Exploring the Intersection of Drug Addiction and Mental Ill-Health in Scottish Prisons: A Qualitative Study of Incarcerated Men

Abstract

This article presents insights from small-scale qualitative research exploring the intertwining nature of drug addiction and mental ill-health among men in Scottish prisons. Semi-structured interviews were conducted with 24 men in two Scottish prisons. The men’s narratives suggested that increased tension in prison halls had stimulated a huge surge in the use of New Psychoactive Substances (NPS), in turn increasing and deepening existing mental ill-health and violence. They believed health care in the prisons to be of low quality, and that methadone was prescribed as a mechanism for social control. Implications for future policy, practice and research are outlined.

Introduction

Scotland has the highest drug death rate in Europe, and deaths reached a record high in 2020 (National Records of Scotland, 2021). Drug harms cost the Scottish economy an estimated £3.5 billion annually (Casey et al., 2009). Nevertheless, very little is known about the lived experience of drug use and addiction in Scotland, especially among the approximately 8000 people residing in Scotland’s 13 public and two privately-managed prisons. A focus on incarcerated persons is important because a large proportion of Scotland’s prison population has an active substance use disorder and/or was incarcerated for a crime involving drugs or drug use (SPS, 2017).

The Scottish Prison Service (SPS, 2017) conducts drug testing to support a sentence’s progression and to identify the incidence and prevalence of drug use in prison. In 2016–17, 76% of people tested on admission to prison, and 30% of people tested on liberation, were positive for illegal drugs. Synthetic cannabis is the most prevalent drug, followed by hallucinogens, according to Scottish Prisoner Survey (SPS, 2017) data. However, knowledge gaps remain about the nature and extent of drug addiction in prison, such as the balance between the consumption of and dependency on New or Novel Psychoactive Substances (NPS) versus Class A drugs such as heroin, cocaine, and methamphetamine.

Further, relatively little is known about the comorbidity of drug addiction with mental health issues in Scottish prisons. HMIPS (2018) indicates that a ‘very large proportion’ of Scottish prisoners have some form of mental health problem, and that around 4.5% of them suffer from severe and persistant mental illness—a far greater proportion than in the general population. Prescribing indicators speak to high rates of depression and psychosis (ScotPHO, 2021). However, there is a paucity of empirical research evidence focused on the intertwining nature of drug addiction and mental ill-health among prisoners in Scotland.

This paper aims to explore the lived experiences of adult men in Scottish prisons in relation to their illicit drug use patterns, what triggers and motivates this, and the overlap with mental health issues. The paper shares rich insights from a small-scale qualitative study involving semi-structured interviews with 24 incarcerated men. Prior to presenting insights from the data, the study is situated within the extant literature on drug use and mental health in prisons. Next, the sample and method are discussed. The empirical findings are then organized under three emergent themes: (1) the role of prison in facilitating and enhancing existing drug use, especially NPS; (2) the experience of mental ill-health and (self-)medication in prison; and (3) what works, what doesn’t, and what makes things worse when it comes to addiction treatment from the perspective of incarcerated persons. The paper concludes with a discussion of the findings in relation to the existing literature and implications for future research, policy, and practice.

Literature Review

Drug Addiction in Prison

The epidemiology of drug addiction is complicated and the direction of causality can be difficult to tease out, but substance use disorder is statistically correlated with social disadvantage and exclusion (McPhee et al., 2019a). People suffering from addiction are often members of socially deprived communities who lack education, employment, or training (Buchanan, 2004; McPhee et al., 2019a). Adverse Childhood Experiences (ACEs), specific abuse, neglect, and household dysfunction exposures such as household substance abuse and family incarceration (Centres for Disease Control and Prevention, 2018), combined with school exclusion and unemployment/under-employment, are also criminogenic risk factors associated with problematic drug use and psychiatric problems in prison (Boys et al., 2002; Kolind & Duke, 2016).

An estimated 50%-to-80% of prisoners in Europe have used illicit drugs in their lifetime (Boys et al., 2002; Dolan et al., 2007; Enggist et al., 2014; O'Hagan and Hardwick, 2017; Zurhold et al., 2004) and globally, around one in three incarcerated persons has used drugs at least once while imprisoned (UNODC, 2019). One reason for this is that prisons are used to punish people who break drug laws and warehouse people with substance use disorders (Dolan et al., 2007; Enggist et al., 2014). Drug users historically have been demonized to such an extent that critical scholars argue the formal tendency towards criminalizing drug users over humanizing them is as damaging to vulnerable populations as addiction itself (Buchanan, 2004; McPhee et al., 2019a). Stigmatized and excluded from mainstream society, for example, people relapse as a direct consequence of the ‘frustration and inability to secure a position in normal community life and establish everyday routines’ beyond any physical and psychological barriers to recovery (Buchanan, 2004, p.394).

Bukten et al. (2020) draw attention to the relationship between drug use in prison and the emergence of other adverse outcomes during and after imprisonment. Research has shown that prison time is often associated with the initiation of injection drug use (for review, see Boys et al., 2002). The risk of suicide in prison is also particularly high for those with substance use disorders and for those experiencing withdrawal; and the risk of a drug overdose is typically high in the weeks immediately following release from prison (Enggist et al., 2014; Fazel et al., 2017; Larney et al., 2012).

Drug use in prison can be an individual coping mechanism for the ‘pains’ of imprisonment (Sykes, 1958), namely the ‘loss of liberty, desirable goods and services, heterosexual relationships, autonomy and security’ (Shammas, 2017, p.1). Drug dealing in prison can also be part of prisoners’ attempts to build ‘personal respect and reputation’ (Kolind, 2015: 799; see also Crewe, 2007). For both reasons, evidence suggests that prison officers may engage in discretionary reactions to prisoners’ drug use, showing some degree of leniency or tolerance depending on ‘known inmate hierarchies and internal relations’ (Kolind, 2015, p.806). Some research finds that prison officers actively engage in ‘enterprise drug supply’, smuggling illicit substances into prison in exchange for ‘large sums of money’ and as a means of placating inmates (Tompkins, 2016, p.147; see also, Penfold et al., 2005). However, in recent years the escalated presence of New Psychoactive Substances (NPS) in prisons has changed many of the parameters and behaviour patterns in prisons completely, as the next section examines.

