Experiences of prison among injecting drug users in England: A qualitative study

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Experiences of prison among injecting drug users inEngland: A qualitative study

Online Publication Date: 01 September 2007To cite this Article: Tompkins, Charlotte N.E., Neale, Joanne, Sheard, Laura andWright, Nat M.J. , (2007) 'Experiences of prison among injecting drug users inEngland: A qualitative study', International Journal of Prisoner Health, 3:3, 189 - 203To link to this article: DOI: 10.1080/17449200701520123URL: http://dx.doi.org/10.1080/17449200701520123

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ORIGINAL ARTICLE

Experiences of prison among injecting drug users inEngland: A qualitative study

CHARLOTTE N.E. TOMPKINS1, JOANNE NEALE2, LAURA SHEARD1 &

NAT M.J. WRIGHT1

1Leeds West Primary Care Trust, Leeds, UK, and 2Oxford Brookes University, Oxford, UK

AbstractImprisonment is common among drug users. However, historically healthcare for injecting drug usersin prison in England and Wales has not been equivalent to that offered in community settings. Fifty-one injecting drug users who had a history of imprisonment were interviewed. Interviews focused onthe experiences of drug-related care and treatment in prison. The interviews were analysed using theFramework method. Accounts of prison drug treatment experiences provided valuable insights intodrug treatment in the English prison. The participants’ accounts provided a historical perspective,many of which reflected the different practices of different prisons and prison staff and the changes inpolicy and practice that have occurred in prison healthcare over recent decades. Positive and negativeexperiences of healthcare and drug treatment in prison were discussed. Issues that affected levels ofdrug use inside prisons and their receipt of care, support and treatment in prison included prescribingpolicies, illicit drug availability and prison staff and doctor attitudes. Whilst negative experiences ofprison and drug treatment prevailed, users identified that recent policy and practice changes hadpositively influenced healthcare provision for drug users in prison, particularly the provision of opiatemaintenance therapy. Drug users often saw prison as an opportunity to detoxify and contemplate theirdrug use. Further work needs to build on the positive experiences identified to ensure that prison drugtreatment in England and Wales is consistent, effective and efficient in the future.

Keywords: Injecting drug users, prison, drug treatment, policy changes, qualitative research

Introduction

The worldwide prison population is increasing and the most marginalised groups of society

are over-represented in these populations (World Health Organization, 1999). Prisoners

suffer high rates of physical and mental health, including infectious diseases, chronic illness,

psychosis and major depression (Lindquist & Lindquist, 1999; Fazel & Danesh, 2002).

Prison populations also include a high proportion of substance users (Singleton et al.

2003a), including those addicted to opiates (Shewan et al., 2005). Physical and mental

morbidity is often exacerbated amongst prisoners with problematic drug use and

Correspondence: Charlotte Tompkins, Centre for Research in Primary Care, 71�75 Clarendon Road, Leeds LS2

9PL, UK. Tel: �44 (0) 113 343 6966. E-mail: c.tompkins@leeds.ac.uk

ISSN 1744-9200 print/ISSN 1744-9219 online # 2007 Taylor & Francis

DOI: 10.1080/17449200701520123

International Journal of Prisoner Health, September 2007; 3(3): 189�203

dependence. However, knowledge about the specific treatment needs of drug using

prisoners is limited, especially when compared to their counterparts in the community

(Neale et al., 2005).

The prison population of England and Wales is predominantly male and in August 2006,

74,526 males and 4559 females were in prison in these countries (National Offender

Management Service, 2006). Imprisonment amongst people who use illicit drugs is

common. Indeed, in 2005, 64% of injecting drug users (IDUs) participating in the United

Kingdom’s Unlinked Anonymous Prevalence Monitoring Programme (UAPMP) agency

survey had been in prison or a young offenders’ institution (Health Protection Agency et al.,

2006). Of these, 42% had been in prison at least five times (Health Protection Agency et al.,

2006). Further, a national survey in England and Wales identified that of the adult male

prisoners who had ever injected drugs, 30% had injected whilst in prison (Weild et al., 2000).

Historically, healthcare provision for IDUs in prison in England and Wales has not been

equivalent to that offered in community settings. However, there have been important

recent changes in policy and practice (HM Government, 1998; HM Prison Service, 1998,

2000; NTA, 2002, 2005; Home Office, 2004) which have been underpinned by a number

of factors. Internationally, the link between prison health and public health has been

acknowledged, culminating in the establishment of the World Health Organization (WHO)

European Health in Prisons Project (HIPP) (Gatherer et al., 2005). The health of prisoners

has become a health and prison service priority and their needs as patients are treated

as comparable to patients in the community. In April 2006, responsibility for prison

healthcare in England and Wales was transferred from the Home Office to the National

Health Service (NHS) Primary Care Trusts (PCT) (Condon et al., 2006). Both the

treatment of drug use within prisons and the development of prison healthcare are now

priority areas for future NHS development (McMurran, 2002; Shaw, 2002).

