20 November 2023

Joint Submission to the SR on Health: Harm Reduction and Prisons

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This joint submission to the Special Rapporteur on the Right to Health provides valuable input for preparing the Special Rapporteur's report on Drug Policies and Responses: A Right to Health Framework on Harm Reduction. It emphasizes harm reduction as an essential element of the right to health for people deprived of liberty. It is co-signed by Harm Reduction International (HRI), European Prison Litigation Network (EPLN), Health Without Barriers (HWB), Penal Reform International (PRI), Promo-Lex, and UnMode.

The state of Harm Reduction in prisons

Despite States’ obligations to protect the right to health of people deprived of liberty, and in disregard of the high risks that closed settings bring for people who use drugs, the Global State of Harm Reduction 2022 reveals that people in prisons are still severely underserved by harm reduction services, showing little expansion since 2020. Only 59 countries globally – with no expansion from 2020 – provide opioid agonist therapy (OAT) in at least one prison. OAT programmes are reported to be operating in prisons in Kosovo, Macau, and Tanzania.  However, new data indicates that prisons in Georgia, Hungary and Jordan only offer opioid agonists for detoxification. The scenario is even worse when it comes to the provision of Needle and Syringe Programmes (NSPs), with only 10 countries in the world operating NSPs in at least one prison. There are no NSPs, OAT or naloxone in Latin America and West Central Africa. Canada has the only world’s prison-based drug consumption room (DCR).

The fact that some harm reduction services are somehow available does not mean that are accessible in all prisons or for all prison populations. In Asia, where only five countries provide OAT in prisons, punitive approaches to drugs have translated to poor prison conditions in those countries, which restrict the already limited access to basic harm reduction services.

Punitive Responses and marginalised populations

Although over 36 countries have removed criminal sanctions for drug possession for personal use, punitive responses to drug policy remain a key contributing factor to prison overcrowding, with drug offences accounting for 22% of the global prison population. Despite the global trend towards abolition of the death penalty, as of 2022, 35 countries still retain the death penalty for drug offences, with 285 people executed which represents and 118% increase from 2021 and an 850% increase from 2020. Additionally, 303 people sentenced to death and more than 3000 currently in death row for drug offences worldwide.

Despite the international law underscoring the States’ obligations to protect the rights of all individuals and UN agencies highlighting the need for an evidence-based and human rights approach to drug policies, marginalised groups, including people who use drugs, racial, ethnic minorities, and women, continue to be targeted by law enforcement and negatively impacted by punitive responses to drug policies, resulting in the overrepresentation of these groups among the prison population. UNAIDS estimates that up to 90% of people who inject drugs will be incarcerated at some point in their life. Data confirms the disproportionate impact of pre-trial detention and prison sentences for low-level drug offences on women. Although women make up 6.9% of the prison population worldwide, this group has grown at a faster rate than men, increasing by 60% from 2000 to 2022, as opposed to 20% for the male population in the same period, with 35% of women being imprisoned for drug offences globally.

Impacts of incarceration

Punitive drug policies and limited access to harm reduction services in prisons have a negative impact on the health of people deprived of liberty and deaths in custody. Prisons are high-risk environments for the transmission of diseases due to overcrowding, limited access to clean water and inadequate sanitary conditions, lack of healthcare and access to good-quality food, and mistreatment of people in detention, to name a few. Additionally, the over-representation of vulnerable groups, such as people who use drugs, who are more likely to suffer from poor health, means many people in prison are at higher risk of becoming seriously ill if contracting a disease.

This has been compounded by the COVID-19 pandemic, which exacerbated the structural problems of the prison system and often worsened inhumane living conditions and access to essential health services, including harm reduction. Research by HRI, PRI and others revealed that the COVID-19 pandemic exacerbated the structural problems of the prison system and often worsened inhumane living conditions, with some measures implemented to control the spread of the virus having the effect of restricting the enjoyment of prisoners’ rights. HRI’s report concluded that measures implemented during the pandemic, such as extended lockdowns and suspensions of visits, seriously impacted the already limited provision of health and harm reduction services, having far-reaching health and human rights implications for people in detention in the countries surveyed. In some cases, these extreme measures continued to be implemented in prisons far beyond when they were lifted in the community, with some health services permanently limited or suspended, raising questions as to their exceptional and temporary nature.

Evidence shows that sharing injecting equipment – a common practice in prison – has been linked to outbreaks of HIV in prisons in Iran, Lithuania, Thailand, the United Kingdom and Ukraine. Globally, the prison population is 7.2 times more likely to be living with HIV that the general community, with 3.2% of prisoners living with HIV, and 15.1% living with hepatitis C. People in prison are also disproportionately vulnerable to overdose, both during their sentence and immediately after their release. Male and female prisoners are 19 and 69 times, respectively, more likely to die from an overdose than the non-prison population.

Finally, according to the joint submission by HRI, Prom-Lex and EPLN, accidental or intentional intoxication is a recurring cause of death in custody. EMCDDA’s report concludes that suicide is the leading cause of death among incarcerated people in Europe, with a considerable proportion of cases linked to drug-related problems. In Ireland and Scotland, drug overdose is a main contributor to deaths in prisons. In the USA overdose is identified as the third leading cause of death in jails. Similarly,  However, due to the lack of official, updated, disaggregated information on deaths in custody for drug use, transparency issues and inadequate death examination policies and practices, it can be difficult to aptly classify intoxication-related deaths as overdoses (accidental) or suicide (intentional) and cases may be under investigated and family’s victims without due remedies. Research by PRI and partners has found that in many countries, data on drug-related deaths in prison is not available (and often not in the community either), with at least 40 countries around the world publishing little or no data globally investigations of deaths in prison remain inadequate and, where investigations do take place, they rarely lead to accountability and reform. In many countries such as Mexico, Japan, France, Portugal, and Turkey, full investigations are usually only triggered in cases of ‘suspicious’ or violent deaths, which rarely result in redress for victims and often exclude any preventive approach.


In line with the information provided through this submission and international standards, we encourage the Special Rapporteur to recommend Member States to:

  1. Decriminalise drug use and apply health and human rights-centred community-based responses to drug use to reduce prison populations and promote the right to health;
  2. Introduce decongestion and early release measures to reduce prison overcrowding;
  3. Ensure drug-related offences are not subject to any blanket restrictions in decongestion and early release mechanisms;
  4. Recognise harm reduction as an essential element of the right to health and incorporate it into prison health programmes and policies;
  5. Ensure that good quality harm reduction services are available, accessible on a voluntary basis for all people in detention;
  6. Ensure that people can continue accessing harm reduction services upon release without discrimination; and
  7. Ensure the same standards of health care that are available in the community and provide access to necessary health-care services to prisoners free of charge without discrimination.

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