9 Steps To Prevent Drug Relapse And Deaths in Custody-Community Transition

In June 2019, the Advisory Council on the Misuse of Drugs (ACDM) published their report Custody-Community Transitions which contains details of the emerging evidence on the increasing drug-related harms in prisons and related to transitions through the criminal justice system. In particular, the increased risk of death, including by overdose, in the weeks immediately following release to the community.

This report from the Advisory Council on the Misuse of Drugs (ACMD) provides advice on how to reduce drug-related harms that occur when people move between custody and the community. It seeks to answer three questions.

  1. What are the drug-related harms and benefits associated with transitions between custody and the community?
  2. What are the most important existing recommendations in this area, and to what extent have they been implemented?
  3. Is there a need for new or adapted recommendations?

The report identifies substantial harms associated with transitions between custody and the community, especially for people who have problems with drugs, including the following:
• Homelessness. In 2017/18, 34.5% of adult prisoners under supervision from the National Probation Service (NPS) or Community Rehabilitation Companies were discharged to unsettled or unknown accommodation on their first night of release.
• Reoffending. Adults serving sentences of less than 12 months in England and Wales had a reoffending rate of 64.4% between April and June 2017, with rates likely to be even higher among those with a drug problem.
• Transmission of blood-borne viruses. Prison is a risk environment for the transmission of HIV and Hepatitis C, so entry to prison can be a risk for infection, and release may spread that risk to the community.
• Increased risk of death, including by overdose. Death rates among prisoners and, especially, those on post-release supervision are many times higher than in the general population. The few weeks immediately after release is a particularly high risk period for drug-related death.

There is a particular problem for people released from custody who use opioids (e.g. heroin). Restricted access to heroin while in custody can reduce physical tolerance to these substances. If these people then relapse to drug use on release, they face a heightened risk of dying by overdose. Such relapses and deaths are particularly likely when people are released without access to housing or drug treatment.

In the last ten years, a new challenge has emerged in the form of synthetic cannabinoid receptor agonists, which are often referred to as Novel Psychoactive Substances (also known by the acronym NPS but not to be confused with the National Probation Service), ‘Spice’ or ‘legal high’s’. These have exacerbated problems in prisons around safety, security and health. Prisoners reported that the main reasons for taking synthetic cannabinoids in prison were ease of access, avoidance of drug testing for other substances, and boredom. Action is already being taken by the Ministry of Justice in the 10 prisons project.

Issues around synthetic cannabinoids that are particularly related to custody-community transitions include the following.
• The frequent movement of people on short sentences or prison recall from the community into custody facilitates the supply of synthetic cannabinoids in prison.
• It is reported that many people begin or deepen a problem with the misuse of synthetic cannabinoids after entering prison, and may continue these problems on release.
• The additional problems caused by the use of synthetic cannabinoids in prison can inhibit effective rehabilitation and resettlement planning. This is because resources are often drawn away from rehabilitation-focused activities to deal with cannabinoid-related emergencies. It is also because the use of synthetic cannabinoids can inhibit individual prisoners’ engagement in pre-release planning.

Key Themes From Previous Recommendations

The biggest challenge, and the greatest missed opportunity for reducing reoffending and improving health, is the absence of continuity of care for people who enter and leave custody with complex needs.

  • That healthcare provided to people in the criminal justice system should be at least equivalent to that provided in the community.
  • Co-morbidity between mental health problems and drug misuse (‘dual diagnosis’) in prisons is prevalent. There needs to be more clearly defined mechanisms for managing patients with dual diagnosis, formal links between mental health and drug treatment provision, and greater awareness among staff.
  • The need for a cohesive, inter-departmental strategy on drug misuse in prison is often raised. Fragmentation between different services and conflict between different organisations’ targets was identified as a problem that leads to inconsistency in care and inefficiencies.
  • Services should be more integrated. The criminal justice system should coordinate with healthcare providers, mental health services, and community supports to ensure that people are given continuity of care in the vulnerable weeks following release. It is often noted that individuals should be involved in pre-release planning and should be put in contact with support and treatment options in the community quickly after leaving prisons.
  • Treatments that help people with drug problems to accrue recovery capital – which includes social relationships, health, skills and aspirations, as well as employment and housing – are identified as valuable to sustained recovery. It is often recommended that local housing and employment organisations are also integrated into the resettlement process.
  • The benefits of mutual aid to recovery are often highlighted. Support groups are linked to improved treatment outcomes, and it is suggested that actively guiding people towards these groups improved engagement.
  • Ensuring access to services and support is consistent across the country, as adapted to local needs. The difficulty of securing continuity of care for people who are imprisoned far from their homes is frequently mentioned.
  • Data collection should be developed, and different organisations should share information where possible to reduce inefficiency, identify areas for improvement and highlight gaps in service provision.
  • There should be a national framework for continual improvement of services by setting clear performance outcomes and analysing local needs and evidence of what works.

