VISITING EXPERTS’ PAPER
EFFECTIVE TREATMENT INTERVENTIONS FOR PEOPLE WITH
SUBSTANCE USE DISORDERS IN CONTACT WITH THE CRIMINALJUSTICE SYSTEM
Wataru Kashino*and Sanita Suhartono※

I. INTRODUCTION
This article is based on the publication “Treatment and care of people with drug use disorders in contact
with the criminal justice system: Alternatives to conviction or punishment”1 (UNODC/WHO, 2019), the draft
summary report on available measures based on an analysis of Note Verbale responses by UN Member
States to UNODC on “Alternatives to conviction or punishment available for people who use drugs and withdrug use disorders in contact with the criminal justice system”2 (UNODC, 2022), the 65th Commission on
Narcotic Drugs (CND) conference room paper on “Treatment of drug use disorders and associated mental
health disorders in prison settings and forensic hospitals”3 (UNODC, 2022), and the 66th CND conference
room paper on “Review of interventions to treat drug use disorders among girls and women in the criminal
justice system in low- and middle-income countries (UNODC, 2023).4
Enhancing prevention and treatment of drug use disorders while creating healthy, safe, and sustainablecommunities is in line with UNODC’s strategy 2021–2025 pillar on addressing the world drug problem. It isan essential demand reduction strategy that contributes to significant public health importance of the 2016
United Nations General Assembly Special Session (UNGASS) on the World Drug Problem outcome document5
and contributes to the overall achievement of Sustainable Development Goal (SDGs) 3,6 targeting goal 3.5(“Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful
use of alcohol”), and SDG 16,7 targeting especially goal 16.3 (“Promote the rule of law at the national and* Dr. Wataru Kashino is Programme Officer at the Prevention, Treatment and Rehabilitation Section at the United Nations
Office on Drugs and Crime. He can be contacted at wataru.kashino@un.org. The information and views set out in this article
are those of the author(s) and do not necessarily reflect the official opinion of the UNODC.
※
Ms. Sanita Suhartono is Associate Programme Officer at the Prevention, Treatment and Rehabilitation Section at theUnited Nations Office on Drugs and Crime. She can be contacted at sanita.suhartono@un.org. The information and views set
out in this article are those of the author(s) and do not necessarily reflect the official opinion of the UNODC.
1
United Nations Office on Drugs and Crime, UNODC and World Health Organization, WHO, “Treatment and Care of People
with Drug Use Disorders in Contact with the Criminal Justice System: Alternatives to Conviction or Punishment”, 2019,https://www.unodc.org/documents/drug-prevention-and-treatment/UNODC_WHO_Alternatives.pdf
2
United Nations Office on Drugs and Crime, UNODC, “Alternatives to Conviction or Punishment available for People
Who Use Drugs and with Drug Use Disorders in Contact with the Criminal Justice System. Draft Summary Report on
Available Measures Based on an Analysis of Note Verbale Responses by UN Member States to UNODC”, 2022, https://www.unodc.org/res/drug-prevention-and-treatment/publications_html/Report_on_NVs_on_Alternatives_to_Incarceration_
FINAL_0609221.pdf
3
United Nations Office on Drugs and Crime, UNODC, E/CN.7/2022/CRP.9, “Treatment of Drug Use Disorders andAssociated Mental Health Disorders in Prison Settings and Forensic Hospitals”, 2022, https://www.unodc.org/documents/
drug-prevention-and-treatment/UNODC_TX_in_Prisons_March22.pdf
4
United Nations Office on Drugs and Crime, UNODC, E/CN.7/2023/CRP.XX, “Review of interventions to treat drug use
disorders among girls and women in the criminal justice system in low- and middle-income countries”, 2023 (forthcoming)
5
United Nations Office on Drugs and Crime, UNODC, “Outcome Document of the 2016 United Nations General AssemblySpecial Session on the World Drug Problem. Our Joint Commitment to effectively addressing and countering the World Drug
Problem”, 2016, https: //www. unodc.org/documents/postungass2016/outcome/V1603301-E.pdf
6
United Nations Sustainable Development Knowledge Platform, SDG Goal 3 “Ensure healthy lives and promote well-being
for all at all ages” https://sustainabledevelopment.un.org/sdg3
7
United Nations Sustainable Development Knowledge Platform, SDG Goal 16 “Promote peaceful and inclusive societies forsustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at alllevels” https://sustainabledevelopment.un.org/sdg16

