INTRODUCTION

Our interest in the issue of the criminal justice system and health promotion for drug users stems from our involvement in prisons in the framework of the European Peer Support Project (EPSP), a project which began in 1993. The focus of this project has been on developing peer support as a means to risk reduction in intravenous drug user (IDU) communities in the different EU Member States. The objective of this project, which was financially supported by the drug prevention program of the European Commission, was to stimulate professional and voluntary drug services as well as inmates and drug user self-organisations to use peer support as part of a strategy to reduce drug use related harm (Trautmann 1995). In November 1996 the EPSP entered its third phase. In its last phase, the project included the development of peer support among injecting drug users as part of a risk reduction strategy in prisons in Germany, Ireland, Italy and Portugal (Verpalen and Trautmann 1997a and 1997b). This pilot project confirmed our impression that there is a need for risk reduction interventions and health promotion for drug users in prison and that prisons can play a significant role in organising such activities (Stöver and Trautmann 1998, Stichting Mainline 1997).

The activities that were organised in prisons in the course of this project were an eye-opener to us in regard to the potential of the legal system in the field of health promotion for drug users. Hence we developed a new project - ‘Encouraging Health Promotion for Drug Users within the Criminal Justice System’ - which, in addition to writing this manual, also entailed the creation of an inventory of existing good practice in the different parts of the criminal justice system and the organisation of an international conference titled ‘Encouraging Health Promotion for Drug Users within the Criminal Justice System’ which was held from 22-25 November 2000 in Hamburg/Germany, this conference has been held in comjunction with the 4th European Conference of Drug and HIV/AIDS Services in Prison of Cranstoun Drug Services (London / UK).

This as other inventories have demonstrated, there is a range of possible options for health promotion within the prison setting. Different professions can play an important role here: general prisons staff, prison health care workers and probation officers. Furthermore, community services and drug users can also contribute. Staff from drug treatment services can play a role in training prison staff. Drug users themselves may also play an important role, supporting their peers to help them realise safer behaviour.

From the many possible options for health promotion in prisons, we include the following measures:

Drug free treatment might be the most common health program for drug users in prisons. It is also the program that has been evaluated most thoroughly. However, the measured effects in terms of helping prisoners attain and sustain drug free status have been shown to range widely, from being ‘quite effective’ (Inciardi 1993) to ‘more or less ineffective’ (Schippers and van der Hurk 1998). In general, expertise and sometimes even staff from existing treatment programs outside the prison are ‘imported’ into prisons.

There are more general health education programs, one example being the Dutch program ‘Everything under control’, a training program for inmates with drug-using experience that is not focused primarily on the need to achieve abstinence from drug use. In this program, participants are taught ways to reduce the risks involved in drug use, and strategies to help them to control their drug use after release. In 11 sessions, people learn to make decisions about their drug use (what drugs do I want to use and in what way?), and learn how to set goals and limits and how to devise strategies to help them reach their goals. The program also covers a broader field of health education including psychosocial aspects, social skills, etc. (Blekman and van Emst 1997).

Substitute drug programs (for example, methadone programs) have been implemented in various countries either as detoxification or as maintenance schemes (Dolan and Wodak 1996; Keppler/Stöver 1998).

Harm reduction programs aim to limit as far as possible drug-use related health risks. The theme of these harm reduction programs is: ‘If you use drugs in prisons, do it as ‘safely as possible!’ The practical support for users matches the individual needs and resources of the drug users. These programs can include the following aspects:

Distribution of syringes has been implemented in a number of prisons in Switzerland, Germany and Spain, initially as an experiment (Stöver 2001) and later as a regular service.
Distribution of bleach to clean syringes is allowed in a number of prisons in various countries (Dolan 1995).
Peer support (see above).

Information or training before release to prepare inmates with experience of drug use for the risks faced after release (information about enhanced overdose risk after release, safer injecting, etc.) is a service available in a number of countries.

This manual describes what can be done to reduce drug-related health risks in prisons. In this manual we integrate the results of various projects done in this field. Besides basic information on drugs, drug use, infectious diseases and risk reduction strategies the manual contains modules of training seminars for staff and inmates.