Despite the difficulty in assessing implementation of these previous recommendations, some concerning trends are visible in the data that are available.

  • Continuity of care. The Patel Report stated that the key issue to address was the continuity of care between prison and the community. However, the latest data from PHE (2017/18) suggest that only 32.1% of people who are assessed as needing treatment when they leave prison enter treatment in the community within 21 days.
  • Equivalence of care. The Bradley Review endorsed the principle of equivalence of health between custody and the community. The current guidelines on clinical management of people with substance misuse problems states that previously heroin-dependent prisoners should be provided with a supply of naloxone on release from prison and that commissioners should support the provision of naloxone and overdose training in the community. However, only 12% of prisoners who were previously heroin- dependent left English prison with naloxone in 2017/18. In Scotland, this figure is better at 35% but much more work is still to be done.
  • Reoffending. The aim of the Transforming Rehabilitation White Paper was to reduce reoffending rates. This was partly to be achieved by providing more support to prisoners released from sentences of less than 12 months, and an expansion of ‘through the gate’ services. However, the performance of CRCs in providing these services has been widely criticised, more recently by Her Majesty’s Inspectorate of Probation who commented on serious shortcomings in supervision of short-term prisoners on release, with no evidence that expanding post-release supervision to this group reduced their reoffending.

In English and Welsh prisons, the provision of screening and treatment was improved through the Counselling, Assessment, Referral, Advice and Throughcare (CARAT) teams and, in England, the Integrated Drug Treatment System (IDTS), which expanded the provision of opioid substitution therapy (OST) in prisons. Although CARAT teams and the IDTS are no longer centrally supported, the legacy of multi-agency working continues. NHS England’s service specifications from 2018 explicitly call for a joint, multi-disciplinary approach to the screening, assessment and provision of services for substance misuse, using a range of services that are equivalent to those used in the community. The provision of ‘opt-out’ testing for blood-borne viruses (BBVs) has increased uptake and the possibility to provide effective treatment in prison.

Systemic Recommendations

  1. That the Drug Strategy Board nominates one Minister who will have over-arching responsibility and accountability for the improvement of custody-community transitions for prisoners with complex health needs, including problems with drugs.
  2. That this Minister be given the following mandate: To assess and improve performance in delivering officially accepted recommendations on transitions between custody and community for people with substance misuse, mental health and homelessness problems. The indicators of progress in this area should include the following.
    a. Reducing the rate of reoffending (within six months and after two years) of people who leave prison and who have an assessed need for drug treatment.
    b. Reducing the numbers of people who die within four weeks of leaving custody (separated by police and prison custody) and while under the supervision of the probation services. These data should be collated separately for suicides and drug- related deaths, following the definitions that the Office for National Statistics uses for the general population.
    c. Reducing the proportion of people who leave prison with unsettled or unknown accommodation on the first night of release.
    d. Increasing the proportion of people who have an assessed need for drug treatment on release who enter treatment in the community within four weeks of release.
    e. Increasing the proportion of prisoners who are assessed as having a problem with opioids who leave prison with naloxone.
  3. That the Minister of Justice (England and Wales), the Cabinet Secretary for Justice (Scotland) and their counterpart in Northern Ireland take further steps to reduce the number of transitions into and out of prisons, especially as multiple short sentences are associated with increased risk of death. This should involve:
    a. reform sentencing to minimise the use of sentences of less than 12 months, with the aim of eliminating the use in sentencing of periods of less than 3 months in prison; and,
    b. reforms to the system of supervision on licence, so as to reduce the number of people who are recalled to prison.

