Drug Use and Incarceration: A Qualitative Study of People Who Use Drugs in Iranian Prisons

Abstract

Introduction

While precise data are limited, approximately 75% of prisoners in various Iranian prisons report using drugs while incarcerated. Previous research has primarily focused on the intersection of incarceration, injection drug use, and infectious diseases, with less attention paid to the subcultural forces and institutional practices that shape prisoners’ substance use. The guiding research question of this study is: How do prisoners experience and navigate drug use within Iranian prisons?

Method

Grounded theory was utilized to examine how drug use is reinforced and functions within the prison environment. Data were collected through semistructured interviews with 60 participants (38 men and 22 women), aged 15–65, most of whom had been incarcerated for drug-related offences. Participants were recruited through snowball, maximum variation, and theoretical sampling techniques across both governmental and non-governmental settings.

Findings

Five key categories emerged: coerced conformity, addiction as governance, access and supply, polydrug use pattern, and struggle for sobriety. Prisoners are coerced to conform to drug use to maintain their social status and avoid isolation, while prison authorities appeared to tolerate drug use as a means of managing institutional behavior. Methadone Maintenance Treatment functioned less as a pathway to recovery and more as a practical tool to stabilize inmates and reduce violence, often coexisting alongside widespread illicit drug availability. Finally, attempts to recovery were constrained by subcultural and structural barriers, with success limited to a small minority of participants.

Conclusion

The study reveals that incarceration itself perpetuates and intensifies substance use, functioning as a mechanism of survival, social integration, and institutional control. Findings indicate that therapeutic efforts of prisons in response to drug-related offences face significant subcultural, structural, and institutional barriers, underscoring the urgent need for more humane, effective, evidence-based approaches to drug use dependency that extend beyond the confines of correctional institutions.

Keywords

drug use prison institutional tolerance drug intervention programs

Introduction

Drug use in prison is a widespread global issue, which is just one of the issues in the criminal justice system (Zunic et al., 2019) that poses significant public health and human rights challenges, particularly in countries with high incarceration rates and punitive drug policies, such as the United States, Iran, Brazil, Mexico, and Russia (Anaraki, 2021a, 2021b, 2022b; Belaunzarán-Zamudio et al., 2017; Boiteux, 2011; Cepeda et al., 2015; Jain, 2015 Oleinik, 2013; Rowell-Cunsolo et al., 2016).

Although the United States makes up less than 5% of the global population, it accounts for nearly 25% of the world's incarcerated individuals, largely as a result of its ongoing war on drugs. Over half of individuals in U.S. federal prisons are serving sentences for drug-related offences (Drug Policy Alliance, 2015). Between 2007 and 2009, in U.S. prisons, approximately 77% of incarcerated individuals reported using marijuana, 47% reported using cocaine, and 42% reported using hallucinogens during their imprisonment (Bronson & Stroop, 2017). In Brazil, between 2006 and 2015, drug trafficking arrests rose from 11% to 45% of total incarcerations, an increase of 427% (Ornell et al., 2020). In fact, in a highly populated Brazilian prison complex, nearly half (49.5%) of inmates reported using drugs while incarcerated. Among them, marijuana was most common (77.8%), followed by crack (1.9%) and cocaine (0.3%) (de Carvalho et al., 2024). In Mexico, Pollini et al. (2009) found that 61% of prisoners reported injecting drugs while incarcerated. Similarly, in Russia, approximately one-third of the prison population was reported to be using drugs (The Moscow Times, 2013).

Estimates suggest that, globally, between 20% and 45% of incarcerated individuals engage in drug use during their time in prison (Carpentier et al., 2018; Norman, 2023). Also, according to UNODC (2019), globally, one in three incarcerated individuals is estimated to have used drugs at least once during imprisonment. Prison systems are intended to serve both punitive and therapeutic functions in response to drug-related offences; however, they often fail to prevent drug use and smuggling within their walls (Armstrong-Mensah et al., 2021).

Iran is no exception to this trend. Iran held an estimated 180,000 incarcerated individuals, placing it among the top 10 countries globally in terms of prison population (World Prison Brief, 2020). A significant proportion of these individuals are incarcerated for drug-related offenses. Although precise and reliable data are lacking, it is known that many enter the prison system with pre-existing drug dependence and continue using drugs during their incarceration (Anaraki, 2021a, 2022b; Calabrese, 2007). Approximately three-quarters (75%) of prisoners in various prisons across Iran reported using drugs while incarcerated, and one in eight reported injecting drugs (Khalooei et al., 2016; Moradi et al., 2020; Zamani et al., 2010). Opioids refer to a class of drugs that include natural forms (e.g., opium), semisynthetic forms (e.g., heroin), and synthetic forms (e.g., fentanyl) (Metcalfe et al., 2017). Among these, opium is the most frequently used drug in Iranian prisons (Khalooei et al., 2016).

Drug use in prison globally is shaped by a complex interplay of factors, including pre-incarceration substance use (Azbel et al., 2018; Favril, 2023), prior arrests and incarceration (Albertie et al.; Karimi et al., 2022; Moradi et al., 2018, 2020), the lack of meaningful rehabilitation programs (Albertie et al., 2017; Woodall, 2011), the widespread availability of drugs within prison settings (Culbert et al., 2015), histories of physical and sexual trauma (Caravaca-Sánchez & Wolff, 2020), institutional complacency and tolerance toward drug use (Cope, 2000; Culbert et al., 2015), and a broader prison culture shaped by peer dynamics and informal norms (Baker, 2015; Mjåland, 2016).