Changes to the provision and system of drug treatment in prison have also been pushed

from a criminal justice perspective. The numbers of drug users in prison led to central

Government in England increasingly turning its attention to the links between drug use and

crime. Increasing the provision of substitute medication was considered a key means of

addressing the link between acquisitive crime and drug use, thereby reducing the overall

levels of crime in society. The most recent policy development in this area has been the

provision of money for opiate maintenance prescribing in prisons through the Integrated

Drug Treatment System (IDTS) (Department of Health, 2006).

This article focuses on drug injectors’ experiences of drug-related care and treatment

within the English prison system, during a period of significant policy and practice change.

Research on the experiences of prison-based drug care and treatment is important to inform

further policy and practice developments. In particular, it is important when attempting to

provide a fair and equitable prison drug treatment service and reduce barriers that drug

injectors face in accessing drug treatment in prisons. Data were collected as part of a wider

study (Neale et al., 2006) which examined the problems IDUs encountered when accessing

drug-related care and treatment from a range of generic and specialist drug treatment

services (NTA, 2002, 2005).

Methods

The study was conducted in three locations (a large city, a medium-sized town and a

smaller town within a rural area) across the county of West Yorkshire in the north of

190 C. N. E. Tompkins et al.

England. Ethical approval from an NHS Multi-Centre Research Ethics Committee

(MREC) was obtained in November 2005.

People who had injected within the last seven days were eligible to take part and were

principally recruited from needle-exchange programmes. Written consent was obtained and

participants were assured of the confidentiality of their responses. Participants were

informed that withdrawal from or non-participation in the research would not jeopardise

care or treatment from any services with which they engaged. Access to more ‘hidden’

users, particularly black and minority ethnic injectors, amphetamine injectors and those not

in contact with needle exchanges was facilitated by snowball sampling whereby participants

asked their injecting friends or associates to become involved. This increased the variability

of experience within the sample. Prior imprisonment was established by self-report.

One-to-one semi-structured interviews were conducted with 51 IDUs who had been in

prison. These were conducted in private at drug services by two qualified interviewers

between January and April 2006. Each interview lasted between 20 and 90 minutes and was

audio-recorded. A £10 payment (either cash or shopping voucher) was given to each

participant on completion. The topic guide used in the interviews covered injecting history,

service use and receipt, experiences and problems of services and the barriers IDUs faced in

accessing treatment. Trained administrators transcribed the interviews and recordings and

transcripts were stored securely in line with data protection arrangements.

Data were analysed using Framework (Ritchie & Spencer, 1994), an approach

particularly suited to policy-relevant qualitative research (Pope et al., 2000). This approach

provided a framework structure to allow detailed analysis of the emerging themes and

concepts raised during the interviews (Pope et al., 2000). All interview transcripts were

loaded into the qualitative data software package MAXqda2. The project team jointly

developed a coding strategy. They then co-coded three interviews into the key themes to

ensure that they were all using the coding frame in the same way. Any coding uncertainties

were discussed with at least one other member of the project team to ensure consistency.

Interview accounts of prison and prison treatments were coded under the broad theme

‘previous experiences of prison’. This theme was then exported from MAXqda2 into a

Microsoft Word file. This document was read carefully, to identify key sub themes, by a

member of the project team. Each sub-theme was later reviewed and participants’

comments were summarised and indexed and grouped into emergent categories by a

different member of the project team. Interview and text reference numbers were included

in the analysis process to facilitate within and between case comparisons in the subsequent

mapping and interpretation.

Findings relating to the sub themes are presented, incorporating both the commonality

and polarity of views and experiences which existed. Illustrative quotations associated with

the themes are included. The participants’ words are unedited and no attempt has been

made to clarify any ambiguities or hesitation. Identification numbers have been used rather

than the participants’ names to protect participant anonymity; however, the ages presented

are genuine.

Findings

Participants

Fifty-one current injectors (42 men, 9 women) who had ever been in prison*either as

remand or sentenced prisoners*were interviewed. They ranged in age from 24 to 45 years.

