Intended for healthcare professionals


Drug taking in prisons: the inside story

BMJ 2005; 330 doi: (Published 07 April 2005) Cite this as: BMJ 2005;330:853
  1. David Crosby, honorary consultant surgeon (gwendacrosby{at}
  1. University Hospital of Wales, Cardiff

    On retirement from surgery I took up a number of different interests, one of which was to join the independent monitoring board of our local prison. This is an improved title for what used to be known as prisons' boards of visitors. We are appointed by the Home Office, and essentially our duties involve visiting the prison on a regular basis and monitoring whether prisoners are being treated decently and fairly under existing prison rules. We make confidential inquiries for them if they believe they aren't being treated properly and representations if they seem to be justified. I believe the system works very well. Had there been something similar in Iraq, I doubt we would now be hearing the recent horror stories coming from its prisons.

    The foremost requirement for this kind of work is to believe that no matter what awful things people have done or how unpleasant they continue to be they must still be treated decently as human beings. Secondly, we encourage as best as we can any initiative that might help to reduce their chances of reoffending when they are released. Additional requirements for the post are having enough free time and being fit enough to walk and climb around the extensive wings, galleries, workshops, and other areas where the prisoners spend their days, months, and years.

    If the solution cannot be found in prisons, what chance is there in society at large?

    It often seems to me that a hospital background is also an advantage. As institutions, hospitals and prisons have a surprising number of common features, including bureaucracy, hierarchies, specialties, budgets, higher authorities, and even rivalries with other prisons. Self harm and mental illness are also common, and even to an old surgeon like me these are more familiar than to the average citizen.

    However, illicit drug taking on the scale that now exists in many prisons is a new experience for me. It is, of course, not surprising that with a literally captive population we have good evidence of the extent of the problem. The problem results in part from the “carrot and stick” system, whereby those who behave sensibly may earn privileges such as access to better cells, television, longer visiting hours, and even recategorisation to allow them to be transferred to an open prison.

    Among the hurdles to be cleared is agreement to “MDT” (mandatory drug testing), which allows the prison's staff to test regularly the urine of between 5% and 10% of prisoners at random for the presence of illicit drugs. Prisoners with negative test results maintain or improve their privileges, and those with positive results lose them. The percentage of prisoners with positive results may vary between 10% and 30% or more, and extrapolation to a UK prison population of around 75 000 gives some idea of the size of the problem. It must be remembered that a major proportion of the prison population is there because of offences related directly or indirectly to drug taking.

    Perversely, MDT has been blamed for aggravating the problem, in that prisoners are well aware that using any form of marijuana on a single occasion can be identified by MDT after several weeks, whereas heroin cannot be detected after a day or so. Therefore, although it is more dangerous, heroin is more popular.

    How do prisoners maintain their supplies? Apart from concealment by new prisoners in bodily sites that are difficult to check, a number of possible vectors include family, friends, and other visitors, as well as small packages thrown over the walls at pre-arranged times and places. Visits to court by prisoners on remand also provide further opportunities. Body searches, sniffer dogs, and closed circuit television at visiting times are all used but are largely ineffective, in the light of current rates of positive MDT results. “Closed visits” in which glass screens prevent physical contact between prisoners and visitors are used in some circumstances but are intensely disliked by prisoners and their families.

    Almost half of new prisoners go first to a “detox” wing, usually for several weeks, before placement elsewhere in the prison. Despite this, and despite the efforts of many outside agencies, the great majority of prisoners relapse when they are released. It seems, therefore, that despite much expenditure of money and effort, there is little discernible effect on the scale of the overall problem.

    Whatever my previous reflections, I am now firmly of the view that legalisation of “recreational” drugs should be resisted. Such drugs are now more refined and potent, and I have no doubt that they make a major contribution to crime rates. Also, they contribute to the erratic and psychotic behaviour of many prisoners.

    If our results are so poor, even in a contained population, what more can be done? It is clear that current countermeasures are not working. I can't help feeling that a sufficiently determined regime should have the desired effect of reducing the prevalence of such institutionalised drug taking, to the benefit of all concerned, including the public.

    If the solution cannot be found in prisons, what chance is there in society at large?