Factors associated with drug use in prison: A systematic review of quantitative and qualitative evidence

Abstract

Background: About a third of people use drugs during their incarceration, which is associated with multiple adverse health and criminal justice outcomes. Many studies have examined factors associated with in-prison drug use, but this evidence has not yet been systematically reviewed. We aimed to systematically review and synthesise the evidence on factors related to drug use in prison. Methods: Three databases (PubMed, PsycINFO and Embase) were systematically searched as well as grey literature, for quantitative, qualitative and mixed-methods studies examining factors related to drug use inside prison. We excluded studies that did not explicitly measure in prison drug use or only measured alcohol and/or tobacco use. Study quality was assessed using the Newcastle Ottawa Scale (NOS) for quantitative studies and Critical Appraisal Skills Programme (CASP) for qualitative studies. The review was prospectively registered on PROSPERO (CRD42021295898). Results: Fifty-four studies met the inclusion criteria, reporting data on 26,399 people in prison. Most studies were of low or moderate-quality, and all used self-report to assess drug use. In quantitative studies, studies found that previous criminal justice involvement, poor prison conditions, pre-prison drug use and psychiatric diagnosis were positively associated with drug use in prison. In qualitative studies, reasons for drug use were closely linked to the prison environment lacking purposeful activity and the social context of the prison whereby drug use was seen as acceptable, necessary for cohesion and pressurised. Conclusion: In the first systematic review of factors associated with drug use in prison, key modifiable risk factors identified from quantitative and qualitative studies were psychiatric morbidity and poor prison conditions. Non-modifiable factors included previous drug use and criminal history linked to substance use. Our findings indicate an opportunity to intervene and improve the prison environment to reduce drug use and associated adverse outcomes.

Full text

International Journal of Drug Policy 122 (2023) 104248
Available online 10 November 2023
0955-3959/© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Systematic Review
Factors associated with drug use in prison: A systematic review of
quantitative and qualitative evidence
Alice Austin
a
, Louis Favril
b
, Sam Craft
a
, Phoebe Thliveri
a
, Tom P Freeman
a
,
*
a
Addiction and Mental Health Group (AIM), Department of Psychology, University of Bath, UK
b
Faculty of Law and Criminology, Ghent University, Belgium
ARTICLE INFO
Keywords:
Drug use
Prison
Criminal justice system
Prison conditions
Systematic review
ABSTRACT
Background: About a third of people use drugs during their incarceration, which is associated with multiple
adverse health and criminal justice outcomes. Many studies have examined factors associated with in-prison drug
use, but this evidence has not yet been systematically reviewed. We aimed to systematically review and syn-
thesise the evidence on factors related to drug use in prison.
Methods: Three databases (PubMed, PsycINFO and Embase) were systematically searched as well as grey liter-
ature, for quantitative, qualitative and mixed-methods studies examining factors related to drug use inside
prison. We excluded studies that did not explicitly measure in prison drug use or only measured alcohol and/or
tobacco use. Study quality was assessed using the Newcastle Ottawa Scale (NOS) for quantitative studies and
Critical Appraisal Skills Programme (CASP) for qualitative studies. The review was prospectively registered on
PROSPERO (CRD42021295898).
Results: Fifty-four studies met the inclusion criteria, reporting data on 26,399 people in prison. Most studies were
of low or moderate-quality, and all used self-report to assess drug use. In quantitative studies, studies found that
previous criminal justice involvement, poor prison conditions, pre-prison drug use and psychiatric diagnosis
were positively associated with drug use in prison. In qualitative studies, reasons for drug use were closely linked
to the prison environment lacking purposeful activity and the social context of the prison whereby drug use was
seen as acceptable, necessary for cohesion and pressurised.
Conclusion: In the rst systematic review of factors associated with drug use in prison, key modiable risk factors
identied from quantitative and qualitative studies were psychiatric morbidity and poor prison conditions. Non-
modiable factors included previous drug use and criminal history linked to substance use. Our ndings indicate
an opportunity to intervene and improve the prison environment to reduce drug use and associated adverse
outcomes.
Introduction
People who use drugs are overrepresented in prison (Montanari
et al., 2022). Approximately half of those in prison in Europe have used
drugs in the year prior to imprisonment (Favril, 2023; van de Baan et al.,
2022) and 30–51 % of prison entrants meet diagnostic criteria for a drug
use disorder (Fazel et al., 2017). While for some people incarceration
may result in cessation of drug use, many continue to use drugs during
imprisonment (although often less frequently) and others may even start
using drugs in prison (Boys et al., 2002; Favril, 2023; Plugge et al., 2009;
Rousselet et al., 2019; Strang et al., 2006). Overall, evidence indicates
that approximately 20–45 % people in prison use drugs in some form
during their incarceration (Bukten et al., 2020; Carpentier et al., 2018;
Favril, 2023; Mundt et al., 2018; Norman, 2022).
Drug use in prisons is linked to a wide range of adverse outcomes.
People in prison who use drugs are more likely to contract infectious
diseases such as hepatitis C, have psychiatric morbidity, self-harm,
overdose, re-offend on release and die prematurely (Chang, Larsson
et al., 2015, Chang, Lichtenstein et al., 2015; Favril et al., 2020; Mon-
tanari et al., 2022). The relationship between drug use and crime is
complex, however, re-offending related to drug use often results in
recurrent short sentences (Montanari et al., 2022). Given the frequent
contact with the community due to repeat sentences, as well as the risks
identied in terms of continued drug use, risk behaviour leading to
* Corresponding author.
E-mail address: t.p.freeman@bath.ac.uk (T.P. Freeman).
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
https://doi.org/10.1016/j.drugpo.2023.104248

International Journal of Drug Policy 122 (2023) 104248
2
infectious diseases and increased mortality, addressing drug use in
prison and related harms is benecial for both people in prison and
wider society (Chandler et al., 2009; Montanari et al., 2022).
The impact of drug use in prison on both individuals and commu-
nities warrants further efforts to prevent and intervene with this
behaviour (Favril, 2023; Montanari et al., 2022). However, a thorough
understanding of the factors, such as individual characteristics and
environmental inuences, related to drug use in prison has not yet been
established. Better characterisation of the population that uses drugs
while in prison in terms of demographics, criminal history variables,
prison inuences and motives for drug use, hereinafter referred to
collectively as ‘factors’, would enhance the current understanding of
potential predictors or drivers for drug use in prison. Identication of
risk factors can help determine the nature and type of interventions
required as well as improve screening and help target interventions for
high-risk groups, enabling prisons to plan and deliver effective services
and treatment (Montanari et al., 2022).
To our knowledge, factors associated with drug use in prison have
not been systematically reviewed. We aimed to systematically review
and synthesise the existing evidence base regarding factors linked to
drug use in prison.
Method
This review was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines (Page et al., 2021; Table S1) and pre-registered on PROS-
PERO (number CRD42021295898).
Eligibility criteria
Studies were included if they met the following criteria: (1) the
sample comprised of people currently in prison (sentenced and/or
remand), (2) the study included a measure of drug use inside prison as
the outcome (either self-report or biologically veried) and (3) the study
measured factor(s) related to drug use. For quantitative studies, factors
were dened as any variable (e.g., sociodemographic, health, criminal
justice, or drug-related variables) on which statistical analysis was
conducted to assess its association with drug use in prison. For quali-
tative studies, factors were dened as any emergent theme that was
identied as being related to drug use in prison. Qualitative studies did
not need to have a comparison group. Qualitative studies that also
included staff perspectives and did not distinguish this in the results
were excluded.
We excluded studies with people released from prison who were
retrospectively reporting on prison drug use and those only examining
pre-prison or lifetime drug use. Studies that dened people who used
drugs by diagnoses (e.g. substance use disorders) without verifying drug
use in prison were also excluded. Any illicit drugs (including non-
prescribed medications) were considered; studies exclusively exam-
ining alcohol and/or tobacco use were not included. No age restrictions
were set. Quantitative, qualitative and mixed-methods studies were
included. Studies without original data (such as reviews), conference
abstracts, and case studies were excluded.
There were no language exclusions as part of the search, however,
terms were developed in English. Due to the multilingual review team,
studies were included if they were written in English, Dutch, French or
German. There was no limit on publication date.
Search strategy and study selection
A systematic search was conducted using PubMed, Embase, and
PsycINFO databases on 5th May 2022 and later updated on 21st March
2023. Title, abstract, and keyword searches were conducted using terms
that were inclusive of drugs AND prison (full search strategy in Table
S2). Grey literature was searched using targeted searches of relevant
organisations (e.g., European Monitoring Centre for Drugs and Drug
Addiction) (August 2022). The reference lists of related systematic re-
views and included studies were also hand searched (November 2022).
After removing duplicates, title and abstract screening was con-
ducted independently by two reviewers (AA and either LF or SC) using
the eligibility criteria. Two reviewers then independently screened the
full text of studies for inclusion. Screening at both stages was completed
using Rayyan, an online screening tool (Ouzzani et al., 2016), with a
blind lter. Disagreements between researchers were resolved through
discussion.
Data extraction
The following characteristics were extracted by two reviewers
independently (AA and either LF or SC): study characteristics, sample
characteristics, prison characteristics, drug use and factors examined in
relation to drug use in prison. For quantitative studies, any examined
association was extracted. Where authors reported both adjusted and
unadjusted estimates of association effects, adjusted estimates were
preferred. For qualitative studies, themes and quotes were extracted.
