Subjective effects of prisoners using buprenorphine for detoxification Alexander Johnstone, Tim Duffy and Colin Martin
Alexander Johnstone is an Associate Lecturer in the Centre for Alcohol & Drug Studies, University of the West of Scotland, Paisley, UK. Tim Duffy is Research and International Project Manager and Colin Martin is Chair in Mental Health, both in the School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK.
Abstract Purpose – Buprenorphine (Subutex) was piloted in two Scottish prisons between 2004 and 2006 and consequently used within other penal establishments in Scotland. This 2007 qualitative study aimed to explore the use of Subutex and its associated effects on 14 participants on detoxification programmes. Design/methodology/approach – All participants were male, aged from 21 to 44 years with prison sentences ranging from a few months to life imprisonment. Buprenorphine was unavailable to female prisoners at the time of this study. Participants were recruited from seven Scottish prisons. All 14 participants were on detoxification programmes, each was prescribed Subutex, and each was selected from a larger investigation that included both those undergoing detoxification and maintenance (n ¼ 21). All participants had previously also used methadone on previous detoxification programmes. Findings – It can be concluded that the majority of detoxification participants within this study indicated that Subutex was a more effective treatment than methadone as it helped reduce craving, eased the process of withdrawal and improved sleeping patterns. In addition, the majority of participants noted higher levels of motivation and the ability to set goals towards obtaining an improved quality of life. Originality/value – This study provides an alternative perspective to the use of Subutex within prison settings, when compared with results from previous quantitative studies reported. The study also highlights inconsistencies drawn from studies in this area, which may be an artefact of study design. It is recommended that further qualitative studies be conducted to explore further this alternative perspective. Finally, the issue of methodological approach taken should be addressed within the context of a related, but independent, research forum. Keywords Detoxification, Buprenorphine, Subutex, Scotland, Prisoners, Penal, Craving, Withdrawal, Sleep, Qualitative, Drug addiction, Rehabilitation Paper type Research paper
Introduction At the time this study was conducted (2007) within the Scottish Prison Service (SPS), prescribed methadone was the main pharmacological treatment available to opiate using prisoners in Scottish prisons. Methadone is prescribed as a legal substitute drug to heroin and some individuals may be maintained on this drug indefinitely. A second treatment option available (though less widely used) for opiate users within Scottish prison settings is a process of detoxification during which the individual is detoxified from heroin using prescribed methadone on a reducing level aiming for zero drug use (abstinence). The use of prescribed methadone has helped many opiate users achieve a more stable lifestyle and has been a useful intervention for opiate using prisoners in assisting maintenance, detoxification and supporting harm reduction programmes. Despite negative reports in the 1990s when many methadone related deaths occurred in the United Kingdom, later research indicates the level of such drastic outcomes has reduced considerably since 1996 (Seymour et al., 2003). The use of prescribed methadone is recognised by many as the acceptable ‘‘standard’’ for opiate maintenance and detoxification.
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DOI 10.1108/17449201111256907
An alternative to methadone (buprenorphine, also called subutex) has increasingly been recognised by many researchers and opiate users as a drug having equivalent or better efficacy in reduction or maintenance treatments, when compared to methadone (Auriacombe et al., 2004). Many clinical studies have compared the efficacy of methadone and subutex, often with differing conclusions (Kosten et al., 1993; Ling et al., 1996; Schottenfeld et al., 1997; Fischer et al., 1999; Petitjean et al., 2001). Earlier research had found methadone to be more effective in terms of retention of treatment but new research (Pinto et al., 2010), alongside increased use and understanding of buprenorphine, has led to valuable research data being produced which indicates that it may become the new gold standard for the detoxification treatment of opiate users. Evidence has shown that buprenorphine is a safer and more effective treatment regime than methadone. Further studies have shown that it can be used more effectively in maintenance or as a short-term agent for detoxification (Gonzalez et al., 2002). There is a shortage of reported studies in the literature which provide a detailed discussion of the effectiveness of detoxification interventions (particularly studies within penal institutions) in relation to prisoners’ subjective experience. In 2004 the Scottish Prison Service piloted the use of buprenorphine (subutex) within two Scottish prisons establishments one high level security, and one low level security (open prison). This was a significant development within the Scottish prison setting and consequently it was deemed appropriate to evaluate the impact of this innovation within the Scottish Prison Service. This is the focus of this research.
Opiate substitution Substitution treatment is a form of medical care for opiate dependence using a similar or identical substance with properties and actions similar to the drug normally used. For many years methadone (taken orally) was used widely in the UK while buprenorphine (subutex) was used more frequently in other countries including for example France (Auriacombe et al., 2004). Subutex is often reported as being appropriate for use in non-traditional treatment settings such as residential detoxification centres. Clinical trials have shown the withdrawal effect from buprenorphine to have less severe subjective and objective opiate withdrawal symptoms, earlier symptom mitigation, better withdrawal completion and longer treatment retention (Ling et al., 2005; Oreskovich et al., 2005). This allows the person undergoing detoxification to focus on normal life activities without the need to obtain and administer drugs. Furthermore, the substitution of prescribed medication such as methadone or subutex from an illicit drug helps in reducing criminal activity, supporting the process of lifestyle change.
Scottish Prison Service addictions policy Substance misuse is extremely difficult to tackle in prison. Like many other organisations concerned about substance misuse, the Scottish Prison Service (SPS) has a role to play in delivering Scotland’s National Drug Strategy: ‘‘Tackling drugs in Scotland – action in partnership’’ (The Scottish Office, 1999). Since the SPS publication on the management of drug misuse in Scotland’s prisons in 2000, there have been many changes in the addictions field both inside prisons and in the community. Following consultation with a range of stakeholders it became clear that the Scottish Prison Service would be required to change from the provision of a mainly punitive response towards substance misuse to a more treatment focussed goal. Home office publications such as the Updated National Drug Strategy (Home Office, 2002b), Tackling Crack – A National Plan (Home Office, 2002c), Social Exclusion Report (Home Office, 2002a) and that of the World Health Organisation (WHO): Prisons Drugs and Society (WHO, 2001), have all impacted on the revision of the Scottish Prison Service Policy. Policy revisions have also reflected the need for more robust assessment procedures, improved action planning and
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transitional care with the aim of ensuring a higher level of community support on release for ex-offenders. Meader (2010) suggests buprenorphine is the most effective method of detoxification. However, there is little research data available on prisoners’ subjective experience of the effects of buprenorphine treatment. The ‘‘misdirection’’ of prescribed buprenorphine in prison settings has been noted by Penfold et al. (2005) and commented on further by Tompkins et al. (2009). However, within this particular study there was no incidence of diversion and abuse of Subutex in the SPS. It is thought this is due to the prescribing and observational setting adhered to by prison and nursing staff. The Scottish Prison Service complies with the Department of Health prescribing guidelines (Department of Health, 1999). Currently, the prescribing of buprenorphine, to lessen intravenous abuse, is dispensed, not only in the form of Subutex, but also in the in the form of Suboxone, whereby naloxone is added to sublingual buprenorphine (Sporer, 2004). Nonetheless, Suboxone contains a far greater percentage of buprenorphine than naloxone. The naloxone is poorly absorbed sublingually and is designed to discourage intravenous use. At the time of this study Suboxone was not yet available to the market, as it is today. This study explored the clinical impact and subjective effect of Subutex on the day-to-day lives of prisoners within Scottish Prisons.
Crime and use A review of the literature indicates that in comparison to non-heroin users, there is a higher level of crime amongst users of heroin (Hammersley et al., 1989) and that criminal activity and opiate use influence each other. The research discourse and its analysis within this study indicate such commonalities relevant to those participants. Further, crime and illicit drug use inside prisons is also commonplace, including the sales of legally prescribed (such as Subutex) and illegal drugs.
Introduction to the qualitative study Within the recently revised assessment process, prisoners (with the assistance of prison health care staff) consider the most appropriate form of intervention in relation to the prisoners drug use while they remain in prison. For some, this intervention will be long-term maintenance using a prescribed drug. Until recently, the only option available for this intervention was methadone. In recent years Subutex has also become an alternative within Scottish prisons. For other prisoners, a short-term intervention of detoxification may be agreed on with a view to facilitating access to longer-term interventions such as counselling or group-work either within prison or in the community following release. In the past methadone was the most frequently used prescribed drug used for this purpose but more recently Subutex has been available to assist with this short-term detoxification process prior to further longer-term intervention. Within the revised Scottish Prison Service treatment policy in 2000 (Scottish Prison Service, 2000), detoxification is not seen as a treatment in itself but as a precursor to further recognised treatment options. The number of Scottish prisoners with experience of both methadone and Subutex is relatively small. The volume of drug using prisoners with experience of illicit drug use in prisons who opt for detoxification is higher than that those opting for longer-term maintenance of prescribed alternatives. To obtain higher numbers for this study, it was therefore decided to recruit participants who had opted to aim for detoxification using Subutex, as recruiting participants on maintenance programmes would at the time of the study generate very small numbers potentially making the study non viable. The study recruited a sample of 14 male opiate dependent drug users who had experience of illicit drug markets within the prison system. At the time of this study, each participant was being prescribed Subutex within a detoxification programme. Each participant had previous experience of being prescribed methadone either for maintenance or detoxification purposes. All 14 participants were interviewed with the focus on their subjective experiences
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of the prescribed drug Subutex. During the interview, participants were also invited to reflect on the effects on their lives, within the social context of the prison, of the effective prohibition to all drugs, unless prescribed. At the time this study was conducted no female prisoners were being prescribed Subutex within Scottish prisons and consequently only males were included in this study.
