Producing the ‘problem’ of new psychoactive substances (NPS) in English prisons

The risk matrix: Drug-related deaths in prisons in England and Wales, 2015-2020

This article explores the factors contributing to drug-related deaths in English and Welsh prisons between 2015 and 2020. Based on content analysis of all Prison and Probation Ombudsman 'other non-natural' fatal incident investigation reports, descriptive statistics were generated. Qualitative analysis explored the circumstances surrounding deaths and key risk factors. Most deaths were of men, whose mean age was 39 years. Drug toxicity was the main factor in causing death, exacerbated by underlying physical health conditions and risk-taking behaviours. A variety of substances were involved. New psychoactive substances became more important over time. A high proportion had recorded histories of substance use and mental illness. During this period, the prison system was under considerable stress creating dangerous environments for drug-related harm. This study highlights the process of complex interaction between substances used, individual characteristics, situational features and the wider environment in explaining drug-related deaths in prisons. Implications for policy and practice are discussed.

Prisoners' Perceptions and Satisfaction with Telepsychiatry Services in Greece and the Effects of Its Use on the Coercion of Mental Healthcare

BACKGROUND

Prisoners are often associated with mental health and substance use disorders. Coercive measures are widely used in prison settings. The objective of this study was to compare inmates' perceptions and satisfaction with telepsychiatry versus face-to-face consultation and the effects of telepsychiatry on the use of coercive measures. The sample consisted of 100 male inmates from various backgrounds who had experienced both approaches of services (face to face and telepsychiatry).

METHOD

The data were obtained through an interview where the individuals completed a Demographic Data Questionnaire, a Participant Satisfaction Questionnaire to assess satisfaction with face-to-face psychiatric services, and a Participant Satisfaction Questionnaire to assess their satisfaction with services offered via telepsychiatry. Additionally, calculations of time spent waiting for a face-to-face psychiatric evaluation and time spent in handcuffs and in confined spaces were made before and after the introduction of telepsychiatry.

RESULTS

Statistically significant improvements (all p-values < 0.001) were noted in waiting times, support for relapse prevention, follow up, quality of mental health care, quality of care in the management of psychiatric problems and related medication, behavior of psychiatrists, duration of the assessment, sense of comfort, and confidentiality. Telepsychiatry led to the elimination of time spent in handcuffs and in confined spaces (transport vehicles).

CONCLUSION

According to the results of this study, telepsychiatry is an acceptable method of service delivery in correctional facilities and was associated with a reduction of coercive practices.

Responding to 'wicked problems': policy and governance on drug-related deaths in English and Welsh prisons, 2015-2021

BACKGROUND

Prison settings have been neglected in the growing literature on drug-related deaths. This paper explores policy and practice issues regarding the governance of drug-related deaths in prisons in England and Wales from 2015-2021.

METHODS

Thematic documentary analysis was conducted on national level policy documents published between 2015-2021 (e.g. drug strategies, prison policy documents, Her Majesty's Inspectorate of Prisons and Prison and Probation Ombudsman (PPO) annual reports and guidance for staff). At the local (prison) level, all of the PPO fatal investigation reports and their associated action plans relating to 171 drug-related deaths from 2015-2021 were analysed thematically. Various modes of governance were identified using Head's 'wicked problems' conceptual framework including avoidance and denial, coercive controls, compartmentalised micro-management, incremental and pragmatic adjustment and technocratic problem-solving.

RESULTS

There was strong evidence of the dominance of denial of the problem of drug-related deaths, coercive controls, micro-management and reliance on technological solutions in the early years (2015-2018). In some prisons, there developed a move towards the adoption of more pragmatic and incremental policies and push towards comprehensive policies over time. In others, remnants of denial and coercion remained. In our analysis, the focus on new psychoactive substances came to dominate attention, to the relative neglect of other substances and of the contribution of mental and physical illness to these deaths. Staff are not equipped, supported or resourced adequately to deal with the two 'wicked problems' of increasing rates of drug use and mental illness which collide in the prison setting.

