Differential substance misuse treatment needs of women, ethnic minorities and young offenders in prison: prevalence of substance misuse

and treatment needs

Home Office Online Report 33/03

The views expressed in this report are those of the authors, not necessarily those of the Home Office (nor do they reflect Government policy).

Differential substance misuse treatment needs of women, ethnic minorities and young offenders in prison: prevalence of substance misuse and treatment needs

Jo Borrill, Anthony Maden, Anthea Martin, Tim Weaver, Gerry Stimson , Michael Farrell and Tom Barnes With the assistance of Rachel Burnett, Sarah Miller, and Daniel Briggs

Acknowledgements
The work described in this report was commissioned and funded by the Home Office and Prison Service. We are extremely grateful for this funding and also for the practical support offered by Prison Service staff during the life of the project. We would also like to thank the many members of staff in the prison we visited for their help. We demanded a lot of staff in a very short time and without their co-operation this project could not have been completed.

Jo Borrill Anthony Maden Anthea Martin Tim Weaver Gerry Stimson Michael Farrell Tom Barnes

Contents
Page 1 2 Background
Study aims

4
4

Method
Design Quantitative survey of prison populations Qualitative investigation

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5 5 7

Findings: women
Prevalence of substance misuse Treatment for alcohol and drugs problems Prevalence and management of substance misuse: findings from the qualitative investigation Demographic and social factors associated with substance misuse Mental health Physical health Illustrative cases

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10 15 18 20 26 33 34

Findings: ethnic minority men

Prevalence and management of substance misuse Management and treatment of drug and alcohol problems Demographic and social factors associated with substance misuse Mental health Physical health Ethnic minority men: findings from the qualitative study Illustrative cases

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36 38 40 42 45 46 47

Findings: young male offenders

Prevalence and management of substance misuse Management and treatment of drug and alcohol problems Demographic and social factors associated with substance misuse Mental health Physical health Young offenders: findings from the qualitative study Illustrative cases

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49 51 54 56 58 59 60

Discussion, conclusions and recommendations

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1.

Background

The study described in this report was developed in response to a brief to investigate the prevalence and management of substance misuse amongst sub-populations of the prison estate. The brief required a series of nested investigations to examine issues in relation to women, ethnic minorities and young offenders.

Study aims
The aims of the study were as follows: 1. To obtain an estimate of the prevalence and nature of substance misuse in women in prison, both before and during their prison sentence. 2. To examine associations between substance misuse and a range of social, psychological and psychiatric factors which may be of particular relevance to women offenders. 3. To assess the treatment needs and experiences of people in prison who have substance misuse problems, focusing in particular on the different needs of women, members of minority ethnic groups, and young offenders. 4. To investigate the factors associated with effective identification, assessment, clinical management and throughcare of substance misuse within the prison setting.

2.
Design

Method

In order to address the study aims described above we implemented a multi-method investigation. This comprised: A quantitative survey of prisoners which was designed and implemented in order to address aims 1-3. A qualitative investigation of the views of prison staff (service providers) which was implemented to address Aim 4. Note about report of findings The findings from the quantitative survey are presented in this report. Findings from the complementary qualitative investigation are presented in other ways. Material of direct relevance to themes covered by the survey (and which therefore illuminate and add depth to the quantitative findings) are presented herein. The qualitative findings have also been drawn on in Home Office Development and Practice Report 8 (2003), by Borrill et al. In addition, the qualitative analysis is also presented in a sister report, available from the authors at Imperial College. (Contact point is Professor Anthony Maden, Department of Psychiatry, Faculty of Medicine, Imperial College of Science, Technology and Medicine, c/o The Academic Unit, West London Community Mental Health Trust HQ, Uxbridge Road, Southall, Middlesex UB1 3EU.) The conclusions and recommendations at the end of this report reflect the findings from both quantitative survey and qualitative investigations.

Quantitative survey of prison population

Study samples Women. The sample of women was drawn from both remand and sentenced populations, in proportion to their relative numbers, selected from ten female establishments in different parts of England. In order to fully investigate substance misuse in the minority ethnic female population, a quota sampling method was used, with the aim of interviewing sufficient numbers of black and mixed race women to enable meaningful comparisons to be made with the white population. Women of Asian, Chinese or other ethnic backgrounds were excluded from the study as their numbers would be too small to enable meaningful comparisons to be made of prevalence rates or patterns of substance misuse. The final sample of women is shown below in Table 2.1.
Table 2.1 Ethnic composition of womens sample. Remand 31 34 65 Sentenced 159 77 236 Total 190 111 301

White Black/mixed race Total

Women who were foreign nationals were also excluded from the study, first because they are likely to be deported at the end of their sentence and therefore their continuing treatment needs would not be met by UK services, and second because they include a high proportion of drug importers who are not themselves dependent. Including them in the prevalence sample would therefore distort the figures for substance misuse within the UK population. Within these parameters the women were selected randomly from official statistical records and/or local prison databases.

Men from minority ethnic groups. Forty men from minority ethnic groups, all with substancemisuse treatment needs, were selected by prison staff and CARAT workers at three prisons. Eighty per cent defined themselves as Black, with the remainder Asian or Mixed race. Eightytwo per cent were sentenced prisoners. Men were selected with a range of substance misuse problems and with different experiences of treatment / no treatment. (See Table 2.2)
Table 2.2 Composition of ethnic minority men sample. Remand 6 1 0 7 (17.5%) Sentenced 26 4 3 33 (82.5%) Total 32 5 3 40

Black Asian Mixed race Total

Young offenders. Eighty young male offenders, aged 18-21, with substance-misuse treatment needs, were selected by prison staff and CARAT workers at four young offender institutions. Young offenders were selected to represent a range of problems and different experiences of treatment /non-treatment. (See Table 2.3)
Table 2.3 Composition of male young offenders sample. Remand 5 2 1 1 9 Sentenced 52 9 9 1 71 Total 57 11 10 2 80

White Black/mixed race Asian Chinese/other Total

Assessments A structured interview was designed to address the following key areas, identified from the previous literature: demographic information; criminal history; education; employment; relationships with family and friends; children; alcohol use/misuse; drug use/misuse; physical health; mental health and illness; selfharm and attempted suicide. The interview also included items from the following standardised measures of substance misuse and health status: AUDIT: Alcohol Use Disorders Identification Test (Saunders et al., 1993). This is a screening instrument for hazardous and harmful alcohol consumption. It covers the domains of alcohol consumption, drinking behaviour and alcohol-related problems. The cut-off score of eight has been used in previous studies (e.g. Singleton et al., 1998) to classify people with hazardous and harmful alcohol use. AUDIT is relevant across different cultures and detects hazardous consumption and frequency of intoxication, not just established dependence. SDS: Severity of Dependence Scale (Gossop et al., 1995). This is a short, easily administered scale designed to measure the degree of psychological dependence experienced by users of different illicit drugs. Scores on SDS have been found to correlate with behavioural indices of dependence, such as frequency of use, contact with other users, and expressed need for treatment. SF36: Short Form 36 Health Survey (Ware et al., 1992). The SF36 is a measure of physical functioning, role limitation due to health problems, subjective health status and change in health status. For the purposes of this survey, those questions were selected which constitute the General Health Perception dimension.

HADS: Hospital Anxiety & Depression Scale (Snaith and Zigmond 1994). This is a selfreport scale designed to detect mild, moderate and severe states of general anxiety and depression. It is a useful screening measure rather than a diagnostic measure, and excludes items which might be caused solely by physical illness. MINI: Mini International Neuropsychiatric Interview (Sheehan and Lecrubier 2000). The MINI is an internationally standardised interview covering the major psychiatric disorders represented in DSM-IV and ICD-10 classifications. Questions from the following modules of the MINI were incorporated into the survey: Section C (Suicidality), Section D (Manic/Hypomanic episode), Section L (Psychotic Disorders). CAPS: Clinician-Administered PTSD Scale (Blake et al., 1997). The CAPS is a structured interview designed to assess symptoms of post-traumatic stress disorder, as defined in DSM-IV. The preliminary checklist from CAPS is used to identify specific traumatic experiences which a person may have experienced or witnessed. For the purposes of this survey the checklist provided an acceptable way of obtaining information about previous trauma, specifically experiences of physical or sexual abuse and experiences of violence.

Additional information was collected from an examination of prison records and medical notes.

Qualitative investigation
Data collection method Data were collected through a series of one-to-one qualitative, depth interviews conducted with 32 individuals involved in the delivery of various prison-based substance misuse treatment services. Twenty-nine participants were service providers. The large majority of these worked in the following services: CARAT, detoxification, drug rehabilitation, probation/throughcare, or healthcare. Two prison officers and a drug liaison worker were also interviewed. Four participants were young offenders operating as peer educators/supporters. Participants were drawn from six establishments selected by the Prison Service Drug Strategy Unit. In order to illustrate and explore the diversity of service provision across different categories of prisoner, one local prison and one training prison housing each of the three target populations were selected to take part in the study. The local prisons were located in London, and the training prisons in the Home Counties. Interviews Qualitative data was gathered by means of in-depth interviewing. All interviews were conducted at the participating establishments. Interviews typically lasted between 60 and 90 minutes, and were tape-recorded with informed consent and later transcribed for coding and analysis. The interview was informed by a three-page topic guide, covering three main areas. These were: (1) the participants role in the establishments substance misuse treatment services; (2) the characteristics of the relevant population of substance-using prisoners; and (3) the prisonbased services available to this population. The guide listed key issues for the target populations and key processes in the delivery of services. These were identified from relevant literature, and used to prompt discussion. The topic guide was developed through a process of drafting and draft amendment, following consultation with the commissioners of the study. The interviewer aimed to elicit detailed accounts of participants knowledge of the target populations as well as their experiences of delivering services to these populations. Their views on the functioning of prison-based services were also sought. These aims were

achieved utilising open-ended questions supplemented by follow-up questions and prompts as appropriate. The use of prompts served to direct the interviewers lines of inquiry such that she sought broadly comparable information from each participant, while in general interviews were sufficiently flexible to allow data collection to flow inductively throughout.

Analysis Data collection and analysis adopted an inductive approach where the emergence of key categories and findings throughout the data-collection period informed the focus and parameters of further investigation and analysis. Such an approach ensured that ongoing coding and analysis of interview transcripts were grounded in the data gathered. The qualitative findings presented in this report have been chosen to supplement the findings of the quantitative investigation. It should be noted that they represent only a minor component of the qualitative analysis, and are necessarily selective. The full report on the qualitative study (available from the authors) explores issues around the substance misuse treatment needs of the target populations from the more holistic perspective adopted by participants.

3.

Findings: Women

Prevalence of substance misuse

Substance misuse in the year before prison Prevalence of alcohol misuse. Table 3.1 shows that 102 women (34% of the sample) reported harmful or hazardous levels of alcohol consumption (i.e. they scored 8 or more on the AUDIT questionnaire). White women had slightly higher rates of harmful drinking (37%) than black/mixed race women (29%) and higher mean AUDIT scores (8.6 compared with 6.6), but the difference in mean scores was not statistically significant [t = 1.747, df 299, p .082] and there was no significant overall association between ethnicity and drinking status. Table 3.1 also shows that 36% of sentenced women scored above the criterion for harmful drinking compared with 26% of women on remand, but again the difference in mean scores was not statistically significant [t = 1.049, df 299, p .295], and there was no significant overall association between sentence status and drinking status [chi square 2.213, df 1, p.137]. These rates of harmful drinking (34% overall and 37% for white women) are close to the rate of 37.5% recorded in the ONS study (Singleton et al 1998), where approximately 76% of the respondents were white. (See Table 3.2)
Table 3.1 Women: prevalence of harmful / hazardous drinking. Yes (AUDIT => 8) 70 (37%) 9 (29%) 61 (38% 32 (29%) 8 (24%) 24 (31%) 17 (26%) 85 (36%) 102 (34%) Mean AUDIT score 8.59 (10.31)

White women White remand White sentenced Black/mixed race women Black/mixed remand Black/mixed sentenced Total remand Total sentenced Total Table 3.2

6.55 (8.79)

6.71 (10.59) 8.15 (9.58)

Women: comparison of AUDIT scores between white and black/mixed-race prisoners (Score of 8+ indicates harmful/hazardous drinking) 0-7 120 (63%) 79 (71%) 8-15 27 (14%) 17 (15%) 16-23 20 (11%) 6 (5%) 24-31 11 (6%) 5 (4%) 32-40 12 (6%) 4 (4%)

White Black/mixedrace

Of those 102 women who exceeded the threshold for harmful drinking, 66 (65%) reported that there had been weeks in the past year when they drank alcohol every day. Twenty (22% of harmful drinkers and 7% of the total sample) said they drank every day of every week of the year. They were also asked whether they could identify particular reasons for drinking more than their usual amount. Fifty-one women who responded cited negative reasons, such as feeling depressed or unhappy, coping with stress (including abusive relationships), or trying to block out painful memories. Eight referred to links between alcohol and drug use, for example using alcohol more if trying to cut down on drugs, if drugs were not available, or to balance the effects of crack use (4). In contrast, only 9 reported positive reasons for

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drinking more, such as a special occasion, and 3 referred to availability of alcohol/money as the main factor affecting consumption. Prevalence of illicit drug use. Many women (244, or 81%) reported using drugs at some time in their lives. Table 3.3 shows that 77% of the women had used cannabis, starting at an average age of 16. Crack, heroin, tranquillisers and amphetamines had each been used by about half the women at some time, with an average age of first use between 18 (amphetamines) and 22 (crack). LSD, amyl nitrite, magic mushrooms and solvents had been used by about a quarter of the sample at some time, starting at around 17 to 18 years (14 for solvents). 217 women (72%) reported using at least one illicit drug in the 12 months prior to prison. 56% of the women reported using cannabis during this time period, with heroin use reported by 44% and crack use by 43%. Relatively few women reported using solvents, LSD, magic mushrooms or amyl nitrite prior to prison.
Table 3.3 Women: prevalence of use (ever and 12 months prior to prison) and age of first use of major drug types. Ever used Age of first use

Used in 12 months before prison N (%) Mean (st dev) N (%) Cannabis 231 (77%) 16.47 (5.72) 169 (56%) Crack cocaine 150 (50%) 22.41 (7.13) 131 (43%) Heroin 148 (49%) 21.46 (6.62) 133 (44%) Tranquillisers 143 (47.5%) 19.3 (5.62) 97 (32%) Amphetamines 143 (47.5%) 18.48 (4.87) 54 (18%) Ecstasy 120 (40%) 20.23 (5.95) 56 (19%) Cocaine powder 108 (36%) 20.64 (5.98) 68 (23%) LSD 105 (35%) 16.75 (3.93) 9 (3%) Methadone 100 (33%) 22.82 (5.95) 65 (22%)* Amyl nitrite 87 (29%) 18.07 (5.02) 13 (4%) Other opiates 82 (27%) 23.29 (6.33) 54 (18%)* Magic mushrooms 78 (26%) 17.21 (4.25) 10 (3%) Solvents 72 (24%) 13.7 (2.46) 7 (2%) Other drugs 20 (7%) 24.8 (6.99) 11 (4%) Bupremorphine 16 (5%) 22.38 (5.62) 8 (3%) Steroids 7 (2%) 18.5 (4.68) 2 (<1%) *Numbers for methadone (22%) and other opiates (18%) include those prescribed

Table 3.4 shows that the proportion of women reporting drug use in the 12 months prior to prison was significantly higher for white women (77%) than for women of black/mixed race (63%) [Chi-square 7.127, df 1, p.008]. There was no significant difference between the proportion of women on remand (75%) and sentenced women (72 %) who reported using any drug 12 months before prison [Chi square 0.446, df 1, p.504]. Thus differences between ethnic groups in drug use cannot be attributed to the different proportions of remand/sentenced women in each ethnic group.
Table 3.4 Women: comparison of prevalence of illicit drug use during 12 months before prison by remand and sentenced status and ethnicity N (%) reporting use 27 (87%) 120 (75%) 22 (65%) 48 (62 %)

White remand White sentenced Black/mixed race remand Black/mixed race sentenced

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The numbers of women from different ethnic groups reporting use of each drug is shown in Table 3.5.
Table 3.5 Women: comparison of prevalence of illicit drug use (by type) during 12 months before prison by ethnicity White 108 (57%) 112 (59%) 91 (48%) 81 (43%) 53 (28%) 41 (22%) 48 (25%) 9 (5%) 8 (4%) 9 (5%) 9 (5%) 7 (4%) 7 (4%) 2 (1%) Black/mixed race 61 (55%) 21 (19%)*** 40 (36%)* 16 (14%)*** 15 (13%)** 15 (13%) 6 (5.4%)*** 4 (4%) 3 (3%) 1 (<1%) 0 (0%) 1 (<1%) 0 (0%) 0 (0%) Total 169 (56%) 133 (44%) 131 (43%) 97 (32%) 68 (23%) 56 (19%) 54 (18%) 13 (4%) 11 (4%) 10 (3%) 9 (3%) 8 (3%) 7 (2%) 2(<1%)

Cannabis Heroin Crack Tranquillisers Cocaine Ecstasy Amphetamines Amyl nitrite Other (ketamine, khat, ritalin etc) Magic Mushrooms LSD Bupremorphine Solvents Steroids * difference between ethnic groups, p<.05 ** difference between ethnic groups p<.01 *** difference between ethnic groups p<.001

Differences between ethnic groups in the use of amphetamines, heroin, and tranquillisers were significant for both remand and sentenced women. Differences between ethnic groups in the use of cocaine were only significant for sentenced women, and ethnic differences in use of crack failed to reach significance when analysed separately by sentence status. Drug dependence. The SDS scale was used to distinguish between women reporting low level, recreational drug use, and women who were rated as dependent on one or more drug. The cut-off for dependence was a score of 7 or more on SDS for any drug. Table 3.6 shows that using this criterion, 49% of the women were dependent on at least one drug. 60% of white women were dependent, compared with 29% black/mixed race women, and the association between ethnicity and dependence was statistically significant [Chi square 28.174, df 1, p .000]. Rates of dependence were highest for white women on remand (64%), but there was no overall difference in dependence between remand and sentenced women. The association between ethnicity and dependence was highly significant for both remand and sentenced women [remand: chi square8.041, df 1, p .005 ; sentenced: chi square 20.171, df 1, p .000]. Thus white women not only had higher rates of using drugs, particularly heroin, tranquillisers, amphetamines, and cocaine, but also reported significantly higher rates of psychological dependence.
Table 3.6 Women: comparison of prevalence of drug dependency (SDS score =>7 any drug) during 12 months before prison by remand and sentenced status and ethnicity N (%) with SDS score indicative of dependency 20 (64%) 95 (60%) 10 (29%) 22 (29%) 147 (49%)

White remand White sentenced Black/mixed race remand Black/mixed race sentenced Total

One hundred (33%) women were dependent on heroin, 70 (23%) were dependent on crack, and 16 (5%) on tranquillisers. Only 5 women (2%) reported dependence on cannabis and 2%

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on methadone. There were marked ethnic differences in dependence on heroin, with 90 (47%) white women dependent on heroin compared with only 11 (10%) black/mixed race women. [Chi square 43.561, df 1, p.000]. However rates of crack dependence were similar for white women (25%) and black/mixed race women (21%). Poly-dependence. Eighty-four women (28%) were dependent on one drug only, mainly heroin (15%) or crack (9%). 46 women (15%) were dependent on two drugs, which in 42 cases were heroin and crack. 15 women (5%) were dependent on three drugs and one on four. Almost half of the white drug-dependent women (46%) were dependent on 2 or more drugs, compared with just over a quarter (28%) of the black/mixed race dependent women. Links between alcohol and drugs misuse. Eighty women (27%) reported both harmful / hazardous drinking and the use of at least one illicit drug in the 12 months before prison. 49 women (16%) were assessed as both harmful drinkers and dependent on at least one drug (Table 3.7).
Table 3.7 Women: association between drug dependency (SDS score =>7 any drug) and harmful alcohol use (AUDIT 8+) during 12 months before prison Harmful drinking: No 101 (34%) 98 (33%) 199 (66%) Harmful drinking: Yes 53 (18%) 49 (16%) 102 (34%) Total 154 (51%) 147 (49%) 301

Not Drug Dependent Drug Dependent Total

Eighteen per cent of white women were dependent on drugs and also had harmful levels of drinking, compared with 13% of black/mixed race women. Most notably, 55% of black/mixed race women were not dependent on either drugs or alcohol, compared with 21% of white women (Table 3.8).
Table 3.8 Women: association between drug dependency (SDS score =>7 any drug) and harmful alcohol use (AUDIT 8+) during 12 months before prison by ethnicity Harmful drinking: No 40 (21%) 80 (42%) 61 (55%) 18 (16%) Harmful drinking: Yes 35 (18%) 35 (18%) 18 (16%) 14 (13%)

White Not dependent White Dependent Black/mixed Not dependent Black/mixed Dependent

Injecting drugs. Ninety-two women (31%) said they had injected drugs at some time, although only 2% reported injecting in prison. Forty-five per cent of white women had injected drugs compared with 9% of black/mixed race women, and the association between injecting and ethnicity was statistically significant [Chi square 41.943, df 3, sig <.000]. (Table 3.9) This is not surprising in view of the higher number of white women using heroin. Of those women who reported injecting outside prison, 90% were injecting heroin. Sixty-three per cent only injected heroin, but 10 % reported injecting both heroin and crack, and 10% both heroin and amphetamines. A small number injected heroin along with cocaine or a tranquilliser. Six women (7%) reported injecting amphetamines only.