Globally, drug use in prison raises serious concerns due to its association with increased risks of HIV/AIDS, mental health disorders, mortality, and recidivism (Chang et al., 2015; Mir et al., 2015; Rubenstein et al., 2016). In the Iranian context specifically, the intersection of incarceration, addiction, shared injection practices, and the transmission of infectious diseases, such as HIV, hepatitis B, and hepatitis C, has attracted growing research attention (Mehmandoost et al., 2022; Mehrabi et al., 2024; Moradi et al., 2015, 2019; Shahesmaeili et al., 2022; Zamani et al., 2010). Studies have reported particularly high rates of HIV among incarcerated populations, with some estimates suggesting that up to 24% of prisoners in certain Iranian settings have tested positive (Akbari et al., 2016).

While several studies have examined drug policies and the health impacts of drug use in Iranian prisons using quantitative methods, there remains a notable lack of research that centers the voices of individuals with drug use experience within the prison system. This study, therefore, aims to explore the experiences of incarcerated individuals in relation to drug use within the prison environment, offering insights that may inform effective and humane policies and interventions.

Context

Iran, officially known as the Islamic Republic of Iran, is located in West Asia and shares its eastern border with Afghanistan, the world's largest producer of opium and a key transit route for drug trafficking to Europe (Amirabadizadeh et al., 2018). Iran has a long history of implementing a war-on-drugs policy. As Mirzaei et al. (2024) note, Iran transitioned from drug policies rooted in the moral model (e.g., emphasizing its moral and social dangers) to those aligned with the disease model (e.g., emphasizing prevention, treatment, and rehabilitation).

Following the 1979 Islamic Revolution, the country's drug policy was characterized by harsh, strict, and punitive approaches toward addiction. Although a shift toward rehabilitation began in the 1990s, this approach ultimately operated as an extension of the earlier punitive framework, rather than a genuine departure from it.

In 1979, the established Islamic state adopted a strict anti-drug stance and punitive approach, framing illicit drug consumption and trafficking as against the rules of Islam and the revolutionary values (Anaraki, 2021a, 2022b). A significant shift occurred in 1999 when Afghanistan banned poppy cultivation, causing a surge in heroin use in Iran due to the rising cost of opium (Ghiabi, 2019). This marked a dramatic increase in heroin addiction and injection, revealing the limitations of Iran's law-enforcement-centered strategy.

In response, policy reform began in 2005 with the approval of a bill to decriminalize the treatment of individuals with drug dependency. The Ministries of Health and Social Security were assigned responsibility for prevention, treatment, and harm reduction. While this did not remove the criminal status of drug use, it reframed it as a “curable crime.” It was around this period that harm reduction programs such as Methadone Maintenance Treatment (MMT) were introduced in Iranian prisons. However, the implementation of needle exchange programs has remained limited or entirely absent (Darbandi et al., 2025; Zafarghandi et al., 2021).

Further legal reforms came in 2010 with amendments to the Anti-Narcotic Law, introducing Articles 15 and 16. These articles distinguish between people who voluntarily seek treatment and those who do not. Under Article 15, individuals who voluntarily enter authorized treatment centers, whether governmental, non-governmental, private, or harm reduction centers, and receive official treatment certification can avoid criminal prosecution, provided they do not publicly relapse. The law encourages voluntary treatment and provides a legal pathway for people who use drugs to avoid punishment. Article 16, by contrast, applies to those who did not voluntarily seek treatment and refuse treatment or do not obtain treatment certification, allowing judicial authorities to detain them in governmental treatment centers for 1–3 months, with the possibility of a 3-month extension. People who use drugs, particularly those living on the streets, who are unwilling to seek treatment continue to be arrested and sent to governmental treatment centers, which closely resemble prisons, where they are categorized as “patient criminals” (Ghiabi, 2019). Building on these ongoing legal interventions in Iran's drug policy, one of the most recent reforms occurred in 2018, when amendments to the country's drug trafficking law raised the threshold for imposing the death penalty. As a result, numerous pending death sentences were reviewed and, in some cases, commuted (Nikpour, 2018).

However, deeper structural issues continue to persist. In 2017, an estimated 5.4% of Iranians aged 15–64 were using drugs (Radio Farda, 2019). Additionally, over half of the prison population is incarcerated for drug-related offences (Anaraki, 2021a, 2021b, 2022a, 2022b). In this context, rehabilitation has become an integral component of the criminalization approach, often functioning as an extension of punitive policies rather than a genuine effort to address addiction. These figures underscore the ongoing complexity of Iran's drug crisis and the persistent tension between punitive and therapeutic approaches.

Research Method

Grounded Theory (GT) was employed as the methodological framework for this study. Qualitative research methods are particularly useful for exploring individuals’ experiences and behaviors, and for demonstrating how social and structural contexts influence actions such as drug use (Small & McNeil, 2018). Data were collected in 2017 through in-depth, semistructured interviews with 60 current and former prisoners in Iran. This study is part of a larger research project exploring the experiences of people with drug use experiences both in governmental organizations (e.g., prisons and governmental drug-treatment centers) and in non-governmental organizations (e.g., Narcotics Anonymous (NA), nongovernmental drug-treatment centers, and harm reduction centers). While the original aim was to compare participants’ experiences across these different settings, for the purpose of this paper, I specifically extracted and analyzed information related to individuals’ experiences with drug use in prison.