New or Novel Psychoactive Substances in Prison

NPS, formerly known as ‘legal highs’ or designer/synthetic drugs, are analogues of existing controlled drugs or newly synthesized chemicals created to mimic their effects (Shafi et al., 2020). Since NPS are typically many times more potent than the drugs they copy, usage comes with a heightened overdose risk (Ford & Berg, 2018). Measham and Newcombe (2016, p.17) report exponential growth in the range of NPS and reference the World Drug Report (UNODC, 2014) that describes NPS use as ‘a truly global phenomenon’ with 94 out of 103 surveyed countries reporting the emergence of NPS markets.

The 2016 Psychoactive Substances Act (PSA) criminalized the production, sale, and supply of any psychoactive substances in the UK (Kirby, 2016; Norman et al., 2020). NPS use has generally declined since the ban, but it is an ‘emergent’ issue in Scotland (Densley et al., 2018) and remains high in UK prisons (Norman et al., 2020). In fact, Gooch and Treadwell (2020, p.1261) argue UK prisons have entered an ‘era of new psychoactive drugs’ that replaces a previous era of hard drugs (see, Crewe, 2005).

Synthetic cannabinoids are generally the most commonly used NPS in prison (Carnie et al., 2017), and in 2014–15, the synthetic cannabinoid ‘Spice’ specifically was a concern in over 60% of men’s prisons inspected in England and Wales (Ford & Berg, 2018). Prison survey data from 2017 suggests that 18% of Scottish prisoners used NPS prior to entering prison, up from 11% in 2015 (Norman et al., 2020). NPS seizures in prisons in England and Wales also reportedly increased from 16 in 2010 to ‘90 in 2011; 138 in 2012; 267 in 2013; and 436 in the first 7 months of 2014’ (Measham & Newcombe, 2016, p.20).

At least 79 prisoner deaths have been linked to NPS since June 2013, when a count was first started in the UK (Kirby, 2016). Surveys have identified multiple mental and physical harms associated with NPS use, including anxiety, paranoia, depression, self-harm, as well as problems with sleep and coordination (McLeod, 2016). Prison authorities warn that NPS intoxication also increases prison violence (Measham & Newcombe, 2016; Norman et al., 2020). Kirby (2016, p.53) concludes that a NPS ‘epidemic’ sweeping through prisons ‘has left prison officers and managers reeling’ as they struggle to get to grips with the multiplicity of problems that these new and abundant drugs are causing, most commonly an increased prevalence of mental ill-health.

Mental Health in Prison

The links between spending time in custody and mental ill-health are well documented (Birmingham, 2003; Fazel et al., 2016; Fraser et al., 2009; McLean & Densley, 2020), and it has been argued that mental health problems are by far the most significant cause of morbidity in prisons worldwide (Birmingham, 2003). Birmingham (2003) highlights that the first reliable estimates of the prevalence of psychiatric morbidity among prisoners in England and Wales emerged in the late 1980s and early 1990s via the outcomes from large-scale point-prevalence studies conducted by the Institute of Psychiatry, London. At the time, mental disorder was found in 37% of sentenced male prisoners and 63% of men on remand, with multiple diagnoses common. Rates of functional psychotic disorder were considerably higher in comparison to those among the general population of adults; schizophrenia and delusional disorder were found more frequently than affective disorders; and the most frequently encountered neurotic symptoms were sleep problems, worry, fatigue, depression, and irritability (ibid). A quarter century later, Tyler et al. (2019: 74) reported similar prevalence rates, although the prison population had ‘dramatically increased’.

The prevalence of mental disorder is higher among the 10 million prison inmates worldwide than in the general population, and, in some countries, there are more people with severe mental illness in prisons than in psychiatric hospitals (Fazel et al., 2016). A 2012 systematic review of around 33,000 prisoners and over 100 studies identified that one in seven had major depression or psychosis (Fazel et al., 2016). Studies have consistently demonstrated that the consequences of incarceration on mental health are immediate and the ‘psychological tolls’ of ‘confinement and regimentation’ result in higher rates of mental disorder for people than they may have had if they had remained in the community (Yi et al., 2017: 900; see also, Goffman, 1961; Sykes, 1958). Research has further demonstrated that people with an incarceration history are significantly more likely to develop depression, mood disorders and psychosis than those who have never been to prison (Birmingham et al., 1996; Boys et al., 2002; Massoglia & Pridemore, 2015; Schnittker et al., 2012; Turney et al., 2012; Yi et al., 2017). With an average rate of 100–150 per 100,000 prisoners, suicide rates are also consistently higher among male prisoners compared to general populations in most countries (Birmingham, 2003; Fazel et al., 2016).

The most exhaustive UK study identified that ‘90% of prisoners aged 16 years and over suffer from mental illness, addiction or a personality disorder, and 70% of prisoners had two or more such problems’ (Enggist et al., 2014, p.88). Other research finds low rates of identification and treatment in prisons, with over half of prisoners’ mental health needs unmet (Fazel et al., 2016; Tyler et al., 2019). Given the high reported rates of drug misuse among prisoners globally, it is also important to acknowledge the relationship between this and the continuing prevalence of mental ill-health among the incarcerated, and the fact that psychiatric co-morbidity is especially apparent among prisoners who use drugs (Birmingham, 2003; Bukten et al., 2020; Enggist et al., 2014).

Drug Treatment in Prison

Against the backdrop of the interconnected issues of drug dependency, addiction and mental ill-health that is prevalent within prisons worldwide, it is essential that effective harm reduction strategies are implemented; indeed, responding to the drug-related issues in prisons has become a ‘public health priority’ around the world (Kolind & Duke, 2016, p.90). Enggist et al. (2014) draw attention to the importance of prison health to public health in a more general sense, since most prisoners will eventually return to the community and carry with them untreated conditions that may pose a threat to wider society. Thus, they argue, governments should prioritize (mental) healthcare for the incarcerated, and at the very least try to ‘stabilise addiction problems’ by providing basic interventions such as psychological counselling and psychotropic medications (ibid, p.91).

