The Public Health Dangers of Drug Abuse in Prisons
Ian Oliver

Abstract:

Globally, many prisons are failing to ensure adequate policies to deal with health, sexual behaviour and the use of illicit drugs by prisoners with the result that they are little more than incubators for serious diseases such as AIDS/HIV and Hepatitis C. It seems that the individual human rights of prisoners are outweighing the public health interests of the wider communities, and the misuse of harm reduction policies in some prisons gives rise to profound concern and raises the question of State approved drug abuse. This in turn begs the question of whether a policy of zero tolerance of drugs in prisons is possible or desirable and what are the long-term consequences of failing to deal with this problem.

The widespread availability of dangerous drugs within the prison systems globally has been common knowledge for many years as has the fact that serious diseases are present at a much higher rate within many gaols than is common in communities. A report issued by The Prison Reform Trust in collaboration with The National AIDS Trust in the UK has drawn attention to some disquieting figures (1). The report has indicated that many UK prisons are failing effectively to provide adequate healthcare for prisoners with hepatitis C and HIV. Over half the prisons in England and Wales were reported to have no sexual health policy despite the fact that hepatitis C levels were 20 times higher than the rate in the general public, and 9% of male inmates and 11% of females were infected. HIV rates in male prisoners were 15 times higher than those of men not in jail. The study found “inconsistent and often sub-standard healthcare” in our prisons, combined with overcrowding and frequent movement of prisoners which contributes to the potential for the spread of the diseases both within and outside the prison system. In other words, UK policy has allowed our prisons to become incubators for infection and the spread of diseases at great risk to the health of the general public, staff and individual prisoners (2). According to figures provided by the Scottish Prison Service for the Chief Inspector of Prison’s Report 2006, 80% of inmates had drug related problems.

 This pattern is reported to be replicated in many prisons globally to a greater or lesser degree, and the World Health Organisation (WHO) has classified AIDS/HIV and Hepatitis C as global pandemics which, in the case of AIDS/HIV, are outpacing our ability to address the problem (3). In a joint paper issued by WHO, the UN Office on Drugs and Crime (UNODC) and UNAIDS, the problem was described:

The rates of HIV infection among inmates of prisons and other detention centres in many countries are significantly higher than those in the general population. Examples include countries in Western and Eastern Europe, Africa, Latin America and Asia. The available data on HIV infection rates in prisons cover inmates who were infected outside the institutions before imprisonment and persons who were infected inside the institutions through the sharing of contaminated injection equipment or through unprotected sex. Certain populations, that are highly vulnerable to HIV infection, have a heightened probability of incarceration because of their involvement in behaviours such as drug use and sex work (4).

Professional Concern about Prison Health Problems
Recently, the British Medical Association (BMA) has drawn attention to the problems in UK prisons. At a conference the BMA asserted that these problems are caused by “incoherent government policy and inadequate funding,” resulting in a crisis that threatens to overwhelm the prison health care system. The Association called for “…an investigation into the health of the prison population and the implementation of well funded, coherent strategies to combat the most serious medical conditions identified. Mental health disorders, drug dependence and the after affects of alcoholism remain endemic problems in the UK’s prisons while the threat posed by sexually transmitted diseases continues to be unquantifiable owing to a lack of research. Urgent action is required to provide prison doctors with the knowledge and tools to arrest the drastic state of prison health” (5). It was also been asserted by some BMA members that cuts in National Health Service budgets will lead inevitably to a diminution in health care services in UK prisons.

This problem has been apparent for a number of years; but surprisingly, while officials concede that there is a major difficulty about this particularly dangerous issue, it does not appear to have resulted in significant concern either with politicians or the general public who ultimately are at great risk from the increased likelihood of the spread of such potentially life-threatening diseases when those incarcerated are released.
The UK has the highest rate of drug use in Western Europe, combined with a significant and increasing rate of the spread of both blood borne and sexually transmitted diseases, but there is no widespread concern about this. There is also a paucity of high profile public health education information to combat this proliferation. Hepatitis C is already the highest cause of demand for liver transplants in the UK. In fact, there is a great deal of public ignorance about the nature of these diseases and the ways in which they may be transmitted to others.