Drug injectors’ experiences of prison 191

Six participants (all men) were from a Black or Minority Ethnic (BME) group. Twenty-

eight participants were primarily heroin injectors, 12 were primarily stimulant injectors

(crack cocaine or amphetamines), and 11 injected both opiates and stimulants equally. All

participants had injected at least once in the week prior to interview and the majority

(33 men and 8 women) had last injected in the 24 hours prior to interview. Participants

were not routinely asked about the reasons why they had been sent to prison. However, it

was common for them to acknowledge in the interviews that their sentences were for crimes

associated with illicit drug use. Shoplifting, theft, drug dealing and non-payment of fines

were frequently cited as the reasons why the participants had been sentenced to prison.

Twelve participants had been in prison in the six months prior to interview.

Although all participants lived and were interviewed in West Yorkshire, they had served in

many prisons throughout England, including all categories of prison. Often they had been

in prison more than once. Long and complex prison histories were frequently described,

with some early sentences dating back many years. Some participants, especially those who

had been in prison from a young age, said how they had spent more of their lifetime in

prison than out of prison.

Drug use in prison

Participants often described how their drug-using patterns changed when in prison. They

noted that these changes were linked to the availability of illicit drugs in prison, personal

choice and the receipt (or lack of) substitute or detoxification medication. Amphetamine

users reported that the prison environment was not conducive to the effects of stimulants.

This resulted in limited access to amphetamines since there was little demand for them

amongst participants whilst in prison. Participants described that heroin use and cannabis

smoking in prison was more common. These drugs were more widely available than

stimulants whilst in prison. Although some individuals stopped injecting whilst in prison,

others described how they had continued to inject. One man described the presence of

drugs in prison and what people did to obtain them:

There were periods obviously when there was a drought when you couldn’t get anything,

but that wasn’t for long. Do you know what I mean? And like obviously you’ve got to

finance it but . . . in prison you’ve got a word called grafting, its called grafting, basically

going out and begging people, or asking for things do you know what I mean? Or conning

people for stuff do you know what I mean and like you have got to do a lot of that to get

by to survive, to get your drugs. (Participant 69, 38-year-old man)

Despite widespread illicit drug availability, some injectors viewed prison as a time to choose

not to take drugs:

I didn’t take them [drugs]. I mean I could’ve done, they [drugs] were under me nose all

the time. I could’ve quite easily taken them but I thought I might as well use this time

now to sort of like sort things out. (Participant 35, 35-year-old man)

Participants commented that choosing whether to take illicit drugs was sometimes

complicated by the influence of other prisoners. Being in prison at the same time as

drug-using friends or associates or sharing a cell with someone who continued to use

drugs were factors that influenced individuals’ choices about whether to take drugs. This

man said:

The lad that I were in with hadn’t wanted to get clean and he were getting drugs in, you

know what I mean, and I weren’t going to grass him up obviously, all I wanted were to be

moved, you know, because I were clean when he come into that cell, we shared a cell and

then when he came by the time I got to see CARAT workers [prison drugs workers] I had

a habit again. So I wasn’t going to be moving. (Participant 44, 32-year-old man)

Participants reported that not using drugs in prison was especially difficult if detoxifica-

tion programmes were not available or if they had been given a challenging detoxification

programme. For example, they described that being given rapidly reducing detoxification

regimes did not ameliorate their opiate withdrawal. This therefore made it hard for them to

overcome the need and desire for illicit drugs. Participants also said that it was hard to avoid

using drugs if their cellmates or other prison inmates were using as this meant that drugs

were more readily available to them.

Drug withdrawal

Whether a participant had continued to use drugs in prison or not, the experience of heroin

withdrawal (‘rattling’) was common. Since individuals often continued to inject until the

day before they were sent to prison, withdrawals were often particularly severe for the first

24�48 hours of imprisonment. Participants often stated that, until fairly recently, prisoners

were not given any medication to alleviate the unpleasant and painful symptoms of drug

withdrawal. This was particularly noted by the older participants and those with complex

prison histories as, historically, there was little offered by way of provision or support for

prisoners in opiate withdrawal. Indeed, they described experiencing opiate withdrawal

when they went to prison but were only given mild painkillers, such as aspirin or

paracetamol:

I did a complete cold turkey in prison several times. But their drug policy*when I first

went to prison you got chucked in a cell with two paracetamols every four hours until

you’d done your cold turkey. (Participant 6, 29-year-old woman)

Participants described that a consequence of being in acute heroin withdrawal in prison

without adequate pain relief was that it tempted them to acquire and use heroin to

ameliorate withdrawal symptoms. The experience of prolonged and severe physical

symptoms of withdrawal in prison was frequently described and included abdominal pain,

muscle aches, nausea, sweating and insomnia. This man described how he felt:

I didn’t sleep properly for weeks you know what I mean? I was just dead fitful and

hallucinate like not people say oh you hallucinate, it’s not hallucinating at all, all it is is

when you’re trying to go to sleep you don’t really sleep properly so you dream but it’s like

you must fall asleep a bit but it doesn’t feel as though you’ve been asleep you know what

I mean? It’s dead weird and you’re all sweaty. It’s just horrible. I was like that for weeks.