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Table 3.9 Reported injecting drugs White Black/mixed race Total

Women: prevalence of injecting drug use by ethnicity Never injected 106 (56%) 101 (92%) 207 (69%) Injected in prison only 3 (2%) 0 3 (1%) Injected outside only 77 (41%) 9 (8%) 86 (29%) Injected both in prison and outside 3 (2%) 0 3 (1%)

Twenty-four white women (13%) reported injecting while sharing needles or syringes, compared with only one black/mixed race respondent. Twenty of the 25 reported that their injecting while sharing equipment was outside prison only. Drug and alcohol use in prison Only 8 women (3%) reported drinking alcohol in prison. The main drugs which women reported using in prison were heroin (27%), cannabis (21%) and tranquillisers (17%). Methadone use was reported by 22% but this included some prescribed use. Use of other opiates (including those prescribed) was reported by 12%. Other drugs were each used by 1% or fewer. (Table 3.10)
Table 3.10 Women: number of women reporting drug use in prison N (%) 82 (27%) 65 (22%) 64 (21%) 50 (17%) 26 (9%)

Heroin Methadone (including some prescribed use) Cannabis Tranquillisers Crack

Ninety-one women (30%) said they were no longer using drugs at all in prison, with a further 6 reporting that they had stopped using a specific drug inside. 66 women (22%) stated that their drug use inside prison was less or much less than outside prison. Those women continuing to take drugs in prison reported less frequent use of specific drugs in prison than in the 12 months before prison. In particular there was a marked reduction in reported daily use of heroin and crack cocaine. (Table 3.11) Changes in method and type of drug in prison, compared with outside, were also reported by a small number of women. Nine (3%) said they had stopped injecting, changing to oral or smoking methods. Eight (3%) appeared to have changed from other drugs to using heroin, though only 5 referred to this as their first use of heroin. Ninety-seven women (32%) said they were currently on a Voluntary Testing Unit (VTU) or a drug-free wing. 52 (54%) of the women on VTU/drug-free wings were drug dependent prior to prison, and 35% of all drug dependent women were currently on a VTU or drug-free wing. A further 35 women (12%) were waiting for a place and 11(4%) had been on a VTU or drugfree wing previously in their sentence.

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Table 3.11

Women: prevalence and frequency of reported drug use prison by drug type. Every day Weekly /several days per week 19 (7%) 8 (3%) 8 (3%) 25 (9%) 11 (4%) 33 (15%) 7 (2%) 19 (7%) 1 (<1%) 10 (4%) 0 18 (6%) Monthly 10 (3%) 1 (<1%) 2 (1%) 1 (<1%) 12 (4%) 10 (3%) 7 (2%) 7 (2%) 3 (1%) 4 (1% ) 1 (<1%) 8 (3%) Once/ occasionally 50 (17%) 8 (3%) 16 (5%) 15 (5%) 41 (14%) 26 (9%) 10 (3%) 19 (6%) 8 (3%) 8 (3%) 3 (1%) 12 (4%)

Heroin: In prison Outside Crack cocaine: In prison Outside Cannabis: In prison Outside Tranquillisers In prison Outside Methadone In prison Outside Amphetamines In prison Outside

1 (<1%) 115 (38%) 0 89 (30%) 0 88 (29%) 20 (7%) 52 (17%) 12 (4%) 42 (14%) 0 16 (5%)

Treatment for alcohol and drugs problems Initial healthcare assessment Women were asked to recall what assessment and/or treatment they had received for alcohol or drugs when they first arrived in prison at the start of their current sentence. Almost all reported receiving a healthcare assessment although less than half of these reported some immediate action being taken for alcohol or drugs. Table 3.12 shows that a quarter said they had been prescribed drug-related medication but few reported receiving direct referral to CARAT workers at this stage. Fifty per cent of white women reported that the doctor took direct action for alcohol or drugs, compared with 20% of black/mixed race women, as would be predicted by the white womens higher rates of substance misuse and dependence. White women were also more often prescribed drug-related medication on admission (36% compared with 10%), and were more often referred directly to detoxification (19 % compared with 9%), reflecting the higher incidence of heroin dependence among the white women.
Table 3.12 Women: reported drug interventions received on arrival at prison. N (%) 277 (92%) 116 (39%) 22 (7%) 79 (26%) 46 (15%)

Given healthcare assessment Immediate action taken re alcohol or drugs Direct referral to CARAT worker Prescribed drug-related medication Referred to detox unit

Further details were given by some women on their experiences of the initial treatment and/or detoxification regime. Eighteen women described being prescribed DF118s for opiate withdrawal, although this varied from 5 days in one prison to 9 days in another. Eight reported being prescribed methadone, which in three cases was combined with valium. One woman was transferred from methadone to valium because of pregnancy. In addition, 5 women were prescribed valium alone or in combination with painkillers or sleeping tablets. Some women said that at the initial assessment they had not wanted to admit to using drugs

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because they felt it would lead to greater surveillance. For example one black woman said she was too scared to ask for help because she would be watched more closely by staff. Alcohol treatment needs and experiences Thirty-four per cent of the sample were rated as having harmful levels of drinking alcohol (see above), yet only 10% of the women said that they would have liked help for drink problems in the 12 months before coming to prison. Nineteen women (6%) said they had received help for alcohol problems while in prison. This included 16 white women (8.5%) and 3 black/mixed race women (3%). The most common form of help reported was attendance at self-help groups but even this was only reported by 4% of women, and most said they did not need help for alcohol in prison (see Table 3.13).
Table 3.13 Women: reported help received in prison for alcohol problems. N (%) 5 (2%) 2 (<1%) 2 (<1%) 0 3 (1%) 12 (4%) 3 (1%)

Advice, education, information Assessment, referral to specialist services Alcohol detoxification Help cutting down, relapse prevention Help giving up alcohol altogether Self-help groups Residential rehabilitation, planning placement

Thirty-two women (11% of the total sample) said they needed further help for drinking problems, either inside or outside prison. When asked for details, 12 said they needed support and/or counselling, both inside and outside prison. Three referred to Alcoholics Anonymous groups or other group-based courses in prison as useful (one suggesting it should be more than once per week) and 3 women said they needed a residential rehabilitation programme when they left prison. The overall picture is that few women perceived themselves as needing help for alcohol misuse, even when their level of consumption was above the threshold for harmful or hazardous drinking. Instead, heavy drinking was seen as a legitimate way of coping with depression or stressful life events or blocking out painful thoughts and feelings. Drug treatment: needs and experiences Treatment for drugs 12 months before prison. One hundred and forty-five women (48% of the total sample and 87% of drug dependent women) said that in the 12 months before prison they would have liked some help with drugs. This proportion was the same for white and black/mixed race women. The types of help drug-dependent women said they would have liked were counselling (23%), help cutting down (19%), help giving up (19%) and residential treatment/rehabilitation (17%). Table 3.14 shows that during that time period, 26% of drug-dependent women reported that they had received medication and 20% of drug-dependent women said they had received counselling. A higher proportion of white women than black/mixed race women received reduction detoxification (31% compared with 12.5%) and needle exchange (11% compared with 3%) reflecting white womens greater use of heroin. Forty-two women specified outside agencies that they had been in contact with before coming into prison, including community drug teams, clinics, and drop-in centres. In addition 7 said they had received help from a drugs counsellor, 6 from their GP and 4 from a probation officer or social worker.

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Table 3.14

Women: reported drug interventions needed / received in 12 months before prison by drug dependent women prison. Help needed 24 (16%) 52 (35%) 61 (41%) 40 (27%) 20 (13.5%) 51 (34.5%) 10 (7%) 5 (3%) 49 (33%) 14 (9.5%) Help received 12 (8 %) 5 (3%) 29 (20%) 22 (15 %) 39 (26%) 4 (2%) 7 (5%) 4 (2%) 13 (9%) 26 (17%)

Education/advice/information Help in cutting down Counselling Reduction detoxification Maintenance medication Help giving up drugs Narcotics Anonymous Therapeutic community Residential treatment/rehabilitation Needle exchange

Treatment for drug problems in prison. One hundred and twenty women (40% of the total sample) reported receiving help for drugs in prison. Of the drug-dependent women, 105 (71%) reported receiving help or treatment for drugs. The proportion of drug-dependent women receiving help was higher for white women (76%) than for black/mixed race women (53%), and this association between ethnicity and help received was just statistically significant [chi square 6.300, df 2, p.043]. In particular, a higher proportion of white women received opioid detoxification in prison, and a slightly higher proportion received counselling. Six women (5 white and 1 black/mixed race) described receiving help through attending drug awareness courses in prison, 5 of whom were drug dependent. Five said that they had been helped by probation workers and two referred to receiving help from prison officers (see Table 3.15.)
Table 3.15 Women: reported drug interventions received in current prison by drug-dependent women. White N (%) 42 (36%) 24 (21%) 33 (28%) 17 (15%) 7 (6%) 5 (4%) 1 (<1%) 5 (4%) 4 (3%) Black/mixed N (%) 11 (34%) 5 (16%) 4 (12.5%) 0 2 (6%) 1 (3%) 1 (3%) 0 1 (3%) Total N (%) 53 (36%) 29 (20%) 37 (25%) 17 (11.5%) 9 (6%) 6 (4%) 2 (1%) 5 (3%) 5 (3%)

Education/advice/CARAT Counselling Opiod detoxification Maintenance medication Methadone reduction Therapeutic community Rehabilitation programme Referral to community service Drug awareness/relapse courses

Six women expressed dissatisfaction with detoxification, for example commenting that one week was not enough, or stating that they had only received valium. Four were critical of the CARAT service, either because of long waiting lists or inappropriate advice. Six women (4 white and 2 black/mixed-race) noted that they had been prescribed tranquillisers to help them cope with drug withdrawal, although 2 of these women were not assessed as drug-dependent. When asked whether they needed further help for drugs, inside or outside prison 111 (37%) said yes (45% of white women and 22.5% black/mixed race women). Suggestions made by the women for further help in prison focussed on detoxification and medication issues, and on the desire for some form of counselling or support. Twenty-six women (including 5 black/mixed race women) said they would like more counselling or someone to talk to, particularly individually tailored help. Ten women, of whom half were black/mixed race, wanted further help specifically from the CARATs service or were waiting for a CARATs appointment. Six women identified a need for better detoxification, including 3 who said

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there should be post-detoxification provision, as in Holloway prison. Better medication for women coming off crack was requested by 4 women, all white. Thirty-three women (including 5 black/mixed race women) said they would like further counselling or support for drugs when outside prison. 13 (5 black/mixed race) referred to needing further help from drug services, including day centres, drug projects and throughcare, while 17 (4 black/mixed race) referred specifically to the need for rehabilitation, including residential rehab. An additional issue, raised spontaneously by 6 white women and 2 black/mixed race women, was the need for help in finding accommodation, particularly in a different, drug-free environment. The women were also asked if there was anything else that would help people remain drugfree in prison. Fifteen (including 6 black/mixed race women) referred to counselling, support, and having someone to talk to. Thirteen emphasised the need to restrict supply by stopping people bringing drugs in (5 of these comments came from non-dependent women). Ten women (8 of whom were drug dependent) wanted greater use of drug-free wings while 5 dependent and 2 non-dependent women called for more frequent drug testing. Six women suggested that more activities would help to distract them from thinking about drugs, for example more time spent outside or in the gym, or opportunities for more enjoyable work.

Prevalence and management of substance misuse: findings from the qualitative investigation
In line with the quantitative findings, practitioners reported a high prevalence of drug and alcohol use among women on admission to prison. The majority of women referred to the detoxification programme at the local prison participating in the qualitative study were said to be using between six and nine substances. The prevalence of dependence was also reported as high: 50% of admissions to this particular establishment were reported to require detoxification from one or more substances. The most problematic illicit drugs were stated to be heroin, methadone, crack cocaine, and benzodiazepines. It was reported that over 70% of women admitted to the detoxification programme were injectors. Fifty per cent of women were reported as dependent on alcohol; the majority of these women were said to also be dependent on other substances. Practitioners commented on perceived differences in patterns of use between the female and male estates. The large majority of women prisoners with drug issues were considered by practitioners to be particularly complicated, hard-core, end-stage drug users. In contrast they perceived drug use among male prisoners to be more diverse, ranging from the recreational use of cannabis through to dependent poly-substance use. Participants also commented on differences by ethnicity. Most significantly, heroin use and injecting were said to be less prevalent among black British, Caribbean and African women. This difference was attributed to the greater stigma attached to these forms of drug use within black cultures. Drug and alcohol use in prison Participants reported that while some women choose to address their drug use while in prison, others continue their use. Drugs were said to be available to and used by women on wings throughout both local and training prisons. However, the pattern of womens use was said to change when they come into prison. Participants reported that women tended to use drugs less frequently, to use smaller quantities, and in some instances to avoid the use of drugs (notably cannabis) that would increase the risk of a positive MDT/VDT result. These changes were attributed to the reduction in the supply available as well as to MDTs/VDTs and prison security more generally.

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A number of reasons were given for womens continued drug use in prison, two of which centred on the nature of their current situation. First, it was emphasised that abstinence in prison is enforced rather than chosen; those not motivated to abstain may continue using drugs when presented with opportunities to do so. Second, imprisonment was said to be a particularly stressful experience for many women; those who dealt with stress in the community with the aid of drugs were seen as likely to resort to this coping mechanism in prison. Other contributory factors suggested by participants were peer influence and peer pressure, and the widespread availability of drugs. Drug use in prison was reported to cause several problems. The supply of drugs was linked with bullying; it was stated that in some instances prisoners were coerced to either bring drugs or arrange for drugs to be brought into prison. Further, the prevalence of use was said to render abstinence difficult to maintain for those who wished not to use. Treatment for drugs and alcohol The CARAT Service comprises the lynchpin of drug treatment services in prison. Participants reported that CARAT workers operate proactively to elicit self-referrals from prisoners and referrals from members of staff. Generally, women were seen as willing to access drug treatment services, particularly if they require detoxification from opiates. However, it was noted that some primary carers might not disclose their status as a drug user because they fear the loss of their children. One participant felt women might be less likely to disclose drug use because of the greater stigma society attaches to womens use. However, the majority felt that this did not seem an issue for the women they encountered, in the prison environment at least. Participants reported many examples of best practice within specific services and establishments. However, all reported a shortfall in the availability and accessibility of substance misuse treatment services for women. In particular, participants identified the need for the development of treatment options for alcohol misuse. A lack of consistency across the womens estate was noted; services and interventions available in some establishments are not available in others. With respect to training prisons, a number of participants stated that formal detoxification programmes are needed; it could not be assumed that women admitted to trainers (training prisons) do not require detoxification. Further, it was stated that there is a large discrepancy between womens demand for rehabilitation programmes in prison and the availability of these interventions. Reports of understaffing and under-resourcing were made in relation to a range of services. These issues were seen to relate particularly to the CARAT service. Many of the consequences of the reported shortfall in staff and funding apply across the prison estate; these will be dealt with elsewhere. However, participants also noted differential consequences for delivering the CARAT service to women. Specifically, a number indicated that the quality of relationships with practitioners might be especially important to women prisoners, thereby increasing the need for CARAT workers to spend time developing relationships with service users. It was also noted that women tend to be less willing than men are to access interventions delivered in a group setting. This suggests that one-to-one sessions may be a particularly significant component of effective service provision to women. Clearly, one-toone sessions are costly in terms of practitioners time; thus, the level of staffing within CARAT teams may be seen to impact directly on their capacity to offer one-to-one sessions among their services.

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Demographic and social factors associated with substance misuse

Current and previous offences Table 3.16 shows that amongst the women interviewed, a charge or conviction for either a drugs or a property offence was most often reported.
Table 3.16 Women: current offence N (%) 59 (20%) 43 (14%) 31 (10%) 28 (9%) 21 (7%) 18 (6%) 16 (5%) 14 (5%) 10 (3%) 7 (2%) 6 (2%)

Supplying drugs Importing drugs Robbery Theft or handling stolen goods Burglary Fraud or forgery Murder Possession of drugs GBH Arson ABH All other offences were = or < 1%

Drug users and those dependent on drugs were most likely to have a current offence of possession or supply of drugs, whereas non-drug users and non-dependent women were most likely to have a current offence of importing drugs. Thirty-one of women who were dependent on drugs had a current offence of possession or supply, and 24% had a current offence of robbery or burglary. The most common current offence for non-dependent women was importing drugs (26%), followed by possession/supplying drugs (18%). (See Table 3.17 / 3.18.)
Table 3.17 Women: current drugs offence by drug use / dependency status. Drug users (N=217) 50 (23%) 11 (5%) 19 (9%) 80 (37%) Non users (N = 82) 9 (11%) 3 (4%) 24 (29%) 36 (44%) Dependent (N = 147) 37 (20%) 9 (6%) 4 (3%) 50 (34%) Not dependent (N = 152) 22 (14%) 5 (3%) 39 (26%) 66 (43%)

Supplying drugs Possession of drugs Importing drugs Total drugs offences Table 3.18

Women: current property offence by drug use / dependency status. Drug users (N=217) 25 (11%) 19 (9%) 25 (11%) 1 (<1%) 70 (32%) Non users (N = 82) 3 (4%) 2 (2%) 6 (7%) 6 (7%) 17 (21%) Dependent (N = 147) 23 (16%) 18 (12%) 18 (12%) 0 59 (40%) Not dependent (N = 152) 5 (3%) 3 (2%) 13 (8.5%) 7 (5%) 28 (18%)

Theft, handling Burglary Robbery Arson Total

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Table 3.19

Women: current violent offence by drug use / dependency status. Drug users (N=217) 3 (1%) 13 (6%) 12 (5%) 3 (1%) 1 (<1%) 32 (15%) Non users (N = 82) 3 (4%) 3 (4%) 5 (6% 1 (1%) 2 (2%) 14 (17%) Dependent (N = 147) 2 (1%) 6 (4%) 7 (5%) 1 (<1%) 3 (2%) 19 (13%) Not dependent (N = 152) 4 (3%) 10 (7%) 10 (7%) 3 (2%) 0 27 (18%)

Assault GBH, ABH Murder/attempt Manslaughter Section 18 Total

There was no clear association between harmful drinking/non-harmful drinking and number of previous convictions. However, women who had used drugs in the previous 12 months, particularly those rated as dependent on drugs, appeared to have a greater number of previous convictions than non-drug users.
Table 3.20 Women: previous convictions, by substance misuse Mean (st dev) Previous convictions 12.95 (22.34) 11.81 (23.20) 15.08 (22.37) 4.70 (22.61) 18.96 (24.51) 5.75 (19.17) Median 4 2 6 0 10 0

Harmful drinking: Yes Harmful drinking: No Drug use in 12 months prior to prison No drug use in 12 months prior to prison Drug dependence: Yes Drug dependence: No

Education Table 3.21 shows that 192 (64%) of the women interviewed had left school with no educational qualifications at all, while 30% had achieved one or more pass at GCSE/CSE/O level. Seventy-six per cent of women who were rated as drug dependent had left school without qualifications, compared with 52% of those who were not dependent on drugs. The association between drug dependence and level of qualifications was highly significant [chi square 20.464m, df 3, p .0000].
Table 3.21 Women: qualifications when left school by drug dependency status. Not dependent on drugs 80 (52%) 59 (38%) 9 (6%) 6 (4%) Dependent on any drug 112 (76%) 31 (21%) 3(2%) 1 (<1%) All women 192 (64%) 90 (30%) 12 (4%) 7 (2%)

None GCSE/CSE/O level A level Other / NVQ etc

Truancy. Two hundred and three women (68%) reported having played truant from school, either occasionally (31%) or regularly (37%). There was a significant association between dependence on drugs and reported truancy [chi square23.320, df 2, p .000], with 48% of drugdependent women reporting regular truancy from school, compared with 27% of non drugdependent women. Use of any drug in the 12 months before prison was also associated with reported truancy [chi square 27.756, df 2, p. 000]. Harmful drinkers had higher rates of reported truancy than non-harmful/non-drinkers, but there was no statistically significant association between truancy and harmful drinking (see Table 3.22.).

