Drug Abuse

RESPONDING TO AIDS AND DRUG USE IN PRISONS IN CANADA

Ralf Jurgen, Canadian HIV/AIDS Legal Network, Canadian AIDS Society & Interagency Coalition on AIDS and Development and Diane Riley, Canadian Foundation for Drug Policy & International Harm Reduction Association

HIV/AIDS and drug use in prisons is seen as a priority concern by the Canadian AIDS and harm-reduction movements. Two reports, both of which have been distributed in more than 2000 copies and have attracted longterm national media attention, have been instrumental in keeping issues raised by HIV/AIDS and drug use in prisons high on political agendas across the country. However, other factors have been equally important: community acti . V1 . s m, research, the involvement of the federal ministry of health, and legal action undertaken by prisoners. Taken together, these factors have made some positive developments in the area of HIV/AIDS and drug use in prisons possible: condoms and bleach are being made available in an increasing number of prison systems; in two provinces, methadone treatment is available to some inmates; and there is some hope that a needle-exchange programme will be piloted in at teast one prison. Nevertheless, much remains to be done. Reducing drug-related harm in society means reducing such harm in prisons too, and in that regard there has so far been only limited success.

'The impression is often given that prisons are a separate world. In fact, of course, the opposite is true: prisons experience the problems experienced outside as well as their own unique problems, and there is a constant flow of people between prisons and the general population.' (Riley, 1994)

'A sentence of imprisonment should not carry with it a sentence of AIDS.' (Note, 1988)

INTRODUCTION

Issues raised by HIV/AIDS and drug use inprisons are of great concern among Canadian prisoners, prison authorities and the public. These issues provoke a great deal of media attention, community discussion and political debate.

HIV/AIDS and drug use in prisons is seen as a priority concern by the Canadian AIDS and harmreduction movements and is high on political agendas across the country. This is the result of many factors including: the creation of a national Expert Committee on AIDS and Prisons (ECAP); a 1996 report by the Canadian HIV/AIDS Legal Network (Network) and the Canadian AIDS Society (CAS), which concluded that prison systems have a moral, but also a legal, responsibility to act without further delay to prevent the spread of infectious diseases among inmates and to staff and the public, and to care for inmates living with HIV and other infections; community activism; research that has provided evidence of the prevalence of HIV and of drug use in Canadian prisons; the active involvement of the Federal Ministry of Health (Health Canada) in issues relating to HIV/AIDS and drug use in federal prisons; and legal action undertaken by prisoners.

HIV/AIDS AND DRUG USE IN CANADIAN PRISONS: OVERVIEW

HIV/AIDS and Hepatitis C seroprevalence
Seroprevalence studies undertaken in federal and provincial prisons have shown rates ofHIV infection between IX, and 7.7% (Correctional Service of Canada, 1994a,jorgens, 1996, appendix 2).Infederat prisons, the number of inmates known to he HIVpositive has increased at an alarming rate: injanuary 1991, 27 inmates were known to he HIV-posit--ive, while in March 1996,159 inmates (more than I % of the total inmate population of 14, 100) were known to be HIVpositive (CSC, 1996a).

Hepatitis C seroprevalence rates are even higher: studies have revealed rates of 28- 40% (Ford et at., 1995; Pearson et al., 1995; Prefontaine and Chaudhary, 1990; Prefontaine et al., 1994). Transmission of hepatitis C has been documented in at least one prison (Jorgens, 1996).

Drug Use
More and more data are becoming available on the prevalence of drug use in Canadian prisons. A total of 54% offecleral inmates have beenclassified as h.aving a serious substance misuse problem (Riley, 1994) and the Parliamentary Ad Hoc Committee on AIDS heard evidence that up to 50% of inmates may use drugs (1990). In a 1995 survey, 40% of 4285 federal inmates self-reported having used drugs since arriving in their current institution (CSC, 1996bc).

