Lloyd C., Page G., McKeganey N. et al.
International Journal of Drug Policy: 2019, 70, p. 107–116.
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While drug recovery wings were specifically designed to facilitate recovery from drug and alcohol problems among prisoners, this small study found that the sharp drop-off in support when they returned to the community ended many recovery journeys prematurely.
Summary Recovery has become the watchword in UK drug and alcohol policy – symbolising a shift away from long-term methadone maintenance in favour of abstinence-oriented approaches. From 2011, this philosophy was also promoted in prisons through pilot ‘drug recovery wings’, which aim to cultivate recovery by providing abstinence-based services in dedicated wings of prisons.
Focusing on the trajectories of a small number of prisoners in pilot drug recovery wings, the featured study analysed the recovery assets and resources that participants had at their interview in prison, the support they received prior to release, and the situations they found themselves in on leaving prison.
A key finding was that many recovery journeys ended prematurely – participants returning to the community without housing or professional support, and subsequently resuming pre-imprisonment levels of drinking and drug use.
The study demonstrated a fundamental mismatch between the extent of prisoners’ past and present problems and the level of support they received, and a failure to plan for recovery beyond the prison gate.
Prison is an unlikely setting for recovery. Not only are illicit drugs readily available, but prison involves separation from existing sources of stability and support that would typically be relied upon to strengthen a person’s resolve and ability to overcome problems with alcohol and illicit drugs.
The drug recover wing model was trialled in seven adult male prisons, two women’s prisons, and one young offender institution, and evaluated over a three-year period through interviews with 345 prisoners and staff, surveys with 631 prisoners about the impact of drug recovery wings, and surveys with 1246 about their quality of life.
The featured study picked up the story as the prisoners in drug recovery wings neared their release date, and followed them up after they had been living back in the community for six months. Researchers analysed interview data from six of the ten pilot drug recovery wings (five adult male prisons and one male young offender institution) to understand the recovery assets and resources (‘recovery capital’) that prisoners had at their interview in prison, the support they received prior to release, and the situations they found themselves in on leaving prison:
• 61 participants were interviewed while in prison, and 21 were followed up after they had been living back in the community for six months;
• 26 ‘recovery supports’ were also interviewed; these were people identified by prisoners who would be able to talk about their progress after they had been released.
In 11 cases, both prisoners and their recovery supports were interviewed. This took the total number followed up to 36 prisoners.
Among participants who could not be followed up, two remained in prison for longer than expected, seven had been re-imprisoned, two did not want to be re-interviewed, and the others could not be contacted, for example because phone numbers had been changed or phones had been disconnected.
Most participants had a long history of alcohol or opioid dependence, and prison did not provide a ‘drug-free’ change of environment. In all but one of the drug recovery wings, cannabis, diverted medications, and new psychoactive substances (especially ‘spice’, a synthetic form of cannabis) were readily available.
Many participants had been in the care system (an experience which was almost universally negative), and most had left school early, with no or very limited qualifications. Participants from one drug recovery wing described similar experiences of being expelled from primary school, and having no structured education after this point; several stated that they were unable to read or write.
Although few had formal qualifications, around half of all participants had a substantial record of employment, mostly in manual trades. The skills and experience the majority had built up over their lives seemed to carry considerable potential for the future, with many referring to job offers and contacts they would approach after leaving prison. Work also proved to be an important part of masculinity for many – something tied to their perceived worth and roles as men, partners, and fathers.
It was common for participants to report mental health problems or mental illness such as depression, anxiety, and schizophrenia. A number referred to self-harming and previous suicide attempts, and others to drug overdoses which were neither entirely suicidal nor entirely accidental.
For many participants there was a strong sense that they were ready to make fundamental changes to their lives – to address their substance use problems and seek more conventional lifestyles and goals. Key motivations for change were relationships, increasing age, and growing tired of a life of substance use and crime.
Many had previous experiences of relapse, reoffending, and homelessness or insecure accommodation, and emphasised that they would need support after leaving prison in order to maintain any progress made in the drug recovery wings. However, none reported having received a concrete offer of housing as they approached leaving prison, and most expected to be released to bed and breakfasts (B&Bs), hostels, and night shelters.
At their follow-up interviews, only three participants were abstinent from alcohol and illicit drugs. One attributed this to his Islamic faith, another through a desire to renew relationships with his children, and a third through family support and Narcotics Anonymous. While a large group had returned to pre-imprisonment levels of substance use, a substantial proportion moderated their substance use, and where this occurred, employment was a key motivating factor.