Pandemic Diseases
During the mid years of the 1980s, Edinburgh was dubbed the AIDS capital of Europe, but it was widely believed that AIDS/HIV was essentially a sub-Saharan African problem that had little bearing on the UK. That thinking is still prevalent despite indications that within three years the problem in Russia and many of the former Soviet Republics (now within greater Europe), Central Asia and the Indian Sub-Continent will outpace the problem which is out of control in Africa. There is too a major problem arising in China and the Far East (6). The Annual Report of the International Narcotics Control Board (INCB) for 2006 has drawn attention to the fact that countries such as Latvia, Estonia and Lithuania are doing little to control the spread of blood borne and sexually transmitted diseases. These countries have problems in their prisons, and once infected prisoners are released, the diseases are likely to spread very quickly into the heterosexual community, with women being particularly vulnerable. With freedom and frequency of travel at relatively low prices throughout Europe and internationally, the dangers of the rapid spread of infections are obvious.

Unsafe Practices
Much has been written about drugs in prisons and the ways in which infections are spread through unsafe sexual practices, the sharing of drug taking equipment (particularly dirty needles), razors and the practice of amateur tattooing that is common amongst prisoners. There is also a strong culture amongst some drug dependent people, particularly in prisons, around sharing drugs and the paraphernalia associated with abuse. These all pose risks for prisoners, staff and the wider community once prisoners are released. However, despite guidelines of good practice having been issued by UNODC, the most recent of which was published in 2006 (7), there does not appear to have been much progress in addressing and reducing the problem, certainly not in the UK. Many other countries have yet to implement comprehensive HIV prevention programmes in prisons or to achieve a standard of prison health care equivalent to the standard outside of prison, thereby jeopardizing the health of prisoners, prison staff and the wider community.

UNODC Framework Document
The UNODC document was issued in recognition of a global problem and as a framework to assist nations to meet their international obligations with regard to human rights, prison conditions and public health. It contains eleven General Principles for HIV/AIDS prevention and care in prisons. These principles provide clear recommendations for developing and implementing an effective response to HIV/AIDS in prisons. These principles are embodied in the following paragraph:

Like all persons, prisoners are entitled to enjoy the highest attainable standard of health. This right is guaranteed under international law in Article 25 of the United Nations Universal Declaration of Human Rights and Article 12 of the International Covenant on Economic, Social, and Cultural Rights. Furthermore, the international community has generally accepted that prisoners retain all rights that are not taken away as a fact of incarceration, including the right to the highest attainable standard of physical and mental health. Loss of liberty alone is the punishment, not the deprivation of fundamental human rights. States therefore have an obligation to implement legislation, policies, and programmes consistent with international human rights norms, and to ensure that prisoners are provided a standard of health care equivalent to that available in the outside community.

In addition to the Guiding Principles, the Framework details 100 specific actions in nine separate areas including political initiatives, legislation, adequate funding, health standards and continuity of care and education, staff training, evidence based practice and international, national and regional co-operation.

Ideally, this means that all prisoners would receive the same standard of care that they would expect to receive as members of the general public from properly trained and competent staff who have the necessary resources and experience to address their health problems. Unfortunately, the reality is frequently much different from the ideal, and many prisons come nowhere near achieving these standards. Too often the situation is one of 23 hour lock-ups, severe overcrowding resulting in shared cells, inadequacy of appropriately trained staff and all too frequently, some staff who are prepared to supply prisoners with illicit substances (8). There is too the problem that the availability of adequate and appropriate treatment for those suffering from drug dependence in the outside communities falls well short of that which is desirable. This is sometimes compounded by the fact that a lack of awareness means that many who are infected with diseases such as Hepatitis C and HIV are unaware that they have a problem until they have blood tests.

Harm Reduction
A major concern arises from the ways in which some regimes have addressed the problem. So called harm reduction methods, including the supply of syringes and needles, have been introduced or are being considered in some prisons; in 2001 there were 20 prisons in Europe reported to have introduced some or all of the measures mentioned below:

Reducing harm associated with transmission of infections
The principle of equivalence suggests that a range of harm reduction measures might be put in place in prisons, similar to those provided in the community. Measures in the community include confidential testing with pre- and post-test counselling, effective treatment, public information campaigns, personal information and counselling, group education on safer drug use and safer sex, peer education and peer led initiatives, vaccination against those viruses where such vaccines are available and approved (e.g. Hepatitis B), advice on using bleach or other disinfecting methods to clean needles and syringes, the provision of sterile needles and syringes, and the provision of condoms (9).
 

The rationale associated with the recommendation of harm reduction measures in the report is:

• The prevention of the transmission of infections, such as HIV and hepatitis;
• the effects on health of violence, coercion and sexual abuse which are associated with the way in which drugs are supplied and paid for in prisons; a particular risk in this regard is the transmission of sexually transmitted infections;
• the risk of overdose;
• the risk of using contaminated drugs;
• the risk of side effects from misused substances.

