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.

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.

The Pub and the People. A Worktown Study by Mass Observation

Mass Observation was an independent social research organization which, between 1937 and 1949, documented the attitudes, opinions and everyday lives of the British people, using a combination of anthropological fieldwork, opinion surveys and written testimony. The Pub and the People is a classic text for its distinctly sociological approach, seeing patterns of drinking and socializing in context, rather than focusing primarily on pathological consequences. The main conclusions were that the pub is a living social organism and that the traditional approach of British sociology which, Mass Observation argued, focused on 'the drink problem' and the links between alcohol, crime and delinquency, failed to take account of the full social context. Mass Observation's focus on the pub as a place anticipates themes taken up in work on alcohol in cultural geography. Later alcohol researchers and epidemiologists have continued this orientation, recognizing the importance of physical and social environments in relation to alcohol consumption. Other studies have built on the MO initiative by looking at how drug and alcohol consumption links to identity, friendship and sociality or at the connections between intoxication and pleasure. The value of this classic text is that it reminds us that paying attention to the social context is not just a useful supplement, but absolutely central to understanding the use of alcohol or drugs.

Does polygenic risk influence associations between sun exposure and melanoma? A prospective cohort analysis

BACKGROUND

Melanoma develops as the result of complex interactions between sun exposure and genetic factors. However, data on these interactions from prospective studies are scant.

OBJECTIVES

To quantify the association between ambient and personal ultraviolet exposure and incident melanoma in a large population-based prospective study of men and women residing in a setting of high ambient ultraviolet radiation, and to examine potential gene-environment interactions.

METHODS

Data were obtained from the QSkin Sun and Health Study, a prospective cohort study of men and women aged 40-69 years, randomly sampled from the Queensland population in 2011. Participants were genotyped and assessed for ultraviolet exposure.

RESULTS

Among participants with genetic data (n = 15 373), 420 (2·7%) developed cutaneous melanoma (173 invasive, 247 in situ) during a median follow-up time of 4·4 years. Country of birth, age at migration, having > 50 sunburns in childhood or adolescence, and a history of keratinocyte cancer or actinic lesions were significantly associated with melanoma risk.

CONCLUSIONS

An interaction with polygenic risk was suggested: among people at low polygenic risk, markers of cumulative sun exposure (as measured by actinic damage) were associated with melanoma. In contrast, among people at high polygenic risk, markers of high-level early-life ambient exposure (as measured by place of birth) were associated with melanoma (hazard ratio for born in Australia vs. overseas 3·16, 95% confidence interval 1·39-7·22). These findings suggest interactions between genotype and environment that are consistent with divergent pathways for melanoma development. What's already known about this topic? The relationship between sun exposure and melanoma is complex, and exposure effects are highly modified by host factors and behaviours. The role of genotype on the relationship between ultraviolet radiation exposure and melanoma risk is poorly understood. What does this study add? We found that country of birth, age at migration, sunburns in childhood or adolescence, and history of keratinocyte cancer or actinic lesions were significantly associated with melanoma risk, while other measures of continuous or more intermittent patterns of sun exposure were not. We found evidence for gene-environment interactions that are consistent with divergent pathways for melanoma development. Linked Comment: Cust. Br J Dermatol 2020; 183:205-206. Plain language summary available online.

Is there a causal relationship between vitamin D and melanoma risk? A Mendelian randomization study

BACKGROUND

Several preclinical studies have identified the antiproliferative effects of 25-hydroxyvitamin D [25(OH)D; vitamin D]. Ultraviolet radiation (UVR) is essential for vitamin D synthesis yet increases the risk of melanoma. Observational studies on the association of vitamin D levels with melanoma risk have reported inconclusive results, and are difficult to interpret owing to the potential confounding from the dual role of UVR.

OBJECTIVES

To determine whether there is a causal association between genetically predicted 25(OH)D concentrations and melanoma using a Mendelian randomization (MR) approach.