Injection-drug use is also prevalent in prisons, and the scarcity of needles often leads to needle sharing. Members of the Expert Committee on AIDS and Prisons were often told by inmates that injection-drug use and needle sharing are frequent and thatsometimes 15 to 20 people will use one needle without cleaning it. Staff of the CSC acknowledge that drug use is a reality in prisons, saying that'drugs are part of prison culture and reality', that 'drug use is widespread in institutions', that'there does not seem to be a way to ensure that there will be no use of drugs' and that there are many needles in the prisons'(CSC, 1994a,b). The following are accounts of the personal expeiences of two prisoners in a federal institution (peronal communication, received on 4 March 1994):

Mr P is a 43-year-old male serving life. He has served 20 years of his sentence. He started using injectable drugs after he was incarcerat, ed; this was his method of dealing with his loneliness. Mr P states his early experiences were with anyone willing to share a hit. After watching one of his peers die of AIDS two years ago, Mr P has his own rig (which is seven years old) and he shares it with no one.

Mr S is a 37-year-old male serving nine years for drugrelated crimes. Mr S does not use injectable drugs but has found a market for his 13 rigs inside the institution. Mr S rents out his needles for one hour at a time for three to five packages of cigarettes. Three packages of cigarettes rents a needle older than two years. Five packages of cigarettes rents a needle less than two years old. Mr S has needles that are less than six months old but they go strictly for cash or stamps valued at $50-100 depending on the demand. All his needles are cleaned with bleach (when he can steal it) or toilet bowl cleaner (if he has no bleach).

Such anecdotal evidence of the existence and extent f drug use in prisons is confirmed by scientific studes (for a comprehensive overview, see J Urgens, 996). A study of HIV transmission among injecion-drug users in Toronto found that'over 80% [of he participating injection drug users] had been in ail overnight or longer since beginning to inject rugs, with 25% of those sharing injecting equipnent while in custody' (Millson, 1991).

In another study, 11% of federal inmates selfeported having injected drugs since coming to their urrent institution; of these, only 57% thought the quipment they used was clean, whereas 17% hought that it was not clean and the rest did not now (CSC, 1996bc). In one institution in western lanada, 7 1 % of inmates responding to a questionaire reported having used intravenous drugs. Of these, 12% reported drug use only in prison; 20% only on the street; and 68% reported having used drugs both inside and outside prison. A total of 89% admitted having shared a needle at least once: 19% reporting having shared on the street; 23% inprison; and 47% both in prison and outside (JUrgens, 1996). These data should not come as a surprise. In Canada, as elsewhere, many inmates use drugs as a part of their lifestyle. There are many reasons for this:

· Worldwide, the main response to drug use and drug dealing is criminalisation and imprisonment. The only countries that do not have significant drug problems in their prisons have the death penalty for both drug use and trafficking.

· Drug use and abuse are ways of dealing with boredom, anxiety and despair; just how many prisons are there that are able to promote stimulation, relaxation and hope in their inmates by natural means? Drug use as a means of altering consciousness is a universal phenomenon that has been documented since the beginnings of recorded history. To imagine that there would not be drug use in prisons would be to ignore facts about human nature as well as about the effects of drugs.

· Drug dealing provides high incomes, requires no equipment or training, and drugs can be easily passed on without detection. In a climate Of prohibition, drug costs are high and correctional officers and other staff can be offered high levels of pay for their assistance. The result is an economy that is almost perfect for the prison environment, especially since many of the participants have been involved in dealing before entering the institution.

Other High-risk Activities
Sexual activity is considered to be a less significant risk factor than the sharing of injection equipment. Nevertheless, it puts prisoners at risk of contracting HIV 6% of federal inmates self-reported having had sex with another inmate, but only 33% of these reported using condoms (CSC, 1996bc). A total of 45% of federal inmates reported having had a tattoo done in prison, and 17% reported having been pierced (CSC, 1996bc).

Evidence of HIV Transmission
Although studies undertaken in prisons in the USA (Mutter et al., 1994), Australia (Dolan et al., 1994; Dolan et al., 1996), Scotland (Taylor et al., 1994; Christie, 1995; Taylor et al., 1995) and other countries (Wright et al., 1994) have provided evidence that outbreaks of HIV infection can and will occur in prisons unless HIV prevention is taken seriously, there have thus far been no documented cases of HIV transmission in Canadian prisons. However, the only reason for this is the absence of research in this area: everyone knows that HIV transmission is occurring.

RESPONDING TO HIV/AIDS AND DRUG USE

Issues raised by HIV/AIDS and drug use in prisons have been extensively studied in Canada. As early as 1988, making condoms and bleach available to inmates was recommended.

