Nearly 30% of men and 51% of women incarcerated around the world are living with a drug use disorder. The Canadian Centre on Substance Use and Addiction estimates that 48% of people detained in federal prisons have a drug problem. In Ireland, about 70% of people enter prison with an addiction.

The offences committed by people struggling with addictions are multifaceted. Some offences (violence, fights, etc.) were committed under the influence of narcotics. Others were pushed to commit offences (robberies, burglaries, pimping, etc.) to support their drug use. The criminalisation of the sale, use and possession of narcotics also contributes to bringing users into prison: more than two of the eleven million prisoners are detained for drug-related offences.

Many countries have chosen a repressive legal framework in the field of drugs. In France, the use of drugs is an offence punishable by a €200 fine. In case of non-payment, the user risks up to one year in prison and a €3,750 fine. In Ireland, a person who is in possession of drugs, even without the intention of selling them, is liable up to seven years in prison and an unlimited fine. In Belgium, the penalty is one month’s imprisonment and a fine of up to €800.
Some countries adopt a less prohibitionist approach. In Canada, it is allowed to possess up to 30 grams of cannabis. The use of all other substances is considered a criminal offence, punishable by up to three years in prison. In Moldova, the possession of a so-called “individual” dose of any narcotic product is not legally reprehensible. Above this threshold, this is considered trafficking, and a 15-year prison sentence may apply.

The sentences remain heavy, despite calls for decriminalisation from civil society, international organisations, and experts around the world. Individuals who have committed a drug-related offence represent a significant part of the prison population. Almost 18% of those detained in Europe in 2019 were incarcerated for possession, use or trafficking of drugs. This figure rises to 22.5% in Belgium, 16% in France, 10.3% in Ireland and 7.4% in Moldova. In Canada, between 2015 and 2016, 18% of prisoners in federal prisons¹ were incarcerated for drug-related offences.

Prison isolates, weakens, and anguishes. Narcotic drugs are often considered as “the only way to relax, calm down, escape and get hold of oneself“¹ to endure the sentence and prison conditions. More than half of the people incarcerated in Belgium who use drugs explained doing so to cope with the stress caused by their imprisonment. Baptiste*², formerly incarcerated in the Fleury-Mérogis prison (France), testified: “I take drugs to distract myself. It is a way to forget my sadness, to feel slightly better. Prison rules are different from those on the outside. It is another world, and I do not wish it on anyone”.

Drugs seem particularly accessible: they are everywhere in the prison. Sources claim that in France, the guards are allegedly “fully aware” of the situation. It is tolerated because it gives prisoners “a way to console themselves”.”The prison administration sees value in it“ affirms Solenn Lebret-Dallaserra, a PhD student in prison sociology at the University of Grenoble.

Although substance use is a means to bear the prison sentence, this environment represents a particularly dangerous place for taking drugs. Prison often worsens user habits. “Some prisoners did not suffer from addiction before being incarcerated. They only began to take drugs in prison“. Jérome*, formerly imprisoned in Fresnes facility (France), testified: “At night before sleeping, you smoke about two joints of hash. Before prison, I never took hash to help me sleep”. For Baptiste*, incarceration also meant increased use: “I smoked about 4 to 5 joints a day in prison. Before being locked up, it was less”.

Psychological and social care check-ups are essential to avoid detrimental effects on the mental health of prisoners with substance use disorder. However, these support programmes are difficult to implement due to a lack of funding. Sophie* is a social in-reach worker in (Ireland) who helps prisoners struggling with substance use. She confirmed the lack of human resources in prisons: “They do not have access to regular in-depth counselling. It is all related to the fact that there is not enough staff. When I ask some of my clients if they got to see their addiction counsellor, they say, ‘yes, between the bars, for 15 minutes’. I know that the counsellors do the best they can. They work full-time. However, for 700 prisoners, for example, there are only 4 counsellors.” In Moldova, Svetlana Doltu, former director of the prison health department, stressed that there are not enough doctors and nurses in the psychiatry department in prisons. In Canada, the observation is the same: Sandra Ka Hon Chu, co-director of the HIV Legal Network, explained that it is very difficult to assign psychology-specialised health personnel in prison.

Prisons, often overcrowded and unsanitary, permanently affect the physical and mental health of prisoners. It is a fertile breeding ground for sexually transmitted and bloodborne infections (STBBIs). The number of people suffering from STBBIs is much higher in prison than outside. The number of HIV-infected people in Canadian prisons is five to 25 times higher than in the general population. They are almost seven times more likely to be infected with hepatitis C in Belgian prisons. In France, they are between three and five times more likely to be infected with HIV and four to five times more with hepatitis C.

