Prison population: substance use and wider support needs

Chapter 1: Introduction

The Scottish Government has committed to undertaking a comprehensive, national assessment of the health and social care needs of Scotland's prison population. The last prison health needs assessment was conducted in 2007 and a great deal has changed in the policy and service delivery landscape since then. This needs assessment is one of four commissioned studies^[1] and focuses on an assessment of the needs of the prison population relating to alcohol, drugs, and tobacco use.

Background

Substance use has long been a concern for the health and wellbeing of people living in Scotland's prisons and remains one of the most prominent challenges to Scotland's prison system. People who live in prison are disproportionately more likely to use alcohol, drugs, and tobacco than those individuals who do not enter prison (Toomey et al., 2022). Crime and substance use are known to be closely associated^[2]. Problemetic substance use often contributes to the factors involved in why someone is in prison and often continues (or for some begins) whilst living in prison (Carnie and Boderick, 2019).

Many people living in prison have substance use needs that pre-date their imprisonment and can stem from multiple factors, such as experiencing trauma and social and economic inequality (Devries et al., 2014; Najavits, 2015). Within custody, people experience limited access to family and community supports, bullying, and feelings of hopelessness which risks perpetuating and escalating substance use. The prevalence of substance use within prisons is a serious threat to the health of people living there and to general public health. It threatens the safety of prison officers and healthcare staff and creates challenges in terms of maintaining good order and discipline (O'Hagan, 2017). With the recent rates in drug-related deaths continuing to soar across Scotland, there is increasing pressure to take more urgent action to address substances and the harms that they present (NRS, 2021).

The exact picture of substance use in Scottish prisons is unclear. There is a lack of available data, which will be highlighted later in this report. Estimating the prevalence of substance use in Scottish prisons is therefore highly challenging, particularly in relation to drug use (Toomey et al., 2022). What is apparent though is that levels of drug deaths across Scotland are very high. In 2019, in reponse to the high levels of drug deaths in Scotland, the Drug Deaths Taskforce [DDTF] was established.^[3] This group is made up of volunteer members who have been proactive about pushing for the implementation of the MAT [Medical Assisted Treatment] Standards.^[4]

Current substance use data often relies on self-reporting^[5] or upon incident reports which do not present the full picture of substance use. In the most recent Scottish Prison Service [SPS] Prisoner Survey (Carnie and Boderick, 2019), 41% self reported that they engaged in problematic drug use prior to imprisonment; 45% had been under the influence of drugs, and 40% reported being drunk at the time of their offence. This is indicative of a high level of need.

People living in prison experience substantially poorer health than the general population, in part because of the high prevalence of smoking amongst those living in prison (Spaulding, 2018). High rates of smoking in prisons had been consistently reported in the SPS Prisoner Survey prior to the introduction of a smoke free prison environment (2018). The 2013 survey reported that 74% of people living in prison smoked which contrasts with a prevalence rate of around 20% in Scotland as a whole.

Whilst the prison system continues to be the host for many of those who are found to have committed substance related crimes, there have been increasing conversations about whether this is in fact the right place for them (Scottish Parliament, 2022). It has long been acknowledged that the opportunities and provisions for rehabilitation within a prison setting are limited (ibid.)^[6]. So too there is a real sense that the revolving door of prisons can exacerbate and encourage substance use:

'We do not rehabilitate prisoners well, we do not prepare them for release well and we do not support them on release well, because our system is chock-a-block with people who should not be in it.' (Professor Fergus McNeill, evidence provided to Scottish Parliament, 2022, pg. 11)

Alcohol and Drugs

Each prison in Scotland has developed its own policies and procedures to manage drug and alcohol use. In part this can be traced back to the NHS takeover of addictions work in Scottish prisons from Phoenix Futures (2011). In the absence of universal guidance, each NHS Board that had a prison in its catchment area decided what approach to take (NHS, 2016). One requirement, however, was that services should be available on an equitable basis to community-based services.

Whilst there are different approaches across prisons, there are a number of policies and documents that offer guidance to all prisons. One of these is the National Naloxone Programme which has been active in Scottish Prisons since 2011. This has provided all those leaving prison with Naloxone in an attempt to address opioid related overdoses upon release (Bird et al. 2014). As data collection for this study progressed, some respondents informed us that naloxone provision had continued to be developed. For example, intranasal naloxone is now offered, making it a needle-less product. Online service, training and learning opportunities have been expanded, and there has also been a move to educate and organise peer naloxone distributors and trainers, something which has enjoyed much success (DDTF, 2021).

Across Scotland, the SPS' Management of Offender at Risk Due to Any Substance [MORS] policy was introduced in December 2014. This guidance instructs prison staff on how to respond if they identify someone as being at risk from a substance and how healthcare staff should engage with the incident.