The Expert Committee on AIDS and Prisons
Perhaps the most comprehensive analysis of the issues was undertaken by ECAP. The committee was created injune 1992 to assist the federal government in promoting and protecting the health of inmates and staff, and preventing the transmission of HIV and other infectious agents in federal correctional institutions.

ECAP interviewed prison authorities, staff and inmates; reviewed Canadian and international policies and reports relating to HIV/AIDS and drug use in prisons; sent questionnaires to prison staff and prisoners to obtain information regarding their concerns about HIV/AIDS and drug use; and released a Working Paper containing the Committee's preliminary conclusions in July 1993 (McGill Centre for Medicine, Ethics and Law, 1993).

In March 1994, the Committee's Final Report was released (CSC, 1994abc). The report takes a strong public health approach to HIV/AIDS in prisons, and a harm-reduction approach to drug use. It contains 88 recommendations, including recommendations to make full-strength household bleach available to inmates and to provide injection drug userswithaccess to methadone. In addition, the report concludes that sterile injection equipment will have to be made available in prison. The report emphasises that, 'as is the case outside prisons, efforts to prohibit drug use [in prisons] are costly and not always successful'. It points out that HIV will'spread relentlessly among injection drug users until they stop sharing their equipment or always clean it between uses'. According to the report, 'the only realistic option to successfully prevent infections is to encourage drug users to always use clean injection equipment and to provide them with the means to do so'.

In contrast, the report continues by saying:

Other alternatives with which to respond to this problem [drug use in prisons] appear unacceptable. Permitting drug use in penitentiaries in such a way that it can be done safely is unrealistic, given the legal prohibitions and public attitudes against drug use. On the other hand, allocating even greater resources to eradicating drug use is unlikely to be successful and would probably only drive drug users further underground and reinforce unsafe injecting practices. (CSC, 1994a).

The report emphasises that adoptic4i of a harmreduction approach to drug use in prisons 'should in no way be interpreted as condoning drug use', but rather'should be seen as discouraging unsafe injecting behaviour'. It concludes by pointing out that it will be essential to reduce the number of drug users who are incarcerated. Canada has one of the highest incarceration rates per capita in the world. This rate is particularly high for drug-related offences and second only to the USA. Many of the problems created by HIV and drug use in prisons could be reduced if alternatives to imprisonment, particularly in the context of drugrelated crimes, were developed and made available.

The Prison System's Response
The CSC accepted many of the recommendations made by ECAP, but announced that it would not make bleach available in all institutions, but initially only carry out a pilot project; would not provide methadone maintenance programmes; and finally, would not pilottest needle-exchange programmes in prisons.

Instead of accepting these recommendations, only a few months after the release of ECAP's report, the CSC announced a 'strategy to combat drugs in federal penitentiaries' that in many ways is inconsistent with ECAP's recommendations. Among other measures, the use of random urine testing for drug use has been increased 'substantially' in federal institutions; searches of visitors are undertaken more frequently; visitors attempting to bring drugs into institutions not only risk facing criminal charges, but may be barred from further visits; and a commitment has been made to offer inmates better access to drug treatment programmes. These measures, with the exception of better access to drug treatment programmes, have been criticised on the grounds that they are extremely costly, intrusive and, ultimately, may be ineffective and even counterproductive.

The Joint Project on Legal and Ethical Issues
As a result of the CSC's failure to implement ECAP's recommendations with regard to drug use, individuals and organisations consulted during phase one of a project on legal and ethical issues raised by HIV/AIDS, undertaken jointly by the Network and CAS, urged the two organisations to continue working on issues raised by HIV/AIDS and drug use in prisons. In particular, they suggested that the joint Network/CAS Project examine whether governments and the prison systems have a legal obligation to provide prisoners with the means that would allow them to protect themselves against contracting HIV and address the issue of the potential liability for not providing condoms, bleach and sterile needles and the resulting transmission of HIV in prisons.

In September 1996, the project published an extensive report that reviews the history of the response to HIV/AIDS in prisons, in Canada and internationally; presents relevant new developments in the area; examines the legal and moral obligations of prison systems; and makes recommendations for action. In particular, it urges Canadian federal and provincial prison systems to:

· adopt a more pragmatic approach to drug use, acknowledging that the idea of a drug-free prison is no more realistic than the idea of a drug-free societyandthat, because of HIV/AIDS, theycannot afford to continue focusing on the reduction of druguse as the primary objective of drugpolicy;

· acknowledge that making bleach, sterile needles and methadone programmes available to inmates does not mean condoning drug use, but is a necessary and pragmatic public health measure; and

· educate the Canadian public and decision-makers about the importance of implementing harmreduction measures in prisons (Jurgens, 1996).