CONCLUSION

The PPO investigations repeatedly recommend reducing supply and improving monitoring and surveillance and the emergency response. There is less focus on prevention and reducing demand or improving the wider environmental context and culture in which the deaths occur. Policy needs to pay more attention to the fundamental issues driving the current deterioration in conditions in prisons.

Factors associated with drug use in prison: A systematic review of quantitative and qualitative evidence

BACKGROUND

About a third of people use drugs during their incarceration, which is associated with multiple adverse health and criminal justice outcomes. Many studies have examined factors associated with in-prison drug use, but this evidence has not yet been systematically reviewed. We aimed to systematically review and synthesise the evidence on factors related to drug use in prison.

METHODS

Three databases (PubMed, PsycINFO and Embase) were systematically searched as well as grey literature, for quantitative, qualitative and mixed-methods studies examining factors related to drug use inside prison. We excluded studies that did not explicitly measure in prison drug use or only measured alcohol and/or tobacco use. Study quality was assessed using the Newcastle Ottawa Scale (NOS) for quantitative studies and Critical Appraisal Skills Programme (CASP) for qualitative studies. The review was prospectively registered on PROSPERO (CRD42021295898).

RESULTS

Fifty-four studies met the inclusion criteria, reporting data on 26,399 people in prison. Most studies were of low or moderate-quality, and all used self-report to assess drug use. In quantitative studies, studies found that previous criminal justice involvement, poor prison conditions, pre-prison drug use and psychiatric diagnosis were positively associated with drug use in prison. In qualitative studies, reasons for drug use were closely linked to the prison environment lacking purposeful activity and the social context of the prison whereby drug use was seen as acceptable, necessary for cohesion and pressurised.

CONCLUSION

In the first systematic review of factors associated with drug use in prison, key modifiable risk factors identified from quantitative and qualitative studies were psychiatric morbidity and poor prison conditions. Non-modifiable factors included previous drug use and criminal history linked to substance use. Our findings indicate an opportunity to intervene and improve the prison environment to reduce drug use and associated adverse outcomes.

Synthetic cannabinoid use in an adult male prison in the UK

INTRODUCTION

Synthetic cannabinoids (i.e. Spice) are a major public health problem in UK prisons, however, research in this area is limited. Here we aimed to draw comparisons between people with and without experience of using synthetic cannabinoids in prison, to characterise the features of, and motivations for use within this setting and evaluate support for different treatment interventions.

METHOD

Questionnaires were administered to 122 people in a category-B prison for adult males in England between July 2022 and March 2023. Participants were asked questions related to their sociodemographic and custodial characteristics, use of synthetic cannabinoids (and other drugs) inside and outside of prison and psychological distress was measured via the Brief Symptom Inventory (BSI-18). Those that had ever used synthetic cannabinoids in prison completed additional questions related to features of use, motivations for use and support for various interventions.

RESULTS

In total 46.7 % (n = 57) of participants reported use of synthetic cannabinoids in prison and this group experienced significantly greater levels of psychological distress compared to those reporting no use (mean (± standard deviation) BSI-18 scores = 23.7 (±16.7) vs 12.8 (±13.6), p < 0.001). Participants mostly reported using paper-based preparations (77.4 %) and use via e-cigarettes (75.9 %). The most strongly endorsed motivations for use included to alleviate boredom (91.1 % strongly agree/agree), to make the sentence pass faster (89.3 % strongly agree/agree) and to cope with stress (80.4 % strongly agree/agree). The interventions that received most support were strategies to better manage time and medication to manage withdrawal.

CONCLUSIONS

The use of synthetic cannabinoids in UK prisons typically involves the use of paper-based preparations via e-cigarettes, and use is associated with greater levels of psychological distress. Motivations for use were mostly pragmatic (e.g. to alleviate boredom or cope with stress) and interventions should prioritise increasing the time individuals spend out of cells and in meaningful activity.

