The framing of contemporary violence policy in England and Wales: An examination of the contributing roles of alcohol and illegal drugs.

Background: In 2018, the UK Government published its Serious Violence Strategy setting out the Government's commitment to adopting a public health approach to 'serious violence' in England and Wales and encouraging a multi-agency, whole system public health approach to violence prevention. There has been very little research attention and commentary on the roles of alcohol and illegal drugs in the construction of "serious violence" within the Strategy. Method: Drawing on thematic analysis of key policy documents, the ways in which drugs and alcohol have been conceptualised in recent violence policy in the English and Welsh context are explored through the analytical framework of "framing". Results: The overwhelming emphasis on violence associated with the drugs market has skewed attention towards exceptional and sensationalist forms of "serious" violence and diverted it from more common and widespread forms of "everyday" violence, including domestic and alcohol-related violence. Omitting these from the policy purview has implications for those affected and how resources are allocated. Conclusion: To advance inclusive and holistic violence prevention, a wider framing of violence is required and both illegal drugs and alcohol need to be embedded for meaningful working across populations and organisational boundaries.

Responding to 'wicked problems': policy and governance on drug-related deaths in English and Welsh prisons, 2015-2021.

BACKGROUND: Prison settings have been neglected in the growing literature on drug-related deaths. This paper explores policy and practice issues regarding the governance of drug-related deaths in prisons in England and Wales from 2015-2021. METHODS: Thematic documentary analysis was conducted on national level policy documents published between 2015-2021 (e.g. drug strategies, prison policy documents, Her Majesty's Inspectorate of Prisons and Prison and Probation Ombudsman (PPO) annual reports and guidance for staff). At the local (prison) level, all of the PPO fatal investigation reports and their associated action plans relating to 171 drug-related deaths from 2015-2021 were analysed thematically. Various modes of governance were identified using Head's 'wicked problems' conceptual framework including avoidance and denial, coercive controls, compartmentalised micro-management, incremental and pragmatic adjustment and technocratic problem-solving. RESULTS: There was strong evidence of the dominance of denial of the problem of drug-related deaths, coercive controls, micro-management and reliance on technological solutions in the early years (2015-2018). In some prisons, there developed a move towards the adoption of more pragmatic and incremental policies and push towards comprehensive policies over time. In others, remnants of denial and coercion remained. In our analysis, the focus on new psychoactive substances came to dominate attention, to the relative neglect of other substances and of the contribution of mental and physical illness to these deaths. Staff are not equipped, supported or resourced adequately to deal with the two 'wicked problems' of increasing rates of drug use and mental illness which collide in the prison setting. CONCLUSION: The PPO investigations repeatedly recommend reducing supply and improving monitoring and surveillance and the emergency response. There is less focus on prevention and reducing demand or improving the wider environmental context and culture in which the deaths occur. Policy needs to pay more attention to the fundamental issues driving the current deterioration in conditions in prisons.

The risk matrix: Drug-related deaths in prisons in England and Wales, 2015-2020.

This article explores the factors contributing to drug-related deaths in English and Welsh prisons between 2015 and 2020. Based on content analysis of all Prison and Probation Ombudsman 'other non-natural' fatal incident investigation reports, descriptive statistics were generated. Qualitative analysis explored the circumstances surrounding deaths and key risk factors. Most deaths were of men, whose mean age was 39 years. Drug toxicity was the main factor in causing death, exacerbated by underlying physical health conditions and risk-taking behaviours. A variety of substances were involved. New psychoactive substances became more important over time. A high proportion had recorded histories of substance use and mental illness. During this period, the prison system was under considerable stress creating dangerous environments for drug-related harm. This study highlights the process of complex interaction between substances used, individual characteristics, situational features and the wider environment in explaining drug-related deaths in prisons. Implications for policy and practice are discussed.

'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK.

BACKGROUND: The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings. METHODS: Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons. RESULTS: Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services. CONCLUSION: The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.

Availability, Accessibility, and Coverage of Needle and Syringe Programs in Prisons in the European Union.

