Background

“Our aim is to provide offenders with access to the same quality and range of healthcare services as the general public receives from the NHS”. (http://www.dh.gov.uk/en/Healthcare/Offenderhealth/index.htm). This is not mere aspirational rhetoric but a realistic aim set by the UK Department of Health. The offenders referred to above include the approximately 80,000 inmates in the 139 prisons across England and Wales, and the healthcare services referred to above encompass care of those prison inmates who misuse or are dependent on psychoactive drugs. Drug misuse is common in prisons in the UK, as has been shown in numerous research studies,1^–3 parliamentary debate (http://www.publications.parliament.uk/pa/cm200708/cmhansrd/cm080311/debtext/80311-0002.htm) and media reports despite considerable improvement in the state of affairs over the past decade or so. It is clear that “many prisoners are still not getting the help they need”.4

As a community-based treatment provider for patients who are heroin dependant, around a third of our patients have served a prison sentence at some point and a significant proportion of our patients are regularly in and out of prison. Hence our interest in the treatment they receive in prisons, and also to ensure continuity of good quality care. It was during the assessment of one such patient who is regularly “in and out of prison” that this story came to light and it is in that context this case description should be interpreted. Our rationale for sharing this story with the addiction community and policymakers is not primarily to criticise the prison service, but instead to open up for debate the issue of drug misuse in prison which, despite some progress and well intentioned regulatory measures, continues to be far from ideal or even acceptable.

Here we narrate how a patient who is heroin dependant, who is attending our community drug and alcohol team for methadone maintenance treatment, smuggled methadone and heroin into prison (which was not picked up during the search and which he only disclosed during assessment), his reasons for doing that, his personal description of the extent of drug use in prisons and finally what can be done to stop it from treatment and policy perspectives.

Case presentation

The patient lives with his partner and their 6-year-old son in a council tenancy in Birmingham. The patient is unemployed and receives state benefits.

The patient was first seen at our drug and alcohol service in October 1998, aged 21 years, following a referral from his general practitioner. At initial assessment, he reported a 4-year history suggestive of heroin dependence. He was smoking about 0.4 g of heroin on foil every day but had never injected. He reported brief periods (3 days to a week) of abstinence from heroin on numerous occasions, but invariably relapsed. He denied concurrent use of any other drug. His chronology of drug use then was cannabis at 15, antifreeze inhalation at 15, cocaine at 19 and heroin at 21. Mental state examination at the time revealed numerous checking and cleaning compulsions. Following that assessment, he was prescribed methadone oral mixture 30 ml daily and citalopram 20 mg daily.

Over the past 10 years, he has been in and out of our treatment program: on some occasions due to him disengaging and on others as a consequence of prison sentences for various acquisitive offences. When in treatment, he has engaged reasonably well in psychosocial and pharmacological treatments for heroin addiction. He has been prescribed up to 110 ml of methadone daily and this has helped him stay off using heroin “on top”, although not always. Over the past 3 years or so, he has also started smoking crack cocaine regularly. Up until very recently he was taking up to £20 worth of crack every other day, but is now clean. However, his compliance with treatment for obsessive–compulsive disorder has been poor.

The patient comes from a family of two, with no family history of substance misuse. His father died from cancer 10 years ago, aged 52. His mother is alive and well and is a great source of support for him. He was born and raised locally, attended normal mainstream schools and left with GCSE grades C and above in four subjects. He has never been in structured employment. He currently lives with his non-drug-using partner of 5 years and their son. The patient has offended regularly during his drug-using career to fund his habit. In all, he has served 4 years in prison for 38 sentences, and has also been subject to numerous non-custodial community interventions.

Patient account

Given below are transcribed excerpts from SG’s (first author) conversation with the patient. Questions asked included “Why did you smuggle drugs into prison?” “How did you do it?” “Are you aware of other drug smuggling practices?” “In your experience, what is the extent of drug misuse in prison?” and finally, “What do you think can be done to stop it?”.

SG: Why did you smuggle drugs into prison?

Patient: I take drugs into prison because I feel that I am going to withdraw and I don’t want to withdraw. I’ll do anything, anything in my power to stop me withdrawing. That’s basically why I take drugs into prison, not to sell it. A lot of people take drugs to sell it, to earn money. You can earn a lot of money in prison but I don’t do that personally, I just take it for my own benefit.

SG: But if you are on methadone and if they are going to give you methadone, why would you withdraw?