When prisoners are released under licence to the supervision of the NPS or CRCs, they can be recalled to prison for breaching conditions of their licence. In the year 2017/18, there were 22,183 licence recalls to prisons in England and Wales. This is an increase of 27% since 2013/14. These recalls increase the number of transitions between custody and community. As noted above, these transitions increase the risk of health problems and often break continuity of care. They also create an opportunity to smuggle substances, including synthetic cannabinoids, into prison.

Practical Recommendations

In support of the systemic recommendations made above, this report makes the following practical recommendations.

  1. That the prison services of the UK take steps to minimise the release of prisoners with complex needs (including substance misuse) on Friday afternoons. As prisoners with release dates on Saturdays, Sundays or a bank holiday Monday are released on Fridays, more than a third of prisoners are released on Fridays. Friday releases makes it difficult to access stable housing, drug treatment, and connections with probations services and job centres. People often have to attend several appointments on their first day of release. If these appointments are missed on a Friday, then the person may be left for the weekend with no housing, no money and no drug treatment. These are circumstances in which relapse to drug use and offending are highly likely to occur.
  2. That the Department for Work and Pensions (DWP) should:
    a. accelerate the introduction of the measures listed in the 2018 Rough Sleeping
    Strategy (MHCLG, 2018) to enable prisoners to access employment or Universal Credit immediately on release;
    The Rough Sleeping Strategy committed the DWP to the following measures:
  • increasing the level of prisoner engagement with Prison Work Coaches;
  • supporting prisoners to begin the Universal Credit claim in prison;
  • continuing work to support prisoners to open bank accounts in prison; and,
  • supporting prisoners to verify their identity for Universal Credit purposes.
    b. work in partnership with Her Majesty’s Courts and Tribunal Services (HMCTS) and the NPS to ensure that people who are imprisoned are not overpaid the housing element of Universal Credit; and,
    c. Following the completion of the evaluation of the pilots, implement the effective elements identified through evaluation.
  1. That the prison and probation services of the UK should develop and extend services that provide face-to-face, individualised support to prisoners who have drug problems in the run up to release and through the transition to the community.
  2. That the Drug Strategy Board should make a clear statement that it is the responsibility of the national NHS bodies to ensure that all people who have an assessed problem with opioid use should be given the opportunity to take home naloxone when they leave prison or police custody. The Board should ensure that resources are made available to the national NHS bodies to support this responsibility.
  3. That relevant agencies (e.g. PHE) establish custody-community pathways into identified treatment for prisoners who have an assessed problem with alcohol, cannabis, cocaine, or other non-opioid drugs – as well as for users of opioids. Additionally, that a pathway should be developed that offers sufficient support to enable prisoners leaving abstinence-focused interventions to maintain such change following release.
    The experience of the drug recovery wing pilots suggests that existing services in England do not provide sufficient responses to the needs of people who have problems with substances other than opioids. It also suggests that the benefits of abstinence-focused interventions in prisons are often lost when people are released. The ACMD recommends that post-release pathways for people with non-opioid problems and for people who have achieved abstinence in prison be strengthened.
  4. That the Home Office should commission research specifically to identify and ameliorate problems and opportunities related to transitions into and out of police custody by people who have problems with drugs. This should include gathering information, across the UK, on:
    a. the levels of overdose and drug-related deaths in police custody and immediately afterwards; and,
    b. the coverage and effectiveness of Liaison and Diversion schemes in meeting the needs of arrestees with drug and alcohol misuse problems.


Transitions between custody and community are inherently risky. People with drug problems are particularly likely to experience such transitions, as they are frequently given short prison sentences for repeated acquisitive offences and are often recalled to prison from probation supervision in the community due to breaches of conditions. These transitions damage continuity of care, and so increase the potential for reoffending and relapse to problematic drug use. Short prison sentences are less effective than community penalties in reducing reoffending.

It is paramount that the government makes sure more is done to help prevent vulnerable people from relapsing after their release from prison.

Full Report Here

GOV.UK News Story

More ACDM Here

Photo by Jonathan Gonzalez on Unsplash

Strep A Guidance For Prisons

On 14th May 2019, the Government published some information and guidance around Group A Streptococcal Disease (GAS). Amongst prisoners, officers and healthcare staff, this is more commonly referred to as Strep A. This guidance was jointly created by Public Health England (PHE) and HM Prison and Probation Service (HMPPS).