Quantitative and qualitative components from mixed-methods studies
were extracted with the relevant extraction form. Data was not cat-
egorised in any way at the point of extraction.
Where multiple publications covered the same or overlapping sam-
ples, data were extracted from the study with the most comprehensive
analysis of factors (e.g. hierarchical regression compared to correlation),
or, if this was equal, the largest sample.
Quality assessment
Study quality was assessed by two independent reviewers (AA and
either SC or PT) and discrepancies were discussed. For quantitative
studies, the Newcastle-Ottawa Scale (NOS; Wells et al., 2000) was used
for cohort and case-control studies adapted by adding relevant examples
to the denitions. Adaptations were made for utilisation with
cross-sectional studies, based on a previous systematic review (Petrilli
et al., 2022) and discussions within the research team (AA, LF, SC, TF).
The maximum score indicating high-quality was 10 for cross-sectional,
11 for case-control, and 12 for cohort studies.
The Critical Appraisal Skills Programme (CASP, 2022) was used for
quality assessment of qualitative studies. The maximum score was 10.
To allow for a comparison across study designs, a standardised score
was created by dividing the sum of items by the total possible score to
create a score from 0 to 100. Studies with scores equal to or less than 75
were considered high-quality, between 74 and 50 moderate, and less
than or equal to 49 low (Favril et al., 2020).
Data analysis
Findings were narratively synthesised. Meta-analysis was not
appropriate due to the substantial heterogeneity in samples and out-
comes. A parallel-results convergent synthesis design was employed
whereby quantitative and qualitative data were extracted and analysed
separately (Hong et al., 2017). The results of each analysis are presented
separately and synthesised in the discussion.
Results
Study identication
A total of 11,421 records were identied (Fig. 1). Following title and
abstract screening, 345 records were assessed for eligibility. An addi-
tional four studies were identied from reference lists and one from
updating the search. This resulted in 54 studies being included in the
narrative synthesis: 42 quantitative, 9 qualitative, and 3 mixed methods.
With duplicate samples removed from analysis, there were 38 unique
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
3
samples for quantitative studies, 8 for qualitative and 3 mixed methods.
Of the 3 mixed methods studies, one was included for its qualitative
component only, one for its quantitative component only and one for
both. Therefore, 40 studies were extracted with the quantitative
extraction form and 10 studies were extracted with the qualitative. The
included studies had a total sample size of 26,399 (M =550.0, SD =
624.9) people in prisons.
Quality assessment
Using the NOS, cross-sectional studies had a mean score of 4.9 out of
10 (SD =2.0, range 1–9). Case-control studies had a mean score of 4.5
out of 11 (SD =0.7, range 4–5) and for cohort studies the mean score
was 7.0 out of 12 (SD =2.6, range 4–9). Overall, 7 studies (17.5 %) were
rated as high-quality, 17 (42.5 %) as moderate, and 16 (40 %) as low
(see Table S3). Common weaknesses were failing to justify sample size,
provide a summary of non-respondents and use a validated measure for
exposure.
On the CASP, the mean score for qualitative studies was 7.6 out of 10
(SD =1.8, range 4–9. Overall, 7 studies (70 %) were rated as high-
quality, 2 (20 %) as moderate and 1 (10 %) as low (Table S4). Com-
mon weaknesses were not providing a detailed description of the anal-
ysis process or considering the relationship between researcher and
participants and how this may bias the research process.
Quantitative study characteristics
Including eligible mixed-methods studies, in total there were 44
quantitative studies reporting on 40 unique samples between 1987 and
2022 (Table 1). Studies reported on data from 17 countries, most were
from the United States (k =7), Australia (k =5), Spain (k =5) and Brazil
(k =4). Most studies (k =35, 87.5 %) were cross-sectional, with three
(7.5 %) cohort and two (5 %) case-control studies. The total number of
participants across all individual studies was 26,152 with individual
study sample sizes ranging between 71 and 3142 (M =670.6, SD =
637.7). Most studies (k =17, 42.5 %) included men and women, while
35 % were men-only (k =14), 20 % (k =8) women-only and one (2.5 %)
did not report this. Most studies included adult samples (k =32, 80 %),
two were exclusively juvenile (<18 years) (5 %), two were a mix of adult
and juvenile (5 %). The rest did not state the population or ages studied.
A third (k =13, 32.5 %) of studies reported how long participants had
spent in prison, 69 % (k =9) of which reported an average which ranged
from 11 to 60 months. Most studies (k =31, 77.5 %) did not report the
type or security level of the prison. In-prison drug use was assessed by
self-report in all studies (k =40, 100 %).
The most common method of assessing drug use in prison was ‘ever
use’ during imprisonment (k =16, 40 %) followed by ‘within the last six
months’ (k =5, 12.5 %) and ‘three months’ (k =5, 12.5 %). Other
measures included ‘past month’ (n =2, 5 %), ‘month following entry’ (k
=2, 5 %) or ‘use at least once a month’ (k =2, 5 %) and ‘past 12 months’
(k =1, 2.5 %). Two studies (5 %) measured drug use from participants’
last reported use (5 %). Five studies (12.5 %) did not state the time frame
in which drug use in prison was measured.
Half the studies (k =18, 45 %) measured the use of multiple drugs
(most commonly cannabis, heroin, cocaine, and non-prescribed medi-
cations such as benzodiazepines) without differentiating in analyses.
Three studies (7.5 %) focused on one specic drug; cocaine (Carvalho
et al., 2005), cannabis (Jacups & Rogerson, 2015) and non-prescribed
medication (Thomas & Cage, 1977). In addition to illicit drugs, 14
studies (35 %) also asked about alcohol and/or tobacco use, 10 of which
included them in their denition of illicit drugs and therefore included
in their analysis. Eight studies (20.5 %) exclusively reported on injection
drug use (IDU) in prison as the outcome variable.
Studies mainly compared people who had used drugs in prison to
those who had not (k =34, 85 %). However, six (15 %) used alternative
comparisons. Specically, one compared people who had used drugs in
prison to those that had used drugs elsewhere (Boys et al., 2002) and
another compared different types of drug use between people in prison
(e.g. heroin and cocaine), excluding people who did not use drugs
(Caravaca-S´
anchez et al., 2022). Two examined drug use in prison in
those with a pre-prison history of IDU (Calzavara et al., 2003; Kinner
et al., 2012). Another compared drug use to never using the drug
(Carvalho et al., 2005), excluding those who had used drugs outside of
prison. One compared people who did not use drugs in prison to those
who had continued their use into prison (Plugge et al., 2009), excluding
those had only used in prison.
Quantitative factors related to drug use in prison
In total, 428 associations for 31 different factors were measured
across the 40 unique samples of which there was evidence for a signif-
icant association (either positive or negative) in 209 (49 %) and no
evidence for a signicant association in 219 (51 %). The factors iden-
tied were organised into ve overarching themes: sociodemographic,
criminal history, prison, substance use, and psychological characteris-
tics. Factors identied in ve or more studies are discussed below.
Substance use characteristics. Factors within this theme related to
drug use and treatment, both before and during imprisonment. Sub-
stance use characteristics were the most frequently identied theme,
examined in 27 (67.5 %) of the 40 studies.
Within this, pre-prison substance use was examined by 22 of the 27
Fig. 1. PRISMA ow diagram of included studies.
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
4
Table 1
Study characteristics for quantitative evidence.
Study Country Prisons
(n)
Sample Outcome Study
quality Sample type Mean age
(range)
Sample
size
(%
female)
Drugs examined
(multiple or
specic)
Measurement of
drug use in prison
Variables
adjusted for in
analysis
Cross-sectional
Albertie et al. (2017) Mexico 3 First time in
prison
≥18 593 (0 %) Multiple Past month S, M, D High
Azbel et al. (2018)* Kyrgyzstan 8 Soon to be
released
37.4 368 (13
%)
Multiple (IDU) Ever (current
incarceration only)
S, D, C, P High
Baltieri (2014) Brazil 1 Convicted of
violent offence
31.6 315 (100
%)
Multiple Past 6 months S, M, D, C High
Ba˜
nuls-Oncina et al.
(2019)
Spain 1 Potential use of
drugs
36.8 178
(38.2 %)
Multiple (IDU) Past 6 months S, D, C, P Low
Boys et al. (2002) UK NR General ≥16 3142
(24.5 %)
Multiple Ever S High
Bukten et al. (2020) Norway 57 General 34.6 1499
(6.4 %)
Multiple Ever S, M, D, C Mod
Butler et al. (2003) Australia 27 General NR 789
(16.7 %)
Multiple (IDU) Ever None Mod
Calzavara et al. (2003) Canada 6 General ≥18 597
(26.5 %)
Multiple (IDU) Past 12 months D, C Mod
Caravaca-S´
anchez et al.
