A qualitative investigation into the personal reasons for illicit prescribed opioid medication use in prison

Background: This novel and original study explored the issue of illicit prescribed medication (IPOM) use in prison from a medicine and mental health nursing perspective; and including the wider field of substance misuse. A literature review was undertaken to explore diversion of IPOM in the Criminal Justice System (CJS). It identified gaps in knowledge related to understanding the personal reasons for IPOM use from a social and environmental context within prison. The review further highlighted a paucity of empirical research from a UK prison perspective on the use of Buprenorphine-Naloxone as an Opiate Substitution Treatment (OST) prescribed in prison and post-release. Aims/Methods: The primary aim was to investigate the personal reasons for IPOM use in prison. A further aim of this research was to explore the participants' experiences of Buprenorphine-Naloxone as an OST both from the prison and post-release; and including whether it can aid recovery, to consider ways to improve clinical practice related to IPOM use and ways to address this growing concern. This study used a Descriptive Qualitative Approach (DQA), undertaken in two Phases. Phase One utilised focus group interviews for the development of the questionnaire, this dataset was integrated with Phase Two which used semi-structured interviews, repeated post-release. Results/Findings: Data was collected from 23 male participants. The results provide a unique knowledge contribution and insights into understanding the personal reasons for IPOM use related to coping with emotions, boredom, and sentencing. This study revealed a significant original contribution to knowledge with an unanticipated finding related to Buprenorphine-Naloxone misuse, when Methadone was prescribed at 30mls or below, without precipitating withdrawal symptoms. Participants reported regurgitated medication, which was then sold, with such practice not discussed previously. Buprenorphine-Naloxone as an illicit drug was deemed less desirable due to its side-effects, evidenced by lower cost in the shadow prison economy. It played a pivotal role in relapse prevention in managing cravings and offered stability related to recidivism. For the newly released individual, Buprenorphine-Naloxone provided safety from drug toxicity related to risk reduction e.g., overdose and death. Dispensing of OST reported to have stigma attached. Individuals were however unexpectedly switched to a cheaper alternative post-release. Conclusion/Recommendation: This study provided clear support for the use of Methadone as an effective OST in the management of IPOM diversion in prison, however the side-effects were debilitating which prevented individuals to focus on recovery. The use of Methadone is restrictive, it does not utilise the full range of best available evidence for OST management for addiction and optimising recovery in prison and post-release. In the absence of an evidence base and clinical guidance, current practice to reduce IPOM diversion in prison and post-release is unsatisfactory. The issue of OST prescribing marred by inequalities, breaching equivalence of care principles. Recommendation: Policy and practice warrant urgent change to delivering an evidence-based treatment, with a focus on the individual patient's requirement, moving away from one size fits all. Due to riskier behaviour and health concerns, call for better screening, health promotion and education in prison. Merit to recommend Buprenorphine-Naloxone as a first line medication in the CJS, with potential to reduce risk of drug toxicity and overdose post-release. Further research is necessary to examine whether it can reduce recidivism, and a better treatment option for this population group.