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Table 3.22

Women: reported history of truancy from school and drug use / dependency / harmful alcohol use status. Drug dependent Yes No 29 (20%) 68 (44%) 48 (33%) 70 (48%) 44 29%) 41 (27%) Drug users Yes No 53(24%) 44 (53%) 67 (31%) 97 (45%) 25 (30%) 14 (17%) Harmful drinkers Yes No 24(24%) 73 (37%) 30 (29%) 48 (47%) 62 (31%) 63 (32%)

Never 97 (32%) Occasionally 92 (31%) Regularly 111 (37%)

Rates of truancy were significantly associated with ethnicity [chi square 21.657, df=2, p< .001], with more white women reporting truancy (72%) than black/mixed race women (60%). Twenty-three per cent of the sample reported drinking alcohol whilst playing truant, 21% reported taking drugs whilst playing truant, and 20% said they had committed an offence while playing truant. Exclusion from school. Table 3.23 shows that 108 women (36%) said they had been excluded from school at some time. This rate was slightly higher for black/mixed race women (39%) than for white women (34%) although the association between ethnicity and exclusion was not statistically significant. Rates of exclusion were higher for women who were dependent on drugs and for women who had used drugs in the 12 months before prison. The association between exclusion and dependence was highly significant [chi square 20.464, df 3, p<.001].
Table 3.23 Women: reported history of school exclusion and drug use / dependency / harmful alcohol use status. N (%) 98 (45%) 10 (12%) 70 (48%) 38 (25%) 43 (42%) 65 (33%) 108 (36%)

Drug users Non-drug users Drug dependent Non dependent Harmful drinkers Not harmful drinkers Total sample

Fifty-four (18%) said they had been excluded for violence or aggression. Very few women said they had been excluded for taking drugs (2%) or drinking alcohol (1%). Thirty (10%) said they had been excluded for disruptive or bad behaviour, including breaches of school rules (for example smoking, swearing, shaving hair). Fourteen (5%) reported that they had been excluded because of repeated truancy. Special needs. Forty-four women (15%) said that while at school they had been assessed as having special educational needs. Forty-three women (14%) stated that they had some current difficulties with reading and/or numbers, while 7 (2%) reported serious difficulties. There was a significant association between drug use in the 12 months before prison and special needs, with 19% women who used drugs having been assessed as having special educational needs, compared with 5% of non drug users [chi square 8.787, df 1, p .003]. Sixty-seven per cent of the women reported receiving some kind of education in prison. This proportion was the same for both white and black/mixed race women.

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Families, children and relationships The majority of women (N=138, 46%) reported that in the 12 months before coming to prison they were living with a partner (male or female), with or without children. Forty-nine (16%) were living with their children but no partner, and 46 (15%) lived with other family members. Forty-seven women (16%) lived alone and 16 (5%) in shared accommodation. Only one woman described herself as homeless. Those women who were living with a partner were asked whether their partner had any problems with alcohol or drugs. Half of the white women with partners said their partner had a drugs problem, compared with just less than a quarter of the black/mixed race women. A quarter of the white women with partners said their partner had alcohol problems, compared with 9% of the black/mixed race women (Table 3.24). There was a significant association between ethnicity and partners drug problems [chi square 15.783, df 1, p.000] and between ethnicity and partners alcohol problems [chi square 8.813, df 1, p.003].
Table 3.24 Women: women living with a partner. White Partner has drugs problems Partner has alcohol problems 67 (50%) 35 (26%) Black/mixed race 17 (22%) 7 (9%) Total 84 (40%) 42 (20%)

The women were also asked whether they thought any members of their family or friends outside prison had problems with alcohol or drug use. Forty-nine women (16%) said that most or all of their family/friends had a problem with alcohol, with similar rates for white women (10.5%) and black/mixed race women (8%). Fifty-nine women (20%) said that most or all of their family/friends had a problem with drugs, with higher rates for white women (22%) than for black/mixed race women (9%). The women were asked whether members of their family or friends had ever been violent towards them. 162 women (54%) reported that family members or friends had been violent to them, with higher rates for white women (62%) than for black/mixed race women (41%). A quarter of women (77, 26%) said that their partner/spouse had been violent towards them, with higher rates for white women (34%) than black/mixed race women (12%). Of those women who had experienced violence, almost half (N=91, 48%) thought that it was related to drug or alcohol use at the time. Although black women overall reported lower rates of family violence, black women with drug dependence had the highest proportion of women reporting violence (Table 3.25). There was a significant association between drug dependence and categories of family violence for black/mixed race women only [chi square 27.262, df 7, p.000].
Table 3.25 Women: women reporting family violence. Drug dependent 74 (63.8%) 22 (69%) Not drug dependent 43 (58%) 23 (29.5%) Total 117 (62%) 45 (41%)

White N=190 Black/mixed N =110

Children. Two hundred and eleven women (70%) said that they had children. Almost half the women had either one or two children (N=138, 46%), 58 women (19%) had three or four children and 15 women (5%) had five or more children. In total, the women had 473 children between them. Only 10 women said that they were responsible for step-children. The women were asked about their childcare arrangements before prison and whilst they were in prison,

23

and were also asked what care arrangements they anticipated once they were released from prison. Details of these arrangements were only recorded for the 360 children who were aged 16 years or under, as older children were more likely to be independent of their parents. Before coming to prison the majority of women (60%) looked after their children at home but one-fifth of children were being looked after by other family members (19%) and almost onefifth of children were in care (17%). Not surprisingly, the number of children living at home whilst their mothers were in prison dropped significantly (6%), whilst the number being looked after by other family members rose (55%). The number of children living with their fathers rose slightly but there was a bigger increase in the number of children going into care (26%). The anticipated care arrangements were very similar to those before the women came to prison although the number of women expecting to live with their children at home was slightly lower. Some women said they were unsure what would happen once they were released from prison (5%).
Table 3.26 Women: care arrangements (all children) Before prison Living at home with parent/s Living with partner (father of child) Living with other family members or friends Living in care/foster home/adopted Living in Mother & Baby Unit at prison Living arrangements unsure/other 215 (60%) 7 (2%) 69 (19%) 61 (17%) 0 3 (1%) At present 22 (6%) 34 (9%) 204 (57%) 92 (26%) 3 (<1%) 2 (<1%) Anticipated care 192 (53%) 9 (3%) 68 (20%) 65 (18%) 0 23 (6%)

Care arrangements for first/only children (child 1) and second children (child 2) were also examined in relation to drug and alcohol use. In relation to their first/only child, women who were drug dependent were less likely than other women to anticipate that they would live with child 1 when released from prison [chi square 4.429, df 1, p .035], more likely to have child 1 living with other family members before prison, [chi square 12.536,df 1, p.000] and more likely to anticipate that child 1 would live with other family members once they were released [chi square 13.390, df 1, p .000].
Table 3.27 Women: care arrangements by mothers drug dependence - child 1 Before prison Child living at home with mother Drug dependent (N = 160) Not dependent (N = 136) Child living with other family members Drug dependent (N = 160) Not dependent (N = 136) Child in care / adopted Drug dependent (N = 160) Not dependent (N = 136) 58 58 32 8 16 7 At present Anticipated care of child on release 45 (28%) 54 (40%) 33 (21%) 8 (6%) 16 (10%) 7 (5%)

6 6 66 49 23 11

Analysis of data for second children showed that women who were drug dependent were more likely than other women to report that their second child was in care before prison [chi square 9.205, df 1, p.002], and during their stay in prison [chi square 7.30, df 1, p.007]. Drug-

24

dependent women were also more likely to anticipate that their second child would be in care after their release from prison [chi square 6.438, df 1, 0.011].
Table 3.28 Women: care arrangements by mothers drug dependence - child 2 Before prison Child living at home with mother Drug dependent N = 162 Not drug dependent N = 136 Child living with other family members Drug dependent N = 162 Not drug dependent N = 136 Child in care/ adopted Drug dependent N = 162 Not dependent N = 136 32 30 12 6 16 2 At present 5 2 27 24 22 6 Anticipated care of child on release 28 (17%) 28 (21%) 9 (6%) 7 (5%) 17 (10%) 4 (3%)

There was no significant association between childcare arrangements and harmful/hazardous drinking. This raises the question of whether drug dependent women are less able to cope with child care responsibilities than women with harmful drinking patterns, or whether the difference is due to greater legal sanctions and social intervention in the lives of women who use illicit drugs. Care arrangements for child 1 and child 2 were also analysed by ethnic group. White women were more likely to report that their first or only child lived with family members and would continue to do so after their release. However this is likely to be explained by the greater proportion of drug-dependent women in the white group. Ethnicity was not associated with any other measure of childcare. The women were also asked directly whether there had ever been a time when they felt unable to look after their children. Twelve women said they had felt unable to care for their children because of alcohol problems, 46 women because of drug problems and 31 women because of mental health problems. Seventy-one women said that alternative care arrangements had been made for their children at this time. Thirty-one of these women said that their children went to live with other family members, 30 reported that their children were taken into care or adopted. The remainder were looked after by their fathers away from home, or by friends. There were no differences in the proportions of women from different ethnic groups who reported being unable to look after their children because of drink, drugs or mental health problems. Families, children and relationships: findings from the qualitative study. Violence and abusive relationships were said to feature in the lives of many drug-using women. Practitioners commented that abuse was often perpetrated by male partners, many of whom were reported to use substances problematically and/or to be offenders. Practitioners also noted that women with drug-using partners often committed acquisitive offences in order to maintain their partners as well as their own drug use. Womens use of drugs and alcohol and their offending was reported to be exacerbated by their relationships with partners. Further, their rehabilitation from substance use and offending was said to be complicated by these relationships. Participants stated that many womens children had been living with parents or other family members, adopted, or living in residential care prior to their imprisonment. Among those women who had been living with their children, there was said to be a fear of intervention by

25

Social Services and of children being taken into local authority care. Practitioners also reported that some women did not access services because of this fear. Further, women who were or had been primary caretakers were said to experience high levels of anxiety and guilt around the care of their children. Several participants stated that greater efforts should be made to enable women prisoners to maintain contact with their children while in custody. Employment Two hundred (66%) of the women interviewed were unemployed immediately before coming into prison. Twenty per cent were employed full-time, with the remaining 14% working parttime or doing casual or occasional work. Fifty-three (18%) had never been employed since leaving school. There was no overall difference in unemployment rates prior to prison between white women (68% unemployed) and black/mixed race women (63% unemployed), although there were differences in the reasons given for unemployment. Table 3.29 shows that the most common reason given for unemployment was the need to look after children, cited by 37% of women. Thirty per cent said they had been unemployed as a result of substance misuse problems, but there was a significant difference between white and black/mixed race women. Thirty-six per cent of white women gave substance misuse as a reason for their unemployment, compared with 18% of black/mixed race women (chi square 10.982, df 2, p.004). Black women were slightly more likely to say they had been unable to find a suitable job (14.5% compared with 8%), but this was not statistically significant. Seventy-three per cent of women who had used any drug in the 12 months before prison were unemployed immediately before coming into prison, as were 78% of drug dependent women. In comparison, 50% of non-drug users and 56% of non-dependent women were unemployed before coming to prison. There was a significant association between drug use and employment status [chi square 15.387, df 3, p.002], and between drug dependence and employment status [chi square17.863, df 3, p.000]. Seventy-four per cent of women who had harmful levels of alcohol consumption were unemployed, although there was no significant overall association between harmful drinking and employment status.
Table 3.29 Women: reasons given for unemployment N (%) 111 (37%) 89 (30%) 42 (14%) 32 (11%) 27 (9%) 20 (7%)

Caring for children Alcohol or drugs problems Not wishing to work Unable to get suitable job Ill health / disability Mental health problems

Mental health
Previous contacts with mental health services outside prison The women were asked whether they had ever visited their GP or any other health professional for emotional or mental health problems. One hundred and seventy-seven women (59%) said that they had visited their GP at some time for emotional or mental health problems, although black/mixed race women were significantly less likely to have visited their GP than white women (47% compared with 66%) [chi square 10.378, df 1, p.001]. Surprisingly the rates of GP attendance for mental health problems were not significantly higher for women with drug dependence (64%) or harmful drinking (62%) than for nondependent women (54%) or non-harmful drinkers (57%).

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The majority of those who had visited their GP for a mental health problem said it was for depression (82%) although 12% of drug dependent women said it was for anxiety, compared with 4% of non drug-dependent women. White women were more likely to have sought help for depression than black women [chi square 5.129, df 1, p.024].
Table 3.30 Women: reason for seeking help from GP White 15 (8%) 101 (53%) 23 (12%) 11 (6%) Black/mixed race 8 (7%) 44 (40%) 8 (7%) 4 (4%) Total 23 (7%) 145 (48%) 31 (10%) 7 (2%) 15 (5%) 35 (11%)

Anxiety Depression Substance misuse Psychosis Self-harm/suicidal thoughts Other

One hundred and twenty-four women (41%) reported that they had sought help from other health professionals outside prison. Forty-two (14%) had seen a counsellor and 69 (23%) had seen a psychiatrist. Black/mixed race women were less likely to have sought help from other professionals, and were particularly less likely to have seen a psychiatrist than white women (14% compared with 28%) [chi square 7.206, df 1, p.007]. Almost half the women (134, 45%) reported that they had been prescribed medication in the 12 months before coming to prison, usually for depression (92 women, 32% of total sample). 69 women (23%) had been admitted to a psychiatric hospital at some time in their lives, the majority on just one occasion. White women were more likely than black/mixed race women to have been prescribed medication (53% compared with 30%) [chi square 15.782, df 1, p.000] and more likely to have been admitted to psychiatric hospital (27% compared with 16%) [chi square 4.319, df 1, p.038]. Contacts with services in prison for mental health problems Table 3.31 shows that 125 women (42%) said that they had sought help while in prison for emotional or mental health problems, usually from the prison doctor or the prison psychiatrist. Black/mixed race women were slightly less likely to have sought help for emotional problems in prison, than white women [chi square 6.181, df 1, p.013] particularly from a psychiatrist [chi square 6.896, df 1. p .009].
Table 3.31 Women: health professionals seen in prison White women Prison doctor Psychiatrist Psychologist Other Total 44 (23%) 32 (17%) 11 (6%) 2 (<1%) 89 (47%) Black/mixed race women 18 (16%) 7 (6%) 5 (4.5%) 6 (5%) 36 (32%) Total 62 (22%) 39 (13%) 16 (5%) 8 (6%) 125 (45%)

Depression was the most common reason for seeking help (62% of those who sought help) but a number of women gave other reasons that were not listed on the questionnaire, for example childhood sexual abuse, not being able to sleep, domestic violence and bereavement. The most common outcome was that women received medication (43% of those who sought help).

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Anxiety and depression in prison Current levels of anxiety and depression were measured using the HADS scale. Thirty-nine per cent of women reported moderate or severe levels of anxiety in the past week, compared with 19% experiencing moderate or severe levels of depression. While completing the HADS a number of women commented that they were more anxious when in prison than outside (Table 3.32).
Table 3.32 Women: prevalence of current anxiety and depression Current depression (HADS scale) Normal Mild depression Moderate depression Severe depression

Current anxiety (HADS scale) Normal Mild anxiety Moderate anxiety Severe anxiety

128 (43%) 52 (17%) 64 (21%) 54 (18%)

200 (67%) 39 (13%) 40 (13%) 19 (6%)

Anxiety levels appear higher for drug-dependent women and those with harmful levels of drinking, although there was a wide range of scores within each group and the differences in mean scores (see below) were not statistically significant. There were also no significant differences in mean scores for depression between drug users and non drug-users, or between harmful and non-harmful drinkers (Table 3.33).
Table 3.33 Women: prevalence of current anxiety and depression by substance misuse status Anxiety score Mean (st.dev) 8.50 (5.80) 9.16 (5.16) 9.41 (4.89) 8.55 (5.73) 9.76 (5.45) 8.57 (5.25) Anxiety Median 9 7 10 7 10 9 Depression Mean(st.dev) 6.38 (4.76) 5.82 (4.82) 5.71 (4.53) 6.23 (5.05) 6.04 (4.81) 5.94 (4.81) Depression Median 4 6 4 5 5 5

Drug user Non-drug user Dependent Non-dependent Harmful drinker Not harmful drinker

Remand prisoners had slightly higher mean scores on anxiety and depression than sentenced prisoners, but these differences in mean scores were not statistically significant. There were no significant differences between white and black/mixed ethnic groups on mean anxiety or depression scores (Table 3.34).
Table 3.34 Women: rating of anxiety and depression by sentence status Anxiety Mean (st dev) 9.86 (5.32) 8.74 (5.33) 8.94 (5.36) 9.04 (5.33) Depression Mean (st dev) 6.95 (5.13) 5.71 (4.69) 5.74 (4.83) 6.38 (4.76)

Remand Sentenced White Black/mixed race

Self-harm and suicide Lifetime self-harm. One hundred and fifty-one women (50.5% of the sample) reported at least one act of self-harm at some time in their lives, with 49 (16%) reporting having harmed themselves 2 to 5 times, and 38 (13%) reporting more than five incidents of self-harm. One hundred and seven women (36% of sample) had harmed themselves through taking an

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overdose, while 66 (22%) had cut themselves. Of those who had self-harmed, 51 (34%) reported starting to self-harm between the ages of 13 and 17. Only six women said they had self-harmed for the first time in prison. There was a significant association between harmful drinking and lifetime self-harm [2 12.862, df = 3, p = 0.005; odds ratio 1.77] (Table 3.35). One hundred and four (55%) of the white women had self-harmed on at least one occasion compared with 47 (43%) of black/mixed race women [odds ratio 1.6]. White women had slightly higher rates of multiple self-harm than black/mixed race women, with 19% white women reporting 2 to 5 incidents of self-harm compared with 12% of black/mixed race women.
Table 3.35 Self-harm (ever) Never Once 2-5 times > 5 times Women: number (%) reporting self-harm, by drug dependence and harmful drinking. Drug dependent 63 (43%) 35 (24%) 31 (21%) 18 (12%) Not dependent 85 (56%) 29 (19%) 18 (12%) 20 (13%) Harmful drinker 41 (40%) 24 (23%) 15 (15%) 22 (22%) Not harmful drinker 107 (54%) 40 (20%) 34 (17%) 16 (8%)

Results of statistical analysis: = 7.31, df = 3, p = 0.62 ( non sig)

2

Results of statistical analysis: 2 = 12.86, df = 3, p=0.005

Lifetime suicide attempts. One hundred and thirty-nine women (47%) said that they had made a suicide attempt in their lifetime. 98 (52%) of white women had made a suicide attempt in their lifetime compared with 41 (38%) of black/mixed race women, and there was a significant association between ethnicity and lifetime suicide attempts [2 = 5.130, df = 1, p = 0.024; odds ratio 1.76]. There was no significant association between drug dependence and suicide attempts in either black or white women. Self-harm and suicide in the past month. The women were also asked about their thoughts and behaviour in the past month concerning self-harm and suicide. Forty-nine women (16%) said they had wanted to harm themselves in the past month. This was most common amongst white women on remand (26%). Forty-six women (15%) said they had thought about attempting suicide in the past month, 26 women (9%) said they had made a suicide plan in the past month and 19 women (6%) reported that they had attempted suicide in the past month. Sixteen of the 19 had been in prison during the whole of that time period. There was a significant association between sentence status and suicide attempts in the past month [2 = 8.193, df = 1, p = 0.004] with 14% of the remand sample reporting a recent suicide attempt compared with 4% of the sentenced women [odds ratio 3.7]. There was no significant association between ethnicity and suicide attempts in the past month. Suicide risk. Current suicide risk was calculated on the basis of thoughts and behaviour during the past month, combined with lifetime attempts at suicide. Forty-one women (14%) were assessed as at high risk of attempting suicide, with a further 12 (4%) at moderate risk. Current suicide risk was not significantly associated with drug dependence or ethnicity. Twenty-one peer cent of women on remand were assessed as high suicide risk, compared with 12% of sentenced women. Self-harm, suicide and experiences of violence. We also investigated associations between reported physical assault (classified as never, experienced, witnessed, or both) and frequency of self-harm (never, once, 2-5 times, >5 times) A significant association was found (2 = 33.727, df = 9, p = 0.000). There was also a significant association between reported sexual assault (never, experienced, witnessed, both) and frequency of self-harm (never, once, 2-5 times, > 5 times) (2 = 42.398, df = 9, p = 0.000). Moreover, a higher proportion of women

