Emerald Group Publishing Limited
Article Type: Editorial From: International Journal of Prisoner Health, Volume 11, Issue 1.
Welcome to our first issue of 2015. As always, we are pleased to present papers from around the world that address common prisoner health issues. Substance use among the prison population continues to be of widespread concern and a number of papers in this issue tackle different aspects of this topic.
In our first paper, Albert M. Kopak assesses how well current programmes serve drug-involved criminal justice populations in the USA. The assessment includes an overview of the most recent research on the prevalence of substance use disorders within the criminal justice system and the demand that they place on the system. Evidence indicates that the majority of prisoners in America's penal institutions can be classified with a substance use disorder. This high concentration warrants attention as the concomitant highly problematic levels of use have a profound impact on the criminal activities of many offenders. The author posits that the current reliance on incarceration as the predominant method to control drug offending is ineffectual for a number of reasons such as the oversimplification of existing programmes that can often lead to inadequate risk assessment or proper treatment. However, a number of programmes that have achieved positive results, including with participants deemed as high risk, are identified by the author. While noting that it is challenging to incorporate risk assessment and the tailoring of programmes to meet offenders’ treatment needs into programmes, the author identifies these two elements as key to a successful outcome. The use of medicated assisted therapy (MAT) is also considered with the author noting that there are many supplemental treatment options available, which could be used to help the most at-risk offenders. However, it is evident that there are many systemic attitudinal obstacles to overcome before these supplemental treatment options will be broadly integrated. The author concludes that apart from a few rare and innovative practices, the criminal justice system as a whole largely continues to rely on incarceration as its most popular response to substance use disorders. In his view, this is both misguided and unsuccessful as it fails to consider the growing body of research that endorses the utility of many other options. To address these shortcomings, the author calls for alternative approaches such as “evidence-based sentencing” and increased accountability for criminal justice officials and programmes that requires criminal justice administrators to justify the continuation of current practices, particularly in cases where reasonable evidence to support their continuation is absent.
Nat M.J. Wright, Charlotte N.E. Tompkins and Tracey M. Farragher explore prison drug injecting prevalence with a view to identifying changes in injecting prevalence and practice during imprisonment including views on prison needle exchange. A random study sample of 267 remand and sentenced prisoners was selected from a large male category B prison in England, which did not operate a needle exchange programme (NEP). Questionnaires were administered with prisoners on reception and, where possible, at one, three and six months during their sentence. Those prisoners who reported ceasing to inject on entry into prison, were questioned regarding their intent to continue injecting if NEPs were available in prison. The type of drug injected prior to their imprisonment was also explored to ascertain any link to prison injecting prevalence. Expected length of sentence was examined to identify if this was related to changes in injecting practice and if those on short sentences were less likely to stop injecting in prison. Results indicate that almost two-thirds of participants were injecting until admission into prison and most began injecting outside of prison. The majority of participants intended to stop injecting whilst in prison, with almost a quarter citing the absence of needle exchange in prison as their reason for doing so. Only 3 per cent indicated they would stop injecting as less drugs were available and 74 per cent selected “other reasons” for intending to stop injecting in prison. Participants did not always expand on what these “other reasons” were, but they included a desire to stop using illicit drugs when in prison. However, when asked if they would inject in prison if needle exchange facilities were freely available, a third of participants believed that they would. While noting the limitations of the study, authors posit their research as indicating a marked decrease in injecting practice amongst men entering a busy remand English prison who were injecting illicit drugs at reception. The findings also show that initiation into injecting in prison was not commonplace. They do concede whether reports of not injecting in prison truly reflected participants’ expected practices when questioned or whether the responses were influenced by social desirability reporting, given the stigma attached to injecting and the illegality of drug use in prison. The authors conclude that not providing NEPs alongside clinical support and treatment to drug-dependent prisoners is a contentious topic, as data from their study suggests provision of such programmes has the potential to prolong the injection careers of a significant number of drug users.