Methodology In conducting studies of this kind, ethical issues have to be considered. The individual’s rights must be protected including remaining anonymous, participating with informed consent, privacy and confidentiality, self respect and dignity, voluntary participation and rights to any services (Holloway and Wheeler, 2002). Ethical Approval for this study was sought and approved from the Scottish Prison Service Ethical Committee. Following approval all Scottish prisons were contacted by the Healthcare Directorate and invited to participate in this study on a voluntary basis. From a possible 15 establishments[1], seven prisons were selected for inclusion in this study including high, medium and low security prisons. Consideration was given to providing an incentive to potential participants to participate in this study. Following consultation with prison personnel it was decided not to provide an incentive for participating participants. Names of prisons and prison locations are not provided within this report. All prisoners were asked to choose a pseudonym from the alphabet. (i.e. Mr A, Mr B etc). The interviews were conducted within the prisoner’s own establishment. Initial contact for the study was facilitated by the prison healthcare staff who also arranged an appropriate private room for the interview to take place. Each interview lasted approximately half an hour. As recruitment of participants emerged from the health care assessment process noted earlier, there were no apparent gate-keeping processes in place preventing potential prisoners from becoming involved in this study.
Data analysis Holloway and Wheeler (2002) note the use of qualitative research methodology is favoured by sociologists to record data related to participants’ experiences of feelings. As this study aimed to focus on the feelings of prisoners in relation to their use of Subutex, qualitative methodology was employed and data analysed using constant comparative method to ensure validity and to minimise the risk of respondent bias (Glaser and Strauss, 1967). All the data fragments that arose within each interview section were inspected and compared with similar from the other interviews. All cases of data were analysed to maximise the reliability of the study and minimise researcher bias (Silverman, 2000). All interviews were fully transcribed and then the data was organised in relation to the corresponding sections of the interview from which the data emerged. This enabled connections to be made between the views participants held on the specific categories of the interview schedule as well as provide a means of organising the data sets (Coffey and Atkinson, 1996). The raw data was read and coded several times. Relevant phenomena were collated and analysed until commonalities, differences, and patterns emerged. This process of ‘‘data simplification’’ and ‘‘data reduction’’ was further supplemented by a process of ‘‘data complification’’ in order to interrogate the data. This is in line with the literature on the facilitation of the development of theories (Coffey and Atkinson, 1996). A computer was used to store and organise the qualitative data (Richards and Richards, 1994).
Results: the participants Study participants were selected from a larger investigation that included both those undergoing detoxification and maintenance. The focus of the current investigation on detoxification required the inclusion of only those[2] who had previously been prescribed
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methadone but had left or been suspended from the programme due to illicit use of other drugs. Such suspension would have been enforced by nursing staff following a mandatory drug test result or via a discipline reporting system. Within this study, all participants who agreed to take part, (n ¼ 14), were informed of the nature of the study. They were informed that they were being asked to take part due to their prescribed use of Subutex and their previous experience of prescribed Methadone. The average length of time participants had been using heroin was 7.9 years. All studied were adult male (21 þ ). The age range was from 21-44 yrs and the mean age was 31 years. There were no females within the study. All participants were informed that their identity would be protected and that they could stop the interview at any time. No prisoners refused to take part and no prisoner asked for their interview to be terminated early. Table I provides summary details of participants. The most commonly used drug in descending order was heroin, cocaine, crack cocaine, cannabis and benzodiazepines. Heroin and cocaine were most commonly administered by smoking and by snorting. It is interesting to note that while some participants previously snorted drugs such as crack and cocaine, there were no reports by participants in this study of snorting Subutex while in prison. Snorting of Subutex while in prison has been reported in other studies such as Tompkins et al. (2009). Benzodiazepines were most commonly swallowed by participants in this study. The number of occasions participants hade been in treatment ranged from one to five times. The mean number of times spent in treatment was 2.5 times. The amount of times spent in prison for custodial sentences ranged from once to 27. The mean amount of times spent in prison was 6.1 times. The time using opiate drugs ranged from one year to 15 years. The mean time using opiates was 7.9 years. Although the prisons involved in the study covered all of Scotland, 71 per cent of the participants who were interviewed lived in the central belt of Scotland, this area being the most highly populated area of Scotland. Remaining participants originated from the North East and East coast of Scotland accounted, with a small number also from Scottish rural[3] communities and from England
Results: discourse from participants From the 14 interviews conducted the following key themes emerged: Table I General data on participants within the study Participant A D E F G H L N O P R S T Z Mean
Age
Drug of choicea
Years using
How usedb
Times in treatment
Times in prison
Type
21 23 35 42 33 41 36 26 22 37 33 22 21 44 31 years of age
H H H, Ca, B H, C H, C H H, Cr H, Ca, B H H H H H, C, B H, Ca
6 5 3.5 2 10 13 14 10 4 12 15 8 7 1 7.9 years using
S S S, Sw S, Sn S, Sn S S, Sn S, Sw S S S S S, Sn, Sw S
2 1 1 3 5 1 4 3 4 1 3 4 2 2 2.5 In treatment
6 1 5 1 2 7 27 3 14 3 4 2 10 1 6.1 In prison
Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox
Notes: aDrug of choice: H¼ Heroin, C ¼ Cocaine, Cr ¼ Crack, Ca ¼ Cannabis, B ¼ Benzodiazepines; bHow drug taken: I¼ Injecting, S ¼ Smoked, Sn ¼ Snorted, Sw ¼ Swallowed; Participant treatment: detox. ¼ detoxification
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B
reasons for illicit use of drugs while in prison;
B
prescribed use of methadone and Subutex while in prison;
B
prison as an intervention;
B
craving, withdrawal and sleep; and
B
goals, expectancy and motivation.
Reasons for illicit use of drugs while in prison It would be naı¨ve to assume that drugs are not available in prisons despite a range of methods to prevent supplies of illegal supplies entering prison and prescribed drugs circulating illegally within prisons. Participants were therefore initially asked why they used illicit drugs in prison. (All talked freely about their drug use and did not seem in any way concerned about discussing this with the research interviewer). While responses varied, the main view expressed was that they enjoyed taking drugs and prison was no deterrent as according to one participant, ‘‘they were already there, doing time’’. All had started smoking heroin and some later had changed to injecting this drug. Other participants noted they used illicit drugs in prison in order to stop withdrawals from and cravings for drugs. Others cited escapism as their main reason for using illicit drugs in prison, i.e. to avoid the reality of being in prison or escape from the problems that affected them. While some prisoners say prison is an easy option, participants in this study were in fact feeling the opposite was the case. Use of drugs while in prison reduces their worries particularly in relation to family and social issues taking place outside of the prison, over which they had little control over while in prison. This external locus of control (confinement) affecting them was regained internally, for a short time, by their drug use while in prison. For example, Mr Z noted he used drugs . . . To get rid of the pain and anguish he felt towards his family (as a result of his imprisonment).
Using drugs in prison and the feeling of helplessness was indicative of Mr Z’s loss of control over his situation. Drugs were also used to relieve boredom as Mr P notes: ‘‘It’s the boredom in here, especially at the weekend’’. Taking drugs ‘‘Helps me to get through my sentence and takes me out of jail’’.
Ease of access of drugs within the prison setting was another reason verbalised by Mr T: I’m sitting here trying to get on without drugs and right in front of me is another prisoner ready with his next fix.
Such comments from prisoners provide valuable insights into reasons why they use drugs within prison settings and such information may not have been so readily elicited using a quantitative methodological approach.
Prescribed use of methadone and Subutex while in prison The next research focus was on participants’ previous methadone and current prescribed Subutex use while in prison. The problem of drug use among prisoners was highlighted as a major matter of concern nationally and internationally (Cabinet Office White Paper, 1998). Prison with its prevalence of drug use can provide a unique opportunity for treatment. It is essential to support users within Scottish prisons for two reasons. The first reason is the high rates of overdose on release (Seaman et al., 1998; Shewan et al., 2000) and secondly many have had difficult life experiences before they started taking heroin. These key issues would be a starting point from which to work. These individuals need good and intensive support structures within prison and post release (Kothari et al., 2002). The research of Kolar et al. (1990) was supported within the data, in that, no positive aspects of methadone programs were found in this research. The participants’ negative views were based upon retrospective experiences with methadone programmes as well as others’ experiences (Koester et al., 1999).
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Mr TD: Yes, I was embarrassed about it. Just the fact it’s called Methadone, its green stuff, you have to go to the chemist everyday. See I never seen myself as a junkie or anything. See until I went on methadone, that’s when I said that’s me a junkie.
Their main perspectives were very negative and similar to those reported by Neale (1999). The impact on their health and physical state and indeed lifestyle was similar to that noted by Fischer et al. (1999). The participants were concerned that methadone was more addictive than their previous heroin habit. They talked of how it had a worse withdrawal effect than heroin. In relation to withdrawal from methadone Mr H stated: I was scared . . . I was very, very scared to come off methadone because . . . I’d been told so many horror stories about people coming off methadone and how hard it was to come off.
This negative expectancy in relation to their methadone usage was echoed by other participants in the way it made them feel. Mr T noted: I hated my methadone. I hated it. I was up at 80 ml so no matter what I did I thought I would be strung out.
In contrast to the participants’ views on methadone, the participants’ views on Subutex were extremely positive. Tompkins et al. (2009) also note that participants in their study had overwhelmingly positive experiences of using Subutex while in prison. Within this current study, all of the participants stated that they thought that the positive aspects of Subutex combined to make it the best available drug. Also, all of the participants’ experiences with it had been far more positive than their experiences with methadone. Mr T expressed this as follows: ‘‘I asked when I saw the drug worker about coming off my methadone. They seemed to think Subutex and I asked to see about it and then I saw their booklet on it. It just seemed ideal, man.’’ He then added, ‘‘If it wasn’t for the fact that I got Subutex. I’d still be on this methadone for another couple of year’’.
This is in line with reports from one study by Schwartz et al. (2008) which identified how attitudes and beliefs can affect better outcomes by having a more positive attitude toward buprenorphine than methadone. Most of the participants stated that abstinence plays a major role in the success of Subutex, especially within prison, and all were very optimistic about their treatment programme. A further positive aspect by participants (recall that they were all on detoxification programmes), was the shorter treatment time completed compared to their previous experiences of methadone detoxification programmes. An additional benefit reported by the majority of participants in this study in using prescribed Subutex was the removal of craving and withdrawals. This is supported by O’Connor and Fiellin (2000) who posited that the shorter-term medical withdrawal from heroin would be far more appealing to clients than longer-term treatments such as methadone programs.