(2022)
Spain 6 General 38.48
(18–66)
1325
(15.6 %)
Multiple Past 3 months S, M, C, P Low
Caravaca-S´
anchez and
García-Jarillo (2020)
Spain 2 General 37.6 174 (100
%)
Multiple Past 3 months S, C, P Mod
Caravaca-S´
anchez and
Wolff (2020)
Spain 3 General 37.2
(18–83)
943 (0 %) Multiple Past 3 months S, P, M Mod
Culbert et al. (2015)** Indonesia 2 HIV positive 31.3 102 (0 %) Multiple (IDU) Ever D, P Low
Ebiti et al. (2012) Nigeria NR General 20.6
(12–39)
401 (0 %) Multiple NR None Low
Favril and Vander
Laenen (2018)
Belgium 15 General 37.7
(18–77)
1326 (9
%)
Multiple Ever (current
incarceration only)
S, M, D, C, P Mod
Jacups and Rogerson
(2015)**
Australia 1 Indigenous 18–40 101 (0 %) Cannabis Past 3 months None Mod
Khalooei et al. (2016) Iran 1 General 32.6
(18–60)
332 (0 %) Multiple At least once a
month
S, D Mod
Kinner et al. (2012)*** Australia 7 General NR 1322
(NS)
(IDU) Ever (current
incarceration only)
S, D, P Low
Korte et al. (1998) Finland 4 General 32
(18–76)
354 (0 %) Multiple Ever (current
incarceration only)
None Low
Koulierakis (2006) Greece 1 General 34.8 103 (0 %) Multiple (IDU) Last injected D Low
Lanza-Kaduce and
Radosevich (1987)
USA 1 General 16.5
(14–20)
148 (0 %) Multiple Ever (current
incarceration only)
None Low
Leigey (2019) USA 2 General 35.8
(18–72)
1821
(100 %)
NR Ever P Low
Lins-Filho et al. (2021) Brazil 1 General 18–63 294
(91.5 %)
NR At least once a
month
None Mod
Martin et al. (2005) Canada 1 General NR 104 (100
%)
Multiple Ever (current
incarceration only)
None Low
Narkauskaite et al.
(2007)
Lithuania 8 General 27
(15–78)
1304
(5.2 %)
Multiple NR None Low
Narkauskaite et al.
(2010)
Lithuania 1 General 34
(20–60)
71 (100
%)
Multiple NR None Low
Nev´
arez-Sida et al.
(2012)
Mexico NR General NR 1223
(17.5 %)
Multiple Past month D, C, P Mod
Plourde et al. (2012)**** Canada NR General NR 493
(35.7 %)
Multiple Past 3 months S, P Mod
Reed et al. (2009) Brazil NR General NR 377 (100
%)
Multiple NR S, C, P Mod
Rowell et al. (2012) USA 1 Black 42.1 (23-
74)
134 (0 %) NR Month/year
stopped using
D, C, P Low
Rowell-Cunsolo et al.
(2016)
USA NR General NR 1361
(43.9 %)
Multiple Past 6 months S, D, P Mod
Sahajian et al. (2017) France NR General NR 457
(9.19 %)
Multiple Ever None Low
S´
anchez et al. (2018) Spain 6 General 37.5
(19–70)
225 (100
%)
Multiple Past 6 months S, D Mod
Simpler et al. (2005) USA 2 General 33.1 103 (0 %) Multiple Ever None Low
Strang et al. (2006) UK 13 General NR 1009 (0
%)
Multiple 1 month following
entry
None Low
Thomas & Cage, (1977) USA 1 General NR 273 (0 %) Prescription
medication
Ever None Low
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
5
studies (81.5 %) with three (13.6 %) being considered high-quality. In
representative samples, cross-sectional studies found that use in the 30
days before prison (Azbel et al., 2018) and frequent (once a week, three
times a week or every day) pre-prison substance use (Albertie et al.,
2017) were positively associated with drug use in prison. Using a
case-control design, prior alcohol use (yes/no) but not cannabis use
(yes/no) before prison was associated with prison drug use (Carvalho
et al., 2005). The remainder of the studies were moderate or low-quality
(k =24). These studies consistently found that pre-prison drug use
including any use (Ebiti et al., 2012; Rowell et al., 2012; Thomas &
Cage, 1977), frequent use (Albertie et al., 2017; Thomas & Cage, 1977),
use in the 6 (Bukten et al., 2020) or 12 (Favril & Vander Laenen, 2018)
months prior to prison were all associated with drug use in prison.
Injecting heroin or other opiates in the year before prison (Calzavara
et al., 2003), ever injected drugs (Kinner et al., 2012) and number of
drugs used in lifetime (Bukten et al., 2020) were also associated with
drug use in prison. The evidence was most frequently for any pre-prison
substance use rather than the use of specic drugs such as heroin.
Five studies examined whether there was an association between
severity of substance use or dependence and drug use in prison. Of these,
one was rated as high-quality and found that, when controlling for
confounders, higher scores on a measure of drug abuse were positively
associated with the use of drugs in prison among those convicted of a
violent offence (Baltieri, 2014). The remaining studies of low and
moderate-quality did not nd an association (Ba˜
nuls-Oncina et al.,
2019; Calzavara et al., 2003; Leigey, 2019; Strang et al., 2006).
Receiving drug treatment before prison was associated with drug use
in prison in two studies (Favril & Vander Laenen, 2018; Strang et al.,
2006), but not in three other studies (Ba˜
nuls-Oncina et al., 2019; Leigey,
2019; Plugge et al., 2009). Treatment in prison was protective against
drug use in prison in one study (Darke et al., 1998) but no association
was found in another (Kinner et al., 2012). All studies examining drug
treatment were of low to moderate-quality.
Sociodemographic characteristics. Sociodemographic factors
related to social and demographic characteristics which dene indi-
vidual populations. These were examined in 28 (70 %) of all quantitative
studies.
Age was examined in 20 studies of the 28 studies (71.4 %). There
were mixed ndings among high-quality studies with cross sectional
studies nding older age was positively (Boys et al., 2002), negatively
(Albertie et al., 2017) and not (Baltieri, 2014) associated with drug use
in prison. Age was most frequently found to be negatively associated
with drug use in prison meaning that as people got older, they were less
likely to use drugs (Albertie et al., 2017; Butler et al., 2003; Car-
avaca-S´
anchez & Wolff, 2020; Carvalho et al., 2005; Cunningham et al.,
2018; Favril & Vander Laenen, 2018; Korte et al., 1998; Rowell et al.,
2012; Sahajian et al., 2017), including IDU (Cunningham et al., 2018).
However, 11 studies found no association for age (Baltieri, 2014;
Ba˜
nuls-Oncina et al., 2019; Boys et al., 2002; Bukten et al., 2020; Car-
avaca-S´
anchez & García-Jarillo, 2020; Caravaca-S´
anchez & Wolff, 2020;
Caravaca-S´
anchez et al., 2022; Jacups & Rogerson, 2015; Leigey, 2019;
Plugge et al., 2009; S´
anchez et al., 2018).
Nationality was examined in ve studies. Three studies
(Ba˜
nuls-Oncina et al., 2019; Caravaca-S´
anchez & García-Jarillo, 2020;
Favril & Vander Laenen, 2018) found domestic nationality, compared to
foreign, was associated with drug use in prison while two found no as-
sociation (Bukten et al., 2020; Caravaca-S´
anchez & Wolff, 2020). All
studies were of low to moderate-quality, most being limited by failing to
justify the sample size (k =3, 60 %). Pre-prison unemployment was
associated with drug use in prison in four studies, including IDU (Kinner
et al., 2012), in male (Leigey, 2019; Thomas & Cage, 1977) and female
samples (Martin et al., 2005), but all were considered low quality.
Furthermore, ve studies found no association (Albertie et al., 2017;
Boys et al., 2002; Bukten et al., 2020; Jacups & Rogerson, 2015; Leigey,
2019).
Male (Bukten et al., 2020; Kinner et al., 2012; Plourde et al., 2012;
Rowell-Cunsolo et al., 2016), female (Butler et al., 2003; Darke et al.,
1998) and transgender (Lins-Filho et al., 2021) status were associated
with drug use in prison while six studies found no sex/gender difference
(Azbel et al., 2018; Ba˜
nuls-Oncina et al., 2019; Boys et al., 2002; Cun-
ningham et al., 2018; Favril & Vander Laenen, 2018; Sahajian et al.,
2017). Studies that found an association were mostly moderate-quality
and were limited by a possible response bias due to lacking informa-
tion on non-respondents (Bukten et al., 2020; Butler et al., 2003; Kinner
et al., 2012; Lins-Filho et al., 2021; Plourde et al., 2012; Rowell-Cunsolo
et al., 2016), while the high-quality studies that examined sex/gender
did not nd an association (Azbel et al., 2018; Boys et al., 2002).
White ethnicity was associated with greater likelihood of using drugs
in prison in one low quality study (Thomas & Cage, 1977) but six studies
found no relationship (Azbel et al., 2018; Boys et al., 2002; Butler et al.,
2003; Kinner et al., 2012; Martin et al., 2005; Plugge et al., 2009).
Four studies found lower educational attainment to be associated
with drug use (Boys et al., 2002; Caravaca-S´
anchez & García-Jarillo,
2020; Caravaca-S´
anchez et al., 2022; Jacups & Rogerson, 2015). One of
these was rated as high-quality, however, two studies found the oppo-
site, that higher educational attainment was associated with drug use in
prison (Khalooei et al., 2016; Thomas & Cage, 1977). Additionally, ten
studies did not nd an association (Albertie et al., 2017; Boys et al.,
2002; Bukten et al., 2020; Butler et al., 2003; Caravaca-S´
anchez &
Wolff, 2020; Caravaca-S´
anchez et al., 2022; Khalooei et al., 2016; Kin-
ner et al., 2012; Martin et al., 2005; Plugge et al., 2009).