In many countries, however, limited resources are dedicated to prisons and ‘security often takes precedence over treatment and health needs’ (Dolan et al., 2007, p.4). One survey of prisons across 27 European countries concluded that investments and improvements were needed to ensure all prisoners had adequate access to drug treatment and harm reduction programming (Zurhold et al., 2016). Birmingham (2003, p.196) highlights that National Health Service (NHS) mental health services in Britain ‘do not tend to go out of their way to involve themselves with people in prisons’. Other research finds mental illness can remain undetected and untreated among prisoners owing to poor quality healthcare that fails below basic ethical standards (Birmingham, 2003; British Medical Association, 2001; Enggist et al., 2014; Reed & Lyne, 1997).

Maintenance prescribing is one of the most common means of prison drug treatment. To help suppress cravings and improve general health and wellbeing, opioid-dependent prisoners are prescribed opioid agonists in the medium- to long-term (Dolan et al., 2007). Methadone is the most common maintenance drug used within Opioid Substitution Therapy (OST) and the goals of Methadone Maintenance Treatment (MMT) include reducing both opioid use and any related criminal behaviours (ibid). As Hughes (2003, p.49) observes, harm reduction approaches such as this are concerned less with the ‘reduction and cessation of drug use and more concerned with the reduction of negative consequences arising from the use of drugs’.

Continuity of substitute prescribing, calibrated to individual needs, is required to make these approaches successful. However, relatively few prisoners who report receiving methadone treatment in the month before coming to prison receive it again in the month after (Singleton et al., 2003). Research finds that maintenance prescribing in prison is often inadequate because it is inconsistently implemented among prisoners (Hughes, 2003). The process in prison is also unethical, Hughes (2003: 49) argues, because it fails to ‘replicate the body’s usual rate of drug withdrawal thereby causing considerable distress’.

Owing to the interconnectedness of drug addiction and mental ill-health in prisons, traditional 12-step programmes have been found to potentially support recovery journeys among some prison inmates. Best et al. (2022) share case study evidence from English prisons suggesting some men in prisons develop increased motivation for recovery through the programme’s focus on ‘nurturing, empathy and understanding’ from peer recovery workers. Further, the creation of recovery plans that extend beyond release points can enhance the programme’s impact (ibid). In wider terms, previous research has identified that spiritually-based approaches (such as 12-step programmes) can increase positive psychological well-being among prisoners (for review, see Deuchar, 2018). In turn, the resulting reduced levels of psychological distress can in some cases enhance inmates’ ability to engage in rehabilitation and wider treatments (Deuchar, 2018, 2020).

Given the above, some prisoner advocates have called for the installation of dedicated drug-free drug-recovery wings in prisons where recovery is incentivized and people are supported through a combined focus on security, testing, and intensive support (Kirby, 2016). About 125 of the UK’s 150 prisons have drug recovery wings (Kirby, 2016) to encourage self-advancement and self-improvement and provide emotional support alongside appropriate levels of activity and distraction to facilitate prisoners’ abstinence (Fraser et al., 2009).

The Current Study

This qualitative, exploratory, study, aims to capture the lived experience of drug addiction and mental ill health in Scottish prisons and centers on the voices of men who rarely have the opportunity to tell their stories. Findings from a series of life history interviews with a sample of incarcerated men explore the triggers and motivations for, and the nature and extent of, illicit drug misuse in Scottish adult prisons and the overlap with mental health issues. This study sought to understand the antecedents of drug use and misuse, offenders’ motivations for continued drug use in prison, the type of substances most commonly used and their psycho-social consequences, as well as prisoners’ views on the provision of mental health and addiction treatment in prison.

Method

To be eligible to participate in this study, men aged 21–65 had to be formally recognized as adult prisoners with prior and/or current involvement in illicit drug misuse and they had to have been incarcerated (on this occasion) for at least one year. In relation to the former criterion, identified gatekeepers, who were trusted sources of support to the men (see further details below) were able to verify those men who were known to be either currently using sustances in prison or have previously used them. The latter criterion also ensured the men selected had adequate recent experience of being in prison halls, thus could share and describe their lived experiences within those settings. Other inclusion and exclusion criteria were as follows: the men had to be in a state of sobriety during the planned interviews; to be willing, and have the ability to, talk candidly about their current and/or previous drug use history as well as their mental health (with the provision that all information would be treated with the utmost confidentiality). The one and only exclusion criterion was that those who were currently experiencing symptoms of psychosis were not permitted to participate in interviews.

Permission to access Scottish prisons was first sought from SPS. We submitted a research proposal to their ethics committee in the spring of 2019 requesting access to two specific adult male prisons known to house long-, medium- and short-term prisoners. The first author was familiar with both sites from prior research (e.g., Deuchar et al., 2016) and had pre-existing networks and contacts in each one—namely, prison chaplains and members of Sustainable Interventions Supporting Change Outside (SISCO), an external charity that develops and delivers recovery support initiatives for prisoners. Said contacts would potentially serve as gatekeepers, facilitating prisoner access and supervising safety, reducing the administrative burden on an already overwhelmed prison staff.

The SPS approved the study and so too did the Institutional Review Board at the first author’s university. A participant information sheet was then designed that provided a thorough but easily understood description of the proposed study, including its aims, asks, benefits, and risks. Through the support of the prison chaplains and SISCO’s staff and volunteers, these forms were placed in the cells of the prisoners who met the study’s criteria along with an accompanying letter and a tear-off form for them to express interest in taking part in the research. The letter made it clear that those men who were currently suffering from the symptoms of any type of psychotic illness should not put themselves forward to participate, and also emphasised the need for interviewees to be in a state of sobriety while attending sessions.

From August 2019 until the closure of Scottish prisons to outsiders owing to the global COVID-19 pandemic in March 2020, the first author visited both prisons on multiple occasions, initially to meet with those who had indicated an initial willingness to participate in the study. These meetings took place either within the allocated space of the prison chaplaincy service (in prison one) or adjacent to the site of routine recovery meetings (in prison two). The author spent some time building rapport with the men, providing them with the opportunity to ask any questions about the research.

