HIGH-RISK GROUPS AND PRISON POLICIES

Jan Keene discusses the implications for prison policies concerning harm minimisation and HIV prevention, and suggests that prison presents an ideal opportunity to target a high-risk group with HIV prevention resources.

INTRODUCTION

This article presents the results of a survey of non-custodial drug use and HIV risk behaviour among a local prison population and a group of ex-prisoners on probation. It is a study of prisoners' drug use before custody and ex-prisoners' drug use after custody. These data indicate that nearly three-quarters of both the prisoner and ex-prisoner population had used drugs in the community. A quarter of these had injected drugs and a quarter received treatment. It is suggested that this population therefore consists of a group of people with high-risk behaviours and presents an ideal opportunity to target HIV prevention and harm minimisation. There has been little research to date on prison populations as a whole, rather than particular subgroups. The exception is the Home Office-funded study of Maden et al. ( 1991, 1992 ) . This study involved 25 prisons, and showed that 34% of inmates had used cannabis before prison, 9% used heroin or

amphetamine and 3% sedatives. In contrast to the study reported here, Maden's work involved formal interviews in a custodial setting and excluded recreational drugs such as LSD, Ecstasy and benzodiazepines.

If the present study is placed in the context of research regarding continued drug use in prison, it can be seen that many drug users spend time in prison and continue to inject while in custody (Dolan et al., 1991; Keene et al., 1991, 1993; Turnball et al., 1991, 1992;Dolan, 1993). It is interesting that the proportion of drug users who continue to inject in prison seems constant. Turnball has shown that 23-33% of injectors continue in prison and that two-thirds to three-quarters of those who inject share. Although sharing is less overall, it is more dangerous, usually involving multiple use of equipment with different networks of users. Therefore, if a quarter or more of community injectors continue to inject in prison, about 6% of the total prison population may be injecting. Although this proportion is fairly small, it is of great concern, because it consists of a high-risk group in a very high-risk environment.

There is a therefore a risk of HIV and drug related harm both inside and outside prison in this population. There exists an opportunity to target high-risk behaviours both in the community and perhaps, more importantly, in prison itself. This article focuses on the need for services in custody; however, there is no doubt that probation can play a larger part in helping drug users in the community in accordance with the provisions of the Criminal Justice Act. Although many of the study population took advantage of help in the community, there was potential for greater probation screening, referral and joint working. This study provided the impetus for the local probation team to create two new posts to develop screening and harm-minimisation procedures for drug users.

Services in prison are, however, a far greater priority, because they lag about 5 years behind those in the community where injecting drug users have access to medical treatment and harm-minimisation services, including maintenance prescriptions, oral alternative drugs, clean needles and syringes, cleaning agents and condoms. When drug users arrive in prison, whether on remand or on a sentence, they find access to these services denied. There are few medical treatment programmes offering oral alternative drugs and very limited access to decontaminants in English and Welsh prisons. There are also, of course, no legitimate condoms, needles and syringes. It follows that where these facilities are most needed they are almost entirely absent. The provision of simple, cheap measures such as decontaminants and condoms would prote4: not only the drug user, but also the community as a whole, because the prison service may in effect be providing a major route for HIV transmission into the community.

THE STUDY

The institution studied was a local prison, where one-third of the population were young offenders and two-thirds were on remand. Short self-completion questionnaires were distributed to all prisoners and a cross-section of probation clients. The questionnaires were anonymous and returned in sealed envelopes to post boxes or probation staff. Half of the prison population responded to the questionnaires and an equivalent number of ex-prisoners on probation.

There are several limitations in the study design. First, the drug use reported here reflects the age of respondents, the locality of the study and the type of prison. The catchment area for the local prison and county probation service was in a part of Britain where amphetamine and steroid use are common. The study is therefore limited in its conclusions by the nature of the populations studied. The research methods may have encouraged greater openness about recreational drug use than other studies, but may also have given more scope for the imagination. Although 87% of the ex-prisoner group had attended the study prison, the prison and probation groups were not matched, and cannot therefore be viewed as part of the same population.