Only one study, rated as high-quality, identied homelessness as
associated with drug use in prison (Boys et al., 2002) with ve moderate
to low-quality studies nding no relationship between pre-prison ac-
commodation status or stability (Boys et al., 2002; Jacups & Rogerson,
2015; Kinner et al., 2012; Leigey, 2019; Martin et al., 2005) and drug use
in prison.
Two studies, one high (Boys et al., 2002) and one low-quality
(Thomas & Cage, 1977), found that those who were unmarried or
divorced were more likely to use drugs in prison but seven did not nd
an association with relationship status (Albertie et al., 2017; Azbel et al.,
2018; Caravaca-S´
anchez & García-Jarillo, 2020; Caravaca-S´
anchez &
Wolff, 2020; Jacups & Rogerson, 2015; Kinner et al., 2012; Leigey,
2019).
Cohort
Cunningham et al. (2018) Australia 23 Pre-prison IDU 28 499 (35.1 %) Multiple (IDU) Ever (current incarceration only) S, C, P Low
Kimonis et al. (2012) USA 1 General 16.4 (14–17) 373 (0 %) NR NR P High
Plugge et al. (2009) UK 13 General 21–39 505 (100 %) Multiple 1 month following entry None Mod
Case-control
Carvalho et al. (2005) Brazil NR General NR 1314 (6.1 %) Cocaine Ever S High
Darke et al. (1998) Australia 5 Methadone maintenance 31.7 (20–48) 100 (53 %) Multiple Past 6 months None Mod
Note. NR =not reported ; ** =Mixed-methods study ; Adjustment key ; S =sociodemographic variables, M =mental health variables, D =drug use variables, C =
criminological, P =prison conditions, *Kyrgyzstan sample same as Polonsky et al. (2016), ***Queensland sample same as Kinner et al. (2013), ****male sample same
as Plourde and Brochu (2002a and 2002b), study quality; mod =moderate.
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
6
No association was clearly demonstrated between family factors,
such as having children (Albertie et al., 2017; Jacups & Rogerson, 2015;
Leigey, 2019; Martin et al., 2005) or experiencing family difculties
(Bukten et al., 2020; Carvalho et al., 2005; S´
anchez et al., 2018) and all
but one study was low or moderate-quality.
Criminal history characteristics. Criminal history characteristics
included factors that related to participants past involvement with any
element of the criminal justice systems (CJS) and were examined in 27
(67.5 %) of the 40 studies.
Previous criminal justice contact was investigated in 21 of the 27
studies (77.8 %), of which four (19 %) were considered high-quality.
Three (Albertie et al., 2017; Boys et al., 2002; Carvalho et al., 2005)
out of the four high-quality studies found previous CJS contact,
including having been to prison before and having more than three ar-
rests prior to prison, to be positively associated with drug use in prison.
Legal problems as a juvenile (Jacups & Rogerson, 2015) and recidivism
(Carvalho et al., 2005; Jacups & Rogerson, 2015; Thomas & Cage, 1977)
were also positively associated with drug use in prison. However, pre-
vious imprisonment was the type of CJS contact most often associated
with drug use in prison within criminal history characteristics (Boys
et al., 2002; Butler et al., 2003; Calzavara et al., 2003; Caravaca-S´
anchez
& Wolff, 2020; Cunningham et al., 2018; Leigey, 2019; Narkauskaite
et al., 2007). One study found that being imprisoned for the rst time
was positively associated with drug use in prison (Narkauskaite et al.,
2007) and women-only samples found that, opposite to the dominant
association pattern, previous imprisonment was negatively associated
with drug use meaning they were less likely to use drugs in prison (Boys
et al., 2002; Narkauskaite et al., 2010).
Nine studies examined drug-related offending. Only one study was
considered high-quality but, using a case control design to compare
people who had used cocaine in prison with those who have never used
cocaine, offending while under the inuence or to obtain drugs was
positively associated with drug use as was being sentenced for drug
dealing (Carvalho et al., 2005). Three further studies of low and
moderate-quality found a similar pattern that being intoxicated at the
time of the offence (Bukten et al., 2020) and being arrested for drug
related offences (Thomas & Cage, 1977) was positively associated with
drug use. Drug-related offending was also found to increase the risk of
polydrug use in prison for both men and women (Caravaca-S´
anchez
et al., 2022). However, two low quality studies found that being in
prison for crimes related to drugs was negatively associated with drug
use (Narkauskaite et al., 2007, 2010) and three studies of low and
moderate-quality found that drug offences and convictions (Favril et al.,
2020; Leigey, 2019) were not associated with use in prison.
There was no clear association between violent (Albertie et al., 2017;
Bukten et al., 2020; Butler et al., 2003; Caravaca-S´
anchez et al., 2022;
Korte et al., 1998; Leigey, 2019) or other types of offence (Baltieri, 2014;
Bukten et al., 2020; Caravaca-S´
anchez et al., 2022; Nev´
arez-Sida et al.,
2012) and drug use in prison.
Prison characteristics. Factors related to any environmental, situ-
ational or contextual characteristics of prison life were considered under
the prison characteristics theme and these were examined in 23 of the 40
(57.5 %) studies.
Eleven studies looked at time spent in prison and drug use. Of these,
four were rated as high-quality and three of these found that time in
prison was positively associated with drug use in prison (Albertie et al.,
2017; Boys et al., 2002; Carvalho et al., 2005). This nding was mirrored
in cross-sectional, case-control and cohort designs with more time in
prison increasing the risk of using drugs (Albertie et al., 2017; Boys
et al., 2002; Carvalho et al., 2005; Nev´
arez-Sida et al., 2012; Rowell
et al., 2012), including injecting them (Cunningham et al., 2018).
Prison conditions were assessed in 11 (47.8 %) studies. Poor prison
conditions, specically, lack of purposeful activity such as education or
work (Albertie et al., 2017; Caravaca-S´
anchez & García-Jarillo, 2020;
Caravaca-S´
anchez & Wolff, 2020; Leigey, 2019; Nev´
arez-Sida et al.,
2012) and poor prisoner-staff relationships (Lanza-Kaduce &
Radosevich, 1987; Nev´
arez-Sida et al., 2012; Thomas & Cage, 1977),
were associated with drug use in prison. However, only one study was
considered high-quality (Albertie et al., 2017). There were fewer asso-
ciations for overcrowding (Albertie et al., 2017), perceived drug avail-
ability (Leigey, 2019), and receiving conjugal visits (Albertie et al.,
2017) being associated with drug use. Studies did not nd an association
between prisoner-on-prisoner violence (Leigey, 2019) or prison location
(city or not) (Nev´
arez-Sida et al., 2012) and drug use in prison. One
women-only study found that being in a same-sex relationships in prison
was associated with using drugs in prison (Baltieri, 2014).
Evidence was not consistent for an association between length of
sentence and drug use in prison which was examined in 6 studies.
Psychological characteristics. Psychological characteristics were
factors that addressed any measurement of wellbeing, both historic and
current, and were the least frequently examined (18 studies, 45 %).
Trauma was assessed in varying ways in 5 of the 18 studies. Expe-
riencing trauma was associated with drug use in prison in four studies
(Boys et al., 2002; Caravaca-S´
anchez & Wolff, 2020; Lanza-Kaduce &
Radosevich, 1987; Reed et al., 2009) but only one was high-quality. The
high-quality study found that being in local authority care as a child and
experiencing another traumatic event (aside from sexual abuse, wit-
nessing or experiencing physical abuse or being bullied) was positively
associated with drug use in prison (Boys et al., 2002). Studies of poorer
quality found that emotional, physical and sexual trauma and/or
violence as well as isolation was associated with drug use (Car-
avaca-S´
anchez & Wolff, 2020; Lanza-Kaduce & Radosevich, 1987; Reed
et al., 2009). Traumas related to serious illness, familial death or injury
were not associated with drug use in prison (Boys et al., 2002).
The presence of psychiatric morbidity (diagnosis or distress) was
looked at in 10 of the 18 (55.6 %) of studies. Of these, six (60 %) found
an association with drug use in prison but only two were considered
high-quality. One of these studies found that in a juvenile cohort study
controlling for prison conditions, secondary psychopathy compared to
primary or no psychopathy was positively associated with drug use in
prison (Kimonis et al., 2012). In a cross-sectional representative study,
heroin use in prison was positively associated with the number of di-
agnoses and antisocial personality disorder (Boys et al., 2002). The low
and moderate-quality studies found that depression was associated with
drug use in male samples while anxiety was associated with drug use in
male and female samples (Caravaca-S´
anchez et al., 2022).
Qualitative study characteristics
With the eligible mixed-methods components included, there were
11 studies (reporting on 10 samples) between 1993 and 2019 (Table 2).
Most studies (k =4, 40 %) were conducted in the UK. The total sample
size was 349, ranging from 4 to 102 (M =34.9, SD =26.5). Three studies
additionally interviewed staff (data which was not included in our
analysis). The most common method used was interview (k =9, 90 %),
followed by focus group (k =3, 33 %) and observations (k =2, 20 %);
three studies used multiple methods. Only 8 studies reported drug use
measurement (80 %), all assessing ‘ever use’ in prison.