In the end, formal consent forms were issued to 24 men (16 in prison one and eight in prison two) who were serving sentences anywhere from 12 months to life imprisonment [mean length = 4.5 years]. The youngest participant was 23 and the oldest was 62 [mean age: 35]. All participants were white. All of the men had served at least one prior prison term, and some were back in prison after being recalled for reoffending and/or missing allocated rehabilitation appointments that were part of their release conditions. Since both prison sites housed a range of short-term, longer-term and life sentence prisoners, samples from both estates had similar range of ages and incarceration lengths. Thirteen of the 24 interviewees were from Glasgow, Scotland’s largest city; eight came from large towns located on the wider west coast of Scotland, either bordering or geographically close to Glasgow; and three participants were from other central Scottish cities. All of the men were educated to secondary school level only, with the majority holding no formal educational qualifications.

Participants were interviewed by the first author, individually, using a semi-structured format for up to 60 min. The majority of interviews across both prison estates lasted 50–60 min. The interviews sought to gain insights from the men about criminal offending and when and why they first started using illegal drugs; their motivations for and experiences with using drugs in prison; any possible overlap between drug misuse and mental ill-health; aspects of prison culture, including issues of safety and violence; and experiences with and perceptions of the support available within the prison system for mental health and addiction treatment.

The information gathered through interviews was treated in a confidential manner and interviewees were informed of this. The men were also informed of the limitations to confidentiality, should any planned criminal activity be disclosed. Interviews were audio recorded and transcribed for ease of data analysis.

Interviews were transcribed by the first author, anonymized, and then analysed thematically. Drawing on elements of a grounded theory approach, an inductive approach to open and axial coding was used to identify the most salient themes (Glaser & Strauss, 1967; Strauss & Corbin, 1998). In so doing, the research team avoided the use of qualitative software to aid data analysis but instead used the commonly recognized approach of manual thematic analysis (Miles et al., 2014) This analytical approach was very much in keeping with the interpretative paradigm suited to privileging participants’ perspectives on the common themes that emerged from the data.

It has been recognised that there are many ways of drawing on grounded theory approaches, and that the process was never intended to be prescriptive (Bulawa, 2014). In this study, it was not necessarily the intention of the researchers to generate new theory from the emerging data, but simply to analyse the data inductively ‘without making assumptions about the findings prior to collecting evidence’ (Bulawa, 2014, p.82). Two priorities in the data gathering and analytical processes were to ensure both credibility and authenticity of the emerging data set.

Credibility was ensured by deepening and intensifying exposure to the empirical reality – in this case within the context of Scottish males prisoners’ ‘lived experience’ (Messner et al., 2017) Accordingly, intermittent but regular visits were made to the two empirical prison sites across a prolonged period of 7 months, while interviews drew upon multiple informants [with an ultimate sample size of 24 incarcerated men] until ‘data saturation’ was reached (ibid). In terms of authenticity, this was upheld through the researchers’ dogged attempts to exploit the richness of the data, rather than simply providing condensed insights from participants within the context of ‘theoretical propositions’ (ibid, p.437). During fieldwork, semi-structured interviews allowed the researchers to explore the insights, perspectives and anecdotes of the participating men in an open-ended way, allowing them to provide extended narratives that were focused on their collective experiences with drugs and mental health. The use of audio recording ensured that the first author (as the interviewer) could focus his attention on what the individual men said to him without the distraction of note-taking, and later both authors were able to analyse the transcribed data individually and then compare and contrast their emerging coded interpretations. Accordingly, as highly experienced academics with a collective qualitative research experience of over 30 years, the authors were able to verify each other’s interpretations – thus providing a further layer of authenticity, rigour, and trustworthiness.

This analytical approach led to the emergence of three key themes: (1) the role of prison in facilitating and enhancing existing drug use, especially NPS; (2) the experience of mental ill-health and (self-)medication in prison; and (3) the men’s views on what works, what doesn’t, and what makes things worse when it comes to addiction treatment in prison. The findings below are organized according to these three themes with direct quotes from the interviews used to illustrate them in detail. To preserve the anonymity of participants, when presenting direct quotations, pseudonyms have been used throughout.

Findings

The Role of Prison in Facilitating and Enhancing Existing Drug Use, Especially NPS

Each and every participant in the study described growing up amid poverty and social inequality with exposure to a multiplicity of ACEs, including physical and emotional abuse and neglect, domestic violence, household dysfunction, substance abuse at home, parental separation, and having family members with an incarceration history. Some men also talked about suffering from father absence and/or being aware of family members’ involvement in criminality during their formative years:

My mum took drugs and I ended up goin’ to live wi’ my gran and grandad when I was four … my mum died when I was 10 and things just changed from there … drugs and stuff. – Ben, age 29 [prison two]

I lived with my mum and my step-dad. Never really got to know my dad. He moved away … my stepdad started abusing’ me, no’ sexually but physically abusin’ me … it was as if it was normality … I associate that wi’ a lot of the anger … I was always fightin’ in school, and getting’ suspended n’things. – Danny, age 28 [prison one]

I’ve got a family full of criminals … shoplifters, bank robbers, pick pockets, till dippers, drug dealers, gangsters … at aged 9 or 10 I started becomin’ aware of it … my dad was a binge drinker, a lot of my uncles and aunts used drugs regularly recreationally, social settings. I started noticin’ that, the smell of cannabis .. I started to use it myself when I was about 10 or 11. – Rory, age 46 [prison two]

Against this backcloth, interviewees experimented with drugs at an early age, which, they argued, facilitated other forms of offending:

A lot of my teens, I started takin’ like ecstasy, valium. Then when I left school n’that, I ended up oot myself, I started using like heroin [at age 15/16] … it was just the thing that [me and the boys] done … there was a big change in like my offending n’that. – Charlie, age 38 [prison one]

I had a joint of cannabis when I was about 12. I just happened to be somewhere when it was gettin’ passed around. It was New Year’s Eve when it occurred. As time went on, I got involved in harder drugs ... I was takin’ LSD and amphetamines. When I started gettin’ older, I started takin’ heroin and cocaine, crack … it had a serious impact. I started committin’ crime to fund my habit. – Jack, age 51 [prison one]

Drug use and dependency preceded prison time for all 24 of our interviewees. Cammy (aged 42, prison two), for example, had a long history of cannabis use, followed by heroin and benzodiazepines in the community. His drug use got worse in prison, however, because drugs were his only ‘release’ from the monotony of prison life, he said. Similarly, Richie (aged 39, prison one) had used cannabis from the age of 16 and cocaine since he was 18. He drew attention to the fact that prison was not a ‘normal environment’ so he used drugs inside as a ‘coping mechanism … it blocks out maybe previous thoughts or past things that have happened to [prisoners] in their life’.