State Approved Drug Consumption
Many current practices in prisons give rise to concern about regimes that tolerate what is, in effect, state approved drug taking. Some see this as perpetuating the associated problems without in any way diminishing the ultimate risks. Many have argued that to tolerate drug abuse in prisons is ultimately posing the great risk of the extensive spread of diseases once prisoners are released, when the responsibility of both the State and the prison authorities should be the control and reduction of drug use in the interests of the prisoners and society. It could be argued that in an ideal world, prisons should be places where detoxification and rehabilitation are achieved, and those prisoners who have dependency problems should be subjected to indeterminate sentences without release until abstinence has been achieved. The reality in the majority of prisons seems to be hugely different with human rights considerations apparently outweighing public health concerns.

If pragmatism and reality make it necessary to follow policies which are less than ideal, then it is argued that the least that should be demanded is that those policies and procedures be carried out under the strictest good practice with adequately qualified staff exercising supervision and treatment in ways that are best calculated to reduce the harm associated with drug abuse. At the same time the prison authorities should be striving to achieve abstinence and the eradication of illicit drugs from prisons.

Prisoners need counselling, education and support and a guarantee that this will be available on a continuing basis after they have been released. This situation does not prevail in the UK, and the reality, according to research published by The Prison Reform Trust (HIV and hepatitis in UK prisons: 2005 A report by the Prison Reform Trust and the National AIDS Trust), is that prisons are failing to provide adequate healthcare for drug using prisoners, with overcrowded conditions, frequent transfers between prison establishments without similar policies and a failure to ensure post release supervision and treatment. A trawl of the UNODC literature has indicated that similar conditions prevail in too many prison establishments globally.

Is Zero Tolerance Practicable?
In Scotland, one of the political parties has called for a policy of zero tolerance of drugs within prisons and has demanded that prison conditions be changed to diminish the possibility that drugs may be transferred during prison visits (10). There has also been criticism of harm reduction policies that accept drug abusing behaviour without in any way attempting to change this such as methadone maintenance rather than treatment aimed at ultimate abstention; the distribution of bleach tablets (of doubtful efficacy) and the proposed handout of needles without any attempt to measure the result of this practice.

Discussions with the persons responsible for drug policy in Scottish prisons left the distinct impression that problems related to drug abuse in these institutions are more to do with a lack of finance, resources and trained personnel than a determination to achieve absence of drugs within prison. There was acknowledgment that for many years prisons have been incubators for disease, and the proposed introduction of harm reduction policies allowing needle distribution, etc., seems to be an attempt to “keep the lid” on prisons rather than a professional and meaningful compliance with best practice. When asked about adopting serious measures to prevent drugs being brought into prisons either by the prisoners themselves, staff or prison visitors, there was an absolute refusal to change existing procedures that might achieve this.

20 Year Prognosis of Addiction
Research by Professor Neil McKeganey at Glasgow University has indicated that if present anti-drug policies are continued, then it is likely that within 20 years the UK will be confronted with the problem of at least one million addicts. It can also be assumed that if there is no change in the approach to the problem of drug abuse within UK prisons, the pandemic presence of blood borne disease will increase significantly at great risk to public health.

In order to combat this problem, it is apparent that:

• much greater political awareness and attention to the problem must occur, combined with a determination to eradicate drug abuse within prisons and eliminate the increasing risk to public health;
• there should be continuous high profile public health awareness education;
• prison conditions and policies must be improved by adequate funding, appropriate sentencing policies to deal with problems of overcrowding and the recruitment and training of sufficiently well trained and motivated staff;
• Any health policy within prisons must only be endorsed once it has been validated by empirical research;
• All future prisons must be designed to take account of these needs and existing problems.

A major consideration in the UNODC document is the necessity to comply with legislation protecting the human rights of prisoners:

Respect for human rights and international law

Respecting the rights of those at risk of or living with HIV/AIDS is good public health policy and good human rights practice. Therefore States have an obligation to develop and implement prison legislation, policies, and programmes consistent with international human rights norms.

However, critics raise the question of the human rights of the greater community to be protected, as far as possible, from the spread of potentially fatal diseases exacerbated by government prison policies. This raises the question: Should the protection of the wider community be more important than the human rights of prisoners which, under present interpretation, tolerate illegal practices in prisons that ultimately will have a seriously detrimental impact on public health?

