Drug use does not stop at the prison gate. In fact, around 4 in 10 people entering prison have a drug dependence, and many continue using drugs during incarceration. On top of this, an estimated 3% to 10% of people report starting to use drugs while in prison. Together, this makes drug use disorders one of the most common health conditions among people in prison, where they are estimated to be around ten times more prevalent than in the general population.
Drug dependence is only part of the explanation. Prison conditions themselves can also sustain drug use. Boredom, stress, untreated mental health problems, isolation, limited purposeful activities and the prison environment have all been identified as important factors that encourage continued drug use during imprisonment.
This does not come without consequences. People in prison experience disproportionately high rates of infectious diseases such as HIV, hepatitis B and C, and tuberculosis. Among people who inject drugs in prison, HIV prevalence is around six times higher, hepatitis C eight times higher and hepatitis B twice as high as among imprisoned people who do not inject drugs.
Drug use in prison is also associated with withdrawal, poor mental health, self-harm, violence and overdose. In Europe, drug overdose is the third leading cause of death in prisons. The risks don’t stop after release, in fact, they only increase: one study in the US found that people leaving prison are up to 129 times more likely to die from an overdose than the general population during the first two weeks.
Over the past decade, these challenges have become even more complex as prison drug markets have evolved.
New psychoactive substances (NPS), particularly synthetic cannabinoids, commonly known as Spice, have become one of the fastest-growing drug-related challenges in prisons across Europe.
Their rise is closely linked to the prison environment. Unlike many traditional drugs, synthetic cannabinoids can be sprayed onto paper or letters, making them easier to smuggle into prisons. They are also much harder to detect through routine urine drug testing, meaning their use is often underestimated.
To complicate things further, their potency is highly unpredictable, creating a new set of health challenges. Synthetic cannabinoids have been linked to psychosis, aggression, seizures, cardiovascular complications, severe withdrawal, overdose and death, placing increasing pressure on both prison healthcare services and staff.
Harm reduction is the practical response
For decades, one approach has consistently been shown to reduce the health harms associated with drug use in prisons: harm reduction.
Harm reduction in prisons can include a wide range of interventions, such as opioid agonist treatment (OAT), needle and syringe programmes (NSPs), naloxone, testing and treatment for HIV and hepatitis, health education, peer support, continuity of care and release planning. Delivered together, these interventions address different health needs throughout imprisonment and are most effective as part of a comprehensive package rather than as isolated measures.
The evidence supporting these interventions is extensive. OAT reduces drug injecting practices and improves engagement with treatment after release. Prison needle and syringe programmes reduce syringe sharing without increasing drug use or violence, while naloxone and continuity of care help reduce the risk of fatal overdose following release from prison.
Yet despite decades of evidence, access to harm reduction in prisons continues to lag behind access in the community.
Globally, opioid agonist treatment is available in prisons in 61 countries, compared with 95 countries where it is available in the community. The gap is even greater for needle and syringe programmes, which are available in prisons in only 11 countries, compared with 93 countries in the community. Naloxone on release is also reported in only 11 countries. Even where services exist, people may avoid using them because of fears of punishment, loss of privileges, breaches of confidentiality and stigma.
Europe shows the same prison-community gap. While access to opioid agonist treatment has improved, needle and syringe programmes remain available in prisons in only 4 countries, while naloxone on release is available in just 10. Recent prison monitoring by Correlation – European Harm Reduction Network (C-EHRN) shows this gap also at the city level: naloxone is available 4 times more often in the community than in prison, while needle and syringe programmes were available 7.4 times more often outside prison. More strikingly, only 1 out of 38 cities reported having all four key harm reduction services available in prison, highlighting that comprehensive harm reduction remains the exception rather than the standard.
Falling short of international standards
For decades, international organisations have consistently recognised that people in prison are entitled to the same standard of healthcare as everyone else. The Nelson Mandela Rules establish the principle of equivalence of care, while the Madrid Recommendation, WHO & UNODC and the EU Drugs Strategy 2021-2025 all call for comprehensive harm reduction, continuity of care and prison health services that are fully integrated with public health systems.
Closing these gaps now requires action. Governments, prison authorities and healthcare providers must move beyond isolated interventions and commit to implementing comprehensive harm reduction services that are available, accessible and continuous throughout imprisonment and after release. Where evidence-based harm reduction services are available in the community, they should also be available in prisons, in line with the principle of equivalence of care.
This also means moving beyond a limited package of interventions. As prison drug markets continue to evolve, so too must prison health responses. Comprehensive harm reduction should address the full range of drug-related harms through interventions that prevent overdose, reduce the transmission of infectious diseases, improve continuity of care and respond to emerging challenges such as new psychoactive substances.
When people leave prison healthier, safer and better connected to care, communities benefit. When they leave prison without access to these services, the consequences extend far beyond prison walls. Prison health is public health. Harm reduction should not stop at the prison gate.