Prison as an intervention Data from the participants discourse identifies that they felt stigmatised in their heroin use within prison and they were aware of negative attitudes of prison staff towards the use of methadone within the prison setting. Participants reported that this had a detrimental effect on the outcome of their experiences with methadone treatment. The majority of prisoners from their discourse stated that prison although bad for them due to easy access to a wide range of drugs, it was also a good thing for them in giving them time for treatment and indeed change from their heroin use. Mr H said: Well, the satisfaction is that I feel for the first time in years that I’m doing the right thing, getting the job done here (in prison).
And Mr T added:
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I know if I was doing this detox outside I’d have just binned the Subutex and gone back to heroin again . . . It’s brilliant I’m off methadone.
Another factor that emerged from the analysis of the interview material was the participants’ views on their experiences with prison. The short-term prisoners (up to four years) had spent various times in jail during their addiction, and all had intended to refrain from illicit drug use on release from prison. Within a short time period after release however, they returned to heroin use again. Mr H verbalised this as follows: I don’t intend drugs to have any part in my life when I get out. There’s no room in my life outside for drugs, so I want to make sure it’s all out my system before I get out the jail.
During their current prison sentence, over 50 per cent of the participants received support and counselling regarding their heroin use and they reported this as being helpful. Those not receiving professional support appeared to rely on other non-users or participants within the Subutex programme for support. Future studies should consider this aspect of prison, as prison sentences appear to provide an excellent opportunity to focus on rehabilitating drug users. Drug using individuals within prison could be selected and offered rehabilitation programs with their release in mind. This would assist them in preparing for lifestyle changes and using appropriate coping mechanisms to overcome heroin addiction when they return to their local communities.
Craving, withdrawal and sleep Participants in this study stated that readiness and motivation for abstinence from drugs were important aspects of recovery from heroin addiction while also being major factors impacting on retention in treatment. From the research data it was found that participants slept on average 8.6 hours with previous methadone use, dropping to 7.4 hours with Subutex use and 5.7 hours after detoxification was complete. Those experiencing withdrawals and cravings slept on average nine hours with previous methadone use, dropping to five hours on Subutex and on completion of detoxification their average hours of sleep per day reduced to 4.5 hours sleep. The majority of participants however noticed that the quality of their sleep improved following their use of Subutex. The importance of making lifestyle changes when overcoming addiction has been supported by Vaillant (1996) who highlighted the importance of social context in addiction and recovery. A number of researchers have also proposed that acquiring a substitute behaviour that competes with the addiction plays a major role in overcoming addiction (Miller and Rollnick, 2002), a viewpoint agreed on by the participants in this study. By using Subutex, which prevents the pleasurable effects of illicit opioids (Jasinski et al., 1978), the temptation to use illicit drugs is taken away from the individual. This consequently enabled participants to focus on issues that led them to addiction in the first instance. They reported a belief that relapse was part of the recovery process, but not an intention they were striving for. In addition, they noted abstinence as a key factor in the change process. This was probably due to the history of the prison system working totally towards abstinence from drug use in their provision of treatment programmes. Over 25 per cent of participants stated that they experienced difficulty whilst on the lowest doses of Subutex. Although these individuals experienced some discomfort whilst on the lowest doses, the majority (71.5 per cent) accepted that the partial agonist properties of Subutex meant they had an easier withdrawal process compared with withdrawals in previous methadone detoxification programmes (Cheskin et al., 1994). It should be noted that previous research data suggested buprenorphine did not differ from Methadone in its ability to suppress heroin (RCGP, 2004). A small number of participants exited early from the detoxification programme (7.14 per cent) most likely due to the rapid reduction of buprenorphine leading to feelings of craving and withdrawals. Thereafter, the retention level remained static during the study with no loss of any other participants. This was despite rates of craving and withdrawals reported at over 28 per cent.
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This was significant as the findings revealed that of those without cravings (n¼ 10), 71.43 per cent had no craving or withdrawal effects during their detoxification programme, which lasted between the range of 18-30 days. Literature on the best length of such programmes indicates that longer term detoxification (. 30 days) towards withdrawal is more effective. However, there is growing support for shorter detoxification (Kakko et al., 2003, Amass et al., 2004). Participants within this study who had no cravings gave data for mean duration of detoxification as 10 per cent at 30 days, 40 per cent at 18 days and 50 per cent at 20 days. When participants within this study were titrated during 18 days and at levels of 2 mg, this appeared to be too high a level for some participants to reduce to abstinence. The data revealed reducing from 2 mg to 0.4 mg and then to 0.2 mg achieved better results for all participants. The properties of Subutex for many of the participants, was attractive to those individuals who did not prefer a full agonist effect (as with methadone). Within the study one participant who went back to illicit use did prefer full effect. The data collected was consistent in that buprenorphine participants reported less of a ‘‘stoned’’ effect, in comparison to previous methadone treatments. The data revealed similar findings of Cheskin et al. (1994) in that the withdrawal discomfort was not so marked. The withdrawal discomfort for participants prescribed Subutex in this study was found to be significantly less to their previous experience of withdrawal from opiates using methadone during previous custodial sentence treatment.
Goals, expectancy and motivation Participants were asked about their goals for the future. One participant summed it up in very simple terms. Mr PD: I wanted to get off the methadone.
This discussion developed through grounded theory and focussed on goals during their prison sentence as well as goals on their release from prison. Participants reported substantial cognitive changes as they became abstinent at the end of their treatment. Fear seemed to be a key negative expectancy[4]. Research suggests that greater negative expectancies about the participants’ use can predict good treatment outcomes in terms of longer periods of abstinence (McMahon and Jones, 1993). This was evidenced through the experience of one the participants. Mr TD: Just to get off my methadone altogether. I hated my methadone. I hated it. I had to go to the chemist every day and take it. I was up at 80 ml, so no matter what I did I thought I would still be craving in the house.
Over 50 per cent of participants reported they had received support services whilst on Subutex and that this played a major role in their attempts at overcoming their heroin dependency during their detoxification programme. Mr HD: There’s two people . . . two people that have been really really supportive for us and that was Ms X and Ms Y from the Health Centre. Drug worker and addiction nurse . . . Brilliant. They’ve been great.
This supports findings by Neale (1999) who reported that counselling plays an important factor in retention in treatment and recovery from opiate addiction. These findings are further supported by Prochaska et al. (1992) in their model of change, which posits that an individual has to be ready to overcome their addiction, otherwise no interventions will affect their behaviour. All participants in this study stated the importance of making lifestyle changes and developing improved coping mechanisms during the rehabilitation stage of treatment. This they believed would help achieve their goals. One of the participants saw Subutex detoxification as a means to giving him the option of a ‘‘normal lifestyle’’. Mr DD: With Methadone you’re drowsy and it’s just like Heroin. Subutex if its used right, you feel normal, it does not feel like you’ve got anything in your body at all . . . that’s the way I want to be . . .
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some people out there might disagree but that’s the way it is to me. You don’t feel doped up to your eyeballs, you don’t feel drowsy, talking different, look different . . . just to look better as well.
Lifestyle changes from prison to prison also offered the opportunity of change. Mr TD: It was coming up here and hearing other prisoners and then I asked when I seen the drug worker about coming off my methadone they seemed to think Subutex and I asked to see about it, so I seen the booklet. It just seemed ideal, man . . . I asked everybody about it not one person had a bad word to say about it.
This confirms the importance of counselling and support, as through these, individuals are provided with the knowledge of how to make changes to their behaviour and thereby reduce the chances of a return to drug use on completion of treatment.
Limitations of this study The main limitation for this study is that the study was based on a small number of participants (all male) and consequently the findings cannot be generalised to the larger prison population. Those participants within the study were not a random sample selection but were an opportunistic sample therefore it does not reflect the extent of the total use of Subutex in the detoxification of prisoners throughout Scottish Prisons. Data was only collected in a general format therefore it cannot be subjected to statistical analysis. Prisoners interviewed gave different views on different prison treatment regimes and so there exists the potential for bias within the data.