Exploring the Intersection of Drug Addiction and Mental Ill-Health in Scottish Prisons: A Qualitative Study of Incarcerated Men

This article presents insights from small-scale qualitative research exploring the intertwining nature of drug addiction and mental ill-health among men in Scottish prisons. Semi-structured interviews were conducted with 24 men in two Scottish prisons. The men’s narratives suggested that increased tension in prison halls had stimulated a huge surge in the use of New Psychoactive Substances (NPS), in turn increasing and deepening existing mental ill-health and violence. They believed health care in the prisons to be of low quality, and that methadone was prescribed as a mechanism for social control. Implications for future policy, practice and research are outlined.

Novel Receptor-Binding-Based Assay for the Detection of Opioids in Human Urine Samples

Consumption of opioids is a growing global health problem. The gold standard for drugs of abuse screening is immunochemical assays. However, this method comes with some disadvantages when screening for a wide variety of opioids. Detection of the binding of a compound at the human μ-opioid receptor (MOR) offers a promising alternative target. Here, we set up a urine assay to allow for detection of compounds that bind at the MOR, thus allowing the assay to be utilized as a screening tool for opioid intake. The assay is based on the incubation of MOR-containing cell membranes with the selective MOR-ligand DAMGO and urine. After filtration, the amount of DAMGO in the eluate is analyzed by liquid chromatography tandem mass spectroscopy (LC-MS/MS). The absence of DAMGO in the eluate corresponds to a competing MOR ligand in the urine sample, thus indicating opiate/opioid intake by the suspect. Sensitivity and specificity were determined by the analysis of 200 consecutive forensic routine casework urine samples. A pronounced displacement of DAMGO was observed in 29 of the 35 opiate/opioid-positive samples. Detection of fentanyl intake proved to be the most challenging aspect. Applying a cut-off value of, e.g., 10% DAMGO binding would lead to a sensitivity of 83% and a specificity of 95%. Consequently, the novel assay proved to be a promising screening tool for opiate/opioid presence in urine samples. The nontargeted approach and possible automation of the assay make it a promising alternative to conventional methods.

What are dually diagnosed patients' problems represented to be in mental health? A WPR analysis of the multistability purpose of digital health records

No previous studies have investigated how political measures, opinions and views of people with dual diagnoses, organisational requirements and professional values are purposefully communicated, mediated and/or integrated in digital records in mental health care. It remains unclear how health records function as both clinical vehicles for documentation, audit and quality assurance in patient care as well as political vehicles of power to articulate and reproduce idealised relations among actors and their roles in mental health. Informed by Bacchi's 'What's the problem represented to be' (WPR) approach, we consider how problems of dually diagnosed persons with co-occurring mental health conditions and drug use (DDPs) are represented and how the tools required to fix the patients' problems are communicated and legitimised in 10 digital health records consisting of 3830 pages of data. In the discussion, we distinguish their multiple purposes by discussing how their structure is shaped by broader discourses in health care. Then, we consider how the structure of records delineates professionals' autonomy, discretionary action and service provision in ways that limit possibilities for including mental health patients' experiences and exclude service users' voices from care planning.

Stakeholders’ Problematisation of Drug Consumption Rooms: A Case Study of the Policy Initiative in Helsinki

Drug consumption rooms are one of the harm reduction interventions to handle complex social problems. The Helsinki city initiative puts drug consumption room (DCR) on a government agenda in Finland, which has also triggered a broader discussion. This study presents how stakeholders problematise and what solutions they propose for DCRs. The research is based on in-depth interviews of 23 stakeholders and the theoretical perspective of Bacchi’s approach – ‘What’s the problem represented to be?’ (WPR).

The results show that while stakeholders’ solutions resemble each other on the core DCR functions, the variations are found mainly in the introduction of extended services, policy development strategy, types of drug allowance in DCRs, and drug testing options. Stigmatisation of PWUDs still leads the harm reduction services to be considered from a moral framework. Stakeholders tend to take their positions according to strategic considerations related to electoral politics, expedience and the symbolic role of policies.