The proposals for issuing needles in prisons in Scotland were described as making syringes and needles available to prisoners as “it is not an offence to inject yourself”. There was no proposal that prisoners addicted to drugs would be provided with officially issued substances and would then inject under medical supervision as a form of treatment, merely an assumption that they would be injecting substances that are both illegal and which have been brought into prisons illegally. At best this is harm reduction of the most questionable type, and at worst it is allowing prisons to be used for the ingestion of Class A drugs which is not medical treatment so much as the toleration of illegal conduct. Such behaviour could result in prosecutions if this were done in premises outside prisons. This in turn begs the question that if prisons are tolerating illegal behaviour by failing to eliminate drugs, why should the State provide prisoners with the paraphernalia to enable dangerous practices which could result in harm to the prisoner and ultimately the spread of blood borne diseases in the community after prisoner release?

The Aims and Objectives of Drug Policy
The primary object of any drug policy should be the elimination of drugs from prisons by attempting to prevent drugs entering prisons by any means. In a properly administered regime this should be achieved by:

• Preventing prisoners from bringing drugs into prison after conviction by swallowing condoms full of illicit substances - for example, heroin or cocaine. This would necessitate those prisoners suspected of being ‘swallowers’ being isolated immediately after confinement until the drug filled condoms pass through their system.
• Preventing visitors from bringing drugs into prisons either by making visits take place between screens without human contact or by selective searching and the use of drug sniffer dogs as the visitors enter prison premises. Where a transfer is suspected, then the prisoner could be searched immediately after visits.
• Preventing the possibility of staff bringing drugs into prisons by the requirement of staff contractually agreeing to submit to searches and other appropriate anti-drug measures.
• Preventing outsiders from throwing drugs into prisons by constant patrolling and searching of unusual objects in the internal perimeters. There have been reports of many different ways of throwing drugs into prisons in such things as tennis balls or even inside dead birds. A ‘cordon sanitaire’ could be introduced around prisons to prevent prisoners having access to thrown objects.
• Where it is judged a medical necessity that prisoners be prescribed drugs that must be injected, then this should be done by a suitably qualified member of staff and at no time should prisoners be allowed to be in possession of syringes and needles. The reasons for this include the risk of the culture of sharing needles and that the needles may be used as weapons or threats against other prisoners or prison staff. Needless to say, this activity is labour intensive, but appropriate numbers of qualified staff should be recruited to overcome existing problems in prisons.

It should also be possible to provide drug-free wings for those prisoners who do not wish to be involved with drugs and to provide isolation of known drug users until such time as they become committed to a drug-free prison life and a desire to become ‘clean’.

Conclusion
Prisons are the last places where authorities should tolerate drug abuse, and most certainly any pseudo harm reduction initiatives should be taboo for the reasons stated above.

Without such commitment to preventing both drug use in prisons and the major public health risks associated with this, then the Prison Authorities should be held liable for the damage caused to anyone afflicted by diseases spread by released prisoners. Clearly, the debate must occur that considers whose human rights take preference and the conflict between inappropriate (or pseudo) harm reduction policies and human rights.

It is recommended that the UNODC and policy makers should step back from the notion that it may be acceptable for prisoners to have syringes, bleach tablets or any other equipment that may facilitate or encourage drug abuse by prisoners and should recommend to all governments that legislation be introduced designed to achieve abstinence and rehabilitation for all persons in custody and prohibiting any distribution of drug abusing equipment.

Dr. Ian Oliver was a police officer in the UK in 4 different forces, including the London Metropolitan Police, for 37 years. During the last 8 years he has been an independent consultant for UNODC and has worked in over 20 countries. He is a member of expert groups and the author of Drug Affliction: What you need to know, published in 2006 by The Robert Gordon University, Aberdeen, Scotland, and available at www.amazon.co.uk.

References

1. The Prison Reform Trust. Prisons failing on HIV and Hepatitis C. Nov 2005.

2. Oliver, Ian. Drug Affliction. Robert Gordon University: 2006.

3. The Lancet Infectious Diseases 2007; 7:1 DOI:10.1016/S1473-3099(06)70662-4.

4. Evidence for Action on HIV/AIDS and injecting drug use. Policy Brief: Reduction of HIV Transmission in Prisons. WHO/HIV/2004.05.

5. BMA Press Release 8.02.07.

6. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006 report on the     global AIDS epidemic.Geneva, Switzerland:UNAIDS; 2006. Available: http://www.unaids.org/en/hiv_data/2006globalreport/default.asp.

7. HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings. Oct 2006.

8. See for example Report of Professor Neil McKeganey, director of Glasgow University's Centre for Drug Misuse Research in Scotland on Sunday 11.02.07 and various reports from police and HM Inspector of Prisons in UK.

9. Report on conference “Prison, Drugs and Society.” WHO and The Pompidou Group of The Council of Europe. Switzerland 2001.

10. Annabelle Goldie (Leader of the Scottish Conservative Party). BBC news 3.12.2006.