Patient: Because they don’t give you enough methadone. For instance, I went into prison. I was on a 110 ml script, smoking on top. I went into prison “X” and the most they gave me was 40 ml and I was still suffering very badly so it’s lucky for me that I brought my own drugs with me.

SG: So how do you cope with withdrawal symptoms then?

Patient: No, basically nothing, they leave you behind your door, that’s it, let you suffer, that’s what they do.

SG: Now [patient’s name], if you can explain in some detail how exactly did you take drugs into prison and what drugs did you take?

Patient: What I do, first of all, everyone does it in prison, well I say 90% of people do it in prison. What I did, before I went to court, luckily this time, I went to court. So what I did was, because I was on a high dose of methadone, I was panicking that much about withdrawal from the methadone off the street and the heroin and blah, blah, blah, so what I done I got a 100 ml bottle of methadone, of juice, tied that up tight, sellotaped all round it, put cling film round it and basically stuck it up my backside.

SG: So that was a bottle of methadone?

Patient: Yeah, and then I took 91 × 5 mg physeptone tablets and 15 × 60 mg DFs [dihydrocodeine], all wrapped up and I took heroin as well and wrapped all that up as well in cling film and stuck that up my bottom as well (fig 1). A lot, a lot of people are doing that, I’d say about 90% of the jail. That’s how people get things through.

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Figure 1

Photograph of the bottle (120 mm in height × 44 mm in diameter) and tablets.

SG: And, obviously did not get caught?

Patient: No I didn’t get caught. I did get slightly caught the once. He opened my door and the tablets were on my bed but he just looked at me and shut the door.

SG: But when you go into prison, presumably, they frisk you?

Patient: All they do, you go through to reception. They take your clothes off and that’s it and so you put your clothes back on.

SG: [Patient’s name], how else do people smuggle drugs into prison?

Patient: I used to go to a prison every week and take in an eighth of smack, quarter of smack every other visit. I would just go to the canteen, buy a “Mars” bar, have a cut of it. I’d keep it in my mouth and I’d have a bite of the “Mars” bar, stick it to the “Mars” bar and say do you want a bite of that and then they’ve got their drugs in there and then they deal with it or, what I’d do is go to the canteen, make a hole in my jeans pocket, put it in my pants—the parcel—go to the canteen, ask for a milky cup of tea. As I’m walking, I’d put the tray down on the table, put my hand in my pocket, through to my pants, get the parcel out, cough, put it in my mouth, pick the tea up. As I’m sipping my tea, let it go back in the tea, put the tea down and then the next man drinks it and it’s in his mouth. It’s easy.

SG: In your experience, how common is drug use in prisons?

Patient: You can get anything, anything in prison. Prison guards bring it in for people. I’ve witnessed it. I’ve been in rooms with prison officers beating a kid up who is causing a bit of grief on the landing. I’ve witnessed it. What else have I witnessed? A few years ago, my mate was ordering stereos from the street, their mum was opening it up, taking the magnet out, putting the block of heroin in, covering it with some, an x ray thing, I don’t whatever it is, put it all back together, sending it into the prison then my mate would get it in his cell. I was amazed. He got a brand new stereo, brand new stereo out the box and he just dropped it on the floor and I was thinking, what the hell are you doing. He said, “I don’t want that, I want what’s in it”. But now they’ve stopped that and it’s only from catalogues in prisons but that was back in the day that was then, a few years ago. Prisons are rife, full of smack or subutex.

SG: Anything else?

Patient: A lot of people in prison are in debt, quite a high percentage of them. They get drugs off the drug dealers and then they can’t afford to pay it back so what they do, they either go on the vulnerable prisoner’s wing but they can still get to you. Believe it or not, prison officers still sort things out so that they can get beatings. Or they do prison “send outs”. So I could say I want £40 worth of smack, I’d have to get on to the phone to my people, my girlfriend, and say “Gemma, put £80 into this account” and I’d give her the account numbers and then once, say give it about 2 h, I’ll phone her back and she’d say yes. Then his people get on to his people and say “has that money gone in that account?” and they say “yeah, yeah, yeah” and then he’ll pass you the drugs.

There is a lot of people on servery who collect all the oranges, apples and all the big geezers will say to the vulnerable people “save your apples, save your oranges, blah, blah, blah…” and what they do is they get marmalade from the kitchens and they make a hooch. They get a big bucket, crush all the oranges and apples, let the air out or something and then you’ve got alcohol then. I’ve witnessed people walking down landings pissed as a skunk, I’m not joking.