However, within these limitations it can be demonstrated that there are few significant differences between the two groups of respondents, although there is a wide range of different responses across questions. Although this does not demonstrate validity, it does indicate a consistency of individual response unlikely to occur by chance

RESULTS

More than one-quarter of the two groups reported injecting drugs in the community, whereas 21% reported using a needle and syringe exchange or buying needles from a pharmacist. The results are expressed as percentages of the overall respondents. As might be expected from other research, cannabis use was most common, 68% and 81% before and after prison, respectively, although an unexpected finding was that nearly half had used LSD (52% and 46%) or Ecstasy (33% and 29%). However, of more significance is the widespread use of injectable drugs (Table 1 ) It is also of some concern that drug use was greater among younger respondents. There was a significant difference between respondents who were under 21 years (91% of whom used drugs) and those who were older (66% used drugs) (X2 = 18.5, d.f. = 1, p < 0.01 ) .

HIV risk is obviously increased if drugs are injected and clean equipment or cleaning fluid is not readily available. Most drugs can be injected, but there is more research evidence of injection of 'hard' drugs such as heroin, amphetamine, cocaine and steroids. It can be seen from Table 1 that more than a quarter of the respondents are injecting drug users. It is of interest that only three heroin and three steroid users did not report injecting. Only 12% used heroin. Of the prison group,16% reported injecting without heroin use, whereas of the probation group 8% did so. Amphetamine is one of the most commonly injected drugs in this area, and nearly half of the respondents had used amphetamine. Thirty-one people who used amphetamine or cocaine, but not heroin, reported injecting (55 did not). Unfortunately these data did not give the proportion of injectors who inject pills together with other drugs. Sharing rates were reported as low, prison (5%) and probation group (14%).

An estimate of the minimum extent of injecting can be gained by calculating the numbers who have bought or exchanged needles and syringes from chemists and/or syringe exchanges. Most injectors obtained needles and syringes from legitimate sources. Whereas 28% and 27% respectively reported injecting drugs,21 % of the total group attended either syringe exchanges or chemists, or both. Both groups took advantage of drug service provision in the community. Nearly a quarter (23%) of the prison group and almost a third (28%) of the probation group had attended a drug agency, whereas slightly more recorded receiving a prescription for drugs from an agency or GP (26% and 33% respectively).

The proportion of one quarter to one-third was also broadly accurate for those suffering withdrawals on reception to prison (29% and 35%) and for those receiving prescriptions while in custody (28% and 29%). However, the drug service provided in prison is not nearly as comprehensive as that in the community. Nor is it as successful. Although prisoners use prison drug services, this is not reflected in any apparent decline in the numbers of people reporting drug use before and after custody.

The following figures give comparisons with official prison and probation statistics for drug problems The levels of drug use reported by prison respondent were higher than those in official prison records Statistics from the prison health-care records indicate that just under half of the prison population had admitted to using drugs before reception (48%); 61% of the young offenders (n = 66),44% of the adult population were using drugs before custody (n = 211). Less than half continued to receive medication in custody. These figures are similar to the numbers reporting help in prison.

The proportion of probation clients with recorded drug problems at the initial report stage and during supervision was approximately a fifth to a quarter. In the period of 6 months corresponding to the survey, 22.4% of 650 pre-sentence reports record drug problems and the same proportion is reported in supervision orders (22.5% of 545). As it is likely that drug use generally is under reported (ISDD,1990/91), it is possible that present monitoring systems may be inadequate for identifying 'non-problematic' recreational and stimulant drug users before custody.

SUMMARY

In this study, the reported rates of drug use before and after custodial sentences are higher than in previous estimates of problematic drug use, but include recreational drug use and stimulant, and hallucinogenic drug use previously not identified. Approximately three-quarters of respondents used drugs, but only a quarter attended drug agencies, had withdrawals on reception or help in custody. Therefore most drug users (two-thirds) had not requested help in the community or in custody and may not have seen their drug use as problematic. The majority had not used cocaine and heroin but less addictive 'recreational drugs' such as amphetamine and diazepam (Valium), and the non-injectable drugs such as cannabis and LSD.

Injecting behaviour is not limited to a small minority of heroin users, but extends to a wide range of different drugs including amphetamine, cocaine and steroids. Reports of injecting were far higher than reports of heroin use. There is a need to identify all types of injector, so that valuable opportunities for the introduction of prevention and treatment measures for drugs and HIV are not lost.

DISCUSSION

This report has emphasised that drug injection is not limited to addicts using heroin and that many recreational users inject a variety of other drugs from amphetamine to steroids. Needles and syringes are in short supply in prison, but available: whether home-made, smuggled in at reception or bought from diabetics. For these people, drug-free treatment is often unnecessary and unwanted but it has been demonstrated that they will make good use of HIV prevention and harm-minimisation facilities when provided. This is perhaps best illustrated by the Principal Officer of the Young Offenders Wing in the study prison.