1    PRODUCTION OF THE MANUAL

The manual is primarily addressed to professionals in health services working either within the prison or outside. They may be employed as civil servants within state agencies or in Non-Governmental Organisations. These groups have the advantage of confidentiality when working with prisoners. Moreover, social workers, prison officers, peer leaders or inmates can use this book as a source of practical information. It has been written as a curriculum, focusing on the question: what information should be provided at any given time? How and by whom? Answering these questions means that - when working in prisons - not only are the form and content important, but organisational and methodological issues must also be kept in mind. Our central subject matter is risk situations for prisoners and staff members. These vary from country to country, sometimes even from prison to prison within a particular country or even a region or city.

So we have tried to write a manual that can be used for developing health promotion activities and can be adapted to the specific needs and circumstances of prisons in different countries. We are sure that a lot of useful information may be added when integrating the experiences of inmates and staff members working in health promotion projects.

The major objectives of this manual are:
To raise awareness of health problems connected to drug use and drug-related infectious diseases
To initiate and support a discussion about risk reduction as response to these health problems
To contribute to knowledge, skills and insight into the problems and encourage a positive attitude towards risk reduction activities by both inmates and personnel
To disseminate information relevant for health promotion by a range of means
To stimulate and support the realisation of risk reduction activities for inmates as well as for staff members

In order to realise these objectives, the manual also contains information for prison staff about health and safety at work, drugs, addiction, infectious diseases and the services needed. For inmates, we have included information about risk situations and risky conditions within the prison setting. We give technical and organisational advice on how to raise certain topics and how to initiate risk reduction activities in a prison context. We introduce specific methods showing how to reach and work with the target groups. We have also included sheets listing central topics and questions, which may serve as a basis for group work or for individual counselling. Finally we have included an overview of relevant literature and a list of addresses of important institutions in various countries.

However, a manual like this cannot cover all issues related to risk reduction. We have inevitably had to make choices. We have limited the scope of the manual to risk reduction as such. This means for instance that we do not cover some important psychosocial issues, such as dealing with the consequences of having been exposed to violence, including sexual violence like abuse and rape. The fact that we consider these issues to be beyond the scope of risk reduction does not, of course, mean that one should not care about them. If and when one does come across them, one should try to find appropriate support and care for the inmates in question. One should also, however, bear in mind that a prison is in no way a therapeutic institution. The opportunities and facilities for psychosocial support and care in prisons are usually quite limited. This is especially true for staff from community services whose task is to contribute to risk reduction. Such staff generally will not have enough time, adequate training or the right to get involved in this type of specialist issue.

Another caveat is that this manual inevitably focuses primarily on individual behaviour change. However, it is evident to us that structural and institutional changes are a prerequisite to building a healthy environment and to supporting individual health behaviour. So we would contend that this level should always be considered at the same time.

In spring 2001, we ‘tested’ parts of the manual in Turin (Italy) and Dublin (Ireland), discussing the draft version with prison governors, prison staff and community health staff. This was done in co-operation with partner organisations involved in the prison part of the European Peer Support Project.

Furthermore, different experts have commented on and contributed to different parts of the manual (see the list of contributing authors). The many helpful insights and critical remarks of all these people have been integrated into this final version of the manual.

Finally, a Russian version of this manual is under preparation in co-operation with AIDS Foundation East West in Moscow, the successor of Médécins sans Frontières - Holland (Moscow).

2    PRISONS, MEDICAL CARE AND DRUG USE

In a European study of health problems arising in prison, Tomasevski (1992) pointed out three main problem areas: substance abuse, mental health and communicable diseases. These problem areas are closely interrelated. In most prisons in Europe drug use has become a substantial problem. Drug use related health problems have to do with a threefold ban on drugs in prison. Drugs are forbidden, drug use is forbidden (urine testing to prove drug use is common practice in many prisons in Europe and a positive test frequently results in additional punishment) and there are no special facilities where inmates can go and use drugs (in growing contrast with the situation outside prison, in countries like Germany, Switzerland and Holland, though this situation does not apply in other countries such as the UK, France, Ireland, etc.). This last point means that there is hardly any ‘private’ space in prison. In most countries, a cell has to be shared with other inmates, the ‘public’ space is intended for use by all prisoners. This inevitably leads to stress, particularly when drugs are being prepared. Hygienic precautions are neglected, with the possible risk of infections with HIV or hepatitis. The risks of overdoses when starting to inject drugs again after release are extremely high (Seaman/Brettle/Gore 1998).

