Overview
Problematic drug use and drug-induced deaths are increasingly viewed in many countries as major societal challenges. Globally, the United Nations Office for Drugs and Crime has registered increases in the supply, use and harms of drugs over the 20th and 21st centuries. Their 2024 report noted that cocaine production has reached record highs; drug use and markets have expanded in Europe, Africa and Asia; and synthetic drugs are inflicting harm, especially methamphetamines in Asia, the Middle East and parts of Europe, and fentanyl in North America. The report confirmed that poverty and insecurity lie at the root of illicit crop cultivation, and that traffickers are constantly producing new psychoactive substances that pose a serious threat to public health. 1,209 new psychoactive substances have been identified since 1995, four times more than the number under international control. Nitazenes
(synthetic opioids which can be more potent than fentanyl) present a new challenge.
The available evidence from international multidisciplinary research about the supply, use and harms of drugs in prisons raises important questions about the relationship between patterns of drug use in people who cycle through prison, the health and social implications of this drug use, and the prison environment. Researchers and policymakers ask:
- What are the problems underlying the use of drugs and drug-induced deaths in prisons?
- What policies and programmes would be most effective in responding to these complex issues?
- What lessons can policymakers draw from international experience for policy learning and transfer?
Key evidence
A growing body of international data is providing insights into the changing drug scene around the world. Particular attention has been given to the situation in North America.
- In North America, drug-related overdose fatalities have become the leading cause of non-natural deaths in the general population: 7,500 opioid deaths were recorded in 2022 (19.6 per 100,000) in Canada, and 82,000 (25 per 100,000) in the USA.
- In the UK, rates of drug-related deaths in the population have more than doubled since 2012 and are above the EU average, largely due to high rates in some English regions and Scotland.
There is less reliable material accessible about the situation in prisons. Europe provides publicly available, consistent and robust data, as the European Union Drugs Agency (EUDA) has collected aggregate data from prisons since 2003 – but elsewhere in the world, data are scarce and patchy.
- In Europe, rates of between 20% and 40% are reported for illicit drug use in prisons, and around 50% before imprisonment. The prevalence of drug use among prisoners in Europe and other high-income countries is often greater than in the general population, as are rates of mental illness and co-morbidity.
- In England and Wales, about half the prison population receive some form of treatment for substance misuse while in prison, indicating the high burden this need places on prison management. Opiates were the most common substance reported by those in treatment to be causing problems (46%) while alcohol was reported by 43%, cannabis by 32% and 25% cocaine. Almost half of those in treatment (44%) receive a pharmacological intervention (73% of the opiate group but 6% of the non-opiate group). The most common form of treatment received was psychosocial intervention.
- In the USA, 65% of the prison population have an active substance use disorder. Only 5% of people with an opiate use disorder in jail or prison settings receive opiate substitution treatment. Most treatment offered is behavioural counselling and/or detoxification without follow-up. The number of drug-related deaths in state prisons increased from 35 in 2001 to 253 in 2019, a rise of 623%. In spite of this increase, in 2022, the proportion of state prisoners who died from drug or alcohol intoxication was still half that for the US resident population.
- In Canada, high levels of substance use and mental health disorders are found in the correctional population, and increasing numbers of drug overdose deaths have been observed among prisoners, a rate higher than in the Canadian general population. Nearly one in four federal inmates are now said to be receiving treatment for opioid addiction.
Policy context
In many countries in recent years, responses to the pressures of drug dependence and mental illness within prisons have had to contend with fiscal pressures following the financial crisis of 2008, the COVID pandemic, wars and inflation. In the UK, this has resulted in a deteriorating prison environment where drug-taking is rife and at times prison wings are out of control: too often people in prison lack purposeful activity. The rise in drug-induced deaths in UK prisons has been linked to increased availability and use of new psychoactive substances, especially synthetic cannabinoids, which were not initially picked up by drug testing, cheap to purchase and easy to smuggle or send in by drone. This phenomenon is now being recognised in other countries.
Internationally, policy on drugs has been polarised between ‘war on drugs’ and ‘harm reduction’ approaches, with different value-orientations resulting in significant differences in policies and prison environments. Increasingly, the policies and interventions encapsulated in the term ‘harm reduction’ have become accepted by experts as the way to respond, and consensus is growing about ‘what works’ in the community. The difficulty lies in transferring these practices into the prison context where resistances exist, and the goals of health and security are often difficult to reconcile.
There are examples of lessons that could be applied cross-nationally. The Netherlands asked what lessons could be learnt from their policy to close emptying prisons. European societies might benefit from considering pioneering interventions in some Canadian prisons, such as experiments with overdose prevention centres.
Recommendations
Based on the available evidence and exchanges of good practices, national and international bodies have produced recommendations that could be applied to reduce and to treat drug-related harms in prisons with the aim of encouraging:
- cooperation and establishing integrated work between public health systems, international nongovernmental organisations, and prison health systems to promote public health and reduce health inequalities;
- prisons to operate within the widely recognised international codes of human rights and medical ethics in providing services for prisoners;
- all prison health services to reach standards equivalent to those in the wider community.
In addition, based on the evidence alluded to above, we recommend:
- non-violent sentenced people with chronic drug dependence should be diverted to treatment in community-based services;
- those sentenced to imprisonment for a violent offence and with a diagnosed mental illness should be diverted to treatment in secure mental hospitals;
- improvements to the wider regime, staffing and overall environment of prisons should be made to help address the demand for drugs, especially by increasing the availability of purposeful activity and active attempts at rehabilitation.
This briefing was written by Susanne MacGregor FAcSS and Karen Duke.