The risk of transmission and infection of STBBIs is particularly high among people who inject or inhale drugs. Anne-Claire Bréchet Bachmann, a prison doctor in Switzerland, explained how these diseases spread: “Being in prison itself increases the risk factors: unprotected sex, use of drugs, and sharing injection materials. Prisoners might also share razors for shaving their beard or their head. These practices provide the right conditions for transmitting infections due to possible droplets of blood remaining on the blades.”
Steve Simons, held for 13 years in a Canadian federal prison, recalled: “I never shared my injection equipment because I knew the risks. But one day, a fellow prisoner took my kit out from my cell and used it without my knowledge or consent. A few months later, I tested positive for hepatitis C”.

Many measures exist to protect the health of people who are struggling with substance use. There are campaigns on raising awareness and disseminating information on STBBIs, screenings, vaccinations, substitution treatments, and sterile supplies (injection kits, syringes, straws), to name a few. This is part of a global policy of risk reduction: an approach focusing on drug prevention rather than withdrawal. It aims to “prevent the transmission of infections, death from drug overdose and the social and psychological damage linked to drug addiction by substances classified as narcotic drugs¹”. The harm reduction policy stemmed from the observation that drugs cannot be completely eradicated from society and that it is urgent to prioritise treatment.

Some countries are implementing harm reduction measures in prisons on a national scale. In Moldova, a needle exchange programme has existed for more than 20 years. Prisoners injecting drugs can access sterile injection materials without needing to inform the prison staff. They have the choice to retrieve the materials through other prisoners – their “peers” who are trained by non-profit groups – or during visits from volunteer groups and their relatives. The programme is free of charge, and bins for the disposal of used needles and syringes are installed in the common areas.
UNAIDS has observed a drop in the prevalence rates of hepatitis B and C in Moldovan prisons. The number of people with hepatitis C dropped from 8.6% in 2012 to 3.6% in 2021. Between 2012 and 2021, the prevalence rate of hepatitis B in detention decreased from 13.1% to 1.6%.

Opioid substitution therapies (OST) are more widely accepted. These are implemented in Belgian, Canadian, French, Irish and Moldovan prisons. OST allows for the prescription of a pharmacotherapy to people addicted to opiates to alleviate withdrawal symptoms when reducing or stopping drug use².
In France, Olivier Bagnis, former head of the Centre for Care, Support and Prevention in Addictology (centre de soins d’accompagnement et de prévention en addictologie, CSAPA) of the Baumettes prison, explained: “Overall, there is no ostracism towards people who take substitution treatments. The staff understands that it is simply a treatment that prisoners must take every day”.
However, there remain barriers to confidentiality. Sophie*, a Dublin-based social in-reach worker (Ireland), said: “There is a lot of shame around going to get methadone. Methadone treatment is not very private. They have to go to the medical hatch, and everyone knows what they are doing there”. In Moldova, Svetlana Doltu explained: “Availability [of OST] is ensured but only a few prisoners ask for it, especially because they have to take their treatment in front of the medical staff”.

However, harm reduction is struggling to gain a lasting foothold. Subjected to strong opposition in society, these measures are even more difficult to become accepted in detention. The prison is faced with a dilemma: How to bring this type of intervention into such a restrictive place? 

Irène Aboudaram and Marie Hornsperger worked for Doctors of the World to implement health awareness campaigns at the Nantes-Carquefou prison (France). For them, “prison guards face an ethical dilemma. It is hard for them to accept the idea of facilitating the use of a substance which is not only illicit, but shouldn’t be on site in the first place.”

Security is often used to justify the refusal to implement harm reduction interventions. This is particularly the case regarding needle exchange programmes. France, Belgium and Ireland do not provide for such programmes in prison. The needle exchange programme raises questions and concerns. Sandra Ka Hon Chu, from the HIV Legal Network, explained that the guards are afraid that the syringes will be used as weapons. However, the findings of health professionals do not support this claim. Svetlana Doltu explained that “in 20 years of needle exchange in the Moldovan prisons, we have not recorded any aggression with needles.”
In Canada, a needle exchange programme has existed since 2018. It is the result of a long legal battle waged by civil society organisations. They considered that the lack of sterile supplies was detrimental to the prisoners’ health. In reality, the programme is hardly implemented. “To gain access to the needle exchange programme, prisoners have to go through so many hurdles”, explained Sandra Ka Hon Chu. The nurses must approve their participation, as well as the chief supervisor. They can therefore freely access the programme only on condition of renouncing their anonymity. “The needle exchange model in Canadian prisons does not conform to any of those recommended by the United Nations. The guards will have a closer eye on people using the programme. They will be more likely to search through their things and to punish them, because drugs are still prohibited.”, regretted Sandra Ka Hon Chu. This approach dissuades people who need it from joining the programme. The HIV Legal Network considers that the existence of the programme is good news“but it is not the right one. As a result, people are still sharing syringes“.

