The tragic story of Jani Rustemi, a drug user arrested for theft, exposed the lack of proper links in the penitentiary system to treat suspects, prisoners, and even those in pretrial detention, according to a standard procedure.
Author: Ermal Vija
Five years ago, an elderly woman knocked on the door of the Pogradec police station, seeking the incarceration of her son, a drug user, whose family had suffered several times due to the violence caused by him.
“My son, E.H., has been a drug user for 15 years. He drinks, gambles. We’ve sought treatment, taken him to the Psychiatric Hospital. He still uses drugs. He gets sick, things get worse; we’ve taken him to the Military Hospital for three sessions. I want him in prison because he harms us, me, my husband, and my daughter. I ask for him to be isolated,” pleaded the mother, F.H.
According to the decision, since the day his mother obtained the protection order, what the family had failed to accomplish was assumed to continue. Facts and data gathered by INA Media indicate that there are no specialized doctors in Albanian prisons to manage this category, while outside the prisons, there are no institutions dedicated to their rehabilitation.
On September 8th, 2018, the court ordered E.H. to participate in rehabilitation programs and toxicological services at the Pogradec Hospital Center. The responsibles of this program were obligated to report weekly to the court, but not only then, even five years later, this hospital lacks a rehabilitation center.
“We don’t have a toxicology department. We are a municipal hospital, and this service is not provided in this type of hospital,” said Erion Thëngjilli, the director of Pogradec Hospital, to INA Media.
“We only have an outpatient service for people with mental health problems, where a doctor and a nurse are employed for emergency cases,” he further explained.
Although the court ordered his release from drug addiction and designated the hospital center for follow-up, Hoxhallari received no service but further plunged into drug use.
A source close to the local police states that the 28-year-old is known as a user of narcotics but has not been arrested since the last detention.
Article 230 of the Code of Criminal Procedure, in its second paragraph, gives special importance to individuals addicted to different substances, excluding them from the “Pre-Trial Detention” security measure. This article specifies that “Pre-Trial Detention” cannot be imposed on a person addicted to drugs or alcohol undergoing a therapeutic program in a specialized institution. However, they can be placed in a cell in cases of serious crimes or when necessary for investigations, and cases under these criteria are not rare.
Official data from the General Directorate of Prisons and the only institution in Albania dealing with drug addiction, the Aksion Plus association, show that 149 incarcerated or pre-trial individuals are being treated for their addiction, mainly from heroin. Their treatment with methadone, a substitute substance, is provided by the Aksion Plus association, and recommendations are made by pharmacists or general-trained prison nurses.
Official data from this association show that the one-year treatment for those in prison costs 13,000 euros, with an average cost of 150 lek per day per person. This cost is covered by Aksion Plus, and the prisons themselves do not have an additional cost for their treatment.
Recent socio-economic changes in society have reflected a significant increase in drug users and consequently in individuals dependent on drugs.
In Albania, a total of 1,009 individuals officially receive methadone treatment. According to data provided by INA Media, there are 60,000 identified drug users, of whom 10,000 have developed dependence on at least one type of drug: cannabis, cocaine, or heroin.
However, despite the growing issue of drug users, Albanian institutions have remained bound by an agreement made 17 years ago to address the situation.
An unresolved issue
Every month, an authorized person (usually a pharmacist or chief nurse) from the IEPV (Institute of Forensic Medicine) appears near the Aksion Plus center to collect methadone for individuals in prison addicted to heroin, as part of a substitute therapy.
Unlike other countries in the region where methadone treatment is provided by the state, in Albania, this delicate procedure has been entrusted to the Aksion Plus center, an NGO supported by the Global Fund for almost two decades for methadone therapy.
The initial agreement for the treatment of drug users held in prisons was signed 17 years ago. The Minister of Justice at that time, Aldo Buçi, delegated this responsibility to the Aksion Plus center.
According to this agreement, the Ministry of Justice is supposed to create the conditions for treatment and implement activities organized in collaboration with the Aksion Plus association, aiming to protect the health of individuals isolated in prisons who are drug-dependent. The center has taken on the responsibility to treat all convicted and pre-trial detainees for free. If a convict is a heroin user, after examinations by toxicologists, the methadone treatment protocol, provided by Aksion Plus, is put in place.