The report points out that, in 1995-96, the CSC spent Can$1,200,000 for its urinalysts programme, Can$ 1,000,000 for other components of its Drug Strategy; but only Can$175,000 for its entire AIDS Programme.

It emphasises that urinalysis programmes are hardly a good use of scarce resources: such programmes cost more than appropriate public health responses to drug use, namely evaluated drug reduction and rehabilitation programmes in all prisons (Bird et al., 1995). Further, they are intrusive, requiring prisoners to urinate on command and in full sight of staff. And, finally, they are likely to have a negative impact on efforts to reduce the harms from drug use.

In theory, drug testing should reduce the amount of drug use in prisons because people should be dissuaded from using drugs through fear of aisciplinary action. However, the long-term effects on levels of drug use remain to be seen. According to inmates in Canadian federal prisons, the urinalysis programme may have led to a slight decrease in drug use: but according to a majority, the programme had 'no impact'on drug use among inmates (CSC, 1996bc). Importantly, even if urinalysis programmes did result in a decrease in drug use, this should not be overvalued. Reduction of drug use is an important goal, but reduction of the spread of HIV and other infections is more important:'The spread of HIV is a greater danger to individual and public health than injection drug use itself' (NAC-AIDS Working Group on HIV Infection and Injection Drug Use, 1994). In particular, there is a fear that, because of urine testing, inmates'drug use, rather than diminish, may shift from relatively harmless drugs that are detectable in urine for up to one month, to potentially more harmful drugs that have much shorter windows of detection. As a result, injection drug use may increase and, with it, the risk of HIV transmission and other harms from drug use (Riley, 1995; Kommission, 1995). Canadian prisoners confirm that this is happening (J Orgens, 1996):

We agree that urinalysis testing is encouraging some inmates to change their drug of choice from marijuana and hashish to harder drugs like cocaine and heroin because they are flushed out of your system faster, thus making random detection much harder. There is also a good portion of inmates that really do not care and will take their chances with random testing. In my opinion, this strategy is not reducing the amount of drugs in prison, instead it is increasing the amount of'hard'drugs available.

According to the report, the CSC's 'drug strategy and, in particular, the urinalysis programme are expressions of an outdated war-on-drugs approach to drug use which, because of the advent of HIV/AIDS, cannot be rationally justified: it fails to focus on the harms from drug use rather than drug use itself. The costs of this approach are high, its benefits unproven.

In addition, the report reviews Canadian and international law and argues that prison systems are failing to meet their legal and moral responsibility, because they are clearly not doing all they could to protect the health of inmates: measures that have been successfully undertaken outside prison with government funding and support, such as making sterile injection equipment and methadone maintenance available to injection-drug users, are not being undertaken in the vast majority of prisons, although some prisons have shown that they can be introduced successfully, and receive support from prisoners, staff, prison administrations, politicians and the public.

The report concludes by stating that 'prisoners, even though they live behind the walls of a prison, are still part of our communities and deserve the same level ofcare and protection that people outside prison get: they are sentenced to prison, not to be infected'.

We owe it to the prisoners, and we owe it to the community, to protect prisoners from infection in prison. Unless we do so, courts or a commission of enquiry may one day have to explore why not enough was done to prevent HIV infection in prisons, although everyone was aware of the risks and knew the measures that could he taken to reduce them. (jurgens, 1996)

Other Developments
The 1992 and 1996 reports, both of which have been distributed in more than 2000 copies and have attracted long-term national media attention, have been instrumental in keeping issues raised by HIV/AIDS and drug use in prisons high on political agendas across the country. However, other factors have been equally important: community activism, research, Health Canada's involvement, and legal action undertaken by prisoners.

Community Activism
In 1992, the Toronto-based Prisoners with HIV/AIDS Support Action Network (PASAN) released a brief advocating a comprehensive harmreduction strategy in Canadian prisons (PASAN, 1992). ECAP's creation is due, at least in part, to this brief and PASAN's pressure on the federal and provincial governments. In addition, rVCAP did not have to reinvent the wheel: many of its recommendations were not new, but had already been made in PASAN's brief. Ever since, advocacy efforts undertaken by PASAN, other HIV/AIDS and prisonerrights organisations and, importantly, by prisoners themselves have greatly assisted efforts to reduce the harms from drug use in prisons.