Conclusion The findings of the current investigation reveal discrepancies between studies considering the users’ views on Subutex prescribing that have used quantitative research methods and studies that have used qualitative research methods. Extensive previous research has been conducted using quantitative methodologies comparing the two substitute drugs, however, the results are often varied and observations and conclusions between studies difficult to reconcile. The majority of studies have reported methadone to be superior to Subutex in retention in treatment. In contrast, the participants’ views from this study, as well as from a number of other qualitative studies (Neale, 1999), have largely favoured Subutex over methadone. Future research could combine quantitative and qualitative approaches to produce services to heroin users that match their needs, and in many respects, mixed-methods approach to unpack the complex and dynamic tapestry of the individuals experience is preferred. This study has shown that Subutex is associated with perceptions of more attractive qualities to the incarcerated individual than methadone. The majority of the British in-treatment heroin dependent population are currently being prescribed methadone. Further qualitative studies comparing the efficiency of methadone and Subutex should be conducted. Comparison of data between both methadone and Subutex treatments did show that there were significant differences between both. Interpreting the participants discourse, the majority perspective was that methadone was associated with a return to illicit use. In conclusion this research has shown that Scottish prisons are working in a positive progression to deal with the proportion of drug users within their custody and care. Removing Subutex from its detoxification regimens may be problematic in clinical efficacy in terms of contrast with the emerging evidence base derived from studies such as this. Developments in treatment strategies and approaches require veracity in terms of their orientating evidence base and where this is not forthcoming, an implicit duty of care focus must emphasise the development of contextually appropriate, acceptable and successful interventions. This may only be achieved through systematic research enquiry and endeavour. Methadone is not the panacea for dealing effectively with all instances of opiate addiction and indeed other approaches, including but not exclusively, pharmacotherapy, should be explored. Economic evaluation for drug treatments are important, however in using Subutex, prisoner/staff time, storage, delivery and more especially, safety for all is both
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desirable and attainable. Consistency and synchrony between treatment approaches, used in prisons and in the community, is a highly desirable goal and represents a seamless transition and translation of the contemporary evidence-base in relation to provision. The present one size fits all approach has been clearly demonstrated to have inherent limitations and individualised programmes of treatment and care are likely to promote both compliance to treatment and improved overall outcome. The findings are indicative of an arbitrary approach to detoxification provision within the prison system, an approach limited in scope, vision and ultimately clinical efficacy. More intensive training is required for practitioners[5] in the exchange of drugs and the proper dosage for each individual. Support groups and counselling are essential. Users should be not be sent to prison for treatment, however if imprisonment is sanctioned then interventions should be consistent with those approaches offered within the community (Davies, 1997). The prisoners’ views and subjective feelings within the study suggest that Subutex can be a better-suited treatment in helping those individuals with their heroin use. To the majority of participants in this study Subutex has been seen to be the ‘‘miracle drug’’, however there is no ‘‘magic bullet’’ (Davies, 1997) to ending opiate addiction. The process of treatment shall always be prioritised with regards to custody and security, in order to protect the public. The regime of prisons still adhere to the prison rules which are challenged on a daily basis in areas such as prisoner rights, equality and diversity, social inclusion and indeed addiction issues[6]. Many rules are archaic and do not adequately address those with addictions. The rank structure within prisons does little to help treatments, the ‘‘my way or highway’’ approach, just does not work, for users, or staff working with such individuals. More qualitative research into drug treatment for users’ within prisons, such as Subutex, is vital. This in turn helps ‘‘all areas’’ of our society.
Notes 1. Includes HMP Kilmarnock – private prison. 2. Participants in the current study numbered 14 as a subset of the larger study (n¼21). 3. No Epidemiological differences between rural and urban setting. 4. Transformation of Meaning in psychological therapies (Power and Brewin, 1997). 5. Ling et al. (2005) states the Clinician’s attitude and the extent to which they embrace buprenorphine will play an important role in determining the future success of using this. 6. In 2006, drug-addicted prisoners who were forced to go ‘‘cold turkey’’ while in jail are suing the Home Office. Six test cases are due to go before the High Court which, if successful, could lead to 198 offenders – all addicted to opiates – seeking compensation.
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O’Connor, P.G. and Fiellin, D.A. (2000), ‘‘Pharmacologic treatment of heroin-dependent patients’’, Annals of Internal Medicine, Vol. 133, pp. 40-54. Oreskovich, M.R., Saxon, A.J., Ellis, M.L., Malte, C.A., Reoux, J.P. and Knox, P.C. (2005), ‘‘A double-blind, double-dummy, randomized, prospective pilot study of the partial Mu opiate agonist, buprenorphine, for acute detoxification from heroin’’, Drug & Alcohol Dependence, Vol. 77 No. 1, pp. 71-9. Penfold, C., Turnbull, P. and Webster, R. (2005), ‘‘Tackling prison drug markets: an exploratory qualitative study’’, Home Office Online Research Report 39/05 Home Office, London. Petitjean, S., Stohler, R., Deglon, J.J., Livoti, S., Waldvogel, D. and Uehlinger, C. (2001), ‘‘Double-blind randomized trial of buprenorphine and methadone in opiate dependence’’, Drug and Alcohol Dependence, Vol. 62, pp. 97-104. Pinto, H., Maskrey, V., Swift, L., Rumball, D., Wagle, A. and Holland, R. (2010), ‘‘The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment’’, The Journal of Substance Abuse Treatment, Vol. 39 No. 4, pp. 340-52. Power, M.J. and Brewin, C.R. (1997), The Transformation of Meaning in Psychological Therapies: Integrating Theory and Practice, Wiley, Chichester. Prochaska, J.O., DiClemente, C.C. and Norcross, J. (1992), ‘‘In search of how people change: applications to addictive behaviors’’, American Psychologist, Vol. 47, pp. 1102-14. Richards, T. and Richards, L. (1994), ‘‘Using computers in qualitative research’’, in Denzin, N.K. and Lincoln, Y.S. (Eds), Handbook of Qualitative Research, Sage Publications, London, pp. 445-62. Royal College of General Practitioners (2004), Guidelines for the Use of Buprenorphine for the Treatment of Opioid Dependence in Primary Care, 2nd ed., Royal College of General Practitioners, London. Schottenfeld, R.S., Pakes, J.R., Oliveto, A., Ziedonis, D. and Kosten, T.R. (1997), ‘‘Buprenorphine versus methadone maintenance treatment for concurrent opioid dependence and cocaine abuse’’, Archives of General Psychiatry, Vol. 54, pp. 713-20. Schwartz, R.P., Kelly, S.M., O’Grady, K.E., Mitchell, S.G., Peterson, J.A., Reisinger, H.S., Agar, M.H. and Brown, B.S. (2008), ‘‘Attitudes toward buprenorphine and methadone among opioid-dependent individuals’’, American Journal on Addictions, Vol. 17 No. 5, pp. 396-401. Scottish Office (1999), Tackling Drugs in Scotland: Action in Partnership, The Stationery Office, Edinburgh, p. 63. Scottish Prison Service (2000), ‘‘Partnership and coordination: SPS action on drugs – revised guidance on the management of drug misuse in Scotland’s prisons’’, Scottish Prison Service, Edinburgh. Seaman, S.R., Brettle, R.P. and Gore, S.M. (1998), ‘‘Mortality from overdose among injecting drug users recently released from prison: database linkage study’’, British Medical Journal, Vol. 316, pp. 426-8. Seymour, A., Black, M., Jay, J., Cooper, G., Weir, C. and Oliver, J. (2003), ‘‘The role of methadone in drug related deaths in the West of Scotland’’, Addiction, Vol. 98 No. 7, pp. 995-1002. Shewan, D., Hammersley, R., Oliver, J. and Macpherson, S. (2000), ‘‘Fatal drug overdose after liberation from prison: a retrospective study of female ex-prisoners from Strathclyde region (Scotland)’’, Addiction Research & Theory, Vol. 8 No. 3, pp. 267-78. Silverman, D. (2000), Doing Qualitative Research: A Practical Handbook, Sage Publications, London. Sporer, K.A. (2004), ‘‘Buprenorphine: a primer for emergency physicians’’, Annals of Emergency Medicine, Vol. 43 No. 5, pp. 580-4. Tompkins, C.N.E., Wright, N.M.J., Waterman, M.G. and Sheard, L. (2009), ‘‘Exploring prison buprenorphine misuse in the United Kingdom: a qualitative study of former prisoners’’, International Journal of Prisoner Health, Vol. 5 No. 2, pp. 71-87. Vaillant, G.E. (1996), The Natural History of Alcoholism, Harvard University Press, Cambridge, MA. World Health Organization (2001), The World Health Report: Mental Health: New Understanding, New Hope, World Health Organization, Geneva, p. 103.
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Further reading Shearer, J., Wodak, A. and Dolan, K. (2004), The Prison Opiate Dependence Treatment Trial, NDARC Technical Report No. 199, National Drug and Alcohol Research Centre, University of New South Wales, Sydney. Strang, J., Sheridan, J. and Barber, N. (1996), ‘‘Prescribing injectable and oral methadone to opiate addicts: results from the 1995 national postal survey of community pharmacies in England and Wales’’, British Medical Journal, Vol. 313, pp. 270-2.
About the authors Alexander Johnstone is an Associate Lecturer at the University of the West of Scotland. He was initially seconded to the Post Graduate Programme in Alcohol and Drug Studies by the Scottish Prison Service. Mr Johnstone has worked in the addiction field for a considerable period, predominantly in criminal justice, both in prisons and the community. In addition he has worked for Alcohol and Drug Studies at UWS, delivering Level 9 modules to full and part-time students across all campuses. Alex has also mentored practice placements for students within Criminal Justice. He is a Fellow of The Higher Education Academy. Alexander Johnstone is the corresponding author and can be contacted at: [email protected] Tim Duffy is the Research and International Project Manager at the University of the West of Scotland. He is a qualified social worker and specialised in working with people with alcohol and drug-related problems. For six years he was National Training Officer with responsibility for training social work and healthcare personnel to develop strategies to help motivate clients and patients of all ages to reduce problems related to alcohol and drug use. He has supported academic staff to develop and deliver distance learning teaching materials for students in 28 countries. His PhD study evaluated the impact of a Self-Administered Motivational Instrument (the SAMI) in a UK higher education setting. He has researched student learning styles and approaches to study, student motivation, methods of supporting students online and student retention. Tim is now a full-time researcher specialising in psychosocial interventions within a wide range of health and social care settings. Colin Martin is Chair in Mental Health at the University of the West of Scotland. He is a registered Mental Health Nurse, Chartered Health Psychologist and a Chartered Scientist and has also trained in analytical biochemistry reflecting the psychobiological focus of much of his research. He is Honorary Consultant Psychologist to the Salvation Army, UK & Eire territories and was instrumental in formulating their addictions policy to develop high-quality and evidence-based clinical care and services. He developed a psychobiological model of alcohol dependency and has published or has in press over 150 research papers and book chapters. He is a keen author and editor and his outputs include the seminal five-volume magnum opus, Handbook of Behaviour, Food and Nutrition (2011) and the forthcoming prophetic insight into the treatment of neurological disease, Nanomedicine and the Nervous System (2012). He has a long-standing interest in perinatal health and is editor of the influential Journal of Reproductive and Infant Psychology; forthcoming books, Perinatal Mental Health: A Clinical Guide (2012) and Scientific Bias of Healthcare: Aids and Pregnancy (2012) are a reflection of this area of focus. He is an investigator and/or named collaborator on research activity and projects that have attracted in excess of £5m in funding and is involved in collaborative international research with many European and non-European countries.
