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Alcohol services in prisons: an unmet need.

HM Inspectorate of Prisons.
HM Inspectorate of Prisons, 2010.
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Prison inspections and surveys of prisoners and staff in England reveal a "depressing picture" of "very limited" services for problem drinking inmates, which leave them with poor prospects on release.


Introduction from HM Chief Inspector of Prisons

For some time, prison inspections have been describing the gap between the needs of prisoners with alcohol problems and the services that exist to support them. This short thematic report reveals the dimensions and the consequences of that gap.

The report draws on inspection surveys of 13,000 prisoners between 2004 and 2009, 72 inspection reports between 2006 and 2009, and surveys of drug coordinators in 68 prisons in 2009. The data cover all kinds of prisons holding those aged over 18.

The survey results, particularly for the most recent year, are startling. Within the whole sample, 13% of prisoners surveyed reported having an alcohol problem when they entered their prison. In the most recent year, 2008–09, this rose to 19%, nearly one in five. It was even higher among young adults (30%) and women (29%). These figures almost certainly underestimate the scale of the problem, as many of those with alcohol problems will fail to recognise or acknowledge them.

While most alcohol users, particularly women, reported concurrent use of illegal drugs, there was a significant proportion of male substance misusers for whom alcohol was the only problematic substance. This was true for half of the men in local prisons who reported having an alcohol problem. Among young adults, only a minority reported having drug problems [without also having] an alcohol problem.

Prisoners with alcohol problems are likely to be more problematic in general and to need greater support. More are high risk offenders and more had been in prison before. They were more likely than other prisoners to come into prison with pre-existing difficulties, such as housing needs and health – particularly mental health – issues. Alcohol use is accepted as a key risk factor in predicting violent reoffending.

Yet this report shows that at every stage in prison, their needs are less likely to be assessed or met than those with illicit drug problems. On entry to prison, alcohol problems are not consistently or reliably identified, nor is the severity of alcohol withdrawal symptoms. Some establishment drug coordinators' estimates of the extent of the problem in their prison appeared to be considerably at odds with our survey findings. Few prisons had an alcohol strategy based on a current needs analysis, and even where analyses had been carried out, some were likely to underestimate need.

Services for alcohol users were very limited, particularly for those who did not also use illicit drugs. There was a shortage of healthcare staff with training in alcohol misuse, or dual diagnosis (mental health and substance use). Interventions so far have largely consisted of Alcoholics Anonymous, an abstinence-based self-help approach which is not suitable for all those with alcohol problems. CARATs (counselling, assessment, referral, advice and throughcare service) teams are not resourced to work with those who have only an alcohol problem. Most drug coordinators identified the lack of specific funding as a major barrier to providing adequate services, even when new interventions became available – whereas there has been ring-fenced funding for illicit drug users.

It is therefore scarcely surprising that alcohol users expected to have more problems on release than other prisoners – for example, with accommodation, employment, and relationships. Worryingly, over a quarter of those who came into prison with only an alcohol problem said that they were likely to leave with a drug problem, suggesting that in the absence of either alcohol or treatment, a new dependency had been created. Since community alcohol provision suffers from the same deficits as provision in prisons, it was hard to put alcohol users in contact with supportive community services on release; there is no equivalent of the drug intervention projects that support those using illicit drugs.

This is a depressing picture. It is clear that alcohol misuse is a growing problem, fuelling violent crime, particularly among young people. Yet, as this report shows, prisons have not grappled effectively with this problem and are not resourced to do so. Such provision as there is has depended on local initiatives and locally sourced funding – a fragile and patchy basis for an essential service. What is needed is a national strategy, based on need and backed by sufficient resources, training and support. The consequences of inaction are much more costly.

Prison Service strategy for alcohol treatment and intervention

In response to the publication of the Alcohol Harm Reduction Strategy for England, the Prison Service produced a strategy in 2004 to support the new emphasis on tackling alcohol misuse, particularly in relation to its connection with offending behaviour. Addressing Alcohol Misuse: A Prison Service Alcohol Strategy for Prisoners laid down the following aims for service development:
• to improve education and communication;
• to improve the identification of prisoners who may have a drinking problem;
• to improve both the capacity and quality of alcohol treatment interventions available to prisoners;
• to spread good practice and ensure greater consistency across the prison estate;
• to reduce the supply and use of alcohol by prisoners, both into and within establishments.