To recruit participants, I employed a combination of sampling strategies. Initially, snowball sampling and maximum variation sampling were used to capture a broad range of experiences and demographics. As Glaser (1978, p. 45) suggests, early data collection involves engaging with individuals most likely to provide relevant insights and leads. As the study progressed, theoretical sampling was employed to refine and deepen emerging categories. According to Glaser and Strauss (2017, p. 36), theoretical sampling involves the concurrent collection, coding, and analysis of data, allowing emerging concepts to guide further data collection. Although this study draws on a larger research project exploring the experiences of people with drug use in governmental and nongovernmental organizations, the inclusion and exclusion criteria reported here are specific to the prison-focused analysis presented in this paper. For this subset, the inclusion criteria focused on current and former prisoners with experience of substance use in prison. Political prisoners were excluded. As categories emerged during data analysis, I specifically sought participants with experience of prison-based NA or individuals who had experiences of being incarcerated in specialized drug-related facilities (alternative to regular prison), in order to explore and saturate emerging concepts.

To ensure diversity and reach saturation, I traveled from Isfahan to three other cities: Tehran, Mazandaran, and Kerman. Data collection concluded once no new themes emerged and repetition was observed in participants’ responses.

Interviews with former or temporarily released prisoners were conducted in settings outside of prisons. Participants were recruited in the Association for the Protection of Prisoners, courts, governmental and nongovernmental drug treatment centers, specialized drug-related facilities, NA¹, harm reduction centers, and night drop-in centers. Participants were introduced to the study through gatekeepers, typically managers or influential community figures. With their consent, I was provided with their contact information. Interviews took place in locations chosen to ensure participants’ comfort and privacy, including quiet corners of institutions, parks, cars, or their homes.

The research sample consisted of 38 male and 22 female participants, aged 15–65. Most had been incarcerated for drug-related offenses, including cases where other crimes, such as murder or theft, were directly or indirectly linked to drug activity. For example, participants convicted of serious crimes like murder often had connections to drugs, whether through disputes over drugs, being under the influence at the time, or involvement in the drug trade.

All interviews were conducted in Farsi by the qualitative researcher. They were digitally recorded, lasted an average of 40 min, and were later transcribed and translated into English by the same researcher. The original interview guide for the larger study covered a broad range of topics, including social relationships in prison, informal and unwritten rules, interpersonal dynamics, violence, and drug use. For this subset of the study, the analysis primarily focused on questions and data related to drug use in prison. All participants gave verbal consent before the interview.

In GT, data collection and analysis occur simultaneously in an iterative and interactive process. Following the Straussian approach (Corbin & Strauss, 1990), data analysis in this study involved three key stages: open coding, axial coding, and selective coding. During open coding, data are broken down into discrete parts, closely examined, and compared for similarities and differences to generate initial concepts and categories. Axial coding follows, in which categories are refined and linked by identifying relationships among them. Finally, in selective coding, a core category is identified.

Findings

Five key categories emerged and were explored in the analysis:

Coerced Conformity

Prisoners described the prison environment as one governed by rigid, unwritten social rules, where drug use was both normalized and, in many cases, expected. Refusing to use drugs often led to social exclusion and could undermine one's identity or safety within the prison hierarchy. Participants emphasized that drug use was not always a matter of personal choice but rather a strategy for survival and social integration, reflecting how unwritten rules can enforce conformity. In fact, drug use becomes a mechanism for acceptance, indicating that the prison subculture actively shapes behavior through social pressures.

There were unwritten rules in the prison, and whether you like it or not, whether it is your preference or not, you have to accept and practice them. Drug use was a pervasive phenomenon in prison, and if you did not use drugs, you would undoubtedly be excluded. Imagine that from 10,000 prisoners, 9,900 prisoners used drugs. I was in a cell with 12 cellmates, all of whom were addicts, and I had to use drugs to be a part of them. I had to live a life there for however many years; it was my home. (Male participant, ten years of incarceration)

In a setting where most inmates used substances, not using drugs could result in isolation, ridicule, or a loss of respect. Even for high-status labels (e.g., murderer), inmates must perform according to expected behaviors, including drug use. Within the prison hierarchy, being a murderer was associated with elevated social standing; performance was required to preserve hierarchy. Drug use was a symbolic act that confirmed one's legitimacy in the social hierarchy within the prison. In other words, drug use became part of a broader survival toolkit to avoid marginalization.

When I entered the central prison, I was just 18 years old. I had to smoke something in the prison, because it was so inappropriate not to smoke. Because I was a murderer, I had committed a violent crime, and everybody respected me. If I did not smoke drugs in the prison, other prisoners would call me a “pasteurized murderer” (a murderer who was too naïve and unprofessional to commit a murder). I did everything that was possible in the prison because of the atmosphere. Yes, I started to use drugs. (Male participant, six years of incarceration)

Addiction as Governance

Among substances used, heroin was reported to be widely accessible in all wings/units (i.e., sections) of one prison in Iran, with syringes commonly found throughout the facility. In some units, nearly all inmates used drugs, and withdrawal often led to violence and unrest. Participants frequently interpreted the tolerance or facilitation of drug circulation by correctional officers as a strategy to maintain order, reduce withdrawal-related unrest, and manage institutional behavior. While this study cannot directly confirm authorities’ intentions, participants’ perceptions highlight how institutional practices may regulate inmate behavior. One participant recalled a warden's attempt to cut off the drug supply, which triggered severe violent protests and multiple deaths. The incident reinforced the perception that prisoners were more manageable while using drugs than during withdrawal, highlighting the strategic use of addiction as a tool of informal governance within the prison system.

