the only two choices in the treatment of drug addicts in a prison setting, methadone or buprenorphine. Although the buprenorphine is also state, it is also described as a moderator of the level of the mood. So it has other impacts on the mental health of the prisoner, not just the one which are restricting him for using the drug. I'm not sure did I heard Mark well about the situation in prison that because of the COVID situation we were not allowed to be supervised in our work. Did I heard you that you said that? Because we did have some restrictions in prison situation, in prison administration because of the COVID, but it didn't stop the regular supervisors from a minister of health, especially from them during this COVID situation. They had several unannounced visits because they wanted to make sure do we are we handling the situation with this epidemic? Okay, and we got lots of assistance during this period of time because what happened outside to the rest of the world happened to each and every prison in penitentiary in the country. So we needed an extra help and we did get it and we did get a lot of other supervised visits because it is mandatory to take care of especially in the demand custody trials. So that didn't vanish but prisoners had a chance not to physically have contact with the judges. They had opportunity to be heard through these video link operations like we do have now. So we also managed to make our communication and to make it possible for prisoners to communicate to the outside of the world through internet connection. Okay, thank you, Blanka. I see Heino, please, if you wanted to comment. I just wanted to add to what Mark and Blanka said that also let's say not only drug specific activities and interventions are necessary but also let's say indirect measures and activities are necessary like a meaningful work and occupation, sports activities and so on. All these measures are necessary in terms of mobilizing people and showing them let's say physical achievements they can or physical achievements they can go for. That's something I think which needs also be mentioned. Thank you. Thank you, Heino. So I think this round also completed. I answered a bit the second question on what are the effective and social responses that can address the drug problem. I don't know if Tiano wants to add something regarding this question. Then there are several questions in the chat and I will comment just after Tiano's. Thank you Linda. Yes, I will mention something different to what my colleagues mentioned and there has to be a realization there is an interconnection between brexit prison plus poor health in many inmates as we noticed. From my respect, it is important. It is important to protect the human rights firstly of people in prison, including the right to highest attainable standard of physical and mental health. Whatever that means in practice they have a human right to have access to highest standards under the circumstances of health and treatment. I think that we should all work having three steps in our mind and first is to identify the nature of the drug problems of each person involved, select potentially effective interventions specified for each one of them and be able to evaluate these interventions so of course there will be improvement if possible. So it has to be maintained and there has to be a continuation after that release to avoid the other problems discussed before. As Alexis mentioned and that was, I will not say scary but it was something that we need to take into account again and again is that 30 years ago they were discussing deaths after release and we are still discussing it now. So this maybe makes it very, very important again to prioritize the problems, the health problems in prison and case. Thank you, thank you, Teanu for this. I profit to answer two questions regarding recent studies we have conducted a rapid assessment on the impact of COVID on drugs and prison, on drugs and the drug issue in the community and in prison. So you will find in our YEMS website the result of the study showing that it was, as I say in the presentation, a reduction in drug use, disruption of the normal drug trafficking route but also for the services. This implied a lot of reduction of all the collective activities and that was problematic for the people who are in prison. There was an increase as Mark and what they were saying of the mental health problems with the higher requests of views of benzodiazepine inside the prison. A specific issue I think Elena Leclerc asked was is the impact of the measure of early release? I don't think there is any assessment that was conducted yet but we had a session in a recent expert meeting on these what could have been the impact of the measures of reduction of the prison population on drugs. And if the Kansas have adopted, I don't know if Teano again, as you were in this meeting, you wanted to comment on this specification and we'll go back to other question on interventions. Well, as you want me, well, what happened in my country there were early releases. There were criteria of course on whoever was released. The problem that I mentioned also earlier was that because of course there had to be releases but people were not prepared to continue their treatment and maybe under the strict lockdown we had an all this strange situation. It was a first time in many, many years situation. There was no access to continue therapy. So yes, there were some problems in psychiatric hospitals. Maybe people needed helping elsewhere. As I said before, what I found interesting was that crime, drug offenses were greatly reduced as the police gave the numbers to me, but this is a different area. So one has to balance COVID in a closed environment, prison and a continuation of treatment. I'm not sure I can give you the answer yet because we don't, it's very early I believe to know exactly what is going on and how things will be in the future. But this is something we noticed that we had these problems in psychiatric hospitals. Thank you, thank you Teano. Going back to the intervention to, there is one question that's probably for Blanca or others. How do you promote motivation to drug treatment to within prison? I don't know who want to reply to this question. I see Mark smiling. You basically create recovery communities within prison and seeing is believing, yeah? So prisoners play an absolutely instrumental part in promoting motivation for other prisoners who are newly arrived to access their relevant treatment and actually more importantly