29

who had been victims of violence from family or friends reported self-harm [2 = 26.096, df = 3, p = 0.000; odds ratio 3.05] and lifetime suicide attempts [2 = 13.792, df = 1, p = 0.000; odds ratio 2.38]. (Table 3.36). Furthermore, 26 women (19%) who reported family violence were assessed as high suicide risk compared with 9 (7%) of those not reporting family violence. (Table 3.36]
Table 3.36. Women: number (%) reporting self-harm and suicide attempts, by reported violence from family/friends. No violence from family or Violence from family or friends ( N = 139) friends (N = 162) Yes : 50 (36%) Yes: 86 (53%) No : 87 (63%) No: 49 (30%) 28 (20%) 30 (22%) 11 (8%) 34 (25%) 11 (8%) 22 (16%) 2 = 26.096, df = 3, p = 0.000 47 (35%) 77 (57%) 2 = 13.792, df = 1, p= 0.000

Reported self-harm and suicide attempts Self-harm ever? Self-harm: once Self-harm: 2-5 times Self-harm: > 5 times Results of statistical analysis: Lifetime suicide attempt Results of statistical analysis:

The association between family violence and self-harm was found for both white and black/mixed race women. However, analysis of the data suggested possible three-way associations, in that family violence appeared to be associated with drug dependence for black women [2 = 19.077, df = 1, p = 0.000] but not for white women, and drug dependence appeared to be associated with self-harm for black/mixed women [2 = 15.642, df = 3, p = 0.001] but not for white women (Table 3.37).
Table 3.37 Number (%) of women reporting self-harm, by ethnicity and drug dependence Black/mixed race Drug dependent Not dependent 7 (22%) 14 (18%) 8 (25%) 5 (6.5%) 7 (22%) 6 (8%) 22 (69%) 25 (32.5%) 2 =15.642, df =3, p = 0.001 White Drug dependent Not dependent 28 (24%) 15 (20%) 23 (20%) 13 (18%) 11 (9.5%) 14 (19%) 62 (53.5%) 42 (57%) 2=3.587, df =3, p= 0.310

Reported self-harm Self-harm: once Self-harm: 2-5 times Self-harm: > 5 times Total self-harm (ever) Results of statistical analysis

In order to examine these possible three-way associations, a log-linear analysis was conducted for the variables ethnicity, family violence, drug dependence and self-harm. Prior to analysis, results on the self-harm variable were collapsed into two categories: some self-harm (once, 25 times, >5 times) and no self harm (never), in order to ensure adequate expected values within each cell of the cross-classified data. Due to the nature of log-linear analysis, all cases with missing values on any of these variables were excluded, so the analyses are based on a sample size n = 272. The results of the log linear analysis provided tentative support for the association between ethnicity, dependence and self-harm, but the possibility that drug dependence may be an important risk factor for self-harm in black women requires further investigation. Stressful life events

30

The women were shown a list of stressful life events and asked to indicate whether or not they had ever experienced or witnessed any of the events. Almost three-quarters of women (N=213, 71%) said that they had been physically assaulted and 126 women (42%) said they had witnessed someone else being assaulted. Nearly half the women (N=128, 43%) said they had been sexually assaulted and 73 women (24%) said that they had had other unwanted sexual experiences. White women were slightly more likely to have experienced physical assault than black women (76% compared with 62%), but there was no association between ethnicity and other stressful events. (See Table 3.38.)
Table 3.38 Women: reported experience of stressful events N (%) 213 (71%) 128 (43%) 73 (24%) 60 (20%) 89 (30%) 221 (73%) 52 (17%)

Physical assault Sexual assault Other unwanted sexual experience Life-threatening illness or injury Witnessed homicide/suicide Sudden death of someone close Serious injury, harm, death caused by you to someone else

These experiences were also examined in terms of drug and alcohol use. There were significant associations between experiencing or witnessing a physical assault and all three of the substance misuse variables: reported drug use before prison [chi square16.865, df 3, p.001], dependence on one or more drugs during this time [12.886, df 3, p.005], and harmful use of alcohol [chi square 10.157, df 3, p.017]. Other unwanted sexual experiences (excluding sexual assault) were associated with both drug dependence [chi square8.233, df 3, p.041] and harmful use of alcohol [chi square 11.492, df 3, p.009] during the 12 months before coming to prison. Causing serious harm or death to someone else was significantly associated with harmful drinking [chi square 8.287, df 3, p.040]. Psychotic experiences The presence of any psychotic symptoms was measured using the MINI, which was adapted for the purposes of the study. The first three questions were used as screening questions. Sixty-five women (22%) reported that they had experienced one or more psychotic symptom in their lifetime and 38 (57%) of these women said that they had been using drugs or alcohol at the time (Table 3.39). There was an association between reported psychotic symptoms and reported drug use in the 12 months before prison [chi square 3.973, df 1, p.046] and also between psychotic symptoms and drug dependence [chi square 4.270, df 1, p.039]. No significant relationship was found between the presence of psychotic symptoms and ethnicity, or between psychotic symptoms and the harmful use of alcohol. Manic episodes Women were also asked about experiences of feeling high, or unusually full of energy, using the first screening question for manic episodes from the MINI. However, unlike the MINI standard format they were not told to exclude episodes when intoxicated by drugs or alcohol. Eighty-three women (23%) reported that they had experienced this kind of episode (30% of white women and 24% of black/mixed race women) and 11% attributed it to use of alcohol or drugs. There was no significant association between manic episodes and ethnicity.

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Table 3.39

Women: reported psychotic experiences Total sample Drug users 13 (6%) 22 (10%) 43 (20%) 41 (19%) 19 (9%) 30 (14%) 32 (15%) 37 (14%) Non drug users 2 (2%) 3 (4%) 8 (10%) 4 (5%) 3 (4%) 2 (2%) 6 (7%) 1 (1%)

Have you ever believed you were being sent special messages through TV/radio/newspaper? Have you ever believed you or some force outside yourself put thoughts in your mind? Have you ever heard things other people couldnt hear, such as voices? Have you ever believed people were spying on you/plotting against you? Have you ever believed that someone was reading your mind / could hear your thoughts? Have your friends or relatives ever considered any of your beliefs strange or unusual? Have you ever had visions when you were awake or ever seen things other people couldnt see? Were you using drugs or alcohol at the time you had any of these experiences?

15 (5%) 25 (8%) 51 (17%) 45 (15%) 22 (7%) 32 (11%) 38 (13%) 38 (13%)

Thirty-two per cent of drug users and 37% of drug dependent women reported an episode of this kind. The association between drug dependence and manic experiences was highly significant (chi square 12.682, df 1, p.000) and there was also a significant association with drug use (chi square 6.541, df 1, p.011). However there was no association at all between harmful drinking and reported manic experiences. Fourteen per cent of drug users and 20% of drug-dependent women attributed their experience to using drugs or alcohol. Mental health: findings from the qualitative study In accord with the quantitative findings, practitioners reported a high prevalence of mental health problems among women prisoners both with and without drug issues. The symptoms displayed by the large majority of women were said to be those of affective rather than psychotic disorders. Factors contributing to psychiatric disorders among substance using women were discussed. It was suggested that in some instances symptoms might be induced by the effects of or withdrawal from particular substances. Separation from children and anxiety around childcare arrangements were seen as contributing significantly to the incidence of affective disorders. The prison environment and key events and stages in womens custodial term were also seen as key contributory factors. The presence of co-morbidity was reported to complicate recovery from drug and alcohol use both in prison and in the community. Women with mental health issues were seen as more likely to both continue using substances and relapse following a period of abstinence. These womens use was often presented as self-medication, motivated by the desire to relieve anxiety, depression, and other negative emotional states. It was also noted by practitioners that the risk of suicide increases when women become drug free. Several participants commented that services in both prison and the community were not seen as set up to deal adequately with co-morbidity. One participant reported knowledge of women being persuaded to come off benzodiazepines, anti-psychotics and/or anti-depressants prematurely in order to access rehabilitation services. More effective diagnosis of psychiatric disorders was seen as vital, as was the provision of drug treatment services able to cater for women with concurrent mental health problems. These needs were linked with the more

32

general need for better mental health services within prisons, and for joint working between substance misuse and mental health services.

Physical health
Health perceptions and reported illness The interview also contained questions about physical health, with specific reference to illnesses related to alcohol and drug use. Firstly the women were asked to describe how they felt at the present time. One hundred and fifteen women (38%) described their health as poor to fair, 117 (39%) as good and 67 (22%) as very good to excellent. Responses to General Health Perception items from the SF36 (Short Form 36 item Health Survey) indicated that 64% perceived their health to be as good as anyone elses, and 53% agreed with the statement my health is excellent. Women who were drug dependent or reported harmful drinking did not perceive their physical health as any worse than women without a history of drugs or alcohol misuse. There were no differences between ethnic groups in subjective perception of physical health. The women were then asked whether they had ever had any of the following illnesses: TB, hepatitis, epilepsy, diabetes, sexually transmitted diseases or HIV/AIDS. Nine per cent of women had contracted hepatitis at some time, with higher rates for drug users (12%), women with harmful drinking (13%), drug-dependent women (14%) and especially women who injected drugs (23%). Epilepsy and diabetes were more common in women who injected drugs (Table 3.40).
Table 3.40 TB Hepatitis Women: prevalence of physical health problems 3% (n=8) total sample 9% (n=28) total sample 13% harmful drinkers 14% drug dependent 23% drug injectors 5% (n=14) total sample 9% drug injectors 2% (n=7) total sample 5% drug injectors 12% (n=37) total sample

Epilepsy Diabetes STD

Women also had the opportunity to describe other illnesses or health problems they had experienced while in prison. One hundred and twenty-four women (41%) identified one additional healthcare problem. 68 (23%) said they had received treatment for this problem in prison although only 29 (10%) reported being satisfied with the treatment received. Thirtyfour women (11%) identified a second healthcare problem, of whom 22 had received treatment. Ten (2%) were satisfied with the management of their second problem. The most common cause of dissatisfaction was the length of time to see the doctor or to receive treatment, especially medication (N=38). For example one woman reported waiting nine months to see the dentist and another said that she waited 18 days for an X-ray. Fifteen women said that they were not prescribed the right kind of medication when they were ill and 12 reported that painkillers, e.g. paracetemol, were inappropriately prescribed for a wide range of serious conditions. Eight women commented that healthcare staff were often

33

unsympathetic, did not take their condition seriously, and that they didnt receive the same level of care or respect from staff as they would outside prison. Two women who were pregnant felt that their condition wasnt being monitored as carefully as it should be and three women who were having abortions complained that appointments were often cancelled, that there was a general lack of information and that staff did not support them. Some women said that they would not even visit the doctor if they were ill because they believed they would not receive the right treatment. Physical health: findings from the qualitative study Participants reported a wide range of health issues among women prisoners. On admission to the local prison, poor physical health was said to be the norm among women using illicit drugs. Practitioners noted that women present with a number of physical problems caused directly by substance use. Abscesses, deep vein thrombosis, HIV and hepatitis C were noted in relation to injecting. Participants emphasised the importance of providing women with harm minimisation information around injecting and sexual practices. A high incidence of asthma and epilepsy was noted among substance-using women; both of these conditions were said to complicate the process of detoxification. Difficulties were reported to arise in relation to pregnancy and childbirth. Pregnancy was said to complicate detoxification, while womens use of benzodiazepines was said to complicate delivery.

Illustrative cases
Four cases were selected to illustrate the varied needs of women in prison with substancemisuse treatment problems. These cases are not representative in any statistical sense, but are included as examples of women whose substance misuse is part of a wider picture of social and psychological difficulties. Case A Case A is a white woman, 38 years old, serving a 4 year sentence for supplying class A drugs. She left school at 16 years old with two O levels and started taking a number of drugs, including crack cocaine. She tried to commit suicide when she was 16 and has experienced a number of stressful life events including physical and sexual assault. She started using heroin intravenously when she was 28 years old and in the 12 months before coming to prison she was dependent on heroin, crack cocaine, cocaine powder and amphetamines. She was also drinking alcohol at a harmful/hazardous level. Her two children live with their father because she feels unable to look after them. In the year before coming to prison she would have liked help for drug problems, for example counselling and medication, but she received no help. In prison she received maintenance medication, counselling and support from CARATs and was also prescribed antidepressants. She says she would have liked more support following detox and would like more rehabilitation. She says that she has massively reduced her drug use in prison although she currently uses heroin on a weekly basis and smokes cannabis occasionally. She does not inject heroin in prison. She suggests that more testing would help her remain drug-free; she is not on a VTU or drug free wing. Case B Case B is a white woman, 46 years old, serving 14 months for shoplifting. She started taking drugs when she was 13 years old, and was expelled from school aged 15 for taking LSD despite achieving 10 O levels. She has experienced a number of stressful life events including physical and sexual assault. When she was 16 she started taking heroin, which she injected outside prison only. She has used a number of different drugs and in the year before coming to prison was dependent on heroin, crack and benzodiazapines. She says that she was spending between 1,500 and 3,000 per week on drugs during this time. She received maintenance medication before coming to prison and again once inside prison, but has not

34

received any advice, counselling or rehabilitation. She says she has experienced some psychotic symptoms in the past, which she attributes to cocaine use, and currently suffers from severe anxiety and epilepsy. She has not used any drugs since she came to prison. Because of her drug problems her younger daughter is being adopted. She is concerned about delays in getting correct prescriptions from outside prison, particularly for benzodiazapines. She believes that she has to help herself, but would like to distract herself from drug use, for example by being able to spend more time in the gym. Case C Case C is a black woman, 25 years old, convicted of robbery. She left school when she was 13 years old with no qualifications. In the 12 months before coming to prison she says she drank up to ten units of alcohol per day. She started smoking cannabis when she was eleven and started using ecstasy when she was fifteen. When she was nineteen she started using crack cocaine and in the 12 months before coming to prison was using it every day in conjunction with alcohol. She uses alcohol to come down off crack. She estimates that she was spending 5000 per week on drugs at this time. She says that although she would have liked help for drug problems before coming to prison she didnt receive any help until she came to prison where she received advice from the CARAT team. However, she felt that crack users didnt really get the help they needed in prison and that the only real help available was for heroin users. She also complained that the courses available werent sufficient and needed to be followed up, and that more help is needed for people on remand. She would like to do a 12-step programme. Whilst in prison she continues to use crack cocaine several days per week. She is on a waiting list to see a counsellor and is worried about her physical health. Case D Case D is a mixed race woman, 26 years old, remanded in custody for armed robbery, false imprisonment and possession of firearms. She left school when she was 17 years old and has a diploma in Business and Finance. In the 12 months before coming to prison she was drinking heavily on a regular basis, especially when depressed or bored. She started using crack cocaine when she was 22 and tried heroin at age 25. In the year before coming to prison she was dependent on crack cocaine and amphetamines and was using these drugs every day, but she had stopped using heroin. Before coming to prison she received an alcohol detox but would also have liked a referral to specialist services for her drinking. She does not think she needs any further help for drinking, in prison or outside. She says that in the 12 months before prison she would have liked help giving up drugs, a reduction detox and residential rehabilitation but didnt receive any help. In prison she has received help from the CARAT team but says that they are not always available when she needs them. Since being in prison she has stopped using crack cocaine but has started using heroin again, about once a month, and is concerned that she will become addicted to it. She is currently experiencing severe anxiety and says that she has thought about suicide in the past month.

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4.

Findings: Ethnic Minority Men

Prevalence and management of substance misuse

The 40 ethnic minority men were all identified by prison staff as having substance misuse problems. Analysis of the data from the AUDIT scale of harmful/hazardous drinking and the SDS measure of drug dependence indicated that 14 men (35%) were both drug-dependent and reported harmful levels of alcohol use. Eighteen men (45%) were dependent on drugs only and five men (13%) had harmful levels of drinking only. Three men (8%) were identified as not being dependent on drugs or having harmful / hazardous alcohol consumption. Use and misuse in the year before prison Alcohol use. Table 4.1 shows that 19 men (48% of the sample) reported harmful or hazardous levels of alcohol consumption in the 12 months before prison, based on a score of 8 or more on the AUDIT scale. The mean AUDIT score was 21.79, which is considered to be extreme alcohol misuse. This may be compared with a mean score for male prisoners of 12 in the recent ONS survey, which was drawn from a random sample of predominantly white prisoners. Fourteen men said there had been weeks when they had drunk alcohol everyday in the 12 months before coming to prison. Seven men said they had drunk alcohol every single day during this period. Nineteen men (48%) who were identified as harmful drinkers also reported using at least one type of drug in the 12 months before coming to prison.
Table 4.1 Ethnic minority men: AUDIT scores AUDIT scores 16-23 2 (5%)

0-7 N (%) 15 (38%)

8-15 11 (28%)

24-31 2 (5%)

32-40 4 (10%)

The men were asked if they could identify reasons why they might drink more alcohol than usual. Some men said they drank more if they felt depressed (4) or if they were using certain types of drugs, particularly crack (4). Only two men said they drank more on special occasions and four men could not think of a reason. The men were also asked if they could think of a reason why they might drink less than usual. Similarly, three men said their level of use could vary depending on their drug use. Three men said they would drink less if they had made social arrangements and two men said they would drink less if they wanted a break from alcohol. One man said he drank less when he had no money. Eleven men could not think of a reason. Drug use. Thirty-eight men (95%) said they had used at least one drug in the year before prison, as expected in a sample selected for substance misuse problems (Table 4.2). Cannabis use was reported by 95% of men at some time in their lives, starting on average when 14 years old. Crack use at some time in their lives was reported by 35 men (88%), with 65% of men having used cocaine powder. Ecstasy use was reported by 53% of men. Almost half the sample, (45%) reported using heroin at some time, beginning on average at 25 years of age. Cannabis, crack, cocaine, ecstasy and heroin were the drugs most commonly used in the 12 months before coming to prison (Table 4.3). Thirty-four men (85%) reported using crack in the 12 months before prison, and half of these men (N=17) said that they used it every day. Three-quarters of the men (N=31, 78%) reported using cannabis, the majority every day (38%). Cocaine use was reported by 15 men (38%), but only two men (5%) said they used it daily. Fourteen men (35%) said they had used heroin in the 12 months before prison, and 10

36

men said that they used it everyday. One-fifth of men (N=8, 20%) said they had used ecstasy but the majority of men reported only occasional use.
Table 4.2 Ethnic minority men: prevalence of drug use (ever, 12 months before prison), age of first use. Ever used Cannabis Crack Cocaine Ecstasy Heroin Amphetamines LSD Solvents Methadone Other opiates Tranquillisers Amyl nitrite Magic mushrooms Steroids Bupremorphine Other 38 (95%) 35 (88%) 26 (65%) 21 (53%) 18 (45%) 12 (30%) 12 (30%) 7 (18%) 7 (18%) 7 (18%) 5 (13%) 5 (13%) 2 (5%) 1 (3%) 1 (3%) 1 (3%) Mean (st dev) age when first used 14.29 (3.33) 22.54 (5.42) 20.42 (4.00) 20.71 (6.11) 25.89 (7.01) 19.62 (7.02) 20.08 (6.26) 15.57 (6.43) 28.29 (2.56) 27.57 (6.60) 20.6 (6.73) 20.4 (7.64) 15.50 (.71) 23.00 (0) 29.00 (0) 30.00 (0) Used in 12 months before prison 31 (78%) 34 (85%) 15 (38%) 8 (20%) 14 (35%) 2 (5%) 0 (0%) 1 (3%) 4 (10%) 3 (8%) 2 (5%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Table 4.3

Ethnic minority men: frequency of use in 12 months before prison Once / occasionally Monthly 1(2.5%) 1 (2.5%) 2 (5%) 0 0 0 Weekly / several days per week 14 (35%) 7 (18%) 6 (15%) 1 (2.5%) 1 (2.5%) 0 Every day 17 (43%) 15 (38%) 2 (5%) 10 (25%) 1 (2.5%) 2 (5%) Total using drug 34 (85%) 31 (78%) 15 (38%) 14 (35%) 8 (20%) 4 (10%)

Crack cocaine Cannabis Cocaine Heroin Ecstasy Methadone

2 (5%) 8 (20%) 5 (13%) 3 (8%) 6 (15%) 2 (5%)