We are painfully aware of the presence of needles and syringes and the risk of HIV . . . The indications lead to the inescapable conclusion that if somebody has reached the stage when they inject, that they would be quite happy to share works in a group, all actually using the same needle and syringe. I would not sanction needle exchange in prison, but I think it essential that we instruct intravenous drug users in the hygienic use of works . . . we should also make cleaning agents available and should explore the possibilities of doing this further.

The growing awareness of the high risk nature of the prison environment has not been matched by increased service provision. The situation at present means:

• No harm-minimisation services.
• No medical treatment programmes providing maintenance or non-injectable alternatives.
• Either no or only short-term (5-10 days) detoxification programmes.
• No access to decontaminants in English and Welsh prisons.
• No condoms.

HIV prevention and harm-minimisation services for this high risk group in a high risk environment are therefore far less than those among lower risk groups in the community. It is clearly necessary to identify the needs of this population and target resources appropriately, having acknowledged:

• The high levels of drug use and HIV risk behaviour in this population.
• The success of harm minimisation outside prison.
• The need to target resources at this particular population inside prison.

This report indicates that present monitoring systems may be inadequate for identifying 'non-problematic' recreational and stimulant injectors. If so, valuable opportunities for HIV prevention may be lost. More effective screening would enable identification of problem drug users and their allocation to a range of services in the community and within prisons. Educational programmes, including harm minimisation, HIV prevention, safe sex and alternative methods of drug use would give the information necessary to make informed choices.

However, there is little point in screening without services. Prevention and treatment services in custody do not even resemble those in the community, whether preventive health measures or medical treatment regimes; and there is less point in educating about safer drug use without incorporating the availability of decontaminants. Although SCODA states that 200 drug agencies are involved in prisons and that there is a 5-10 day recommended detoxification period, these interventions do little to prevent HIV in prison as they do not incorporate basic harm minimisation and HIV prevention methods.

Recent changes in custodial provision have not included those proven in the community but instead revived the idea of urine testing. Voluntary testing can be used as an integral part of medical treatment. This serves two purposes: to diagnose seriousness of problem on reception and to monitor prescribed drug programmes. The alternative, compulsory, random urine testing can serve no useful purpose but may well drive high-risk behaviour underground and prevent prisoners using services. Random testing would put a great deal of strain on prison security and it is likely that compulsory testing for drug abuse would infringe the European Convention on Human Rights A cheaper, efficient and less risky alternative may be simply to make sterilisation tablets or bleach available in hospital or health care facilities and on the wings. This has been undertaken in Scottish prisons, where reports of hepatitis B and HIV in prison led the Director of Prisons, Alan Walker, to provide drug users in custody with access to sterilising tablets to clean cutlery, cups, chamber pots and provide some means of sterilising unlawful equipment. As he said, 'We cannot just stand and watch people become infected with HIV in prison'.

This study has shown that the levels of HIV risk through injecting drug use are unexpectedly high among the respondents and this risk is increased in the prison environment, where the level of service provision is low. There are clear implications for the policy regarding the development of HIV prevention and drug services in prisons.

J. Keene, PhD, Social Policy and Applied Social Studies, University College Swansea, S. Wales.

REFERENCES

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Dolan, K.A. (1993). Drug injectors in prison and the community in England. International Journal of Drug Policy, 4, 178-189.

Keene, J., Parry-Langdon, N. and Stimson, G.V. (1991). HIV prevention amongst drug users: specialist and community based provision. International Journal on Drug Policy, 2, 26-29.

Keene, J., Stimson, G.V., Jones, S. and Parry-Langdon, N. (1993) . Evaluation of syringe-exchange for HIV prevention among injecting drug users in rural and urban areas of Wales. Addiction, 88, 1063-1070.

Maden, D.A., Swinton, M. and Gunn, J. (1990). Drug dependence in prison. British Medical JournaI, 3 02,180.

Maden, D.A., Swinton, M. and Gunn, J. (1992). A survey of pre-arrest drug use in sentenced prisoners. British Journal of Addiction, 87, 27-33.

Tumball, P.J ., Dolan, K.A. and Stimson, G .V . (1991) . Prisons, H1V and AIDS: Risks and Experiences in Custodial Care. Horsham, AVERT.

Turnball, P.J., Dolan, K.A. and Stimson, G.V. (1992). Prevalence of HIV infection among ex-prisoners in England. British Medical Journal,304,90-91.