Drugs in prisons: Exploring use, control, treatment and policy

Drugs are an increasingly salient concern in many prisons around the world. Specific prison drug policies are made, drugs are illegally used and legally prescribed, drug use and drug sale is sanctioned, drug profits are generated, and drug use is an important public health and treatment priority in most prisons. A growing number of prisoners are using drugs and a large proportion of people who use drugs have been in prison. As a consequence of such developments, everyday life in many prisons is dictated by drug-related issues. The purpose of this Special Issue is to critically examine and advance research relating to the growth in use, control and treatment of drugs within the prison environment as well as research on relevant governmental policies and practices. The articles highlight a diverse range of issues including the dynamic nature of the drugs problem in prison in relation to the substances being used, how they are administered, the meanings and motives associated with drug use and dealing and the way in which the drug market operates, but also the ways in which supply reduction, demand reduction and harm reduction responses have developed within different prison settings. The papers draw on a range of different quantitative and qualitative research designs and methodologies, highlighting the voices of the prisoners themselves as well as the practitioners and policy-makers who are tasked with dealing with the problem of drugs in prisons.

Studies in many countries have found an over-representation of drug users in prisons and that prisoners have higher rates of lifetime drug use, injecting drug use and problematic drug use compared with the general population (AIHW, 2013; Boys et al., 2002; CASA, 2010; EMCDDA, 2012; Fazel, Bains, & Doll, 2006; Ministry of Health, 2006). However, as argued by Duke and Kolind (in press), the data available on drug use and drug users in prisons have a number of limitations in relation to validity and reliability. This is due to the sensitive nature of the topic (i.e. an illegal, stigmatised activity), the rules and surveillance within the prison environment and the reluctance of prisoners to self-report such activities for fear of further surveillance, sanctions and punishment. The methodological problems also create ethical issues for researchers in terms of compromising individual prisoner confidentiality and anonymity by exposing drug use patterns in individual prisons, particularly in small jurisdictions. For example, Codd, Mehegan, Kelleher, and Drummond (2016, this issue) found that drug use is a significant problem among Irish prisoners, but only in particular prisons. If characteristics of the prisons and prisoners were used to describe drug use, their research carried the risk of exposing the identities of individual prisoners. Therefore, they employed hierarchical cluster analysis as a system to categorise prisons by drug use patterns of inmates and to facilitate tailored planning of service provision, without compromising individual prisoner confidentiality or anonymity.

Prisons are high-risk environments for initiation into drug use or for starting to use drugs again after a period of abstinence, for more unsafe forms of drug using behaviour, and for transmission of HIV and other blood-borne infection; the rates of HIV and Hepatitis C infection are significantly higher among prisoners than the general population (Indig et al., 2010; Strang et al., 2006; Stöver & Weilandt, 2007). In particular, prisoners have much higher rates of reported experience of heroin use compared with the general population (Butler, Lim, & Callendar, 2011; EMCDDA, 2012; Ministry of Justice, 2010). However, upon entry into prison, heroin users may switch opiates as a result of changes in availability within the prison setting. For example, Mohammed, Hughes, Hearty, and Wright (2016, this issue) highlight the problem of prisoners switching to using prescribed buprenorphine intra-nasally in British prisons. As a result, buprenorphine-naloxone increasingly has been used as a treatment for opiate maintenance. The authors explore the experiences and perceptions of the effects of intranasal misuse of buprenorphine-naloxone within a prison setting and the implications for policy and practice.

Prisoners who continue to inject in prison often do so in a more high-risk fashion by sharing syringes which increases the risk of infection (AIHW, 2013; Kerr, Wood, Betteridge, Lines, & Jurgens, 2004). For these reasons, it is of utmost importance to implement effective harm reduction strategies in prisons (Duke, 2011). This has been recognised since 1991 by the World Health Organisation (WHO) when it recommended the provision of sterile injecting equipment in prisons (WHO, 2004). However, as argued by Stöver and Hariga (2016, this issue), harm reduction, and especially needle exchange programmes, are still highly controversial in prisons even after 25 years of implementation and evidence of their efficacy. Moreover, as outlined in Moazen et al.’s study (2016, this issue), which focuses on Iran (a country with experience of needle exchange programmes in prisons), there are still obstacles to the provision of harm reduction strategies in prisons as expressed by the views of prison managers and health staff, many of whom are rather ambivalent towards needle exchange programmes.