Qualitative factors related to drug use in prison
A consistent theme throughout the studies was the identication of
boredom or excess time as a factor linked to drug use. The use of drugs
appeared to act as a coping mechanism in response to a limited prison
regime (Ralphs et al., 2017) and the absence of purposeful activity
(Woodall, 2011). As outlined by one participant discussing their
cannabis use, “the way I look at it is it makes time go faster” (Cope,
2000, p. 360). Similarly, the use of synthetic cannabinoids (also known
as ‘Spice’) was described as a “time killer” (Ralphs et al., 2017, p. 63).
Managing insomnia was also frequently mentioned as a motivation for
use (Clua-García et al., 2019). Additionally, drugs were used to help
manage the ‘pains of imprisonment’ (Kolind et al., 2016; Mjåland,
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
7
2016). Using drugs was seen as “an escape from reality, an escape from
jail, an escape from life, things like that” (Dillon, 2001, p. 73) as well as
to avoid experiencing certain emotions (Clua-García et al., 2019).
Studies highlighting this theme were mostly high-quality (k =5, 83.3
%).
Other studies highlighted the unique social culture of prisons as key
for understanding drug use. Using drugs in prison represented a way to
gain social cohesion, as one participant explained it meant other people
in prison “respect you in a completely different way” (Mjåland, 2016, p.
159). Drug use was also part of marking life events with others (Clua--
García et al., 2019; Mjåland, 2016). Peer pressure was cited as leading to
drug use (Baker, 2015), especially when people had been successful at
stopping their drug use in prison, others seemed to target them to re-use
(Woodall, 2011). For some, drug use was felt to be an act of deance
against the prison (Baker, 2015; Kolind et al., 2016; Mjåland, 2016).
Most studies that examined social culture were considered high-quality
(k =4, 80.0 %), with one being rated as moderate (20.0 %).
The inuence of pre-prison drug use was identied in several studies
(Cope, 2000; Dillon, 2001; Ralphs et al., 2017; Woodall, 2011), the
majority of which (k =3, 75.0 %) were high-quality, with drug use in
prison being described as a continuation of pre-prison use. Those who
found it harder to resist drugs in prison were noted to likely have a
history of substance misuse (Cope, 2000; Woodall, 2011)
,
especially
heroin and/or crack cocaine (Dillon, 2001; Ralphs et al., 2017).
Finally, studies highlighted the inuence of the wider prison culture.
Drugs were described as acceptable and normalised in prison. One
participant stated, “I don’t think ofcers really care about you smoking
drugs” (Cope, 2000, p. 357) and another explained “we use drugs here in
the open space… it’s normal… it can be anywhere” (Culbert et al., 2015,
p. 21). This open culture was identied as a factor that increased the
chances of using drugs despite intentions to abstain (Baker, 2015;
Kolind et al., 2016; Woodall, 2011). Furthermore, there seemed to be
little concern with being caught and therefore the illegal nature of drug
use in prison did not seem to inuence decisions to use (Inciardi et al.,
1993). Moreover, the choice of drugs was also described to be shaped by
the prison environment. Cocaine or amphetamines were not seen as
desirable in a prison setting (Clua-García et al., 2019; Kolind et al.,
2016) whereas the effects of cannabis were better suited to the envi-
ronment and easier to hide the effects of (Kolind et al., 2016). Similarly,
synthetic cannabinoids were often chosen due to being undetectable on
mandatory drug testing (Baker, 2015; Ralphs et al., 2017). Furthermore,
due to the limited and unreliable nature of drug trafcking into prison,
people in prison who used drugs were more likely to inject drugs to
maximise the effects of their limited drug supply (Dillon, 2001). Most (k
=7, 77.8 %) of the studies that identied the inuence of the prison
culture were of high-quality.
Discussion
To our knowledge, this is the rst systematic review of factors
associated with drug use in prison. We synthesised data on 54 studies,
reporting on 49 unique samples with a total of 26,399 people in prison.
By summarising quantitative and qualitative evidence from both pub-
lished and grey literature across 18 countries and spanning 35 years, this
review represents a comprehensive overview of the evidence.
Data synthesis
Broadly speaking, the quantitative and qualitative studies identied
factors associated with drug use in prison that can be understood as
modiable and non-modiable.
Non-modiable factors found in high-quality studies included drug
use before entering prison, in varied frequencies and durations. Quali-
tative studies corroborated this, noting that those using drugs in prison
were likely to have also used outside prison. This underscores previous
ndings that in-prison drug use commonly represents the continuation
of pre-prison drug use (Favril, 2023; Strang et al., 2006). Nearly a third
of quantitative studies found that people who had previous CJS
involvement were more likely to use drugs in prison and this appeared to
be especially the case among those with a history of committing sub-
stance related crimes, for example being under the inuence of drugs at
the time of the crime or offending to obtain drugs. Together, our review
suggests that in-prison drug use can be partly understood as related to
vulnerability proles that people ‘import’ into prison. Quantitative
studies, including those of high-quality, found that the risk of drug use in
prison increased the longer people had been incarcerated.
There were two main modiable areas associated with drug use in
prison. First, psychiatric morbidity was positively associated with drug
use in mixed quality quantitative studies. However, qualitative studies
of high-quality corroborated this by highlighting the use of drugs in
prison to cope with negative emotions. Second, prison conditions were
identied to be associated with drug use in both quantitative and
qualitative studies. High-quality qualitative studies emphasised drug use
as a method to manage boredom, excess time and insomnia. Taken
together with ndings above related to time spent in prison, this sug-
gests that long periods of time in unstimulating prison conditions en-
courages people to seek out alternative ways to pass the time.
Furthermore, qualitative studies highlighted the open, normalised and
sometimes pressured nature of drug use. Drug use in prison can be un-
derstood broadly as a coping mechanism to mitigate not only individual
Table 2
Study characteristics for qualitative evidence.
Study Country Prisons
(n)
Sample Mean age
(range)
Sample size (%
female)
Outcome Study
quality Drug examined
(multiple or specic)
Measurement of drug
use in prison
Baker (2015)* UK 1 General 20 s –30s 4 (0 %) Synthetic cannabinoids Ever High
Clua-García et al.
(2019)
Spain 1 General 24–25 29 (26.1 %) Multiple Ever High
Cope (2000)** UK 1 General 15–21 30 (0 %) Cannabis NR Mod
Culbert et al.
(2015)*
Indonesia 2 HIV positive 31.3 102 (0 %) NR (IDU) Ever High
Dillon (2001) Ireland 1 General 19–43 29 (NR) Heroin and cannabis Ever High
Inciardi et al.
(1993)
USA 2 Drug treatment NR 18 (NR) Multiple Ever Low
Kolind et al.
(2016)
Denmark 8 Drug treatment NR 51 (NR) Multiple Ever High
Mjåland (2016) Norway 1 Drug rehabilitation 25–45 23 (0 %) NR NR Mod
Ralphs et al.
(2017)
UK 1 In treatment or caught
dealing drugs
mid 20 s
–50s
27 (0 %) Synthetic cannabinoids Ever High
Woodall (2011) UK 3 General NR 36 (NR) NR Ever High
NR =Not reported, * =Mixed methods study, **same sample as Cope (2003), study quality: mod =moderate.
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
8
distress but also the adverse prison environment characterised by
deprivation. Therefore, people’s wellbeing and prisons themselves can
be understood as creating further susceptibility to drug use in prison,
presenting opportunities to intervene and reduce in-prison drug use.
Overall, the convergence of evidence relating to key modiable and
non-modiable factors highlight the importance of including both
quantitative and qualitative research in the review which examine
different elements of drug use in prison as this enabled a triangulation of
ndings across these different methodologies.
Limitations of the literature and directions for future research
Our ndings should be interpreted in light of the limitations of the
extant literature. All studies relied on self-report data for drug use in
prison. While a recent meta-analysis found that self-reports of drug use
can be reliable and valid within criminal justice populations (Bharat
et al., 2023), there may be additional inuences of the prison setting
which prevent accurate reporting.
Most studies were cross-sectional in design which means that while
ndings provide insight into relationships between variables, conclu-
sions about directionality cannot be drawn. For example, psychological
distress could be a reason for and/or a consequence of drug use. Given the
lack of longitudinal studies, future research should utilise this method to
further understand the direction of associations.
A quarter of studies also set inclusion criteria which further limited
the sample such as a history of IDU or soon-to-be-released status. Future
research should focus on specic sampling and reporting of participants
related to particular variables of interest (e.g. females, European
prisons), frequency (e.g. initiated, habitual) and drugs (e.g. heroin,
synthetic cannabinoids) in order to better summarise specic factors
associated with drug use in these subgroups. Similarly, drug use in
prison was operationalised very differently across studies. Some studies
included substances which are not considered illicit such as alcohol
(although prohibited in prisons), while others focused on specic types
of drugs. Utilising standardised measures in further research would help
to improve comparability across ndings (Carpentier et al., 2018).
Overall, the majority (k =36, 72.0 %) of studies included here were
rated as low or moderate-quality, indicating possible bias in the results
reported. The quality assessments highlighted weaknesses due to limited
information regarding non-respondents in quantitative studies and a
lack of transparency with analysis methods or a consideration of the
relationship between researcher and participant in qualitative studies.
