International Guidelines on Human Rights and Drug Policy

3. Persons deprived of liberty

All persons deprived of their liberty must be treated with humanity and with respect for the inherent dignity of the person. This includes those held in prisons and other closed settings and places of detention for drug-related reasons. Such persons have the right to a standard of health care equivalent to that available to the general population.

In accordance with these rights, States should:

i. Adhere at all times to the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules).

ii. Adhere at all times to international standards relating to specific groups deprived of their liberty, including women (the Bangkok Rules) and children (the Beijing Rules).

iii. Ensure that all persons deprived of their liberty have access to voluntary and evidence-based health services, including harm reduction and drug treatment services, as well as essential medicines, including HIV and hepatitis C services, at a standard that is equivalent to that in the community.

iv. Organise such drug-related and other health care services in close parallel with general public health administration, taking into account the specific nature of individuals’ detention, and design services to ensure the continuity of harm reduction, drug treatment, and access to essential medicines through transitions of entering and exiting the detention facility, as well as transfer between institutions.

v. Ensure that drug-related and other health care services for these populations are provided by qualified medical personnel able to make independent, evidence-based decisions for their patients.

vi. Ensure the provision of training for health care professionals and other staff working in prisons and other closed settings and places of detention on drug treatment, harm reduction, and palliative care and pain management, as well as other medical conditions that require the use of controlled substances for medical purposes.

Commentary:

The act of depriving a person of liberty imposes specific and enhanced obligations on States. Both the right to life and the prohibition of torture and other forms of cruel, inhuman, or degrading treatment or punishment create obligations to refrain from inflicting harm on a detainee.765 At the same time, States have ‘positive obligations’ to do everything reasonably possible to safeguard the lives and well-being of those being detained.766

The International Covenant on Civil and Political Rights imposes further positive obligations on the State to ensure minimum standards of treatment consistent with the humanity and inherent dignity of the person.767 In the context of drug control, persons in pre-trial detention or imprisoned after conviction for drug-related offences should not be subjected to harsher treatment than other persons in detention or in places of imprisonment. This has particular relevance for the deprivation of liberty on the basis of drug offences and for the detention or imprisonment of persons who use drugs (regardless of their criminal charge or conviction), as well as for standards of health care available to such persons.

States have legal obligations to ensure that people deprived of their liberty have adequate access to good-quality health facilities, goods, services, and information equivalent to those available in the general community, which are necessary to meet State obligations under the right to health768 and the prohibition on torture and ill-treatment.769 This includes the obligation to provide access to voluntary, evidence-based drug treatment and harm reduction services,770 including needle and syringe programmes and opioid substitution therapies,771 and to provide people deprived of liberty naloxone during their detention and upon their release.772 Guidance by the UN Office on Drugs and Crime, World Health Organization, United Nations Development Programme, Joint United Nations Programme on HIV/AIDS, International Labour Organization, and UN Population Fund also recommends that that naloxone be made available to people in prison, prison staff, and other people in prisons and other closed settings who might witness an opioid overdose and provided to people upon release from prison to prevent post-release overdose deaths.773

A number of UN human rights treaty bodies have raised concerns that the excessive use of incarceration and pre-trial detention as a drug control measure and disproportionate punishments for drug use and minor drug-related crimes have resulted in serious prison overcrowding, calling into question States’ compliance with their obligations to prevent torture and ill-treatment and to protect the right to health.774 They urge States to consider the greater use of non-custodial measures in line with the Tokyo Rules775 and recommend that States reconsider their penalisation of drug use as part of a health- and rights-based approach to drug use.776 The UN Working Group on Arbitrary Detention has found that over-incarceration for drug-related offences contributes significantly to prison overcrowding, which can call into question a State’s compliance with guarantees that everyone in detention shall be treated with humanity and respect for their dignity.777

The Special Rapporteur on the right to health has recommended that States take measures to protect against the spread of COVID-19 in prisons and other detention centres, including by considering the early release of prisoners with drug dependence and other health vulnerabilities (such as HIV, hepatitis C, and tuberculosis) and those charged with minor and non-drug-related crimes, and to adequately plan for the health care of those released.778 The Special Rapporteur has recommended that in the context of the COVID-19 emergency, wherever compulsory drug treatment centres operate, States ‘should take immediate measures to close such centres, release people detained in such centres, and replace such facilities with voluntary, evidence-based care and support in the community’.779 The Special Rapporteur has further recommended that adequately funded, effective measures be put in place to ensure that those released from prisons and other detention settings have continuity of care, as well as access to adequate housing and health care in the community. Thirteen UN entities, recalling the 2012 joint statement on compulsory drug detention centres, have likewise called on States operating compulsory drug detention centres to close them permanently without delay and to implement voluntary, evidence- and rights-based health and social services in the community as part of efforts to curb the spread of COVID-19.780

The UN General Assembly Special Session 2016 Outcome Document promotes the provision of drug treatment and harm reduction services both in the community and in prisons, with a special emphasis on imprisoned women who use drugs.781 Such services must include ‘gender-sensitive and evidence-based drug treatment services to reduce harmful effects for women who use drugs, including harm reduction programmes for women in detention’.782 The denial, removal, or discontinuation of effective drug treatment and harm reduction services in prisons and other places of detention violates the right to health and may in some circumstances contribute to conditions that meet the threshold of cruel, inhuman, or degrading treatment or punishment.783