as a route out of abstinence. And there is a kind of a historic sort of evidence around recovery communities and therapeutic communities within prisons across Europe I believe as well. Thank you Mark, Blanca do you want to add? I have mentioned before that we have very good results in working in rehabilitation programs with drug addicts based on the cognitive behavior model. One of the most common technique is called the motivational interview. So prison personnel, prison and probation officers had to go through the education. It lasts for two days, it's a training and it is a very good method for people to be triaged before involvement of the rehabilitation process. So the motivation is the keyword, the key, the base of all and it's something that we have to do with our prisoners during the whole staying in and during the whole sentence. It's not something that we just touch at the beginning of the imprisonment and then leave it there. We have to nourish motivation of the prisoners. We have amplitude, we are going down, we are going up. So it is a process that starts by entering inside and hopefully ends with a good solid motivation to take care and to be involved in this continuous of the process that we already have mentioned here several times. It is, I think the only positive effect is to be continued, to be inside the prison in some kind of treatment and after release. One without the other doesn't work. Thanks, thanks Blanca. I see Haino, you want to comment, maybe linking also to his experience on the heart reduction intervention. Haino, you're muted. I think what is motivating is that people can make choices that they have options they can take. If there's only one size fits all strategy then I think it is not very motivating. So I think we have to have a compendium, a comprehensive package of services in place, the same as outside in the community in order that people can make informed decisions and informed choices. So I think this is the baseline for motivation. Thank you, thank you Haino. And there were several questions on the best practice or evidence of effectiveness. As I say in the presentation, there is evidence for the community intervention less for prison because there is less research, less information inside the prison. In the report we report, we discuss the evidence but also in the chapter where we map the intervention we report several examples from country. They are not best practices but they are example. I don't know if Haino, you can comment in particular on the evidence and the effectiveness of heart reduction intervention in prison. So we just carried out an overview of let's say the state of harm reduction in 30 European countries, 28 plus Norway and Turkey. And what we found out with regards to harm reduction oriented interventions was that the availability and the coverage of harm reduction interventions in European prisons was limited compared to the community and there is a gap between international recommendations on paper and on paper availability of interventions and the actual implementation. So we've concluded that scaling up harm reduction in prison and through care can achieve important individual and public health benefits. I put the link to the survey into the chat so each and everybody can enter it. And I think that is very important. You mentioned that already Linda that most of the interventions are coming into prisons with some delay and with very limited coverage. Just two examples. Germany is put under the three countries who offer a needle exchange program, but this is only implemented in one out of 181 prisons. So it's a coverage rate less than 0.5%. The second example is OST. Also, let's say there are only few countries who have offered OST like UK and France to a high extent. And many countries are below 50% coverage. You are highlighting that in the report very well. And even let's say you highlighted the case of Mr. Wanner against Germany, a case court before the European court for human rights. There a prisoner went finally to Strasbourg before he failed two times on, let's say, two levels of courts in Germany because his OST was interrupted on the day of incarceration. And that, of course, is a breach of the European Convention of Human Rights. And Germany has been sanctioned for that. And so we see that it is not only, let's say a topic of money and let's say resources, it's often a topic of attitude and morale which hinders and hampers the introduction and the implementation of harm reduction interventions. Thank you. Thank you, Haino. And as Haino was saying, I think it's important also to remember that we have collected in the report, reported in the report, the officially available interventions. So for instance, needle and syringe exchange are available officially in two countries extensively and in Germany, just in one prison, but there are single doctors that took the initiative to do this intervention. And also, obviously, the tuition treatment is, let's say, it's available now as a continuation from the community, but not just in two-thirds of the countries is possible to start, obviously, the tuition treatment in prison. And I think it's important to highlight as what Haino was saying that the coverage is low, but also we don't have good information to establish the coverage. So that's another gap that we should, I think, feel. There are several other questions in the chat. Regarding, I don't know if Mark or Blanca can reply, there is one question on the use of prescribed medication in prison and what are the issues around misuse and diversion. I don't know if you have any information on this. Blanca. As to my knowledge, the prescription medication from the outside, I hope that is the question, yes, it is available inside the prison, but it can be changed to the other generic treatment because it depends on the provider for the pharmaceutical of the prison administration. So the cure itself has to be the same, like from the outside world, but if we do not have the same provider or the manufacturer, it has to be the same line of the drug. So thanks, Blanca. I don't know if anyone want to add anything else on this. I would then move to the last question so that we prepare that is how this report, the MCDDA report can be useful in your work. So let's start with Teano. Thank you, Linda. And thank you for involving us in this webinar and thank you for the application, which I found very, very interesting. And not only it can help all kinds of experts dealing in this area, but me personally, I realized things, I didn't