Drug dependence. Drug dependence was measured using the Severity of Dependence Scale (SDS). Thirty-two men (80%) were classified as dependent on one or more drug in the year before coming to prison. Almost three-quarters of the men were dependent on crack (N=27, 68%) and 10 men (25%) were dependent on heroin. Severity of Dependence was also measured for three further drugs, if appropriate, and 4 men (10%) were recorded as being dependent on one other drug. Twenty-four men (60%) were dependent on one drug only, seven men (18%) were dependent on two drugs and one man was dependent on three drugs. Injecting drugs. The men were asked whether they had ever injected drugs, either inside or outside prison. Only two men said they had injected drugs, one man had injected heroin both inside and outside prison and one man had injected heroin but only outside prison. Two men reported sharing crack pipes and foil outside prison. Drug and alcohol use in prison Over half the men (N=22, 55%) reported using cannabis in prison and 10 men said they used it weekly or more. Fourteen men (35%) reported using heroin and 8 men reported using it weekly or several days per week. Crack cocaine use was reported by seven men (18%), who said they used it monthly or less. Less than 10% of men also reported using tranquillisers,

37

LSD, cocaine, bupromorphine and methadone in prison. None of the men reported drinking alcohol in prison.
Table 4.4 Ethnic minority men: drug use reported in prison N (%) 3 (8%) 1 (2.5%) 22 (55%) 2 (5%) 7 (18%) 14 (35%) 1 (2.5%) 3 (7.5%) 6 (15%)

Tranquillisers LSD Cannabis Cocaine powder Crack cocaine Heroin Bupromorphine Methadone Other opiates

The men were asked to describe how their drug use had changed since being in prison. Two men said they had changed from crack to heroin since being in prison and one man said he had started taking heroin for the first time. Thirty men (75%) said that they had greatly reduced their level of use or had stopped taking drugs altogether since being in prison. Almost half the men said that they were currently on a voluntary testing unit or drug-free wing (N=16, 40%) or were waiting for a place (N=3, 8%).
Table 4.5 Ethnic minority men: frequency of drug use in prison Once / occasionally Cannabis Ecstasy Cocaine Crack cocaine Heroin Methadone 10 (25%) 2 (5%) 6 (15%) 6 (15%) Monthly 2 (5%) 1 (2.5%) Weekly / several days per week 6 (15%) 8 (20%) Every day 4 (10%) 3 (8%) Total 22 (55%) 0 0 7 (18%) 14 (35%) 3 (8%)

Management and treatment of drug and alcohol problems

The men were asked in detail about their experiences of alcohol and drug use, both outside and inside prison. Thirty-eight men (95%) said they had received a healthcare assessment on arrival at prison, and 17 men (43%) said they had been identified as having alcohol or drug problems. As a result of this initial assessment, 13 men (33%) received drug reduction medication, 9 men (23%) were referred to a CARAT worker, 7 men (18%) were referred to a detoxification unit and two men (5%) received other forms of help, not specified. Alcohol treatment: needs and experiences The men were asked whether they would have liked any help for drinking problems in the 12 months before coming to prison. Four men said they would have liked help but only one man said he had received help. Since being in prison, six men said that they had received help for drinking problems. The men were asked if they would like any further help for drinking problems in prison. Five men said they would have liked more support/counselling and more rehabilitation programmes, such as the 12-step programme. Once released from prison, four men said they wanted counselling, rehabilitation or to be able to attend AA meetings or a drop in centre.

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Table 4.6

Ethnic minority men: treatment for alcohol problems Help wanted 12 months before prison 3 (8%) 2 (5%) 1 (2.5%) 2 (5%) 2 (5%) 1 (2.5%) 2 (5%) Help received 12 months before prison 0 0 1 (2.5%) 0 0 0 0 Help received in prison 3 (8%) 0 0 1 (2.5%) 0 5 (13%) 0

Advice, education Assessment, referral Alcohol detox Help cutting down Help giving up Self-help group, e.g. AA Residential rehabilitation

Drug treatment: needs and experiences The men were asked whether they would have liked any help for drug problems in the year before coming to prison. Twenty-three men (58%) said they would have liked help, mainly residential treatment/rehabilitation (28%), counselling (25%) and help giving up drugs altogether (20%). Only a small number of men had received help during this time. Five men received counselling (13%), three men (8%) received reduction detoxification and three men (8%) received residential treatment/rehabilitation.
Table 4.7 Ethnic minority men: 12 months before prison: type of help needed / received for drugs Help needed 3 (8%) 5 (13%) 10 (25%) 3 (8%) 8 (20%) 3 (8%) 3 (8%) 11 (28%) 1 (3%) 2 (5%) Help received 1 (3%) 5 (13%) 3 (8%) 2 (5%) 2 (5%) 1 (3%) 3 (8%) 2 (5%)

Education/advice/info Help in cutting down Counselling Reduction detoxification Maintenance medication Help giving up drugs Narcotics Anonymous Therapeutic community Residential treatment/ rehabilitation Needle exchange Other

The men were also asked about what other types of help they would have liked and about other types of help they had received. One man said that being in prison stopped him taking drugs and two men wanted residential rehabilitation. However some men complained that there was not sufficient funding or that it was difficult to get help immediately because of waiting lists. Seven men (18%) said that they had received help from drug projects but with mixed success. Three-quarters of the men (N=29, 73%) said they had received help for drug problems in prison. Twenty-eight men (70%) said they had received help from CARATs in prison. One third of men (N=13, 33%) had received counselling and 10 men (25%) had attended NA meetings. Three men (8%) said they had attended courses in prison.

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Table 4.8

Ethnic minority men: help received for drugs in prison In current prison Previous prison (this sentence) 1(3%) 1 (3%) -

Education/advice/CARATS Medication Opioid detoxification Maintenance medication Methadone reduction Counselling Therapeutic community Narcotics Anonymous Referral to community services Rehabilitation programme Drug courses, e.g. Turning Point Other

28 (70%) 6 (15%) 1 (3%) 1 (3%) 13 (33%) 2 (5%) 10 (25%) 1 (3%) 6 (15%) 3 (8%) 8 (20%)

The men were asked what further help they wanted for drug problems. Thirty-four men (85%) said they wanted further help in prison. The majority of men wanted more courses and groups (N=12, 30%), and more education, advice and support for drug problems (N=11, 28%). Outside prison, the men wanted continued support, advice and education (N=11, 28%), aftercare and relapse prevention (N=7, 18%) and practical help with housing and employment (N=6, 15%). The men were asked if they could think of anything else that would help them to remain drug-free in prison. The men thought that more drugs testing and more stringent searches would prevent drug use in prison (N=5, 13%) and that there should be more drug free wings (N=5, 13%). The men also felt that there should be more activities/association time to prevent boredom (N=3, 8%).

Demographic and social factors associated with substance misuse

Current and previous offences The majority of the men were convicted or charged with acquisitive offences (N=26, 65%), five men (13%) with drugs offences and three men with violent offences. Four of the men (10%) who had been identified as drug-dependent were convicted of drugs offences, one man who was not drug-dependent was convicted of possession of drugs. Thirty-three of the men (83%) were sentenced prisoners.
Table 4.9 Ethnic minority men: current offence N (%) 16 (40%) 9 (23%) 1 (2.5%) 4 (10%) 1 (2.5%) 2 (5%) 1 (2.5%) 6 (15%) 40 (100%)

Burglary Robbery Theft or handling stolen goods Supplying drugs Possession of drugs GBH ABH Other offence not listed Total

The mean number of previous convictions was 10.65 (s.d 10.52). The mean was slightly higher for men who were identified as drug-dependent (12.19, s.d. 11.10) and for men who were identified as harmful drinkers (12.11, s.d. 13.49).

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Table 4.10

Ethnic minority men: number of previous convictions N (%) 15 (38%) 13 (33%) 5 (13%) 7 (18%) 40 (100)

05 6 10 11 15 16 or more Total

Education The men were asked questions about their education. Over half the men, (N=24, 60%) had no qualifications but 14 men (35%) had either GCSEs/O Levels or A Levels. Twenty-seven men (68%) said that they had played truant occasionally or regularly whilst at school. Sixteen of these men reported using drugs, 10 reported using alcohol and 14 said they committed offences whilst playing truant. Over half the men (N=21, 53%) said that they had been expelled from school on at least one occasion. Twenty-six men (65%) said they had not gained any further qualifications since leaving school and nine men said that they had some difficulty with basic reading, writing or maths. Almost three-quarters of the men (N=28, 70%) said that they had received some form of education in prison. Families, children and relationships The men were asked whether they had been in a relationship in the 12 months before coming to prison. Twenty-five men (63%) described themselves as in a relationship with a female partner and 15 men said they were not in a relationship. The majority of men (N=36, 90%) described their legal status as single and 4 men were married. Only two men said that their partners had criminal convictions and two men said that their partners had drug problems. None of the men described their partners as having a problem with alcohol. Almost one quarter of men (N=9, 23%) said that most or all of their family/friends outside prison had a problem with alcohol and 11 men (28%) said that most of their family/friends had a problem with drugs. Inside prison, 12 men (30%) thought that most or all of their friends had problems with alcohol and three quarters of men (N=30, 75%) thought that most or all of their friends had problems with drugs. Fourteen men said that they had experienced violence from family or friends, usually from their father (N=7, 18%). Six of these men thought that it was related to alcohol or drug use at the time.
Table 4.11 Ethnic minority men: family and friends: substance misuse None 24(60%) 20 (50%) 15 (38%) 5 (13%) A few 7 (18%) 9 (23%) 13 (33%) 5 (13%) Most 7 (18%) 11 (28%) 11 (28%) 24 (60%) All 2 (5%) 0 (0%) 1 (3%) 6(15%

Alcohol friends / family outside prison Drugs friends / family outside prison Alcohol friends inside prison Drugs friends inside prison

Children. Thirty-two men (80%) said that they had children of their own. The majority of men (N=20, 50%) had one or two children, eight men had three or four children (20%) and three men had five or more children (8%). The men had a total of 78 children between them. Only four men said that they had step-children. The men were asked about care arrangements for their children, before they came to prison, whilst they were in prison and anticipated care once they were released. The men reported that the majority of their children (77%) were living at home with their parents before prison and this figure only dropped slightly to 62% when the men were inside prison. However, the number of children living with other family members rose whilst the men were in prison, from 10% to 20%. Only one child was

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described as being in care/adopted, which was not affected by the man being in prison. The high percentage of children who remain at home whilst their father is in prison suggests that the men are not the primary carers for their children. The men were also asked whether they had ever felt unable to care for their children for any reason. Seven men (18%) said they were unable to care for their children because of drug problems, three men (8%) because of alcohol problems and two men (5%) for other reasons, not specified. In five of these cases the children became sole responsibility of the mother.
Table 4.12 Ethnic minority men: children care arrangements Care arrangements before prison 47 (77%) 6 (10%) 1 (1.6%) 5 (8%) Care arrangements at present 38 (62%) 12 (20%) 1 (1.6%) 3 (5%) 6 (10%) Anticipated care arrangements 42 (70%) 10 (16%) 1 (1.6%) 1 (1.6%) 5 (8%)

Living at home with parent/parents Living with other family members In care/adopted Living with partner Other

Employment The men were asked to describe their employment status in the 12 months before coming to prison. Almost three-quarters of the men were unemployed, (N=27, 68%), six men had parttime or casual jobs (15%) and only seven men (18%) were employed full-time. Thirteen men (33%) stated that their main reason for being unemployed was substance misuse.

Mental health
Previous contacts with mental health services outside prison The men were asked whether they had ever visited their GP or any other health professionals outside prison for emotional or mental health problems. Ten men (25%) said they had visited their GP, mainly for depression (N=8, 20%).
Table 4.13 Ethnic minority men: reason for seeking help from GP N (%) Anxiety Depression Eating disorders Substance misuse Psychosis Self-harm/suicidal thoughts Other 2 (5%) 8 (20%) 3 (8%) 1 (2.5%) 1 (2.5%) 2 (5%)

Six men said they had sought help from other health professionals outside prison, usually from a psychologist (N=4, 10%). Only three men said that they had been prescribed medication in the 12 months before prison, for depression, anxiety and substance misuse. None of the men had ever been admitted to a psychiatric hospital.

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Table 4.14

Ethnic minority men: help sought from health professionals outside prison N (%) 2 (5%) 4 (10%) 1 (2.5%) 2 (5%) 3 (8%)

Child guidance Counsellor Psychologist Psychiatric nurse Psychiatrist Other

Contacts with mental health services in prison A quarter of men (N=10, 25%) had sought help in prison for emotional or mental health problems, usually from the prison psychologist (N=5,13%) or psychiatrist (N=4, 10%), for either depression (N=7, 18%) or anxiety (N=3, 8%). Three men reported receiving medication and 2 received counselling.
Table 4.15 Ethnic minority men: health professionals seen in prison N (%) 3 (8%) 4 (10%) 5 (13%) 1 (2.5%)

Prison doctor Medical officer Psychiatrist Psychologist Other Total

Anxiety and depression Levels of anxiety and depression during the past week were measured using the HADS scale. Almost one quarter of men reported experiencing moderate to severe levels of anxiety (23%) and less than one fifth of men (16%) reported experiencing moderate to severe levels of depression.
Table 4.16 Ethnic minority men: prevalence of current anxiety and depression Current depression Normal Mild depression Moderate depression Severe depression

Current anxiety Normal Mild anxiety Moderate anxiety Severe anxiety

25 (63%) 6 (15%) 7 (18%) 2 (5%)

30 (75%) 4 (10%) 5 (13%) 1 (3%)

Self-harm and suicide The men were asked if they had ever self-harmed or made a suicide attempt in their lifetime. One man (2.5%) said he had self-harmed just once, two men (5%) said they had self-harmed between 2-5 times and one man (2.5%) said he had self-harmed more than 5 times. One man (2.5%) believed that his self-harm was linked to alcohol/drug use. Three men reported taking overdoses (8%), two men reported cutting (5%), one said he had attempted to hang himself (2.5%) and one man had tried to electrocute himself in the bath. In the past month, 6 men (15%) had thought they would be better off dead and two men (5%) reported wanting to harm themselves. One man (2.5%) said he had thought about suicide and three men (8%) had attempted suicide. Two men (5%) were identified as being a moderate suicide risk.

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Stressful life events Less than half the men (38%) said they had been physically assaulted and only three men (8%) said they had been sexually assaulted. A quarter of men (25%) said they had caused serious injury, harm or death to someone else and over half the sample (55%) had experienced the sudden, unexpected death of someone close to them.
Table 4.17 Ethnic minority men: reported experience of stressful life events N (%) reporting personal experience 22 (55%) 15 (38%) 10 (25%) 3 (8%) 2 (5%)

Sudden unexpected death Physical assault Serious injury/harm/death you caused to someone else Sexual assault Other unwanted sexual experiences

Psychotic experiences The MINI, which had been adapted for the purposes of the study, was used to identify the presence of any psychotic symptoms. Nineteen men (48%) said that they had experienced one or more psychotic symptom in their lifetime and 16 of these men (40%) said that they had been using drugs or alcohol at the time.
Table 4.18 Ethnic minority men: self-reported psychotic experiences N (%) reporting symptoms 6 (15%) 10 (25%) 10 (25%) 12 (30%) 5 (13%) 8 (20%) 11 (28%) 16 (40%)

Have you ever believed you were being sent special messages through TV/radio/newspaper? Have you ever believed you or some force outside yourself put thoughts in your mind? Have you ever heard things other people couldnt hear, such as voices? Have you ever believed people were spying on you/plotting against you? Have you ever believed that someone was reading your mind / could hear your thoughts? Have your friends or relatives ever considered any of your beliefs strange or unusual? Have you ever had visions when you were awake or ever seen things other people couldnt see? Were you using drugs or alcohol at the time you had any of these experiences?

These rates are considerably higher than the rates of clinically-assessed psychosis reported in the ONS survey, suggesting that there is a significant minority of men in this group who have sub-clinical psychotic experiences. Almost half of the men attributed these to using alcohol or drugs, the majority of whom were dependent on crack cocaine . Manic episodes Men were also asked about experiences of feeling high or unusually full of energy, using the first screening question for manic episodes from the MINI. However, unlike the MINI standard format they were not told to exclude episodes when intoxicated by alcohol or drugs. Fourteen men (35%) reported that they had experienced this kind of episode and 9 (23%)

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attributed it to alcohol or drugs. These figures should be interpreted with extreme caution as they are based on a subjective self-report of unusual experiences, which cannot be directly compared with a clinical assessment. It is likely that men interpreted the definition of manic experiences liberally; nevertheless they did see alcohol and drugs as implicated in their unusual feelings or behaviour.

Physical health
The men were asked how they felt in terms of their physical health. Half the men (N=20, 50%) described their health as good and a quarter of the men (N=10, 25%) described it as very good or excellent. The men were also asked to describe how they perceived their health, using part of the Short Form 36 Health Survey (SF36). In general, the men were positive about their health, 78% disagreeing with the statement I get ill more than other people. Eighty per cent of the men considered themselves to be as healthy as anybody else they knew, describing this statement as mostly or definitely true. Over half the men described the statement I expect my health to get worse as definitely false and 73% of men agreed with the statement My health is excellent describing it as mostly or definitely true.
Table 4.19 Ethnic minority men: items from SF 36 Health Survey Definitely true 1 (2.5%) 24 (60%) 5 (13%) 13 (33%) Mostly true 4 (10%) 8 (20%) 6 (15%) 16 (40%) Not sure 1 (2.5%) 2 (5%) 5 (13%) 4 (10%) Mostly false 3 (8%) 2 (5%) 2 (5%) 2 (5%) Definitely false 31 (78%) 4 (10%) 22 (55%) 5 (13%)

I get ill more than other people I am as healthy as anybody I expect my health to get worse My health is excellent

The men were then asked if they had suffered from a number of illnesses that may be more prevalent amongst people who abuse drugs or alcohol, including TB, epilepsy, hepatitis, diabetes and sexually transmitted diseases. Very few men reported suffering from any of these illnesses and in general the men were satisfied with how these problems were managed. Nineteen men said they had received a hepatitis test and 21 men had received an HIV test at some time in their lives.
Table 4.20 Ethnic minority men: reported physical health problems N (%) 2 (5%) 2 (5%) 1 (2.5%) 6 (15%) -

TB Hepatitis Epilepsy Diabetes STD HIV/AIDS

Three men complained that they had not received the right medication for a specific health problem, two men felt that the staff were unsympathetic and did not provide the right care and two men complained that they had waited a long time to receive treatment.