(Participant 5, 24-year-old man)

In more extreme cases, being locked alone in a prison cell whilst in severe drug withdrawal

led to intense emotional and psychological responses, such as participants feeling isolated

and depressed. Participants found these reactions difficult to cope with, especially if they

were alone for prolonged periods of time. In some cases, this resulted in episodes of self-

harm and suicidal behaviour, as this woman described:

The amount of girls that hung their selves on there, because its bang up [time locked in

cell] you know what I mean, and when you are rattling you don’t want to be on your own.

(Participant 36, 36-year-old woman)

More extreme experiences of drug withdrawal were associated with those who had been in

prison prior to the introduction of substitute prescribing. An issue that was raised in the

interviews and frequently linked to experiences of drug withdrawal in prison was that of

mental health problems. Some participants, who also had unresolved bereavement issues,

also identified that they had experienced mental health problems whilst in prison. These

participants identified that, in many instances, their mental health needs, such as the need

for counselling or anti-depressant medication, had not been met.

Prison staff attitude and stigma

Participants reported experiencing negative attitudes whilst in prison from prison staff,

including officers and healthcare staff, such as prison doctors and sometimes nurses.

Participants believed that these attitudes were based on their perceived marginalised

position in society*both as IDUs and as criminals. They perceived that these attitudes

impacted on the care and treatment they experienced during their sentence. For example,

receiving treatment was felt to be dependent on the attitude of the doctor during the

consultation:

There were one doctor and he says, ‘I ain’t giving you nothing for your medication, for

your withdrawal because you had enough drugs on out, I aren’t giving you none in here’.

So it depends really what doctor you get. It’s whether you land lucky or not. (Participant

39, 30-year-old man)

Participants also felt that different doctors treated individuals in prison differentially, rather

than according to agreed clinical guidelines. This led to drug users articulating that there

were elements of ‘luck’ in receiving help and medication. This was true of both previous and

current practice and depended on the doctor they saw and the attitude of that doctor

towards them:

Most people just get five days, ten days if you are lucky, depending on the doctor you see.

Different doctors will give you different. See, I could go in front of one doctor and he

would give me 5 days. The same lad could go in front of the same doctor and get ten days,

but why? If he’s using the same amount as me I should be getting the same as him and

vice versa. (Participant 64, 45-year-old man)

Participants believed that this differential treatment meant that, until recently, the prison

treatment system had not been fair and equitable as these perceived negative attitudes had

impacted on the care and treatment they were offered and received whilst inside. However,

these apparent negative attitudes did not directly impact on treatment take up, as

participants often accepted any medication that the prison was prepared to prescribe.

Participants spoke of how they had been refused medication on numerous occasions.

Some believed that this was as a further form of punishment and led to the doctors

having a reputation amongst prisoners for declining medication or being insensitive and

unfeeling:

The prison officers really don’t care and the doctors don’t care. We used to joke and call

him ‘Doctor No’, cos that’s all you got out of him, ‘no, no, no’. But like I said in the

beginning they used to call it hostage really because you didn’t get out of your cell, you

was thrown in until you had done your rattle and then you’d get a job and just live life as a

prisoner, just ‘til the end of your sentence. But now it seems a lot better giving you 30ml

of methadone. The medical help’s there, the practical help’s not there. Like I said you just

you are thrown the medicine and that is it. There is no help. (Participant 6, 29-year-old

woman)

Participants stated that discriminatory treatment from prison staff was a function of the

stigma associated with both being a prisoner and having a history of injecting. Expanding

upon this, they sometimes reported that doctors had exercised their power and control over

prisoners by refusing them drug treatment, by being unsympathetic to their needs and by

being dismissive during consultations. Participants also reported that some nurses were

distant, mistrustful and unwilling to believe drug users. This participant described how and

why prison doctors seemed aloof and detached:

