BMJ No 7099 Volume 315
Papers Saturday 5 July 1997
Substance use in remand prisoners: a consecutive case study
Debbie Mason, Luke Birmingham, Don Grubin
See Papers p 21, p 30, Letters p 61, and Personal view p 65
Abstract
Objectives: To determine the prevalence of drug and alcohol use among newly remanded prisoners, assess the effectiveness of prison reception screening, and examine the clinical management of substance misusers among remand prisoners.Design: A consecutive case study of remand prisoners screened at reception for substance misuse and treatment needs and comparison of findings with those of prison reception screening and treatment provision.
Setting: A large adult male remand prison (Durham).
Subjects: 548 men aged 21 and over awaiting trial.
Main outcome measures: Prevalence of substance misuse; treatment needs of substance misusers; effectiveness of prison reception screening for substance misuse; provision of detoxification programmes.
Results: Before remand 312 (57%) men were using illicit drugs and 181 (33%) met DSM-IV drug misuse or dependence criteria; 177 (32%) men met misuse or dependence criteria for alcohol. 391 (71%) men were judged to require help directed at their drug or alcohol use and 197 (36%) were judged to require a detoxification programme. The prison reception screen identified recent illicit drug use in 131 (24%) of 536 men and problem drinking in 103 (19%). Drug use was more likely to be identified by prison screening if an inmate was using multiple substances, using opiates, or had a diagnosis of abuse or dependence. 47 (9%) of 536 inmates were prescribed treatment to ease the symptoms of substance withdrawal.
Conclusions: The prevalence of substance misuse in newly remanded prisoners is high. Prison reception health screening consistently underestimates drug and alcohol use. In many cases in which substance use is identified the quantities and numbers of different substances being used are underestimated. Initial management of inmates identified by prison screening as having problems with dependence producing substances is poor. Few receive a detoxification programme, so that many are left with the option of continuing to use drugs in prison or facing untreated withdrawal.
Introduction
There has been a dramatic increase in the use of illicit drugs in England and Wales in recent years. This is reflected in the increase in numbers of notifiable drug addicts from around 17,000 in 1990-1 to around 33,000 in 1995-6. An even steeper rise has been noted in prisoners, who accounted for 12% of notifications in 1990 and 23% in 1995.(1) In addition to the general social problems and adverse effects on health associated with illicit drug use, there are particular problems secondary to drug use in prison, such as the fostering of gangs, debt to other prisoners, and violence.
We recently reported that 26% of men newly remanded to a large prison
in north east England had some form of mental disorder (excluding drug
and alcohol misuse diagnoses) at the point of reception.(2)
By using data on substance use from the same subjects this paper
reports on the prevalence of drug and al The study was conducted at Durham prison, a typical male remand
and short sentence prison. All new pr Screening Virtually all interviews were conducted on the working day after
reception into prison, shortly after the medical officer had seen the
inmate. Interviews lasted between 20 minutes and one hour depending on
the complexity of an inmate's presentation. On the basis of our
findings a decision was made about suitability for a detoxification
programme. After each inmate had been interviewed his medical record
was examined. The findings of the healthcare officer's screen and the
prison doctor's assessment were recorded and any treatment prescribed
was noted.
A pilot study was undertaken. During the pilot study and throughout the
main study, interrater reliability was monitored. A total of 116
prisoners were interviewed by one researcher in the presence of the
other. Both researchers recorded lifetime diagnoses independently. From
this information the agreement between raters was measured by means of
a K coefficient.(5) Agreement in this setting is likely to
be higher than with separate interviews; given the practicalities of
research in prison, separate interviews were not feasible.
During the study 606 unconvicted men were newly remanded to Durham
prison. Of those available for interview, 548 were comprehensively
screened for substance use. In the 116 interviews that were jointly
rated to asses interrater reliability, 184 separate diagnoses of
substance misuse were recorded by either one or both raters. There was
diagnostic agreement in 175 cases (K=0.930).
Prevalence and patterns of substance use
Intravenous drug use was reported by 101 men (26%; 22% to 30%), 29
of whom said they had shared needles. Table 2 shows the extent of
multiple drug use. Of the 181 subjects with drug abuse or dependence
diagnoses, 60 had two such diagnoses and 20 had three or
more.
Treatment needs and expectations of substance users Alcohol use
Detection of substance use by reception screening Drugs
Subsequent interviews with the prison medical officer identified a
further 42 subjects as "using drugs" (without identifying the class
of drug ), increasing the number detected to 172 (32%; 28% to 36%).
Six subjects who when asked by us denied ever using illicit drugs were
identified by prison screening as using c Drug users were increasingly likely to be detected by the prison
reception screen as the number of drugs they were using increased
(P<0.0001, chi2=60.14; df=6) and if they had one or more
current drug abuse or dependency diagnoses (P<0.0001,
chi2=56.90; df=1).