know, and this is the most important thing for me. I got information, evidence-based information, and I realized, I think it's number one, is the basis to build on and continue and finding solutions in complicated and difficult issues as dealing with the dependence and health issues in prisons. And to me, it was very, very important class. We now know it was an easy way, it is the way, not easy for you to draft it, but we find information easily, which country could be facing same issues as we do, and follow examples or give our examples to other countries. So really, I was very, very, very impressed at reading the application. And the first thing I can say, the main thing is the realization of various issues around drugs and prison. Drugs and prison, as we mentioned before, is correlated, unfortunately. So, to me, it was very, very, very useful, and I'm sure our experts now that we have it and our institutions will have a chance to study it and maybe contact you for further help on this. Thank you. Thank you, Dr. Blanca. Do you want to comment on how is it possible to reach? Better our audience and those who can make direct use of this information? I, as a practitioner, can say that all the publications from the MCDDA that I have been reading were very good and informative for us, because as Tiano said, it gives on the oversight what is good, what is happening in the region, and perhaps somebody did something better than we did. So the coping with this problem of the drug dependence in the prison administration is very complex and it is not the one-way ticket. So the publications are, for me, valuable because they are evidence-based. So that is something that I also cherish. This document has some several main chapters which are really helpful because it targets all the issues that we are facing while trying to improve our existing model of treatment of drug addicts in the prison setting. I only can say that thank you for publishing this. Thank you for the good work that you have done. And I'm looking forward to have some colleagues of mine which I gave them the link to the PDF so they can read and that we can comment because I think that this particular insight is very well done because of the data you have collected. Thank you, thank you Blanca. Now I give the floor to Marc to have his view on this, how this can be useful for your work. Yeah, I mean, as you know, Linda, I'm a great supporter of your work and the report is really informative from sort of data and sort of what the issues are. I read the report concludes most of these are needed on the outcomes and interventions targeting demand as well as supply, reduction in prison settings. I think that these are some of the things that we must think about going forward around looking at the criminal justice systems as a whole and why the regimes actually are in the systemic sort of the system of those regimes actually go to exacerbate drugs and misuse in prison themselves and actually what some of the solutions are. So I think it's crucial that we not only involve prisoners and ex-prisoners but we actually start to look at how they can contribute like I have with you, their own research projects and services and actually go one step further and it's something we've been looking at around how you get because often this problem, we can talk about the global issue of data which is really, there's a really rich here but actually it's site specific or country specific and site specific that actually where it sort of has the most impact and prisoners play a crucial role in that site specific element. So if we had a mechanism that looked at things like procurement involving prisoners in site specific environments about the procurement of healthcare services that they receive is one way that we could think global about this addressing this issue but act local as far as making services relevant to that community in that country within that right set and I think that we could perhaps look at that sort of one of the areas sort of going forward but yeah, thanks. Thanks, thanks Mark and the last is I know what is your view on this, are you unmuted still? So it's a very important document Linda and thanks to all the authors and all those who contributed to that. It's important in that way that we will use it definitely as a reference point, as a source when we argue with ministries of justice, interior health in order to show them what can be done what should be done. It has a fantastic data collection on the point and this has really improved in the last 20 years. When I remember in 1999 I was doing some sort of the first version of data collection in the field of prison and drugs and then at that time the data basis was very weak but I think it improved a lot. And as I mentioned, it has gone down now to the European drug strategy at 21, 25 and so far it's a very good book, a very good document which I think can show stakeholders and key persons in the ministries what can be done elsewhere in Europe. It's not, let's say, exotic in a way but if I tell people that, for instance, in Luxembourg they have a professional tattooer coming into the prison in order to avoid infectious risks when people are doing their tattoos in prison then it is a very good reference document for that. Thank you very much. Thank you, thank you. I know I continue with you because then there are some other questions I think we have still seven minutes and there is one question for you if you can tell please some example of good practices of social workers in the field of drug addiction prevention and treatment in prison based on your experience of training and so on. Yeah. You want me to repeat? No, no. Yeah, yeah, yeah, okay. So social work I think is being done by prison-based social worker and by people coming from outside, inside prison, also within NGOs there's a lot of social work coming in. I think what can be done, what could be done from the social work perspective is reintegration all activities that go in that direction can be pushed by the social worker inside prison. That means housing first, for instance, occupation, contact to families, parents and children even and also let's say working on the two key standards or the key principles that is equivalence of care and continuity of care. So fight for the introduction or the implementation of the same size, standard and quality of services which are done offered outside, inside prison and also to do everything as a social worker to guarantee a continuity of care once people are released. And a very good example