“According to our estimates, the overall cost of treatment for an individual at liberty is around 150 lek per day,” says Genci Muçollari, director of the Aksion Plus center.
However, the lack of doctors in the penitentiary system is also posing challenges for this category of individuals. Currently, there are 53 doctors working within the prison system. Only 28 of them are full-time, while the others work part-time, but none are specialized in treating individuals with drug addiction. These doctors are also responsible for serving 1,400 chronic patients as well as 378 others suffering from mental health issues, for whom the court has ordered compulsory hospitalization. Additionally, there are 159 nurses employed in this system.
The latest report from the Ombudsman’s Office finds that the primary reason for the lack of timely and quality healthcare services in correctional institutions is the shortage of healthcare staff, primarily doctors.
“During 2023, within the inspected penitentiary institutions nationwide, we recommended measures to fill the position of a full-time doctor as provided in the institution’s organic law,” explains the Ombudsman through an official response.
The Ombudsman clarifies that complaints related to the quality of healthcare services continue to be the largest number of grievances submitted by prisoners or their families during inspections. However, despite this long-standing critical stance of the Ombudsman, the Directorate of Prisons states that “the system lacks only 5 doctors and 8 nurses.”
According to the toxicology specialist, Tedi Rudha, it’s crucial to urgently establish specialized medical staff within prison premises. He explains that in most cases, these individuals require more specialized treatment from toxicology doctors.
“There’s an urgent need to place specialized staff within these institutions to treat and monitor these patients specifically, following contemporary and specialized medical protocols,” says Dr. Rudha.
For jurist Bledar Meminaj, the prison system lacks the capacity to handle individuals who are drug users.
“They don’t have the capacity to treat a certain category of persons, who could receive this treatment in specialized clinics at the QSUT or in private clinics under family care, including the costs associated with these types of treatments,” explains Meminaj.
He doesn’t hide his surprise that despite this situation, where the prisons insist on not altering the security measures, they take on the burden of providing healthcare.
“From precedents we’ve had, although the penitentiary system didn’t have the capacity to treat these patient cases, when presenting the matter before the court to substitute security measures due to health reasons, the penitentiary system surprisingly maintained the position that the pre-detainee could be treated at the pre-trial institution without delving deeper into the specific diagnosis,” expresses jurist Meminaj.
Troubles with methadone patients
Jani Rustemi, a young man who was on methadone treatment, was arrested on the afternoon of April 12 for stealing a carpet and a pair of shoes in Tirana. He admitted to investigators that he was a heroin user and that he stole to obtain money to buy drugs. Two days after his arrest, on April 14, he didn’t feel well, so Emergency Services were notified.
“His vital signs were normal. This individual was in a state of anxiety, and the Emergency medical team administered a sedative, diazepam,” as explained in Jani Rustemi’s medical report, obtained by INA Media.
A day after this health episode, Rustemi appeared in court and was assigned the security measure of “Arrest in prison”. Due to the lack of space in the pre-trial detention center Jordan Misja, he was sent back to the Security Block near Police Commissariat No. 3, which had initially arrested him. During his time in the Security Block, Rustemi was also being treated with methadone.
“Citizen Jani Rustemi was being treated with the medication methadone, as he was registered at the Aksion Plus center and this medication was given to him according to the recommendation of the DVP doctor, Tirana, with entries made in the respective logbook at the Security Block in DVP, Tirana,” – as stated in the police response to INA Media.
On April 17, Rustemi again experienced issues and was urgently admitted to QSUT in critical health condition. Rustemi passed away at this hospital, one month after being in a coma. For experts, what aggravated his health condition remains unclear.
According to the hospital’s record, available to INA Media, it states that “the references are confusing.”
“At the time of examination by the medical staff at the commissariat’s premises, the patient was found unresponsive, with no peripheral pulse, but with a central pulse and in bradypnea conditions. Consultation with the toxicologist reveals that the patient is a heroin user and has been under substitute therapy with methadone for 4 days, but the references are confusing,” – as stated in the document.