In relation to the social, health and demographic characteristics of drug users in prisons, they also fare worse off than the general population. Drug using prisoners have generally experienced deprivation, low educational achievement, unemployment and problems with stable housing (EMCDDA, 2012). The complex needs of prisoners accessing drug and alcohol services in English prisons is elaborated on by McKeganey et al. (2016, this issue). They describe the characteristics of prisoners entering enhanced drug and alcohol treatment within the newly established Drug Recovery Wings in England and Wales. Their analyses reveal that the group had wide ranging needs in relation to their substance use, mental health, attitudes to criminality and motivations for treatment. Their recovery from problematic drug and alcohol use and desistance from crime requires not only effective drug and alcohol treatment services, but also a wide range of support and interventions to tackle their complex needs both in prison and on release in the community (see also: Neale et al., 2015).

Prisoners suffer poor physical and mental health, including infectious diseases such as HIV/AIDS, Hepatitis C and B, and psychiatric co-morbidity such as personality and post-traumatic stress disorders and psychosis (WHO, 2014). Risk of suicide in prison may be particularly high for prisoners with drug problems (Fazel, Grann, Kling, & Hawton, 2011). There are also high rates of problem drinking and smoking within prison populations (AIHW, 2013; CASA, 2010; Ministry of Health, 2006). Research also indicates high rates of drug-related deaths, particularly opioid overdoses, on release from prison (Farrell & Marsden, 2008). Finally, women prisoners are more likely to have serious drug-related health problems (Fazel et al., 2006) and infectious disease than men (UNODC, 2008). Responding to such drug-related issues has become an important public health priority in prisons throughout the world. For example, in the most recent EU Drug Strategy and Action Plan for 2013–2020, a key action is to “scale up the development, availability and coverage of health care measures for drug users in prison and after release with the aim of achieving a quality of care equivalent to that provided in the community” (European Commission, 2012, C402/4, para 19.6). However, as demonstrated by Zurhold and Stöver (2016) in this issue, in a survey of 27 European countries, improvements in the quality, availability and access to health care are still necessary in order to make evidence-based drug treatment and harm reduction available in the prison setting and to ensure access to these services to all prisoners in need of them (see also Michel et al., 2015).

Compared with the extensive research on prevalence and patterns of drug use in prisons, qualitative research exploring the meanings and motives of drug use in prison settings have been less prominent (Mjåland, 2016, this issue). Explanations of prisoners’ drug use in prisons have shown how it can be understood as a response to the “pains of imprisonment” (Sykes, 1958) encountered by the prisoners, such as boredom, violence, deprivation of personal autonomy and denial of important social relations. Drugs like heroin and cannabis are preferred due to their sedative and analgesic effects to relieve stress, to facilitate sleep, to deal with the boredom of “doing time” and ultimately to relieve pains of imprisonment (Boys et al., 2002; Cope, 2003; Kolind, 2015; Ritter, Broers, & Elger, 2013). In this way, drug use is analysed as a way of coping or as self-medication. However, as Kolind et al. (2016) show in this Issue, drugs take on a range of different overlapping meanings highly influenced by the different institutional arrangements of the prison; and drugs as medicine (including drugs used for self-medication) is one of them. Moreover, drugs also take on meaning as illegal substances and as a constrainer of desirable self-development in drug therapy and treatment. The authors also argue that the different practices and rationalisations attached to drugs in prison inform different prisoner subjectivities: the criminal subject of illegal drug use, the sick subject of therapeutic drug use, and the subject of self-improvement enacted through drug treatment.

