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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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Changing patterns of substance misuse in adult prisons and service responses.

HM Inspectorate of Prisons
[UK] HM Inspectorate of Prisons, 2015.
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Inspection findings on individual prisons were supplemented by fieldwork in eight prisons in 2014 to generate an overall picture of drug use and responses to it in prisons and England and Wales. In the face of rapidly changing and varied drug use patterns, policy and operational responses were seen as insufficiently flexible and dynamic, though treatment had dramatically improved.

Summary This thematic inspection by the Inspectorate of Prisons examined drug misuse in prisons in England and Wales. The context was that drug misuse in prisons damages the health of individual prisoners, undermines the security and safety of prisons, and hampers rehabilitation. Prisoners are more likely than the general population to have histories of drug misuse, and in some cases this misuse continues in prison. When work on this inspection began, there had been a recognised shift away from the use of opiates and drugs controlled under class A of the Misuse of Drugs Act [such as heroin, cocaine and amphetamines] towards the misuse of medication in prisons. During this work patterns of substance misuse in prison changed again and the use of new psychoactive substances (NPS), and in particular synthetic cannabis, emerged as a major problem.

The inspection drew on 61 reports on prisons published by HM Inspectorate of Prisons between April 2014 and August 2015. A total of 10,702 survey responses were included in the analysis.

These inspection findings were supplemented with findings from fieldwork conducted in eight prisons between June and November 2014, including 1,218 responses to a confidential survey which asked prisoners about their drug use before going into custody and in their current prison. Interviews with prisoners further explored their drug use and their experiences of prison-based drug treatment, while staff involved in supply reduction and treatment were asked about trends in and motivations for drug misuse in the community and in the prison, and the support available. In addition, interviews were conducted with commissioners of community and prison drug treatment services in England.

Key points icon

Key points
From summary and commentary

Inspection findings on individual prisons were supplemented by fieldwork in eight prisons in 2014 to generate an overall picture of drug use and responses to it in prisons in England and Wales.

Though still significant, misuse of opiates appeared to be declining but there had been an increase in the use of diverted medications and in synthetic cannabis.

Policy and operational responses had not been sufficiently flexible and dynamic to cater for these changing and varied patterns of use.

Main findings

Substance misuse is a serious threat to the security of individual prisons, the health of prisoners and the safety of prisoners and staff. Crime associated with the supply of drugs to prisons and the negative impact of drug use on measures to reduce reoffending adversely affects the community as a whole. Crime and disorder associated with the supply and distribution of illicit substances in prisons undermines effective security in individual prisons. Substance misuse damages the health of prisoners and in some cases leads to death. Violence and disorder associated with substance misuse affect the safety of prisoners and staff. The involvement of organised crime in the supply of drugs to prisons may lead to pressure on prisoners’ families and friends, and have wider effects on the community as a whole. Some prisoners report that they have developed a drug problem in prison, and drug use undermines measures to rehabilitate them and reduce reoffending.

Patterns of drug use are changing in the community. Though this will be reflected in patterns of drug use by prisoners before and, to some extent, within custody, there are some important differences between drug misuse in the community and in prison. Offenders are more likely than the general population to misuse drugs and prisoners report high use of illegal drugs before imprisonment. There is a preference for depressants rather than stimulants. Security measures affect the choice and quality of what is available. The misuse of opiates in prisons appears to be declining but remains an important issue. There has been an increase in the use of diverted medication. Large numbers of prisoners present with chronic pain, and some come into prison taking inappropriately prescribed drugs or are started on these regimens in prison. In recent years, the use of new psychoactive substances – in particular, synthetic cannabis, known as ‘Spice’ or ‘Mamba’ – has grown significantly.

Synthetic cannabis use has spread to most prisons and has destabilised the safety and security of some of those inspected. Synthetic cannabis has caused or is still causing wide-ranging problems, including medical emergencies, deaths, bullying, violence and debt. The extent of the problems and level of use appears most severe in category C establishments [for inmates who cannot be trusted in open prison, but who have been recognised as being unlikely to attempt an escape]. There is the potential for large profits to be made from synthetic cannabis, and this has led to gangs and organised crime becoming involved in its distribution in some prisons.

The extent and the nature of illicit drug misuse vary between individual establishments and can even be different in different parts of the same establishment. Patterns of use change rapidly at both a national and individual level. The problems associated with synthetic cannabis can be very obvious and have a clear adverse effect on some prisons, but most prisons have wider-ranging drug issues, including illicitly brewed alcohol, traditional drugs (including cannabis and opiates) and illicit medication. Successful measures to reduce the supply of synthetic cannabis are likely to increase demand for other substances. Policy and operational responses have not been sufficiently flexible and dynamic to meet these changing and varied patterns of use.