Needle and syringe programs (NSPs) are among the most effective interventions for controlling the transmission of infection among people who inject drugs in prisons. We evaluated the availability, accessibility, and coverage of NSPs in prisons in European Union (EU) countries. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, we systematically searched 4 databases of peer-reviewed publications (MEDLINE (PubMed), ISI Web of Science, EBSCO, and ScienceDirect) and 53 databases containing gray literature to collect data published from January 2008 to August 2018. A total of 23,969 documents (17,297 papers and 6,672 gray documents) were identified, of which 26 were included in the study. In 2018, imprisonment rates in 28 EU countries ranged between 51 per 100,000 population in Finland and 235 per 100,000 population in Lithuania. Only 4 countries were found to have NSPs in prisons: Germany (in 1 prison), Luxembourg (no coverage data were found), Romania (available in more than 50% of prisons), and Spain (in all prisons). Portugal stopped an NSP after a 6-month pilot phase. Despite the protective impact of prison-based NSPs on infection transmission, only 4 EU countries distribute sterile syringes among people who inject drugs in prisons, and coverage of the programs within these countries is very low. Since most prisoners will eventually return to the community, lack of NSPs in EU prisons not only is a threat to the health of prisoners but also endangers public health.

Producing the 'problem' of new psychoactive substances (NPS) in English prisons.

BACKGROUND: There has been a significant change in the types of substances consumed within English prison settings in the last eight years. There have been particular concerns regarding the acceleration in the use and availability of New Psychoactive Substances (NPS), mainly synthetic cannabinoids. Although NPS were identified as a 'problem' in prisons in 2011, government responses emerged only in 2015. As yet, there is no overarching policy document or strategy for dealing with NPS. This paper analyses the various strands of the response to NPS in prisons published from January 2015 to December 2016. METHODS: Drawing on Bacchi's 'What's the problem represented to be' framework, the ways in which the NPS 'problem' in prisons has been represented is analysed through a number of related policy texts including press releases, new legislative and regulatory measures, government documents and training package. RESULTS: From the various measures introduced to deal with the 'problem', NPS use is produced primarily as a law, order and control 'problem' requiring regulation, penalties and control, rather than a 'demand problem' calling for prevention, education, treatment and harm reduction or a 'regime problem' demanding greater emphasis and resources for purposeful activities such as education, training and work opportunities. This problematisation of drug use in prisons has a history dating back to the 1995 prison drug strategy and has become entrenched and reproduced within policy development over time. CONCLUSION: The law, order, and control problematization blames the volatility of the substances and the individual prisoners who use them as key factors contributing to the current prison crisis, rather than as consequences of the wider practices, cultures, contexts, and conditions. Multiple representations of the problem of NPS in prisons are needed in order to address the regime and structural issues which lead those imprisoned to use substances.

Exchanging expertise and constructing boundaries: The development of a transnational knowledge network around heroin-assisted treatment.

Over the last 20 years, supervised injectable and inhalable heroin prescribing has been developed, tested and in some cases introduced as a second line treatment for limited groups of entrenched heroin users in a number of European countries and Canada. Based on documentary analyses and eleven key informant interviews, this paper investigates the growth of 'expertise' and the sharing of knowledge between scientific stakeholders from different countries involved in researching and developing this area of treatment. Drawing on Stone's concept of the 'knowledge network' (Stone, 2013) and Gieryn's theory of 'boundary-work' (Gieryn, 1983), the analysis demonstrates the collective power of this group of scientists in producing a particular form of knowledge and expertise which has accrued and been exchanged over time. It also illustrates the ways in which this type of science has gained credibility and authority and become legitimised, reinforced and reproduced by those who employ it in both scientific and political debates. Boundaries were constructed by the knowledge network between different types of professions/disciplines, different forms of science and between the production of science and its consumption by non-scientists. The uniformity of the knowledge network in terms of their professional and disciplinary backgrounds, methodological expertise and ideological perspectives has meant that alternative forms of knowledge and perspectives have been neglected. This limits the nature and scope of the scientific evidence on which to base policy and practice decisions impacting on the work of policy makers and practitioners as well as the experiences of those in treatment who are most affected by this research and policy development.

Producing the 'problem of drugs': A cross national-comparison of 'recovery' discourse in two Australian and British reports.