METHODS

We performed MR using summary data from a large genome-wide association study (GWAS) meta-analysis of melanoma risk, consisting of 12 874 cases and 23 203 controls. Five single nucleotide polymorphisms associated with 25(OH)D concentration - rs12785878, rs10741657, rs2282679, rs6013897 and rs116970203 - were selected as instrumental variables. An inverse variance weighted method was used to access the evidence for causality. MR results from the melanoma meta-analysis were combined with results from an MR study based on a melanoma risk GWAS using UK Biobank data.

RESULTS

A 20 nmol L^-1 decrease in 25(OH)D was not associated with melanoma risk [odds ratio (OR) 1·06, 95% confidence interval (CI) 0·95-1·19]. Results from the UK Biobank were concordant with this, with meta-analysis of our and UK Biobank-derived MR causal estimates showing no association (OR 1·02, 95% CI 0·92-1·13 for a 20 nmol L^-1 decrease).

CONCLUSIONS

The results suggest that vitamin D levels may not be causally associated with the risk of melanoma. What's already known about this topic? Antitumour activity of vitamin D has been identified in preclinical studies. Observational studies link vitamin D deficiency with an increased risk of a range of cancers. There is a growing public interest for vitamin D supplementation. Observational studies of melanoma are fraught with difficulties because while higher ultraviolet radiation levels increase vitamin D levels, such exposure is also associated with increased melanoma risk. Results from observational studies are inconclusive regarding the effect of vitamin D on melanoma risk. What does this study add? Using Mendelian randomization, an approach to causal inference, which is analogous to a natural randomized controlled trial, we found no causal association between vitamin D levels and melanoma.

Survival outcomes in patients with multiple primary melanomas

BACKGROUND

A substantial number of melanoma patients will develop multiple primary melanomas (MPM). Currently, little is known about the impact of MPM on survival.

OBJECTIVE

We aimed to determine whether melanoma survival is worse for patients with MPM compared to those with a single invasive primary melanoma (SPM).

MATERIALS AND METHODS

A cohort study was conducted. Patients were sourced from an Australian population, with follow-up information collected retrospectively from registry data. Melanoma-specific survival analysis was performed to find associated variables after adjustment for known prognostic factors, using four different models, each selecting a different index melanoma lesion.

RESULTS

1068 stage I and II melanoma patients were followed up for a median of 24.4 years. MPM was found in 17.8% of the cohort (190 patients), more likely among males and older age groups. Other clinicopathological parameters were similar between the MPM and SPM (878 patients) cohorts. After adjustment for age, sex and Breslow thickness, MPM was a hazard for death from melanoma, across all models, reaching significance when considering the last invasive lesion as the index melanoma (HR = 2.76, P = 0.017).

CONCLUSION

Patients with multiple invasive lesions seem more at risk of death from melanoma, independent of known prognostic factors.

The alcohol improvement programme: evaluation of an initiative to address alcohol-related health harm in England

Aims: The evaluation aimed to assess the impact of The Alcohol Improvement Programme (AIP). This was a UK Department of Health initiative (April 2008–March 2011) aiming to contribute to the reduction of alcohol-related harm as measured by a reduction in the rate of increase in alcohol-related hospital admissions (ARHAs). Methods: The evaluation (March 2010–September 2011) used a mix of qualitative and quantitative methods to assess the impact of the AIP on ARHAs, to describe and assess the process of implementation, and to identify elements of the programme which might serve as a ‘legacy’ for the future. Results: There was no evidence that the AIP had an impact on reducing the rise in the rate of ARHAs. The AIP was successfully delivered, increased the priority given to alcohol-related harm on local policy agendas and strengthened the infrastructure for the delivery of interventions. Conclusion: Although there was no measurable short-term impact on the rise in the rate of ARHAs, the AIP helped to set up a strategic response and a delivery infrastructure as a first, necessary step in working towards that goal. There are a number of valuable elements in the AIP which should be retained and repackaged to fit into new policy contexts.