In our third paper, Kate Dolan, Ana Rodas and Adam Bode report on work undertaken to compare the use of drugs and alcohol by Indigenous and non-Indigenous prisoners and examine relevant treatment in Australian prisons. In addition to undertaking a literature review, prison authorities were surveyed about drug and alcohol use by prisoners prior to and during imprisonment and drug and alcohol treatment programmes available in prison. Representatives from each Corrective Service Department and Prison Health Service were asked to provide aggregate data and comment on inmates’ use of drugs and alcohol before and during incarceration and the range of drug and alcohol treatments provided for inmates in 2009. The year 2009 was chosen to allow for an analysis based on the implementation of the first National Corrections Drug strategy 2006-2009. The authors report that drug and alcohol use was a significant health issue among the Australian prison population, while a history of imprisonment was significantly related to substance use disorders. Prisoners were over five times more likely than the general population to have a substance use disorder. In addition, prisoners’ drug and alcohol use prior to imprisonment was extraordinarily high, while the level of risky alcohol consumption has actually increased over the last decade. This contrasts with declining patterns of drug and alcohol use in the Australian community. More surprising was that prisoners’ high level of drug and alcohol use continued even though an array of treatment programmes were available in prison. The authors also posit that drug treatment options within Australian prisons continue to be under evaluated. Drug and alcohol treatment options were more likely to be accessed by non-Indigenous inmates than Indigenous inmates despite Indigenous prisoners having a disproportionate health profile with higher levels of smoking and risky alcohol consumption. A possible explanation for this was the reluctance by Indigenous inmates to access services that were not culturally specific. They also note that the state of prison research is limited by a disinvestment in research within prisons and by a lack of transparency about how prisons meet the health needs of prisoners. This is affecting the levels of accountability and making it difficult to measure the extent to which government policy is implemented across the nation.
Ashleigh Djachenko, Winsome St John and Creina Mitchell review the available literature relating to smoking cessation (SC) interventions for the male prisoner population. A number of databases were searched for English language studies from 1990 to 2012 with 12 papers identified for inclusion. Of these, four studies focused on forced abstinence (a smoking ban) while the remainder looked at various combinations of nicotine replacement, pharmacology and behavioural techniques. Analysis of the selected studies revealed that forced abstinence (a total or partial smoking ban) had little impact on SC among prisoners, while the impact of local and national tobacco policies on prisoners’ perceptions of smoking and forced abstinence was a recurring theme. No robust studies were identified which specifically examined the role of the health care professional in promoting SC among prisoners. Several studies noted that the delivery of SC programmes was inconsistent due to under-resourcing or understaffing and that SC outcomes received lower priority than issues deemed more “important” such as drug misuse, infection control and mental health. All twelve studies described the promotion of SC in the prison environment as unique and challenging. A central theme was the identification of a “pro-smoking” culture in prison and the entrenched role of tobacco in prison society. The authors note that key findings from the review indicate that certain SC interventions can be successfully implemented in a prison setting with various combinations of counselling, Nicotine replacement therapy and pharmacology demonstrating quit rates comparable to those achieved in the wider community. It would also appear that tobacco control, which has contributed to a reduction in smoking in the wider community are having less of an impact in prison. While noting the paucity of relevant research, the authors conclude that their review identifies that SC interventions can be successfully implemented in prison settings provided that the underlying policies are clear and consistent. However, it is apparent that the current level of evidence is scant and further research is needed to determine the best approaches for SC in the prisoner population.
In the final paper of this issue, Tyson Pankey and Megha Ramaswamy explore incarcerated women's awareness, beliefs and experiences of human papilloma virus (HPV) infection and vaccination. Given that women incarcerated in jails and prisons report multiple risk factors for HPV and cervical cancer and that incarcerated women have been four-five times more likely to have cervical cancer compared to non-incarcerated women, the primary purpose of the study was to generate baseline information about this high-risk group's awareness, beliefs and experiences with HPV infection and vaccination as a way to inform future public health education efforts for such vulnerable groups. Researchers conducted focus groups with 45 incarcerated women in an urban midwestern US jail to assess how women talked about their papanicolaou (Pap) test screening and abnormal Pap test follow-up experiences. Some focus group questions specifically assessed individual awareness, beliefs and experiences with HPV infection and vaccination. While all 45 participants reported experiencing an abnormal Pap test event within the last five years, only two-thirds of participants (n=30) reported having heard of the HPV infection. Beliefs about the cause and severity of HPV varied. Women expressed frustration towards an age-restricted vaccine, and others reported having rather different experiences with vaccinations for themselves and their children. Many of the women who had heard of HPV reported learning about it through media exposure and they often had a desire to get more information about the infection and vaccine. While acknowledging the limitations of the study, the authors conclude that women with ongoing criminal justice involvement may be at increased risk for HPV infection and cervical cancer. A range of measures is recommended that may serve to close the cervical health gap between incarcerated and non-incarcerated women.
Morag MacDonald, Robert Greifinger and David Kane