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RESOURCE MATERIAL SERIES No. 116
international level and ensure equal access to justice for all”) and 16.6 (“Develop effective, accountable andtransparent institutions at all levels”).
The United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO)initiative on “Treatment and Care of People with Drug Use Disorders in Contact with the Criminal Justice
System” was launched in 2016, in response to the Commission on Narcotic Drugs (CND) resolution 58/5
entitled “Supporting the collaboration of the public health and justice authorities in pursuing alternative
measures to conviction or punishment for appropriate drug related offences of a minor nature”.8 The initiative
aims at enhancing the knowledge, understanding, scope and potential for non-custodial alternative measures
to conviction or punishment for drug-related offences of a minor nature. As part of the initiative, UNODC
and WHO published a handbook on Alternatives to Conviction or Punishment” in 2019. Options of diverting
people with drug use disorders who are in contact with the criminal justice system to treatment are being
explored at a global level, in line with the international drug control conventions and other relevantinternational instruments, including human rights treaties and UN standards and norms in crime prevention
and criminal justice.9
Moreover, providing effective treatment interventions for people with drug use disorders in contact withthe criminal justice system, such as in prison settings responds to CND resolution 61/7 on “Addressing thespecific needs of vulnerable members of the society in response to the world drug problem”10 and the 2016
UNGASS Outcome Document that suggests United Nations (UN) Member States to “promote and strengthen
regional and international cooperation in developing and implementing treatment-related initiatives (…),
enhance technical cooperation and capacity-building and ensure non-discriminatory access to a broad range
of interventions, including psychosocial, behavioural and medication-assisted treatment, as appropriate andin accordance with national legislation, as well as to rehabilitation, social reintegration and recovery-support
programmes, including access to such services in prisons and after imprisonment (…)”.
Understanding that prison is a high-risk environment for many health threats, including drug use andassociated mental health disorders, the United Nations Standard Minimum Rules for the Treatment of
Prisoners (the Nelson Mandela Rules) highlight the needs for equitable access to health care, including
mental health services and services for the treatment of drug use disorders.11 The provision of treatment ofdrug use disorders in prison settings, as well as the integrated treatment of drug use disorders and related
mental health disorders, has been furthermore described in the UNODC/WHO “International Standards for
the Treatment of Drug Use Disorders”.12

II. GOBAL SITUATION WITH REGARD TO DRUG USE DISORDERS
IN THE CRIMINAL JUSTICE SYSTEM
According to the 2022 World Drug Report, there are currently about 284 million people worldwide whohave used drugs at least once in 2020, of which an estimated 36.7 million people suffer from drug use

8

United Nations Office on Drugs and Crime, UNODC, Commission on Narcotic Drugs (CND) resolution 58/5, ”Supportingthe collaboration of the public health and justice authorities in pursuing alternative measure to conviction or punishment for
appropriate drug related offences of a minor nature”, 2015, https://www.unodc.org/documents/commissions/CND/CND_
Sessions/CND_58/2015_Resolutions/Resolution_58_5.pdf
9
The United Nations Standard Minimum Rules for Non-Custodial Measures (the Tokyo Rules); the United Nations Rules for
the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (the Bangkok Rules)
10
United Nations Office on Drugs and Crime, UNODC, Commission on Narcotic Drugs (CND) resolution 61/7, “Addressing
the specific needs of vulnerable members of the society in response to the world drug problem”, 2018, https://www.unodc.
org/documents/commissions/CND/CND_Sessions/CND_61/CND_res2018/CND_Resolution_61_7.pdf
11
United Nations Office on Drugs and Crime, UNODC, “The United Nations Standard Minimum Rules for the Treatmentof Prisoners. (the Nelson Mandela Rules)”, 2015, https://www.unodc.org/documents/justice-and-prison-reform/GARESOLUTION/E_ebook.pdf
12
United Nations Office on Drugs and Crime, UNODC and World Health Organization, WHO, “International Standards for
the Treatment of Drug Use Disorders”, 2020, https://www.unodc.org/documents/drug-prevention-and-treatment/UNODCWHO_International_Standards_Treatment_Drug_Use_Disorders_April_2020.pdf

