Social and environmental factors influencing in‐prison drug use

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.

Implementation of a national smoke-free prison policy: an economic evaluation within the Tobacco in Prisons (TIPs) study

OBJECTIVE

To determine the cost-effectiveness of a smoke-free prison policy in Scotland, through assessments of the trade-offs between costs (healthcare and non-healthcare-related expenditure) and outcomes (health and non-health-related non-monetary consequences) of implementing the policy.

DESIGN

A health economic evaluation consisting of three analyses (cost-consequence, cost-effectiveness and cost-utility), from the perspectives of the healthcare payer, prison service, people in custody and operational staff, assessed the trade-offs between costs and outcomes. Costs associated with the implementation of the policy, healthcare resource use and personal spend on nicotine products were considered, alongside health and non-health outcomes. The cost-effectiveness of the policy was evaluated over 12-month and lifetime horizons (short term and long term).

SETTING

Scotland's national prison estate.

PARTICIPANTS

People in custody and operational prison staff.

INTERVENTION

Implementation of a comprehensive (indoor and outdoor) smoke-free policy.

MAIN OUTCOME MEASURES

Concentration of secondhand smoke, health-related quality of life (health utilities and quality-adjusted life-years (QALY)) and various non-health outcomes (eg, incidents of assaults and fires).

RESULTS

The short-term analyses suggest cost savings for people in custody and staff, improvements in concentration of secondhand smoke, with no consistent direction of change across other outcomes. The long-term analysis demonstrated that implementing smoke-free policy was cost-effective over a lifetime for people in custody and staff, with approximate cost savings of £28 000 and £450, respectively, and improvement in health-related quality of life of 0.971 QALYs and 0.262, respectively.

CONCLUSION

Implementing a smoke-free prison policy is cost-effective over the short term and long term for people in custody and staff.

Drug use before and during imprisonment: Drivers of continuation

BACKGROUND

Many people who enter prison have recently used drugs in the community, a substantial portion of whom will continue to do so while incarcerated. To date, little is known about what factors may contribute to the continuation of drug use during imprisonment.

METHODS

Self-reported data were collected from a random sample of 1326 adults (123 women) incarcerated across 15 prisons in Belgium. Multivariate regression was used to investigate associations between in-prison drug use and sociodemographic background, criminological profile, drug-related history, and mental health among participants who reported pre-prison drug use.

RESULTS

Of all 1326 participants, 719 (54%) used drugs in the 12 months prior to their incarceration and 462 (35%) did so while in prison. There was a strong association between drug use before and during imprisonment (OR = 6.77, 95% CI 5.16-8.89). Of those who recently used drugs in the community, half (52%) continued to do so while incarcerated. Factors independently associated with continuation (versus cessation) were young age, treatment history, polydrug use, and poor mental health. In a secondary analysis, initiation of drug use while in prison was further related to incarceration history and low education.

CONCLUSION

Persistence of drug use following prison entry is common. People who continue to use drugs inside prison can be differentiated from those who discontinue in terms of drug-related history and mental health. Routine screening for drug use and psychiatric morbidity on admission to prison would allow for identifying unmet needs and initiating appropriate treatment.

Harm reduction: a public health approach to prison drug use

PURPOSE

As prison drug use continues to be a concern worldwide, harm reduction practices serve as an alternative approach to traditional abstinence-only or punishment-oriented methods to address substance use behind bars. The purpose of this study is to present a summary of research surrounding prison-based harm reduction programs.

DESIGN/METHODOLOGY/APPROACH

This narrative review of the international literature summarizes the harms associated with prison drug use followed by an overview of the literature surrounding three prison-based harm reduction practices: opioid agonist therapy, syringe exchange programs and naloxone distribution.

FINDINGS

A collection of international research has found that these three harm reduction programs are safe and feasible to implement in carceral settings. Additionally, these services can effectively reduce some of the harms associated with prison drug use (e.g. risky injection practices, needle sharing, fatal overdoses, etc.). However, these practices are underused in correctional settings in comparison to their use in the community.

ORIGINALITY/VALUE

Various policy recommendations are made based on the available literature, including addressing ethical concerns surrounding prison populations' rights to the same standard of health care and services available in the community. By taking a public health approach to prison drug use, harm reduction practices can provide a marginalized, high-risk population of incarcerated individuals with life-saving services rather than punitive, punishment-oriented measures.

A complex increase in hepatitis C virus in a correctional facility: bumps in the road

OBJECTIVE

The prevalence of hepatitis C virus (HCV) in correctional facilities in Australia among people who inject drugs is 60%, with disproportionate effects observed in Aboriginal and Torres Strait Islander people. Following the micro-elimination of HCV in a Queensland correctional facility (QCF), newly acquired cases began to increase in mid-2019. Here we discuss the public health response to increasing HCV in a QCF.

