Prison population: substance use and wider support needs

Chapter 2: Rapid Literature Review

• Substance use in prisons remains higher than in the community and is implicated in the high rate of avoidable deaths that do occur in Scottish prisons. Prisons are high-risk environments for substance use and risky behaviours. The nature of substance use in prisons is fluid.
• There have been significant and ongoing changes in Scotland's substance use policy and delivery plans for prisons over the last decade or so. Most recently there have been attempts to respond to the high rates of drug deaths with the formation of the Drug Deaths Task Force and the implementation of the MAT Standards.
• Scotland has had a smoke-free prisons policy since 2018 and this has been hailed as a successful and well-implemented change.

Introduction

Recent and prominent literature was identified by the research team and compiled into a rapid literature review. There was a further focus on literature that was Scotland specific.

Our review offers an overview of some of the available literature that indicates the current areas of interest and concern in relation to substance use and associated health and social care issues in Scottish prisons. It should be acknowledged, however, that the distribution of available literature across different substances is by no means equal. In the lead up to and aftermath of the smoking ban in Scottish prisons there was a significant amount of literature produced, whereas the available literature on alcohol use in prisons is sparse and often overshadowed by a drugs-focus.

Existing evidence

Alcohol and drugs

Problem drug and alcohol use remains higher in prison populations than in the wider community and 25-28% of those who access community-based substance use services have a history of offending (Rose et al., 2012). On average, 78% of prison admissions test positive for illicit substances at prison reception in Scotland (Scottish Government, 2018). This is higher in some prisons - with 86% of those presenting at Barlinnie testing positive for drug use (Ibid., 2018). Alcohol problems are under-recognised in Scottish prisons, although an estimated 20% of those living in prisons within Greater Glasgow and Clyde Health Board were alcohol dependent and half were intoxicated at the time of their offence (Scottish Government, 2019).

Around 83% of those who admit to using drugs in prison stated that their drug use had changed during their time living in prison (Toomey et al., 2022). The type of substances seen in prisons has changed in recent years with a move away from opioids as the prominent substance towards NPS (Ibid., 2022). The 2017 Alcohol Use Disorders Identification Test^[9] (AUDIT) revealed that 63% of those who live in Scotland's prisons had been drinking at 'harmful' or 'hazardous' levels, and that around a third were classed as alcohol dependant (SPS, 2019). There is evidence too to suggest that this rate is higher (around 73%) in remand populations (Graham et al., 2012).

Drug and alcohol use contributes significantly to prison death rates, particularly amongst those who are imprisoned for the first time (Sturup et al., 2018). Whilst the true numbers of deaths in prison that are related to substances is unclear, there is evidence to suggest that the rates are high and reflect the rates seen in the community. Drug deaths in Scottish prisons have increased in recent years (Toomey et al. 2022). Opioids remain the substance associated with the most drug-related deaths in Scottish prisons and for those who have been recently liberated (Toomey et al. 2022). Those serving prison sentences are significantly more likely to die an alcohol-related death in prison than those outside prison with the rate being three times higher for men and nine times higher for women (Alcohol Focus Scotland, 2021). Whilst the above literature reflected rates in the community at the time, they are now outdated and likely do not reflect the current picture, with drug deaths becoming more prevalent. The most recent UK data, although sparse, shows that in 2020-21 the number of deaths in the community attributed to drug overdoses increased from 99 to 146. Notably, 36 of these occurred within 28 days of release indicating the considerable risk to those who have just left prison (Ministry of Justice, 2021). Death rates amongst men during the first week following their release are 29 times higher than the general population and this is overwhelmingly the result of opioid toxicity (Page et al., 2018). As a response to these high rates, all Scotland's prisons have offered naloxone kits upon release since 2011. The number of naloxone kits distributed to prison leavers in Scotland increased by 16% between 2019 and 2020 (DDTF, 2021).