It was impossible to cut the drugs from the prison, and no matter what section of the prison you were in you could find syringes. In our section, there were 700 prisoners who were all heroin addicts. If they did not have heroin, they turned into monsters. So, how could guards control them? Just by controlling the transfer of drugs into prison. (Male participant, ten years of incarceration)

Five years ago, a prison's warden decided to abandon drugs in the prison; there were a lot of protests against this decision and a lot of people were killed. Then, they did not ever abandon drugs. They found out that prisoners are more manageable by using drugs than without them. (Male participant, 7 years of incarceration)

Participants emphasize the widespread and visible drug use and the apparent indifference of staff. This reinforced the perception that drug use is institutionally tolerated, rather than actively prevented. It also implied that the normal rules about drugs were not applied consistently, which may contribute to prisoners’ interpretation that this tolerance was functional, helping authorities manage a potentially volatile population.

All guards know who delivers drugs to the prison; this is exactly what they want. (Male participant, five years of incarceration)

All of the prisoners in our cell, about 80 people, used heroin. Even the wardens were witnessing our drug consumption in the yard and did not care at all. (Male participant, nine years of incarceration)

In some wings housing hundreds of inmates—many of whom had no family support, no visits, and no emotional connection to the outside world—drugs became the only available means of coping. With limited capacity among fellow prisoners, available programs, and correctional officers to provide meaningful support, drug use was often tolerated, and even facilitated, as a way to maintain emotional stability.

It felt so bad to admit the fact that all prisons’ managers tend to distribute drugs in the prison. They themselves kept some doors open to allow drug transferring to the prison. The most important reason was that, for example, in our section, there were about 400 prisoners without any sign of hope in their faces; their family members were not there to support them emotionally. Most of them did not have any visits from their family. Along with that, the prisoners, cell mates, and guards do not have that much capacity to support each other. Thus, the only thing to keep them calm was drugs. (Male participant, six years of incarceration)

Although MMT in Iranian prisons was implemented to reduce illicit drug use, prevent needle sharing, and reduce infectious diseases, participants described it as a “topping-up” measure for themselves, while a tool for managing institutional behaviors for authority. Prisoners described that authorities regulate inmate behavior, reduce withdrawal-related unrest, and suppress aggression or violence by daily prescription of methadone.

If we did not use methadone in prison, there was a fight every day. Methadone was distributed to calm down prisoners. (Male participant, five years of incarceration)

Methadone was distributed in prison at a specific time of day. Methadone was distributed among prisoners for three reasons: (1) To medicate people who use drugs, (2) To make them calm, and (3) To decrease the risk of shared injections and HIV. Not only do they use methadone but also all other kinds of drugs. (Male participant, nine years of incarceration)

Access and Supply

Participants emphasized the widespread availability of drugs inside the prison, noting that even high-quality and expensive substances were regularly smuggled in. In some cases, obtaining drugs inside the facility was reportedly easier and faster than outside, sometimes taking just minutes. One participant ironically remarked that in the absence of necessities like bread, hashish could serve as a substitute, highlighting how deeply ingrained substance use had become in everyday prison life.

You can buy drugs in the prison quicker and easier than outside; if it takes one hour to buy drugs outside, it takes just one minute to buy and use drugs inside the prison. (Male participant, nine years of incarceration)

If there was no bread in the prison, you could just use hashish instead. (Male participant, seven years of incarceration)

Article 42 of the Anti-Narcotic Law of the Islamic Republic of Iran authorizes the judiciary to house certain drug-related offenders in specialized facilities (camps) ² instead of prisons, with the intention of separating them from violent criminals and providing a more therapeutic approach. However, participants’ experiences indicated that these camps did not necessarily provide safer or more rehabilitative environments. The frequent overdoses and drug-related violence highlighted the widespread and easy access to drugs within the facility, leading many prisoners to report a preference for the regular prison over the specialized drug camp. Despite the prison housing a broader range of offenders, including violent criminals, this camp was equally dangerous, with frequent drug-related overdoses and murders. This underscores a disconnect between the legal intent of Article 42 and the practical outcomes of incarceration in these camps, suggesting that structural factors such as uncontrolled drug availability undermine efforts to create safer, recovery-oriented environments.

I was in [specialized drug offender camp], which was established for drug-related offenders. Actually, I wanted to escape from that prison because it was unbearable. I went to sleep one night, and in the morning, my cellmate next to me had passed away; he had overdosed. It was difficult to see someone pass away next to you because of drugs. There were a wide variety of drugs in that prison, and the price was not as high as in other prisons. The opportunity for using drugs in [this camp] was more than in the central prison. Although it was a true fact that all kinds of offenders, from murderers to drug traffickers, were incarcerated in the central prison, and they had to deal with violent criminals, in [this camp] several people were murdered because of drugs. Therefore, there was no difference between these two prisons. Most of the prisoners in [this camp] would even prefer to be in the central prison. (Male participant, 5 years of incarceration)

Some participants revealed that the prison drug economy was so profitable that certain inmates preferred to remain incarcerated or even attempted to get re-arrested. Selling drugs—particularly high-value substances like methamphetamine—provided a steady source of income. For some, the financial rewards of the illicit prison economy outweighed the motivation to seek release.

Some prisoners do not want to be released. They want to stay and sell more drugs and earn money. (Male participant, six years of incarceration)

Some prisoners just set up a fake scene to be arrested and sell drugs in the prison to afford their family life outside of the prison. (Male participant, nine years of incarceration)

Participants described multiple routes through which drugs were smuggled into prisons. One common method involved inmates returning from leave or furlough, often concealing drugs inside their bodies. Additionally, prisoners who held positions in prison departments with external contact, such as the prison health center, were frequently recruited by gang leaders or influential inmates to coordinate drug smuggling operations.