What is Strep A?

Strep A is a type of bacteria often found in the throat and on the skin. The most invasive GAS (iGas) infections happen when the bacteria get past the skin and other bodily defence. The less common, but more severe cases on the invasive disease could be life threatening.

Over the past 18-24 months this bacteria has caused infection with ever increasing frequency amongst the prison population and across the wider prison estate. Local prisons are the most at risk of infections, given the correlation with those who are part of the homeless community (also a high risk area) and those active within the drug sub-culture being the most common.

Strep A – Signs And Symptoms.

Signs and symptoms of invasive group A streptococcal disease include:

  • High fever
  • Severe muscle aches
  • Localised muscle tenderness
  • Redness at the site of a wound

Where any of these symptoms develop, seek medical advice immediately. If anyone you know develops these symptoms, they should also seek medical advice immediately.

Actions To Minimise Risk.

  • Prisoners should be encouraged to maintain clean cells.
  • Prisoners should have opportunities for clothing to be washed at the right temperature and dried fully.
  • Prisoner bedding should be regularly changed and washed. This should be more frequent for those who have wounds.
  • Prisoners should have opportunities to wash and shower at least daily.
  • Prisoners should be reminded of the importance of good hand hygiene – washing hands after using the toilet and before the eating or preparing of food.
  • For those prisoners who have infected wounds, the guidance is that they should not use the gym, until they have had 48 hours of antibiotics and/or the wound is covered or healed.

The concerns will rise where the this guidance is not adhered to, and the disease is allowed too become more prevalent as a consequence of denial, ignorance or complacency. In all reality, it is likely to a combination of all of these factors.

The full guidance is found here.

Photo by Brian Patrick Tagalog on Unsplash.

Hepatitis C Report – Prisons In England 2019

In this latest report (published on 9 April 2019), Hepatitis C in England 2019, Public Health England summarises the current data and the impact of action plans in England to drive down mortality from Hepatitis C Virus (HCV) and to reduce the number of new infections. Also included is an outline the actions required to make further progress. It is clear that progress is being made, but there is still much to do.

This post provides a summary of the key points relative to the levels of activity ongoing through the prison estate in England.

Latest modelled estimates suggest that around 143,000 people in England were living with chronic HCV infection in 2015. Prevalence is estimated to have fallen in recent years, and was predicted to decline to 113,000 in 2018 with the advent of new treatments. HCV affects a larger proportion of people in prison and other detention centres than the wider population, principally as a result of the relatively higher levels of injecting drug use that are observed among this population.

Partnership Working – HMPPS, NHSE and PHE.

Since 2013/14, PHE in partnership with NHS England and Her Majesty’s Prison and Probation Service (HMPPS) have overseen the rollout of BBV testing in adult prisons on an ‘opt-out’ basis. A significant milestone was reached in April 2018, when after more than 4 years of implementation, the programme was successfully rolled out across the entire adult prison estate.

Testing and Diagnosis.

Opt-out bloodborne virus (BBV) testing is now fully implemented across the prison estate, and among new receptions to English prisons, levels of testing have risen from 5% in 2010/11 to 19% in 2017/18. In the 2017/18 financial year, Health and Justice Indicators of Performance (HJIP) testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing, 26% were tested, 11% of those tested were found anti-HCV positive but less than half (46%) went on to have HCV Ribonucleic acid (RNA) testing. About 40% of those testing positive for HCV RNA received specialist referrals for their HCV infection.

Overall, these data suggest an increasing awareness of HCV in prisons with significant increases in testing, including Dried blood spot (DBS) testing. Whilst testing volumes remain sub-optimal, work is ongoing to move from the implementation of BBV testing to improving the quality of the offer and uptake of testing within prisons.

HJIP Metrics.

Prison Health Performance and Quality Indicators and HJIPs have shown a rise in HCV tests performed, from 5.3% in 2010/11 to 19.4% in 2017/18. It is likely that the recent increase in testing of people in prisons is due to the introduction of BBV opt-out testing, which was agreed in October 2013 by PHE, NHS England and HMPPS and is now fully implemented across the prison estate. While this increase in testing is welcomed, current levels are still below the lower BBV testing threshold proposed by NHS England (50-74%), and well below the target threshold of at least 75% uptake.