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Alexander Johnstone is an Associate Lecturer in the Centre for Alcohol & Drug Studies, University of the West of Scotland, Paisley, UK. Tim Duffy is Research and International Project Manager and Colin Martin is Chair in Mental Health, both in the School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK.
Abstract Purpose – Buprenorphine (Subutex) was piloted in two Scottish prisons between 2004 and 2006 and consequently used within other penal establishments in Scotland. This 2007 qualitative study aimed to explore the use of Subutex and its associated effects on 14 participants on detoxification programmes. Design/methodology/approach – All participants were male, aged from 21 to 44 years with prison sentences ranging from a few months to life imprisonment. Buprenorphine was unavailable to female prisoners at the time of this study. Participants were recruited from seven Scottish prisons. All 14 participants were on detoxification programmes, each was prescribed Subutex, and each was selected from a larger investigation that included both those undergoing detoxification and maintenance (n ¼ 21). All participants had previously also used methadone on previous detoxification programmes. Findings – It can be concluded that the majority of detoxification participants within this study indicated that Subutex was a more effective treatment than methadone as it helped reduce craving, eased the process of withdrawal and improved sleeping patterns. In addition, the majority of participants noted higher levels of motivation and the ability to set goals towards obtaining an improved quality of life. Originality/value – This study provides an alternative perspective to the use of Subutex within prison settings, when compared with results from previous quantitative studies reported. The study also highlights inconsistencies drawn from studies in this area, which may be an artefact of study design. It is recommended that further qualitative studies be conducted to explore further this alternative perspective. Finally, the issue of methodological approach taken should be addressed within the context of a related, but independent, research forum. Keywords Detoxification, Buprenorphine, Subutex, Scotland, Prisoners, Penal, Craving, Withdrawal, Sleep, Qualitative, Drug addiction, Rehabilitation Paper type Research paper
Introduction At the time this study was conducted (2007) within the Scottish Prison Service (SPS), prescribed methadone was the main pharmacological treatment available to opiate using prisoners in Scottish prisons. Methadone is prescribed as a legal substitute drug to heroin and some individuals may be maintained on this drug indefinitely. A second treatment option available (though less widely used) for opiate users within Scottish prison settings is a process of detoxification during which the individual is detoxified from heroin using prescribed methadone on a reducing level aiming for zero drug use (abstinence). The use of prescribed methadone has helped many opiate users achieve a more stable lifestyle and has been a useful intervention for opiate using prisoners in assisting maintenance, detoxification and supporting harm reduction programmes. Despite negative reports in the 1990s when many methadone related deaths occurred in the United Kingdom, later research indicates the level of such drastic outcomes has reduced considerably since 1996 (Seymour et al., 2003). The use of prescribed methadone is recognised by many as the acceptable ‘‘standard’’ for opiate maintenance and detoxification.
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DOI 10.1108/17449201111256907
An alternative to methadone (buprenorphine, also called subutex) has increasingly been recognised by many researchers and opiate users as a drug having equivalent or better efficacy in reduction or maintenance treatments, when compared to methadone (Auriacombe et al., 2004). Many clinical studies have compared the efficacy of methadone and subutex, often with differing conclusions (Kosten et al., 1993; Ling et al., 1996; Schottenfeld et al., 1997; Fischer et al., 1999; Petitjean et al., 2001). Earlier research had found methadone to be more effective in terms of retention of treatment but new research (Pinto et al., 2010), alongside increased use and understanding of buprenorphine, has led to valuable research data being produced which indicates that it may become the new gold standard for the detoxification treatment of opiate users. Evidence has shown that buprenorphine is a safer and more effective treatment regime than methadone. Further studies have shown that it can be used more effectively in maintenance or as a short-term agent for detoxification (Gonzalez et al., 2002). There is a shortage of reported studies in the literature which provide a detailed discussion of the effectiveness of detoxification interventions (particularly studies within penal institutions) in relation to prisoners’ subjective experience. In 2004 the Scottish Prison Service piloted the use of buprenorphine (subutex) within two Scottish prisons establishments one high level security, and one low level security (open prison). This was a significant development within the Scottish prison setting and consequently it was deemed appropriate to evaluate the impact of this innovation within the Scottish Prison Service. This is the focus of this research.
Opiate substitution Substitution treatment is a form of medical care for opiate dependence using a similar or identical substance with properties and actions similar to the drug normally used. For many years methadone (taken orally) was used widely in the UK while buprenorphine (subutex) was used more frequently in other countries including for example France (Auriacombe et al., 2004). Subutex is often reported as being appropriate for use in non-traditional treatment settings such as residential detoxification centres. Clinical trials have shown the withdrawal effect from buprenorphine to have less severe subjective and objective opiate withdrawal symptoms, earlier symptom mitigation, better withdrawal completion and longer treatment retention (Ling et al., 2005; Oreskovich et al., 2005). This allows the person undergoing detoxification to focus on normal life activities without the need to obtain and administer drugs. Furthermore, the substitution of prescribed medication such as methadone or subutex from an illicit drug helps in reducing criminal activity, supporting the process of lifestyle change.
Scottish Prison Service addictions policy Substance misuse is extremely difficult to tackle in prison. Like many other organisations concerned about substance misuse, the Scottish Prison Service (SPS) has a role to play in delivering Scotland’s National Drug Strategy: ‘‘Tackling drugs in Scotland – action in partnership’’ (The Scottish Office, 1999). Since the SPS publication on the management of drug misuse in Scotland’s prisons in 2000, there have been many changes in the addictions field both inside prisons and in the community. Following consultation with a range of stakeholders it became clear that the Scottish Prison Service would be required to change from the provision of a mainly punitive response towards substance misuse to a more treatment focussed goal. Home office publications such as the Updated National Drug Strategy (Home Office, 2002b), Tackling Crack – A National Plan (Home Office, 2002c), Social Exclusion Report (Home Office, 2002a) and that of the World Health Organisation (WHO): Prisons Drugs and Society (WHO, 2001), have all impacted on the revision of the Scottish Prison Service Policy. Policy revisions have also reflected the need for more robust assessment procedures, improved action planning and
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transitional care with the aim of ensuring a higher level of community support on release for ex-offenders. Meader (2010) suggests buprenorphine is the most effective method of detoxification. However, there is little research data available on prisoners’ subjective experience of the effects of buprenorphine treatment. The ‘‘misdirection’’ of prescribed buprenorphine in prison settings has been noted by Penfold et al. (2005) and commented on further by Tompkins et al. (2009). However, within this particular study there was no incidence of diversion and abuse of Subutex in the SPS. It is thought this is due to the prescribing and observational setting adhered to by prison and nursing staff. The Scottish Prison Service complies with the Department of Health prescribing guidelines (Department of Health, 1999). Currently, the prescribing of buprenorphine, to lessen intravenous abuse, is dispensed, not only in the form of Subutex, but also in the in the form of Suboxone, whereby naloxone is added to sublingual buprenorphine (Sporer, 2004). Nonetheless, Suboxone contains a far greater percentage of buprenorphine than naloxone. The naloxone is poorly absorbed sublingually and is designed to discourage intravenous use. At the time of this study Suboxone was not yet available to the market, as it is today. This study explored the clinical impact and subjective effect of Subutex on the day-to-day lives of prisoners within Scottish Prisons.
Crime and use A review of the literature indicates that in comparison to non-heroin users, there is a higher level of crime amongst users of heroin (Hammersley et al., 1989) and that criminal activity and opiate use influence each other. The research discourse and its analysis within this study indicate such commonalities relevant to those participants. Further, crime and illicit drug use inside prisons is also commonplace, including the sales of legally prescribed (such as Subutex) and illegal drugs.
Introduction to the qualitative study Within the recently revised assessment process, prisoners (with the assistance of prison health care staff) consider the most appropriate form of intervention in relation to the prisoners drug use while they remain in prison. For some, this intervention will be long-term maintenance using a prescribed drug. Until recently, the only option available for this intervention was methadone. In recent years Subutex has also become an alternative within Scottish prisons. For other prisoners, a short-term intervention of detoxification may be agreed on with a view to facilitating access to longer-term interventions such as counselling or group-work either within prison or in the community following release. In the past methadone was the most frequently used prescribed drug used for this purpose but more recently Subutex has been available to assist with this short-term detoxification process prior to further longer-term intervention. Within the revised Scottish Prison Service treatment policy in 2000 (Scottish Prison Service, 2000), detoxification is not seen as a treatment in itself but as a precursor to further recognised treatment options. The number of Scottish prisoners with experience of both methadone and Subutex is relatively small. The volume of drug using prisoners with experience of illicit drug use in prisons who opt for detoxification is higher than that those opting for longer-term maintenance of prescribed alternatives. To obtain higher numbers for this study, it was therefore decided to recruit participants who had opted to aim for detoxification using Subutex, as recruiting participants on maintenance programmes would at the time of the study generate very small numbers potentially making the study non viable. The study recruited a sample of 14 male opiate dependent drug users who had experience of illicit drug markets within the prison system. At the time of this study, each participant was being prescribed Subutex within a detoxification programme. Each participant had previous experience of being prescribed methadone either for maintenance or detoxification purposes. All 14 participants were interviewed with the focus on their subjective experiences
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of the prescribed drug Subutex. During the interview, participants were also invited to reflect on the effects on their lives, within the social context of the prison, of the effective prohibition to all drugs, unless prescribed. At the time this study was conducted no female prisoners were being prescribed Subutex within Scottish prisons and consequently only males were included in this study.