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VISITING EXPERTS’ PAPER
disorders (UNODC, 2022).13 Cannabis remains the most used drug globally. Drug use disorders are a
multifactorial health disorder, associated with socio-economic inequalities, criminal behaviour and social
exclusion. They account for 31 million healthy lives lost due to disability and premature deaths (DALYs) in2019.
Although the majority of people using drugs is men, only 1 in 3 people using drugs is a woman. For thisreason, treatment services are primarily designed to cater to the male patient majority and females who use
drugs may not be adequately met. With increasing numbers of people using drugs, the treatment gap keeps
growing, only 1 in 8 people with drug use disorders have access to any form of treatment globally. In termsof women with drug use disorders, they continue to be underrepresented in drug treatment, as only 1 in 6
women have access to treatment globally. This proportion of women in drug treatment varied greatly acrossregions, influenced by factors such as the prevalence of substance use disorders among men and women,
accessibility and availability of treatment, as well as societal stigmas and additional barriers women may facewhen seeking treatment.
People with drug use disorders are often in contact with the criminal justice system, and many people inthe criminal justice system have a history of drug use disorder (UNODC, 2019). The 2020 World Drug Reportpresented data on an estimated number of people in the criminal justice system for drug-related offences.
There are about 3.1 million people arrested due to drug-related offences of which 61 per cent are arrested
due to drug possession for their personal use (UNODC, 2019).14 This data indicates that more people are incontact with the criminal justice system on drug possession charges globally and implies the need of noncustodial alternatives to conviction or punishment for people with drug use disorders and for key intervention
points and types of diversion programmes along the criminal justice continuum. Non-custodial measures as
an alternative to conviction or punishment are effective ways of treating people with drug use disorders in
the criminal justice system, and diversion mechanisms should be applied whenever appropriate.
According to the 2015 World Drug Report, people who use drugs that have a history of incarceration areaffected by increasing vulnerability to infectious diseases (UNODC, 2015).15 Drug use does not stop in thecriminal justice system or prison settings. Data from the 2017 World Drug Report confirms that the prevalenceof drug use in prison settings is higher than drug use among the general population (UNODC, 2017).16
Updated data from the 2019 World Drug Report confirms that 31 per cent of people have used any kind of
drugs during incarceration globally at least once and 19 per cent of those even in the past month, 16 per centof those have been reporting current use of cannabis and 10 per cent reporting heroin use (UNODC, 2019).
Moreover, people who inject drugs often represent a large part of the prison population (WHO, 2014).17
Currently, there are nearly twelve million people in prison globally with about one-third of the people inprison being unsentenced and a solid majority of countries worldwide are operating with overcrowded
prisons (UNODC, 2021).18 According to the 2019 World Drug Report, it is important to note that with 35 per
cent, there is a higher proportion of women than men, comparatively 19 per cent in prison for drug-related
offences (UNODC, 2019).19 Deeply concerning is also the rate of increase in the female prison population.
Although they only make up 10 per cent of the world’s prison population, they are increasing at a much
faster rate than the male population, as there has been a 50 per cent increase since 2000, compared to 18 percent for males in prisons (UNODC, 2021).18 Fortunately, there has been a drastic reversal in the trend from13

United Nations Office on Drugs and Crime, World Drug Report 2022. https://www.unodc.org/res/wdr2022/MS/WDR22_
Booklet_1.pdf
14
United Nations Office on Drugs and Crime, UNODC, World Drug Report, “Global Overview of Drug Demand and Supply”,
2019. https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_2_DRUG_DEMAND.pdf
15
United Nations Office on Drugs and Crime, UNODC, World Drug Report, “Status and Trend Analysis of Illicit Drug
Markets”, 2015, https://www.unodc.org/documents/wdr2015/WDR15_Chapter_1.pdf
16
United Nations Office on Drugs and Crime, World Drug Report “Drug Demand and Supply” 2017. https://www.unodc.org/
wdr2017/index.html
17
United Nations Office on Drugs and Crime, World Drug Report “Drug Demand and Supply” 2017. https://www.unodc.org/
wdr2017/index.html
18
United Nations Office on Drugs and Crime, UNODC, Data Matters, 2021. https://www.unodc.org/documents/data-andanalysis/statistics/DataMatters1_prison.pdf
19
United Nations Office on Drugs and Crime, UNODC, World Drug Report, “Global Overview of Drug Demand and Supply”,
2019. https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_2_DRUG_DEMAND.pdf