Rights, Respect and Recovery, Scotland's strategy for reducing drug and alcohol related harms and deaths, was published in 2018 (Scottish Government, 2018). The strategy provided a specific focus on prisons as one of the key organisations that should be involved in delivering on national substance use goals. In January 2021, the strategic approach was further enhanced through the announcement by the First Minister of a new 'National Mission' to reduce drug-related deaths and harms, supported by an additional £50 million funding per year (for the next five years).^[7]

In response to the Covid-19 pandemic, the Scottish Government allocated £1.9 million to support people to switch to Buvidal as an OST treatment option (MacNeill, 2021). Buvidal is a longer-acting form of OST that means people can switch from a daily medication regime to only needing to take their presciption on a weekly or monthly basis. Intial small-scale feedback on Buvidal has highlighted its potential to support people to make positive changes to their lives and demonstrated it may improve outcomes for prison leavers, such avoiding relapses in the community or helping them look employment (MacNeill, 2020). Increasing the number of people being prescribed Buvidal in Scotland's prisons may also go some way towards alleviating the current burden placed on prison operations and healthcare by the daily administration of methadone.

Tobacco

SPS and partners have successfully delivered smoke free environments since November 2018. This change was introduced as part of a wider Scottish Government focus on changing smoking habits for future generations. In the lead up to, and in the aftermath of the introduction of a smoke free policy, smoking in prison has transformed from an under-researched and poorly understood policy area, to one which is underpinned by a rich literature base which engenders ongoing policy and practice conversations.

In January 2022 the final report for the Tobacco in Prisons Study [TiPS] was published (Hunt et al., 2022). The study documents the impact of smoke free prisons in Scotland. It indicates that smoke free prisons policy have quickly become the 'new normal'. Second hand smoking has been reduced by 90% and e-cigarette use has became commonplace.

TiPS was the first study internationally to explore this topic and did so extensively. As such it has not been appropriate nor useful for this needs assessment to replicate or duplicate evidence gathering with regard to current policy and programmes around Tobacco. Therefore, the team has focused on alcohol and drug use as a priority for the data collection for this project whilst considering the place of tobacco use alongside other substance use.

Study Aim and Objectives

The aim of this needs assessment study was to help the Scottish Government and its partners better understand what the healthcare needs of people with substance use problems living in Scotland's prisons are.

The specific objectives of the needs assessment were to:

1. Conduct a rapid review of the research literature from the UK and (if there is a strong rationale for it) comparable jurisdictions on the nature and extent of substance use needs and support within prison populations.

2. Synthesise available national and local-level data and research to report on the epidemiology of substance use experienced by Scotland's prison population, including newer trends such as New Psychoactive Substances [NPS] usage, compared to others in the criminal justice system (e.g. people serving community sentences) and the general population.

3. Map current models of substance use care/interventions within Scotland's prisons, how they interface with other healthcare interventions within prisons, and how they interface with community care models and services, including assessing aspects of treatment continuity, finding examples of best practice, and throughcare pathways during transition from custody to the community.

4. Assess the scope for the improved collection of routine data that can be made available to analysts, managers, and service providers for continued monitoring and analysis of support needs relating to substance use.

5. Offer insights for future data linkage and data collection priorities.

6. Include the perspectives of people with lived experience of prison and substance use to incorporate their views and insights.

Methodology

Study methods

The core elements of the study focused on qualitative approaches (comprising of: (1) semi-structured interviews with a broad range of professional stakeholder groups; (2) a short-life working group with a diverse range of professional stakeholders from key partners in SPS, NHS, and the Third Sector; and (3) interviews with those who have lived and/or living experience). These approaches were supplemented with a rapid literature review, a review of existing (published) data, and a mapping exercise (see Table 1 below).

Although the original study design included a desk-based review and synthesis of all available (published) datasets, and that this would be expected to be seen within a Health Needs Assessment report, it is not included in the usual way in this report. From our early review of available Scottish health datasets, it became evident that published healthcare data regarding substance use for Scotland's prisons was deficient and would not provide meaningful, real-time insights. We have included (see Table 2 in Chapter 5) an overview of the available datasets (including comments upon their individual strengths and limitations), but have focused our approach on a qualitative high-level strategic review of how healthcare data is gathered and used in order to identify the areas where substance use data collection, analysis and linkaging needs to improve (see Chapter 5).

The context of the Covid-19 pandemic necessitated a flexible approach, with all working group sessions and semi-structured interviews conducted remotely or on the phone.

Full details of study methods and our approach to analysis is provided in Appendix A.

Recruitment, sampling, and activity completed

A summary of study methods, recruitment, sampling and activity completed is presented in the table below. Fieldwork activities took place between October 2021 and February 2022.

Language considerations

The world of substance use treatment is full of jargon and abbreviations. We have chosen to use 'people-first' language which emphasises the individuality, equality and dignity of people rather than defining people primarily by a problem or issue. We want to emphasise the importance of language in helping to challenge and reduce the pervasive stigma that is still attached to being a person who experiences problems with substances.

For details of the considerations we have made regarding language, please see Appendix B.