Alcohol and Alcoholism Advance Access originally published online on March 6, 2007
Alcohol and Alcoholism 2007 42(3):272-273; doi:10.1093/alcalc/agm002
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The Author 2007. Published by Oxford University Press on behalf of the Medical Council on Alcohol.
Alcohol and prisons: report of a workshop held by WHO HIPP at the eurocare bridging the gap conference, Helsinki, November 2006
Author to whom correspondence should be addressed at: E-mail: Lesley.Graham{at}isd.csa.scot.nhs.uk
A major European Alcohol Policy Conference, Bridging the Gap, was held in Helsinki, Finland from 20th to 22nd of November 2006. The World Health Organisation Health in Prison Project (WHO HIPP)1 convened a workshop on the subject of Alcohol in Prisons. The workshop was led by Dr Alex Gatherer, WHO HIPP; Dr Andrew Fraser, Director of Health and Care, Scottish Prison Service; Dr Lesley Graham, Public Health Specialist, Scottish Prison Service and Dr Heikki Vartiainen, Medical Director, Prison Health Services, Helsinki, Finland.
Major strategic objectives of WHO HIPP were outlined, namely, to harmonize and integrate public health with prison health and to promote international awareness and best practice. A recent development in global public health thinking is the underpinning of human rights, and therefore the right to health, as a driver for health development and health for all. The principle that prisoners have the right to health care at least equivalent to that being provided in the community and that prison health is part of public health was endorsed by WHO in the Moscow declaration of 2003.2 Prisons are disproportionately filled with some of the most vulnerable people of society and have multiple, complex health care needs. This provides an opportunity to deliver interventions to those who are often the hardest to reach and importantly, an opportunity to address health inequalities, another key principle of the new public health.3 The recent public health success in the arena of tobacco control, at times without political support, is leading to a new confidence in addressing other public health challenges in modern society such as violence. Alcohol problems are a major and growing public health problem in Europe and concerted attention is rightly now being focused there. The prison setting is one in which alcohol problems should be acknowledged and addressed. Crucially, it should be included in wider public health alcohol strategies, both nationally and internationally.
In recent years, drug problems have dominated the substance misuse agenda. Drug misuse is rightly considered a major public health problem, is associated with serious disease (such as blood born viruses); incurs preventable deaths; incurs high costs for society and is linked with crime. The same factors are true for alcohol, on an even greater scale and with some alarming worsening trends. In the EU, 58 million adults are drinking at levels likely to be harmful to their health. Alcohol can cause direct damage to organs such as the liver and brain and is implicated in over sixty other conditions, including many cancers. Over 195 000 deaths per year are attributable to alcohol and it is the third largest cause of death.4 Although consumption levels are falling in some European countries, in others it is rising, such as Ireland and the UK. In England, annual societal costs for Class A drug use were estimated at £12 billion.5 For alcohol, the figure is £20 billion.6
Scotland has recently been shown to have the highest mortality rate from liver cirrhosis in western Europe.7 Statistics from a general population survey show that young men are those most likely to drink to excess, as are those from deprived areas. 1 in 8 men and 1 in 20 women in Scotland are problem drinkers.8 Alcohol is linked with crime, though the relationship is complex and difficult to measure. Some crimes are clearly alcohol related, such as drink-driving. Many will be recorded as other offences, such as assault. There are strong links between alcohol and violence. There are four broad areas of risk, namely personal characteristics; effects of alcohol; the consumption environment and the cultural context. These risk factors are important to understand in order to be able to deliver effective interventions.
Key facts on alcohol and crime include:
- Alcohol is a known factor in half of those accused of homicide in Scotland.9
- 1 in 6 deaths on Scotland's roads are caused by drink-driving.10
- Alcohol is involved in the majority of domestic abuse incidents.11
- Binge drinkers are more likely to offend than other young adults.12
- Alcohol issues identified as a need in 40% of offenders in England.13
The Scottish prison population is predominately young and male from deprived areas, those most likely to be consuming alcohol excessively. Prisoners are also known to have high rates of other risk factors for alcohol problems, such as mental health problems; drug misuse and homelessness. Many women prisoners report histories of childhood sexual abuse, a major risk factor in substance misuse. In the prison setting, it is therefore likely that there will be many people with alcohol problems, often with co-morbidity, complex needs and linked to offending behaviour. The prison offers the opportunity to offer and deliver interventions to those with, often major and complex, alcohol problems and who can be hard to reach in the community setting. Statistics from the Scottish Prison Survey, an annual self-report of all prisoners, substantiates these assertions. Forty four percent of prisoners reported they were drunk at the time of their offence; 2 in 5 were problem drinkers and 46% said they would accept help in prison for alcohol problems if offered.14
Examples of development of alcohol policy and intervention in the prison setting have taken place both in the English15 and the Scottish Prison Services. The range of interventions in Scotland includes management of alcohol withdrawal; harm reduction awareness (including alcohol) for all prisoners at induction; specialist alcohol assessment with delivery of one-to-one and group work if appropriate. Contact with Alcohol Anonymous (AA) volunteers also takes place.