The notion of 'recovery' as an overarching approach to drug policy remains controversial. This cross-national analysis considers how the problem of drugs was constructed and represented in two key reports on the place of 'recovery' in drug policy, critically examining how the problem of drugs (and the people who use them) are constituted in recovery discourse, and how these problematisations are shaped and disseminated. Bacchi's poststructuralist approach is applied to two documents (one in Britain and one in Australia) to analyse how the 'problem of drugs' and the people who use them are constituted: as problematic users, constraining alternative understandings of the shifting nature of drug use; as responsibilised individuals (in Britain) and as patients (in Australia); as worthy of citizenship in the context of treatment and recovery, silencing the assumption of unworthiness and the loss of rights for those who continue to use drugs in 'problematic' ways. The position of the organisations which produced the reports is considered, with the authority of both organisations resting on their status as independent, apolitical bodies providing 'evidence-based' advice. There is a need to carefully weigh up the desirable and undesirable political effects of these constructions. The meaning of 'recovery' and how it could be realised in policy and practice is still being negotiated. By comparatively analysing how the problem of drugs was produced in 'recovery' discourse in two jurisdictions, at two specific points in the policy debate, we are reminded that ways of thinking about 'problems' reflect specific contexts, and how we are invoked to think about policy responses will be dependent upon these conditions. As 'recovery' continues to evolve, opening up spaces to discuss its contested meanings and effects will be an ongoing endeavour.

The role of evidence and the expert in contemporary processes of governance: the case of opioid substitution treatment policy in England.

BACKGROUND: This paper is based on research examining stakeholder involvement in substitution treatment policy which was undertaken as part of the EU funded FP7 ALICE-RAP (Addictions and Lifestyles in Contemporary Europe - Reframing Addictions Project). In England, the research coincided with a policy shift towards a recovery orientated drug treatment framework and a heated debate surrounding the role of substitute prescribing. The study aimed to explore the various influences on the development of the new 'recovery' policy from the perspectives of the key stakeholders involved. METHODS: The paper is based on documentary analyses and key informant interviews with a range of stakeholders, including representatives of user organisations, treatment providers, civil servants, and members of expert committees. RESULTS: Drawing on the theoretical insights offered by Backstrand's 'civic science' framework, the changing role of evidence and the position of experts in the processes of drugs policy governance are explored. 'Evidence' was used to problematise the issue of substitution treatment and employed to legitimise, justify and construct arguments around the possible directions of policy and practice. Conflicting beliefs about drug treatment and about motivation for policy change emerge in the argumentation, illustrating tensions in the governance of drug treatment and the power differentials separating different groups of stakeholders. Their role in the production of evidence also illustrates issues of power regarding the definition and development of 'usable knowledge'. There were various attempts at greater representation of different forms of evidence and participation by a wider group of stakeholders in the debates surrounding substitution treatment. However, key national and international experts and the appointment of specialist committees continued to play dominant roles in building consensus and translating scientific evidence into policy discourse. CONCLUSION: Substitution treatment policy has witnessed a challenge to the dominance of 'scientific evidence' within policy decision making, but in the absence of alternative evidence with an acceptable credibility and legitimacy base, traditional notions of what constitutes evidence based policy persist and there is a continuing lack of recognition of 'civic science'.

Stakeholders in opioid substitution treatment policy: similarities and differences in six European countries.

Based on the research papers within this special issue, this overview discusses similarities and differences in stakeholding in drug user opioid substitution treatment policy in Britain, Denmark, Italy, Austria, Poland, and Finland. It explores factors that have influenced stakeholder activity, including the importance of crisis, the impact of evidence, the availability of resources, the wider political context, the influence of moral frameworks and ideologies, and the pressure of external influences. The paper highlights the important differences in the emergence and evolution of stakeholder groups and in the political, cultural, and economic circumstances, which both constrain and enable their activities.

Substitution treatment in the era of "recovery": An analysis of stakeholder roles and policy windows in Britain.

Based on documentary analyses and interviews with twenty key informants in 2012, this paper analyses the shift in British drugs policy towards "recovery" from the perspectives of major stakeholders. The processes involved in reopening the debate surrounding the role of substitution treatment and its re-emergence on to the policy agenda are examined. Drawing on Kingdon's work on agenda-setting, the ways in which methadone maintenance was challenged and defended by key stakeholders in the initial phase of policy development and the negotiation of a "recovery" focus as the organizing concept for British drugs policy are explored. Study limitations are noted.