Many of the men in the sample felt unsafe in prison and they referenced a dangerous, ‘hypermasculine’ prison culture that forced them to wear a metaphorical ‘mask’ and project a false identity simply to navigate contested spaces. Drug use was for them a way to manage the constant associated feelings of tension, anxiety, and stress:

You need to survive in here … there’s 46 bodies in my section, so I’ve got 46 faces and different personalities I need to put on for different people … so you’re never really 100% settled because you’re always on your toes. – Richie, age 39 [prison one]

Sometimes I sit in my cell and I’m always feelin’ anxious … I’ll use drugs to take that nervousness away … I wasnae like that before I came to prison … it’s just being in prison just takes all your confidence away. It’s just so stressful being in prison. – Ryan, age 41 [prison two]

In relation to the above, some men referenced overcrowding in prisons and an increasing double occupancy of cells. For our interviewees, in instances where people trying to stay away from drugs were housed with people still using them, double occupancy meant no escape from the pains of imprisonment and addiction both.

The men serving longer prison sentences also shared that a complete smoking ban that took effect in Scottish prisons in 2018 (see Sweeting et al., 2021) had elevated tensions in the halls. Electronic cigarettes became available in Scottish prisons before the comprehensive national smoke-free policy was introduced, in part to assist with its implementation (Brown et al., 2021). E-cigarettes helped some prisoners quit smoking, but the majority of the men believed E-cigarettes were less therapeutic than tobacco cigarettes in terms of stress management and some even argued that E-cigarettes helped facilitate illicit drug use in prisons, in part because vapes functioned as a form of prison ‘currency’ that was exchanged for other drugs and as a ‘tool’ to covertly ingest other substances, especially NPS.

One of the most prominent themes in the interview data was how the increased use and abuse of NPS in recent years had exacerbated what Gooch and Treadwell (2020: 1276) describe as the ‘collective pains of imprisonment’. Without exception, all of the men argued that Spice and other ‘legals’ (i.e., legal highs) were directly responsible for worsening mental health, paranoia, and violence in prison:

It’s just all ‘legals’ now [in the jail]. It’s destroyed the jail, all the good people. It’s made them mentally insane n’that … just made everyone paranoid. You canny trust anyone. My pal attacked me on Christmas morning with a snooker cue … for nothin’, he was just pure paranoid. – Joel, age 23 [prison one]

That legal stuff people are takin’ … you see people gettin’ freaked out with it … the jail ‘s ruined with it … you could turn your back for two minutes and someone could hit you and they don’t even know they’re dain it so you don’t know what to expect. It’s dangerous stuff … it’s like chemicals on a bit of paper. – Ben, age 29 [prison two]

Some of the men shared their own experiences of using NPS. While they clearly felt that the substances had a short-term benefit for them in terms of helping them to escape and switch off, they also described experiencing extreme adverse psychological and physical reactions:

It’s kinda just like a deep stone thing … it just blocks your thought process for a wee couple of hours … at one point I was speakin’ to myself … I started throwin’ radios n’that aboot me. It just made me go dead, dead mad, it was makin’ me hallucinate … it scared me. – Stuart, age 23 [prison one]

I was experiencing pains in my stomach and I was constantly vomiting for about three weeks. I wasn’t able to hold anythin’ down. I don’t know if it was somethin’ I had done to my insides through smoking it … [I was smokin’] half an A5 page over a day … I’m no’ sure what’s in it. It would be anythin’ in they chemicals, you don’t know, do you? – Lewis, age 27 [prison two]

For David, the repercussions of NPS were enormous. He used them to manage a period of bereavement following the death of his wife and cousin while he was in prison. The substances offered a short respite from the grief and stress, but at a huge physical cost— David suffered a series of heart attacks associated with his drug addiction:

When I’m takin’ it, my stomach’s bubblin’ away, [and] the following day after takin’ legal highs … the diarrhoea, the nausea, the sickness comes with it and it’s as if you’re bein’ cooked from the inside out. That’s the way I felt, ‘I’m fuckin’ cookin’ here, what the fuck am I puttin’ into my body?’ – David, age 31 [prison one]

The data show that NPS contribute to prisoners’ mental ill-health. The impact was particularly acute, given that the men had very clearly entered prison carrying the burden of a wide range of ‘imported vulnerabilities’ (Maruna & Liebling, 2005), including histories of problematic drug use, mental health conditions, and unresolved and untreated ACEs. Extended discussions with the men revealed the nature of these mental health issues and the apparent lack of support to address them against the backdrop of the ‘pains’ of confinement and regimentation that defined prison life.