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RESOURCE MATERIAL SERIES No. 116
the preceding decades since the start of the Covid-19 pandemic. From 2019 to 2020, the global prison
population actually declined by around 4.7 per cent from about 11.8 million to 11.2 million people held inprison settings.20

III. DRUG USE DISORDER TREATMENT AS AN ALTERTNATIVETO CONVICTION OR PUNISHMENT
Individuals with drug use disorders who are in contact with the criminal justice system have complex
needs and require a range of interventions that address both their drug use disorder and other social andhealth needs. When people with drug use disorders commit an offence of a minor nature, non-custodial
measures for treatment, education or social reintegration should be applied as alternatives to conviction orpunishment or be applied in addition to conviction and punishment. Providing treatment as an alternative toconviction or punishment for people with drug use disorders who are in contact with the criminal justicesystem in appropriate cases, contributes to improving public health and public safety.
UNODC’s support in promoting non-custodial measures for people with drug use disorders in contact
with the criminal justice system, along all stages of the criminal justice continuum is in line with theinternational policy and legal frameworks mentioned above. Moving from a coercive to a cohesive approach
towards people with drug use disorders in contact with the criminal justice system requires the involvementof a multisectoral approach, including close collaboration among the health, social and justice sectors as well
as a concerted investment in evidence-based treatment services in the community.
Health is a fundamental right, indispensable for the exercise of other human rights. The right to healthextends to any person in contact with the criminal justice system and thus people with drug use disorders
who are in contact with the criminal justice system should be provided with effective treatment of drug use
disorders. The provision of treatment as an alternative to conviction or punishment, based on the international
drug control conventions, can be implemented in appropriate cases of a minor nature:• 	 Community: Parties shall take all practical measures for the prevention of abuse of drugs and for the
early identification, treatment, education, after-care, rehabilitation and social reintegration of thepersons involved• 	 Persons in contact with the criminal justice system: Parties may provide (those measures) either as analternative to conviction or punishment or in addition to conviction or punishment• 	 Cases of drug consumption-related offences and other cases of drug trafficking of a minor nature:
Parties shall measure those cases as an alternative to conviction or punishment
Treatment and care as an alternative to conviction or punishment has been implemented in different
countries and different legal systems. However, the process, time frame and key judicial actors, in particular
the roles of the prosecutor and the judge, can differ. A key task in implementing treatment and care requires
provision of appropriate sensitization and training to the key policymakers, practitioners and advocates fromdifferent sectors. Sensitization and capacity-building should also be offered within communities to reduce
stigma, both from the justice side as well as from the health side and strengthen a common understandingof drug use and drug use disorders, especially in the criminal justice setting.
Through the UNODC-WHO initiative and handbook on “Treatment and care for people with drug use
disorders in contact with the criminal justice system – alternatives to conviction or punishment”, sevenprinciples highlight the importance of using treatment and care strategies for individuals with drug use
disorders who come into contact with the justice system.