Injecting drug use in detention contributes to the risk of spreading communicable diseases like HIV/AIDS, hepatitis, Sexually Transmitted Diseases (STD’s) or Tuberculosis (TB). A spread of these diseases from drug users into the wider community is likely and poses a serious threat to public health as prisons are not an isolated reality. The high, and in some countries, rapidly rising levels of communicable diseases among prisoners clearly show that the health of prisoners (and prison staff) is becoming a matter of growing concern for the general public health. The high turnover rate of prisoners who often serve short-term sentences plays an important role here.

In addition, the following factors serve to enhance the spread of the aforementioned communicable diseases in prisons:

Overcrowding, malnutrition and poor hygiene conditions.
The fact that prisoners often belong to poor, deprived and marginalized population groups, which are particularly vulnerable to HIV and TB infection.
The fact that imprisonment in many countries limits access
to the means of prevention and medical care compared to the general standards in the community.
The fact that risk behaviours such as injecting drug use and sex among prisoners do occur and that injecting drug users in many countries constitute a large proportion of the prisoners (see also Joint WHO/UNAIDS European Seminar 1997).

Drug users when entering the prison system frequently suffer from multiple drug dependencies and from severe health problems, i.e. withdrawal symptoms, abscesses, infectious diseases and mental health problems. The prevalence of infectious diseases like HIV/ AIDS and/or hepatitis A, B and C in prisons is often higher than in the general population. A relatively high percentage of inmates first began to use drugs while in prison. According to a recently published study in Ireland, more than one prisoner in five began to inject drugs while in prison (Houston 2000).

Prison medical and security staff have to deal with these drug-related problems, while the causes of the problems usually remain far beyond their reach. Furthermore an adequate response to the health problems encountered within the prison is often beyond the responsibility (and capacity) of the prison staff and administration - prisons are in no way therapeutic institutions.

But both inmates and prison staff are exposed to similar health risks (i.e. accidental needle stick injury when searching the cells) and thus have vital common interests in health and security measures in the prison (see II 8.3.).

There are also significant differences between the countries medical care provision in prisons. In all but two of the EU Member States, medical care is provided by the administration of the Ministry of Justice. France and Italy are the only countries in which the community health services are responsible for providing health care in prison. Moreover, there are substantial differences in the approach towards drug use in prisons. In most of the countries the emphasis is on supply reduction. Demand reduction is generally limited to drug free treatment. This approach fits in with an understanding of the prisons’ job as being to prepare prisoners for a life without offending, as in many countries the use of illegal substances remains a criminal offence.

While in the past decade risk reduction measures have been applied successfully in the community, in prisons, drug free orientation still is the predominant perspective. Risk reduction strategies, which are used outside prison, are often regarded as undermining the measures taken inside prison to reduce the supply of drugs. Such measures are also often regarded as a challenge to the policy of drug free orientation in penitentiaries and as a threat to prison security. The health risks connected with drug use are generally seen as of secondary importance. However, it would be more appropriate to view drug use as something that should be avoided, but when it does occur - and that seems to be a fairly frequent occurrence in most European prisons - then damage to the user’s health and to that of other inmates and personnel should be avoided. Inmates should not leave prison with health problems in excess of those that they had when entering prison - a point of view that is clearly supported by the World Health Organisation (WHO).

According to estimates by WHO and information provided by EMCDDA, drug users form a substantial group among inmates throughout Europe. Although the figures given by various European countries widely differ, it can be assumed that approximately 15 - 50% of the 350,000 prison inmates in Europe currently use drugs or have used drugs in the past. There is a high turnover rate, with 180,000 - 600,000 drug users passing through the system annually. This fact inevitably affects life in European penal institutions. “There is probably no institution in society that has felt the influx of drugs has become a central theme, a dominating factor in the relationships between prisoners, as well as between prisoners and staff. Many of the security measures are aimed at controlling drug use and drug trafficking within the prison system” (Kingma/Goos 1997, p. 5).

The spread of communicable diseases, especially HIV/AIDS within the prison system has led to efforts on the part of the WHO to develop guidelines aimed at dealing with HIV/AIDS in prisons. Since the guidelines were issued in 1993, they serve as a basis for assisting policy developments on the subject. The guidelines on preventive measures point out that the same measures which are generally applied in the community should also be applied in prisons: “In countries where bleach is available to injecting drug users in the community, diluted bleach (e.g., sodium hypochlorite solution) or another effective viricidal agent, together with specific detailed instructions on cleaning injection equipment, should be made available in prisons housing injecting drug users, or where tattooing or skin-piercing takes place. In countries where clean syringes and needles are made available to injecting drug users in the community, considerations should be given towards providing clean injecting equipment during detention and on release to those prisoners who request this” (WHO 1993).

