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: [email protected]
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
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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
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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
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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:
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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:
Drug injectors’ experiences of prison 193
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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:
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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:
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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)
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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
unit:
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
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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
man)
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)
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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
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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
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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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