20

https://dataunodc.un.org/dp-prisons-persons-held

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VISITING EXPERTS’ PAPER
1) Drug use disorders are a public health concern requiring responses that are health-centred. Individuals
with drug use disorders should not be punished for their drug use disorder but be provided withappropriate treatment.
The right to health is a crucial aspect of drug policies, and promoting public health is a key part ofaddressing drug use disorders. Access to essential medicines and treatment, as well as the right to theprevention and treatment of diseases should be a universal right to health. However, due to varying levelsof capacity, the full realization of the right to health is achieved progressively, and significant gaps still exist
in the delivery of prevention, treatment and rehabilitation services for people with drug use disorders.
2) The use of alternatives to conviction or punishment at all stages of the criminal justice system foroffenders with drug use disorders, on the basis of an assessment using established criteria, should be
encouraged.
The criminal justice system should provide a range of non-custodial alternative measures at all stages ofthe process, considering the nature and gravity of the offence, offender background, and protection of victims
and society. Non-custodial alternatives are effective in reducing reoffending and promoting social reintegration,and international drug control conventions allow Member States to provide drug treatment and othermeasures as an alternative or addition to conviction or punishment. The selection of alternatives should bebased on established criteria related to the offence, offender, sentencing purpose and victim rights.
3) Proportionality is required at all stages of the diversion and supervision process.
Proportionality should be applied as a guiding principle throughout the criminal justice process, such as
when deciding on the eligibility of an offender for diversion, the intensity and the length of supervision andthe responses to non-compliance or breaches of conditions.
4) A diversion to treatment should be made with the informed consent of the offender.
The right to health includes the right to be free from torture, non-consensual treatment and experimentation.
This means that alternatives to conviction or punishment shall not involve non-consensual medical or
psychological experimentation or undue risk of physical or mental injury to the offender. In general, notreatment should be given to a patient without their informed consent, and nobody should be compelled toundergo medical treatment against their will, unless in an extreme acute emergency.
5) The implementation of alternatives to conviction or punishment should respect legal and procedural
safeguards.
The observance of legal and procedural safeguards for protecting the rights of individuals with drug use
disorders during the implementation of alternatives to conviction or punishment is crucial. Authorities must
adhere to relevant laws and define and prescribe the application of alternative measures and conditions forsupervision. Furthermore, special attention must be paid to respecting the rights to dignity and privacy, andindividuals should have the right to review decisions, seek recourse, and appeal against decisions to modify
or revoke alternatives. Lastly, the text emphasizes the importance of providing clear information to offenders
about their obligations and rights and conducting drug treatment only by trained professionals.
6) Specific attention to special groups and their access to treatment as an alternative to conviction orpunishment is required to avoid discrimination.
This principle highlights the importance of giving specific attention to the particular needs of various
population groups such as women, young adults, persons with co-occurring mental health and drug use
disorders, persons with cognitive and intellectual disabilities, and racial and ethnic minorities. Nondiscrimination principles require adopting specific measures to eliminate existing forms of discrimination
faced by particular groups in areas such as justice or health. For instance, women offenders and prisoners
have unique needs that are often not adequately met by criminal justice systems dealing with male offenders,and gender-specific options should be implemented. Women with drug use disorders should be diverted orreferred to gender-sensitive, trauma-informed treatment programmes, and residential treatment should
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RESOURCE MATERIAL SERIES No. 116
either be women-only or have gender segregation to increase safety and enhance outcomes.
7) Prisoners with drug use disorders may not be deprived of their right to health and are entitled to thesame level of treatment as the general population.
The last principle emphasizes that even when individuals with drug use disorders are in prison, they still
have the right to receive health care, which is the State’s responsibility. They should have access to necessary
health care services without discrimination, and these services should be organized in a way that ensurescontinuity of treatment and care, including for infectious diseases and mental and behavioural disorders. The
relationship between health care professionals and prisoners should be governed by the same ethical andprofessional standards as those applicable to patients in the community, including the adherence to prisoners’autonomy with regard to their own health and informed consent in the doctor-patient relationship.
Between 2016 and 2021, UNODC consulted Member States three times to gather different information on
non-custodial alternative measures to conviction or punishment for people with drug use disorders in contact
with the criminal justice system. In 2016, UNODC reached out to UN Member States to obtain information
on national responses with regard to justice and health collaboration on alternative measures to conviction
or punishment for appropriate drug-related offences of a minor nature through a Note Verbale (NV). In
December 2020, the Commission of the African Union, together with UNODC reached out especially toAfrican Union Member States to identify existing practices on alternatives to conviction or punishment forpeople with drug use disorders in contact with the criminal justice system through another Note Verbale
and lastly, in February 2021, UNODC invited UN Member States to provide information on existing national
tools on the collaboration of justice and health authorities with regard to alternatives measures to conviction
or punishment for appropriate drug-related offences of a minor nature and the roles of different professionalgroups that divert people with drug use disorders in contact with the criminal justice system in appropriate
cases at each stage of the criminal justice continuum, from pre-arrest to post-sentencing stage, through thelast Note Verbale.
Based on these, a draft summary of NV responses was prepared by UNODC to provide an overview ofexisting laws, legislation and practices between justice and health authorities on alternative measures toconviction or punishment for appropriate drug-related offences of a minor nature. The report highlights bothprogress and challenges in implementing the international drug conventions. Although Member States
generally agreed on the need for alternatives to conviction or punishment for people with drug use disorders
in contact with the criminal justice system, challenges in implementing these alternatives were highlighted,
such as the lack of availability to treatment for drug use disorders and limited infrastructure and insufficienttrained human resources for evidence-based assessment, treatment and supervision. To make non-custodial
alternatives for people with drug use disorders in contact with the criminal justice system work, they need
to be appropriately tailored to different groups and evaluated to demonstrate their effectiveness in achieving
positive health, social and justice outcomes. It is also important to have a multisectoral approach and support
from professionals and communities form the health, justice and social sectors, in establishing networks andmentoring programmes for sharing good practices and experiences between countries. More monitoring andevaluation efforts are needed to ensure that alternatives for people with drug use disorders in contact withthe criminal justice system are successfully used. Further, efforts must be made to develop legal frameworks
and national budgets to allow for a drug use disorder treatment infrastructure, in line with the UNODCWHO International Standards for the Treatment of Drug Use Disorders. Overall, there is a need to build on
the existing policy consensus and interest expressed by Member States to provide effective non-custodial
alternatives to conviction or punishment for those in need.
To further advance the UNODC-WHO’s initiative on “Treatment and care for people with drug use
disorders in contact with the criminal justice system”, UNODC has embarked on the development of detailed
principles for the implementation of treatment as an alternative at the various stages of the criminal justicesystem, highlighting the different roles of health, justice and relevant professionals.
To start identifying these principles, UNODC organized four informal preparatory consultations from2020 to 2022. The objective of these meetings was to outline options along the criminal justice continuum,
namely at pre-arrest, pre-trial, trial and post-trial stages. While gaps and opportunities have been identified
in implementing alternatives to conviction or punishment for people with drug use disorders in contact with34

