People who commit criminal offences and enter the criminal justice system have higher rates of drug use and injecting than the general population. People with drug problems in the criminal justice system are often repeat offenders, and make up a significant proportion of prisoners. Adherence to the international drug conventions does not necessitate incarceration as a response to the use of controlled substances. Nevertheless, a significant number of offenders with drug problems are incarcerated for use or possession offences. Many others are imprisoned for other drug law offences or crimes, such as theft committed to obtain money for drugs. The complex health care needs of these individuals need to be assessed on prison entry.
As the average duration of a prison sentence for this group is a few months, they are a dynamic population with regular contacts with the community; this has implications for public health. Drug use occurs in prisons and also presents a public health and safety risk to prisoners and prison officers. The use of synthetic cannabinoids is an emerging issue of concern in some countries.
- Opioid substitution treatment in prisons is reported by 28 of the 30 countries monitored by the EMCDDA (28 EU Member States, Norway and Turkey).
- Detoxification, individual and group counselling, and therapeutic communities or special inpatient wards are available in prisons in most countries.
- Infectious diseases testing is available in prisons in most countries, but hepatitis C treatment is rare. Hepatitis B vaccination is reported in 16 countries.
- Needle and syringe programmes in prisons are reported in four countries.
- Many European countries have partnerships between prison health services and providers in the community to ensure continuity of care on prison entry and release.
- Preparation for prison release, including social reintegration, is done in most countries. Programmes to prevent drug overdose among opioid injectors are reported in five countries which provide training and naloxone on release from prison.
Summary of the available evidence
Implications for policy and practice
- The principles of equivalence of care and continuity of care require the provision of the same range of evidence-based interventions for people with drug problems in prison as in the community, provided by staff properly qualified for treating addiction (whether prison staff or outside professionals), and mechanisms to ensure continuity of treatment; this is especially important for those incarcerated for short periods.
- Preparation for release should include activities to support social reintegration and training on overdose prevention — the provision of take-home naloxone should be considered.
- Alternatives to punishment are recognised in the international conventions as a potentially valuable option for offenders with drug problems.
- Prison settings may provide an opportunity to have a significant impact on morbidity, mortality and public health. Firstly, by engaging people with opioid problems in treatment, their illicit opioid use and risk behaviours in prison and overdose risks on release may be reduced. Secondly, by offering testing for infectious diseases to everybody on entry to prison and following up with treatment as needed.
- Increasing the use of alternatives to punishment through review of the regulations that govern their application and addressing public and professional attitudes to their use may have the potential for improving long-term outcomes and reducing criminal justice expenditure.
- UN/WHO guidance recommends the provision of harm reduction measures (needle and syringe programmes, condom distribution, safe tattoos) in prison, but this is currently rare — scaling up these programmes could make an important contribution to health improvement.
- Studies are needed to improve the evidence base around alternatives to punishment, with particular attention being paid to the groups that can most benefit from these, and the stages in the criminal justice process at which they are best applied.