When asked to reflect on what recovery meant to them and whether they would describe themselves as ‘in recovery’, a number laughed and responded that they certainly were not in recovery, having already described their relapse. Others referred to always being in recovery. Definitions of recovery were primarily tied to participants’ levels of substance use. However, there was also an awareness of how other problems they were experiencing affected their chances of making ‘real’ changes to their drinking and drug use.
Only six participants reported receiving any level of professional support on release; of these, two stopped engaging with their caseworkers and returned to substance use, and the other four were offered very limited support.
The most fundamental source of recovery capital needed by participants was housing. Yet, none reported accessing adequate housing through prison services. As they had feared when previously interviewed, many were released with no option but to sleep on the streets, stay in temporary housing, or stay with friends – situations associated with relapse, re-offending, and a return to dependence on drugs and alcohol.
The most common type of housing was a hostel or B&B place funded by local authorities. No participants found this a positive experience and nearly all thought that living in this accommodation undermined any hopes of making changes to their lives, and made a return to prison more likely. Hostels and B&Bs also represented a stark contrast to the structured and orderly prison regimes people had become used to.
Those that eventually found alternative forms of housing tended to do so through their own initiative. One started dealing drugs which provided him with the money to move elsewhere, one moved to a different city, and one moved back in with his father. Another person left temporary housing in favour of ‘sofa surfing’ and occasional street homelessness. Lastly, after a suicide attempt, one interviewee was fast-tracked to his own flat through the intervention of the mental health crisis team.
Only two participants were able to maintain their tenancies over the course of their prison sentence and were therefore able to return to their old address. One did so through the help of a drug dealing associate who had paid his rent while he was in prison.
The majority of interviewees had been in employment since returning to the community. This was often short-term, ‘cash-in-hand’ work, and nearly always obtained through personal contacts, including family and friends.
Among those whose situation improved on release it was often attributed to support from a partner or getting work.
The featured study took a narrower scope than the evaluation of the drug recovery wing pilots, exploring how drug recovery wings shaped the recovery journeys of a small group of people from the time they were in prison, to their lives back in the community.
As only a third of participants interviewed in prison could be followed up after their release, it is possible or even likely that important narratives of recovery were lost. However, the study was unusually successful in managing to keep in contact with (and interview) some particularly vulnerable people in hostel accommodation, who would normally be among those excluded or absent from follow-up data.
The findings indicated a fundamental mismatch between the extent of prisoners’ past and present problems and the level of support they received, particularly on release. Many participants’ histories included adverse childhood experiences (eg, time in the care system), a lack of education (in some cases including an inability to read and write), homelessness, and mental health issues. When they arrived in prison, illicit drugs were prevalent, and when they left prison, they more often than not had nowhere safe or suitable to go, and no professional support to help them transition to post-prison life and continue with their recovery journey.
At a time when there have been renewed calls in the UK for prisons to focus on reform, it is important to find new ways to prevent or mitigate the damage caused to prisoners’ recovery potential while incarcerated, and moreover to substantially invest in support on release.
commentary At its outset the featured paper described the contradiction inherent in someone trying to ‘do recovery’ while in prison – an environment largely cut off from existing social supports and sources of stability (known as ‘recovery capital’), and by no means free from exposure to illicit drug use. While a logical question, therefore, might be whether drug recovery wings succeeded in cultivating a space for recovery, the findings of this study suggest that the answer might not matter if all is lost when people leave prison. One of the main aims of pilot drug recovery wings was to “support prisoners’ recovery journeys into the community”. Yet, for almost all participants followed up, support ceased when they left prison, which meant that the approach didn’t conceptualise or plan for people’s recovery beyond the prison gate.
In 2010, drug recovery wings were identified by the Conservative-led coalition government as an important element in the turn towards abstinence-based recovery and a more ‘challenging’ treatment regimen:
“We believe that, given the substantial investment in drug services, and the strong association between drug use and reoffending, we should be more ambitious in our aims to improve efficiency and effectiveness. We will therefore focus on recovery outcomes, challenging offenders to come off drugs.”
The first wave of drug recovery wing pilots was rolled out in June 2011 for prisoners with short-term sentences in eight English men’s prisons. A second wave, launched in April 2012, focused on prisoners serving a longer sentence and included two women’s prisons and a young offender institution.
The Effectiveness Bank has also analysed the final evaluation of the drug recovery wing pilots, and the continuity of care between drug recovery wings in two English women’s prisons and the community.
The final evaluation report published in 2017 found that drug recovery wings were associated with considerable reductions in drinking, drug use, and self-reported offending. However, this was only for the one third of prisoners living in the community who remained in contact. On that basis there was no way of knowing about the extent to which the other two thirds of the sample were using drugs, drinking excessively, or engaging in criminal behaviour. Nevertheless, the fact that many prisoners who were followed from treatment initiation to living back in the community were able to reduce their drinking and drug use, and their offending could have been seen as a positive outcome.