Alcohol
Provision of detoxification programmes Before their reception into Durham prison over 70% of unconvicted
remand prisoners reported the use of illicit drugs, regular consumption
of excessive amounts of alcohol, or both. Amounts of drugs and alcohol
consumed were often substantial, reflected by 56% of the population
having one or more current diagnoses of substance abuse or dependency.
Multiple substance use was also common.
Our results show that whereas over one third of all newly remanded
prisoners provisionally needed to be considered for detoxification,
only about one in four actually received treatment to help manage
withdrawal from drugs and alcohol. Clinical assessment of substance use
at reception relies to a large extent on self reporting. We found that
when questioned by prison staff many inmates played down the extent of
their substance use, disclosing only what they thought was necessary,
as they were not confident of receiving treatment but risked being
labelled as drug users. When interviewed by researchers, who were not
perceived to be part of the system, inmates seemed more willing to
disclose substance misuse. The fact remains, however, that substantial
numbers of drug users were missed by prison reception
screening.
Though considerable emphasis has so far been placed on the role of the
inmate, this is not the only factor that determines the effectiveness
of screening for substance use. We found that information recorded by
prison staff at the time of reception was often in The prison service has other means than clinical assessment of
identifying drug use which do not rely so heavily on a prisoner's
cooperation. Compulsory urine testing of prisoners for drugs, with
penalties for positive results or refusal, was piloted in early 1995.
Despite a lack of evidence for its effectiveness in reducing drug use,
testing was extended to all prisons in England and Wales by March 1996.
The cost of this programme is estimated at around half the total
healthcare expenditure for a prison of 500.(9) This is
pr There are no other published studies of substance misuse at the time of
reception into prison in the United Kingdom, but there is no reason to
suspect that the scale of the problem differs in other remand prisons.
A recent national study of mental disorder in remand prisoners by
Brooke et al reported harmful or dependent misuse of alcohol or other
drugs in 38% of subjects(10) (compared with a similar
finding in 56% of our population). There are, however, important
differences between their study and our own. Many of the inmates
screened by Brooke et al had already spent a considerable period on
remand before being interviewed (median time 64 days), and therefore
the results of their study cannot be interpreted as accurately
reflecting the scale of substance misuse at the point of reception. In
addition, Brooke et al reported a much higher refusal rate (18%
compared with 3% in this study), which may have biased their results.
Without adequate detoxification programmes many inmates will continue
to use drugs in prison. In some cases this will be accompanied by the
risk of n
Funding: Northern Regional Health Authority and the prison
service.
(Accepted 15 April 1997)
Department of Forensic Psychiatry,
Correspondence to: Dr Debbie
Mason, References
1 Joyce L. Drug use in prison: the current picture.
Prison Ser J 1996;107:16-23.
2 Birmingham L, Mason D, Grubin D. Prevalence of mental disorder
in remand prisoners: consecutive case study. BMJ
1996;313:1521-4.
3 Mayfield D, McLeod G, Hall M S W. The CAGE questionnaire:
validation of a new alcoholism screening instrument. Am J
Psychiatry 1974;131:121-3.
4 Phillips G T, Gossop M R, Edwards G, Sutherland G, Taylor C,
Strang G. The application of the SODQ to the severity of opiate
dependence in a British sample. Br J Addict
1987;82:691-9.
5 Maxwell A E. Coefficients of agreement between observers and
their interpretation. Br J Psychiatry 1977;130:79-83.
6 Smith R. Prison medicine: beginning again. BMJ
1992;304:134-5.
7 Bluglass R. Recruitment and training of prison doctors.
BMJ 1990;301:249-50.
8 Ross M, Grossman A B, Murdoch S, Bundey R, Golding J, Purchase
S, et al. Prison: shield from threat, or threat to survival?
BMJ 1994;308:1092-5.
9 Gore S M, Bird G. Cost implications of random mandatory drugs
tests in prisons. Lancet 1996;348:1124-7.
10 Brooke D, Taylor C, Gunn J, Maden A. Point prevalence of mental
disorder in unconvicted male prisoners. BMJ
1996;313:1524-7.
Subjects and methods
A semistructured interview designed specifically for the study was
used. A comprehensive drug and alcohol history was taken, levels of use
recorded, and DSM-IV (Diagnostic and Statistical Manual of
Mental Disorders, fourth edition) diagnoses of abuse and
dependence made when appropriate. The CAGE questionnaire(3)
was incorporated to help detect problem drinking and the severity of
dependence scale(4) was used to quantify severity of drug
dependence.