highlighted in the report or in the insight is the example of naloxone. So naloxone training a few days before release and giving out the kit so that let's say the first 48 hours out can be survived in a way that many people will have naloxone to help themselves, to give it out to the family also in order of an overdose and in relapse that something can be done. Thank you, I know. And regarding the contract of drug users or people in prison with their family, there is a question. Maybe Mark wants to reply to this. So how is it possible to improve the contact with family during incarceration as this may be an important factor for rehabilitation? Yes, it's a simple answer. In the UK, they call it, I think Blanka mentioned it as well around video contact and stuff during COVID. However, we run a risk of overusing that method. And so for the regime, prison regimes, it's actually quite convenient that we provide screen and actually not have human contact. So they call it purple visits in the UK and they've been very much welcomed, you know what I mean? Like, especially during the last 18 months. However, I'll give you a situation. Met a young girl, 21. She's been literally COVID locked, bang up for 17 months. She's got a three-year-old baby. She's just had a visit last week when I met, when she told me the story and she had to visit four metres apart and had to wear a bin liner to have contact with her daughter and her daughter called her auntie, okay? So, and she'd been having these visits with a young child running around the house, but no contact. So a video screen is limited, but very convenient for a system that wants efficiency. So we could tick a box to say, you know, our video screens are great and we have contact and that's very convenient, but the reality of it is for a young child who doesn't pay attention to a screen or whatever. And we have to think about these things. It goes in some way around. And also the acknowledgement is such a lot of effort and resource goes into family visits. Whereas there are such a lot of prisoners without family or if they've got family, they're the reasons or part of the dysfunctional reasons that they're in there in the first place. And we look at addiction is the person suffering instead of what we know as practitioners, it's a family illness. You know what I mean? It involves that family. So it's really important. For me, it's about the cognitive behavioral support around peer-led support around the 12 step fellowships or smart recovery or whatever is available and allowing healthy attachments and a positive message to get across from prisoners returning into society. Yeah, because, you know, reality of it is family or no family to recover from addiction is tough and people need to be prepared and armed with a fact about what they're about to face. Thanks, Mark. So I give the floor now for really a very short last comment to Blanca and Teano, if you want, please. Well, I wanted to say that Mark has really... He hits the bull's eyes. It is true that many of the prison and penitentiaries have, so to speak, benefit from the COVID situation and really did use this situation to, so to speak, do not organize under the... They use the situation to try to, so to speak, try to hand to this issue of video call as long as possible. There is, how to say, a silent war between us, which are treatment personnel and the security officers. We in treatment personnel usually we're saying the video call is okay, but it's not okay. Usually we're saying the video call is okay, but it is a short term, it's not normal and the prisoners have to have their families in physical way, but the police officers use this situation and said no. So we are still struggling with them, but now since the epidemic situation is better looking, the visitations are currently available, but it is something that we are struggling with our colleagues not to use this situation and not to provide our prisoners context with their families. Thank you, Blanca. Last comment. Thanks, and Teano? Well, as far as this communication is concerned, I must say that in Cyprus we managed to have, I think it's the only COVID-free prison in Europe. There was no other COVID-free, completely zero patients. And I was trying to find out until when one of the steps taken was no visit, no visit, but Skype calls were available. This is what I was trying to find, but I don't have it now. I think during the whole day, there's no limitation to that. So that helped a little bit in balancing the no visitations to communicating. There was a gradual restoration of visits, of course, but there was a checkup of people, of visitors, of webcasts, of everybody. So it's admirable there was no COVID symptoms in Cyprus. I need to make a final comment if I can, not concerning communication. As a civil lawyer, as I said, 20, maybe 25 years ago, I was defending this case against the government. I was a very young lawyer working for the government. And there was a death from another dose in prison. And I was so angry and called the prison department and said, and how did drugs get into prison? It was unheard of. So many years later, of course, the real, the realization that this is what we, maybe number one of what we need to tackle to attack is very, very important. But the change in attitude, I'm sure, not only me, but in everybody dealing with such issues. It's very interesting, I think, but we're talking 25 years ago, not that was one of my first cases. Thank you very much. Diana also to finish up with the personal experience, I think is always nice. So thanks to all the speaker, but I will pass the floor to Manika. I just want to say thank you. I would like also to thank, because I didn't mention the initial focal points that without them, we wouldn't have had all this data in the report. So please, Marika. No, I just would like to say that there were more questions. We weren't able to answer, but we recorded them. So we will put the people asking in contact with our speakers so that they can go on with their, and also there was a very lively chat. We also personal and felt experiences. It has been very, very interesting. Thank you all. I will, we had the good attendance. People remained until the end. I will launch a poll for our attendance to know their opinion. You don't need to remain. I know that we took a lot of your time already. Thank you everybody. Really. It has been interesting. And I hope we will have more questions. And I hope we will have more opportunities to meet together and to reply to our public. Thank you very much.