Introduction and method: This is a literature review mapping the contemporary picture of drugs and Scottish prisons. It was completed through a grant from the SCCJR. Three research questions guided the search, relating to: prevalence and patterns of use in prisons; treatment and harm reduction services available in prison; and, the needs of people in Scottish prisons in relation to their drug use. A total of 85 documents, reflecting latest data available, were gathered using systematic review techniques. 

Prevalence and patterns of drug use in prison: A high number of people have drugs in their system as they enter prison, complete a period in prison and exit prison. Between 40-75% reported a drug problem or tested positive for illegal substances on entering prison. Nearly 40% reported using illegal drugs while in prison. Between one-quarter and one-third of those tested on leaving prison have illegal substances in their bodies. Most people (83%) change their drug use whilst in prison. This includes decreased use (44%) and switching substances (22%). Slightly more than one in ten started using illegal drugs in prison. Benzodiazepines, opiates and cannabis were the most commonly used illicit drugs amongst Scottish prisoners. A small number of prisoners report injecting drugs (5%), mainly heroin, in prison. New Psychoactive Substances (NPS), with synthetic cannabis being the most common, were used by 30% of prisoners responding to the Scottish Prisoner Survey in 2019. Age and gender: Opiate and alcohol-only users have higher average ages (35 and 37, respectively) than non-opiate and alcohol users (28). Women are overrepresented in drug using and treatment populations in prison. 

Drug use support in prison: Opioid replacement therapy (ORT) is widely used in Scottish prisons. Data suggests between one-fifth and a quarter of the prison population has an ORT prescription. In a 2019 self-report survey, over a quarter of respondents reported ever having used someone else’s medication. There is wide variation between prisons in Scotland in the numbers using ORT, from a high of 35% prisoners in HMP Greenock on methadone/Subutex compared to less than 10% of prisoners in HMPs Castle Huntly, Inverness and HMP/YOI Polmont in 2018. There are some psychosocial interventions available in prison, including peer-based but little research on the practices or outcomes of these. A national Naloxone programme exists in Scotland and aims at reducing drug deaths. Some research has noted operational and implementation issues. Take home Naloxone kits are available for those leaving prison, and there is relatively higher take up by women, which further emphasises the need for gender-focused research. 

Needs of Scottish prisoners: Scotland’s drug deaths are high, and its prison drug death rates are even higher. Of those dying after leaving prison, opiates are a key cause; those dying tend to be older than the average prisoner. This suggests the need of targeting and personalising support before and after liberation. Research has pointed out variation between prisons and lack of connection and coordination between prison-based health care, wider health services, prison, police and social work. Demand for drugs, which indirectly relates to prisoner treatment needs, often arises from boredom, limited regimes/frequent lock-up, isolation and more. This indicates attention to the general regime of a prison is central to addressing needs of prisoners with drug use issues. 

COVID-19 policy changes: Buvidal, an alternative to methadone, was rolled out to all prisons in Scotland during Covid, with evidence of positive effects for some, but not all, who were switched to this. More data is needed to assess its effectiveness. Numerous changes to criminal justice took place during the pandemic, and there were impacts on support resulting from lockdowns. However, there is little available literature documenting all these changes and impacts of these for prisoners with drug use issues. 

Limitations and conclusions: The research is limited and collected data only through July 2021. Of the evidence gathered, Covid-19 has affected some of the regular monitoring needed to gain a comprehensive sense of drug use in prison. A strong evidence base exists for high prevalence and patterns of drug use among prisoners. Opiate use is common (both prescribed ORT and illicit use) with resort to other substances such as NPS also common. Drug support services are centred around ORT, though there are a range of medical and psychosocial services in addition to this. These are not evenly spread across prisons, however, and availability was sharply restricted during Covid. Age, gender and individual factors like dual diagnosis of a mental health issue are areas where urgent attention is needed to develop tailored responses. The research base, which would support development of effective policy responses, is limited especially in relation to qualitative dimensions of drug use in prison and effectiveness of interventions, specifically psychosocial ones.