Disinfectants are sometimes distributed instead of sterile equipment. In France, according to the “Handbook for new inmates”, “the prison administration provides a bottle of 12° bleach every two weeks to decontaminate objects that might come in contact with blood (razor, needle, shaver, etc.)”.
Distributing the bleach to prisoners is laborious. Olivier Bagnis explained: “Bleach distribution is complicated as all services are constantly passing the buck. For the 12 years that I have worked in detention, this has not changed. We have reached a point where we [the medical teams] are handing them out. This should be done by the prison administration, but this is not usually the case”. Its effectiveness is also questioned, including by Doctors of the World: “The bleach is diluted to 12° to limit the risks of intoxication and suicides by ingestion. There is no proof that such a low concentration can properly disinfect anything.”

Avoiding incidents and assaults, preventing suicides… so many reasons given to not implement certain prison risk reduction programmes. The argument on security has its limits, and the prison administrations sometimes struggle to explain their reluctance. This is also the case for condom distribution. In France, the “Handbook for new inmates” specifies that condoms are made available free of charge by the prison administration and the health staff. Olivier Bagnis nevertheless explained that, in general, “it is very difficult to hand out condoms. There is always reluctance, not only from the prison administration but also from the prisoners. The administration insists that there are no sexual activities in prison. Although untrue, this is often their statement. An elephant in the room, male homosexuality in detention is frowned upon and unaccepted.” Condoms, when handed out, are often only available at the medical unit, as explained by Mélanie Kinné, head of the prison health units in the University Hospital of Nîmes.
In Ireland, access to condoms is also considered difficult. Sophie*, a social in-reach worker , explained: “I know of one prisoner who asked for a condom in Wheatfield prison. They gave him, but it made the headlines (2014). We are very backwards with anything to do with sex.” In Canada, Sandra Ka Hon Chu reported that condoms, lubricants and dental dams¹ should be made available. She specified that the situations vary from one prison to another, but the reality is that prisoners report difficulties accessing them.

In the absence of official guidelines, some health workers take personal initiatives. In the prison infirmary, they provide the necessary treatment with or without the consent of the prison administration. According to Doctors of the World, “while it’s encouraging to see that people are setting up such measures, unfortunately there is no systemisation. The day the doctor giving out syringes retires, the whole system stops. This really raises the question of how sustainable these initiatives are.”

People living with substance use disorder who have benefited from medical and psychosocial check-ups in prison often have their treatment abruptly interrupted upon release. The United Nations Standard Minimum Rules for the Treatment of Prisoners (also known as the “Nelson Mandela Rules”) require that health care services be organised “in a way that ensures continuity of treatment and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence¹”.

Respect for the continuity of treatment implies that individuals who have continued or started treatment in prison should still have access to treatment once they are released. In Ireland, the FusionCPL association helps newly released prisoners to get in contact with doctors. Their objective is that individuals can benefit from their substitution treatment from the day of their discharge. Otherwise, their release is postponed.

In France, doctors sometimes do not have the opportunity to see their patients before they are discharged. The patients risk having their treatment interrupted and then relapsing. Individual initiatives are observed in some prisons. Mélanie Kinné explains that in Nîmes “when there are scheduled releases, we give the person prescriptions and three days of anticipated treatment so that there is no break in their care”. In Belgium, the continuity of treatment after release is considered even less satisfactory. The Ambulatoire Forest, an outpatient service, noted that “the vast majority of people leave prison unable to arrange replacement therapy for after their release. They receive no support and instead must wait to see a doctor.”

Decreased tolerance to the substance, risk of relapse, interruption of treatment… former prisoners are 37 times more likely to die of an overdose within a week of their release than the rest of the user population. In the event of an overdose, some products can prevent a fatal outcome. Naloxone can, in the case of an opiate overdose, be prescribed as an antidote. In Canadian federal prisons, this medicine can be given upon release. In France, the situation varies according to the prison facility.
“Relapse is common in the recovery journey and, unfortunately for those who have been incarcerated, it is likely to coincide with another stay in prison”, recalled the Ambulatoire Forest.