SG: Is this the case in one prison only or…?

Patient: All prisons.

SG: Have you been to many?

Patient: I’ve been to a lot of prisons… [patient listed nine different prisons]. It happens everywhere, everywhere, trust me, it’s everywhere.

SG: How expensive are drugs in prison?

Patient: How expensive? You’d pay £100 worth of drugs at an eighth. I can get an eighth for £100 and probably make about £400.

SG: So it’s four times as expensive?

Patient: Yeah, about £400. It’s like subutex as well. Nowadays, it’s the second most popular drug in prison now or coming close to heroin is subutex because people who do the rattle off the heroin will sniff subutex and that just gives them the same effect as when you first started to smoke heroin like. So nowadays it’s mainly subutex in jails like.

SG: Now [patient], have you done this before and would you do it again?

Patient: I have done it before and I would definitely do it again.

SG: So in your view [patient], what would stop you from doing this?

Patient: It’s simple, there is one thing to the answer is, that if I’m on 110 ml script on the outside, I should be on 110 ml script on the inside, not 40 ml as that is a third of what I’m on the outside. If they did that, I wouldn’t do nothing and that is the truth, I wouldn’t seriously. I wouldn’t do anything. But those who want to sell them inside will still take them in or get it from the outside. The only way you are going to stop drugs in prison is like in America: no screen so there is no physical contact, nothing, that is the only way your going to stop it.

Investigations

Urine and saliva tests at various points in the patient’s treatment have corroborated his history of illicit and prescribed psychoactive substance use.

Treatment

The patient is currently prescribed oral methadone (1 mg/1 ml solution) 110 ml daily.

Outcome and follow-up

The patient is currently prescribed oral methadone 110 ml daily, as part of a methadone maintenance program. Although compliant with the treatment regime, he continues to smoke heroin (up to 0.4 g/day) three to four times a week and crack cocaine (up to 0.5 g) once a week. His attendance at medical and drug worker appointments is erratic, hence engaging him in structured psychosocial treatments to address his drug dependence has been difficult. He is unemployed and shoplifts every day to get money to buy drugs. As a result of his drug use, he has ongoing interpersonal relationship problems with his partner. Our plan with him continues to be to work on his motivation, engage him better in treatment and then offer him a more effective combined pharmacological and psychosocial treatment package.

Discussion

We acknowledge that this case presents only one patient’s experiences and viewpoints. Hence, although unlikely, it is still possible that this is a biased picture, which would mean that the generalisability and implications are limited. However, in our view, there are some key issues that this case throws up that merit further discussion.

First and foremost, the case demonstrates the powerful grip that heroin addiction can have on those addicted, in that it can lead those affected to resort to extreme measures and take high risks to ensure continued availability of the drug. This is likely unsurprising to those who work in the field of addictions.

Second, and perhaps more importantly, this case raises the question of why did this patient smuggle drugs into prison? As he himself states, it was because he rightly assumed, based on his previous experience, that he wouldn’t be given sufficient methadone (in this case, 40 ml instead of 110 ml) and so was “forced” to smuggle methadone into prison. Also, if we can believe him (which the authors are inclined to do), he hadn’t taken drugs into prison to sell them or to use them to trade for something else of value and interest.

The broader question this case poses is what can be done to prevent people smuggling drugs into prisons? At the treatment level, it can be argued that if the “right” dose of methadone was made available “inside” as on the “outside”, this might discourage some patients from smuggling drugs into prison. However, this still would not prevent those who smuggle drugs into prison with the intention to sell. This is where stricter frisking measures on entry into prison and regular body and cell searches in prisons, and a host of other measures discussed elsewhere, play a part. Finally, although beyond the remit of discussion here, this case report supports previous research evidence that has shown high rates of drug misuse in prison. We do not want to be unrealistic and state that all drug misuse in prisons can be prevented, or that there are easy solutions to prevent drug smuggling into prisons, but the “system” cannot continue to be complacent.

When all the resource limitations are considered and the various “on the ground” pressures are taken into account, it is still inexcusable to provide unacceptable and inadequate treatment to drug-dependent prison inmates, who are patients first and foremost and inmates second. The wider and more complex policy ramifications in attempting to reduce the prevalence of drug misuse in prisons highlighted by this case also need to be addressed.