In terms of building recovery capital, drug recovery wings had very limited impact. People who entered prison with robust access to resources left in a similar position, and those who were imprisoned with nothing returned to nothing (ie, precarious housing, marginalisation from employment, and unstructured lives filled with the temptation of illicit earnings). Drug recovery wings also failed to deliver or facilitate support in the longer term (1 2). Many prisoners experienced a sudden drop off in professional support on leaving prison, and did not receive adequate support in accessing housing.
Women’s experiences were under-represented in the final evaluation: only one women’s drug recovery wing was included in the processProcess evaluation: the processes which help and hinder the daily operation of the drug recovery wing intervention. evaluation; and no women’s drug recovery wings were included in the impactImpact evaluation: the impact of each drug recovery wing on participants’ drug use and recovery at the end of treatment and six months after release from prison. or economicEconomic evaluation: whether continuing to fund drug recovery wings represents good value for money. evaluations. As the featured study relied upon information collected in the evaluation, it was therefore unable to examine the trajectories of women. However, what another study gathered is that neither of the drug recovery wings in women’s prisons established a clear exit strategy, which was a cause of considerable anxiety for prisoners, and gave no reason to be optimistic that women were better catered for in terms of continuous care.
Together with evidence about drug recovery wings in men’s prisons, findings suggest a systematic failure to consider and deliver post-release support for prisoners leaving drug recovery wings in England and Wales. However, rather than drug recovery wings being a flawed concept, what may have ultimately undermined their potential was the context in which they were implemented, including under-resourcing (£30,000 made available to each prison) and strain in prisons (the drug recovery wing pilots happened at a time of substantial decline in prison officer numbers).
In all but one recovery wing, drug availability was a problem. The Prison Drugs Strategy for England and Wales has acknowledged this challenge, both from drugs being smuggled into prisons and drugs being diverted from their prescribed medical use for illicit consumption. The latter has been used to implicitly frame abstinence-based recovery as superior to and more desirable than medication-assisted treatment within the prison complex. Although the prison strategy avoided narrowly defining recovery, it posed medication-assisted treatment as a problematic approach through:
• only mentioning opioid substitution therapies (eg, methadone and buprenorphine) in the context of the misuse of prescribed medicines;
• describing the use (not just the misuse) of prescribed medicines as “presenting considerable challenges to safety”.
The prison strategy took a hard line on drugs in prisons – advocating for security and testing measures to be improved and upgraded, and not conceding room for harm reduction measures such as needle exchange and naloxone provision. Though one of its key aims was to reduce drug-related deaths in custody, the protective effect of being in treatment and the heightened risk of overdose death while not in treatment and after leaving was overlooked in the text.
The European Union Drugs Strategy 2013–2020 advocates “[scaling] up the development, availability and coverage of drug demand reduction measures in prison settings, as appropriate and based on a proper assessment of the health situation and the needs of prisoners, with the aim of achieving a quality of care equivalent to that provided in the community and in accordance with the right to health care and human dignity as enshrined in the European Convention on Human Rights and the EU Charter of Fundamental Rights”. Under their definition, this would include “a range of equally important and mutually reinforcing measures, including prevention (environmental, universal, selective and indicated), early detection and intervention, risk and harm reduction, treatment, rehabilitation, social reintegration and recovery”.
An overview of harm reduction in prisons in seven European countries (not including the UK) found that the provision of harm reduction in prisons continues to be largely inadequate compared to the progress achieved outside prisons. All of the countries reviewed provide a wide range of harm reduction services in the broader community, but most failed to provide these same services, or the same quality of these services, in prison settings, in clear violation of international human rights law and minimum standards on the treatment of prisoners. Where harm reduction services have been available and easily accessible in prison settings for some time, better health outcomes were observed, including significantly reduced prevalence and incidence of both HIV and hepatitis C.
In 2015, the Scottish Prison Service published a framework for the management of substance use in custody. This included a pledge to “take all reasonable measures to reduce the availability of illicit substances and provide services broadly equivalent to those available in the community, whilst recognising that prisoners require different routes to recovery”. This includes “offering a range of harm reduction measures to reduce the transmission of blood borne viruses”. Promoting parity of services with the community, Scotland echoes the European drug strategy as well as UK treatment guidelines.
Last revised 21 August 2019. First uploaded 06 August 2019
HOT TOPIC 2018 Ethics and evidence on naltrexone treatment of offenders