Performance in relation to the BBV opt-out testing programme is measured at the prison level by NHS England through the collection of data via HJIPs. These metrics include specific reports on:

  • the number of BBV tests offered within 72 hours of reception,
  • the number of tests undertaken,
  • the number of people newly diagnosed,
  • the number of patients referred for specialist treatment following diagnosis,
  • the number who received treatment.

These data are used by NHS England commissioners to performance manage healthcare providers in prisons and are important for identifying potential attrition points in the testing pathway.

In the 2017/18 financial year, HJIP testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing and of these 26% were tested. Of those tested, 11% were positive and 46% of these went on to have HCV RNA testing.

The image with this post illustrates the Hepatitis C testing cascade in the English prison estate (112 prisons).

World Hepatitis Day is held on 28 July 2019.

Read the full report Here

Eradicating Hepatitis C In Prisons

In March 2018, the All-Party Parliamentary Group published the report – Eliminating Hepatitis C in England. A report produced with the aim of moving towards achieving NHS England’s ambition to eliminate hepatitis C by 2025 at the latest. A target date some five years before the World Health Organization target of 2030.

One of the key risk factors was the acknowledgment that Hepatitis C disproportionately affects people who inject drugs (PWID) are the group most at risk of becoming infected with hepatitis C, with transmission occurring via shared syringes and other injecting equipment. Approximately 50% of PWID remain undiagnosed, and prevalence of hepatitis C among recent initiates in drug use was found to be 26%. PWID are a key target population for hepatitis C prevention, diagnosis, and treatment initiatives.

There is a high prevalence of hepatitis C among people in prison, due to a high population of PWID in prison, as well as unsafe injecting and tattooing taking place within prison.

Prisons, substance misuse services, and sexual health services have traditionally been the key settings to offer hepatitis C testing to high concentrations of at-risk populations. People in touch with these services are highly likely to have put themselves at risk for transmission, and the aim in these settings should be universal testing and regular re-testing of all service users. There are unique challenges and missed opportunities in each of these settings.

This report puts forward a series of desired outcomes and action-based recommendations to support objectives leading to elimination of hepatitis C, which are specific to prisons and prison healthcare providers:

Desired Outcomes:

  • Increased awareness of hepatitis C among PWID and people in prison.
  • Increased awareness of the ease and short duration of new direct acting antiviral (DAA) treatments among prisoners.
  • Increased awareness of the ease and short duration of new DAA treatments among PWID.
  • Prison staff are an effective source of information for prisoners on harm reduction and prevention.
  • Fewer new infections as a result of improved knowledge of transmission risks.
  • Increased coverage and uptake of testing in substance misuse services.
  • Increased coverage and uptake of testing in prisons.
  • Opt-out dry-blood spot testing for hepatitis C is fully implemented in substance misuse services and prisons.
  • A target of 20,000 people per year treated is set, incentivised, and monitored.

Recommendations & Actions:

  • Awareness-raising talks delivered by peers to be commissioned as an integral part of contracts for substance misuse services and in prisons.
  • Nationally-approved NHS England Health and Justice publicity highlighting the ease of new treatments to be rolled out across HM prison estate.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts in prisons.
  • Nationally-approved publicity highlighting the ease of new treatments to be rolled out across substance misuse services.
  • Hepatitis C peer programmes to be commissioned as an integral part of commissioning contracts for substance misuse services.
  • BBV training to be made compulsory for prison staff.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts for substance misuse services and in prisons.
  • Opt-out testing for hepatitis C to be commissioned by local authorities in substance misuse services.
  • Re-offer of testing to all those engaged with substance misuse services every six months to be mandated and commissioned.
  • Testing to be re-offered in prisons to those who did not receive a test at reception.
  • Opportunities to be provided for those who previously tested to re-test in prison.
  • Clear national protocol to be developed surrounding wording of opt-out test offer in prisons.
  • Commissioners to support access for prisoners to second reception screening.
  • Research to be conducted on transmission risk within prisons to determine impact of re-testing.
  • Commissioning contracts for substance misuse services and prisons to have clear mechanisms to hold services to account for failures to meet testing targets.
  • Unnecessary tests and appointments to be reduced, and the use of reflex tested dry blood spot samples, which necessitate only one sample and can be delivered in the community, to be mainstreamed.
  • Proportional prison treatment targets to be set for prisons specifically in every ODN depending on prison population.