While there is a correlation between drug use and crime, it must be acknowledged that this is a complex relationship, and should not be construed as causal (Hammersley, 2008). A reported 38% of those in prison used drugs when committing their offence (Scottish Government, 2019). Substance use is a known risk factor for reoffending upon release, but both prison and community based programmes are known help reduce these reoffending rates. These programmes are most effective if in-prison support is followed up with aftercare post-release. Desistance^[10] is also more likely when people receive treatment quickly and for as long as required (Ministry of Justice, 2013). Education too is a valuable treatment, particularly for those imprisoned for offences such as drink driving (Ibid., 2013). All prisons in Scotland at the time of writing provide acute detoxification from both drugs and alcohol and Opioid Substitution Treatment [OST]^[11] (Flanigan, 2020). Methadone remains the primary OST prescribed in Scotland's prisons unless an individual is already on buprenorphine (Royal College of General Practitioners, 2019).

Prisons are high-risk environments for drug taking with syringe sharing and reintroduction to drug use after periods of abstinence being noted (Kolind and Duke, 2016). In Scotland, some of the highest rates of Blood Borne Viruses are found in prison populations with there being a high likelihood that this is being amplified by intravenous drug use (Flanigan, 2020). In Scottish prisons, 19% of the population are positive for Hepatitis C Virus antibodies and half of these have a history of intravenous drug use (Ibid., 2020).

Beyond physical health, substance use in prisons is importantly linked to poor mental health amongst the prison population. Substance use and dependence represent the most common mental health needs in the UK prison population. Research indicates that individuals in prison are more likely to have a substance use problem than to not have one. Mental health statistics demonstrate a significant mental health crisis in prisons. Research into the English, male prison population has estimated that 70% of those in prison have 2 or more mental health diagnoses (Flanigan 2020, p 19). Poor mental health is also an indicator and catalyst for reoffending and for relapsing into problem drug and alcohol use following release from prison.

Smoking

Historically, around 85% of people in prison in the UK report smoking, a statistic that has stayed consistent over time (Baybutt et al. 2014). There was evidence to suggest that across Europe many people take up smoking in prisons (Ibid.). Pro-smoking cultures have also been identified in some prisons and tobacco is sometimes seen as central to certain elements of prison life (Brown et al., 2020).

In November 2018, Scotland was the first UK nation to fully implement a smoke-free prison policy (Brown et al, 2019). E-cigarettes and vapes are provided to those who live in Scoltand's prisons as an alternative. The decision was controversial at the time, however, with a significant number of those living in Scotland's prisons expressing their frustration and arguing that smoking is a pleasurable pursuit in a place where few others are available (Brown et al., 2020). The policy was also felt to reduce the limited freedoms that those in prisons had. There is currently no data available on smoking rates following release and how living in a smoke-free prison might impact on smoking habits back in the community.

Following the smoking ban, e-cigarettes have been available in Scottish prisons for purchase. Whilst the move to e-cigarettes in prisons is one that was made with the health of those inside in mind, there are still health concerns associated with smoking e-cigarettes, especially when this is as a replacement for smoking rather than an aid to quit (Brown et al, 2019). The long term effects of smoking e-cigarettes or vaping are unknown. However, the majority contain potentially unhealthy levels of nicotine which is a harmful and addictive substance.^[12]

Conclusions

The exact scale and nature of substance use in Scottish prisons remains unclear and poorly understood. Whilst emerging literature does its best to track the patterns of substance use, this is subsequent to the patterns of use forming. This means that even the most up-to-date literature often does not offer a true indication of patterns of substance use. Therefore, making informed changes to service and treatment responses to ever-changing patterns of substance use can be difficult. There is a lack of literature and an overall lack of focus on alcohol use in prisons. Alcohol use in prison is often subordinate to and given less prominence than drug use with data seemingly hard to access and collect. More positively, the literature around smoking in prisons has developed significantly and there is increasing information both from before and after the introduction of smoke-free prisons in Scotland, demonstrating the role of smoking in prisons and the associated health concerns.