VISITING EXPERTS’ PAPER
the criminal justice system along the different criminal justice stages, the principles will be developed after
a technical consultation that will be held in 2023, where all stages of the criminal justice continuum anddifferent professional groups will be considered.
Lastly, UNODC prepared a Conference Room Paper (CRP) which will be published at the upcoming 66th
CND on the “Review on interventions to treat drug use disorders among girls and women in the criminal
justice system in low-and middle-income countries”, due to the unique needs of women with drug use
disorders including those in criminal justice systems. Women with drug use disorders should be diverted orreferred to gender-sensitive, trauma-informed drug treatment programmes, and if residential treatment isneeded, they should either be women-only or consider gender segregation to increase safety and enhanceoutcomes.
The findings of this study indicated a public health concern for girls and women with drug use disorders
who are involved with the criminal justice system. For those girls and women who come into contact withthe criminal justice system, screening for substance use disorders should take place immediately. They
should also be considered for alternatives to punishment or conviction, and gender-sensitive and traumainformed treatment should be provided and evaluated for its effectiveness. While this study has summarized
available findings on drug use disorders among women and girls in the criminal justice system, data from
low-and-middle-income countries (LMIC) are limited. Therefore, further research is necessary to understandthe factors that influence drug use and to develop effective interventions for this population, especially in
low-and-middle income countries.
The report aimed to investigate the factors influencing drug use, including alcohol and tobacco use, in
women and young girls who have had contact with the criminal justice system and live in LMIC. Available
evidence of interventions targeting drug use and related harms in this group were discussed. Evidence of
research in LMIC that include female cohorts was found in China and Thailand and studies providing
psychosocial interventions for drug use disorders treatment such as cognitive behavioural therapy (CBT)and peer-based support groups in LMIC show no positive impact on drug use, injecting risk behaviours or
sexual risk behaviours.
Government approaches and inter-agency cooperation within the criminal justice system were encouraged
to ensure that drug use among women and girls are addressed and Member States responses adequately
documented and evaluated. Additionally, development of national programmes that specifically target womenand their traumatic experiences influencing their drug use was recommended.

IV. TREATMENT OF DRUG USE AND ASSOCIATED MENTAL HEALTHDISORDERS IN PRISON SETTINGS
Prison overcrowding severely impacts the quality of nutrition, sanitation, activities of people held inprison settings, physical and mental health conditions, and the care available for vulnerable groups in prison
settings. Applying alternatives to conviction or punishment for people with drug use disorders in contact
with the criminal justice system should be the first priority for all Member States. When alternatives toconviction or punishment are used to replace imprisonment, they contribute directly to the reduction of theprison population. A further advantage of using alternatives to imprisonment is that they can help reduce
reoffending, and thereby lower the prison population in the long term. For people with drug use disorders incontact with the criminal justice system, treatment as an alternative to conviction or punishment can beapplied in all appropriate cases to benefit public health and public safety. Moreover, drug treatment is morecost-effective than imprisonment.
The global prison population is on the rise, which poses serious negative health and social consequences
including financial challenges for governments. It is estimated that around 10 to 50 per cent of all people held
in prison have a drug use disorder. The rate of imprisonment varies across different regions, with some areas
having higher rates of drug use and infectious diseases like HIV and tuberculosis among people held in prison
settings. This makes them more vulnerable to health risks compared to the general population.