Given that all quantitative studies were self-report, data on non-
respondents would enable an assessment of the degree to which the
sample are biased or skewed in some way. Furthermore, there exists an
inherent power imbalance between people who are in prison and re-
searchers which may impact on people’s choice to participate (Abbott
et al., 2018). Closer consideration of the relationship between partici-
pants and researchers was missing from qualitative studies and would
strengthen transparency and reexivity regarding research in custodial
environments.
Limitations of the review
We were not able to examine associations with the use of specic
drugs, nor could we consider the inuence of frequency of use. This was
because most studies did not differentiate frequencies or types of illicit
drug use, coding drug use dichotomously as used in prison or not.
However, we recognise that occasional versus daily use or the presence
of drug use disorders are likely to have different predictors or reasons for
use. We could not comment on differences between prison types or sex/
gender differences due to limited provision of this information but are
aware that drug use may differ depending on the setting and this
behaviour requires a gender-responsive approach (Messina, 2021). We
also did not examine differences between countries but acknowledge the
possible inuence of societal and drug policy factors (Carpentier et al.,
2018) on drug use in prison, for example, noting the increase in syn-
thetic cannabinoid use in the UK (Baker, 2015; Craft et al., 2023;
Lafortune et al., 2021). Furthermore, as we were unable to conduct a
meta-analysis, it was not possible to comment on the strength of asso-
ciation between the factors identied and drug use in prison. Future
studies could assess which non-modiable and modiable factors are the
most impactful. Therefore, while this review provides a broad synthesis
of the factors related to drug use in prison, we are unable to comment on
whether the factors identied are relevant for all types of using fre-
quencies, drugs, prisons, genders and countries or which factors have
the strongest relationship to drug use in prison.
Implications
This review suggests that there are several static, non-modiable
characteristics associated with drug use in prison identied in high-
quality studies such as pre-prison drug use, time spent in prison and
previous criminal justice contact. Such factors could be screened for
upon reception to prison, utilising screening tools such as the Drug Use
Disorder Identication Test (DUDIT; Pape et al., 2022), in order to
identify those who may require additional support and services to pre-
vent or manage drug use in prison.
Furthermore, the non-modiable characteristics identied, such as
previous criminal justice contact, including substance-related offending,
and time spent in prison, also point to populations that may be better
suited to diversion schemes such as community sentences with drug
rehabilitation requirements (Black, 2021). This was outlined in an in-
dependent review for the UK government which highlighted people who
use drugs have repeated, short sentences which are rarely restorative
and argued for diversions away from prisons as cost-effective and
rehabilitative (Black, 2021). Such schemes could provide further op-
portunities for reducing drug use in prison.
Modiable factors that appear linked to using drugs in prison are
linked to psychiatric morbidity and poor prison conditions. This can be
understood in the context of the high prevalence of co-morbid mental
health and substance use disorders in prison populations (Baranyi et al.,
2022). Qualitative studies clearly emphasised the role that boredom,
driven by a lack of purposeful regime, has in acting as a motivator to use
substances. By addressing wider contextual and cultural conditions
(Duke, 2020) such as increasing opportunities for meaningful activity,
improving relationships between staff and those in prison and providing
support for mental health difculties, it could be expected that under-
lying motivations for drug use, such as boredom and distress, would be
reduced, therefore dissipating the demand for drugs. In line with the
implications of this review, future research should focus on the effec-
tiveness of whole prison interventions on levels of drug use in prison and
associated harms. Given the evidence for the inuence of the prison
environment on drug use, attention should be paid to those programmes
that aim to increase activity and improve relational aspects of the
environment such as incentivised substance-free living units.
Conclusion
In conclusion, non-modiable factors associated with drug use in
prison include pre-prison use of drugs, criminal history and time spent in
prison, and modiable factors include the presence of psychiatric
morbidity and poor prison conditions. Overall, this evidence suggests
that people in prison should be assessed for the risk of using drugs to
identify those at greater risk and efforts to improve the environment to
increase purposeful activity and meaningful regimes could reduce in-
prison drug use.
Ethics approval
No ethical approval was required.
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
9
CRediT authorship contribution statement
Alice Austin: Writing – review & editing, Writing – original draft,
Validation, Project administration, Methodology, Investigation, Formal
analysis, Data curation, Conceptualization. Louis Favril: Writing – re-
view & editing, Validation, Project administration, Methodology,
Investigation, Data curation. Sam Craft: Writing – review & editing,
Validation, Methodology, Investigation, Data curation, Conceptualiza-
tion. Phoebe Thliveri: Writing – review & editing, Validation, Meth-
odology, Conceptualization. Tom P Freeman: Writing – review &
editing, Supervision, Conceptualization.
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Data availability
Data sharing is not applicable to this article as no new data were
created or analysed in this review.
Funding
LF is supported by a Research Foundation – Flanders (FWO) Post-
doctoral Fellowship (1247123N).
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.drugpo.2023.104248.
References
Abbott, P., DiGiacomo, M., Magin, P., & Hu, W. (2018). A scoping review of qualitative
research methods used with people in prison. International Journal of Qualitative
Methods, 17(1), Article 1609406918803824. https://doi.org/10.1177/
1609406918803824
Albertie, A., Bourey, C., Stephenson, R., & Bautista-Arredondo, S. (2017). Connectivity,
prison environment and mental health among rst-time male inmates in Mexico city.
Global Public Health, 12(2), 170–184. https://doi.org/10.1080/
17441692.2015.1091023
Azbel, L., Wegman, M. P., Polonsky, M., Bachireddy, C., Meyer, J., Shumskaya, N.,
Kurmanalieva, A., Dvoryak, S., & Altice, F. L. (2018). Drug injection within prison in
Kyrgyzstan: Elevated HIV risk and implications for scaling up opioid agonist
treatments. International Journal of Prisoner Health, 14(3), 175–187. https://doi.org/
10.1108/IJPH-03-2017-0016
Baker, S. (2015). An examination of the reasons that prisoners use spice (synthetic
cannabinoids). [Unpublished Master thesis, University of Cambridge].
Baltieri, D. A. (2014). Predictors of drug use in prison among women convicted of violent
crimes. Criminal Behaviour and Mental Health, 24(2), 113–128. https://doi.org/
10.1002/cbm.1883
Ba˜
nuls-Oncina, E., Clua-García, R., Imbern´
on Casas, M., & Jim´
enez-Vinaja, R. (2019).
Substance use characteristics, health risk practices and associated factors among
people imprisoned in Catalonia: A cross-sectional study. Revista espanola de Sanidad
Penitenciaria, 21(2), 80–87.
Baranyi, G., Fazel, S., Langerfeldt, S. D., & Mundt, A. P. (2022). The prevalence of
comorbid serious mental illnesses and substance use disorders in prison populations:
A systematic review and meta-analysis. The Lancet Public Health, 7(6), e557–e568.
https://doi.org/10.1016/S2468-2667(22)00093-7
Bharat, C., Webb, P., Wilkinson, Z., McKetin, R., Grebely, J., Farrell, M., …
Degenhardt, L. (2023). Agreement between self-reported illicit drug use and
biological samples: A systematic review and meta-analysis. Addiction (Abingdon,
England), 118(9), 1624–1648. https://doi.org/10.1111/add.16200
Black, C.. Review of drugs part two: Prevention, treatment and recovery. https://www.gov.
uk/government/publications/review-of-drugs-phase-two-report/review-of-drugs-
part-two-prevention-treatment-and-recovery.
Boys, A., Farrell, M., Bebbington, P., Brugha, T., Coid, J., Jenkins, R., Lewis, G.,
Marsden, J., Meltzer, H., Singleton, N., & Taylor, C. (2002). Drug use and initiation
in prison: Results from a national prison survey in England and Wales. Addiction
(Abingdon, England), 97(12), 1551–1560. https://doi.org/10.1046/j.1360-
0443.2002.00229.x
Bukten, A., Lund, I. O., Kinner, S. A., Rognli, E. B., Havnes, I. A., Muller, A. E., &
Stavseth, M. R. (2020). Factors associated with drug use in prison - results from the
Norwegian offender mental health and addiction (NorMA) study. Health & Justice, 8
(1), 10. https://doi.org/10.1186/s40352-020-00112-8
Butler, T., Levy, M., Dolan, K., & Kaldor, J. (2003). Drug use and its correlates in an
Australian prisoner population. Addiction Research & Theory, 11(2), 89–101. https://
doi.org/10.1080/1606635021000021403
Calzavara, L. M., Burchell, A. N., Schlossberg, J., Myers, T., Escobar, M., Wallace, E.,
Major, C., Strike, C., & Millson, M. (2003). Prior opiate injection and incarceration
history predict injection drug use among inmates. Addiction (Abingdon, England), 98
(9), 1257–1265. https://doi.org/10.1046/j.1360-0443.2003.00466.x
Caravaca-S´
anchez, F., & García-Jarillo, M. (2020). Perceived social support, resilience
and consumption of psychoactive substances amongst inmates in prisons. Revista
Espanola Sanidad Penitenciarira, 22(2), 75–79. https://doi.org/10.18176/resp.00013
Caravaca-S´
anchez, F., & Wolff, N. (2020). Predictors of substance use among male
prisoners in Spain: The role of childhood abuse and social support. Journal of the
Society for Social Work and Research, 11(2), 313–337. https://doi.org/10.1086/
709752
Caravaca-S´
anchez, F., Aizpurua, E., & Wolff, N. (2022). Latent class analysis of self-
reported substance use during incarceration: Gender differences and associations
with emotional distress and aggressiveness. Journal of Substance Abuse Treatment,
132, Article 108582. https://doi.org/10.1016/j.jsat.2021.108582
Carpentier, C., Royuela, L., Montanari, L., & Davis, P. (2018). The global epidemiology of
drug use in prison. In S.A. Kinner & J.D.J. Rich (Eds.), Drug use in prisoners:
Epidemiology, implications, and policy responses (pp. 17–41). Oxford Univeristy Press.
