Opioid Agonist Treatment in prison
I have just (26 December 2023) had a new piece of research into the lived experience of people accessing Opioid Agonist Treatment (substitute medication such as methadone or buprenorphine) in prison published. The International Journal of Prison Health published a study undertaken in England and Scotland by myself and six colleagues: Colin Fearns, Paula Harriott, Lisa Millar, Jardine Simpson, Jason Wallace, Michael Wheatley. The study Accessing opioid agonist treatment in prison in England and Scotland remains problematic – the views of people with lived experience examined lived experiences of opioid agonist treatment (OAT) during and immediately following release from detention in prisons in England and Scotland. Using surveys & focus groups, the research was conducted in Spring/Summer of 2022 and collected the experiences of 207 people who use heroin and other opiates and sought OAT in prison in England and Scotland.
Findings
Survey respondents were asked whether they wanted medication for their opiate dependency in prison and their preferences for the type of prescription. Just over three quarters (76%) of the 180 respondents who answered this question did want medication, with a majority wanting a maintenance prescription. In England a majority of respondents expressed a preference for methadone over buprenorphine; in Scotland this preference was reversed.
The pros and cons of disclosure
Focus group discussions revealed that different individuals had developed their own decision-making processes on whether to disclose heroin dependency and seek substitute medication. Several people were reluctant to disclose their status as heroin users to both prison staff and other people in prison, saying that it was impossible to keep information on one’s drug use confidential in prison. The main perceived negative consequences of disclosing one’s use of heroin included:
- Being looked down on, considered “scum” by prison staff and other people in prison;
- Being considered weak and a target for bullying by other people in prison;
- Receiving more attention from prison security including more frequent searches of an individual and their cell; and
- Damaging one’s prospects of being awarded Home Detention Curfew, Release on Temporary Licence and parole.
Nevertheless, many people did decide to disclose their use for a range of reasons: because they were withdrawing and needed medication; because they wanted help with their drug problem and to make a change in their life or, simply, because they already known by prison or probation staff as a heroin user.
Interestingly, there was agreement that while the prison system did offer help to people who disclosed drug use on first arrival at a prison (“reception”), disclosure at a later date met primarily with a punitive response with people often suspected of selling drugs or being involved in other activities which are against prison rules.
Accessing medication
After giving their views on what medication they wanted, survey respondents were then asked whether they succeeded in getting that medication. A large majority (88%) did receive at least some medication. However, almost half (45%) of those who did get medication either had to fight hard to get it or did not succeed in getting either the type or amount of medication they wanted.
Several people said that they experienced problems in getting their medication reliably with both healthcare staff and uniformed officers intervening to deny individuals their medication, frequently citing suspicions that people had been using other substances and therefore should not receive their methadone or buprenorphine. There was a consensus that staff made people “work for their drugs” and that if staff could justify not giving out OAT, they would do so. There was a consensus that no other medication is obstructed as much as OAT and that denial of medication had become an element of many prisons’ behaviour control strategies. This was a view that was shared equally by people in both countries.
Conclusions
Respondents were also asked to rate their overall satisfaction with the help they were given. Interestingly, the views of English respondents were split almost down the middle with just over half (51% of the 167 people who answered this question) rating the help available as excellent or good with just under half (49%) assessing it as poor or terrible. In Scotland 8 out of 13 survey respondents rated the treatment on offer as poor or terrible.
How to improve prison treatment for heroin users
Survey respondents were also asked to share the “one thing that would most improve help for heroin users in prison”and a number of key themes emerged:
- More support services; in particular more peer support and help from people with lived experience of opiate dependency, more groupwork, better access to recovery wings and therapeutic communities, more access to help with mental health issues and more fellowship meetings.
- Less judgmental attitudes from prison and healthcare staff and more of a rehabilitative (rather than punitive) culture, illustrated by these contributions:
“To be listened to, Drug users are looked at like vermin”
“The attitude of staff, mocking people in the medication queue”
- More information about the range of treatment options available
- Appropriate levels of OST medication dosage
- More work focused on the underlying reasons for addiction
- Quicker access to treatment inside
- Greater involvement of families in drug
Finally, a key theme explored in the focus group was the fact that treatment and recovery are fundamentally a human process. Participants were keen to emphasise that, almost universally, the key to them becoming engaged in and fully committing to treatment/recovery came as a result of a peer or worker treating them with compassion, as a fellow human being, as someone in pain, rather than as a prisoner or a long term drug user looking only to manipulate the system.
“We need some compassion and consideration, not more punishment. Prison is the punishment, we shouldn’t get punished on top for being drug users.”
Continuity of care
English respondents who had been released from prison were asked whether they were offered a continuing prescription on release (it was not possible to organise a post-release survey in Scotland). Two thirds (66%) were either offered medication on release or asked for it and secured it easily. However, more than one in five (22%) either received no medication or did not get the type or as much as they wanted.
For some people, the process of getting continuity of prescribing was straightforward and well-organised
“Once you get on the drug programme in prison, it is easy to get linked into services when released as long as you are in for a while. In the past I was in for a few weeks and that wasn’t long enough for them to get their arses into gear”
Several people who were released with little notice reported problems:
“I was released suddenly and wasn’t offered anything”
The fundamental conclusion of this research is surely that half of the English people in prison wanting substitute medication for their opioid use were pleased with the service they received, while the other half were disappointed. This repeats the findings of a study I conducted in 2016 and the lack of progress is frustrating to all involved. It is clear that the prison service is able to provide a good OAT service yet profoundly disappointing that it continues to do so in only half of the prison estate.
It is hard not to conclude that both good and poor practice is mainly due to the culture and commitment – or lack of it – of both healthcare and prison staff in individual establishments.
Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here