Proceeding from this internationally acknowledged principle of equivalence, namely the idea that the health care measures successfully applied outside prison should also be applied inside prison, it seems necessary here to take an inside/outside perspective. This means that the prison drug services should be perceived in the context of community drug services based on the standards of a regional or national drug policy. This is the main approach applied at all levels of our manual.

It should, however, be kept in mind that full equivalence to the situation outside prison is not possible. The infrastructure of services in the community is much more differentiated. Outside, anonymity is guaranteed and easily manageable (e.g. concerning HIV testing), participation is voluntary and users have (relative) freedom of choice between drug services in the community - qualities that are hardly realisable within the conditions of the ‘total institution’ prison. Here, such basic prerequisites (i.e. confidentiality) are often hard to realise, although officially efforts might have been taken. Many aspects of HIV testing and prevention are therefore not equivalent to those available in the community (O’ Brien/Stevens 1997). Thus it still seems we are a long way from implementing the WHO guidelines, although the necessity of doing so becomes more and more apparent: “Governments and prison authorities have a moral and legal responsibility to prevent the spread of HIV infection among prisoners and prison staff and to care for those infected. They also have a responsibility to prevent the spread of HIV among communities. Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities” (Kingma/Goos 1997, p. 7).

This principle of equivalence has been the point of reference for the risk reduction activities underlying this manual. There are va-rious risk reduction activities outside prisons in most of the EU Member States: methadone detoxification and maintenance, needle exchange programs, training seminars on safer sex, safer drug use and safer work, support of drug user self-organisations, integration of drug users into the work of information units etc. This kind of support towards reducing drug-related harm should also be available in prison as part of a broader health promotion approach.

The problems around sex in prison are very similar to the aforementioned problems around drug use. Sex is taboo, especially among male inmates. But just as penitentiaries are not drug free areas, they are also not free of sex. Sexual contacts occur in different ways among inmates. Condoms are theoretically available in most of the prisons as a protection for sexually transmitted diseases, sometimes even free of charge. However, in practice they are not easily accessible, at least not without the risk that the person involved is getting stigmatised as potentially ‘homosexual’ (a characteristic that reduces one’s status within the prisoner’s subculture and hierarchy). In some of the prisons condoms have to be ordered at the prison shop. In others, a doctor’s visit or a visit from the social worker has to be arranged in order to be supplied with condoms. Finally, there are still countries where prisoners do not have any access to condoms. Therefore it is fair to conclude that the capability of inmates to protect themselves against sexually transmittable infections is very limited, meaning that the risk of becoming infected through sexual contact is particularly high.

DRUG USE IN PRISON: SUBSTANCES, PATTERNS AND FREQUENCY OF USE, ROUTES OF ADMINISTRATION

The extent of our knowledge about drug use in prisons is fragmented. There has been some research about the substances used in prisons about the patterns and frequency of substance use and the routes of administration. Needle sharing is evidently the riskiest mode of dividing a quantity of drugs between several users. However, a considerable number of drug-users continue to use this technique with varying degrees of regularity. Drug sharing, a process in which one quantity of heroin or cocaine provides the drug for several different syringes is also a source of infection, particularly if one or more of the needles or syringes used is not sterile. If one brings together the available information and research findings about drug use in EU prisons, we are faced with the following picture (Stöver 2001):

The use of illegal drugs in prisons seems to be a longstanding phenomenon dating back to the mid or late seventies; needle sharing at that time was extremely widespread.

Some studies state that the same substances available outside are to be found inside prisons, with the same regional variations in patterns of use; some studies state that these drugs are often of a poor quality compared to that in the community.

The prevalence of drug consumption varies, depending on the institution. The phenomenon is more significant in large institutions and in short-stay prisons, more in women’s prison than in men’s prison, more in prisons located close to a major city than in prisons in the countryside. There are also indications that there is a lower prevalence of drug use in remand prisons due to the lack of organised trafficking networks.

The most commonly used drug in prison besides tobacco is certainly cannabis, used primarily for relaxation purposes. Studies revealed that out of those using drugs during detention, 45% to 78% reported cannabis use in prison, 18% reported using injectable drugs in prison. Heroin use does seem to play an important role among prisoners: results following the introduction of Mandatory Drug Testing in England and Wales revealed that in 1998 18,9% of the inmates tested used illegal drugs (opiates about 4%; higher prevalences reported by other studies).