(Some) prisoners are well known for delivering drugs by storing them in their body. They made fake scenes to get arrested and sell drugs and then get released. They come with just 50 grams of opium and get released with a large box of money. (Male participant, four years of incarceration)

Also, through any linkage between the prison and outside such as a ‘health centre’, we import drugs through the inmates who are recruited there. (Male participant, eight years of incarceration)

One participant described a clever tactic used to smuggle drugs into prison. By causing clogs in the bathroom, they would create a situation where a plumber had to come in. Through building a relationship with the plumber, they were able to persuade him to bring drugs into the prison, exploiting the lack of thorough inspections on outside visitors.

We found a way to deliver drugs to the prison; for example, we would drop something in the bathrooms to cause clogs and then when the plumber came to the prison, we made friends with him. That was one way to persuade someone from the outside to bring drugs for us because they did not usually physically inspect them. (Male participant, seven years of incarceration)

Another common route for drug smuggling was through family members during visits. Participants described how relatives occasionally brought drugs into the prison using creative methods, such as hiding them under the prison carpet, which was then passed to the inmate through cleaning staff. In other instances, drugs were transferred during physical contact, like hugging or kissing, and later concealed within the inmate's body. Substances were also sometimes hidden inside food or clothing items brought during visits.

My mother smuggled drugs to prison to help me financially. I wanted to sell the drugs to earn money and afford my life in prison and to pay some portion of my debts and afford the payment of blood money. I stored them in my body where it couldn’t be searched. After that, every time my mother brought me drugs. But that was so risky, because sometimes we are strip searched, and the officers may find that. (Female participant, seven years of incarceration)

Several participants reported that even prison employees (e.g., correctional officers, administrators, maintenance staff, medical staff, religious personnel such as Muslim clergy, etc.) were actively involved in drug smuggling operations, motivated by the financial incentives. Participant explained that staff members could earn significantly more from trafficking drugs than from their official salaries.

Employees in the prison themselves deliver drugs into the prison. Last time, one of the employees delivered one kilogram of heroin into the prison. (Male participant, six years of incarceration)

However, it is worth noting that gangs generally maintained a monopoly over the illicit drug market. High-ranking traffickers controlled exclusive access to drugs, which maintained control over people who used drugs and may also encouraged corruption among correctional staff. This situation can result in serious and far-reaching consequences.

I remembered the day that one of the most powerful gangs were executed all together by the authorities. Why? Because they gained too much power to be handled by authorities. The gang had ultimate control over drug smuggling into the prison; the drug market was in their hands. In other words, they control and manage the prison instead of correctional officers. They even control and govern correctional officers as well. Some of the corrupted guards cooperated with that gang in the process of smuggling drugs into the prison. The gang members know all the personal information of those guards—from their home address to their family members’ names and affiliations. Guards were like prisoners: they had nowhere to escape or hide. The gang became more powerful day-by-day until one day they had been set up and all were killed in one night. (Male participant, 10 years of incarceration)

Polydrug Use Pattern

Participants frequently described how incarceration not only sustained but also intensified their addiction. Many reported transitioning and shifting from one substance to another due to the easy availability of certain substances, scarcity of others, or inflated prices of specific drugs within prison walls. This inconsistent drug market fostered polydrug use, where individuals consumed different types of drugs simultaneously or sequentially.

I used opium and heroin, but I became familiar with methamphetamine in the prison. (Male participant, seven years of incarceration)

I was addicted to opium, but I became familiar with heroin in prison. (Female participant, one year of incarceration)

I was addicted to crack, but once I got released, I started injecting heroin. (Male participant, two years of incarceration)

I just used hashish before I got imprisoned, but while in there I used all available drugs. (Female participant, three years of incarceration)

Participants explained that the high cost of certain substances inside prison such as methamphetamine, which could be up to ten times more expensive than outside, often led them to enroll in prison-based MMT as an accessible alternative. For some, this substitution was not a path to recovery but a financial necessity. Also, Heroin remained accessible within the prison environment, alongside the availability of MMT.

I tried methadone in prison for the first time, because methamphetamine was 10 times more expensive than outside. Once I was released, I started to use methadone and methamphetamine simultaneously. (Female participant, three years of incarceration)

I don’t know what to choose, but thank God there are lots of way to be intoxicated in prison, from methadone to heroin. On one hand, we are encouraged or forced to use methadone in the prison, while on the other hand you witness people who inject heroin in the bathrooms. I end up using both. It is like a joke, but not a funny one. You get your daily dose of methadone, and right after that you buy heroin to inject. It is unbelievable. (Male participant, nine years of incarceration)

The drug-related wings of prisons, as described by participants, are considered the most dangerous and chaotic areas. To the extent that prison authorities use these wings as a disciplinary tool. Despite taking methadone, which could potentially reduce harms associated with the illicit drug market, many prisoners continue to seek other substances, sometimes engaging in risky behaviors to obtain them.

The drug-related units in the prison were the most dangerous and unsafe parts of the prison. To punish prisoners in other sections, especially murderers, they would exile them to the drug section. There were continued fights among prisoners who could not be controlled at all. Even with the methadone being distributed every day, there are several prisoners who need other drugs as well. Some of them did not have money, and they would do anything to get drugs. If one group of prisoners found out about the existence of drugs in another cell, they would fight to take their drugs. (Male participant, 3 years of incarceration)

Struggle for Sobriety

NA was another program available to address drug addiction within Iranian prisons. However, participants described deep skepticism and limited engagement with prison-based NA. Participants indicated that correctional staff themselves questioned the value of prison-based NA, reinforcing the perception that the program lacked legitimacy within the prison environment and contributing to the belief that incarcerated individuals were incapable of understanding or applying NA's principles. At the same time, stigma, rumors, and ridicule among prisoners created additional barriers to engagement. For example, some prisoners were misinformed that joining NA could lead to being sent to forced labor camps, while others mocked members by referring to them as “Soldier Anonymous,” a derogatory label used to ridicule NA participants and undermine the legitimacy of the program. Together, these factors illustrate how institutional skepticism and peer dynamics can weaken participation in treatment initiatives, limiting the potential of programs like NA to support recovery within prison settings.

