From Lithuania to Estonia: learning harm reduction management in prisons

30 May 2016

In early 2016, Lithuania’s Ministry of Justice started to look into the possibility of introducing opioid substitution therapy (OST) in national prisons. Two months ago, the Prison Department of the Ministry of Justice expressed interest in visiting Estonia, where similar programs have been in place since 2008, to study their colleagues’ expertise in developing OST in prisons. The Eurasian Harm Reduction Network and the Lithuanian coalition I Can Live joined efforts to organize this study tour. From May 22 to May 25, a delegation from Lithuania visited Estonia to see how methadone substitution therapy services are organized in prisons.

A group of experts from the Ministry of Justice in our Lithuanian delegation was matched with a group of national community-based organizations that deal with substitution therapy issues and provide services to prisoners. We were accompanied by Maria Urbel, psychologist from the city of Tartu prison rehabilitation program, who facilitated our study tour on behalf of our host, the Ministry of Justice of Estonia.

In the first place, we had a meeting at Riigikogu, Estonia’s national assembly, with Mr. Ken-Marti Vaher, a member of the parliament from the Estonian Pro Patria and Res Publica Union party. In 2011–2014, when Mr. Vaher served as Minister of Internal Affairs, he actively supervised the issues of prevention, medical and social programs for most affected populations in a close cooperation with the National Institute for Health Development. In this role, he supported the development of a take-home emergency naloxone program for people who use drugs, to prevent deaths from overdose.

Mr. Vaher is a strong advocate for harm reduction approaches. He has initiated an inter-sectoral Group on Treatment and Prevention of Socially Significant Diseases that involves government officials, Parliament members and expert communities. This helped to employ a more systematic approach to coordinating initiatives across the field as well as to strengthen the profile of expert community in a sensitive media topic such as harm reduction. Furthermore, Mr. Vaher promotes a comprehensive, social determinants approach to public health.

Mr. Vaher said: “If we are seriously determined to help people with drug addiction issues, we must think ahead of what would happen in ten years. When I hold office, my role as a minister included furthering assistance services to help out families in difficult situations and developing programs to prevent school bullying.”

For this meeting, our Lithuanian delegation also was joined by Alyona Kurbatova, Head of prevention department of the National Institute for Health Development.

With a general population of 1.3 million, Estonia currently has a prison population of less than 3,000. There are a total of three prisons in the country that are located in Tallinn, Tartu and Jyhve. Within our three-day study tour, we have visited all the three. We could talk to psychologists, social workers and medical workers who are in charge of rehabilitation and substitution therapy programs, and we had meetings with Mr. Priit Kama, Prison Department Vice Chancellor, and Ms. Maret Miljan, Director of Rehabilitation Division, Prison Department, Ministry of Justice of Estonia.

Rehabilitation programs are run by all three Estonian prisons. However, if an inmate is diagnosed with an advanced drug addiction issue, he or she would be sent to the Tartu prison that has a specialized drug treatment department—the only specialized prison department in the country. It offers a four-step rehabilitation program, consisting of step 1 — motivation development, step 2 — moving on to therapy, and steps 3 and 4 — sustaining treatment outcomes. On steps 3 and 4, many patients are able to provide peer advice and support to new inmates.

Opioid substitution therapy is made available in all prisons to those inmates who have already been on methadone treatment prior to jail. As of now, an established practice is to not initiate opioid substitution therapy for new patients in jail. A total number of inmates on OST in Estonian prisons ranges from 50 to 100. Other rehabilitation programs are offered to those opiate-dependent inmates who were not on methadone therapy prior to jail. According to prison personnel, OST can be provided to a particular inmate on their insisting request, however, it is not widely encouraged as priority is given to rehabilitation programs. Methadone is made available in Estonian prisons since 2008.

As regards detainees held in police stations for short periods, methadone therapy for those in need is provided through community-run OST sites. In pretrial detention, OST shall be provided by prison medical personnel. Therefore, therapy sustainability is ensured throughout all stages of police detention, pretrial investigation and imprisonment.

Last year, a new education program was launched in Estonian prisons to address overdoses. Prior release from prison, the inmate receives a take-home emergency supply of naloxone (several syringes), that can be used in the case of an overdose by drug users themselves and their family members. One of the most innovative interventions among European countries, the Estonian naloxone program makes naloxone available to all society members, including prisoners who are being released from prison. Alyona Kurbatova, Head of prevention department of the National Institute for Health Development, and Maret Miljan, Director of Rehabilitation Division, Prison Department, Ministry of Justice of Estonia, work in close cooperation to review the naloxone program progress and to plan its further development.   

Regimantas Kavalyauskas, Director of a correctional facility in Maryampole and a member of the Lithuanian delegation, has pointed out: "For me as a correctional system officer, most interesting issues in the Estonian system are how they provide continued therapy and care to the inmate, as well as their four-stage drug treatment model and the wide scope of decision-making responsibilities delegated to the mid-level personnel.”

Other delegates also noted the importance of their first-hand introduction to practical issues of opioid substitution therapy in prisons as well as broader issues related to medical and social assistance services for inmates. 

We think that the success of the Estonian model is determined by a number of factors, such as:

  • The human rights paradigm is unconditionally upheld by all society institutions, including prisons;
  • Policy makers, officials and health experts work in close partnership, regularly meet to discuss and jointly plan further steps;
  • The credibility of the National Institute for Health Development is highly recognized by stakeholders; as a result, policy-makers and state officials’ awareness is raising and they are strongly motivated to implement evidence-based prevention and public health programs;
  • Regular exchange networks are established to share expertise and experience with colleagues from other European countries.

This study tour was organized with the financial support of the Global Fund to Fight AIDS, Tuberculosis and Malaria under the regional program “Harm Reduction Works — Fund It!”, and the regional project "Harm Reduction Works! Improving funding for harm reduction and HIV prevention in the European Union," funded by the European Commission.

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