Methodology In conducting studies of this kind, ethical issues have to be considered. The individual’s rights must be protected including remaining anonymous, participating with informed consent, privacy and confidentiality, self respect and dignity, voluntary participation and rights to any services (Holloway and Wheeler, 2002). Ethical Approval for this study was sought and approved from the Scottish Prison Service Ethical Committee. Following approval all Scottish prisons were contacted by the Healthcare Directorate and invited to participate in this study on a voluntary basis. From a possible 15 establishments[1], seven prisons were selected for inclusion in this study including high, medium and low security prisons. Consideration was given to providing an incentive to potential participants to participate in this study. Following consultation with prison personnel it was decided not to provide an incentive for participating participants. Names of prisons and prison locations are not provided within this report. All prisoners were asked to choose a pseudonym from the alphabet. (i.e. Mr A, Mr B etc). The interviews were conducted within the prisoner’s own establishment. Initial contact for the study was facilitated by the prison healthcare staff who also arranged an appropriate private room for the interview to take place. Each interview lasted approximately half an hour. As recruitment of participants emerged from the health care assessment process noted earlier, there were no apparent gate-keeping processes in place preventing potential prisoners from becoming involved in this study.
Data analysis Holloway and Wheeler (2002) note the use of qualitative research methodology is favoured by sociologists to record data related to participants’ experiences of feelings. As this study aimed to focus on the feelings of prisoners in relation to their use of Subutex, qualitative methodology was employed and data analysed using constant comparative method to ensure validity and to minimise the risk of respondent bias (Glaser and Strauss, 1967). All the data fragments that arose within each interview section were inspected and compared with similar from the other interviews. All cases of data were analysed to maximise the reliability of the study and minimise researcher bias (Silverman, 2000). All interviews were fully transcribed and then the data was organised in relation to the corresponding sections of the interview from which the data emerged. This enabled connections to be made between the views participants held on the specific categories of the interview schedule as well as provide a means of organising the data sets (Coffey and Atkinson, 1996). The raw data was read and coded several times. Relevant phenomena were collated and analysed until commonalities, differences, and patterns emerged. This process of ‘‘data simplification’’ and ‘‘data reduction’’ was further supplemented by a process of ‘‘data complification’’ in order to interrogate the data. This is in line with the literature on the facilitation of the development of theories (Coffey and Atkinson, 1996). A computer was used to store and organise the qualitative data (Richards and Richards, 1994).
Results: the participants Study participants were selected from a larger investigation that included both those undergoing detoxification and maintenance. The focus of the current investigation on detoxification required the inclusion of only those[2] who had previously been prescribed
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methadone but had left or been suspended from the programme due to illicit use of other drugs. Such suspension would have been enforced by nursing staff following a mandatory drug test result or via a discipline reporting system. Within this study, all participants who agreed to take part, (n ¼ 14), were informed of the nature of the study. They were informed that they were being asked to take part due to their prescribed use of Subutex and their previous experience of prescribed Methadone. The average length of time participants had been using heroin was 7.9 years. All studied were adult male (21 þ ). The age range was from 21-44 yrs and the mean age was 31 years. There were no females within the study. All participants were informed that their identity would be protected and that they could stop the interview at any time. No prisoners refused to take part and no prisoner asked for their interview to be terminated early. Table I provides summary details of participants. The most commonly used drug in descending order was heroin, cocaine, crack cocaine, cannabis and benzodiazepines. Heroin and cocaine were most commonly administered by smoking and by snorting. It is interesting to note that while some participants previously snorted drugs such as crack and cocaine, there were no reports by participants in this study of snorting Subutex while in prison. Snorting of Subutex while in prison has been reported in other studies such as Tompkins et al. (2009). Benzodiazepines were most commonly swallowed by participants in this study. The number of occasions participants hade been in treatment ranged from one to five times. The mean number of times spent in treatment was 2.5 times. The amount of times spent in prison for custodial sentences ranged from once to 27. The mean amount of times spent in prison was 6.1 times. The time using opiate drugs ranged from one year to 15 years. The mean time using opiates was 7.9 years. Although the prisons involved in the study covered all of Scotland, 71 per cent of the participants who were interviewed lived in the central belt of Scotland, this area being the most highly populated area of Scotland. Remaining participants originated from the North East and East coast of Scotland accounted, with a small number also from Scottish rural[3] communities and from England
Results: discourse from participants From the 14 interviews conducted the following key themes emerged: Table I General data on participants within the study Participant A D E F G H L N O P R S T Z Mean
Age
Drug of choicea
Years using
How usedb
Times in treatment
Times in prison
Type
21 23 35 42 33 41 36 26 22 37 33 22 21 44 31 years of age
H H H, Ca, B H, C H, C H H, Cr H, Ca, B H H H H H, C, B H, Ca
6 5 3.5 2 10 13 14 10 4 12 15 8 7 1 7.9 years using
S S S, Sw S, Sn S, Sn S S, Sn S, Sw S S S S S, Sn, Sw S
2 1 1 3 5 1 4 3 4 1 3 4 2 2 2.5 In treatment
6 1 5 1 2 7 27 3 14 3 4 2 10 1 6.1 In prison
Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox Detox
Notes: aDrug of choice: H¼ Heroin, C ¼ Cocaine, Cr ¼ Crack, Ca ¼ Cannabis, B ¼ Benzodiazepines; bHow drug taken: I¼ Injecting, S ¼ Smoked, Sn ¼ Snorted, Sw ¼ Swallowed; Participant treatment: detox. ¼ detoxification
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B
reasons for illicit use of drugs while in prison;
B
prescribed use of methadone and Subutex while in prison;
B
prison as an intervention;
B
craving, withdrawal and sleep; and
B
goals, expectancy and motivation.
Reasons for illicit use of drugs while in prison It would be naı¨ve to assume that drugs are not available in prisons despite a range of methods to prevent supplies of illegal supplies entering prison and prescribed drugs circulating illegally within prisons. Participants were therefore initially asked why they used illicit drugs in prison. (All talked freely about their drug use and did not seem in any way concerned about discussing this with the research interviewer). While responses varied, the main view expressed was that they enjoyed taking drugs and prison was no deterrent as according to one participant, ‘‘they were already there, doing time’’. All had started smoking heroin and some later had changed to injecting this drug. Other participants noted they used illicit drugs in prison in order to stop withdrawals from and cravings for drugs. Others cited escapism as their main reason for using illicit drugs in prison, i.e. to avoid the reality of being in prison or escape from the problems that affected them. While some prisoners say prison is an easy option, participants in this study were in fact feeling the opposite was the case. Use of drugs while in prison reduces their worries particularly in relation to family and social issues taking place outside of the prison, over which they had little control over while in prison. This external locus of control (confinement) affecting them was regained internally, for a short time, by their drug use while in prison. For example, Mr Z noted he used drugs . . . To get rid of the pain and anguish he felt towards his family (as a result of his imprisonment).
Using drugs in prison and the feeling of helplessness was indicative of Mr Z’s loss of control over his situation. Drugs were also used to relieve boredom as Mr P notes: ‘‘It’s the boredom in here, especially at the weekend’’. Taking drugs ‘‘Helps me to get through my sentence and takes me out of jail’’.
Ease of access of drugs within the prison setting was another reason verbalised by Mr T: I’m sitting here trying to get on without drugs and right in front of me is another prisoner ready with his next fix.
Such comments from prisoners provide valuable insights into reasons why they use drugs within prison settings and such information may not have been so readily elicited using a quantitative methodological approach.
Prescribed use of methadone and Subutex while in prison The next research focus was on participants’ previous methadone and current prescribed Subutex use while in prison. The problem of drug use among prisoners was highlighted as a major matter of concern nationally and internationally (Cabinet Office White Paper, 1998). Prison with its prevalence of drug use can provide a unique opportunity for treatment. It is essential to support users within Scottish prisons for two reasons. The first reason is the high rates of overdose on release (Seaman et al., 1998; Shewan et al., 2000) and secondly many have had difficult life experiences before they started taking heroin. These key issues would be a starting point from which to work. These individuals need good and intensive support structures within prison and post release (Kothari et al., 2002). The research of Kolar et al. (1990) was supported within the data, in that, no positive aspects of methadone programs were found in this research. The participants’ negative views were based upon retrospective experiences with methadone programmes as well as others’ experiences (Koester et al., 1999).
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Mr TD: Yes, I was embarrassed about it. Just the fact it’s called Methadone, its green stuff, you have to go to the chemist everyday. See I never seen myself as a junkie or anything. See until I went on methadone, that’s when I said that’s me a junkie.
Their main perspectives were very negative and similar to those reported by Neale (1999). The impact on their health and physical state and indeed lifestyle was similar to that noted by Fischer et al. (1999). The participants were concerned that methadone was more addictive than their previous heroin habit. They talked of how it had a worse withdrawal effect than heroin. In relation to withdrawal from methadone Mr H stated: I was scared . . . I was very, very scared to come off methadone because . . . I’d been told so many horror stories about people coming off methadone and how hard it was to come off.
This negative expectancy in relation to their methadone usage was echoed by other participants in the way it made them feel. Mr T noted: I hated my methadone. I hated it. I was up at 80 ml so no matter what I did I thought I would be strung out.
In contrast to the participants’ views on methadone, the participants’ views on Subutex were extremely positive. Tompkins et al. (2009) also note that participants in their study had overwhelmingly positive experiences of using Subutex while in prison. Within this current study, all of the participants stated that they thought that the positive aspects of Subutex combined to make it the best available drug. Also, all of the participants’ experiences with it had been far more positive than their experiences with methadone. Mr T expressed this as follows: ‘‘I asked when I saw the drug worker about coming off my methadone. They seemed to think Subutex and I asked to see about it and then I saw their booklet on it. It just seemed ideal, man.’’ He then added, ‘‘If it wasn’t for the fact that I got Subutex. I’d still be on this methadone for another couple of year’’.
This is in line with reports from one study by Schwartz et al. (2008) which identified how attitudes and beliefs can affect better outcomes by having a more positive attitude toward buprenorphine than methadone. Most of the participants stated that abstinence plays a major role in the success of Subutex, especially within prison, and all were very optimistic about their treatment programme. A further positive aspect by participants (recall that they were all on detoxification programmes), was the shorter treatment time completed compared to their previous experiences of methadone detoxification programmes. An additional benefit reported by the majority of participants in this study in using prescribed Subutex was the removal of craving and withdrawals. This is supported by O’Connor and Fiellin (2000) who posited that the shorter-term medical withdrawal from heroin would be far more appealing to clients than longer-term treatments such as methadone programs.