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Ethnic minority men: findings from the qualitative study

Practitioners reported different patterns of substance use among white male prisoners and men from minority ethnic populations. Opiate use was said to be less prevalent among black British, Caribbean and African men, reflecting the greater stigmatisation of heroin use within black cultures. Crack cocaine use was considered the primary form of problematic drug use among black British and Caribbean prisoners. Several participants indicated that heroin use was also less common among Asian than white prisoners. However, they noted that the incidence of use among Bangladeshi men admitted to prison was increasing. Injecting was reported to be far less common among both black and Asian prisoners, reflecting the greater stigma attached to injecting drug use within black and Asian cultures. Alcohol use was said to be prevalent among ethnic minority men. Drug use in prison was reported to be common among men from minority ethnic populations. Use in mens prisons, as in womens, was linked with bullying and said to render abstention from drug use particularly problematic for those prisoners who choose to abstain. Differential patterns of substance use and attitudes towards the use of certain substances were reported to reduce the likelihood of ethnic minority prisoners accessing and engaging with drug treatment services. Men using crack cocaine in the absence of heroin were seen as less likely to self-refer to services for several reasons. The absence of pronounced physical symptoms on withdrawal from crack cocaine and the lack of a prescribed substitute for this drug were two reasons given for lower rates of self-referral to Detoxification Services. It was also reported that users of crack-cocaine were less likely than heroin users to perceive their drug use as problematic. Further, several participants indicated that while black prisoners were generally willing to disclose crack cocaine use if they needed to access services, they were less willing to disclose heroin use. Similarly, it was indicated that Muslim prisoners might be less likely than non-Muslims to approach services with issues around alcohol use. The development of services targeting alcohol misuse was identified as a need for ethnic minority men as it was for women. Participants also commented on the lack of treatment options for users of crack-cocaine. The prevalence of crack cocaine use among black prisoners suggests that this deficit may be particularly problematic for this population. A number of participants expressed the need for their establishment to engage a worker specialising in crack-cocaine use. It should be noted that this need has been addressed in at least one establishment formerly lacking a specialist crack cocaine worker. Toward the close of fieldwork, it was revealed that funding has been made available for a specialist worker to join the CARAT Team at the male local prison participating in the study. A further point raised in relation to service provision for ethnic minority prisoners was the present shortfall in substance misuse workers from black and Asian populations. This shortfall was seen to impact negatively on prisoners willingness to access services in general, and Rehabilitation Services in particular. Prisoners reluctance to access services was said to be grounded in their expectation that they would be the only black person there, and that they would encounter both a lack of understanding of their culture and racism. Participants related reports from prisoners who had accessed Rehabilitation Services that suggested these expectations had been met in some instances. It should again be noted that attempts are being made to address the disparity in the numbers of white and ethnic minority practitioners delivering prison-based substance misuse treatment services. It was reported that funding has been ring-fenced for a black or an Asian substance misuse worker to join the CARAT Team at the participating male local prison. It was indicated that the issue of co-morbidity among substance-using ethnic minority prisoners may be especially complex. A number of participants felt that mental health problems often went undiagnosed. Alternatively, it was suggested that patterns of behaviour

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induced by the effects of or withdrawal from substances might be misdiagnosed as the symptoms of affective or psychotic disorder. It was also suggested that the behavioural repertoires displayed by men from certain minority ethnic populations might increase the likelihood of misdiagnosis. Illustrative cases Case H Case H was born in Pakistan and came to England as a child. He had difficulties understanding English in school and was excluded for bad behaviour and sent to a young offender institution at the age of 15. He is now 28, married with a five year old son. He rarely drinks alcohol but is dependent on heroin and was also using crack and cannabis prior to prison. His heroin use was exacerbated by the death of his baby daughter. In the year before coming to prison he received some help in detoxification from a local Turning Point project. He applied several times for a rehabilitation programme but couldnt get funding. He attended Narcotics Anonymous but felt he needed rehabilitation first for it to be useful. Early in his sentence he lost 100 days remission through testing positive on MDTs. Finally in his current prison he got help, when the governor recommended it, and after asking lots of times. He has now attended a Turning Point three-month rehabilitation course, and received advice and counselling from the CARAT workers. He applied to do the RAPt course at another prison but was turned down because of his history of positive drug tests. He would also like to have been able to continue the relaxation training, which was part of the rehab course. He feels that he has been penalised for his drug taking and positive MDT results, even though he has repeatedly asked for help and is trying to stop. He also says he feels that he is stigmatised for going on a drugs course, leading to even more monitoring. His believes strongly that drug programmes should be available to people with the greatest need and that MDT should not be used punitively. Case J Case J is a 30 year old black man, serving a sentence for burglary. He is a qualified electrical installation engineer who was employed full-time before coming to prison. He has no problems with alcohol but is dependent on crack and was also using cocaine, ecstasy and cannabis in the year before his sentence. On average he was spending 3,500 per week on drugs. Before coming to prison he received counselling and detoxification from a community drugs project, but although this helped for a while he continued taking drugs because his friends were also users. In prison he has received advice from CARATs, rehab, therapeutic community and counselling and has also attended meetings of Narcotics Anonymous. He has also had help in prison from NACRO, in fixing up a post-release hostel place. He is very positive about the help he has received in this particular prison, which he thinks is exceptional, but emphasises that the most important factor now is keeping away from drugusing friends outside prison. He believes that more frequent testing and the greater use of drug-free wings would help people remain drug-free in prison. Case K Case K is a 28-year-old black man on remand, charged with burglary. He has qualifications in travel and tourism but was unemployed before coming to prison. He has a severe problem with drinking and was picked up three times by emergency services. On arrival at prison he was prescribed valium for 2 weeks to cope with alcohol withdrawal. In prison he has received help from a counsellor; he found it a big help to have someone to talk to. He also attended AA meetings but didnt like them, stating that he would rather drink than be like the people at AA. He also believes that if he stopped drinking altogether he would lose all his friends. Before prison he was using a range of illicit drugs on an occasional basis, including heroin, cocaine and amphetamines, although he was not dependent on any drug and prefers to use alcohol.

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Case L Case L is a black male, 40 years old, serving a 4 month sentence for burglary. He has 40 previous convictions and has previously served six custodial sentences. He left school when he was 16 with 8 O Levels. He started smoking cannabis when he was 17 years old but took no other drugs until he was 35, when he started smoking crack. At 37 he started taking heroin. In the year before he came to prison he was using heroin on a weekly basis and crack cocaine every day. He was also drinking heavily, usually every day, and reports that his drinking regularly prevented him from carrying out everyday tasks. He says that he went in to rehab before coming to prison for his drug problem and that this was useful. He also says that he would have liked education, advice and counselling for his drinking problem but did not receive any help before he came to prison. In prison, he has received help from CARAT workers, for both his drug and alcohol problems, and has had counselling and attended AA meetings. He would like to have further counselling after his release to monitor his progress. He has never sought help for any emotional or mental health problems outside prison but has seen the prison psychologist for depression. He is currently experiencing moderate anxiety. He says that he has experienced a manic episode while using crack, heroin and alcohol and also reports experiencing all the psychotic symptoms listed on the MINI. He has used crack once and heroin occasionally since being in prison.

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5.

Findings: Young Male Offenders

Prevalence and management of substance misuse

The 80 young offenders were all identified by staff as having problems related to substance misuse. Analysis of the data from the AUDIT scale of harmful/hazardous drinking and the SDS measure of drug dependence indicated that 47 (59%) were both drug-dependent and had harmful levels of drinking. Twenty (25%) were dependent on drugs only, 8 (10%) had harmful levels of drinking only, and 5 (6%) were neither drug dependent or drinking at a hazardous level at this stage, although they had used illicit drugs in the 12 months prior to prison (see below). Use and misuse in the year before coming to Young Offender Institution (YOI) Alcohol use. Fifty-five young men, nearly 70% of the sample, reported harmful or hazardous levels of alcohol consumption in the 12 months before coming to the YOI, based on a score of 8 or more on the AUDIT scale. The mean AUDIT score was 18.16 which may be considered to be extreme alcohol misuse. This can be compared with a mean score for men of 12 in the ONS survey, which was drawn from a random sample of the male prison population across all ages. However, as this sample of young offenders was specially selected to investigate substance misuse problems, the pattern of drinking cannot be generalised to the general YOI population.
Table 5.1 Young offenders: AUDIT scores AUDIT scores 0-7 N (%) 12 (15%) 8-15 15(19%) 16-23 20 (25%) 24-31 13 (16%) 32-40 8 (10%)

Thirty-seven young men said that in the past year there had been weeks when they drank every day (67% of harmful drinkers, 46% of overall sample). Nine men reported drinking every day for 4 weeks, 4 men for 5-24 weeks, 13 men for 25-44 weeks and 11 men reported drinking every day for 52 weeks. Interviewees were asked whether they could identify any reasons why they might drink more or less than their usual amount. Comments relating to drinking more alcohol fell into two main categories: Negative mood/experience. Fifteen men reported drinking more when they were feeling depressed, experiencing stress or when something bad happened in their lives. In these circumstances alcohol was often used as a way of escaping or forgetting. Peer influences and positive mood. Ten men reported drinking more when socialising with friends. Men referred to 'keeping up with friends' or being in an environment where drinking is the norm i.e. pub or parties. 3 men referred to drinking more when celebrating or on special occasions, and 2 increased their drinking when more alcohol was available. Comments relating to drinking less referred to four types of constraint: Lack of finances. Seven young men stated that they drank less when they had less money. External commitments. Seven reported drinking less due to family/work commitments. Physical effects. Five men reported drinking less when physically ill from alcohol. Drug related. Five men said that drug use reduced alcohol consumption. This related to either preferring to take drugs if available, or to certain types of drugs not mixing with alcohol e.g. amphetamines or cannabis.

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Drug use. Seventy-nine (99%) of the young men reported using at least one illicit drug in the 12 months prior to coming into prison. Cannabis use was reported by almost all the young men interviewed, and two-thirds reported using ecstasy.
Table 5.2 Young offenders: use of each drug in the 12 months before coming to YOI

N (%) Cannabis 75 (94%) Ecstasy 49 (61%) Crack cocaine 39 (49%) Cocaine powder 39 (49%) Heroin 33 (41%) Tranquillisers * 28 (35%) Amphetamines 25 (31%) LSD 18 (22.5%) Other Opiate Substitutes eg DF118 ** 18 (22.5%) Magic mushrooms 14 (17.5%) Methadone *** 13 (16%) Other (e.g.Ketamine, GHB, khat, ) 9 (11%) Solvents 5 (6%) Amyl nitrite 5 (6%) Bupremorphine 2 (2.5%) Steroids 1 (1%) * four young men reported that tranquillisers used were prescribed ** five young men reported that other opiate substitutes used were prescribed *** two young men reported that methadone used was prescribed

Drug dependence. Using the SDS scale, 76% of the young men were assessed as dependent on at least one drug. Altogether, 22 (27.5%) were dependent on crack cocaine, and 22 (27.5%) were dependent on heroin. 35 young offenders were dependent on one drug only. Of these, 11 were dependent on heroin, 9 on crack, 5 each on cocaine powder and cannabis, 4 on amphetamines and 1 on ecstasy. Nineteen young men were dependent on 2 or more drugs, mainly a combination of heroin and crack, sometimes with an additional drug. Thus, despite having tried a wide variety of drugs before coming to prison, most of the young men were rated as psychologically dependent on heroin, crack, or both, with other drugs being used occasionally or recreationally.
Table 5.3 Young offenders: drug dependence N (%) 22 (27.5%) 22 (27.5%) 9 (11%) 8 (10%) 7 (9%) 5 (6%) 3 (4%) 1 (1%)

Crack cocaine Heroin Cocaine powder Cannabis Amphetamines Ecstasy Tranquillisers LSD

Injecting. Sixteen young men (20%) said they had injected drugs at some time. Of this figure, 6% reported injecting in prison only, 11.5% reported injecting outside prison only and 2.5% reported injecting in and out of prison. Four men (5%) reported injecting while sharing needles or syringes outside prison only. Eight young men (10%) reported sharing other equipment such as filters, or water, or spoons (six outside prison only and two inside prison only).

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Alcohol and drug use in current Young Offender Institution Only 2 young men said they had used alcohol while in their current institution. Fifty-five (69%) said they had used cannabis inside, compared with 94% outside. Sixteen per cent said they had used heroin, compared with 41% outside, and 11% had used crack, compared with 49% outside. Very few reported using any other drug inside the institution.
Table 5.4 Young offenders: use of each drug inside and outside YOI Inside YOI N (%) 55 (69%) 13 (16%) 9 (11%) 6 (7.5%) 5 (6%) 4 (5%) Outside N (%) 75 (94%) 33 (41%) 49 (61%) 18 (22.5%) 39 (49%) 28 (35%)

Cannabis Heroin Crack cocaine Other opiates (including prescribed) Cocaine powder Tranquillisers [All other drugs used by 1% or fewer inside YOI.]

Those young men who continued to use drugs inside the YOI reported that they used specific drugs less frequently than outside, with most reporting occasional rather than regular drug use. Even cannabis, the most frequently used drug, was only used on a daily basis by 6% of the sample. When asked about changes in their drug use since coming into the YOI, 70 (87%) said they had reduced the amount of drugs taken, including 28 (35%) who said they had stopped taking drugs altogether. One young man said that he had started using crack in prison.
Table 5.5 Young offenders: frequency of drug use Every day Cannabis In YOI Outside Heroin In YOI Outside Crack cocaine In YOI Outside Cocaine powder In YOI Outside Weekly / several days per week 13 (16%) 18 (22.5%) 1 (1%) 4 (5%) 2 (3%) 11 (14%) 1(1%) 16 (20%) Monthly Once / occasionally 25 (31%) 5 (6%) 3 (4%) 7 (9%) 6 (7.5%) 7 (9%) 3 (4%) 10 (13%)

5 (6%) 50 (62.5%) 1 (1%) 21 (26%) 0 19 (24%) 0 9 (11%)

12 (15%) 2 (2.5%) 1 (1%) 1 (1%) 1 (1%) 2 (2.5%) 1 (1%) 4 (5%)

Management and treatment of drug and alcohol problems

The interviewees were asked to recall what assessment and treatment they had received when they first arrived at the YOI. All but one reported receiving a healthcare assessment, although only a third reported some immediate action being taken for alcohol or drugs. Fourteen per cent said they were referred directly to the CARATs team at that stage.

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Table 5.6

Young offenders: on arrival at YOI N (%) 79 (99%) 28 (35%) 11 (14%) 18 (22.5%) 3 (4%)

Given healthcare assessment Immediate action taken re alcohol or drugs Direct referral to CARATS worker Prescribed drug-related medication Referred to detoxification unit

Five young men commented on the perceived lack of appropriate detoxification. Three said they had been given only painkillers, which were insufficient, especially for heroin withdrawal. One wanted help in withdrawing from amphetamines and one for alcohol withdrawal but said they had received nothing. Two men commented that they had referred themselves to the CARATs team rather than waiting longer for a referral from the doctor. Drug treatment in the year before coming to the YOI Fourteen young men (17.5% of overall sample, 25% of harmful drinkers) reported that in the year before prison they would have liked help/treatment for drinking. However, only 4 (7%) young men reported receiving help during this period. The types of help wanted and received by the 14 men were:
Table 5.7 Young offenders: type of help/treatment: 12 months before YOI Wanted 7 (9%) 6 (8%) 5 (6%) 5 (6%) 3 (4%) 2 (3%) 1 (1%) Received 0 2 (3%) 0 0 1 (1%) 0 1 (1%)

Cutting down/controlling/ relapse prevention Self-help group i.e. AA Education/advice/ information Help in giving up drinking altogether Referral to specialist services Alcohol detoxification Residential rehabilitation (planning for detoxification)

Of the young men with harmful hazardous drinking, 19 (34.5%) said they had received help for alcohol problems in the young offender institution while 27 (49%) felt that they did not need help for drinking problems inside. Nine young men (16% of harmful drinkers) wanted help for drinking problems inside the YOI, but had not yet received help.
Table 5.8 Young offenders: type of help received in YOI N (%) receiving help 12 (15%) 4 (5%) 3 (4%) 3 (4%) 2 (3%) 1 (1%)

Advice/education/information Self-help group i.e. AA Alcohol detoxification Help in cutting down/controlling/ relapse prevention Referral to specialist services Residential rehabilitation (including planning/ preparation for detoxification)

Eleven young men described further help for drinking problems which they said they would like while inside the YOI. The majority mentioned counselling, alcohol advice/awareness and relapse prevention. Some referred to not 'knowing what help options are available', one questioned why there were no alcohol detoxification facilities at his institution and one referred to the importance of having activities (particularly in the evening) to keep his mind occupied. When asked what kind of help they wanted for alcohol outside (i.e. on release), a similar number of men wanted counselling. However, more men said that they wanted

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emotional support from family/partners. As before a few men mentioned that they wanted to keep occupied, e.g. "getting a job would help" or "keeping busy". In summary, almost half of the young men who were drinking very heavily did not feel they needed help, or at least not within the YOI environment. Those who did want help for alcohol wanted to talk to someone about their problems (i.e. counselling), either inside or outside the institution. They wanted practical help such as advice/information/awareness while inside the YOI, and emotional support when released. Forty-six young men (57.5% of sample, 78% of drug dependent interviewees) reported that they would have liked help/treatment for drugs in the 12 months before prison.
Table 5.9 Young offenders: type of help - 12 months before YOI Help needed N (%) 21 (26%) 16 (20%) 14 (18%) 12 (15%) 11 (14%) 9 (11%) 7 (9%) 2 (3%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) Help received N (%) 3 (4%) 2 (3%) 1 (1%) 0 2 (3%) 4 (5%) 3 (4%) 0 0 1 (1%) 2 (3%) 0

Counselling Help in giving up drugs altogether Education/advice/ information Cutting down/ reducing drug use Residential treatment/rehabilitation Maintenance medication Reduction detoxification Moving away from drug environment Narcotics Anonymous Therapeutic community Drop-In drug centre Help with housing and job

Treatment for drug problems in the YOIs Sixty-four young men said they had received help or treatment for drug problems during their current sentence (81% of those who had used any illicit drug in the previous year and 100% of those rated as dependent on drugs). This high percentage reflects the fact that interviewees were selected by CARATS workers from their caseload; it should not therefore be seen as typical of the young offender population.
Table 5.10 Young offenders: type of help received in current YOI N (%) 53 (66%) 11 (14%) 12 (15%) 5 (6%) 6 (8%) 4 (5%) 2 (3%) ( + 4 in previous YOI) 2 (3%) 3 (4%) 1 (1%) 1 (1%) 1 (1%)

Advice/education/CARAT Drug courses ('Awareness' and/or 'Relapse Prevention') Counselling Rehabilitation programme Maintenance medication Drug free wing Opioid detoxification Therapeutic community Narcotics Anonymous Acupuncture Routine/exercise/eating well Referral to Community Service pre-release

Forty-five young men reported that they would like further help for drug problems whilst in the YOI (74.5% of those dependent on drugs). The majority said that they would like counselling. Many referred to the need for more one-to-one help but commented that it was "difficult getting to see anyone". A number reported that they would like advice/education

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from CARATs or drug courses. However, one man commented that he would like courses to "focus on the positive aspects of not taking drugs", and another commented that he would like "specific courses for individual drugs, e.g. one for heroin". Other young men referred to drug- free wings as being helpful but pointed out that there were often long waiting lists to get on these wings, rehabilitation programmes and relapse prevention. Finally some men commented that they wanted "any help possible whilst inside" or "whatever is offered". When asked what kind of help was wanted outside (i.e. on release), the majority of young men again reported that they wanted counselling and/or support: "someone to talk to, stay in check with" and as a way of "keeping motivated. Others mentioned that they were not sure "what kinds of help are available, I haven't looked before". Indeed a number of young men said that they were prepared to "do it by myself", but that if help were set up they would be interested. Finally, many said that they wanted help with employment and housing. Only one man mentioned family support. Compared with alcohol problems, young men were more inclined to say they would seek help for drug problems from professionals.

