Prison population: substance use and wider support needs

Chapter 4: Perspectives of people with lived and living experience

• Lived-experience respondents reported high levels of trauma, bereavement, poor mental health and challenges with structural issues such as poverty and homelessness.
• Patterns of susbtance use often change or increase in prison compared to the community.
• Overwhelmingly substance use was described as a response to the monotony of prison life/culture and the mental and physical health challenges people face in prison.
• Treatment options were limited and delays in accessing prescriptions created significant challenges around detox.
• The availability of support and treatment options in Scotland's prisons is often inconsistent, inaccessible and rigid.
• Autonomy in treatment and support choices is limited and often those with lived experience didn't seek support for fear of punishment. Covid-19 has amplified all of these challenges.

This section provides the key messages arising from interviews with people currently living in one of Scotland's prisons (n=15) and people who have left prison within the last twelve months (n=6).

A selection of illustrative qualitative examples are included under each sub-heading, with a full sample of examples provided in Appendix C.

Impacts of trauma and loss

'There were just certain things that I hadn't dealt with, like my mum died, my dad died and my little brother died, all while I was taking drugs … I didn't actually notice that my mental health wasn't where it was supposed to be.' [Lived Experience interviewee #13]

Respondent reports of substance use from an early age were characterised by trauma and bereavement as precipitating events. We heard that many had turned to substance use as of coping with the loss of loved ones. Others had adopted substances as a coping method for experiences of violence. Often those using substances had experience of generational trauma and parental substance use.

Structural issues

'I had to go to a homeless unit, and for a lot of people … as soon as you go to a place like that, you're surrounded by drugs and alcohol, and you find it hard to stay off it. It's the wrong place to be going.' [Lived Experience interviewee #04]

Issues including a lack of suitable accommodation upon liberation were noted as significant contributing factors to continuing substance use and associated offending. Those with histories of substance use often found homeless accommodation challenging due to the easy availability of substances there, inhibiting self-detox or rehabilitation.

Mental health

'Mental health is a big problem within prisons, and it's an underlying problem that's not really addressed … a lot of these substances will mask mental health as well.' [Lived Experience interviewee #15]

Conditions in prison negatively impacted the mental health of those inside. For some, the prison setting itself increased depression, and this was combined with a feeling of being overwhelmed about the future. Mental health needs were often unmet and the prison environment aggravated symptoms. This was especially the case when the individual took NPS, which compounded mental ill health. For some, substance use became a method of coping with the prison environment and the boredom and repetitiveness of their time spent inside.

A prison culture of substance use

'[Substance use] became part of the prison culture … everything's like an evil version of Groundhog Day … and the atmosphere can be quite poisonous and nasty and evil. So, if you can't escape that physically, you're going to try to escape it mentally, aren't you?' [Lived Experience interviewee #06]

'I was using Valium and I was using speed, coke, I was using alcohol. I was mixing them together. I wasn't just using one. I was mixing them together because it was just completely blanking my mind from what was happening in everyday life.' [Lived Experience interviewee #05]

According to interviewees, the increased use of NPS (which as described is commonly sent in paper that has been soaked) has had significant impact on prison culture. The rising use of NPS and the associated physical and psychological harms it causes has increased the prominence and visibility of a discreet drug using subculture within prisons. The demand for NPS was thought to be contributing to increased violence and disruption in prisons. It was reported that the use of NPS was met with prejudice and stigma which in turn limited the help that was offered to people using it.

We have noted a general preference among respondents for downers including benzodiazepines, heroin and other opioids, and alcohol, though stimulants, including cocaine and crack were also not uncommonly reported. Aside from individuals who recounted problems solely with alcohol, no interviewees reported using single substances. Polysubstance use was described as common both within prisons and in the community. Individuals who offered reasons for their substance use reported poor mental health, a desire to numb feelings, the effects of peer pressure and managing boredom and stress. Availability, rather than preference, dictated which substances people used in prison.

Substance use linked to offending

'It could range from anything ... It could be assault, assault and robbery. If I take any Valium, that's when things start going wrong.' [Lived Experience interviewee #02]

For many respondents their offending was linked to their substance use. Some committed crimes while under the influence and others were imprisoned for substance use-related crimes such as a theft and aggravated assault. Recent leavers and more prolific offenders feared the association between chaotic substance use, repeated prison sentences, and premature death. For those who had been in and out of the system over a long period this was something that they had seen play out with others they had known.

Patterns of substance use inside prison

'I'd always done drugs in jail, whether that be prescription drugs, non-prescription drugs, legal highs, whatever was floating about the jail … I was for a while a specific drug user, but then I became like a poly drug user and would just use anything.' [Lived Experience interviewee #13]

Access to substances in prison dictated which substances were commonly used by people and availability and opportunity drove patterns of consumption. The example of the common use of paper/NPS was again dominant in these conversations owing to the ease with which it could be posted in undetected and its relative affordability. ^[26] Mirroring the prevalence and effects of illicit benzodiazepines in Scottish communities beyond prison walls, and the views of stakeholders, 'street valium' was also a commonly used substance by lived experience respondents.