Guards did not believe in the function of NA in prison. They told us that prisoners do not understand the NA principles. (Male participant, nine years of incarceration)

In our section, there were 400 prisoners, and fewer than 10 prisoners attended the program. In fact, from those 10 prisoners, just three of them came to the program every week, and the rest of them came rarely. Prisoners are not well-informed about the principles of the program unless they attend the class. In fact, making different rumors and jokes around NA holds some prisoners back from attending this program. We made a joke about the NA meetings and the members in the prison. Instead of Narcotics Anonymous, we called them Soldier Anonymous. I did not attend any NA meetings in the prison as I was afraid of being sent to the forced labor camp. Some prisoners heard of NA's influence in quitting drugs, and thus they decided to attend the sections. (Male participant, seven years of incarceration)

In prison, those who pursued recovery through NA faced a culture that normalized indifference and self-preservation. A common saying among prisoners “even the gazelle does not feed its child” captured the perception that survival in prison required prioritizing oneself rather than supporting others. However, some NA members in prison attempted to challenge this norm by promoting mutual respect, accountability, and recovery-oriented values. In fact, NA members could create small pockets of resistance to the dominant prison culture by fostering collective responsibility and support for recovery. At the same time, the participant's observation that only one or two out of hundreds of prisoners successfully overcame addiction underscores the limited reach of these efforts within the broader prison environment.

It was a well-known idiom in the prison that “even the gazelle does not feed his child” (nobody cares about anybody) in the prison; however, we as NA members in the prison attempted to encourage prisoners not to return to the prison again. We actually tried to expand their horizons in the prison. I was a manager in one cell in the prison; I told all the prisoners in the cell that nobody has a right to smoke even one cigarette in this cell. I told them on any occasion that you are not allowed to fight, just have a dialogue. They were not allowed to sell drugs in the cell. All of them must respect other cellmates’ rights. I practiced all NA principles in the prison. Also, the number of former drug users who overcame addiction in prison is no more than 1 or 2 out of 400 inmates. (Male participant, seven years of incarceration)

Even when prisoners successfully achieved abstinence and recovery through NA, maintaining it in prison remained challenging due to the social environment, where drug use was common and often reinforced through peer networks. Prisoners who attempted to stop using drugs frequently faced pressure from friends and cellmates who continued to use and offered them drugs. This highlights that recovery in prison extends beyond individual commitment and is influenced by multiple factors: structural factors, such as the availability of drugs, institutional practices like tolerating drug use and smuggling, and social factors, including pressure for conformity and the need to navigate complex interpersonal relationships.

I became a part of an association in the prison where I could share my thoughts and feelings with them. It was called NA. I had several friends and cellmates in the prison, and we did not have any problems with each other after I participated in NA meetings. I was sick of my friends, and I could not stand them anymore. Once I quit drugs, I remember, I did not know what I was supposed to do with my friends. Every time I came back from the NA sessions, they surrounded me and offered me drugs. They told me to come to use drugs. Fortunately, I was trained by NA to say NO simply and immediately refusing this request. All the prisoners are sick of using drugs, and they have lost everything already in their life, but they could not quit that. My friends did not fight with me during the rehabilitation process in the prison, because I know that they wanted to stop using drugs, but they could not. (Male participant, nine years of incarceration)

