Substance Use During Imprisonment in Low- and Middle-Income Countries

Abstract

Substance use disorders are among the most common health problems of people involved with the criminal justice system. Scaling up addiction services in prisons is a global public health and human rights challenge, especially in poorly resourced countries. We systematically reviewed the prevalence of substance use in prison populations in low- and middle-income countries. We searched for studies reporting prevalence rates of nicotine, alcohol, illicit drug, and injection drug use during imprisonment in unselected samples of imprisoned people in low- and middle-income countries. Data meta-analysis was conducted and sources of heterogeneity were examined by meta-regression. Prevalence of nicotine use during imprisonment ranged from 5% to 87%, with a random-effects pooled estimate of 56% (95% confidence interval (CI): 45, 66) with significant geographical heterogeneity. Alcohol use varied from 1% to 76% (pooled prevalence, 16%, 95% CI: 9, 25). Approximately one-quarter of people (25%; 95% CI: 17, 33; range, 0–78) used illicit drugs during imprisonment. The prevalence of injection drug use varied from 0% to 26% (pooled estimate, 1.6%, 95% CI: 0.8, 3.0). Lifetime substance use was investigated in secondary analyses. The high prevalence of smoking in prison suggests that policies regarding smoking need careful review. Furthermore, the findings underscore the importance of timely, scalable, and available treatments for alcohol and illegal drug use by people involved with the criminal justice system.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

“…Despite widespread recognition that exclusive reliance on supply reduction is ineffective in regulating illicit drug markets ( 33 , 34 ) and that prisons concentrate people who are substance dependent, supply reduction is the predominant method of substance use control in prison settings. Mundt et al ( 35 ) reviewed the prevalence of substance use in unselected, representative samples of prisoners in low- and middle-income countries (LMICs). Despite marked heterogeneity in prevalence estimates, which was partially explained by regional differences, they generated random effects pooled-prevalence estimates of 56% for tobacco smoking, 16% for alcohol use, 25% for illicit drug use, and 1.6% for injection drug use.…”

“…As in the community, it is abundantly clear that zero-tolerance responses to substance use in prison are ineffective. Accordingly, in addition to targeted responses for people who inject drugs in prison, the authors call for evidence-based alcohol treatments and argue that prison smoking bans, detoxification, and addiction treatment services “have the potential to address the large burdens of smoking and substance use in LMICs” ( 35 , p. 70).…”

“…For example, Wirtz et al ( 30 ) highlighted an almost complete lack of evidence on BBVs in key populations from low-income countries, including those in Eastern Europe and Central Asia. The importance of country- and region-specific evidence is illustrated by Mundt et al ( 35 ), who observed important regional differences in patterns of substance use in prison in LMICs. A lack of evidence specific to these settings and to key populations in these settings precludes the development of tailored interventions.…”

“…Retaining people released from prison in survey-based longitudinal studies is notoriously challenging ( 72 ), but a methodology that holds promise is data linkage. Administrative data can be a valuable complement to self-reported data in both routine data collection and research, particularly when examining proscribed or stigmatized behaviors ( 14 , 32 , 35 , 72 ). Linkage with administrative health data also provides opportunities to accurately document the considerable costs of health care for people released from prison ( 73 ), which may assist in health economic analyses and in advocating for investments in primary and preventive health care for this population ( 74 ).…”

Editorial: Synthesizing the Evidence on Prisoner Health—Taking Stock and Moving Forward

“…The current issue of Epidemiologic Reviews comprises a number of systematic reviews and meta-analyses in which the authors address emerging challenges for prison health—delineating the health problems of the growing number of older prisoners ( 4 ), understanding the adverse effects of incarceration on the families of those in custody ( 5 ), and mitigating risky behaviors in prison ( 6 , 7 )—and synthesize the latest evidence on health problems that remain central in prison, such as the prevalence of treatable mental disorders ( 8 ), interventions for and the modeling of infectious diseases ( 9 ), treatments for substance misuse ( 10 ), and health needs of prisoners in low- and middle-income countries ( 11 ). The 2 overriding themes that are apparent from reading these papers are 1) the methodological issues that cut across the different reviews and 2) the various implications arising from them.…”