The development of a coordinated response to synthetic cannabis has not kept pace with its rapidly increasing use in adult male prisons. National developments, such as new legislation, new drug tests and dogs trained to detect synthetic cannabis, are now being established. Pockets of good practice were seen to have been developed in individual prisons and by specific treatment providers, but national prison guidance only emerged in 2015, which has resulted in some inconsistent and inadequate approaches across the estate.

There are no effective testing methods for synthetic cannabis available nationally, though some are in development. Assessments of local needs are currently hindered by inadequacies in the mandatory drug testing system. The system is a useful supply reduction strategy but some illicit drugs, such as synthetic cannabis, are popular in prisons simply because they do not show up in drug tests. This makes test results an inaccurate measure of drug misuse in prisons and an inappropriate measure of prison performance.

Few establishments have the necessary ‘whole-prison’ approach to addressing illicit drug use. Drugs have the potential to affect all areas of prison life and, similarly, all aspects of prison life have the potential to influence demand for drugs. A ‘whole-prison’ approach is necessary which tackles:
• Supply reduction: stopping drugs getting into the prison.
• Demand reduction: reducing the demand for drugs by addressing wider issues that may lead to drug use in prison and on release.
• Effective treatment for drug and alcohol issues, including harm reduction.

A prison’s drugs and alcohol strategy needs to be embedded into every department, with effective structures to coordinate activity across the prison. Strategies and treatment should not just focus on drugs. Effective drug treatment also needs to address the wider issues that affect drug use, including adequate purposeful activity, and to include joint working between agencies and prison departments to address all the wider issues, including housing, employment, physical health and mental health. Poor performance in these areas in some prisons undermines effective treatment.

Efforts to reduce the supply of drugs are too variable across the prison estate. In some cases, this is exacerbated by a shortage of suitable resources. The strategies to detect illicit new psychoactive substances and medication distribution and misuse are broadly the same as for other drugs. Some prisons are more effective than others at reducing supply, and in some cases a lack of suitable resources, such as a lack of trained drug dogs or sufficient staffing to carry out necessary testing or searches, contributes to inadequate responses.

Prison-based drug treatment services have improved dramatically in England over the past 10 years. The introduction of evidence-based and individualised treatment and support services, such as counselling, assessment, referral, advice and throughcare (CARAT) and the integrated drug treatment system (IDTS), and the subsequent developments in commissioning and provision, have greatly improved drug treatment in English prisons and the community for offenders with opiate dependence. However, prisoner outcomes are adversely affected in some prisons by various factors, including: poor prescribing; infrequent reviews; an insufficient range, quantity or quality of psychosocial support; and inadequate integration between services and departments. Community and prison drug services need to be innovative to make their services attractive to, and relevant for, people who use drugs other than opiates.

Lack of the integrated drug treatment system in Wales leads to poorer outcomes for some prisoners and creates inconsistency in substance misuse treatment between prisons in England and Wales. Inspection findings have demonstrated that large numbers of prisoners in Wales have drug and alcohol problems on arrival. Unlike their counterparts in England, prisoners in Wales who are dependent on illicit opiates do not receive first-night opiate substitution treatment. Instead, they are generally offered symptom relief only, which increases the risk of physical and mental distress in prison and of accidental overdose on release if they return to illicit drug use. Inspections of Welsh prisons have found that those who arrive in prison from confirmed opiate substitution treatment in the community will have this prescribing continued in prison, although the length of time for which the prescribing will be continued and the level of psychosocial support available vary between prisons. This lack of consistent, coordinated, evidence-based treatment, including access to opiate substitution prescribing on arrival, has led to poorer outcomes for some prisoners. The drug treatment system in prisons needs to be the same across the estate and equivalent to that in the community.

Insufficient use is made of prisoners’ families, friends and prisoner peer supporters to reduce supply of and demand for illicit substances. Well-trained and supervised peer supporters contribute to improved outcomes for prisoners. High-quality, properly supervised peer-led social, emotional and information support is key to effective drug treatment. Too many prisons do not do this effectively. Family and friends are also a largely untapped but key resource for substance misuse recovery in prisons. Research, the recent resettlement report from HM Inspectorate of Prisons, and interviews with prisoners for this thematic inspection, confirm that an offender’s family and friends are critical to their successful rehabilitation, including from addiction and into recovery. Families and friends may also be a negative factor and, willingly or through coercion, be a source of supply. Targeting families and friends for education and support is essential to improving outcomes for individual prisoners and to reducing supply. Too few prison drug treatment services do this effectively.


Findings logo commentary The findings reported above were accompanied by a series of recommendations which in March 2017 were responded to and generally at least partially accepted by the UK government. Apart from resources, the main barrier to fully implementing some of the recommendations seems to have been the government’s rejection of national programmes in favour of the discretion afforded to prison governors and local health services.

Last revised 16 August 2017. First uploaded 16 August 2017

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