Results
A total of 382 men (70%; 95% confidence interval 66% to 74%)
gave a history of illicit drug use at some point in their lives. Of
these men, 312 (57%; 53% to 61%) said they had used illicit drugs in
the past year and 181 (33%; 29% to 37%) currently met abuse or
dependence criteria for one or more drugs. Table 1 gives the
nTable 1 - Numbers of subjects currently using each
class of illicit drug at recreational (non-abusive or non-dependent
use), DSM-IV abuse and DSM-IV dependence levels (n=312
subjects*)
Drug
Recreational
use
Abuse
Dependence
Total
Amphetamine 67 25 44 136
Benzodiazepines 32 12 75 119
Cannabis 244 13 1 258
Cocaine 35 8 4 47
Hallucinogens 32 4 0 36
Opiates 13 3 84 100
Solvents 4 0 5 9
Other
substances 2 5 1 8
*Many subjects were using more than one illicit substance.
Table 2 - Numbers of illicit drugs used by 312
subjects
No of drugs used currently
No (%) of subjects
1 108 (34.6)
2 96 (30.7) 3 55 (17.6)
4 27 (8.7) 5 17 (5.4)
6 8 (2.6) 7 1 (0.3)
Of 391 men (71%; 67% to 76%) who admitted using illicit drugs
regularly or abuse of or dependence on a
Table 3 shows the levels of reported alcohol use in the previous
year. Four diagnoses of acute alcohol withdrawal syndrome were
made.
Table 3 - Current levels of alcohol use in 548 subjects
Level of use
No (%) of subjects
None 122 (22) <
21 U/week 193 (35) 21 U/week (with no DSM-IV
alcohol diagnosis) and over 56 (10) DSM-IV
abuse 61 (11) DSM-IV dependence 116
(21)
The inmate medical records of 536 of the 548 subjects were
inspected. In general the healthcare officers' screens were more
comprehensive than the doctors' assessments. In particular, they
contained information about which substances were being used whereas
the doctors' assessments usually just recorded "drugs" when their
use was detected and "alcohol abuse" when alcohol consumption was
thought to be excessive. To some extent prison screens are designed to
be complementary and doctors may have thought it unnecessary to
duplicate information recorded by the healthcare worker. However, in
cases in which the healthcare worker had not detected substance use but
this had been identified subsequently by the doctor, information was
still minimal. In most cases when it would have been appropriate to do
so, neither screen sought further information on quantities of
substances used or problems associated with substance
use.
The healthcare officers' questionnaire identified 131 of 536
subjects (24%; 20% to 28%) using illicit drugs recently. Table 4
shows the detection rates for each of the four drugs that we identified
as being used most commonly. The healthcare officers' screen detected
56 of the 81 subjects we had identified as currently dependent on
opiates (difference=0.046; 0.028 to 0.063), 22 of the 70 subjects we
identified as currently dependent on illicit benzodiazepines
(difference=0.088; 0.076 to 0.100), and 15 of the 43 we identified as
currently dependent on amphetamines (difference=0.051; 0.032 to
0.069).Table 4 - Numbers identified by hospital officers'
screening according to level of use of four most frequently encountered
illicit drugs
Drug Level of use according to research
screening Use identified by hospital
officer No Yes
Cannabis Not
used 118 6
Recreational 191 45
Abuse or
dependence 10 4
Amphetamines Not
used 234 4*
Recreational 58 7
Abuse or
dependence 45 23
Benzodiazepines Not
used 256 2*
Recreational 33 3
Abuse or
dependence 61 22
Opiates Not
used 274 4*
Recreational 11 0
Abuse or
dependence 25 57
*All subjects identified by study as currently using illicit
drugs other than cannabis..
Problem drinking was identified by one or both prison screens in
88 of the 172 subjects identified by us as having a current alcohol
abuse or dependency diagnosis. A further 15 men were said to have
alcohol problems when no alcohol diagnosis was made by us
(difference=0.133; 0.099 to 0.168).
Of 197 subjects potentially requiring a detoxification regimen,
113 needed a reducing course of benzodiazepines to ease withdrawal
from benzodiazepines or alcohol or both. Only six men (5%) received
this, though a further five men were prescribed benzodiazepines for
other reasons. Forty two subjects were judged by us to require
methadone detoxification, of whom 15 (36%) received it; three men were
given bDiscussion
Key Messages
In screening for substance use in remand prisoners a positive
finding must be considered the norm rather than the exception Present prison reception procedures fail to identify the
extent to which substances are used and misused by people newly
remanded to prison Provision of detoxification programmes for prisoners
identified by reception screening as having serious drug and alcohol
related problems is inadequate Prisoners who need help but think that asking for this is more
likely to result in punishment than treatment are not likely be
truthful about their substance use More consideration needs to be given to reducing substance
misuse in prisons by improving assessment at reception and providing
better treatment for misusers rather than using random urine screening
to detect and punish offenders
Conflict of interest: None.
University of
Newcastle upon Tyne,
St Nicholas Hospital,
Gosforth,
Newcastle upon
Tyne NE3 3XT
Debbie Mason, research
associate
Luke Birmingham, research
associate
Don Grubin, senior lecturer in
forensic psychiatry
Parkhead Hospital,
Glasgow G31
5ES.
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