Over the last decade, Europe has seen an increase in the size of its prison population. As of 1 September 2010, there were an estimated 635 000 inmates in prison in EU Member States (Aebi and Del Grande, 2012; Walmsley, 2012). Most of those in Europe’s prisons are from poor communities and vulnerable social groups (WHO Regional Office for Europe, 2007), with the proportion of inmates who are immigrants or from minority ethnic backgrounds on the increase (Ronco et al., 2011). Drug users form a large part of the overall prison population, with studies showing that a majority of prisoners have used illicit drugs at some point in their life and many have chronic and problematic drug use patterns. Because of the illegality of the drugs market and high cost of drug use, which is often funded by criminal activity, the more problematic forms of drug use are accompanied by an increased risk of imprisonment.

Although some prisoners do stop or reduce their use of drugs on prison entry, others initiate drug use or engage in more damaging behaviours when they are incarcerated (Lukasiewicz et al., 2007). In addition to high levels of drug problems, prisoners also experience poorer health than the general population, with higher prevalence of blood-borne infections, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV), as well as mental illness. Reported rates of self-harm and suicide among prisoners are particularly high compared with the general population of the same age. In addition, overcrowding and poor hygienic conditions may further aggravate the stress, social and health problems experienced by prisoners.

For opioid users, the risk of dying from drug overdose greatly increases in the period after release from prison — due to high rates of relapse and lower opioid tolerance (Farrell and Marsden, 2008). This is a critical time for action, when ensuring continuity of care and targeted interventions can both support recovery and save lives. The services offered to prisoners, however, have historically compared poorly with those provided in the community (Stöver and Weilandt, 2007). In general, services provided for prisoners have tended to mirror those provided in the community, but with a considerable time lag.

Nevertheless, when appropriate drug services are in place, periods of incarceration may provide an opportunity for some to reduce their drug use and engage with treatment, and, in recent years, many European countries have increased the provision of services for drug users in prison, particularly substitution treatment.

Recent years have also seen an increasing acknowledgement from international and European institutions of the importance of treating prison health as an inseparable component of public health. The Council Recommendation of 18 June 2003 and the 2009–12 EU action plan on drugs have both called for the development and implementation of prevention, harm reduction and treatment services in prison that are equivalent to services outside prison.

This Selected issue approaches the important topic of prisons and drugs in Europe from two perspectives. The first section aims to provide an insight into patterns and levels of drug use among the European prison population, the health profile of prisoners and risk behaviours while incarcerated. The second section examines Europe’s prison health policies and models of delivery of drug-related healthcare to detainees, including the provision of prevention, treatment and harm reduction services. The report concludes with reflections on ways forward.

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Prisons and drugs in Europe: the problem and responses

Most people don’t use drugs and don’t approve of drug abuse. But is someone who is drug dependent an out of control “junkie” slipping ever deeper into despair and degradation or a ‘heroin user’, in control of his or her use of an illegal substance leading what to the outside world is considered a“normal” life?

Both descriptions may fit and either candidate could be as desperate to overcome a powerful habit as much as any reformed alcoholic or someone desperate to give up smoking.

The award of a deviant social status to drug users may serve to discourage use but it does little to assist those most in need of help. Studies have consistently shown that perceived devaluation and worthlessness on behalf of the user does little to spur them towards recovery. The ‘shame’ of addiction is a reason why people with drug problems – and their families – often do not seek help.

Widespread stigma remains a barrier to recovery for drug users. And the media can help – just as it has had a positive influence on public understanding of the problems of stigma associated with mental illness, disabilities and poverty.

Whether used consciously or lazily, certain words continue to imply a moral judgment in an era when the explosion of digital technologies has created a bigger platform than ever before for education.

The UK Drug Policy Commission identified that, aside from being consistently distasteful and backward, negative connotations attached to the term ‘junkie” made it more difficult to encourage addicts to join rehabilitation programmes. ‘Getting serious about stigma’ found that more than twothirds of the sample agreed that we have a responsibility to provide the best possible care for people with drug dependence.