Discussion

Understanding why and how people use drugs in prisons is essential for identifying the individual, social, and structural factors shaping drug use. Qualitative research is particularly valuable for revealing these dynamics and informing more effective policies and interventions (Small & McNeil, 2018). Throughout this qualitative study, five key categories emerged, capturing experiences of people who use drugs in Iranian prisons. Drug use is deeply embedded in prison subculture, where coerced conformity forces prisoners to engage in substance use to gain social acceptance, which also is reinforced by systemic tolerance. Mass incarceration in prison in Iran enforces regular interactions and adherence to unwritten rules, so-called prison subculture, as a means of surviving one's sentence. Prison subculture tends to be stronger in countries that use group imprisonment compared to those with individual cell confinement (Oleinik, 2013). In contrast to Crewe's (2005) study in the United Kingdom, which emphasizes drug use in prison as an individualized act, in Iranian prisons, drug use, particularly in such close proximity, is often viewed as essential for adapting to the dominant prison culture. The findings of this study align with Mjåland's (2016, pp. 158–159) observations in Norwegian prisons, which describe drug use in prison as a central aspect of social life. It functions as a means of gaining social acceptance, building friendships, and integrating into the prison community. As Mjåland notes, drug use serves both “inclusionary and exclusionary functions,” helping to “produce and reproduce social relations” within the prison environment. The implicit and explicit pressure to conform and align drug use with the majority was described as intense and overwhelming in Woodall's (2011) study in England and Wales. Similarly, Lafferty et al. (2018) found that in Australian prisons, injecting networks create subtle social pressures, where participation and adherence to informal rules, such as assumptions about hepatitis C status or “queue order” for injections, shape individual behavior. Prisoners often conform to these norms to maintain trust, avoid exclusion, or secure access. Also, as O'Hagan & Hardwick (2017) study in England and Wales reveals, prisons facilitate the spread of drug use through peer pressure and easy social connections among inmates. The findings suggest a pattern of institutional tolerance toward drug trafficking and use within the prison setting. In Iranian prisons, the majority of incarcerated individuals are people who use drugs, disrupting access to drugs often results in unrest, violence, and protest (Anaraki 2021a, 2021b, 2022a, 2022b). Consequently, prison authorities in Iranian prisons tend to adopt a permissive approach, allowing drugs to enter the prison and often overlooking their open use. This perception of selective indifference is consistent with findings from Cope (2000, p. 357) in United Kingdom, where a participant similarly noted, “I don't think officers really care about you smoking drugs” and findings from Culbert et al. (2015, p. 21) in Indonesia where a participant stated, “We use drugs here in the open space … it's normal … it can be anywhere.” However, participants in the current study perceived this open culture surrounding illegal drugs as a deliberate means of regulating institutional behavior, employed by prison authorities. This perception extended beyond illicit substances to include legally prescribed medications, such as methadone. In this context, both legal and illegal substances were understood by prisoners as mechanisms through which inmate behavior could be managed by minimizing unrest and stabilizing the prison environment. Empirical literature lends indirect support to the behavioral dimension of this perception. Johnson et al.' (2001) study in Canada reported that prisoners receiving prison-based MMT spent less time in involuntary segregation compared to those not enrolled in the program. These findings suggest that prison-based MMT may reduce disruptive behavior in correctional settings. While this does not confirm intentional use of MMT as a control strategy, it indicates that opioid substitution treatment can have regulatory effects on institutional conduct, which may help explain why prisoners interpret it as a mechanism of governance. Concerns about control and the perception of MMT as a mechanism of institutional power are not unique to Iranian prisoners. Research conducted in Scotland similarly found that “control” was one of the most common reasons for refusing prison-based MMT among prisoners. Some incarcerated individuals viewed the program as an extension of prison authority and a tool for institutional leverage. In contrast, others feared that methadone itself would foster long-term dependency and restrict their autonomy (Taylor et al., 2006). However, unlike the Scottish context, such perceptions did not appear to constitute a barrier to MMT uptake among Iranian prisoners. Instead, participants described MMT as integrated into the broader prison drug landscape, often functioning alongside continued illicit drug use.

All participants unanimously reported the widespread availability of drugs in prison, noting that substances were easily accessible in nearly every corner of the facility. Similarly, a study conducted in prisons in England and Wales found that a third of prisoners believed it was easier to obtain drugs inside prison than outside (O'Hagan & Hardwick, 2017). Similarly, in a study by Crewe (2005) conducted in an English prison, both officers and inmates viewed drug use and dealing as inevitable and almost routine aspects of daily prison life. Inmates at Oakwood Prison in Staffordshire reported that drugs were easier to obtain than soap, with similar accounts emerging from Brixton Prison (DrugWise, 2016; The Economist, 2013). These findings align with the study by Culbert et al. (2015, p. 7), in which one participant noted, “We can find drugs easier inside the prison. In every corner, people are using,” highlighting the widespread availability of drugs within the prison environment. Mjåland's (2016) study on Norwegian prisons also highlights the abundant availability of drugs. However, Woodall (2011) in prisons across England and Wales notes that some prisoners reported the availability of drugs in prison is often overestimated; in reality, access is relatively limited and supply can be restricted.

Drugs find their way into the prison through different and often creative ways, such as family visits, returning or new prisoners, and corrupt prison staff. One of the most common methods of smuggling drugs into Iranian prisons is through family visits. This finding aligns with reports from the American Addiction Centers Editorial Staff (2020)) and Woodall's (2011) study of three prisons in England, both of which emphasize that drugs are frequently smuggled in by visiting relatives and friends. A study in Ghana found that visitors smuggled cannabis into prisons by concealing it inside food items (Parimah et al., 2021). In Iranian prisons, participants revealed that drugs, regardless of how visitors smuggle them in, are often passed to inmates during physical contact, such as hugging or kissing, a practice also noted in previous literature (Norman, 2023). In some cases, in Iranian prisons, drugs are hidden under carpets in visiting rooms or dropped in discreet corners, with inmate cleaners responsible for transferring them to recipients. This is similar to other facilities where drugs are dropped around the prison perimeter and later retrieved by inmates upon re-entry, methods documented in studies conducted by the United States Department of Justice (2018) and in Canada (Watson, 2016). Similar to some prisoners in Iranian prisons who intentionally commit offences to enter prison for the purpose of smuggling drugs and earning money, prisoners in the United Kingdom on probation or parole have been found to commit minor offenses to return to prison temporarily for the same purpose (Ralphs et al., 2017). In Iranian prisons, corrupt correctional staffs also play a pivotal role in drug smuggling, often driven by financial hardship. Human Rights Activists News Agency (2024) reports that prison officials play a key role in the circulation of drugs inside Ghezel Hesar Prison in Iran, often facilitating the distribution process rather than preventing it. Similarly, a study in the Delaware correctional system found that 17 out of 46 participants reported receiving drugs directly from a prison officer (Inciardi et al., 1993). Beyond correctional officers, in Iranian prisons other staff members, such as religious staff (e.g., Muslim clergy), has also been implicated in drug smuggling (Anaraki, 2022a, 2022b). Although such routes are less common (Norman, 2023), they have been documented in a study by Lee & George (2005). In Iranian prisons, aside from occasional smuggling, gangs hold exclusive control over the drug market, granting them near-absolute power over prisoners who use drugs and corrupting some guards (Anaraki, 2021b, 2022b). As Schelling (1967) explains, this control is maintained by exploiting vulnerable individuals who lack protection and are caught in a continuous cycle of extortion.