Research
Research undertaken in Canadian federal and provincial prisons has provided evidence that levels of HIV infection in prisons are at least 10 times high, er than in the general population; that hepatitis C seroprevalence rates are very high; that risk behaviours are prevalent in Canadian prisons; and that, once implemented, harmreduction measures are supported by inmates and prison staff. Acknowledging the importance of research, the 1996 report recommended that:

In order to monitor the evolution of the epidemics of HIV and hepatitis in Canadian prisons, and to evaluate and improve existing and future initiatives, research should be encouraged and funded by provincial and federal prison systems and health ministries. This research should provide information about seroprevalence, risk behaviours and transmission of infections in prison, and help to improve necessary interventions to prevent the further spread of infectious diseases, and to care for infected prisoners.

Health Canada Involvement
Since the early 1990s, Health Canada has taken an active role in issues relating to HIV/AIDS and drug use in prisons, working in close collaboration with the federal prison system. In particular, Health Canada employees, as national AIDS co-ordinators of the CSC, have been instrumental in co-ordinating ECAP and CSC's response to it. This has brought a health perspective to an environment that has always been more concerned with security than with health, and led to a vastly increased understanding and sometimes even acceptance - of the concept of harm reduction within the CSC.

In addition, Health Canada has funded much of the important research on HIV/AIDS and drug use in prisons. 'Because prisoners come from the community and return to it, and because what is done - or is not done - in prisons with regard to HIV/AIDS, hepatitis, tuberculosis and drug use has an impact on the health of all Canadians', the 1996 report urges Health Canada and provincial health ministries to take an even more active role and work in closer collaboration with prison systems 'to ensure that the health of all Canadians, including prisoners, is protected and promoted'.

Legal Action
As early as in 1989, a Canadian court held that detention centres in Toronto were failing to come to grips with the detention of people with HIV/AIDS by not providing adequate treatment and by not educating staff about HIV/AIDS. That case and other similar cases since have been important: they have shown that Canadian courts are willing to closely scrutinise the action or inaction of prison authorities in the area of HIV/AIDS.

Recent evidence of this is a 1996 case in which an HIV-positive woman undertook legal action against a provincial prison system for failing to provide her with methadone. The woman, who at the time of her sentence was on a methadone maintenance programme, had been refused continuation of the treatment in prison. She petitioned the court for relief in the nature of habeas corpus, arguing that, under the circumstances she found herself in, her detention was illegal. In response to the petition, and despite the position it had originally taken, the prison system arranged for a staff doctor to examine the woman, and he prescribed methadone for her. After this, she withdrew her petition (McLeod, 1996).

Importantly, the case provided the catalyst necessary for a change to the provincial prison policy which has since been amended to allow for methadone treatment of prisoners. The court did not even have to pronounce itself on the substantive issues raised in the cases: the government and correctional authorities, at least in part because of the case, have acted before the courts forced them to do so.

In another 1996 case (R v Povilaitis), a man with a longstanding, 'serious heroin problem' who had committed a number of acquisitory crimes and had been in treatment, without success, several times already, was convicted to two years mi~us one day imprisonment - and thus to imprisonment in a provincial prison in Qu6bec - because that prison had agreed to provide him with methadone treatment. The defence in the case had submitted that it was necessary to deal with the root causes of the man's crimes, namely his heroin addiction, and that treatment with methadone was essential to overcome that addiction. This was the first case in which an accused in a criminal case was sentenced to a term of imprisonment with the specific aim that he be allowed to undergo methadone treatment (see Turcotte, 1996).

Because of such precedents, where courts have, among other things, shown a willingness to hold that not providing those already infected with adequate care constitutes a violation of their constitutional rights, there is hope in Canada that courts may be willing to hold that denying incarcerated people the opportunity to prevent infection in the first place is also unconstitutional. It is being increasingly argued that law (constitutional law, the law of negligence and criminal law) could be used to force prison systems to introduce long-overdue harm-reduction measures, or to hold them liable for not providing them and for the resulting transmission of HIV in prisons (for an overview, see Jtirgens, 1996).