Technical guidance from the World Health Organization and UN Office on Drugs and Crime recommends that health personnel in prison have complete professional independence from prison authorities and preferably be employed by a health authority. Prison health services should be integrated into national health policies and systems and be fully independent of prison administrations, yet liaise effectively with them.784 The Committee of Ministers of the Council of Europe has likewise concluded that national health authorities should be responsible for health care provision in prisons, which would facilitate the continuity of treatment and ‘enable prisoners and staff to benefit from wider developments in treatments, in professional standards and in training’.785 A number of countries have already transferred responsibility of prison health care to public health services because of concern about the quality of care and the role of medical staff.786

The UN has adopted detailed norms for the fulfilment of the above obligations. Such norms include the Mandela Rules, the Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, the Basic Principles for the Treatment of Prisoners, the Bangkok Rules, the Beijing Rules, the Riyadh Guidelines, the United Nations Rules for the Protection of Juveniles Deprived of Their Liberty, and the Guidelines for Action on Children in the Criminal Justice System.787 These instruments are of general application and, for the most part, are not specifically tailored to the treatment of persons who may have drug-related issues during detention or imprisonment. However, both the Mandela Rules and the Bangkok Rules include guidance directly related to drug use, cited by the UN General Assembly Special Session 2016 Outcome Document.788

The Mandela Rules include three provisions of particular relevance. The first notes that the provision of health care for prisoners is a State responsibility and that people in prison should enjoy the same standard of health care as that available in the community, free of charge and without discrimination on grounds of their legal status.789 The second states that ‘[h]ealth-care service should be organized in close relationship to the general public health administration and in a way that ensures continuity and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence’.790 The third notes that ‘[a] physician or other qualified health care professional … shall see, talk with and examine every prisoner as soon as possible following their admission and thereafter as necessary’ and that ‘[p]articular attention should be paid to … withdrawal signs from the use of drugs … and undertaking all appropriate individualized measures or treatment’.791

The Bangkok Rules also include numerous relevant provisions. They establish that HIV/AIDS programmes and services in penal institutions ‘shall be responsive to the specific needs of women, including prevention of mother-to-child transmission’ and that ‘[i]n this context, prison authorities shall encourage and support the development of initiatives on HIV prevention, treatment and care, such as peer-based education’.792 Furthermore, they establish that prison health services ‘shall provide or facilitate specialized treatment programmes designed for women substance abusers, taking into account prior victimization, the special needs of pregnant women and women with children, as well as their diverse cultural backgrounds’.793 Similar to the Mandela Rules, the Bangkok Rules provide that for women prisoners and detainees, ‘[h]ealth-care service should be organized in close relationship to the general public health administration and in a way that ensures continuity and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence’.794 Furthermore, ‘[a] physician or other qualified health care professional … shall see, talk with and examine every prisoner as soon as possible following her admission and thereafter as necessary’, and ‘[p]articular attention should be paid to … withdrawal signs from the use of drugs … and undertaking all appropriate individualized measures or treatment’.795 Finally, ‘[t]he provision of gender-sensitive, trauma-informed, women-only substance abuse treatment programmes in the community and women’s access to such treatment shall be improved, for crime prevention as well for diversion and alternative sentencing’.796

Regarding the issue of staff attending to people deprived of liberty, the Mandela Rules instruct that all prison staff, prior to entering duty, be provided with training tailored to their general and specific duties and then also provided with ongoing in-service training that includes material on the rights and duties of prison staff in the exercise of their functions, such as respecting the human dignity of all prisoners and the prohibition of certain conduct, particularly torture and other cruel, inhuman, or degrading treatment or punishment.797 Prison staff who work with certain categories of prisoners or who are assigned other specialised functions should receive training that has a corresponding human rights focus.798 The Bangkok Rules further require that all staff assigned to work with women prisoners receive training relating to these prisoners’ gender-specific needs and human rights.799

UN human rights mechanisms have called attention to the multiple and extreme forms of violence faced by LGBTI persons, which is exacerbated when they are deprived of their liberty and subjected to serious violence and to abuse, including sexual assault and rape, by fellow inmates and staff.800 Transgender people, especially transgender women, are often housed in prisons according to their sex assigned at birth, and exposed to a high risk of rape and other violence and ill-treatment.801 The lack of training and polices aimed at understanding the needs of LGBTI people, recognising people’s self-identified gender, and carrying out proper risk assessments compounds these problems.802 UN human rights mechanisms have recommended that States adopt legislative, administrative, and judicial measures to address and prevent violence against LGBTI people in prison, stressing the fundamental importance of the involvement of LGBTI people in the design, implementation, and evaluation of measures to prevent torture and ill-treatment against them.803

Guidance issued by the UN Office on Drugs and Crime, World Health Organization, United Nations Development Programme, Joint United Nations Programme on HIV/AIDS, International Labour Organization, and UN Population Fund recommends that the comprehensive package of HIV prevention, care, and treatment interventions, which includes needle and syringe programmes, overdose prevention and management, opioid substitution therapy, and other evidence-based medical treatment, be tailored to the specific needs of women and transgender people, including with respect to sexual and reproductive health and hormone therapy (according to national guidance), and equivalent to services in the community. The guidance also notes the need for initiatives to acknowledge and address sexual and other forms of violence faced by women, men who have sex with men, and transgender people in prison and highlights the importance of ensuring that representatives of different population groups in prison – including adolescents and young people, women, men, people who inject drugs, transgender people, and people living with HIV – enjoy meaningful participation in the planning, implementing, and monitoring of prison HIV, tuberculosis, and hepatitis programmes in order to develop effective strategies that are responsive to their respective realities.804

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