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 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 alcohol use, the extent to which prison reception screening detects this, and the initial management of subjects whose substance misuse is identified. Subjects and methods The study was conducted at Durham prison, a typical male remand and short sentence prison. All new prisoners are screened at reception by a healthcare officer for physical and mental health problems as well as substance use. A standard prison questionnaire (F2169) is used which contains several specific questions about recent drug and alcohol use. This provides useful information for the prison doctor, who assesses each inmate the next working day and decides about detoxification regimens and any other treatment needs. All unconvicted men remanded into custody over seven months from 1 October 1995 to 30 April 1996 were eligible for the study. The research was explained to each man and assurances given that any information he offered was confidential and would not be passed on to prison staff. Each man gave written consent. Subjects were interviewed by one of two researchers trained in psychiatry. Screening 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. 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. Results 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 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 numbers of men currently using each class of drug according to level of use. Many inmates using drugs complained of withdrawal symptoms, but only 12 diagnoses of drug withdrawal syndrome were made. Table 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. 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. 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) Treatment needs and expectations of substance users Of 391 men (71%; 67% to 76%) who admitted using illicit drugs regularly or abuse of or dependence on alcohol, or both, and who were judged to require treatment directed at their substance use, 244 (62%; 58% to 66%) said they wanted help. A total of 197 (36%; 32% to 40%) of the study population who were physiologically dependent on benzodiazepines, alcohol, opiates, or a combination of these substances at the time of reception into prison were judged to be potential candidates for a detoxification programme. Of these, 64 requested treatment including detoxification, 22 wanted methadone maintenance, 45 wanted other treatments such as group work, and 66 did not want help. Alcohol use 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) Detection of substance use by reception screening 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. Drugs 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.. 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 cannabis. 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 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). Provision of detoxification programmes 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 benzodiazepines instead. A further 42 subjects potentially required detoxification with both benzodiazepines and methadone, of whom 10 received this, nine were given methadone alone, and four were given benzodiazepines alone. Discussion 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 inadequate or ambiguous. Such standards have led to criticism of prison medical staff in the past.(6, 7) Concern has also been expressed about treatment programmes for drug misusers in prisons based on Home Office guidelines, which are said to breach normal standards of professional ethical care.(8) 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 primarily a deterrent measure, however, as tests give little information about substance related problems or health needs and are not a substitute for thorough clinical assessment. We believe that if drug use in prison is to be tackled effectively greater emphasis needs to be placed on more rigorous clinical screening and provision of drug treatment programmes comparable to those in the community. 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 needle sharing. Others who attempt to stop or who do not establish a supply quickly enough are exposed to the effects of acute withdrawal. Ultimately the picture that emerges is one of a self perpetuating and rapidly growing problem of substance use in prisons, which, because most prisoners are released after comparatively short periods (the mean length of remand was under two months in our sample), will inevitably spill over into the community. 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 Funding: Northern Regional Health Authority and the prison service. Conflict of interest: None. (Accepted 15 April 1997) Department of Forensic Psychiatry, 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 Correspondence to: Dr Debbie Mason, Parkhead Hospital, Glasgow G31 5ES. 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. 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