Demographic and social factors associated with substance misuse

Current and previous offences The majority of young men interviewed had been charged or convicted with a property offence (59%), violent offence (17.5%) or a drug offence (12.5%). Only 5 (8%) of the 61 young men rated as drug dependent had been convicted of a drugs offence. Five (26%) of the 19 rated as non-drug-dependent had been convicted of possessing or supplying drugs. None of the young offenders interviewed had been convicted of importing drugs. The mean and median number of previous convictions was calculated, comparing young men with and without substance misuse problems. Harmful drinkers and drug-dependent young men had slightly higher mean numbers of pre-convictions, although the number of young men in the sample without drug dependence or harmful drinking was too small to carry out a meaningful statistical comparison. Education The majority of the young men interviewed (77%) left school between the ages of 14-16. Sixty-three interviewees (79%) left school with no qualifications at all and 16 (20%) had achieved one or more GSCE level qualifications. Truancy. Overall, 71 (88.5%) of young men interviewed reported having played truant from school, most regularly (62.5%), but some occasionally (26%). Of those reporting truancy, 64% reported taking drugs, 51% reported committing an offence and 45% drinking alcohol whilst truanting. There was a significant association between harmful drinking in the 12 months before coming to the YOI and drinking alcohol whilst playing truant [chi square 13.258, df 2, p=<.001]. Exclusion from school. Overall, 63 (79%) young men reported being excluded from school at some time. The mean number of exclusions was 3.86, with most (65%) being excluded for 2 weeks or less. Very few young men said they had been excluded for taking drugs (8%), and none specified being excluded because of alcohol consumption. The majority of interviewees said that they had been excluded for violence (57%) or bad behaviour / behaviour problems (24%). Twenty-five per cent of those rated as drug-dependent had been excluded at some time, compared with 9.5% of those rated as not dependent on drugs. Special needs. Twenty-two young men (27.5%) said that whilst at school they had been assessed as having special educational needs. Seventeen (21%) stated that they had some

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current difficulties with reading, writing and/or numbers, while 4 (5%) reported serious difficulties. Families, children and relationships Fifty of the young men (62%) described themselves as in a relationship with a female partner; none reported being in a relationship with a male partner. Thirty-seven (46%) were living at home with family members before coming to the YOI, while 19 (24%) were living with their partner. Twelve were living alone. Of those who had partners, relatively few reported that their partners had criminal convictions (9%), alcohol problems (6%) or drugs problems (10%). In contrast, two-thirds of the young men said that members of their friends or family had drugs problems, including 40% who said that most or all of their family/friends outside had drugs problems. Over half (51%) said that most or all of their friends/family outside had alcohol problems. 34 (43%) said that family members or friends had been violent towards them at some time. In contrast with the womens data, none reported violence from their partners. Most reported that the violence was committed by their fathers (16%) or by their friends (14%). Fifteen young men (19%) had children of their own and none had stepchildren. Twelve had one child and 3 had two children. All the children were being cared for by the young mens partners or by members of the family; none of the children were in care or adopted. Four young men said they had been unable to care for their children at some time because of problems related to drugs, and 2 had been unable to care for their child because of drinking. However in each case the child had been looked after by their partner or by their mother. Employment Fifty-six per cent of the young men interviewed were unemployed in the 12 months before coming to the YOI. 31% were employed full-time, with the remaining 13% employed parttime or doing casual work. Nineteen per cent had never been employed since leaving school, with 40% having had less than 6 months continuous employment since school. Forty-one per cent cited alcohol/drugs problems as a reason for their unemployment since leaving school. Forty per cent said they had been unemployed because they did not wish to work. A quarter had been unable to find a suitable job.
Table 5.11 Young offenders: reported reasons given for unemployment N (%) 33 (41%) 32 (40%) 19 (24%) 10 (12.5%) 2 (2.5%) 2 (2.5%)

Alcohol/drug problems Not wishing to work Unable to get a suitable job Criminal activity Ill health/disability Mental health problems

Mental health
Contacts with mental health services Twenty-four young men (30%) said that they had had contact with a health professional outside prison for mental health problems at some time in their life. Ten (12.5%) had been to a child guidance clinic, 11 (14%) had seen a counsellor, 8 had seen a psychiatrist and 5 a psychologist. Six (7.5%) had been admitted to hospital for a mental health problem. Fourteen

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(18%) had been prescribed medication for a mental health problem in the 12 months before coming to the YOI. While in the YOI 25 (31%) had had contact with mental health services. Of these, 10 had seen the doctor, 6 had seen a psychologist and 5 a psychiatrist (6%). Eight of the young men had wanted help with depression and 7 with problems related to substance misuse. Three wanted help in coping with bereavement, including one who had witnessed a suicide. Three had problems of violence or wanted to attend an anger management course. Anxiety and depression Levels of anxiety and depression during the past week were measured using the HADS scale. Almost a fifth of the young men had moderate to high levels of anxiety (about half the proportion in the total womens sample) and one in six had moderate to high levels of depression.
Table 5.12 Young offenders: prevalence of current anxiety and depression Current depression Normal Mild depression Moderate depression Severe depression

Current anxiety Normal Mild anxiety Moderate anxiety Severe anxiety

53 (66%) 12 (15%) 8 (10%) 7 (9%)

60 (75%) 9 (11%) 5 (6%) 6 (7.5%)

There was some suggestion from the data that harmful drinking might be associated with greater anxiety, in that 40% of harmful drinkers had higher than normal levels of anxiety compared with 20% of non-harmful drinkers. However, no statistically significant association was found between anxiety and harmful drinking, and the numbers of nonharmful drinkers were probably too small to make reliable comparisons. Self-harm and suicide Eighteen young men (22.5%) reported at least one act of self-harm in their lives, with 5 of these men reporting having harmed themselves 2 to 5 times and 4 men reporting more than 5 incidents of self-harm. Forty-four per cent of young men had harmed themselves through taking an overdose, 33% had cut themselves, 22% had hung themselves, 22% had jumped off a bridge or house and 5% had cut their wrists. Twenty-four per cent of drug dependent young men had self-harmed in their lifetime, as had 25% of those with harmful/hazardous drinking. Only 3 said that the incident of self-harm was related to their use of alcohol or drugs. Current suicide risk was calculated on the basis of thoughts and behaviour during the last month alongside lifetime suicide attempts. Eighteen young men were assessed as having some level of risk of suicide: 15 young men were low risk (19%), 2 moderate risk (2.5%) and 1 high suicide risk (1%). Nineteen per cent had attempted suicide at some time in their life. Stressful life events The majority of the young men interviewed had been victims of physical assault at some time in their lives and almost half had caused serious harm or injury to someone else. Five per cent had been victims of sexual assault.
Table 5.13 Young offenders: stressful life event experienced N (%) 65 (81%) 53 (66%) 34 (42.5%) 2 (2.5%)

Physical assault Sudden unexpected death of someone close Serious injury/harm/death caused to someone else Sexual assault

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Psychotic experiences Twenty-six young men (33%) reported one or more psychotic experience at some time in their lives (Table 5.14). Most of these confirmed that they were using alcohol or drugs at the time of the experience. This rate is lower than that for the ethnic minority men (see below), but still indicates a surprisingly high rate of sub-clinical psychotic experiences, probably related to poly-drug use.
Table 5.14 Young offenders: psychotic symptoms experienced N (%) reporting symptoms 5 (6%) 11 (14%) 14 (18%) 20 (25%) 11 (14%) 8 (10%) 16 (20%) 24 (30%)

Have you ever believed you were being sent special messages through TV/radio/newspaper? Have you ever believed you or some force outside yourself put thoughts in your mind? Have you ever heard things other people couldnt hear, such as voices? Have you ever believed people were spying on you/plotting against you? Have you ever believed that someone was reading your mind / could hear your thoughts? Have your friends or relatives ever considered any of your beliefs strange or unusual? Have you ever had visions when you were awake or ever seen things other people couldnt see? Were you using drugs or alcohol at the time you had any of these experiences?

Manic experiences were reported by 35 (44%), of whom 23 (29%) attributed it to using alcohol or drugs. However this figure should be interpreted with caution and is not equivalent to manic psychosis.

Physical health
Thirty-three young men (41%) rated their physical health as good, with a further 23 (28%) rating it as very good or excellent. Similarly, on one of the items from the SF36, 40% believed that the statement my health is excellent was mostly or definitely true. The incidence of serious illnesses, which may be related to substance misuse, was low, with none of the interviewees recording that they had contracted TB, Hepatitis or HIV. Forty per cent had had a hepatitis test at some time, and 37.5% had had a test for HIV. Three young men had had sexually-transmitted diseases (one in the last month), 2 young men had epilepsy and one had diabetes. Despite their overall positive self-ratings of health, 22 young men identified a specific health problem that they had experienced in prison and about which they were dissatisfied. As with the womens sample, most of the dissatisfaction was concerned with perceived delays in receiving treatment. Three young men had asthma, of whom two were waiting for either an appointment or an inhaler. One young man said he had waited four years for an operation for a knee injury, while another said he had waited two months to be referred to hospital for a chest examination/treatment. Two young men were concerned about delays in receiving the results of blood tests, one was waiting for an appointment for eczema treatment and two complained about poor standards of dental treatment.

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Young offenders: findings from the qualitative study Practitioners commented that male young offenders substance use tends to differ from that of adult prisoners. Certain patterns of use were represented as intrinsic features of youth cultures. For example, several participants related the prevalence of ecstasy use among young offenders to the popularity of clubbing and raving among young people. It was noted that heroin use and injecting appear to be less common among young offenders than adult prisoners. Participants attributed this to the greater stigma attached to these activities by young people in general, and by those from minority ethnic populations in particular. Conversely, it was mentioned that young mens use of crack cocaine might function to enhance their status among their peers, at least in the prison environment. Participants reported that alcohol use frequently comprises a component of poly-substance use among young offenders. Several participants noted that young offenders were potentially in only the early stages of their substance-using careers. This was seen as cause for optimism. Problematic substance use was seen as generally less entrenched in male young offenders than in adult prisoners, and hence more amenable to treatment. Further, young offenders were seen as less likely to have experienced serious substance-related health problems. Drug use was reported to be prevalent among young offenders in prison. As in adult prisons, this was associated with bullying and was said to cause difficulties for prisoners wishing to abstain from drug use. However, use was said to be rare on the self-contained wing housing the Drug Rehabilitation Unit for young offenders at one of the training prisons participating in the study. Peer Supporters as well as practitioners agreed on this point. Crucially, young men on the wing were reported to exert a level of self-policing, such that drug use was not tolerated. As for adult prisoners, practitioners identified a need for the development of alcohol misuse treatment options for young offenders. With respect to treatment services more generally, they felt that there are number of specific issues to be considered when delivering a service to young offenders. A number indicated that the immediacy of young offenders need to access services is greater than that of adult prisoners. This suggests that the shortfall in drug treatment services may be a particularly pressing issue in establishments housing young offenders. Other issues related to the young mens developmental stage. Participants acknowledged that peer influence is greater among young people than adults; they cautioned that membership of a drug-using peer group might render young offenders especially difficult to engage with services. However, peer influence was also reported to operate more positively, such that the presence of abstinent peers might operate to support young men in their attempts to abstain from substance use. Level of maturity was also considered an issue. Participants felt that greater efforts were required to engage young offenders with services. Programmes designed for adult prisoners were seen as inappropriate for this population. For example, mode of delivery was said to be vital. Activity-based group work was promoted as one means by which young mens interest might be held successfully. The provision of harm minimisation interventions to young offenders was stated to be particularly important. Participants commented that in general young offenders level of knowledge about substance use is lower, and their use of substances more cavalier, than that of adult prisoners. In support of the quantitative findings, participants reported that young offenders generally failed to gain any qualifications while in compulsory education. Opportunities to access education in prison and in the community are widely promoted as a means of offering young offenders meaningful activity that might serve as an alternative to drug use and offending. However, participants noted that young offenders experience of schooling had typically been

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negative. Several cautioned that the provision of formal education should not be overemphasised, and that equal emphasis should be placed on engaging young men in vocational training. It was suggested that this latter strategy might be most effective if training were directed toward young men gaining employment in industries valued within their cultures. Participants reported that affective disorders were relatively common among young offenders. This was said to be the case among both those with and those without substance use issues. The prison environment was seen as a primary factor in the incidence of anxiety and depression among young offenders; levels of bullying, boredom, and frustration were reported to be high. In particular, the prison environment and imprisonment per se were seen as primary factors in the incidence of self-harm among young offenders.

Illustrative cases
Case E Case E is a young white man of 19, serving an 18 month sentence for ABH. He started taking ecstasy at 11 years old and cannabis at 12, while playing truant from school. He began to self-harm at 12, following the death of his mother. He left school at 16 without qualifications, having been excluded eight times for bad behaviour. He has never had a job and says he cant get work because of his criminal record. He has also been prescribed anti depressant medication by his GP. Before coming to the YOI he was drinking very heavily, in order to feel better and forget things, and commented that he drank less only when he saw his friends vomit blood. In the YOI he has received some help from the CARAT team for alcohol, but would like further counselling and help in dealing with the past. Although he appears to be dependent on cannabis, he no longer uses ecstasy or LSD and does not feel he needs any help for drugs. He is on a VTU but is using cannabis about once a week. Case F Case F is a young black man of 19 serving a four-year sentence for robbery. He appears to have had little education past the age of 7, having been excluded from school four times for aggressive or violent behaviour. He was assessed as having special needs at school and still has serious literacy / numeracy problems. He has never had a job and lives with his family. In the year before prison he was drinking heavily, particularly when socialising. In the YOI he has attended self-help groups for alcohol and does not think he needs any further help. By the age of 12 he was using cannabis, ecstasy, LSD and cocaine and was using all of these regularly in the 12 months before his sentence. He does not perceive himself as dependent on any of these substances, despite spending approximately 1400 per week on drugs. He has attended Narcotics Anonymous in the YOI and received some advice from CARAT workers in a previous establishment, but he does not think he needs any further help for drugs. He says he has felt tense or wound up most of the time during the past week. Case G Case G is a young white man aged 20, convicted of possessing drugs with intent to supply. He has a number of previous convictions for drug offences. Prior to coming to the YOI he was employed, although before that he was unemployed for over a year as a result of substance misuse problems. In the year before his conviction he was dependent on heroin, crack and tranquillisers and was also using cannabis, cocaine powder, and amyl nitrite. Before coming to the YOI he received help (detoxification and maintenance medication) from a local agency. On arrival at the YOI he was given valium and sleeping tablets. Since then he has had advice from the CARAT team and also attended a drug awareness course focusing on relapse prevention, which he thought was good. He is waiting for a place on a VTU. He believes that he needs further help when he leaves the YOI, in particular someone to talk to such as a drugs counsellor, and further help with relapse prevention.

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6.

Discussion, Conclusions and Recommendations

Overview
The central purpose of this research was to identify those factors which impact on minority group treatment needs, to show how such factors impact on drug use, and to suggest how such factors might be combated. This section highlights some of the main findings from the survey and makes a number of key recommendations. These are based on findings from both the quantitative survey and the qualitative investigation.

Women
Prevalence of drug misuse and dependence The rates of drug use outside prison reported by women in this survey are very high, with 81% reporting using drugs at some time in their lives and 72% reporting drug use in the previous 12 months. In the twelve months before prison women used mainly cannabis (56%), heroin (44%) and crack cocaine (43%), with a third reporting tranquilliser use. White women had higher overall rates of drug use than black/mixed race women did. There were also ethnic differences in the pattern of drug use, with black/mixed race women significantly less likely to use heroin, tranquillisers and amphetamines, although equally likely to use cannabis. Our method of quota sampling complicates straightforward comparison with other studies of prevalence but it is still possible to draw conclusions. Despite the higher proportion of nonwhite women in our sample (which might have been expected to have reduced the overall rate) the headline rates of drug use we observed are higher than those found by Singleton et al. (1998) in their survey of Psychiatric Morbidity among Prisoners in England and Wales. Almost half the sample was dependent on at least one drug (as defined by scores on the Severity of Dependence Scale), with significantly higher rates of dependence for white women than black/mixed race women. About 20% of women were dependent on more than one drug, most commonly combining heroin and crack. White women were more likely to be dependent on heroin, and more likely to inject, whereas the proportion of women with crack dependence was similar in the two ethnic groups. Any attempt to address the specific needs of ethnic minority women must therefore consider the different patterns of heroin and crack use. Drug use in prison Despite the strengthening of controls over the supply of drugs into prisons, over a quarter of the women interviewed said they were still using heroin while in prison, albeit mainly on an occasional basis compared with daily use outside. Six women (2%) reported injecting in prison. The figure for heroin use inside prison is slightly higher than that recorded by Singleton et al. (1998), whereas the rate of cannabis use in prison appears to be lower. As noted above, direct comparisons are complicated by the different sampling methods and it is probably safest to conclude that both studies arrive at similar rates for drug use within prison. It has been suggested that MDT may lead people to change from cannabis use to heroin to avoid detection in tests (Edgar and ODonnell, 2000). The numbers previously self-reporting a changing to heroin are small and the change may not be permanent (Edgar and ODonnell, 2000). In our study a change from cannabis to heroin was reported by 3% of the women in this sample. 1
1

At the time of writing a study commissioned by the Home Office Prison Service, is investigating possible changes in patterns of drug use in response to MDT.

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The significance of this finding depends on a complex balancing of the benefits of MDT (reducing temptation and facilitating treatment) against its risks (providing a reason to move from cannabis to heroin use). Our study provides relevant data, particularly in the finding that over a quarter of women still have their recovery jeopardised by the availability of heroin within prison. Nevertheless, the study was not designed to evaluate MDT and any weighing up of risks and benefits is beyond our remit. Thirty-seven per cent of women who had used drugs in the twelve months before prison were currently on a voluntary testing unit (VTU) or drug free wing. This is very close to the 38% of male drug users on VTUs reported by the BMRB study (2000). An additional 12% of women were waiting for a place on a VTU at the time of interview and several women called for more places to be made available. A slightly smaller proportion of drug dependent women (35%) were on a VTU or drug free wing. However, this latter rate compares favourably with the 22% of dependent male drug users on VTUs, reported by the BMRB (2001) study. On the other hand, the qualitative research highlighted the tension that may arise between the collective need for a drug-free environment and the needs of individuals (particularly the most vulnerable and needy prisoners) who may relapse. The qualitative work suggests there may be a pragmatic approach to abstinence in the VTUs at some prisons and that CARAT workers will offer support in such settings where positive tests are recorded. A wider debate is needed, about the appropriate management of those women with the highest propensity to relapse. We recognise that this is an old and probably insoluble dilemma. If one directs scarce resources to the most efficient treatment of the majority of inmates, the treatment may not be ideal for the most vulnerable, who have special needs. On the other hand, a concentration on a vulnerable and needy minority may dissipate resources with no impact on the majority of drug users and by concentrating on the worst cases, risks a low success rate in the minority who are treated. The traditional response within public health medicine is to direct resources at the majority, milder problem, as this is the strategy most likely to improve the overall health of the population. We explore the issue here, as the projects emphasis is on minority needs. When implementing the findings, it will be necessary to consider the wider principles of improving the health of a population. Drug treatment needs Women with drug problems were generally very aware of their need for help and/or treatment, starting with adequate detoxification regimes. The qualitative work confirms findings from the survey that arrangements for detoxification appeared to vary considerably between different prisons. The most frequent concern was that detoxification was not long enough the same concern as voiced by men in the BMRB (2001) survey. The survey findings indicate that a lower proportion of black women than white women received opioid detoxification, and the same was true of maintenance medication using opioid substitutes. This is most likely to result from the different patterns of drug use, with white women having problems mainly with opiates, whereas black women were more likely to use crack cocaine. This is the most important finding of the study, in respect of ethnic differences. The problem is wider than the technical issues surrounding the two classes of drug and their associated problems. Different subcultures surround the use of the stimulant crack on the one hand, and the sedative opiates on the other. A drug treatment service may be truly colourblind, in having the highest standards in non-discrimination. Nevertheless, if it caters mainly to heroin users, it will look like a white service, and vice versa. The qualitative findings support the survey results, confirming that black women need more interventions focused on crack use (see, for example, Case C, at the end of Chapter 3).

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Although the literature on variations between ethnic groups is sparse, anecdotal evidence is entirely consistent with our findings, and services in some prisons have responded appropriately. They face ongoing problems, in that the management of crack misuse is seen as less straightforward than the treatment of opiate dependence. In our view, this is a misunderstanding based on the fact that the pharmacological response to opiate dependence is simpler. Once one turns to the psychology of relapse prevention, the principles are identical and problems can only be due to a lack of experience in applying them to stimulant dependence. We are aware that any general statements risk offending those who are providing a good service. Several women who had been in Holloway saw their detoxification and post-detoxification provision as an example of good practice that should be replicated in other prisons. Just over a third of women dependent on drugs reported receiving some kind of advice or education from CARAT workers (compared with 23% of drug-using men in the BMRB study), although in many cases this was simply an initial assessment. Altogether 71% of dependent women reported receiving some kind of help, for many this referred only to medication for detoxification. A quarter of the drug-dependent women reported receiving counselling, while fewer than 10% reported attending drug courses or rehabilitation programmes. On the face of it, this appears to indicate a mismatch between supply and demand. We are not able to comment on the level of supply but we are confident about the level of unmet demand. In part, the CARAT scheme can be seen as a victim of its own success. Women see a service that was not there before, and express a desire to take advantage of it. One of the purposes of this study was to identify specific factors impacting on the treatment of women with drug problems. Whilst it may be unrelated to their gender, it is impossible to avoid the conclusion that one of the main negative factors is the unmet demand for treatment services after the initial assessment and detoxification. In addition to an apparent demand for a service already in existence, there was a strong message from the women about wanting counselling. In fact, this statement appeared to mean someone to talk to rather than a particular kind of therapy. CARAT workers have been very successful in identifying women with drug problems, assessing their needs and setting up therapeutic programmes. However, those who participated in the qualitative study reported that the resources (human and physical) available to offer follow-up, supportive counselling or any kind of proactive work are finite. The qualitative findings support the implications of the survey findings, that alternative ways of offering someone to talk to should therefore be considered, for example extending and evaluating peer support initiatives to ensure that they are reaching drug users. The demand for someone to talk to begs the question what about? but it is impossible to generalise in response to this question. Issues range from problems within prison (such as bullying) through problems with partners, children or others outside. There is also a spectrum of perceived mental health problems ranging from mild anxiety through severe depression to psychosis. The literature has always identified such problems more frequently among female prisoners than male. Indeed, the same is true of the general population, outside prison. There is also evidence that women with such problems are more likely than men to present them to medical or other services. In this respect, our findings are consistent with other sources, and they will not surprise anyone who is familiar with womens prisons. The implications for services are not straightforward. It would be counterproductive to dissipate the resources of CARAT, or any other drug service, in attempting to deal with a wide range of problems whose connection to drug use may be indirect, even though it is important. In looking for a solution, it is best to return to the community, and consider how problems are solved there. The key medical person is a GP, who can sort out those requiring an occasional ear, from those who require specialised counselling or other help. We have no wish to be seen as proponents of a medical model, but our findings suggest that the work of

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drug services within prison would be made much easier by an effective primary care service. Whilst realising that this is true of all prisons, the lack of such a service is most keenly felt by women in prison. We are aware that a major initiative is underway to improve medical services in prisons through partnership with the NHS. While acknowledging the important role of services such as in-house psychology, seconded probation staff and voluntary agencies, our findings suggest that drug services in womens prisons would benefit from improved primary care services, which would allow them to concentrate on their primary task. It will be important for there to be good liaison between CARATs and the evolving primary care and psychiatric services within prisons for women. Recommendations: 1. Our findings suggest that initial assessment is widely available and of good quality. However, there is a need to review assessment procedures to ensure that remand and short-sentence prisoners are prioritised for rapid assessment and referral to community-based services. The qualitative study suggested that current Key Performance Targets may constrain the capacity of the CARAT service to prioritise these remand and short-sentence prisoners for assessment and hence compromise service delivery. This recommendation applies equally to each population studied. The qualitative study suggests that identification and referral of inmates with drug problems could be promoted by ensuring prison staff are able to access CARAT referral forms and other information about available services. Treatment for heroin users is vital for the female population. The exceptionally high rates of heroin dependence (particularly for white women) compared with men must be taken into account when planning gender-appropriate services. There is also a need for services targeted specifically at users of crack cocaine. To be successful these services will need to ensure they are culturally appropriate for black women, for whom crack appears to be the most common drug of choice. In attempting to create a service that is responsive to the needs of ethnic minorities, the single most important factor is to ensure that the service caters fully for users of crack. It must not be seen as a secondary or less important drug. The qualitative study shows that there is also a need to offer young women (and other populations studied) interventions addressing age-related issues. A clear model of good practice for detoxification has been developed but our findings suggest this needs to be implemented more consistently across the womens estate. Detoxification regimes for crack and other non-opiates, and appropriate post-detoxification care, are key areas for future development. Urgent and serious consideration should be given to our finding that a small number of women change from cannabis to heroin use in prison. There is considerable unmet demand for places on VTUs and drug-free wings. This is not, in any sense, a criticism of current provision. Rather, it is an indicator of the success of such facilities. There is a need for more places. The single most common request for help was presented as a desire for someone to talk to about drug-related problems. It is inevitable that CARAT teams will be called on to meet this demand, which falls outside their core task, but the true

2.