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The Covid-19 pandemic has drastically shifted attention towards the issue of prison overcrowding.
According to a global analysis, nearly 550,000 people held in prisons have contracted Covid-19 in 122 countries.
Globally, close to 4,000 fatalities of people held in prison settings due to Covid-19 occurred in 47 countries.21
In response to the pandemic, some prisons limited recreation, work opportunities and visitation rights – allessential components of rehabilitation programmes. Some countries opted to release people in prison settings
at least temporarily, as prevention measures were difficult to implement, especially when they are
overcrowded. Large numbers of people in custody, particularly people in remand, or the pre-trial stage, andthose convicted of non-violent offences were among those released early. Since March 2020, at least 700,000
persons around the globe – or roughly 6 per cent of the estimated global prison population – have beenauthorized or considered eligible for release through emergency release mechanisms adopted by 119 Member
States.
While criminal sanctions no doubt deter some people from drug use, those with more severe drug use
disorders are relatively insensitive to the threat of criminal sanctions, and higher incarceration rates havenot led to reduced drug use in the community. At the same time, incarceration has severe negative
consequences for people with drug use disorders, their families and their communities, and incarceration canworsen the underlying health and social conditions associated with drug use. Above all, imprisonment should
always be a measure of last resort and community-based interventions for people with drug use disorders,
including those in contact with the criminal justice system, should always be considered.
UNODC supports Member States in addressing treatment of drug use and associated mental healthdisorders in prison settings, specifically for people with drug use disorders in contact with the criminal
justice system, who have committed a more serious crime and, due to the nature of their crime, alternatives
to conviction or punishment cannot be considered. Promoting appropriate, evidence-based drug use disorder
treatment services in prison settings, in line with the UNODC WHO International Standards for theTreatment of Drug Use Disorders, coordination should take place between the criminal justice system andhealth and social services.
Prison health is an integral part of public health, as the right to health extends to people in contact withthe criminal justice system, no matter the legal status of a person. This is in line with the UNODC Nelson
Mandela Rules, specifically rule 109 which states that individuals with severe mental disabilities or healthconditions should not be held in prisons and should be transferred to appropriate mental health facilities fortreatment. Furthermore, all prisoners who require psychiatric treatment should receive it from the healthcare service.
Evidence-based treatment of drug use disorders that seeks to promote a balanced, human rights-centred
and compassionate approach for individuals with drug use disorders contributes to the overall quality of careand outcomes for people with drug use disorders, including those in contact with the criminal justice system.
According to the UNODC-WHO International Standards for the Treatment of Drug Use Disorders, and inline with other international conventions, drug use disorders should be considered primarily as healthproblems rather than criminal behaviours and, as a rule, people with drug use disorders should be treated in
the health care system rather than the criminal justice system. Not all people with drug use disorders
commit crimes and, even if they do, these are typically low-level crimes committed to sustain their drug use.
Moreover, it is important to understand that drug use does not automatically lead to dependence.
In cases of drug use disorder treatment within prison settings, the criminal justice system shouldcollaborate closely with the health and social sectors to ensure that treatment for drug use disorders in thehealth care system takes precedence over criminal prosecution or imprisonment. Law enforcement, legal
practitioners and penitentiary or prison staff should receive appropriate training to effectively engage in andsupport drug use disorder treatment, rehabilitation and social reintegration. Upon prison release, providing
a continuum of care, such as effective continuous drug use disorder treatment, lowers the risk of relapse,
overdose death and reoffending. In all justice-related cases, people should receive the same health standards,
including treatment and care for drug use disorders, of a standard, equal quality as available in the community.
21

https://www.unodc.org/unodc/frontpage/2021/July/one-in-three-people-globally-imprisoned-without-trial--whileovercrowding-puts-prisoners-at-risk-of-contracting-covid-19--says-unodcs-first-global-research-on-imprisonment.html