They [prison doctors] deal with that many people and a lot of the people won’t be nice

really I suppose, you know. They just ask you what they need to ask you and that is it

really and give you what they need to give you. You know, just get through as many as

they can. Because they don’t want to know what you have got. They are not there to

listen. They just if you have got something wrong what is it, right there you go, here is

your medication. (Participant 34, 25-year-old man)

In some cases participants thought that prison doctors did not offer medical care as they

believed that drug injectors’ health problems were self inflicted as a result of ‘choosing’ to

inject drugs:

He [doctor] said to me, ‘self inflicted, nowt but a good 20 press ups and a good wank

wont cure.’ (Participant 53, 32-year-old man)

Access to the prison doctor was also discussed as a factor that affected the care and

treatment that drug users received in prison. After the first night in prison, when all

prisoners automatically see a doctor, obtaining an appointment often took a long time as it

relied on submitting an application and waiting for an available appointment. Even when

drug users accessed a doctor, care and treatment were again dependent on the doctor

judging whether or not they were in genuine need of help:

You’ve gotta go through umpteen nurses to get to see a doctor and I genuinely, obviously

there must be some girls in there that are on the blag [using deception to gain advantage],

but they don’t actually believe that you’re ill if you say you’re ill. (Participant 57, 31-year-

old woman)

Whilst the experience of negative treatment from prison staff was overwhelming for

participants, other injectors sometimes expressed more positive views. Often this was after

they had seen a more sympathetic prison doctor who had listened to their problems and had

appeared to understand their needs. Additionally, there was some acknowledgement from

participants that being a prison doctor would be challenging, given the combined difficult

nature of the prison environment and the characteristics of prison patients:

Obviously it is hard for them [prison doctors and nurses]. They’re working with criminals

you know they’re not working with the best people in the world. They’re okay. They

were not bad, they’re quite jolly, they’re quite happy. They try to help you. They were

quite nice. You don’t get nice people in prison all the time. So when you wake up in the

morning and you go and see the doctor and he is still smiling things are okay. (Participant

46, 30-year-old man)

Drug treatments in prison

Drug treatment experiences varied widely amongst participants and reflected the different

nature of different prisons and their varying prescribing policies. Participants’ accounts also

reflected the differences between doctors and their attitudes towards drug users and

prescribing. Negative views of traditional prison drug treatments (such as the lack of

treatment provision for drug misuse or the provision of dihydrocodeine) were commonly

expressed. However, it was clear that participants realised that prison drug treatment

policies had changed over time, with positive change being apparent more recently.

Participants, especially those with numerous imprisonment experiences, had received

various detoxification regimes whilst in prison. Many had been prescribed the painkiller

dihydrocodeine (common trade name is DF-118s), sometimes in conjunction with

benzodiazepines such as diazepam, nitrazepam and temazepam. However, there was a

consensus amongst participants that this was inadequate for alleviating the acute effects of

opiate withdrawal, especially for those who were heavily addicted to illicit opiates prior to

imprisonment:

It is either a week’s course of DFs or something which doesn’t touch you and like if you’re

taking a £100 a day of heroin, £80 a day of heroin and you have been for weeks and

months as you have been you might as well throw it over your shoulder. (Participant 9,

33-year-old man)

Participants who had been prescribed dihydrocodeine detoxifications commented that they

had been reduced too quickly, often over five days. They articulated that this meant that the

regime did not really help them as much as they would have expected it to if it had lasted

longer. Participants described how detoxification using DF-118s had more recently been

replaced with more conventional community opiate detoxification medications, such as

buprenorphine (common trade name is subutex) and methadone. The experiences of

having been prescribed these medications were generally more positive than those of

painkillers which had a mild opiate effect. Buprenorphine and methadone were noted as

being better for reducing, or at least controlling the effects of drug withdrawal. Whilst

concerns were expressed, especially amongst those participants who had large drug habits

prior to sentence, that these medications were sometimes reduced too quickly and dosing

was insufficient, they recognised that the provision of these medications was a recent

positive development in prescribing policies:

When I went back they were doing DHC, dihydrocodeine, and that was a crap

programme and now you are getting 30 ml of methadone. And something to help you

sleep for the first two nights. So their treatment plan’s a lot better than what it was.