The Experience of Mental Ill-Health and (Self-)Medication in Prison

Many of the men disclosed that they had suffered from various types of neuroses, including phobias, PTSD, and reactive depression (arising as a result of an internal response to an external situation), and in some cases, psychoses such as schizophrenia. The majority admitted that their symptoms had worsened during incarceration. Among those who had reached out for medical and psychological help, it was common for them to describe a lack of available support to help treat their symptoms. Interviewees talked of broken promises of treatment and referrals unfulfilled, stigmatization from medical staff, and being taken off medication that provided them with some psychological respite without warning:

I break doon two or three times every day … the last time I seen somebody for mental health, they were like that, ‘oh. we’re gonna maybe get somebody from Psychology or somethin’ to see you,’ you know? But I’ve never heard anythin’ aboot that, you know? And I’ve told them, like what are the main issues … depression, anxiety n’all that … but they go, ‘oh, all he wants is medication.’ That’s the way they look at it, know what I mean? … the first time I’ve used heroin since last year was last night … [because] they’ve took me off my medication … Gabapentin … I need to try and sleep. – Fraser, age 43 [prison one]

Fraser (above) described being prescribed the anticonvulsant Gabapentin to treat his anxiety and the chronic pain he suffered after a difficult surgery he survived when he was younger. Once Gabapentin was removed from his prescription, however, Fraser turned to heroin simply to get better sleep, and he was not the only interviewee to imply that prison indirectly initiated their heroin use. For example:

I got my first sentence in 2012 and started takin’ subbie [buprenorphine, commonly known by the tradename ‘subutex’: a mixed opiod agonist-antagonist that helps to prevent withdrawal symptoms caused by stopping other opiates]. So when I was released I had a habit wi’ subbie … I remember someone saying, ‘take a line of this’ and it was heroin. It took the pain away, the way I was feelin’. So I ended up stuck on heroin … the subbie causes the same withdrawals as heroin, so basically me coming to the jail gave me a heroin habit. From the subbie in the halls. – Ben, age 29 [prison two]

Another interviewee, Lewis, started using NPS following multiple suicide attempts and the prison’s failure to meet his mental health needs. Daryl similarly began ‘self-medicating’ on NPS after he admitted feeling suicidal to the Doctor but received little medical intervention:

I’ve had sertraline and stuff, anti-depressant-wise but it never really helps … I’ve had numerous suicide attempts … I’ve put in umpteem [multiple] forms for mental health [treatment], but I’m still waitin’ … - Lewis, age 27 [prison two]

I said [to the Doctor] last time that I was feelin’ suicidal. They put me on observation, where they come and look through your door every hour and ask if you’re alright … they never gave me any medication … I’ve been self-medicatin’ on legal highs … I wanted to stop but I’m strugglin’ to stop because I canny sleep at night … I start … feelin’ suicidal if I can’t sleep properly. – Daryl, age 26 [prison two]

Joel summed up the dual presence of multiple mental health issues in prison halls and the tendency for the men not to open up about this due to the hypermasculine prison culture but simply to use drugs to self-medicate:

There’s a lot of cunts in the jail wi’ mental health [issues] … but they’re no’ really wantin’ to come out and speak about it … [so they] just take drugs n’shit. – Joel, age 23 [prison one]

Accordingly, the men found themselves caught in a vicious cycle. On the one hand, they used drugs to self-medicate the symptoms of mental ill-health. On the other, using drugs was making their mental health worse.

As highlighted earlier, dedicated drug-recovery wings, where prisoners can be supported through a combined focus on security, testing and incentives alongside intensive support programmes, exist in some Scottish prisons, but none were in operation within the two data collection sites. Many of the men interviewed advocated for the creation of these facilities. They felt dedicated drug-recovery wings could lower their daily exposure to bad influences inside the prison halls; however they doubted if prison authorities would support the idea, adding it would be difficult to ensure that a ‘drug-free’ area would actually stay drug-free:

I’ve been in some prisons where they had a drug-free landing and it gives you the chance to get away from it all … it’s definitely a good idea … but I don't believe the Governor here, the ones that make the decisions, are interested … it doesnae matter what the prisoners say, they’re makin’ the decisions … it's a numbers game .. money seems to come into decisions they’re makin’ rather than people’s mental health. – Jack, age 51 [prison one]

Maybe [they could have] a section [that’s drug-free] … but it’s just gonna be the same everywhere. If people have done a lot of time and then you’ve got a drug-free hall, then ‘cos there’s no drugs in it, someone will try and get drugs in. – Joel, age 23 [prison one]

In terms of drug treatment, moreover, the men made many references to the further detrimental impact of maintenance prescribing while also referring to other interventions that they had experienced that provided some respite.

The Men’s Views on What Works, What Doesn’t, and What Makes Things Worse when it Comes to Addiction Treatment in Prison

As previously discussed, maintenance prescribing like MMT is the most common form of addiction treatment in Scottish prisons, promoted as a way of suppressing opioid cravings and improving overall health and well-being. The Scottish Prison Service introduced a prison-based OST policy in 2002 (Bird et al., 2015). The men in the sample talked at length about how methadone was prescribed in prisons and its effect on themselves and others. Some described being offered MMT but refusing it because they considered methadone to be even more addictive than heroin with side effects worse than other alternative opioid agonists such as buprenorphine (or ‘subutex’):

They’ve offered me it multiple times. I don’t see the point – if you want to take any drug, fuckin’ take smack, don’t fuckin’ take methadone. Methadone’s actually worse than smack … it’s harder to come off it. – George, age 62 [prison two]

I’ve asked to get off the subbie before I get oot n’that, and all [medical staff] keep offering me is methadone. I told them, ‘I want to get off the subbie, and methadone’s a lot worse than the subbie’ … it just sedates people, really. – Joel, age 23 [prison one]

Many others, however, were currently on MMT, or had been in the past, and described how they were encouraged to go onto methadone by medical staff. Some had experienced adverse reactions, and many felt that they had simply replaced one habit with another and that the drug was overly and unnecessarily prescribed and actually set those with addictions one step back:

I’m on 90 [ml of methadone] now … it just took the withdrawal away, but you’re just replacin’ it wi’ another habit. Methadone’s the worst, it rots your teeth … can make you feel sluggish, you don’t want to get up in the morning, headache, toothache. – Ben, age 29 [prison two]

In here, they offer you [methadone] for literally anythin’ … people have been offered it for comin’ off alcohol. – Danny, age 28 [prison one]

They put you on [methadone] for anythin’ – they’ll put you on it for back pain. It’s extremely difficult to come aff … it’s supposed to be subutex that you take to come aff the methadone, but there’s people in here, they’re tryin’ to come aff the subbie and they’re puttin’ them on methadone – so they’re basically puttin’ them back a step. – Barry, age 32 [prison two]

Danny summed up the views of many of the men when he said methadone was being prescribed as a mechanism for social control. Eventually, he argued, he took matters into his own hands to try and reduce his intake:

It’s a controlling mechanism. If they could get everyone in the jail on it, they would because everybody would just be sittin’ in the jail like that and they wouldnae have the energy or motivation to dae anythin’ … I’m in a battle the now to get the methadone reduced. I’ve actually started takin’ a drink and leavin’ what I’m judgin’ to be between five and 10 ml and pourin’ it oot … so I’ve started to reduce it myself because they’re no’ willin’ to dae it … because they control you wi’ it. – Danny, age 28 [prison one]

Among the intense feelings of frustration and desperation that the men in the sample felt due to lack of support for mental health and addiction within the prison system, they evidently believed that the OST policy in general, and MMT specifically, caused more problems than it solved in the halls of Scottish prisons.