Cannabinoid receptor activation potential of the next generation, generic ban evading OXIZID synthetic cannabinoid receptor agonists

In recent years, several nations have implemented various measures to control the surge of new synthetic cannabinoid receptor agonists (SCRAs) entering the recreational drug market. In July 2021, China put into effect a new generic legislation, banning SCRAs containing one of 7 general core scaffolds. However, this has driven manufacturers towards the synthesis of SCRAs with alternative core structures, exemplified by the recent emergence of "OXIZID SCRAs". Here, using in vitro β-arrestin2 recruitment assays, we report on the CB₁ and CB₂ potency and efficacy of five members of this new class of SCRAs: BZO-HEXOXIZID, BZO-POXIZID, 5-fluoro BZO-POXIZID, BZO-4en-POXIZID and BZO-CHMOXIZID. All compounds behaved as full agonists at CB₁ and partial agonists at CB₂ . Potencies ranged from 84.6 - 721 nM at CB₁ and 2.21 - 25.9 nM at CB₂ . Shortening the n-hexyl tail to a pentyl tail enhanced activity at both receptors. Fluorination of this pentyl analog did not yield a higher receptor activation potential, whereas an unsaturated tail resulted in decreased potency and efficacy at CB₁ . The cyclohexyl methyl analog BZO-CHMOXIZID was the most potent compound at both receptors, with EC₅₀ values of 84.6 and 2.21 nM at CB₁ and CB₂ , respectively. Evaluation of the activity of a seized powder containing BZO-4en-POXIZID suggested a high purity, in line with HPLC-DAD, GC-MS, LC-QTOF-MS and FTIR and NMR analysis. Furthermore, all tested compounds showed a preference for CB₂ , except for BZO-POXIZID. Overall, these findings inform public health officials, law enforcement agencies and clinicians on these newly emerging SCRAs.

'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK

BACKGROUND

The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings.

METHODS

Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons.

RESULTS

Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services.

CONCLUSION

The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.

New psychoactive substances, safety and mental health in prison officers

BACKGROUND

The use of new psychoactive substances (NPS) in UK prisons is believed to have increased substantially. As well as posing a significant threat to prisoners' health, NPS use can trigger violent, unpredictable and aggressive behaviour. Dealing with the direct and indirect effects of NPS therefore has the potential to compromise the physical and psychological safety of prison staff.

AIMS

This study investigates prison officers' perceptions of NPS use in their workplace and their risk of exposure. Relationships between NPS exposure, the workplace safety climate and mental health were also examined.

METHODS

We assessed prison officers' perceptions of the prevalence of NPS use among prisoners in their workplace, their personal exposure and the safety climate in their institution through an online survey. The General Health Questionnaire-12 measured mental health. Descriptive statistics were used to assess officers' perceptions of NPS use in their workplace and their personal exposure and correlations examined relationships between variables.

RESULTS

The sample comprised 1956 prison officers (86% male). Most respondents (85%) highlighted NPS as a serious cause for concern in their institution. Two-thirds (66%) reported being personally exposed to NPS at least sometimes, with 22% being exposed once a day or more. Significant relationships were found between officers' perceived NPS exposure, assessments of safety climate and self-reported mental health.

CONCLUSIONS

Our findings highlight the need for urgent action to reduce the use of NPS among prisoners. This is likely to improve the safety climate of UK prisons and the mental health of staff.

Producing gender-blind drug knowledge and representations in prison spaces

Purpose

This paper aims to examine knowledge production and problem representation with regard to new psychoactive substances (NPS) in Her Majesty’s Chief Inspector of Prisons (HMCIP) annual reports.

Design/methodology/approach

Seven annual reports published by HMCIP for England and Wales between 2014 and 2020 have been systematically reviewed drawing on thematic analysis.