Newspapers and broadcasters, now more than ever, can set new benchmarks for recovering drug addicts to throw off the stigma and overcome the dependencies that prevent them leading full and valued lives.

With the badge of the Society of Editors on the front page, this simple, practical guide does not seek to criticise the media or tell editors and journalists what to think or say or write. David Seymour has mastered the issues and presents the facts to help journalists report accurately and objectively so that stigma born of ignorance can be replaced with proper understanding and support for drug users who want to help themselves.

Dealing with the stigma of drugs: A guide for journalists

Cannabis use is relatively common in the European Union (EU) and Norway, with around 23 million people (6.8 % of all 15- to 64-year-olds) having used the drug in the past year and about 12 million (3.6 % of all 15- to 64-year-olds) in the last month. Although the prevalence of last-year cannabis use among the general population is generally stable or decreasing in many countries, demands for treatment in which cannabis is the primary drug continue to rise, indicating a possible increase in related problems. The substance is currently the most frequently mentioned drug by those demanding drug treatment for the first time in the EU and Norway. This suggests that, even though most cannabis use at the population level is likely to be transitory and at low levels, a significant minority of users use the substance intensively and/or for long periods of time. These patterns of use are reported to be associated with harms to the user and possibly with a need for treatment. Although this problem has been increasingly recognised, knowledge of the prevalence of the more intensive forms of cannabis use has been limited at the EU level.

This report brings together, for the first time in Europe, an integrated overview of the prevalence of intensive cannabis use, defined as daily or almost daily cannabis use (use on 20 or more days in the month preceding survey). Self-reported data regarding frequency of cannabis use from large, probabilistic, nationally representative samples of general population surveys from 20 countries, representing more than 83 % of the population of EU and Norway, were collected through two rounds of ad hoc data collection in 2004 and 2007 and through a routine, standard data collection instrument since 2010.

Prevalence of daily cannabis use in the European Union and Norway

Article 5.1 of Council Decision 2005/387/JHA stipulates that ‘Where Europol and the EMCDDA, or the Council, acting by a majority of its members, consider that the information provided by the Member State on a new psychoactive substance merits the collection of further information, this information shall be collated and presented by Europol and the EMCDDA in the form of a Joint Report. The Joint Report shall be submitted to the Council, the European Medicines Agency (EMA) and the Commission.

At the end of 2011 and in 2012, the EMCDDA and Europol examined the available information on a new psychoactive substance, 4-methylamphetamine, through a joint assessment based upon the following criteria:

evidence of the potential for further (rapid) spread; and,

evidence of cases of serious intoxication or fatalities.

The EMCDDA and Europol agreed that the information collected on 4-methylamphetamine satisfied all criteria (1 to 6). The two organisations therefore concluded that sufficient information had been accumulated to merit the production of a Joint Report on 4-methylamphetamine as stipulated by Article 5.1 of the Decision.

EMCDDA-Europol joint report on 4-methylamphetamine

The Trans European Drug Information project (TEDI) is a network of European fieldwork Drug Checking services that share their expertise and data within a European monitoring and information system. TEDI’s chief aim is to improve public health and intervention programs. Toward this goal, TEDI has developed a database system that collects, monitors and analyses the evolution of various European drug trends in recreational settings. TEDI project is inside of the European NEWIP project.

This very first trend report includes 1,690 analyses from the period January–May 2012. These analyses were developed by four Harm Reduc2on groups located in three countries: Spain’s Ai Laket!! Analysed 71 samples and Energy Control 808 samples, Austria’s Checkit! Analysed 444 samples, while Switzerland’s Saferparty.ch analysed 367 samples. As is usual for these types of services, the most analysed substances remain MDMA (29%), cocaine (25%) and amphetamine (24%), which combined represent over 78% of the total analysed samples. This further mirrors current usage trends of substances in recreational settings. However, it must also be emphasised that the number of samples of LSD (58), heroin (41), ketamine (28), methamphetamine (24) and 2C--‐B (19) were also not insignificant.