10.1093/med/9780199374847.001.0001.
Carvalho, M. L., Valente, J. G., Assis, S. G., & Vasconcelos, A. G. (2005). Predictive model
for cocaine use in prisons in Rio de Janeiro, Brazil. Revista de Saúde Pública, 39(5),
824–831. https://doi.org/10.1590/s0034-89102005000500019
Chandler, R. K., Fletcher, B. W., & Volkow, N. D. (2009). Treating drug abuse and
addiction in the criminal justice system: Improving public health and safety. JAMA,
301(2), 183–190. https://doi.org/10.1001/jama.2008.976
Chang, Z., Larsson, H., Lichtenstein, P., & Fazel, S. (2015). Psychiatric disorders and
violent reoffending: A national cohort study of convicted prisoners in Sweden. The
Lancet Psychiatry, 2(10), 891–900. https://doi.org/10.1016/S2215-0366(15)00234-
5
Chang, Z., Lichtenstein, P., Larsson, H., & Fazel, S. (2015). Substance use disorders,
psychiatric disorders, and mortality after release from prison: A nationwide
longitudinal cohort study. The Lancet Psychiatry, 2(5), 422–430. https://doi.org/
10.1016/S2215-0366(15)00088-7
Clua-García, R., Ba˜
nuls-Oncina, E., Imbern´
on-Casas, M., & Jim´
enez-Vinaja, R. (2019).
The discourses of risk of drug users in prison. Revista Espanola de Sanidad
Penitenciaria, 21(1), 28.
Cope, N. (2000). Drug use in prison: The experience of young offenders. Drugs: Education,
Prevention & Policy, 7(4), 355–366. https://doi.org/10.1080/dep.7.4.355.366
Cope, N. (2003). It’s no time or high time’: Young offenders’ experiences of time and
drug use in prison. The Howard Journal of Criminal Justice, 42(2), 158–175. https://
doi.org/10.1111/1468-2311.t01-1-00273
Craft, S., Austin, A., Tooth, T., Glover, C., Garrett, T., Blagbrough, I. S., … Freeman, T. P.
(2023). Synthetic cannabinoid use in an adult male prison in the UK. International
Journal of Drug Policy, 122, Article 104219. https://doi.org/10.1016/j.
drugpo.2023.104219
Critical Appraisal Skills Programme (2022). CASP qualitative studies. Available at: Https
://casp-uk.net/casp-tools-checklists/Accessed 13th September 2022.
Culbert, G. J., Waluyo, A., Iriyanti, M., Muchransyah, A. P., Kamarulzaman, A., &
Altice, F. L. (2015). Within-prison drug injection among HIV-infected male prisoners
in Indonesia: A highly constrained choice. Drug and Alcohol Dependence, 149, 71–79.
https://doi.org/10.1016/j.drugalcdep.2015.01.018
Cunningham, E. B., Hajarizadeh, B., Amin, J., Bretana, N., Dore, G. J., Degenhardt, L.,
Larney, S., Luciani, F., Lloyd, A. R., & Grebely, J. (2018). Longitudinal injecting risk
behaviours among people with a history of injecting drug use in an Australian prison
setting: The HITS-p study. International Journal of Drug Policy, 54, 18–25. https://doi.
org/10.1016/j.drugpo.2017.12.013
Darke, S., Kaye, S., & Finlay-Jones, R. (1998). Drug use and injection risk-taking among
prison methadone maintenance patients. Addiction (Abingdon, England), 93(8),
1169–1175. https://doi.org/10.1046/j.1360-0443.1998.93811695.x
Dillon, L. (2001). Drug use among prisoners: An exploratory study. Dublin: The Health
Research Board. https://www.lenus.ie/handle/10147/338175.
Duke, K. (2020). Producing the ‘problem’of new psychoactive substances (NPS) in
English prisons. International Journal of Drug Policy, 80, Article 102479. https://doi.
org/10.1016/j.drugpo.2019.05.022
Ebiti, N. W., Ike, J. O., Sheikh, T. L., Lasisi, D. M., Babalola, O. J., & Agunbiade, S.
(2012). Determinants of psychoactive substance use among incarcerated delinquents
in Nigeria. African Journal of Drug and Alcohol Studies, 11(2), 117–127.
Favril, L. (2023). Drug use before and during imprisonment: Drivers of continuation.
International Journal of Drug Policy, 115, Article 104027. https://doi.org/10.1016/j.
drugpo.2023.104027
Favril, L., & Vander Laenen, F. (2018). Predictoren van druggebruik tijdens de
detentieperiode: Data van 1326 gedetineerden uit 15 Vlaamse gevangenissen.
Panopticon, 39(4), 296–312.
Favril, L., Yu, R., Hawton, K., & Fazel, S. (2020). Risk factors for self-harm in prison: A
systematic review and meta-analysis. The Lancet Psychiatry, 7(8), 682–691. https://
doi.org/10.1016/S2215-0366(20)30190-5
Fazel, S., Yoon, I. A., & Hayes, A. J. (2017). Substance use disorders in prisoners: An
updated systematic review and meta-regression analysis in recently incarcerated
A. Austin et al.

International Journal of Drug Policy 122 (2023) 104248
10
men and women. Addiction (Abingdon, England), 112(10), 1725–1739. https://doi.
org/10.1111/add.13877
Hong, Q. N., Pluye, P., Bujold, M., & Wassef, M. (2017). Convergent and sequential
synthesis designs: Implications for conducting and reporting systematic reviews of
qualitative and quantitative evidence. Systematic Reviews, 6(1), 1–14. https://doi.
org/10.1186/s13643-017-0454-2
Inciardi, J. A., Lockwood, D., & Quinlan, J. A. (1993). Drug use in prison: Patterns,
processes, and implications for treatment. Journal of Drug Issues, 23(1), 119–129.
https://doi.org/10.1177/002204269302300108
Jacups, S., & Rogerson, B. (2015). Lifetime inuences for cannabis cessation in male
incarcerated indigenous Australians. Journal of Psychoactive Drugs, 47(2), 117–124.
https://doi.org/10.1080/02791072.2015.1014949
Khalooei, A., Mashayekhi-Dowlatabad, M., Rajabalipour, M. R., & Iranpour, A. (2016).
Pattern of substance use and related factors in male prisoners. Addiction and Health, 8
(4), 227–234.
Kimonis, E. R., Tatar Ii, J. R., & Cauffman, E. (2012). Substance-related disorders among
juvenile offenders: What role do psychopathic traits play? Psychology of Addictive
Behaviors, 26(2), 212–225. https://doi.org/10.1037/a0028047
Kinner, S. A., Jenkinson, R., Gouillou, M., & Milloy, M. J. (2012). High-risk drug-use
practices among a large sample of Australian prisoners. Drug and Alcohol Dependence,
126(1), 156–160. https://doi.org/10.1016/j.drugalcdep.2012.05.008
Kinner, S. A., Moore, E., Spittal, M. J., & Indig, D. (2013). Opiate substitution treatment
to reduce in-prison drug injection: A natural experiment. International Journal of Drug
Policy, 24(5), 460–463. https://doi.org/10.1016/j.drugpo.2013.01.004
Kolind, T., Holm, K., Duff, C., & Frank, V. A. (2016). Three enactments of drugs in Danish
prison drug treatment: Illegal drugs, medicine and constrainers. Drugs: Education,
Prevention & Policy, 23(2), 135–143. https://doi.org/10.3109/
09687637.2015.1109608
Korte, T., Pyk¨
al¨
ainen, J., & Sepp¨
al¨
a, T. (1998). Drug abuse of Finnish male prisoners in
1995. Forensic Science International, 97(2), 171–183. https://doi.org/10.1016/
S0379-0738(98)00159-5
Koulierakis, G. (2006). Drug use and related precautions prior to imprisonment, inside
prison and intentions after release among Greek inmates. Addiction Research &
Theory, 14(3), 217–233. https://doi.org/10.1080/16066350600608604
Lafortune, D., Blais, M., Miller, G., Dion, L., Lalonde, F., & Dargis, L. (2021).