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In 2021, UNODC conducted an online and informal technical consultation on addressing treatment of druguse disorders and associated mental health disorders in prison settings, which brought together 120 experts
from 53 countries. Health and justice practitioners, researchers, policymakers, civil society, people with lived
experience, and representatives of regional and international organizations shared practices, challenges andneeds on drug use and associated mental health disorders in prison settings. This year, the UNODC-WHO
Informal Scientific Network is also preparing a statement of recommendations to be presented to policymakers
at the 66th CND plenary on how to strengthen treatment of substance use disorders in prison settings.
In both meetings, closing the overall treatment gap for people with drug use disorders and increasing theaccessibility of evidence-based treatment were underlined as key efforts to reduce substance use and criminal
justice contacts, as well as associated prison overcrowding. Thus, improving public health and public safety
in a synergic approach are beneficial for communities and prison settings. Pharmacological treatments for
opioid use disorders, including when offered in prison settings, are effective clinical interventions in reducing
substance use, related mortality and morbidity, as well as recidivism and reincarceration. Psychosocial
interventions such as cognitive behavioural therapy, contingency management, the community reinforcement
approach and therapeutic communities, including opioid overdose prevention trainings, were also consideredbeneficial.
Furthermore, UNODC conducted a literature review on the effectiveness of treatment options for druguse disorders in prison settings and forensic hospitals, soon to be published in the scientific journal Criminal
Justice and Behaviour. Its findings suggest that the coverage of treatment at a global level is low.
Lastly, during the 65th CND, UNODC published a CRP that reported on treatment of drug use andassociated mental health disorders in prison settings and forensic hospitals. Member States were asked: 1)
to share information on existing national level programmes, protocols and good practices addressing mental
health including the treatment of disorders/drug use disorders for people in prison settings and in forensic
hospitals; and 2) to provide relevant evaluation of research data on the effectiveness of such treatment formental health disorders and substance/drug use disorders in prison settings or in forensic hospitals. A totalof 35 countries submitted information in response to the NV.
Responses to the NV request showed that Member States acknowledge the need for a high-quality
response to drug use disorder treatment in prison settings. In particular, countries reported good practices
in relation to drug use disorder treatment for people in prison settings and confirmed that the principle ofequity is widely acknowledged. Countries provided an overview on inter-ministerial collaborations andsynergies. Despite this progress, the responses highlighted a number of challenges, including drug treatment
gaps and less common interventions.

V. CONCLUSIONUN Member States promote evidence-based treatment for people with drug use disorders in contact withthe criminal justice system in cases of a minor nature an alternative to conviction or punishment and formore severe crimes also in prison settings, in line with relevant international policy agreements. Good
practices were described by Member States but, overall, only with limited evaluation data on the outcomes.
More efforts on monitoring and evaluation to inform policymakers on the importance of evidence-based
treatment and care of drug use disorders for people in contact with the criminal justice system and associatedpublic health and public safety benefits is recommended. Member States acknowledged that imprisonment
by itself is ineffective in addressing drug use and drug use disorders. Alternatives to conviction or punishment,
therefore, are a crucial component of proportionate responses to certain criminal offences. They have thepotential to reduce reoffending, promote social reintegration and offer an opportunity to foster recovery fromdrug use disorders and a reduction in drug use and associated criminal behaviour.
The provision of treatment as an alternative to conviction or punishment can be implemented at allstages of the criminal justice process (pre-trial, trial, post-trial) in line with the International Conventions andother relevant legal documents as well as in coordination with the International Standards for Treatment ofDrug Use Disorders. It is widely recognized that imprisonment alone is not a sufficient solution for dealing
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with drug use and drug use disorders. Consequently, it is essential to have alternatives to conviction orpunishment as a significant part of appropriate measures for certain criminal offences. Such alternatives
have the potential to decrease recidivism rates, encourage social reintegration, and provide a chance forindividuals to recover from drug use disorders and reduce their drug use and related criminal conduct.
Universal health coverage and equity are critical concepts for quality prison health service, and cooperation
between health, justice and social services will ensure that people with drug use and associated mental
health disorders in prisons are not left behind.
Above all, imprisonment should always be a measure of last resort, and community-based interventions
for people with drug use disorders, including those in contact with the criminal justice system, should always
be considered. Prison-based drug treatment needs to be of the same standard as community-based
interventions and can only be effective if there is a continuity of treatment and care in the community. Noncustodial measures to increase access to drug dependence treatment, address prison overcrowding andreduce recidivism and alternatives to conviction or punishment are crucial for responding to the world drug
problem more effectively and proportionately. Multisectoral partnerships are crucial to promote both publichealth and public safety. UNODC will continue to support Member States in promoting alternatives toconviction or punishment, including as an integral part in prison health services.

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