Late first-trimester invasive prenatal diagnosis: results of an international randomized trial

OBJECTIVE

To assess, in a randomized trial, the safety and accuracy of amniocentesis and transabdominal chorionic villus sampling (CVS) performed at 11-14 weeks of gestation, given that this time frame is increasingly relevant to early trisomy screening.

METHODS

We compared amniocentesis with CVS from 77 to 104 days of gestation in a randomized trial in a predominantly advanced maternal age population. Before randomization, the feasibility of both procedures was confirmed by ultrasonography, and experienced operators performed sampling under ultrasound guidance; conventional cytogenetic analysis was employed. The primary outcome measure was a composite of fetal loss plus preterm delivery before 28 weeks of gestation in cytogenetically normal pregnancies.

RESULTS

We randomized 3,775 women into 2 groups (1,914 to CVS; 1,861 to amniocentesis), which were comparable at baseline. More than 99.6% had the assigned procedure, and 99.9% were followed through delivery. In contrast to previous thinking, in the cytogenetically normal cohort (n = 3,698), no difference in primary study outcome was observed: 2.1% (95% confidence interval 1.5, 2.8) for CVS and 2.3% (95% confidence interval, 1.7, 3.1) for amniocentesis. However, spontaneous losses before 20 weeks and procedure-related, indicated terminations combined were increased in the amniocentesis group (P =.07, relative risk 1.74). We found a 4-fold increase in the rate of talipes equinovarus after amniocentesis (P =.02) overall and in week 13 (P =.03, relative risk = 4.65), but data were insufficient to determine this risk in week 14.

CONCLUSION

Amniocentesis at 13 weeks carries a significantly increased risk of talipes equinovarus compared with CVS and also suggests an increase in early, unintended pregnancy loss.

LEVEL OF EVIDENCE

I

A genome scan for quantitative trait loci in a wild population of red deer (Cervus elaphus)

Recent empirical evidence indicates that although fitness and fitness components tend to have low heritability in natural populations, they may nonetheless have relatively large components of additive genetic variance. The molecular basis of additive genetic variation has been investigated in model organisms but never in the wild. In this article we describe an attempt to map quantitative trait loci (QTL) for birth weight (a trait positively associated with overall fitness) in an unmanipulated, wild population of red deer (Cervus elaphus). Two approaches were used: interval mapping by linear regression within half-sib families and a variance components analysis of a six-generation pedigree of >350 animals. Evidence for segregating QTL was found on three linkage groups, one of which was significant at the genome-wide suggestive linkage threshold. To our knowledge this is the first time that a QTL for any trait has been mapped in a wild mammal population. It is hoped that this study will stimulate further investigations of the genetic architecture of fitness traits in the wild.

Single vs weekly courses of antenatal corticosteroids for women at risk of preterm delivery: A randomized controlled trial

CONTEXT

The practice of administering weekly courses of antenatal corticosteroids to pregnant women at risk of preterm delivery is widespread, but no randomized trial has established the efficacy or safety of this practice.

OBJECTIVES

To evaluate the efficacy of weekly administration of antenatal corticosteroids compared with a single course in reducing the incidence of neonatal morbidity and to evaluate potential complications of weekly treatment.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled intention-to-treat trial conducted in 13 academic centers in the United States from February 1996 through April 2000.

PARTICIPANTS

A total of 502 pregnant women between 24 and 32 completed weeks' gestation who were at high risk of preterm delivery.

INTERVENTION

All patients received a complete single course of antenatal corticosteroids (either betamethasone, 12 mg intramuscularly repeated once in 24 hours for 2 doses, or dexamethasone, 6 mg intramuscularly repeated every 12 hours for 4 doses). Participants who had not delivered 1 week after receipt of the single course were randomly assigned to receive either betamethasone, 12 mg intramuscularly repeated once in 24 hours for 2 doses every week until 34 weeks' gestation or delivery, whichever came first (n = 256), or a similarly administered placebo (n = 246).