However, while legal cases have been and continue to be important, it would be'a shame if incarcerated persons were obliged to have recourse to the courts in order to claim and have recognised certain rights, in particular with regard to access to preventive means for protecting oneself against HIV transmission'(Morissette, cited injargens, 1996). There can be no question that the issue of providing protective means to prisoners would be more appropriately dealt with by swift action by correctional systems than by court action.

Positive Steps
Taken together, the developments reviewed in this paper have made some positive developments in the area of HIV/AIDS and drug use in prisons possible. More are expected later in 1997, when the CSC will announce its response to the 1996 report.

Condoms have been available in federal prisons since 1992. While each prison has established its own system for making them available, and while for many years access remained a problem, condoms are now increasingly made easily and discreetly accessible to inmates. Some of the provincial systems have also started making condoms available to prisoners. Some provinces, however, are still refusing to make them available.

Bleach had been available in Canadian prisons for a long time without any suggestion of it being a threat to institutional security, until it became associated with the sterilisation of injection equipment and was removed from most institutions. However, in some institutions it has remained informally available and there is no evidence that this has created any problems. In addition, some prison systems have reintroduced bleach specifically for the purpose of allowing prisoners using injection drugs to clean their equipment. Since late 1996, bleach is made available also in federal prisons: the initial decision only to pilottest a bleach-distribution programme in one institution was reversed.

Staff in some federal institutions have vehemently opposed the Commissioner's decision and are attempting to sabotage it, but many prisons are reporting that bleach distribution is well accepted by staff and has created no problems. In particular, {3. sur- j
vey undertaken among inmates and staff at the institution in which the bleach-distribution pilot was undertaken showed that: support for the bleach distribution programme among inmates was overwhelming - the vast majority of respondents said they would use bleach if it was given to them in prison 63 % of staff felt that making bleach available to inmates as a preventative measure was important 5 1 % of staff did not have any concerns about one ounce bottles of bleach being distributed in the
institution; and surprisingly, many staff thought that it was a waste of time to study how bleach could best be handed out to inmates and that, instead, a needle-exchange programme should be made available to inmates.
As mentioned above, one prison system changed its policy in 1996 to allow prisoners who were on methadone treatment to continue that treatment in prison. In another system, that of Quebec, methadone treatment is available in a few prisons only. Finally, some prison systems are considering making methadone treatment available in the near future.
Making sterile injection equipment available to prisoners who inject drugs has been recommended by PASAN, ECAP, in the 1996 report, and by many other groups and organisations, but has thus far been opposed by Canadian prison systems. However, the1996 report points out that the introduction of needle-exchange programmes in Canadian prisons has not only become more pressing over the years, but also morerealistic because the results of pilot projects in Switzerland and Germany have demonstrated that sterile needles can be made available in prisons safely, with good results, and that prison staff can be a
brought to accept and even support needle-exchange programmes.

CONCLUSION

While first steps have indeed been taken in the right direction in Canadian correctional institutions, much remains to be done. In Canada, as in the vast ajorityofcountries, harmreduction in thecriminal ustice system remains something of an oxymoron. or those of us who have started to feel that we have egun to make headway in introducing harm reducion as an acceptable policy in our countries, the sitation in prisons should make us realise how much as still to be done. Reducing drug-related harm in ociety means reducing such harm in prisons too, and n that regard we have so far had only limited success. Harding writes:

The responses to the drug taker in the prison environment ... reveal society's ambivalence towards the problems of drug users and reminds us that there is a real risk that efforts to combat the AIDS epidemic by applying well-established public health principles and respecting fundamental ethical values concerning personal autonomy, relief of suffering and promotion of health can be undermined and replaced by other, sinister reactions based on fear and rejection. Experience has shown us that the drug taker is especially at risk of nonrespect of basic human rights - and nowhere more than in prisons. (1990)

In attempting to put a comprehensive harm-reducion programme in place we need to recognise that arm comes not just from drug misuse, but also from he present system of prohibitionist measures mployed to control the manufacturing, sale and use f drugs.

What we need most of all now is an open and ank debate about how we can reduce drug-related arm in all its forms: this includes restructuring the riminal justice system, rethinking drug strategy and eassessing our social policies. We need to expand ommunity-based programmes to combat excessive prisonment: this means we must develop new pproaches to drug issues and social policy that nvolve many agencies working together to reduce rug-related harm to the individual, the community nd society as a whole.

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