Experiences of substance use treatment

'What a difference it was being on the Suboxone from being on the methadone. You kind of get the majority of your function back and hopefully sometime soon I can get onto the Buvidal injections which means I'm not even having to go to the chemist anymore.' [Lived Experience interviewee #14]

Treatments discussed included medication-assisted (i.e., OST), mutual aid and therapy-based, both in prison and in the community.

Treatment options in prison

The most common treatment reported by respondents was OST. This included methadone and buprenorphine. Methadone was received in the traditional form of an oral solution. People were prescribed buprenorphine in three different formulations: Espranor (rapidly dissolving wafer), Suboxone (sublingual tablet with the opioid overdose reversal agent, 'naloxone') or Buvidal (long-lasting depot injection).

Autonomy/choice

MAT Standards place individual choice as central in the treatment of problem substance use. However, we heard of many occasions where there was perceived resistance from treatment providers to acknowledge individual choice relating to preferred medications, dosage, or indeed, a stated desire to exit treatment altogether.

Access

Access to substance use treatment and interventions were reported as being variable across Scotland's prisons. Variations related to differing access to the various forms of OST described above and addiction-related mental health specialists. Starting OST during a sentence was reported to be difficult and it took a long time to access. A lack of treatment options for those experiencing problems with NPS was also reported.

It is worth noting here that OST is used to treat those who use opiates. As noted previously, stakeholders perceived that the use of opiates in Scotland's prisons has been declining. There are no recommended prescription treatments for those experiencing harm and/or dependence as a result of NPS usage, which is currently the seemingly dominant prison substance use culture. Consequently, there was a perception amongst those in prison that no treatments were available for those who use NPS, which resulted in a culture of silence and an avoidance of disclosing substance use even when on OST. In part, this culture of silence was perpetuated by the punishments which often followed disclosures of drug use, including being segregated or secluded from everyone.

Continuity of care

Transitions between prisons were viewed as mostly acceptable in terms of treatment continuity. However, transitions into and out of prison were highlighted as key junctures where access to drug and/or alcohol treatment/prescribing was interrupted resulting in unmet needs. For many, a delay in receiving their prescriptions after being released meant that they experienced an unplanned detox resulting in physical and psychological harm.

Experiences of entering and exiting prison

The medical inductions people receive during prison reception were widely perceived to be too short and insufficient to meet people's needs, particularly relating to substance use and mental health.

Reports on throughcare and onward referral varied and experiences seemed to be impacted by where and when a person was released^[27]. Accommodation was a challenge for some, with homeless accommodation impacting the wellbeing of those released into it. Some people struggled to access basic care upon release such as access to a GP.

Community reintegration services

'If it wasn't for [name of service], then I think I would have been drinking, do you know what I mean, but I'm glad I'm not … They were brilliant with us … I was getting a lot of trust off them. Then they started believing that I would do it.' [Lived Experience interviewee #06]

Community reintegration services were successful at supporting the psychosocial needs of some recent prison leavers. Supported transitions, which included liaison with individuals prior to their release and pickups from prison, were particularly effective for protecting against immediate relapse into substance use. The practical support provided by these services included housing, help to initiate and maintain benefit claims, financial aid for transport, and guidance around locally provided training, development and employment opportunities, as well as service-delivered psychosocial support programmes. However, access to these reintegration support services appeared to be dependent on an individual's convicted status and the provisions available within a person's preferred Local Authority area of release.

Physical health needs

'Physical health… I think it's a disgrace … I had a stroke four years ago in this prison … I was an inmate, and I got downgraded to [name of prison] … all sorts of promises were made when I was in the rehab centre that I'd get this help, I'd get that help. I was given no help at all. I was just left and abandoned.' [Lived Experience interviewee #10]

Among our lived-experience interview sample, care for established physical health conditions was reported as being generally acceptable, though Covid-related issues disrupted regular outpatient treatment. By contrast, responses to emergent health needs including appointment access, physical health check-ups and dentistry are often delayed, and these were exacerbated significantly during the pandemic. This said, living in prison could ultimately result in access to healthcare, and subsequently address some health conditions, which some people would not have accessed in the community due to their chaotic lifestyles and substance use. Examples of these included blood-borne virus screening and successful treatment for hepatitis C, wound care and rehabilitation following injecting related injuries and improved nutrition.

Psychosocial interventions

'The only help I've ever had in here is speaking to people at the recovery café … I think it's the only thing in here that's actually working or doing anything for anybody to be honest.' [Lived Experience interviewee #12]

Differences in psychosocial support for people experiencing problem substance use were noted across Scotland's prisons. Prisons operating recovery 'café' models were well received by people in prison, people reported how cafes often hosted psychosocial support and access to various mutual aid groups, yoga, and exercise. However, Covid-19 restrictions and related staff shortages often meant severe reductions in the services offered by the recovery cafés. Another form of support reported was substance use-related peer mentoring programmes that supported at risk individuals entering prison, while affording the mentors themselves opportunities to reinforce their own recovery.