The findings of this inquiry give us much cause for optimism, and the firm belief that elimination of hepatitis C in the very near future is an achievable national ambition. Given the concentration of this at-risk population within the prison setting, these suggested actions offer real opportunities for prisons and prison healthcare providers to make a positive contribution to society for the elimination of Hepatitis C.



Photo by Matthew T Rader on Unsplash.

Smoke Free Prisons: What Does A Post-Implementation Smoking Cessation Service Look Like?


All prisons in England and Wales are commissioned to provide stop smoking services in partnerships with relevant health providers.

Nearly 2 years have passed since many (closed) prisons in England and Wales transitioned to becoming smoke free. In January 2019, the MOJ published the Smoke Free Policy Framework in addition to the NHS England Minimum Service Offer that was already in place.

With this in mind, what makes for an effective smoking cessation service?

Post Implemention Prisons

Access to Nicotine Replacement Therapy (NRT), with patches and lozenges being the most often provided, are all too often prone to being abused or misused. Both patches and lozenges are being traded as a form of currency, whereas the boiling and smoking of patches in not an uncommon practice. In the Post Implementation Smoke Free prison estate, those who are serving their sentences have made their choices to vape or use e-cigarettes or not smoke at all.

The challenges lie for those prisoners who arrive on remand, who are smokers. Being a new reception on remand and with some much going on in their lives, e.g pending court case, trying to maintain external relationships, or perhaps some financial worries etc. smoking (to a smoker) would be a reassuring coping mechanism for so many. Being a new reception in prison would most certainly not be the time/place to decree “I’m going to give up smoking!”

Smoking cessation becomes more a matter of something best described as a “Nicotine Maintenance Programme” for those on remand or perhaps serving very short sentences. That is until at least they are released when they can then return to tobacco smoking or vaping, if they so wish.

As prisons are now fully smoke-free, and at the post implementation stage, there will continue to be a need for ongoing stop smoking support and relapse prevention. This is at a very different level to pre-implementation.

A harm reduction option will be more suitable than a programme of cessation for patients transferring into smoke-free accommodation, who intend to return to smoking on transfer or release. All prisoners who are on sentences of less than 8 weeks should initially be offered a harm reduction intervention, to help them manage their addiction whilst in prison.

Those prisoners in a reception or local prison should be offered harm reduction interventions as a first line treatment, with full cessation being offered at the point of sentence or on transfer to another prison, whether that is to another place of detention, or to the community.

Points to consider when delivering an effective service:

  • Smokers identified as vulnerable and at risk of self-harm or suicide due to smoke free policy will have safer custody processes applied to support them whilst in custody.
  • Smokers must be seen by a stop smoking adviser within 48 hours of arrival into custody. Prisoners will be referred to a smoking cessation programme if they wish to participate.
  • Providing a prison regime that encourages and supports abstinence from smoking.
  • Provision of a range of stop smoking support, including harm minimisation approaches, to assist prisoners to abstain from smoking.
  • Developing strategies to address continued smoking seeking behaviour including misuse of Nicotine Replacement Products.
  • Recent popularity of electronic cigarettes (e-cigarettes) and more so vapes, has demonstrated that many smokers are interested in using these as less harmful sources of nicotine.

This level of ongoing need will also be dependent on prisoner movement and turnover within the establishment, whether prisoners are received from smoking or smokefree establishments and consideration should be given to what is required in a reception prison with comparatively high turnover as compared to a training prison with a more stable population.


All this condenses down to 3 simple actions to take when delivering an effective smoking cessation service:

  • For all new reception prisoners, provide access to e-cigarettes or vapes as part of first night reception packs.
  • For all new reception prisoners who are sentenced to more than 8 weeks, see within 48hrs and offer smoking cessation services to all those who’ve not opted to use e-cigarettes or vapes.
  • For all new reception prisoners who are on remand of sentenced to less than 8 weeks, promote harm reduction options.




Photo by Dev Asangbam at Unsplash