(Participant 6, 29-year-old woman)

There was evidence that other recent changes in prescribing policy had occurred within

some prisons. However, the continuation of community maintenance prescriptions in

prison was not without its problems for participants. Indeed, participants sometimes did

not understand why their community substitute medication maintenance prescriptions

could not be continued at the same dosing level when they were in prison. Participants also

described how there was often a delay in receiving substitute medication. They were told by

the prison that this was often as the prison waited for medication confirmation from the

community prescribing services:

I was on a script when I went to jail, about 6 week sentence, but they’d not had enough

time to get all me paper work into prison, yeah, get me down healthcare and put me on a

maintenance script in jail because I got a 6 week sentence so I only did 3 week of that so

they’d not had enough time to do it you see so I was on just a normal reduction period err

detox which were reduction of 2 milligram a day from 30 mil and I mean I were on 75 at

time so it weren’t too bad but it were just bad when I got out you know what I mean it

were just back to square one. (Participant 1, 27-year-old man)

More positive prison drug treatment experiences were also discussed. These included the

potential for drug treatment in prison to enable users to become drug-free during their

sentence. Indeed, providing a detoxification was seen as empowering by participants. This

was because it provided them with more choice about whether or not to continue using

illicit drugs whilst they were in prison and whether or not to resume drug use on release

from prison:

Prison does you good actually. You have time to reflect, put your feet up, get your detox

done. I mean you have no choice have you in prison? I mean, you can get the gear if you

want but I didn’t bother. I just stuck to me detox. And it is like once you get out, you go

this way or you can go that way. You go back to using or you stay clean. The choice is

yours. I mean I fucked up, I relapsed. (Participant 20, 33-year-old man)

Participants often commented that the time to receiving treatment in prison was much

quicker than being on community drug service waiting lists, as they usually received

medication on their reception into prison. Again, this was described as a change from how

things used to be. Going to prison was therefore discussed by participants as a viable

alternative to waiting for detoxification medication in the community. Some participants

had been sent, or considered getting sent, to prison intentionally with the ultimate motive of

receiving an immediate detoxification. This man describes the benefits of being intention-

ally sent to prison as accessing services akin to a residential detoxification and rehabilitation

The life I were leading I couldn’t live no more. You know going round in a circle thieving

and not knowing what is next from one day to the other. And I thought the safest thing

was go to prison. You know there you are going to get treated, you are going to do your

rattle, you have got your bed, you have got your three meals a day and that is it, you are

going to be clean and like I say I have done it twice, got sent to jail on purpose.

(Participant 39, 30-year-old man)

Participants who had been in prison noted that the presence of support other than

prescribed medication was another recent development that had gradually occurred over

the last few years. This included having group work on drug and addiction related issues,

complementary therapies and access to drugs workers in some prisons:

Last year, I got remanded and it has changed quite a bit inside now actually. They seem

to have got their act together because what they do now is you get a minimum of 14 day

detox now plus they do this detox programme where you can have saunas, massages,

aromatherapy, you can have the needles put in your ears. (Participant 35, 35-year-old

For some individuals, receiving medication and support in prison reduced, or even stopped,

their illicit drug use and therefore enabled them to leave prison drug-free. Whenever this

occurred, the key issue was what happened to their drug use on release from prison.

Accessing treatment on prison release

An important aspect of prison treatment that was discussed in the interviews related to

aftercare and the continuity of treatment when moving from prison back into the

community. Whether or not a participant had received continuity of treatment appeared

rather arbitrary, although some had experienced the continuation of medication on release

from prison. This included opiate blocker medication such as naltrexone or the

continuation of substitute medication. Continuation of substitute medication was

dependent on the prison staff, including healthcare and the CARAT (Counselling, Advice,

Referral, Assessment and Throughcare) team liaising with community prescribing services,

including criminal justice initiatives such as the DIP (Drug Intervention Programme) and

DISC (Developing Initiatives Supporting Communities):

They [prison] wouldn’t put me on subutex because they couldn’t get a prescribing doctor

on outside for when I got out. So that’s a I think that’s a problem there they need to have

more doctors that are willing to prescribe for when you get out . . . cos they wont prescribe

in prison, subutex, unless they’re gonna 100% guarantee a doctor on outside’s gonna

prescribe you. (Participant 50, 33-year-old man)

When drug users had received medication on release from prison they were very

appreciative. Importantly, they described how it provided them with a choice not to use

street drugs, especially for those who had become drug free and abstained from using

during their sentence. Effective aftercare was occasionally discussed in the interviews,

where arrangements had been made between the prison and community prescribing

services and substitute or blocker medications had been continued on release:

When I went into prison I was on methadone so*and I got two and a half years

sentence, and throughout that sentence I never did me rattle. I were always on a

prescription of DFs or I were buying them in prison or buying gear or whatever. So it got

to the point where I had been in about six or seven month and that were really getting to

me that I couldn’t*well I don’t suppose I wanted to or whatever, I never got off it

anyway. So I went to see the doctor and they were starting people on subutex. So I saw

him and he agreed to keep me on it for the rest of me sentence. Like I say before I got out

they made arrangements with [community prescribing service] to say I were coming out

and could they carry on prescribing it. (Participant 30, 29-year-old man)

Despite successfully detoxifying in prison, some participants described how they immedi-

ately went back to using drugs on release. They linked this to the lack of prescribed

substitute drugs on release and the difficulties that participants had previously encountered

in quickly accessing a community prescribing service. Having no accommodation or not

having non drug-using friends also appeared to be factors that increased the likelihood of a

person using drugs on prison release. When medications were not provided, users discussed

that they felt that the hard work that had been done in prison had been wasted and they

questioned why prisons had not offered or provided them with medication. Further, they

felt let down, especially if they had actively tried to access this support in time and

preparation for being released from prison.

Discussion

Many negative aspects of drug treatment in prison were discussed including experiences of

insufficient, restrictive and inconsistent treatment. The experience of drug withdrawal in

prison was widespread. Alleviating withdrawal and accessing prison drug treatments were

affected by accessing a doctor, the perceived doctor’s attitude, the availability of suitable

treatments and perceived inconsistencies in treatment provision. This concurs with

previous qualitative research conducted with drug users in England in 1997 which

identified considerable variation and inconsistencies in prison drug treatment (Hughes,

2000). These experiences were often also influenced by negative and stigmatising attitudes

from prison staff (Hughes, 2000).

This research has a number of limitations. Firstly, it was conducted in only one county in

England. However, in order to be inclusive of the county’s range of drug service provision,

three fieldwork locations were chosen. This study was of reasonable size for exploratory

qualitative research, giving access to current drug users and their experiences and

perceptions of prison drug treatment. Despite being limited to one county, we identified

a rich source of data from which to examine prison policy and practice regarding local

and national drug treatment in England and Wales. However, care should be taken in

generalising the findings to injectors in other geographic areas nationally and internationally

due to location specific issues that might affect the findings and their subsequent

interpretation. A further limitation is that the sample was of current injectors. By virtue,

they may view their prior prison experiences as having ‘failed’ them by not helping them

abstain from injecting illicit drugs. Their responses may therefore reflect these feelings.

Care should therefore be taken when generalising these findings to injectors who have been

to prison but who are not in contact with needle exchange services, and also to non-

injecting illicit drug users, such as drug smokers. Whilst we were concerned that only nine

BME injectors were interviewed, this was representative of injectors accessing the needle

exchanges in the areas, including one area which has an almost exclusively white British

population. Finally, the research focused on the problems that drug users had experienced

and the interviews were orientated in this way. This will have some bearing on the

participants’ responses, although it is striking that some participants spoke of many positive

factors associated with drug treatment in prison.

Despite the negative experiences, injectors’ accounts showed how prison treatments were

considered better now than previously. This was largely because prisons more commonly

initiated maintenance methadone and buprenorphine prescriptions, would continue

community prescriptions of maintenance therapy and CARAT workers offered help and

advice. Access to drug-free wings helped those wishing to remain abstinent and opiate

antagonist medications helped prevent relapse upon release. Participants recognised and

mostly appreciated these steps to make effective drug treatments more accessible in prison.

This highlights that recent national and international policy initiatives to increase the

provision and quality of drug treatment in prisons are starting to be appreciated by drug

users. This is a positive change, especially when compared to earlier times. Interestingly,

participants wishing to pursue abstinence often viewed a period of imprisonment as an

opportunity to secure help with drug problems more easily than in the community. Users

were therefore keen to access any support whilst in prison which would help them to change

their drug use behaviour. Indeed, it was evident that time in prison could trigger changes in

patterns of drug use, although the chance for positive change was not always fully exploited,

as it depended upon a number of factors outside the user’s control.

Until recently, some prisons in England and Wales only prescribed IDUs mild opiate

analgesics for detoxification. As policy changed, methadone and buprenorphine were

offered for detoxification. Methadone is inexpensive and is less amenable to diversion into

the shadow prison economy compared to buprenorphine or dihydrocodeine. Buprenor-

phine takes several minutes to be absorbed, making it amenable to diversion if not closely

supervised during dispensing. As dihydrocodeine only has a mild opiate effect, large

numbers of tablets need to be prescribed to control withdrawal symptoms. Such a large

number of tablets given ‘in-possession’ to drug users increases the risk of diversion into

the prison. Participants in this study reported that dihydrocodeine was inadequate to

control withdrawal symptoms when detoxifying from a serious heroin addiction in prison.