Prison as an intervention Data from the participants discourse identifies that they felt stigmatised in their heroin use within prison and they were aware of negative attitudes of prison staff towards the use of methadone within the prison setting. Participants reported that this had a detrimental effect on the outcome of their experiences with methadone treatment. The majority of prisoners from their discourse stated that prison although bad for them due to easy access to a wide range of drugs, it was also a good thing for them in giving them time for treatment and indeed change from their heroin use. Mr H said: Well, the satisfaction is that I feel for the first time in years that I’m doing the right thing, getting the job done here (in prison).
And Mr T added:
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I know if I was doing this detox outside I’d have just binned the Subutex and gone back to heroin again . . . It’s brilliant I’m off methadone.
Another factor that emerged from the analysis of the interview material was the participants’ views on their experiences with prison. The short-term prisoners (up to four years) had spent various times in jail during their addiction, and all had intended to refrain from illicit drug use on release from prison. Within a short time period after release however, they returned to heroin use again. Mr H verbalised this as follows: I don’t intend drugs to have any part in my life when I get out. There’s no room in my life outside for drugs, so I want to make sure it’s all out my system before I get out the jail.
During their current prison sentence, over 50 per cent of the participants received support and counselling regarding their heroin use and they reported this as being helpful. Those not receiving professional support appeared to rely on other non-users or participants within the Subutex programme for support. Future studies should consider this aspect of prison, as prison sentences appear to provide an excellent opportunity to focus on rehabilitating drug users. Drug using individuals within prison could be selected and offered rehabilitation programs with their release in mind. This would assist them in preparing for lifestyle changes and using appropriate coping mechanisms to overcome heroin addiction when they return to their local communities.
Craving, withdrawal and sleep Participants in this study stated that readiness and motivation for abstinence from drugs were important aspects of recovery from heroin addiction while also being major factors impacting on retention in treatment. From the research data it was found that participants slept on average 8.6 hours with previous methadone use, dropping to 7.4 hours with Subutex use and 5.7 hours after detoxification was complete. Those experiencing withdrawals and cravings slept on average nine hours with previous methadone use, dropping to five hours on Subutex and on completion of detoxification their average hours of sleep per day reduced to 4.5 hours sleep. The majority of participants however noticed that the quality of their sleep improved following their use of Subutex. The importance of making lifestyle changes when overcoming addiction has been supported by Vaillant (1996) who highlighted the importance of social context in addiction and recovery. A number of researchers have also proposed that acquiring a substitute behaviour that competes with the addiction plays a major role in overcoming addiction (Miller and Rollnick, 2002), a viewpoint agreed on by the participants in this study. By using Subutex, which prevents the pleasurable effects of illicit opioids (Jasinski et al., 1978), the temptation to use illicit drugs is taken away from the individual. This consequently enabled participants to focus on issues that led them to addiction in the first instance. They reported a belief that relapse was part of the recovery process, but not an intention they were striving for. In addition, they noted abstinence as a key factor in the change process. This was probably due to the history of the prison system working totally towards abstinence from drug use in their provision of treatment programmes. Over 25 per cent of participants stated that they experienced difficulty whilst on the lowest doses of Subutex. Although these individuals experienced some discomfort whilst on the lowest doses, the majority (71.5 per cent) accepted that the partial agonist properties of Subutex meant they had an easier withdrawal process compared with withdrawals in previous methadone detoxification programmes (Cheskin et al., 1994). It should be noted that previous research data suggested buprenorphine did not differ from Methadone in its ability to suppress heroin (RCGP, 2004). A small number of participants exited early from the detoxification programme (7.14 per cent) most likely due to the rapid reduction of buprenorphine leading to feelings of craving and withdrawals. Thereafter, the retention level remained static during the study with no loss of any other participants. This was despite rates of craving and withdrawals reported at over 28 per cent.
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This was significant as the findings revealed that of those without cravings (n¼ 10), 71.43 per cent had no craving or withdrawal effects during their detoxification programme, which lasted between the range of 18-30 days. Literature on the best length of such programmes indicates that longer term detoxification (. 30 days) towards withdrawal is more effective. However, there is growing support for shorter detoxification (Kakko et al., 2003, Amass et al., 2004). Participants within this study who had no cravings gave data for mean duration of detoxification as 10 per cent at 30 days, 40 per cent at 18 days and 50 per cent at 20 days. When participants within this study were titrated during 18 days and at levels of 2 mg, this appeared to be too high a level for some participants to reduce to abstinence. The data revealed reducing from 2 mg to 0.4 mg and then to 0.2 mg achieved better results for all participants. The properties of Subutex for many of the participants, was attractive to those individuals who did not prefer a full agonist effect (as with methadone). Within the study one participant who went back to illicit use did prefer full effect. The data collected was consistent in that buprenorphine participants reported less of a ‘‘stoned’’ effect, in comparison to previous methadone treatments. The data revealed similar findings of Cheskin et al. (1994) in that the withdrawal discomfort was not so marked. The withdrawal discomfort for participants prescribed Subutex in this study was found to be significantly less to their previous experience of withdrawal from opiates using methadone during previous custodial sentence treatment.
Goals, expectancy and motivation Participants were asked about their goals for the future. One participant summed it up in very simple terms. Mr PD: I wanted to get off the methadone.
This discussion developed through grounded theory and focussed on goals during their prison sentence as well as goals on their release from prison. Participants reported substantial cognitive changes as they became abstinent at the end of their treatment. Fear seemed to be a key negative expectancy[4]. Research suggests that greater negative expectancies about the participants’ use can predict good treatment outcomes in terms of longer periods of abstinence (McMahon and Jones, 1993). This was evidenced through the experience of one the participants. Mr TD: Just to get off my methadone altogether. I hated my methadone. I hated it. I had to go to the chemist every day and take it. I was up at 80 ml, so no matter what I did I thought I would still be craving in the house.
Over 50 per cent of participants reported they had received support services whilst on Subutex and that this played a major role in their attempts at overcoming their heroin dependency during their detoxification programme. Mr HD: There’s two people . . . two people that have been really really supportive for us and that was Ms X and Ms Y from the Health Centre. Drug worker and addiction nurse . . . Brilliant. They’ve been great.
This supports findings by Neale (1999) who reported that counselling plays an important factor in retention in treatment and recovery from opiate addiction. These findings are further supported by Prochaska et al. (1992) in their model of change, which posits that an individual has to be ready to overcome their addiction, otherwise no interventions will affect their behaviour. All participants in this study stated the importance of making lifestyle changes and developing improved coping mechanisms during the rehabilitation stage of treatment. This they believed would help achieve their goals. One of the participants saw Subutex detoxification as a means to giving him the option of a ‘‘normal lifestyle’’. Mr DD: With Methadone you’re drowsy and it’s just like Heroin. Subutex if its used right, you feel normal, it does not feel like you’ve got anything in your body at all . . . that’s the way I want to be . . .
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some people out there might disagree but that’s the way it is to me. You don’t feel doped up to your eyeballs, you don’t feel drowsy, talking different, look different . . . just to look better as well.
Lifestyle changes from prison to prison also offered the opportunity of change. Mr TD: It was coming up here and hearing other prisoners and then I asked when I seen the drug worker about coming off my methadone they seemed to think Subutex and I asked to see about it, so I seen the booklet. It just seemed ideal, man . . . I asked everybody about it not one person had a bad word to say about it.
This confirms the importance of counselling and support, as through these, individuals are provided with the knowledge of how to make changes to their behaviour and thereby reduce the chances of a return to drug use on completion of treatment.
Limitations of this study The main limitation for this study is that the study was based on a small number of participants (all male) and consequently the findings cannot be generalised to the larger prison population. Those participants within the study were not a random sample selection but were an opportunistic sample therefore it does not reflect the extent of the total use of Subutex in the detoxification of prisoners throughout Scottish Prisons. Data was only collected in a general format therefore it cannot be subjected to statistical analysis. Prisoners interviewed gave different views on different prison treatment regimes and so there exists the potential for bias within the data.