The criteria for successful recognition and integration of alcohol issues in the prison setting were identified as:
- Commitment at the highest level.
- Alcohol strategy on equal terms with the rest of health policy.
- Clear care pathways based on evidence-based good practice.
- Robust governance with built in evaluation/monitoring.
- Research to address the evidence gaps.
- Integrated care (pre, in and post prison).
- Adequate capacity (skilled staff).
- Partnership working.
The workshop defined the issues of alcohol in prisons, highlighted the evidence of the size and nature of the problem, and set out the case that alcohol problems in the prisons setting should be included in broader public health alcohol policies.
This report of the workshop will be circulated to WHO HIPP members. The resulting action will include:
- WHO HIPP joining as collaborating partner in the EU funded Building Capacity initiative (further information will be available in 2007).
- Establishing links with other key networks on alcohol through the WHO Drugs and Alcohol Programme.
- Continuing to promote awareness of the issue of alcohol in prison and of the contribution that prisons health can make to EU and WHO alcohol strategies by e.g. reporting regularly to the above network.
- Addressing the problem in a new publication that will be developed in 2007 on Prisons and Mental Health.
- Gathering comments, experiences, epidemiology and evidence of best practice from the 34 member countries of WHO HIPP through a survey and the recently launched health in prisons database.
- Identifying further examples of good policy and practice from partner organizations and from the USA and elsewhere.
- Promoting research on prisons and alcohol where funds become available but in association with other projects in the meantime.
This report was written by Dr Lesley Graham with comments from Dr Alex Gatherer; Dr Andrew Fraser; Dr Heikki Vartiainen and Dr Lars Moller.
For further information on WHO HIPP, visit the website at www.euro.who.int/prisons
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FOOTNOTES |
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1WHO Health in Prison Project http://www.euro.who.int/prisons
2Prison Health as Part of Public Health WHO Europe 2003 http://www.euro.who.int/Document/HIPP/moscow_declaration_eng04.pdf
3Closing the Gap: Strategies for Action to Tackling Health Inequalities http://www.healthinequalities.org/
4Alcohol in Europe P Anderson and B Baumberg European Commission 2006 http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm
5Economic and social costs of Class A drug use in England 2000 Godfrey etal. Home Office Research Study 249 2002.
6Alcohol Harm Reduction Strategy Prime Minister's Strategy Unit 2004 http://www.strategy.gov.uk/work_areas/alcohol_misuse/index.asp
7Liver Cirrhosis Mortality Rates in Britain. David Leon and Jim McCambridge; The Lancet; 367(9504); 52–56; 2006.
8Scottish Health Survey 2003 Scottish Executive 2005 http://www.scotland.gov.uk/Publications/2005/11/25145024/50251
9Homicide in Scotland 2003 Scottish Executive 2005 http://www.scotland.gov.uk/Publications/2004/11/20292/47178
10Road Accidents Scotland 2003 Scottish Executive 2004 http://www.scotland.gov.uk/Publications/2004/11/20290/47032
11Scottish Crime Survey 2003 Scottish Executive 2004 http://www.scotland.gov.uk/Publications/2004/12/20379/48077
12Drinking Crime and Disorder Richardson, Budd et al. Findings 185 Home office 2003 http://www.homeoffice.gov.uk/rds/pdfs2/r185.pdf
13Figures from the Offender Assessment System (OASys) database.
14Figures from the Scottish Prison Survey 2006 Scottish Prison Service 2006.
15Addressing Alcohol Misuse A Prison Service Alcohol Strategy for Prisoners HM Prison Service 2004. http://www.hmprisonservice.gov.uk/resourcecentre/publicationsdocuments/index.asp?cat=88
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