Prison drug use, nonetheless, is not merely part of individual prisoners’ coping strategies. It also has to be understood in light of the everyday social lives within prison: the prisoner culture, social networks, economics, cultural capital and so on (Wheatley, 2007, pp. 403–406). Crewe (2005, 2006), for instance, has shown that drug use and dealing tend to accentuate existing inequalities in prisons between powerful and more vulnerable prisoners, and also contribute to the prison becoming a low trust environment. Although less antagonistic cultures of (drug) sharing within prisons have also been documented (Mjåland, 2014; see also: Sandøy, 2015). Drug supply and dealing in prisons are therefore understood as more than simply economic activities. Drug selling is also strongly bound up with masculinity, self-identity, and internal hierarchies, and thus plays a role in creating important social and personal interactions in the prison. Tompkins (2016) in this Issue identifies two systems of drug selling in prison: Established Enterprises and Separate Suppliers. The first is organised and related to drug sellers and gang structures outside prisons whereas the second is more spontaneous, individual and opportunistic, and an increasing range of prisoners have taken up this route/strategy. Especially for the Separate Suppliers, drug dealing is used in order to enhance the dealers’ status and symbolic capital (i.e. by being able to bring drugs into prisons, making connections to outside drug and criminal networks, and displaying courage) and the feeling among prisoners that they are part of a larger social network. This is also in line with Mjåland’s (2016) findings in this Issue. Similarly, he found that prisoners who distributed and also shared drugs could earn respect. In addition, drug trafficking could also carry subversive meanings for prisoners in a highly controlled and stigmatised environment. In fact, he found vibrant drug subcultures existing among prisoners who participated in the drug rehabilitation programmes under study. In sum, drugs in the prison market are a profitable commodity (either economically or in terms of symbolic capital) with a powerful influence on the prison environment.

Criminal justice systems and prison settings differ markedly from country to country. Commentators have for instance raised concerns about mass incarceration in countries such as the USA or Russia, or highlighted assumable lenient penal practices related to “Scandinavian exceptionalism” (Pratt, 2008). Despite such differences, most governments around the world have responded to the growing presence of drugs and drugs problems in prisons with increased control and sanctions. These policy developments in prisons are often influenced by the general thrust of wider national drugs and criminal justice policy and practice frameworks. As Mazhnaya et al. (2016) show, in this Issue, national drug policy and law enforcement practice in the Ukraine clearly influence the cycles of imprisonment-release-imprisonment among people who use drugs. After prison-release, the confluence of police surveillance and societal stress contributed to Mazhnaya et al.’s research participants’ drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Especially important in this respect is to understand how law enforcement policies and practices contribute to the low rates of utilisation of opioid agonist therapies in the Ukraine. Fear of police and arrest contributes to avoiding opioid agonist therapies since system-level requirements identify clients accessing these treatments as targets for police harassment (see also: Bojko et al., 2015).

Other countries, however, have also increasingly implemented successful drug treatment and health programmes in prisons. For example, Elison, Weston, Davies, Dugdale, and Ward (2016, this issue) report on the positive potential of the Breaking Free Online programme in supporting prisoners to begin the process of recovery from substance use in prison settings. Although the authors conclude that recovery may only be optimal if the appropriate support around issues, such as accommodation and employment, is provided upon release to the community. However, what we have also seen in many countries is a dual prison drug policy: increased control and increased drug treatment (Duke, 2003). In political discourse such dual policy is at times presented as beneficial and mutually supportive (Kolind, Frank, Lindberg, & Tourunen, 2013). In particular, it is argued that increased control will force drug users to enter into drug rehabilitation programmes, and conversely, that such programmes can help fulfil the political aims of zero tolerance towards drugs. In this way, prison drug policy is to be seen as a clear product of its time (Garland, 2001a).

In a study of the recent “criminal justice turn” in British drug policy (i.e. away from former penal-welfare thinking and the focus on rehabilitation (Garland, 2001b)), Seddon, Williams, and Ralphs (2012) among others argue that this development relates to a more general societal shift characterised by a preoccupation with risk and security influenced by the neo-liberal principles of efficient management of welfare services. Increasingly, drug problems, as well as social problems more generally, are understood, tackled as well as produced within this framework of risk and risk management (see also: Bullock, 2011) and a criminalisation of drug problems and policy (Duke, 2006). However, as suggested by Hardy (2013) and by the various articles in this Special Issue it may be more correct to see the prison as being in a state of flux, characterised not by a wholesale rejection of the penal-welfare ideal, but by a mixture of welfare, risk and security. Rarely, however, is the mass incarceration of people who use drugs in itself questioned in official policy; neither ethically nor as being an effective strategy to reduce drug-related harms in prisons and society. It is clear that drugs and drug use will endure both in prisons and the community, so perhaps the best strategy is to simply reduce the number of drug users sentenced to prisons.