The basic question of whether prison influences the motivation to stop drug use can be answered as follows: “... prison on the whole does not motivate individuals to stop drug use ... in the ... countries reporting a reduced drug use within prison, this would appear to be unrelated to the motivation of the drug user to stop per se but rather is a consequence of reduced availability, lack of resources to procure drugs or the fear of detection”. Whether these factors finally create a sustainable motivation to stop drug use is unclear. Relapse into the drug-using patterns before imprisonment is widespread (and dangerous). Many drug users seem to stop the habit mostly in the fourth decade of life by the processes that have been described in the literature as ‘maturing out’ (Muscat 2000).

There might also be further reasons for inmates to use drugs while in prison: Some users describe their constant search for drugs as a strategy for fighting boredom and enduring imprisonment, i.e. dealing with the hardships of prison life, to overcome a crisis (bad news, conviction and sentencing, violence, etc.). It seems that imprisonment sometimes provides even more reasons for taking drugs or continuing the habit, or may even cause relapse after a period of withdrawal.

Lifetime prevalence of the use of illegal drugs (any) prior to imprisonment is relatively high: i.e. 62% for men and 54% for women in Portugal. A study of 1009 prisoners in 13 prisons in England and Wales revealed that three quarters had used cannabis at sometime during their life. More than half had used opiates (mainly heroin) and/or stimulant drugs (amphetamines, cocaine and crack), while 40% of them had injected the drug(s).

In some countries (France, Belgium, Finland) alcohol seems to be the first or the second most commonly used drug (after cannabis, apart from nicotine) among people either admitted to prison or being already in prison. Recent figures (from France) show that 33.5% of newly admitted inmates claim excessive use of alcohol (more than 5 glasses per day and or 5 glasses consecutively at least once in a month).

Due to the scarcity of the preferred drug changes in patterns of drug use (volume and type of drug) are reported from many countries. The frequency of drug use decreases in relation to levels in the community. Those who continued to inject did it on irregular intervals and a reduced level. In a study in the UK, it turned out that those who do manage to inject on a daily basis are more likely to be imprisoned for a shorter period of time, often on remand and were held in a prison in, or close to their home town. Other studies and observations by prison officers indicate that switching to alternative drugs is widespread (for example, from opiates to cannabis) or to any substitute drugs with psycho-tropic effects, no matter how damaging this might be (illegal drugs and/or medicine). Due to lack of access to the preferred drug of choice, or to strict controls (like mandatory drug testing), some prisoners seem to switch from cannabis use to heroin or at least experiment with heroin, because cannabis is deposited within the body’s fatty tissues and therefore may still be detected up to 30 days after consumption.

Drug use in prison may be characterised as follows:
Highly sporadic availability of drugs, resulting in dra matic periods of change between consumption and withdrawal
Quality, purity and concentration is even harder to calculate than outside
Widespread poly-drug use used to bridge periods of inability to finance drugs

Despite the difficult circumstances some prisoners use prison as an opportunity ‘to take a break, to recover physically’ (Trabut 2000, 26), or to stop using drugs in prison because of the threat of detection via drug testing (especially for those using cannabis). Often this period of abstinence is accompanied by a stabilisation or improvement of the general health status (increases in weight etc.). Furthermore, many drug users in prisons come from the more disadvantaged groups in society with low educational attainment, unemployment, experience of physical and sexual abuse, relationship breakdown or mental disorder. Many of these prisoners never have had, or perhaps never have chosen to take up, access to health care and health promotion services prior to their imprisonment. Consequently, the medical services may offer an opportunity to improve their health and personal well-being.

With respect to cessation of injecting several reasons have been identified:
Personal choice (including an assessment of the risks associated with injecting)
Practical (including the problem of acquiring drugs, needles and syringes)
Economic (the cost of drugs)
Decreases in overall drug consumption

The percentage of those prisoners continuing their use of injectable drugs in prison is around 16% - 60% according to different studies in Europe. A survey was carried out at local level in seven European countries in 1997 using a common methodology. It showed proportions of active intravenous drug users (i.e. drug users who have injected drugs within the 12 month period prior to imprisonment) among prisoners in 21 prisons ranging from 9% in France to 59% in Sweden, and 16 to 46% in Belgium, Germany, Spain, Italy and Portugal.