MAIN OUTCOME MEASURE

Composite neonatal morbidity (including severe respiratory distress syndrome, bronchopulmonary dysplasia, severe intraventricular hemorrhage, periventricular leukomalacia, proven sepsis, necrotizing enterocolitis, or perinatal death).

RESULTS

Composite morbidity occurred in 22.5% of the weekly-course group vs 28.0% of the single-course group (unadjusted relative risk, 0.80; 95% confidence interval, 0.59-1.10). Neither group assignment nor the number of treatment courses was associated with a reduction in composite morbidity.

CONCLUSIONS

Weekly courses of antenatal corticosteroids did not reduce composite neonatal morbidity compared with a single course of treatment. Weekly courses of antenatal corticosteroids should not be routinely prescribed for women at risk of preterm delivery.

Lameness in feedlot cattle

This article examines the various causes of lameness in feedlot cattle, with an emphasis on clinical signs, treatment, and prevention. Specific conditions are discussed, including interdigital necrobacillosis, laminitis, feedlot injuries, and feedlot lameness associated with Mycoplasma bovis. Immune management of the foot is also reviewed.

Evaluation of bacteria isolated from infected eyes of captive, non-domestic animals

Bacteria isolated from the eyes of captive species with suspected ocular infections at London Zoo were identified by standard methods. The sensitivity of the organisms to several topical antibiotics was determined by using sensitivity discs, and the minimum inhibitory concentrations of chloramphenicol and fusidic acid were determined. Correlations were evaluated between the results from the antibiotic discs and the minimum inhibitory concentrations and, where possible, between the clinical response to treatment and the results of bacteriological sensitivity tests. Unlike the isolates found in cats and dogs gram-positive cocci accounted for 54 per cent of isolates but almost half of the bacteria isolated were gram-negative organisms.

Drug treatment systems and policy frameworks: a comparative social policy perspective

The article offers a discussion of drug treatment systems from a social policy perspective. Comparative studies of social policy have utilised typologies to aid analysis. These are briefly characterised in this article. Current analysis of social policy points to changes in the shape of policy regimes. How are these changes impacting on drug treatment systems? Key principles around which policy forms are organised are the desire to effect social control, the desire to meet human need, and the need to minimise harm from risks present in the environment. In practice, these principles operate in tension and different outcomes are observable in different societies. The article argues that, in spite of these historical and cultural differences, some convergence is observable in systems as they adapt to global influences. There remains however an urgent need for more detailed empirical research on policy responses in different countries, utilising the case-study approach adopted by the ISDRUTS collaborators.

Reluctant Partners: Trends in Approaches to Urban Drug-Taking in Contemporary Britain

This paper reviews recent trends in drug policy in Britain. It identifies the influence of American perspectives in encouraging greater attention to prevention and a stress on partnership. Receptivity to these influences is explained by reference to restructuring of contemporary cities and to wider developments in British urban policy.

Effects of plasma exchange on sperm antibody levels in males with subfertility

Three men with subfertility secondary to sperm antibodies with measurable serum sperm antibody levels underwent a course of 3 plasma exchanges over a period of 1 week. The levels of serum anti-sperm antibodies fell by a mean of 3.3 dilutions. This fall was maintained for approximately 4 weeks, after which there was a return to the original levels. Plasma exchange is time-consuming and relatively expensive but it offers a possible alternative to steroid treatment (with its potential side effects) in men with sperm antibodies and warrants further investigation.

Could Britain inherit the American nightmare?