Psychological and interpersonal factors associated with sexualized drug use among
men who have sex with men: A mixed-methods systematic review. Archives of Sexual
Behavior, 50, 427–460. https://doi.org/10.1007/s10508-020-01741-8
Lanza-Kaduce, L., & Radosevich, M. (1987). Negative reactions to processing and
substance use among young incarcerated males. Deviant Behavior, 8(2), 131–148.
https://doi.org/10.1080/01639625.1987.9967738
Leigey, M. E. (2019). Female institutional misconduct: A test of deprivation, importation,
and gendered importation theories. The Prison Journal, 99(3), 343–362. https://doi.
org/10.1177/0032885519837532
Lins-Filho, P. C., Carvalho, F. M. T.d., Freitas, J. L.d. M., Ferreira, A. K. A., Melo, M. C. F.
d., Godoy, G. P., & Caldas, A.d. F., Jr (2021). Drug use pattern among non-
heterosexual and transgender people detained in a female prison complex. Journal of
Substance Use, 27(2), 206–211. https://doi.org/10.1080/14659891.2021.1916850
Martin, R. E., Gold, F., Murphy, W., Remple, V., Berkowitz, J., & Money, D. (2005). Drusg
use and risk of bloodborne infections. A survey of female prisoners in British
Columbia. Canadian Journal of Public Health, 96(2), 97–101. https://doi.org/
10.1007/bf03403669
Messina, N. (2021). The evolution of gender and trauma responsive criminal justice
interventions for women. Journal of Addiction and Addictive Disorders, 8(070), 37–41.
https://doi.org/10.24966/AAD-7276/100070
Mjåland, K. (2016). Exploring prison drug use in the context of prison-based drug
rehabilitation. Drugs: Education, Prevention & Policy, 23(2), 154–162. https://doi.
org/10.3109/09687637.2015.1136265
Montanari, L., Royuela, L., Hasselberg, I., & Vandam, L. (2022). Prison and drugs in
Europe: Current and future challenges. European Monitoring Centre for Drugs and
Drug Addiction.
Mundt, A. P., Baranyi, G., Gabrysch, C., & Fazel, S. (2018). Substance use during
imprisonment in low-and middle-income countries. Epidemiologic Reviews, 40(1),
70–81. https://doi.org/10.1093/epirev/mxx016
Narkauskaite, L., Juozulynas, A., Mackiewicz, Z., Surkiene, G., & Prapiestis, J. (2007).
The prevalence of psychotropic substance use and its inuencing factors in
Lithuanian penitentiaries. Medical Science Monitor, 13(3), 131–135.
Narkauskaite, L., Juozulynas, A., Mackiewicz, Z., Venalis, A., & Utkuviene, J. (2010).
Prevalence of psychoactive substances use in a Lithuanian women’s prison revisited
after 5 years. Case Reports and Clinical Practice Review, 16(11), 91–96.
Nev´
arez-Sida, A., Constantino-Casas, P., & Castro-Ríos, A. (2012). Socioeconomic factors
associated with drug consumption in prison population in Mexico. BMC Public
Health, 12, 33. https://doi.org/10.1186/1471-2458-12-33
Norman, C. (2022). A global review of prison drug smuggling routes and trends in the
usage of drugs in prisons. Wiley Interdisciplinary Reviews: Forensic Science, 5(2),
e1473. https://doi.org/10.1002/wfs2.1473
Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016). Rayyan—A web
and mobile app for systematic reviews. Systematic Reviews, 5, 1–10. https://doi.org/
10.1186/s13643-016-0384-4
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D.,
Shamseer, L., Tetzlaff, J. M., Akl, E. A., & Brennan, S. E. (2021). The PRISMA 2020
statement: An updated guideline for reporting systematic reviews. Systematic
Reviews, 10(89). https://doi.org/10.1186/s13643-021-01626-4
Pape, H., Lobmaier, P., & Bukten, A. (2022). An evaluation of eight short versions of the
Drug Use Disorder Identication Test (DUDIT). A prison population study. Drug and
Alcohol Dependence Reports, 3, Article 100043. https://doi.org/10.1016/j.
dadr.2022.100043
Petrilli, K., Ofori, S., Hines, L., Taylor, G., Adams, S., & Freeman, T. P. (2022).
Association of cannabis potency with mental ill health and addiction: A systematic
review. The Lancet Psychiatry, 22(9), 736–750. https://doi.org/10.1016/S2215-0366
(22)00161-4
Plourde, C., & Brochu, S. (2002a). Drogue et alcool durant l’incarc´
eration: Examen de la
situation des p´
enitenciers f´
ed´
eraux qu´
eb´
ecois. [Drugs and alcohol in prison:
Examination of the situation in Quebec federal penitentiaries.]. Canadian Journal of
Criminology, 44(2), 209–240.
Plourde, C., & Brochu, S. (2002b). Drugs in prison: A break in the pathway. Substance Use
& Misuse, 37(1), 47–63. https://doi.org/10.1081/ja-120001496
Plourde, C., Brochu, S., Gendron, A., & Brunelle, N. (2012). Pathways of substance use
among female and male inmates in Canadian federal settings. The Prison Journal, 92
(4), 506–524. https://doi.org/10.1177/0032885512457555
Plugge, E., Yudkin, P., & Douglas, N. (2009). Changes in women’s use of illicit drugs
following imprisonment. Addiction (Abingdon, England), 104(2), 215–222. https://
doi.org/10.1111/j.1360-0443.2008.02419.x
Polonsky, M., Azbel, L., Wegman, M. P., Izenberg, J. M., Bachireddy, C.,
Wickersham, J. A., Dvoriak, S., & Altice, F. L. (2016). Pre-incarceration police
harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan
and Azerbaijan: Results from a nationally representative cross-sectional study.
Journal of the International AIDS Society, 19. https://doi.org/10.7448/
IAS.19.4.20880
Ralphs, R., Williams, L., Askew, R., & Norton, A. (2017). Adding Spice to the Porridge:
The development of a synthetic cannabinoid market in an English prison.
International Journal of Drug Policy, 40, 57–69. https://doi.org/10.1016/j.
drugpo.2016.10.003
Reed, E., Raj, A., Falbo, G., Caminha, F., Decker, M. R., Kaliel, D. C., Missmer, S. A.,
Molnar, B. E., & Silverman, J. G. (2009). The prevalence of violence and relation to
depression and illicit drug use among incarcerated women in Recife, Brazil.
International Journal of Law and Psychiatry, 32(5), 323–328. https://doi.org/
10.1016/j.ijlp.2009.06.006
Rousselet, M., Guerlais, M., Caillet, P., Le Geay, B., Mauillon, D., Serre, P., Chameau, P.-
Y., Bleher, Y., Mounsande, S., & Jolliet, P. (2019). Consumption of psychoactive
substances in prison: Between initiation and improvement, what trajectories occur
after incarceration? COSMOS study data. PloS One, 14(12), Article e0225189.
https://doi.org/10.1371/journal.pone.0225189
Rowell, T. L., Wu, E., Hart, C. L., Haile, R., & El-Bassel, N. (2012). Predictors of drug use
in prison among incarcerated Black men. The American Journal of Drug and Alcohol
Abuse, 38(6), 593–597. https://doi.org/10.3109/00952990.2012.694536
Rowell-Cunsolo, T. L., Sampong, S. A., Befus, M., Mukherjee, D. V., & Larson, E. L.
(2016). Predictors of illicit drug use among prisoners. Substance Use & Misuse, 51(2),
261–267. https://doi.org/10.3109/10826084.2015.1082594
Sahajian, F., Berger-Vergiat, A., & Pot, E. (2017). Use of psychoactive substances in
prison: Results of a study in the Lyon-Corbas prison, France. Revue d’Epidemiologie et
de Sante Publique, 65(5), 361–367. https://doi.org/10.1016/j.respe.2017.05.007
S´
anchez, F. C., Fearn, N., & Vaughn, M. G. (2018). Prevalence and correlates of in-prison
substance use among incarcerated women in Spain. Journal of Ethnicity in Substance
Abuse, 17(3), 356–374. https://doi.org/10.1080/15332640.2016.1255579
Simpler, A. H., & Langhinrichsen-Rohling, J. (2005). Substance use in prison: How much
occurs and is it associated with psychopathology? Addiction Research & Theory, 13
(5), 503–511. https://doi.org/10.1080/16066350500151739
Strang, J., Gossop, M., Heuston, J., Green, J., Whiteley, C., & Maden, A. (2006).
Persistence of drug use during imprisonment: Relationship of drug type, recency of
use and severity of dependence to use of heroin, cocaine and amphetamine in prison.
Addiction (Abingdon, England), 101(8), 1125–1132. https://doi.org/10.1111/j.1360-
0443.2006.01475.x
Thomas, C. W., & Cage, R. J. (1977). Correlates of prison drug use. An evaluation of two
conceptual models. Criminology; an Interdisciplinary Journal, 15(2), 193–210. https://
doi.org/10.1111/j.1745-9125.1977.tb00061.x
van de Baan, F. C., Montanari, L., Royuela, L., & Lemmens, P. H. (2022). Prevalence of
illicit drug use before imprisonment in Europe: Results from a comprehensive
literature review. Drugs: Education, Prevention and Policy, 29(1), 1–12. https://doi.
org/10.1080/09687637.2021.1879022
Wells, G.A., Shea, B., O’Connell, D., Peterson, J., Welch, V., Losos, M., & Tugwell, P.
(2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of
nonrandomised studies in meta-analyses. Available at: Http://www.ohri.ca/progr
ams/clinical_epidemiology/oxford.htm. (accessed 13 September 2022).
Woodall, J. (2011). Social and environmental factors inuencing in-prison drug use.
Health Education, 112(1), 31–46. https://doi.org/10.1108/09654281211190245
A. Austin et al.