The strategy stated an intention to adopt the National Treatment Agency's (NTA) model of care framework for alcohol treatment – a pathway model determined by individual need. A comprehensive strategic approach as defined by the NTA incorporates:
• targeted screening with brief intervention for hazardous and harmful drinkers;
• comprehensive assessment for those with identified alcohol problems;
• individualised care planning with "treatment goals, the treatment interventions and services to be provided, and the responsibilities of professionals, the individuals, their carers and others in the coordination and delivery and treatment";
• provision of a range of alcohol treatment interventions to meet local need;
• post-treatment support with information, advice and help to maintain "improvements in health and social wellbeing and reductions in alcohol consumption";
• managing alcohol treatment by means of, for example, ensuring staff competence or reviewing performance by utilising service user monitoring data.

The Prison Service alcohol strategy was supplemented by the Alcohol treatment/interventions good practice guide. In the absence of dedicated resources for the implementation of improvements in alcohol services, this document offers guidelines for service development where this is possible through locally sourced funding. The guide describes treatment for alcohol misuse that starts on arrival to prison and continues through to release, and that is flexible enough to meet individual needs. In sequential order the interventions outlined are:
• dependency assessment;
• alcohol detoxification;
• screening assessment;
• substance misuse triage assessment;
• substance misuse comprehensive assessment and care planning;
• general awareness raising;
• one-to-one motivation sessions;
• group work;
• Alcoholics Anonymous;
• structured treatment programmes;
• pre-release intervention;
• post-release access to community services.

The Prison Service alcohol strategy states that it will expand existing treatment provision where resources are available. It acknowledges a requirement for tailoring treatments to individual need and motivation levels. However, the scope for doing so is inherently constrained by a scarcity of resources to expand on current provision, particularly in the current climate. Unlike the provision of drug-related treatment, there is a conspicuous absence of centrally allocated funding to enhance alcohol services, and the strategy has been criticised for being no more than "an illusion of action to tackle alcohol".

Many strategies produced locally by establishments for enhancing services for alcohol users have lacked conviction, and this is likely to be a consequence of insufficient resources. Despite the publication of the national and Prison Service alcohol strategies, funding for and access to substance use services in prisons has continued to be primarily ring-fenced for those with a problem with illegal drugs, with alcohol often only addressed as part of a poly-substance misuse issue.

The scope of the report

HM Inspectorate of Prisons has published criteria, called Expectations, for the treatment and conditions of prisoners, covering all aspects of prison life. Prisons are then assessed under four key tests: safety, respect, purposeful activity and resettlement.

The Expectations for substance use services, including alcohol service provision, at an establishment include:
• a multi-disciplinary strategy team implements and monitors a written substance use strategy which is informed by regular population needs assessments;
• the treatment programmes provided are appropriate to the requirements of the population served, taking account of patterns of substance use;
• all prisoners with substance use problems are identified at reception and given information about the services available;
• after clinical intervention for substance dependency, treatment is integrated with psychosocial interventions;
• there are specialist dual diagnosis services provided for those with both a mental health and substance-related problem;
• those with substance use problems have prompt access to a range of psychosocial treatment and support, which meet their identified needs. Prisoners are also actively involved in the care planning and reviewing process;
• work related to substance use is integrated and coordinated, and linked to custody and sentence planning. Resettlement needs are addressed by linking prisoners with community service providers so they can access appropriate support and continued treatment on release.

The findings in this report focus solely on provision in young adult and adult prisons, for both men and women aged 18 and over, and come from the three sources described below.

Prisoner surveys This is a dataset of a representative sample of prisoners surveyed, in the course of inspections, at 144 prisons between May 2004 and March 2009. It consists of responses from 13,093 prisoners, of whom 1682 (13%) stated that they had an alcohol problem (either alone or together with drugs) when they arrived at the prison where they were surveyed. Analyses have been completed for the overall sample and for each functional prison type, except for dispersal and open prisons, where numbers were too small for statistical comparison, but responses from these prisons were incorporated into the overall analysis.

Comparisons are made between those reporting that they had an alcohol problem (whether alcohol only or alcohol and drugs) on arrival and those who did not; for ease the former are referred to simply as those with an alcohol problem throughout the text. At some points, however, there is a comparison between those with alcohol-only (ie, no coincident drug use) problems and those with drug, or drug and alcohol, problems.

Inspection reports This is data from 72 reports of full inspections conducted between April 2006 and March 2009, of 24 training prisons, three dispersal prisons, 19 local prisons, seven women's prisons and 14 young offender (aged 18–21) institutions.

Establishment drug coordinators survey This derives from surveys of establishment drug coordinators about services available in their prisons. Sixty-eight surveys were returned out of 129 sent out in June 2009, a response rate of 53%.