Harm reduction initiatives

'I'm a peer [mentor] for the new guys … We speak about overdose prevention, sort of dos and don'ts if you find somebody kind of like unconscious or whatever … speak about naloxone, NPS awareness, what are the signs and symptoms of overdoses, blood-borne viruses … it's just basically harm reduction.' [Lived Experience interviewee #11]

Where discussed, harm reduction education was peer-delivered, with sessions covering topics such as, blood borne-viruses, naloxone training, NPS awareness and overdose prevention. According to respondents, some prisons devote time during mandatory inductions for harm reduction training and education, while others offer courses on a needs-led basis to those considered to be most at risk. Several respondents also identified engagement with certain substance use specific programs as being beneficial for influencing parole decisions. Being a peer mentor had considerable significance in supporting individual recovery. Individuals reported drawing on their lived experience of overdose and harmful drug use and were grateful for the opportunity to help others.

Relationships with staff

'You'll get some staff that are all right. You'll get some staff that are just ticking boxes and you'll get some staff that are just… they go out of their way to be a pure idiot. I suppose that's the same as anywhere, but it shouldn't really be the place for that to happen.' [Lived Experience interviewee #12]

Lived-experience interviewees indicated that relationships between staff and people in prison were largely functional, civil, and respectful. Individuals described how they would navigate their time in prison by knowing which officers to approach for assistance and when. It was generally acknowledged and accepted, for example, that the prison system was often stretched by overpopulation and staff shortages. This created an environment where needs were frequently prioritised by individuals in prison so as not to bother staff with less urgent issues. Some interviewees felt particularly stigmatised by some prison staff on account of their substance use. Relationships with healthcare staff were impacted by structural conditions, including staffing pressures, appointment processes and power dynamics perceived to be specific to criminal justice settings ^[28]. Of note however, was how respondents described relationships with specialist addiction and/or recovery staff, which were often distinctly valued, particularly by individuals engaging in substance use treatment and/or detoxing.

Future improvements

'It would be more helpful having more [prison] staff that are … trained in substance misuse things … the drug workers are only here Monday to Friday through the day and … at night-time if somebody's got an issue or whatever it can be quite hard for them to get the help that they need.' [Lived Experience interviewee #11]

Addressing the overcrowding and long-standing prison staff shortages were highlighted as central to improving conditions in Scotland's prisons. Some interviewees suggested the prison population would be better managed by splitting those who are serving long compared to short-term prison sentences and establishing 'drug-free wings'. These ideas were highlighted as key to promoting safety in prison. Responsivity to health and psychosocial needs was further identified as an area for improvement. Tackling NPS usage was recognised by some as paramount to improving prison conditions and individual safety. People in prison suggested that training more prison staff in harm reduction and managing problem substance use would support these outcomes. It was also felt that drug treatment should be person-centred with options provided from a range of pharmacological and psychological therapies. Some individuals with varied experience across multiple Scottish prisons suggested that recovery café models should be employed as standard for meeting substance use needs. Greater in-reach twelve-step recovery fellowships was also noted as desirable for better outcomes. Lastly, support for nicotine dependence was identified as lacking with some respondents suggesting more options needed to be available to reduce examples of withdrawal and the attendant mental discomfort this brings.

Impact of Covid-19

'There's vulnerable people in prison and they're always looking for company. They don't want to be on their own. So, when you lock them up early that means they're on their own for longer, which makes them more vulnerable, right?' [Lived Experience interviewee #06]

People currently living in prison reflected on their resilience in relation to the changes to prison regimes during the pandemic, with some noticing little difference to their routines or service provision. However, concerns were voiced about the impacts of extended periods of 'lock-up' (more time spent in cells) for those already vulnerable to being overwhelmed by feelings of isolation and loneliness. Attempts to mitigate these negative impacts by individual prisons included the addition of large communal televisions, and games consoles which people could access in lieu of exercise and other forms of recreation.

Social distancing requirements and Covid-related staff shortages meant increased waiting times for appointments within prisons, while outpatient appointments were largely cancelled. Rapid increases in Buvidal prescribing were welcomed by people currently living in prison (due mainly to monthly rather than daily administration) and this transition from other forms of OST simultaneously satisfied public health requirements to reduce face-to-face consultations. The halting of in-reach twelve step recovery fellowships and other groups had a negative impact on people addressing their substance use problems.

While substance use support services were reduced, there was little evidence of Covid-19 restrictions impacting the availability of illicit substances in prisons (due to the flexibility and adaptability of those operating drug markets). Though challenging for some, visitation and telephone contact with loved ones continued through online platforms and the provision of mobile phones. Those released from custody during the pandemic, however, were impacted by reduced access to support and poor communication regarding the availability of all required services.