Rustemi was known as a drug user, even by the Aksion Plus center, and was being treated with a dose of 40 mg of methadone. This center maintains a specific database for all those treated in prisons.
“Based on the data we have, Jordan Misja was treated with the same dose from 13.05.2022-04.07.2022. Then he returned to continue the therapy at our center, with a daily dose of 30 mg. The last time the citizen/client appeared at Aksion Plus, Tirana was on 10.04.2023 and took the medication with him,” – says the Aksion Plus center.
However, lawyer Franc Terihati considers the case negligent treatment and abuse of duty. He alleges that the police hid the incident and reported the case to the Police Oversight Agency and the Prosecutor’s Office in Tirana.
“The problem is that we don’t know the reason why Jani Rustemi’s health deteriorated. It’s unclear who gave him methadone and if the doctor at the Security Block may have given it to him in a higher dose,” – expressed Terihati, representing Jani Rustemi’s family.
The Albanian Helsinki Committee has raised questions about the treatment method and who treated him in a monitoring report conducted for the case.
“There was no consultation with the toxicology specialist for the method of treatment with antidote. The emergency doctor at QSUT, who treated citizen Jani Rustemi on 14.04.2023, noted treatment with “diazepam solution”. The dosage of this treatment is not specified, which is a requirement in medical protocols,” – is highlighted in the AHC report.
This case has raised questions about the treatment of these patients. Aksion Plus Center claims to have provided doctors, nurses, and pharmacists in the penitentiary services with the necessary treatment protocols and continuously trains them.
“Methadone is prescribed in many ways: for long-term use, short-term use, and detoxification treatment. Evidence shows that the longer the dependency, the higher the maintenance dose should be and the longer the treatment duration,” – explained Genci Meçollari on how therapy is used for isolated individuals who are also drug users.
According to him, those entering this therapy for the first time should be supervised for the first 2-3 hours. Initial doses should be low. Patients under supervision may be given an additional dose if signs of pallor appear.
“It’s important to gather information if the patient expected to start methadone maintenance therapy (MMT) has previously used methadone,” – explained Muçollari.
Is there a standard procedure for methadone treatment?
If a person has used heroin, the recommended dose of methadone depends on various factors, including the time and quantity of heroin use, the body’s tolerance level, eating habits, and body weight. But the final recommendation should always come from the toxicologist.
“The initial recommended dose should be between 20-30 mg. In cases where tolerance is high, the normal dose might be 40 mg. When tolerance is low or unknown, a dose between 10-20 mg. is more suitable,” – explains Muçollari.
“Too much methadone can be fatal, and insufficient methadone may not be effective,” – he further adds.
Once the decision for security measures or sentencing is executed, the convicted or pre-trial detainee is questioned by a commission about their physical and mental health. The commission consists of the director or deputy director, a doctor, psychologist, educator, and police chief.
Cocaine and hashish
In our prison system, there’s another isolated category: individuals who use narcotics, including cocaine and cannabis sativa. This group of convicts or detainees is treated by medical staff within the prisons, collaborating with toxicology specialists. Doctor Tedi Rudha has noted an increase in the number of users.
“In recent years, with the rise in the incidence of cocaine users, challenges have emerged in the medical service regarding the management and treatment of these individuals while they are in detention or serving their sentences in correctional facilities,” says Doctor Rudha.
Prisons are overcrowded also due to the Temple operation. Within the framework of the operation launched in mid-September, 435 people have been arrested nationwide for drug distribution near schools and places frequented mainly by young people.
During the session to determine security measures, the majority of defense lawyers for the arrested individuals claimed that their clients are drug users and sought their release from custody. According to jurist Erjon Kullolli, police officers often abuse those caught in flagrante with narcotics, whether they are users or sellers.
“Albanian criminal legislation lacks a legal definition regarding the quantity of narcotics considered a small amount, and this gap leads to abuses,” Kullolli states. “In practice, there is an issue where young users and those with a long history of drug use are treated similarly in terms of criminal responsibility,” he concludes.
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