Among the general despondency surrounding the level of support in place for their addiction and mental health issues, the men in Prison One highlighted the huge benefit they had gained from recovery cafés in recent years. As alluded to above, these cafés were managed and run by SISCO, an external, third sector organisation but also involved a strong focus on a peer-led approach where prisoners were actively involved in setting the agendas and activity within the meetings and supporting each other. The cafés had been active in the research sites for several years and provided those with addiction issues the opportunity to come together and engage in peer support for several hours once or twice a week.

Interviewee Rory was a member of the steering group for the recovery café in the prison where he resided. He highlighted the huge importance of the open and honest peer support that took place, with the men able to be completely open and honest because no prison officers were present during meetings. He also drew attention to the throughcare support that external members of the café provided for men leaving prison:

It’s just prisoners sharing their thoughts and feelings in a safe environment without any officers in the room … it’s genuine, prisoners helping other prisoners. There’s a lot of experience in that room … [the] barriers are down … it’s one con leaning on other cons … it’s a good support network … anybody walking into a group scenario, there’s a kind of apprehension … [but] once they sit in and they see the format and they listen to the guys open and talking about thoughts and feelings and this and that, they’re like, ‘wow’ … it links you in wi’ other organisations in the community that guys have maybe no’ realised was there, for throughcare … when they get out … - Rory, age 46 [prison two]

Other men drew attention to the important role that external speakers coming into the café played, who were able to share their own lived experience of struggling against addiction; some also highlighted the important role that they and other members of the café played in sharing their own experiences of recovery with each other:

Just listenin’ to other people’s stories n’that … you see that they’ve had their problems as well, it’s not just us … whether it’s drink, drugs or bein’ in prison n’that. – Ben, age 29 [prison two]

The recovery café’s really inspirational for me … I’ve always took a lot from them, I always like to dae my inputs as well … I was nearly a year clean, so I like to share my experience and say to the boys, ‘well, this is what I’ve done, this is how I did that, this is how I started on the recovery … my mum is an ex-police officer and she talks to me and likes to try and get through to me, but I think ‘you don’t know the half of it’ … but a guy in there can tell me the same thing my mum tells me and it works because he walks in my shoes. – Ben, age 29 [prison two]

Some men talked about how they struggled to open up to each other within the café to begin with as a result of the hypermasculine ‘prison code’ which prioritises ‘bravado’ and the rejection of open emotional expression. However, they also talked about the barriers gradually breaking down and the way in which they eventually found it cathartic to open up about their emotions with each other:

At first I didn’t feel comfortable at all and then I seen the other guys who have sort of changed and come into themselves, because in prison you sort of put on a face sometimes for some people, you might put on an act, but in there the barriers come down … it’s something I’ve never really talked about before, my emotions n’that … it feels good, though, to talk about it, you feel better. - Lewis, age 27 [prison two]

Discussion

The insights from our empirical research reinforce the frequently-identified fact that a large number of people in prisons have experiences with drug use and abuse (Dolan et al., 2007; Enggist et al., 2014). Having suffered from ACEs that subsequently stimulated trauma and the onset of drug use and offending at young ages, the participating men had entered the prison system accompanied by a range of ‘imported vulnerabilities’ (Maruna & Liebling, 2005; Duke, 2020: 6). In most cases, they had already served several short-to-medium sentences or, in some cases, life imprisonment, and the men voiced recurring feelings of anxiety and depression, alongside pressure to keep up appearances within the ‘hypermasculine’ prison setting (Jewkes, 2005). Continued and, in many cases, accelerated, drug use was for many interviewees their only available coping mechanism.

As previous scholars have argued, criminalizing and imprisoning drug users may ultimately be more damaging than the addiction itself (Buchanan, 2004; McPhee et al., 2019a). Wider empirical research has demonstrated that high levels of overcrowding and cell sharing can be predictive of stress, self-harm, and suicide among prisoners (for review, see Molleman & van Ginneken, 2015). The men’s narratives equally suggested that prison overcrowding, the high prevalence of sharing cells, and even a complete prisoner smoking ban, had increased tensions within Scottish prisons, inadvertently encouraging greater use of NPS among prisoners.

Echoing earlier insights by Kirby (2016), Measham and Newcombe (2016), Norman et al. (2020), Gooch and Treadwell (2020), and Brown et al. (2021), moreover, the men’s extended reflections made clear that NPS use, which was administered in part through E-cigarette use, contributed to deleterious mental health outcomes in the prison halls, adding to the collective pains of imprisonment. Some argued that E-cigarettes helped facilitate illicit drug use in prisons (see also, Brown et al., 2021). Consistent with the work of Young-Wolff et al. (2015), they even described vapes as a form of prison ‘currency’ that encouraged NPS use.

This, of course, was set against a wider presence of existing mental ill-health problems exacerbated by continual confinement and regimentation in prison (Yi et al., 2017; see also Goffman, 1961; Sykes, 1958). The insights from the interviewees appeared to underline those made in earlier research that suggested that (mental) healthcare provision in prisons is inadequate, in part because ‘social control’ and prison security take precedence over addiction and mental health treatment (Reed & Lyne, 1997; British Medical Association, 2001; Birmingham, 2003; Hughes, 2003; Dolan et al., 2007; Enggist et al., 2014). For better or worse, the men were highly sceptical of MMT, for example, believing that it substituted one addiction for another and set back any progress made previously with managing addiction (Luyt, 2007; Magura et al., 2009). From a Foucauldian perspective (e.g., McPhee et al., 2013: 244), they believed that methadone was often being prescribed as a control mechanism in prisons, and they made reference to the apparent medical reluctance to reduce some individual men’s intake leading them to make covert attempts to reduce this themselves.