METHODS

Enhanced surveillance was performed to obtain contextual outbreak data on risk factors including injecting drug use, sharing of personal hygiene equipment and do-it-yourself-tattooing.

RESULTS

In the sixteen months, there were 250 notifications of new and re-infected HCV infections in prisoners in the QCF. Qualitative data revealed the leading factor in transmission to be injecting drug use.

CONCLUSIONS

Drivers for increased HCV transmission in correctional facilities include boredom, waiting lists for opioid substitution programs, changes in injecting behaviours and sharing of injecting paraphernalia. Point-of-care testing combined with education and the development of a needle and syringe program may be promising ways forward for managing HCV in correctional facilities.

IMPLICATIONS FOR PUBLIC HEALTH

Correctional facilities are key locations to target sexually transmitted infection (STI) and blood-borne virus (BBV) testing and treatment as well as health promotion to improve the health of inmates and the communities they return to.

"It Goes on Everywhere": Injection Drug Use in Canadian Federal Prisons

BACKGROUND

International and Canadian research on in-prison injection drug use has documented the frequency of its occurrence as well as some of the resulting consequences such as increased prevalence of HIV and hepatitis C virus. Access to prison-based harm reduction programing is thus important.

OBJECTIVES

The aim of this study was to learn from former prisoner experiences and insights on in-prison injection drug use in order to advance and improve access to harm reduction options, in particular prison-based needle and syringe programs (PNSPs).

METHODS

The qualitative and community-based study was conducted in 2014/2015 and included former prisoners from Ontario, Canada (N = 30) who had recent experience of incarceration in a federal prison and knowledge of injection drug use. Data analysis followed the deductive approach, drawing on the expertise of the academic and community-based research team members.

RESULTS

Interview and focus group participants disclosed that drugs are readily available in Canadian federal prisons and that equipment used to inject is accessed in a variety of ways, sometimes gained through illicit means and sometimes made by prisoners themselves. Equipment sharing is a frequent occurrence, and disposal of such supplies is rare. Conclusions/Importance: While not yet available in Canada, PNSPs have led to positive outcomes in international contexts, including reductions in needle sharing and transmission of HIV and hepatitis C. Support for PNSPs among numerous Canadian organizations and associations, along with a recent change in government, could suggest a renewed opportunity for PNSP implementation.

Prescription opioid abuse in prison settings: A systematic review of prevalence, practice and treatment responses

BACKGROUND

To systematically review the quantitative and qualitative evidence base pertaining to the prevalence, practice of, and treatment response to the diversion of prescribed opiates in the prison setting.

METHODS

Medline, Embase, CINAHL, PsycINFO, Google Scholar, ASSIA and Science Direct databases were searched for papers from 1995 to the present relevant to the abuse of prescribed opiate medication. Identified journals and their reference lists were hand searched for other relevant articles. Of the abstracts identified as relevant, full text papers were retrieved and critiqued against the inclusion criteria for the review.

RESULTS

Three hundred and fifty-five abstracts were identified, leading to 42 full-text articles being retrieved. Of those, 10 papers were included in the review. Significant differences in abuse behaviours between different countries were reported. However, a key theme emerged from the data regarding a culture of nasal administration of prescribed sublingual buprenorphine within some prisons due to both reduced prevalence of injection within prison and reduced supplies of illicit drugs within prison. The buprenorphine/naloxone preparation appears to be less amenable to abuse. The review highlighted a paucity of empirical research pertaining to both prevalence of the phenomenon and treatment responses.

CLINICAL AND RESEARCH IMPLICATIONS

Healthcare providers within prisons need to prescribe opioids in the least abuseable preparation since the risk of abuse is significant, despite widespread processes of supervised dispensing. Prescription medication abuse is not limited to opioids and the predominant drug of abuse in an individual prison can rapidly change according to availability.

Psychometric Analysis of the Multidimensional State Boredom Scale and Its Condensed Versions

The Multidimensional State Boredom Scale (MSBS) is a promising new self-report measure of state boredom. Two condensed versions of the scale have also been introduced. This study helped explore the psychometric qualities of these scales, using a large sample of Australian adults ( N = 1,716), as well as two smaller samples ( N = 199 and N = 422). Data analyses indicated strong convergent validity and very high internal consistency for the scales. Test–retest reliability over a 6- to 8-day period was moderately high. Confirmatory factor analyses of the MSBS authors’ suggested factor structure indicated good fit for this model. However, some of the data analyses raise questions as to whether the scale includes meaningful subfactors. Overall, the MSBS (and Short Form) is recommended for researchers who wish to assess state boredom.