Findings

This paper demonstrates how framing in HMCIP annual reports produced a characterisation of NPS in prisons that inadvertently obstructed gender-sensitive knowledge production and problem representation. The framing formalised knowledge silences about spice in women’s prisons.

Originality/value

HMCIP annual reports monitor drugs in prisons and this affects how these spaces are represented to government and other stakeholders. This paper provides theoretical and practical insights into how gender-blind knowledge is produced by discussing examples of gender-blind drug representations in a specific policy context.

The perspectives of people who use drugs regarding short term involuntary substance use care for severe substance use disorders

BACKGROUND

In the Canadian Province of British Columbia (BC), the BC Mental Health Act permits involuntary care for treating mental disorders. However, the Act has also been applied to provide involuntary care to individuals with a primary substance use disorder, in the absence of specific guidelines and legislation, and with insufficient understanding of perspectives of people who use drugs (PWUD) regarding this approach.

METHODS

As part of a larger mixed-methods research project providing an overview of involuntary care for severe substance use disorders in BC, three focus groups were convened with: PWUD, families and caregivers, and Indigenous community stakeholders. This analysis examines perspectives from the focus group of PWUD, consisting of nine participants from local and regional drug user and advocacy organizations regarding involuntary care. A qualitative descriptive approach and thematic analysis were conducted, using a coding framework developed deductively and inductively, and participant perspectives were interpreted drawing on problematization theory.

RESULTS

Participants did not endorse the use of involuntary care, instead emphasizing significant changes were needed to address shortcomings of the wider voluntary care system. When asked to conceptualize what an acceptable involuntary care scenario might look like (under hypothetical and ideal conditions), participants recommended it should include: individual control and autonomy, peer advocacy in decision-making, and elimination of police and criminal justice system involvement from treatment encounters. Participants saw involuntary care to be an inappropriate approach given the shortcomings of the current system, noting also problems inherent in its use to manage severe SUDs and imminent harm, and prioritized alternate approaches to offsetting risks.

CONCLUSION

Improving voluntary care for substance use, along with addressing the social determinants of health that put individuals at risk of problematic substance use and harm, were prioritized in participant perspectives. Participant comments regarding the use of involuntary care bring forward alternate solutions in the context of the opioid overdose crisis, and a reconceptualization of the 'problem' of managing severe substance use disorders.

"People need them or else they're going to take fentanyl and die": A qualitative study examining the 'problem' of prescription opioid diversion during an overdose epidemic

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

Adding more "spice" to the pot: A review of the chemistry and pharmacology of newly emerging heterocyclic synthetic cannabinoid receptor agonists

Synthetic cannabinoid receptor agonists (SCRAs) first appeared on the international recreational drug market in the early 2000s in the form of SCRA-containing herbal blends. Due to the cannabimimetic effects associated with the consumption of SCRAs, they have acquired an ill-informed reputation for being cheap, safe, and legal alternatives to illicit cannabis. Possessing high potency and affinity for the human cannabinoid receptor subtype-1 (CB₁ ) and -2 (CB₂ ), it is now understood that the recreational use of SCRAs can have severe adverse health consequences. The major public health problem arising from SCRA use has pressed legislators around the world to employ various control strategies to curb their recreational use. To circumvent legislative control measures, SCRA manufacturers have created a wide range of SCRA analogs that contain, more recently, previously unencountered azaindole, γ-carbolinone, or carbazole heterocyclic scaffolds. At present, little information is available regarding the chemical syntheses of these newly emerging classes of SCRA, from a clandestine perspective. When compared with previous generations of indole- and indazole-type SCRAs, current research suggests that many of these heterocyclic SCRA analogs maintain high affinity and efficacy at both CB₁ and CB₂ but largely evade legislative control. This review highlights the importance of continued research in the field of SCRA chemistry and pharmacology, as recreational SCRA use remains a global public health issue and represents a serious control challenge for law enforcement agencies.