Following publication of the Clinical Management Guidelines for Drug Dependence in

the Adult Prison Setting (Department of Health, 2006) changes regarding the length of

detoxification programmes have taken place in many prisons in England and Wales.

Detoxification regimes at admission to prison of five days duration have now been replaced

with regimes lasting between two and three weeks. Often the regime will have an initial

minimum five-day stabilisation period where the dose is gradually introduced and then

continued at a stable level (Department of Health, 2006). This moderates withdrawal

symptoms during a period of high suicide and self-harm risk and makes detoxifications

more effective and comparable to prescribed community treatment. Prisoners were

appreciative of these longer, more ‘humane’ detoxification programmes. Some drug users

taking substitute medication may have spent a number of days in police custody prior to

imprisonment. During this time, it is unlikely that they will have received any substitute

medication and may have therefore partially lost tolerance to opiates. This would

necessitate re-starting the medication in prison at a lower dose so as to mitigate against

the risk of overdose (although there is minimal overdose risk with buprenorphine

medication). Our research suggests that this needs to be clearly explained to users so

they understand that it is in the interest of their safety, not a punitive practice.

Previous commentators in Australia recommended the introduction of methadone

programmes in prisons where community programmes exist to ensure the continuity of

care between community and prison programmes and initiate treatment entry as early

as possible in people’s drug using and prison careers (Dolan et al., 2005). Our research

shows that where this is implemented the results are valued by prisoners. However,

logistical issues such as different prescribing policies in different prisons in England and

Wales still require resolution before such programmes can claim to be equivalent to those in

the community. In general, good continuity of maintenance treatment between prison and

the community was appreciated but not always practised. Some participants in our study

described being drug-free on release from prison, but returned to drug use often because

they could not get treatment quickly enough from community services (Shewan et al., 2001;

Kinner, 2006). This represents a missed opportunity to engage with those who became

abstinent whilst in prison but who needed additional support from community prescribing

services to ensure continued abstinence. The importance of overdose risk on prison release

cannot be underestimated if drug users are in withdrawal on release and return to using, as

a reduced body tolerance to opiates puts them at increased risk of fatal overdose (Seaman

et al., 1998; Shewan et al., 2000; Singleton et al., 2003b; Stewart et al., 2004).

The accounts of participants in this study demonstrate how changing practice towards

IDU prisoners is leading to improvements in treatment provision. It would appear that

nationally the quality of drug treatment is variable as evidenced by a recent legal class action

that was upheld against some prisons for negligent care offered to prisoners (Silverman,

2006). At the time of writing the National Institute for Health and Clinical Excellence is

consulting on its guideline pertaining to the Psychosocial Management of Drug Misusers in

the Community and in Prison, due to be issued in July 2007. It is hoped that a combination

of improved clinical guidelines and legal action will drive further change to improve the

quality of drug treatment provision in prisons in England and Wales and shift away from

negative prison treatment experienced in earlier times. This will result in improved health

for drug users, both in and out of prison.

This is important, especially for those drug users who spend a significant amount of their

lives between prison and community settings. Addressing drug treatment within prison will

therefore lead to their improved health and general wellbeing when they return to the

community on release from prison, particularly if their drug use has reduced and is

stabilised whilst in prison. Reduced levels of drug use amongst released prisoners over time

will also facilitate the improvement in public health and wellbeing more generally. This is

because populations are the sum of the individuals and when individuals are released from

prison into the community they reintegrate with their family, friends, peers and other

individuals in the wider society more generally. For example, their reduced injecting drug

use should result in reduced levels of drug-related morbidity and mortality, reduced levels

of virus and disease transmission (particularly of blood-borne viruses), less used injecting

paraphernalia discarded in public places, thus lessening the health and social consequences

for the wider population.

Acknowledgements

Particular thanks go to the drug injectors who were interviewed for the study and the staff

working at the three needle exchanges who facilitated access to the study participants. We

must also thank Chris Godfrey, Steve Parrott, Katy Harris, Toni Tattersall and Karen

Stewart.

‘The Barriers to the Effective Treatment of Injecting Drug Users’ was funded by the

Department of Health as part of Phase II of the Drug Misuse Research Initiative (DMRI)

Research on Understanding Treatment Experiences and Services (ROUTES) programme.

The views expressed are those of the authors and should not be attributed to the

Department of Health.

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Experiences of prison among injecting drug users in England: A qualitative study

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