Needle sharing and drug sharing is widespread among prisoners who continue their injecting drug use. Although injecting drug users are less likely to inject whilst in prison, those who do inject in prison are more likely to share injecting equipment, and with a greater number of people. In Greek penitentiaries, examinations have found that 50% of those who reported injecting in prison admitted shared their equipment with other prisoners. The EMCDDA (2000) also reports a high prevalence of sharing injecting equipment within prison, which may reach 70% of the injectors in some prisons. The majority of inmates who continue their injecting drug use do this with used equipment. That means for many drug-using inmates that they experience a relapse in hygienic injecting technique, because they were mostly used to having easy and anonymous access to sterile injection equipment outside prison. These findings conform to prison studies throughout the world describing injecting and the sharing of injecting equipment within prisons. Turnbull et al. (1996) found that when considering other injecting equipment, more sharing occurred than was actually reported. Much re-use of equipment was viewed simply as “using old works”. The sharing of “cookers” and “filters”, and drug sharing by “backloading” and “frontloading” were common. The concept of “sharing” tended to be understood by respondents as relating to the tool of injection (needles and syringes rather than other equipment); the use of tools in the art of injection (rather than for mixing drugs); proximity (multiple use of needles and syringes in the presence of others); temporality (shorter time elapse between consecutive use of needles and syringes previously used by another) and source (hired rather than borrowed or bought).They conclude that syringe sharing is an integral part of drug use and drug injecting in prison. Many of those interviewed displayed a restricted understanding of what actually constitutes syringe sharing.

Figures from a European study and some national and single prison-based surveys indicate that the number of those starting to inject while in prison ranges from 7% to 24%.

According to a French study, some prisoners discover new substances while in prison (medicines, Subutex®) or develop habits of mixing certain drugs they didn’t take in that combination outside prison.

Due to a study that included data on treated drug users in 23 European cities (Pompidou Group 1999, 12) the classic picture of the injecting drug user is vanishing and smoking heroin (‘chasing the dragon’) now plays a significant role all over Europe. In countries where injecting is not widespread outside prison (i.e. Netherlands), this route of administration is also not widespread within the prisons. There has also been some indication that users of injectable drugs turn to alternative (and risk reduced) routes of administration namely inhaling, smoking or sniffing (Greece, Spain). However, in those countries where injecting is the predominant route of administration outside, alternative ways are not applied in prisons, because they seem to be less effective and more expensive than injecting which is regarded as the best method of getting the maximum effect out of a minimal dosage of the drug.

There is a high risk of acquiring communicable diseases (esp. HIV/AIDS and hepatitis) in prison for those who continue their injecting drug use and obviously those sharing needles and drugs. Several studies conducted outside penal institutions reveal that a strong correlation exists between previous detention and the spread of the aforementioned infectious diseases. Although injecting drug use in prison seems to be less frequent than outside, each episode of injecting drug use is far more dangerous due to the combined factors of a lack of sterile injecting equipment, a high prevalence of sharing and an already widespread of level of infectious disease.

The attitude towards drug use in prison indicates that certain drugs (in particular cannabis and benzodiazepines) are often regarded as serving a useful function or helping to alleviate the experience of incarceration: “Many inmates seem to regard cannabis as essentially harmless. Alongside these attitudes, inmates recognise a need for treatment among those with serious drug problems and were aware of some of the health implications of injecting. They also displayed a concern, possibly exaggerated, about the problems of drug withdrawal. In the same study, prison officer staff shared many of these attitudes, with some commenting on the uses of drugs as palliatives and the relative harmlessness of benzodiazepines and cannabis. Others were concerned about the development of a black market in drugs. In general, staff were acutely aware that the problem of drug misuse in prisons reflected a similar problem in the community” (Marshall et al. 1998, 62). Some prison managers confirm the view that the use of some drugs in prison doesn’t vary considerably from that outside. “We do still accept that prisoners who use cannabis are breaking the law and they will be treated accordingly, but we are reflecting the way the world is outside prisons” (The Scotsman 13/5/98). In the UK, The Howard League for Penal Reform recommends in its ‘Submission to the Home Affairs Select Committee’ the ‘depenalisation’ of cannabis within prisons and makes a plea for cannabis to be treated in the same way as alcohol, in that it should be primarily considered a health issue rather than a punishment issue.

Many of the drug users in prison had had no previous contact with drug services prior to their imprisonment despite some having severe drug problems.

After release, many drug injectors continue with their habit. Studies showed that 63% of those who had injected before entering prison, injected again in the first three months after release. “Prison therefore cannot be seen as providing a short or longer term solution to individuals’ problems with drugs”.