The article offers a critical review of the debate on policy towards illegal drugs in the United States and demonstrates how discussion of the 'drugs' issue there is linked to perceptions of the condition of African-American people and to the contentious concept of the 'underclass'. Alternatives to the Reagan-Bush policies include the extension of treatment options, possibly compulsorily, and pro-legalization arguments. The links between these perspectives and wider social philosophies and programmes are indicated. Ripples of the legalization debate are now felt in Britain and Europe. The paper concludes that understanding of the social problem of 'drugs' cannot be divorced from judgements about wider socio-cultural conditions and appropriate policies. US definitions of the problem and views of policy are not as yet the only options for Britain. A 'third way' is possible between neo-conservative and free-market approaches, that of a 'new public health'.

Substance abuse in pregnant women: recent experience at the Perinatal Center for Chemical Dependence of Northwestern Memorial Hospital

Drug abuse during pregnancy is associated with adverse perinatal outcome. Patterns of abuse have changed in recent years with the increasing popularity of cocaine. We compared pregnancy outcome data from 137 women receiving prenatal care in the Perinatal Center for Chemical Dependence of Northwestern Memorial Hospital with those of matched controls. Among drug-using women, the mean gestational age at delivery and mean birth weight were significantly lower than those of controls. In addition, study pregnancies were more frequently complicated by the need for antenatal hospitalization, preterm delivery, low birth weight (less than 2500 g), and abruptio placentae.

Temporal patterns of cocaine use in pregnancy. Perinatal outcome

Seventy-five cocaine-using women enrolled in a comprehensive perinatal care program were divided into two groups: those who used cocaine in only the first trimester of pregnancy (group 1 [N = 23]) and those who used cocaine throughout pregnancy (group 2 [N = 52]). Perinatal outcomes of these pregnancies were compared with perinatal outcomes of a matched group of obstetric patients with no history or evidence of substance abuse (group 3 [N = 40]). Group 2 women had an increased rate of preterm delivery and low-birth-weight infants as well as an increased rate of intrauterine growth retardation. Group 1 women had rates of these complications similar to the drug-free group. Mean birth weight, length, and head circumference for term infants were reduced in only the group 2 infants. However, both groups of cocaine-exposed infants demonstrated significant impairment of orientation, motor, and state regulation behaviors on the Neonatal Behavioral Assessment Scale.

Ultrasonic growth parameters in fetuses of mothers with primary addiction to cocaine

Sixty-seven women with primary addiction to cocaine were evaluated during their pregnancies by multiple ultrasound studies. Ultrasonic parameters included biparietal diameter, femur length, abdominal circumference, and head circumference. These values were compared with ultrasonic growth parameters in nonaddicted fetuses. Head and abdominal circumference data were used to evaluate the fetuses according to growth pattern. With this system of scoring, subtleties of asymmetric versus symmetric intrauterine growth retardation become apparent. In addition, birth weights of addicted infants were compared with birth weights of nonaddicted infants. The results suggest that, although statistically significant differences in birth weights cannot be demonstrated, abnormal growth of the addicted fetuses does occur. Addicted fetuses show a greater proportion of biparietal diameter and abdominal circumference values below the 50th and 25th percentiles than nonaddicted fetuses, and addicted fetuses more frequently exhibit intrauterine growth retardation patterns. These data suggest that it is fruitful to study these infants with near-normal size but with abnormal intrauterine growth patterns.

The Northwestern University triplet study. IV. Biochemical parameters

Umbilical arterial and venous blood gas indices of 11 triplet pregnancies were reviewed. Ten sets of triplets were delivered by cesarean section and one set was delivered vaginally. Mean 1-minute Apgar scores were significantly lower in the group of infants delivered third than in either of the other birth order groups. There were no statistically significant differences when the mean umbilical arterial or venous pH, PCO2, and base deficit were compared among any one triplet and the other two. Similarly, no significant differences were found when these parameters were compared by birth order in relation to mean 5-minute Apgar scores, mean birth weights, and mean gestational ages at delivery. Birth order did not appear to significantly influence acid-base status, although it may become significant with an increasing time in utero after delivery of the firstborn infant. Further study is necessary to investigate whether there is a critical interval of delivery whereby the infants remaining in utero become acidotic.