Conclusions

We must be cautious about generalising the insights from the qualitative data contained within this exploratory study, given the small-scale nature of the sample and the way in which it was confined to two prison sites in Scotland. However, the insights presented under our three emergent themes—(1) the role of prison in facilitating and enhancing existing drug use, especially NPS; (2) the experience of mental ill-health and (self-)medication in prison; and (3) the men’s views on what works, what doesn’t, and what makes things worse when it comes to addiction treatment in prison—contribute to wider debates about how best to manage and treat drug addiction in Scotland’s prison estate and improve mental health outcomes for incarcerated men.

The SPS Strategy Framework for the Management of Substance Misuse in Custody was introduced in 2010 and aims to reduce reoffending by adopting the principles of recovery to ‘reduce the supply and demand of illegal substances and the harm caused by problematic drug and alcohol use’ (SPS, 2017: 1). Its core principles are focused on: ensuring comprehensive ‘security measures’ are in place to reduce the availability and supply of illegal substances in prisons as well as implementing addiction testing to identify the prevalence of illegal drug use; ensuring that recovery is the ‘explicit aim of all services providing treatment and rehabilitation for those with drug and alcohol problems’ by ensuring equity of access to treatment and rehabilitation services and ensuring that delivery of recovery services is focused on an evidence-based approach; providing safe and supportive environments to promote recovery, and multi-disciplinary approaches to substance misuse services with access to ‘wraparound care’; ensuring treatment services are integrated with wider services to address prisoners’ complex needs through (for example) offering integrated care packages; ensuring that the principles of recovery are reflected in staff and service providers’ training; and facilitating evaluation and research that supports the aims of the strategy.

Enggist et al. (2014: 116) highlight that ‘it is well-established that good drug treatment for prisoners can reduce both drug use and rates of offending.’ They cite the Patel Report (Patel, 2010: 24), which argued that ‘the reality of supported self-change is vital in a recovery-focused treatment system in order to raise aspirations and create opportunities for further self-change and personal development’. Enggist et al. argue that ‘the opportunities prisons may provide in terms of health care, social support and the involvement of community health agencies should be used’. They draw attention to the potential use of measures such as ‘counselling on drug-related issues by prison staff or specialised personnel, integrated with external drug services’ and ‘housing for drug-using prisoners in specialised units with a treatment approach and multi-disciplinary staff’ (p.116). These measures resonate well with the core policy principles outlined by the SPS over a decade ago, with their strong focus on evidence-based treatment and recovery; safe, supportive environments; multi-agency approaches; and integrated wraparound care for addressing complex needs underpinned by a robust staff development focus.

However, the Scottish men’s narratives outlined in this paper suggest that a focus on ‘supported self-change’ through effective use of specialised units and integrated multi-disciplinary treatment and support may be very far removed from the lived reality that they experience in prison. The men’s experiences suggest that wider policy initiatives introduced over the past decade in Scotland (including increased double occupancy of cells, a blanket prisoner smoking ban, and continued acceleration of MMT programmes) may have increased, rather than reduced, drug addiction among male prisoners.

In wider terms, the policy document, The Road to Recovery (Scottish Government, 2008), released 2 years prior to the emergence of the SPS strategy framework, described drug users as ‘economically unproductive’ which ultimately stigmatized drug users, including those in treatment (McPhee et al., 2013). As McPhee et al. (2019a, 2019b: 29) argue, despite the methadone user being classed as ‘patient’ not ‘criminal’ in society, dependency on methadone causes ‘anger and depression’ and also impacts on users’ ‘cultural integration’ and their ability to recover from stigma. Combined with the added stigma of being incarcerated, this may ultimately impact negatively on the types of men who took part in our fieldwork, a clear barrier to recovery and reducing reoffending post-release (Enggist et al., 2014).

Bird et al.’s (2015) findings suggest that the introduction of an OST policy in Scotland may have reduced drug-related deaths in the first 12 weeks of incarceration, but it has had no impact on the proportion of deaths occurring within the first 14 days following liberation. Lest we forget, the vast majority of people who go to prison one day will get out. The evidence suggests that MMT programmes may do little to reverse rising drug-related death rates in Scotland, most of which are opioid-related (ibid). OST may well reduce deaths by suicide among prisoners, but at what cost if methadone is used simply as a regulatory technology that sets people up to fail upon release? More consideration needs to be given to the confinement, regimentation, and hypermasculine culture associated with prisons, and how this, alongside the huge rise in NPS use, may adversely affect mental health, as the data in this paper suggest.

Accordingly, the insights in this paper tentatively suggest that – at least for the men participating in the research – the prioritised policy focus on recovery may have limited success unless the punitive and oppressive culture associated with incarceration changes and wider measures are found to rehabilitate men with a history of offending. In addition, the focus on creating ‘safe environments’ for wrap-around care and integrated health packages may be far from reality, given the growing concern of NPS and the increased presence of violence and mental ill-health in prison halls since the time of the SPS’s strategy emerging.

The SPS (2017) has drawn attention to its willingness to contribute to a refreshed national drugs strategy to replace the now outdated Road to Recovery, championing investments in security, new staff training, and the introduction of recovery cafés to ensure that its services ‘better meet the needs of those in [its] care’ (p.7). In addition to its potential contribution to the forming of a refreshed national drugs policy, it is also perhaps pertinent to suggest that the more specific SPS strategy for addiction and mental health treatment would also benefit from being refreshed and updated. In doing so, we would draw attention to the SPS’s decade-old commitment to ‘facilitating evaluation and research’ to underpin its substance misuse strategy. Future research of this kind must focus on gaining wider insights into the triggers and motivations for, and the lived experience of, illicit drug misuse in Scottish prisons and how this continues to affect mental health, as well as prisoners’ own views about potential ways forward. It is hoped that the insights contained within this paper may help to stimulate such future research.