3.

4.

5.

6. 7.

8.

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solution lies in the development of good primary care services. There should be full liaison between CARAT teams and the developing NHS/prison partnership. At the same time, it must be recognised that the demand for this type of service in prison may be so large that no service could satisfy it. There should also be further development of the peer support schemes that are already in operation and, according to the findings of the qualitative study, are working well. 9. Therapeutic community and rehabilitation programmes had reached only a small proportion of the women in our survey sample who could have benefited. It is sensible for a new service to have concentrated on assessment and detoxification, but further development should be concentrated on interventions and treatments, particularly for women on remand or serving short sentences.

10. The qualitative study suggested that CARAT workers experienced pressure to perform tasks beyond the services remit and, in some instances, beyond the practitioners areas of expertise. Strategies for better supporting CARAT workers need to be identified. Alcohol The survey results suggest that over a third of women in prison have patterns of drinking alcohol that may be described as harmful or hazardous. Rates of harmful drinking were marginally higher for white women than for black/mixed race women (with the rate for white women close to that reported by Singleton et al. (1998) in a predominantly white sample). Women reported drinking primarily to cope with negative emotions, stress and painful memories but only one in ten of the women said they had wanted help for alcohol problems before coming to prison, so it is not surprising that few reported receiving help in prison. Co-occurrence of drug and alcohol misuse Eighty women (27%) reported both harmful drinking and the use of at least one illicit drug in the 12 months before prison, including 49 (16%) who were assessed as co-morbid (i.e. drinking at harmful levels and dependent on at least one drug). Crack users in particular referred to using alcohol as a sedative, to balance the stimulant effects of crack. Both the survey and qualitative findings suggest there is a general need for better identification of alcohol problems in women and to educate women about the harmful effects of excessive alcohol consumption. The latter problem is one of health education and, in that sense, requires a broader approach than one could expect from a treatment service. It could even be argued that women in prison are reflecting wider trends in society, and that the task of education must begin outside prisons. On the other hand, treatment services should be taking a lead in focusing on those women who have co-morbid drug and alcohol problems. The qualitative study suggests that CARAT workers are aware of these problems, identify a need for intervention and often address co-occuring alcohol and drug use. However, they also expressed the view that their ability to act in relation to alcohol misuse is limited. Resources are finite, and their service gives priority to drug problems. Our concern is that a service directed at drug problems alone is wasted on those women who have co-morbid alcohol problems, and there is a need to remove the artificial barriers that exist between services for different substances.

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Recommendations: 11. Assessment of womens treatment needs for alcohol should be based on objective assessments of level, amount and pattern, since few women subjectively identify harmful drinking as problematic. An example of a suitable assessment scale is the Alcohol Use Disorders Identification Test (AUDIT) used in this survey and the ONS survey. We recognise that this may not be a priority for CARAT workers, but it is an approach that fits well with the needs assessment exercise taking place following the publication of The Future of Prison Healthcare. 12. It is inevitable that treatment interventions will have a low take-up if women do not see their drinking as harmful. In these circumstances, it can be argued that attempts to provide treatment for straightforward harmful drinking are pointless and a waste of resources. The priority should be health education. Apart from emphasising the limits to safe drinking, health education should have a specific focus on the dangers of combining alcohol with drugs, and there should be an attempt to promote alternative methods of managing stress and coping with negative emotions. The latter task is part of primary care rather than drug treatment services. 13. Drug treatment services need to develop a co-ordinated treatment programme for women who are co-morbid for drug and alcohol misuse. Many such women attribute their substance misuse to emotional problems, so there should be close liaison with primary care and psychiatric services. This recommendation applies equally to each of the populations studied. 14. The qualitative research indicates that, despite the availability of good alcohol detoxification services in some local prisons, this service is thinly spread and compares unfavourably with the availability of drug detoxification services. There appears to be unmet need in training prisons, because of the rapid onward transfer of inmates from locals, and we recommend that such prisons work towards providing an appropriate level of residential detoxification service for both drugs and alcohol. These findings apply equally to each of the three treatment populations studied and require specific service interventions to be developed. Mental health Much of the literature from the US has suggested that womens drug-taking is linked to family influences, abuse, violence, low self-esteem and mental health problems. Our results are consistent with this picture, to the extent that both alcohol and drug misuse were associated with the experience of being physically assaulted. However, the picture is more complicated than these simple associations suggest. Alcohol problems were also associated with causing physical harm to others, suggesting that the association may result from underlying personality or lifestyle characteristics, rather than a causal link between victimisation and substance misuse. This is a complex issue that is probably not amenable to a simple explanation, and it is certainly beyond the scope of the present study. For our purposes, it is sufficient to note that female drug users are more likely to report problems of victimisation. Recommendation: 15. As recommended in much of the American work on substance misuse, therapeutic programmes for women should continue to take into account the links between substance misuse and experiences of being a victim of violence. The guiding principle is to acknowledge past traumas, whilst learning ways of coping with present distress.

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Our findings do not support the widespread application of a victim model in female substance misuse, any more than in men. Women with substance misuse problems often have impressive offending histories and, during therapy, will have to acknowledge the extent to which their problems have led them to harm others, as well as themselves. Two-thirds of the women in this survey had sought help for emotional problems outside prison, with 40% seeking help in prison, usually defining their problem as depression. Measures of the womens emotional state in prison showed that almost one in five women were currently experiencing severe anxiety, between a quarter and a third were experiencing mild to moderate anxiety or depression, and six per cent reported severe depression. These problems were not specifically associated with substance misuse. They were presented by many women as a response to the experience of imprisonment but the high levels of symptomatology prior to imprisonment suggest that this explanation is an oversimplification. Our study cannot identify the causes of these symptoms and, to some extent, the search for causes is a distraction from the question of how to respond. In our sample, 43% of women who sought help for anxiety or depression had been prescribed medication, but few reported receiving other kinds of intervention. It is ironic that women who find themselves in prison because of offending associated with substance misuse find that other substances are the primary response to emotional problems. There is an extensive literature on the psychological treatment of anxiety and depression. The weight of evidence probably favours psychological over pharmacological treatments in all women and, in those with a history of substance misuse, the argument in favour of psychological interventions is overwhelming. The aim must be to develop alternative strategies for managing mild to moderate anxiety, without recourse to alcohol or drugs, whether prescribed or illicit. It is recognised that this task impinges on primary care and mental health services, as well as drug treatment services. Again, there is a strong argument for joined up services, as womens substance misuse problems often have their roots in wider emotional difficulties. Recommendation: 16. The successful treatment of substance misuse problems in many women will depend on the development of psychological strategies for managing anxiety and depression. This will require assistance from primary care and mental health services, not least so that the occasional case of severe depression can be distinguished from the common, milder forms. 17. Consideration should be given to the use of guided self-help programmes, which have been found effective in managing mild to moderate anxiety and depression in other settings. Whilst recognising that such factors are beyond the control of any substance misuse service, it must also be acknowledged that improvements in the prison regime (including better access to purposeful activity and exercise) would be obvious strategies for decreasing the prevalence of anxiety and depression in the population. We found that black women were less likely to seek help for emotional problems, whether inside or outside prison, despite the fact that their anxiety and depression within prison was at levels similar to those of white women. We found also that drug dependence was associated with deliberate self-harm in black women but not in white women. The precise meaning of this finding is not clear, but it shows the importance of improving the treatment of emotional problems in black women. It has been observed, in the wider community, that mental health services tend to concentrate on psychosis, whilst neglecting less serious problems in ethnic minorities. This is a complex problem, so it is only possible to make recommendations in general terms.

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Recommendation: 18. There is a need to ensure that new developments within prison mental health care include arrangements for monitoring use by different ethnic groups, in order to ensure equality of access. One in five women reported two or more psychotic experiences in their lifetime, and these experiences were more common amongst women who were dependent on drugs. Selfreported manic experiences were also associated with dependence on heroin or crack cocaine. Causality is complex and beyond the scope of the present study. Drugs may cause the abnormal experiences that, in turn, may affect a womans ability to manage or control her drug taking. In some cases, drugs may have been a response to serious mental illness. The problem for services within prison is similar to that outside, in that co-morbid women fall between the two stools of mental health and drug treatment services, neither of which wants to address the other services problems. Recommendation: 19. Drug treatment programmes should include closer liaison with mental health services, and there should be more awareness among drug workers of the mental health risks associated with dependence on specific drugs. A significant minority of drug-using women will require specific help for psychotic symptoms. Physical health Womens views of their physical health were generally positive, although they often expressed concerns about delays in treatment and lack of information. In this respect, women with substance misuse problems were no different from the rest of the sample. Almost a quarter of women who injected drugs had had hepatitis at some time, and injectors also had slightly higher rates of epilepsy and diabetes than other women in prison. Recommendation: 20. Healthcare assessments should continue to pay particular attention to women who inject drugs, including providing information on safer practice, due to the higher risk of epilepsy, diabetes and hepatitis in this group. 21. Womens dissatisfaction with prison healthcare services falls outside the specific remit of this research. Release planning and through-care The qualitative study suggested that current application procedures for funding and for access to community-based services were both complex and lengthy. The time taken to arrange these resources is a critical factor in the delivery of effective service provision to remand and shortsentence prisoners. 22. For all populations, there is a need for standard forms and procedures for applying for funding for and access to community-based services.

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Men who are members of an ethnic minority

Drugs In most studies of (predominantly white) male prisoners (e.g. Singleton et al., 1998; BMRB 2001; Burrows et al., 2001), the picture is dominated by heroin. At worst, crack cocaine has been found to be of equal prevalence, but many of the crack users had heroin as their main drug of misuse. In essence, the picture in prison was similar to that in drug treatment services throughout England and Wales, with the focus being on heroin. Patterns of drug use in our ethnic minority sample were quite different, with 85% reporting use of crack in the year before prison, including 68% who were dependent on it, but only 35% using heroin. Recommendations: 23. Treatment programmes for ethnic minority men should have crack cocaine as their primary focus. 24. We have noted in relation to women that detoxification practice was not implemented consistently across the womens estate. This was also apparent amongst the male estate. Reported inconsistencies between local and training prisons in the range of interventions and quality of care available need to be addressed. There is a need to ensure appropriate management of medication regimes on transfer, and to provide residential provision within training prisons. A significant number of men identified as heavy users outside, reported a reduction in their crack use inside prison, whereas heroin use tended to be maintained, presumably reflecting differences in supply and control. Forty-two percent of the men who had used drugs in the twelve months before prison were currently on a VTU. Comments received from prisoners (eg. Case H in Chapter 4) about voluntary and mandatory drug testing are consonant with the earlier finding by Edgar and ODonnell that prisoners associated drug testing with punishment. There is an element of contradiction between these findings, as drug control measures had been helpful to many former crack users, in keeping them off the drug in prison. Recommendation: 25. More publicity should be given to the apparent success of drug control measures in reducing the use of crack cocaine in prison, with consequent therapeutic benefit to former users. There is a need to reduce the supply of heroin, as its availability is jeopardising treatment. As expected in this selected sample, the majority of men had received some help for drugs in prison, including a third who had had counselling and a quarter who had attended Narcotics Anonymous groups. Approximately a quarter had attended courses or rehabilitation programmes. These interventions were well received and appreciated by the men, but there was a demand for further courses inside prison and for continuing support outside. As with the women, the successes have been in the areas of initial assessment and treatment, with the service yet to address fully the questions of ongoing therapy and rehabilitation. The need for practical help with employment, and with housing away from drug contacts, was mentioned spontaneously by one in six men. It is important to bear in mind the findings from American studies, suggesting that the crucial factor in maintaining abstinence is support after leaving prison, more or less irrespective of treatment within the custodial setting.

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Recommendation: 26. Further developments in CARAT teams should concentrate on (i) increasing the number of places on therapeutic programmes and (ii) pre-release planning to address employment and housing needs, and to establish ongoing contact with services outside prison. Alcohol Half of the sample was assessed as having harmful or hazardous levels of drinking alcohol, with just over a third classified as both harmful drinkers and dependent on drugs. Of particular importance in this group was the apparent association between alcohol and crack use, with many men commenting that their crack use determined their patterns and level of alcohol consumption (alcohol being used as a depressant to counter the stimulant effects of crack). Recommendation: 27. Treatment interventions for ethnic minority men need to pay particular attention to the relationship between crack and alcohol use. For example, crack users may not identify their alcohol use as problematic, viewing it instead as an appropriate way of managing their crack use. This should be addressed as part of the overall treatment package for crack users, and there is a strong case against the separation of drug and alcohol services for this group. Mental health About a quarter of the men were experiencing moderate to severe levels of depression and anxiety, although few had asked for help (seeing depression as a normal part of the crack experience) and even fewer reported receiving help. The very high rates of reported subclinical psychotic and manic experiences (48% and 35% respectively) are of concern and were frequently associated with alcohol and drug (especially crack cocaine) use, suggesting that this sub-group are at particular risk for violent behaviour when intoxicated. Recommendations: 28. The high rate of psychotic symptoms in this sample suggests a need for close cooperation between CARAT teams and psychiatric services. CARAT workers should have a low threshold for requesting a full psychiatric assessment in this high risk population. 29. The promotion of practical anxiety management strategies is recommended.

Young offenders
Drugs The young offenders reported using a wider variety of drugs in the 12 months before their sentence than the similarly selected ethnic minority men. In particular, they reported a wider use of recreational drugs, with rates of dependence remaining relatively low. For example, 94% had used cannabis but only 10% were dependent on it. Heroin and crack were the two drugs with the highest rates of dependence, and 20% had already injected drugs, with 5%

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having shared needles or syringes outside prison. Forty percent of the young men reported that their friends and family also had problems with drugs. The findings are consistent with the natural history of drug dependence and with other literature on young peoples drug use. They portray an experimental, pick and mix approach to drugs, with little awareness of the long-term consequences, suggesting an urgent need for health education on safe practice. One would expect that young drug users would not be receptive to calls for abstinence but, on the whole, the young offenders in this selected sample were receptive to the possibility of further help. They asked for more courses, more support and counselling. They also noted that there were often long waiting lists for places on treatment programmes or drug-free wings. Recommendations: 30. Programmes for young offenders need to adopt a broad educational approach to cover the wide range of substances used. At the same time, it should be acknowledged that much of their recreational drug use is determined by social settings and drug-using peer groups, and may only be addressed by changes in lifestyle or environment. A concentration on drug use in isolation is unlikely to be successful. Programmes focusing on positive alternatives to drug taking would be welcomed. 31. Both the quantitative and the qualitative findings support the case for further resources to improve access to drug-free wings and rehabilitation courses. 32. The one in five young offenders in our selective survey sample who are already injecting drugs need urgent education about health risks and harm minimisation strategies. The qualitative research suggested that peer educators were a valued intervention and appeared to merit wider extension. Peer educators were seen as helping the engagement of young offenders both with CARAT and with rehabilitation service interventions. Young offenders were also felt to respond well to age-appropriate and challenging interventions delivered within a structured programme and supportive environment. Alcohol Many of the young offenders selected for interview were drinking heavily and frequently. In comparison with the women and older men, more young men reported drinking for social reasons, particularly to keep up with friends and to conform to social and cultural expectations. Like the women, many young offenders did not recognise the need for help with alcohol problems. They were less likely to identify anxiety or depression as reasons for drinking. Over half of the young men said that most or all of their family or friends outside prison had problems related to alcohol use. This implies that interventions focusing on abstinence will have little relevance for young men who return to an environment where drinking is a social necessity. Health education and programmes directed towards alcohol management and controlled drinking are more realistic. Recommendations: 33. Health assessments of young offenders should include objective measures of level and frequency of drinking, such as the AUDIT scale used in this survey, since young offenders are unlikely to report harmful drinking as problematic. 34. Health education is a necessary precursor to offering treatment programmes for alcohol. Take-up of alcohol treatment is likely to be low unless young offenders

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understand the health consequences of excessive drinking, and are able to confront the social and cultural pressures on them to misuse alcohol. 35. Programmes for young offenders on alcohol misuse should incorporate a range of alternative treatment goals, including controlled drinking programmes for the majority, in whom abstinence is not a realistic option.

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Mental health A third of the young offenders had had contact with mental health services outside prison and a similar proportion received help inside. Almost a quarter of the young men had self-harmed at some time in their lives and one in five had attempted suicide, although they tended not to relate this to their substance misuse. On the other hand, about a third of the young men recognised a relationship between their substance misuse and psychotic experiences. A very high percentage had been victims of physical assault, including high rates of violence within the family. In general these young men emerged as having a range of psychological and emotional problems that need to be addressed in parallel with attempts to manage their substance misuse. Recommendation: 36. It is important to recognise that young offenders with substance misuse problems also have high rates of psychological and emotional problems, and need help in recognising and understanding the links between these factors. These needs have been discussed in the literature in relation to women but also apply to young men. Of course, young men will differ considerably from young women in the presentation and treatment of emotional problems. Wider policy implications Young offenders are at a critical stage, having already tried a range of drugs without yet becoming dependent on most of them. They have not yet experienced most of the negative consequences of substance misuse, they may not see themselves as having any problem with alcohol, and are likely to be unclear about what help they need. We found that although some young offenders were resistant to the idea of treatment, others wanted help but did not know what to ask for. Although somewhat beyond the brief of this study, we also believe there are policy implications arising from the association between substance misuse, offending and educational failure, particularly apparent in the young offender population. Many of the young offenders with substance misuse reported using drug and alcohol when playing truant or excluded from school; 79% left school without qualifications, 28% were assessed for learning difficulties, and two thirds were unemployed before their sentence. These are associations we observed and inevitably the relationship between educational failure, social exclusion, drug use and offending behaviour is a complex one that requires investigation and intervention at a societal level.

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Produced by the Research Development and Statistics Directorate, Home Office This document is available only in Adobe Portable Document Format (PDF) through the RDS website Home Office Research, Development and Statistics Directorate Communication Development Unit Room 275 50 Queen Annes Gate London SW1H 9AT Tel: 020 7273 2084 (answerphone outside of office hours) Fax: 020 7222 0211 Email: publications.rds@homeoffice.gsi.gov.uk ISBN 1 84473 082 4 Crown copyright 2003