Conclusion The findings of the current investigation reveal discrepancies between studies considering the users’ views on Subutex prescribing that have used quantitative research methods and studies that have used qualitative research methods. Extensive previous research has been conducted using quantitative methodologies comparing the two substitute drugs, however, the results are often varied and observations and conclusions between studies difficult to reconcile. The majority of studies have reported methadone to be superior to Subutex in retention in treatment. In contrast, the participants’ views from this study, as well as from a number of other qualitative studies (Neale, 1999), have largely favoured Subutex over methadone. Future research could combine quantitative and qualitative approaches to produce services to heroin users that match their needs, and in many respects, mixed-methods approach to unpack the complex and dynamic tapestry of the individuals experience is preferred. This study has shown that Subutex is associated with perceptions of more attractive qualities to the incarcerated individual than methadone. The majority of the British in-treatment heroin dependent population are currently being prescribed methadone. Further qualitative studies comparing the efficiency of methadone and Subutex should be conducted. Comparison of data between both methadone and Subutex treatments did show that there were significant differences between both. Interpreting the participants discourse, the majority perspective was that methadone was associated with a return to illicit use. In conclusion this research has shown that Scottish prisons are working in a positive progression to deal with the proportion of drug users within their custody and care. Removing Subutex from its detoxification regimens may be problematic in clinical efficacy in terms of contrast with the emerging evidence base derived from studies such as this. Developments in treatment strategies and approaches require veracity in terms of their orientating evidence base and where this is not forthcoming, an implicit duty of care focus must emphasise the development of contextually appropriate, acceptable and successful interventions. This may only be achieved through systematic research enquiry and endeavour. Methadone is not the panacea for dealing effectively with all instances of opiate addiction and indeed other approaches, including but not exclusively, pharmacotherapy, should be explored. Economic evaluation for drug treatments are important, however in using Subutex, prisoner/staff time, storage, delivery and more especially, safety for all is both
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desirable and attainable. Consistency and synchrony between treatment approaches, used in prisons and in the community, is a highly desirable goal and represents a seamless transition and translation of the contemporary evidence-base in relation to provision. The present one size fits all approach has been clearly demonstrated to have inherent limitations and individualised programmes of treatment and care are likely to promote both compliance to treatment and improved overall outcome. The findings are indicative of an arbitrary approach to detoxification provision within the prison system, an approach limited in scope, vision and ultimately clinical efficacy. More intensive training is required for practitioners[5] in the exchange of drugs and the proper dosage for each individual. Support groups and counselling are essential. Users should be not be sent to prison for treatment, however if imprisonment is sanctioned then interventions should be consistent with those approaches offered within the community (Davies, 1997). The prisoners’ views and subjective feelings within the study suggest that Subutex can be a better-suited treatment in helping those individuals with their heroin use. To the majority of participants in this study Subutex has been seen to be the ‘‘miracle drug’’, however there is no ‘‘magic bullet’’ (Davies, 1997) to ending opiate addiction. The process of treatment shall always be prioritised with regards to custody and security, in order to protect the public. The regime of prisons still adhere to the prison rules which are challenged on a daily basis in areas such as prisoner rights, equality and diversity, social inclusion and indeed addiction issues[6]. Many rules are archaic and do not adequately address those with addictions. The rank structure within prisons does little to help treatments, the ‘‘my way or highway’’ approach, just does not work, for users, or staff working with such individuals. More qualitative research into drug treatment for users’ within prisons, such as Subutex, is vital. This in turn helps ‘‘all areas’’ of our society.
Notes 1. Includes HMP Kilmarnock – private prison. 2. Participants in the current study numbered 14 as a subset of the larger study (n¼21). 3. No Epidemiological differences between rural and urban setting. 4. Transformation of Meaning in psychological therapies (Power and Brewin, 1997). 5. Ling et al. (2005) states the Clinician’s attitude and the extent to which they embrace buprenorphine will play an important role in determining the future success of using this. 6. In 2006, drug-addicted prisoners who were forced to go ‘‘cold turkey’’ while in jail are suing the Home Office. Six test cases are due to go before the High Court which, if successful, could lead to 198 offenders – all addicted to opiates – seeking compensation.
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O’Connor, P.G. and Fiellin, D.A. (2000), ‘‘Pharmacologic treatment of heroin-dependent patients’’, Annals of Internal Medicine, Vol. 133, pp. 40-54. Oreskovich, M.R., Saxon, A.J., Ellis, M.L., Malte, C.A., Reoux, J.P. and Knox, P.C. (2005), ‘‘A double-blind, double-dummy, randomized, prospective pilot study of the partial Mu opiate agonist, buprenorphine, for acute detoxification from heroin’’, Drug & Alcohol Dependence, Vol. 77 No. 1, pp. 71-9. Penfold, C., Turnbull, P. and Webster, R. (2005), ‘‘Tackling prison drug markets: an exploratory qualitative study’’, Home Office Online Research Report 39/05 Home Office, London. Petitjean, S., Stohler, R., Deglon, J.J., Livoti, S., Waldvogel, D. and Uehlinger, C. (2001), ‘‘Double-blind randomized trial of buprenorphine and methadone in opiate dependence’’, Drug and Alcohol Dependence, Vol. 62, pp. 97-104. Pinto, H., Maskrey, V., Swift, L., Rumball, D., Wagle, A. and Holland, R. (2010), ‘‘The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment’’, The Journal of Substance Abuse Treatment, Vol. 39 No. 4, pp. 340-52. Power, M.J. and Brewin, C.R. (1997), The Transformation of Meaning in Psychological Therapies: Integrating Theory and Practice, Wiley, Chichester. Prochaska, J.O., DiClemente, C.C. and Norcross, J. (1992), ‘‘In search of how people change: applications to addictive behaviors’’, American Psychologist, Vol. 47, pp. 1102-14. Richards, T. and Richards, L. (1994), ‘‘Using computers in qualitative research’’, in Denzin, N.K. and Lincoln, Y.S. (Eds), Handbook of Qualitative Research, Sage Publications, London, pp. 445-62. Royal College of General Practitioners (2004), Guidelines for the Use of Buprenorphine for the Treatment of Opioid Dependence in Primary Care, 2nd ed., Royal College of General Practitioners, London. Schottenfeld, R.S., Pakes, J.R., Oliveto, A., Ziedonis, D. and Kosten, T.R. (1997), ‘‘Buprenorphine versus methadone maintenance treatment for concurrent opioid dependence and cocaine abuse’’, Archives of General Psychiatry, Vol. 54, pp. 713-20. Schwartz, R.P., Kelly, S.M., O’Grady, K.E., Mitchell, S.G., Peterson, J.A., Reisinger, H.S., Agar, M.H. and Brown, B.S. (2008), ‘‘Attitudes toward buprenorphine and methadone among opioid-dependent individuals’’, American Journal on Addictions, Vol. 17 No. 5, pp. 396-401. Scottish Office (1999), Tackling Drugs in Scotland: Action in Partnership, The Stationery Office, Edinburgh, p. 63. Scottish Prison Service (2000), ‘‘Partnership and coordination: SPS action on drugs – revised guidance on the management of drug misuse in Scotland’s prisons’’, Scottish Prison Service, Edinburgh. Seaman, S.R., Brettle, R.P. and Gore, S.M. (1998), ‘‘Mortality from overdose among injecting drug users recently released from prison: database linkage study’’, British Medical Journal, Vol. 316, pp. 426-8. Seymour, A., Black, M., Jay, J., Cooper, G., Weir, C. and Oliver, J. (2003), ‘‘The role of methadone in drug related deaths in the West of Scotland’’, Addiction, Vol. 98 No. 7, pp. 995-1002. Shewan, D., Hammersley, R., Oliver, J. and Macpherson, S. (2000), ‘‘Fatal drug overdose after liberation from prison: a retrospective study of female ex-prisoners from Strathclyde region (Scotland)’’, Addiction Research & Theory, Vol. 8 No. 3, pp. 267-78. Silverman, D. (2000), Doing Qualitative Research: A Practical Handbook, Sage Publications, London. Sporer, K.A. (2004), ‘‘Buprenorphine: a primer for emergency physicians’’, Annals of Emergency Medicine, Vol. 43 No. 5, pp. 580-4. Tompkins, C.N.E., Wright, N.M.J., Waterman, M.G. and Sheard, L. (2009), ‘‘Exploring prison buprenorphine misuse in the United Kingdom: a qualitative study of former prisoners’’, International Journal of Prisoner Health, Vol. 5 No. 2, pp. 71-87. Vaillant, G.E. (1996), The Natural History of Alcoholism, Harvard University Press, Cambridge, MA. World Health Organization (2001), The World Health Report: Mental Health: New Understanding, New Hope, World Health Organization, Geneva, p. 103.
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Further reading Shearer, J., Wodak, A. and Dolan, K. (2004), The Prison Opiate Dependence Treatment Trial, NDARC Technical Report No. 199, National Drug and Alcohol Research Centre, University of New South Wales, Sydney. Strang, J., Sheridan, J. and Barber, N. (1996), ‘‘Prescribing injectable and oral methadone to opiate addicts: results from the 1995 national postal survey of community pharmacies in England and Wales’’, British Medical Journal, Vol. 313, pp. 270-2.
About the authors Alexander Johnstone is an Associate Lecturer at the University of the West of Scotland. He was initially seconded to the Post Graduate Programme in Alcohol and Drug Studies by the Scottish Prison Service. Mr Johnstone has worked in the addiction field for a considerable period, predominantly in criminal justice, both in prisons and the community. In addition he has worked for Alcohol and Drug Studies at UWS, delivering Level 9 modules to full and part-time students across all campuses. Alex has also mentored practice placements for students within Criminal Justice. He is a Fellow of The Higher Education Academy. Alexander Johnstone is the corresponding author and can be contacted at: [email protected] Tim Duffy is the Research and International Project Manager at the University of the West of Scotland. He is a qualified social worker and specialised in working with people with alcohol and drug-related problems. For six years he was National Training Officer with responsibility for training social work and healthcare personnel to develop strategies to help motivate clients and patients of all ages to reduce problems related to alcohol and drug use. He has supported academic staff to develop and deliver distance learning teaching materials for students in 28 countries. His PhD study evaluated the impact of a Self-Administered Motivational Instrument (the SAMI) in a UK higher education setting. He has researched student learning styles and approaches to study, student motivation, methods of supporting students online and student retention. Tim is now a full-time researcher specialising in psychosocial interventions within a wide range of health and social care settings. Colin Martin is Chair in Mental Health at the University of the West of Scotland. He is a registered Mental Health Nurse, Chartered Health Psychologist and a Chartered Scientist and has also trained in analytical biochemistry reflecting the psychobiological focus of much of his research. He is Honorary Consultant Psychologist to the Salvation Army, UK & Eire territories and was instrumental in formulating their addictions policy to develop high-quality and evidence-based clinical care and services. He developed a psychobiological model of alcohol dependency and has published or has in press over 150 research papers and book chapters. He is a keen author and editor and his outputs include the seminal five-volume magnum opus, Handbook of Behaviour, Food and Nutrition (2011) and the forthcoming prophetic insight into the treatment of neurological disease, Nanomedicine and the Nervous System (2012). He has a long-standing interest in perinatal health and is editor of the influential Journal of Reproductive and Infant Psychology; forthcoming books, Perinatal Mental Health: A Clinical Guide (2012) and Scientific Bias of Healthcare: Aids and Pregnancy (2012) are a reflection of this area of focus. He is an investigator and/or named collaborator on research activity and projects that have attracted in excess of £5m in funding and is involved in collaborative international research with many European and non-European countries.
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