Key findings

Overall, in the 2004–09 period, in surveys carried out by HM Inspectorate of Prisons, 13% of prisoners said that they had arrived at prison with an alcohol problem. The number reporting alcohol problems rose considerably, to 19%, for prisons in the 2008–09 inspection year, reaching 30% in young offender institutions and 29% in women's prisons. The high prevalence of problematic alcohol use in the prison population is supported by O-DEAT data.

Over half (54%) of prisoners with alcohol problems also reported a problem with drugs, and 44% said they had emotional or mental health issues in addition to their alcohol problems. The correlation with emotional or mental health issues was especially pronounced among the women surveyed.

The analysis of inspection reports and the surveys sent to establishment drug coordinators revealed that a considerable number of establishments had no alcohol strategy. Where strategies existed, inspections often found them inadequate. Few were based on accurate population needs analysis, and a number prioritised the detection of alcohol consumption in the prison, or lacked detail.

In local prisons, the onus for screening prisoners for alcohol problems rested primarily on reception processes, and training prisons relied heavily on this process being completed at local prisons. However, two establishment drug coordinators from local prisons said that they did not use a standardised screening tool for identifying alcohol problems, and in total nearly half of all prisons reported that no screening tool was used.

Arrival in custody

Establishment drug coordinators at all local prisons said that they offered alcohol detoxification for prisoners with physical withdrawal symptoms, and all except one were able to locate those undergoing clinical treatment on either a substance misuse or healthcare inpatient unit.

A large majority of those entering prison receptions with an alcohol problem reported problems in other areas of welfare, in areas such as housing, emotional wellbeing and physical health.

Life in prison

In all prison types, those reporting alcohol problems said that they felt less safe than the rest of the population: nearly half (45%) had felt unsafe at some time in the prison, and for those in local prisons, just under a quarter (24%) felt unsafe at the time they were surveyed. Adults with alcohol problems were less likely to report respectful treatment by staff, or that they had a member of staff to turn to if they had a problem.

Those with alcohol problems were twice as likely as other prisoners to report an emotional wellbeing or mental health issue. Some prisons still did not have mental health staff with dual diagnosis expertise, and the two services – alcohol and mental health – were usually separate.

Treatment and interventions for alcohol problems

There is considerable unmet need for ongoing treatment and support. Links with Alcoholics Anonymous (AA) appeared reasonably well established, but were the sole specific provision for those with alcohol problems at a number of prisons. Responses from establishment drug coordinators showed that those with alcohol-only problems were much less likely to have access to interventions than those who had both drug and alcohol problems. This was supported in prisoner surveys, especially for those in local prisons. Fewer prisoners with alcohol-only problems (60%) reported that they had received any help or intervention than prisoners with either a drug and alcohol problem (75%) or drug-only problem (84%). In 43% of cases where offenders had been assessed by criminal justice staff as disinhibited by alcohol or where alcohol was linked to offending, no intervention for alcohol use was prescribed. This compared with only 28% in cases involving drug use.

Counselling, assessment, referral, advice and throughcare services (CARATs) were not funded to provide ongoing support for those with alcohol-only problems. Fewer than half (42%) of inspection reports described a CARAT team able to provide even a minimal level of support for alcohol-only users.

Very few treatment or offending behaviour programmes have been developed or accredited specifically for alcohol misusers, and none were yet available in any prison inspected except for a non-specific programme in dispersal prisons and a pilot alcohol dependency programme at one prison. This had not yet been rolled out to other prisons. During 2009, a recently accredited alcohol and violence programme was being piloted in four prisons. Enhanced services for alcohol were dependent on staff initiatives and locally sourced funding, which could be difficult to obtain or sustain. It is apparent that those support services which require supplemented funding are less widely available, and AA, which comes at a minimal cost, is most prevalent.


When prisoners were asked if staff had helped them to prepare for release, there was no significant difference in response between those reporting an alcohol problem and those who did not. However, only around a fifth of both groups felt that staff had helped them.

In every area of resettlement, and in all prison types, prisoners reporting alcohol problems were more likely to feel that they would have problems on release from prison. Their knowledge of the services available in custody to help them prepare for release was also considerably worse than those without alcohol problems. They were over twice as likely as other prisoners to say that they thought they would leave prison with a drug problem, and 60% said that they would leave with an ongoing alcohol problem.

Those with an alcohol problem who said that they would still have this problem on release reported considerable deficits in substance use treatment received in prison, access to purposeful activity, and resettlement.

Last revised 03 April 2011. First uploaded

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