Current and future challenges
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has just 925 June 2021) published a new report, “Prison and drugs in Europe: current and future challenges“. The report explores in depth the epidemiology of drug use and drug-related problems among the prison population, the available social and health service responses to drug-related problems in prison, including the most recent evidence of effectiveness, and the drug supply and markets inside prison. It also discusses recent and future challenges in this area.
As readers will know, people in prison report high levels of lifetime prevalence of substance use before imprisonment and increased levels of consumption, especially of heroin, cocaine and amphetamines, compared with the general population. Although many people will stop injecting drugs when they enter prison, for those that continue, the use and reuse of contaminated equipment is not uncommon, contributing to an increased risk of transmission of infectious diseases in these settings.
The lifetime prevalence of substance use before and during imprisonment varies by country and is influenced by differences in prison organisation, drug policy and drug use prevalence in the community, as well as differences in survey methodology. Women in prison are reported to be particularly vulnerable and at risk of problematic drug use.
A particular challenge (well documented in the UK) in recent years has been the increasing use of new psychoactive substances in prison, particularly synthetic cannabinoids. The initial undetectability of these substances in routine urine testing is thought to be a main contributing factor.
People in prison have poorer physical and mental health and social well-being than their peers in the community and a lower life expectancy. They also have higher rates of infection of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV) and tuberculosis. Mortality among people with prison experience is higher than that in the general population, due to several risk factors in this population, including drug use and injecting drug use. For those injecting opioids, the risk of dying from a drug overdose increases markedly in the initial period after release.
Many drug demand reduction interventions that have been demonstrated to be effective in the community have been implemented in prisons in Europe, often following some delay and with insufficient coverage, including assessment of drug use; drug information provision and drug prevention; pharmacological treatment, including opioid substitution treatment (OST); psychosocial interventions; interventions targeting drug-related infectious diseases; and preparation for release and social reintegration. OST in prison is available in Norway, Turkey, the United Kingdom and all EU Member States except Slovakia, yet in most European countries coverage in prison remains low.
Interventions available in prison to prevent and control infectious diseases include testing, HBV vaccination, treatment of HIV and hepatitis C, and education on infection risk and prevention. However, access to testing and treatment remains low. Other harm reduction interventions with proven effectiveness in the community, including needle and syringe programmes, condom distribution programmes and safe tattooing programmes, are available in only a few prisons in Europe. Interventions preparing people for release from prison include social interventions, referral to external services and overdose prevention strategies; only a limited number of countries provide naloxone to those leaving prison.
The chart below shows that the UK compares well with many European countries in terms of the range of helping services provided in prisons; the two main exceptions are needle and syringe exchange programmes and early release.
The prison and the community connect and intersect as people move between one and the other, and this is particularly so in the case of people with drug-related problems. Providing continuity of care as people move between prison and the community is key to achieving sustainable and effective treatment outcomes, and it is likely to have a significant impact on public health.
Compared with the early 2000s, the availability and levels of provision of health and social care services targeting the needs of people who use drugs in prison have improved in several European countries; yet, for the most part, people in prison are faced with a limited range of treatment options, and equity and continuity of care remain unachieved principles in the majority of countries in Europe. The World Health Organization recommends that health ministries provide and be accountable for healthcare services in prisons and that the management and coordination of all relevant agencies and resources contributing to the health and well-being of people in prison be a whole-of-government responsibility, where prison health services and professionals are fully independent of prison administrations and yet liaise effectively with them.
Health and social service responses in prison may have a significant public health impact on morbidity and mortality, not only for people in prison but also for the community as a whole. Engaging people with drug-related problems in treatment while in prison may reduce their drug use, their risk behaviours (including the risk of contracting infectious diseases) and the risk of overdose upon release.
Drug-related problems are just one of many vulnerabilities experienced by people who spend some part of their lives in prison. Social marginalisation and inequality are important risk factors for both drug use and offending behaviour, requiring integrated multiagency approaches that address drug use and drug-related problems along with other important health and social problems.
There is a high demand for drugs in prison settings, and people in prison, their friends and families, and those working in prisons, as well as organised criminal groups, may be involved in facilitating drug supply to prisons. Routes of supply and mechanisms of distribution in prison are adapted to the particular circumstances of each prison and flexible enough to be adjusted to make use of new technologies (e.g. drones) or to overcome new challenges, such as increasing security measures and attempts by prison authorities to deter drug use. Although a variety of security measures have been implemented to prevent drugs from entering the prison environment, there is limited information about the impact
of these measures.
Overall, the report focuses on four key areas where most countries can improve their response to the issues of drug use in prisons:
- The social vulnerabilities of people in prison who use drugs,
- The connection between prison and the community (it will be interesting to see whether the new Reconnect service can help continuity of care on release in England and Wales,
- The balance between care and control, and
- Alternatives to imprisonment – again it will be interesting to see if we see real uptake of Community Sentence Treatment Requirements.
Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here.