First trend report of the Trans-European Drug Information project

Injecting drug use is a growing problem in Africa and a growing risk factor for contracting HIV in the region. It is imperative that HIV research includes injecting drug users so that they too are able to benefit from safe and effective behavioural interventions and biomedical HIV prevention and treatment products.

This article relates a critical review of the findings of a desk review of previously published literature. The article examines injecting drug use in relation to HIV-related risk and research in Kenya, Mauritius, Nigeria, South Africa and Tanzania. The ethical challenges of including people who inject drugs in HIV research in Africa are also presented. The review found injecting drug use to be on the increase in all the countries reviewed.

HIV-risk behaviour among people who inject drugs, such as needle-sharing and higher-risk sexual behaviour, was also found to be widespread. Furthermore, criminalisation of drug use and strict anti-drug laws are common in the countries reviewed, while harm-reduction programmes for people who inject drugs were found to be limited.

The review identified a number of ethical challenges to the involvement of people who inject drugs in HIV research in Africa. This includes the illegal status and stigma surrounding injecting drug use, which may complicate participant recruitment, enrolment and retention. In addition, a lack of funding for supportive programmes to help injecting drug users may hinder the provision of appropriate standards of prevention and care and treatment for those who seroconvert.

The ethics of HIV research with people who inject drugs in Africa: a desk review

Guerra as drogas

This comic book by Stuart McMillen highlights the consequences of the war on drugs. To read the full document, please click here.

War on drugs

El mercado y sus dimensiones: una propuesta para usuarios y autoridades

As the 2015 target date for achieving the Millennium Development Goals (MDGs) approaches the United Nations, governments, civil society and other global and national stakeholders are involved in a series of processes that will determine the new development goals. These processes are evolving quickly without strong participation of HIV and AIDS groups or stakeholders.

There are key opportunities for the HIV community to engage in these processes and to influence for the inclusion of HIV in the post-2015 development framework.

A High-Level Panel has been appointed by the UN Secretary-General to advise on the global development agenda beyond 2015. The panel will deliver a report with recommendations informed by country and global thematic consultations. Donors such as the European Union and the UK Government have also conducted consultations to develop their positions on the post-2015 framework. A number of parallel processes will also inform the final set of development goals, in particular the Sustainable Development Goals as a follow-up from the Rio+20 Summit and the 20 year review of the International Conference on Population and Development (ICPD+20).

This paper aims to support discussion and engagement with the post-2015 development agenda among the HIV community. It explores the barriers and opportunities for including HIV in the process and suggests how HIV and related global health needs should be addressed in the new development framework.

Discussion Paper: How the HIV community can shape the future HIV and development agenda post-2015

With a total area of over 58,000 hectares in 2012, most opium poppy cultivation in South-East Asia takes place in Lao People's Democratic Republic, Myanmar and Thailand. In order to assess the scope of opium poppy cultivation and opium production in the region, UNODC has been conducting opium surveys in cooperation with the Governments of Lao People's Democratic Republic (since 1992) and Myanmar (since 2002), while Thailand has established its own monitoring system. This report contains the results of the UNODC-supported opium poppy cultivation surveys in Lao People's Democratic Republic and Myanmar. In addition, the results from the opium poppy surveys implemented by the Government of Thailand are presented in this regional overview.

South-East Asia : Opium survey 2012

This Selected issue gives a broad overview on the extent of, and available responses to, the problems of pregnant drug users and families that are affected by drug use.

In the first part of the report, a description of the available data on the extent of drug use during pregnancy and associated risks is followed by a review of responses to drug use among pregnant women across Europe.

The second part of the publication focuses on children living in the care of drug users. Here, a review of the risks related to drug use in the family sets the scene for European overviews of responses targeting drug-using parents and responses aimed at the children of drug users. The policy and legal frameworks concerning the two situations are described, both for pregnant drug users and drug-using parents and their children.

Publications