Polydrug use emerged as a significant pattern in the findings. As noted by Khalooei et al. (2016), approximately 41% of incarcerated individuals in a prison in southeast Iran reported using two or more substances. Polydrug use is pervasive in prison, driven by the wide availability of various substances, the scarcity of habitual drugs, and the need to manage financial constraints. Human Rights Activists News Agency (2024) further highlights that drug prices inside Ghezel Hesar Prison in Iran are up to 10 times higher than outside due to restricted supply and profit-driven distribution, often facilitated by prison staff. This economic context likely exacerbates polydrug use, as inmates may combine or substitute drugs based on availability and affordability. Prison-based MMT, as a substitution therapy, is designed to reduce illegal drug use and lower the transmission of infectious diseases (Stallwitz & Stöver, 2007). However, in Iranian prisons, MMT is often considered an additional available substance or used as a form of “insurance” when habitual drugs are unavailable or financially unaffordable. In some countries, prison authorities discontinue methadone treatment at entry, citing the need for stricter monitoring of opioid substitution therapy (OST) to prevent diversion (Dolan et al., 2018). In contrast, structural limitations within the Iranian prison healthcare system may shape how MMT is implemented and perceived. As noted by Zamani et al. (2010), Iranian prisons face a shortage of healthcare personnel, which can result in relatively lax supervision of methadone administration, alongside the absence of a formal referral mechanism for inmates transitioning to community-based treatment after release. These conditions may contribute to prisoners perceiving methadone less as a recovery-oriented intervention and more as an additional drug within the existing prison drug environment, particularly when continuity of treatment after release remains uncertain. The act of “topping up” or “twin track of continuing illicit drug use” whilst being maintained on MMT was also a habit in Scottish Prisons (Taylor et al., 2006). Similar to findings United States by Frank (2018), which MMT was often considered by prisoners as a means of mitigating harms related to illegal opioid use (e.g., withdrawal, the dangers of the illegal market, and structural pressures from criminalization) less as a pathway to recover, MMT in Iranian prisons is as a strategy for managing financial strain and sacristy of some habitual drugs. In this context, concurrent use of methadone and illicit substances did not necessarily signal treatment failure, but reflected efforts to balance stability, cost, availability, and embodied need within the prison setting.

In contrast to Culbert et al. (2015, p. 7), who found that MMT was highly stigmatized within prison culture for undermining the illicit drug economy, MMT in Iranian prisons is generally viewed as an additional substance or/and as a substitute. Unlike in other contexts, MMT in Iranian prisons does not face significant resistance or stigmatization, likely because it does not threaten the existing prison drug economy. In contrast to Johnson et al. (2001), which found that individuals participating in MMT exhibited fewer behaviors associated with the prison drug subculture (e.g., drug seeking and trafficking) this study reveals that, in practice, MMT is often treated as an additional substance or as a substitute in cases of scarcity of other drugs or financial constraints while prisoners continue engaging in regular drug use.

However, stigmatization is notably directed toward NA, which faces significant social resistance within the prison environment. NA is frequently ridiculed and dismissed by both prisoners and prison staff. Given that drug use is deeply embedded in the prison subculture, initiatives aimed at abstinence or rehabilitation are often met with skepticism or resistance. According to Woodall (2011), maintaining sobriety and a drug-free lifestyle in prison is extremely challenging, as incarcerated individuals often become embedded in groups or cliques. Choosing sobriety may require breaking away from these social networks, which can be perceived as violating group norms, or as Mjåland (2016) mentioned, choosing to stay off drugs in prison resulted in limited inclusion and trust within the prison wing community.

This study has some limitations. The primary concern may be the use of data collected in 2017. While such a critique is understandable, the findings remain valid and relevant, as the broader context of drug policy and addiction in Iran has seen little meaningful change. As Mirzaei et al. (2024) emphasize, one of the most pressing concerns is “the lack of revision in substance use disorder treatment laws and policies,” highlighting the continued relevance of the data and findings presented here. Another limitation of this study is its limited generalizability, which is a common characteristic of qualitative research. However, generalizability is not the aim of this approach. Instead, the emphasis is on transferability, enabling researchers and practitioners to assess the relevance and applicability of the study's insights to similar contexts.

Conclusion

Drug policies in Iran have fluctuated between punitive measures and treatment-oriented approaches, often blurring the line between punishment and rehabilitation. This ambiguity has, at times, led to the reintroduction of criminalization under the guise of rehabilitation—an approach that has failed to address drug use both in society and within prisons. While prisons aim to serve both punitive and therapeutic purposes, this study highlights the limits of these efforts, including the widespread availability of drugs and institutional neglect. As Human Rights Activists News Agency (2024) indicated, treatment programs in prisons are often symbolic and have not effectively reduced drug use. The widespread availability of drugs, combined with institutional tolerance and neglect, undermines the rehabilitative goals of incarceration.

This is further reflected in the divergence between two dominant responses to drug use within prison: MMT and NA. Although both are framed within a rehabilitative approach, participants’ experiences suggest that, in practice, this distinction becomes blurred. MMT was largely experienced as a tool of institutional governance, aimed at reducing withdrawal, stabilizing behavior, and maintaining order, which align more closely with the system's punitive and control-oriented functions. In contrast, NA, despite being marginal and stigmatized, was one of the few spaces perceived as offering a pathway to recovery, although its effectiveness remained severely constrained by the broader prison environment. Even when individuals manage to reduce or stop drug use during incarceration, this does not guarantee long-term recovery. Upon release, many return to the same or worse social, psychological, and financial conditions that contributed to their substance use in the first place. As Schenwar and Law (2021) emphasize, sustainable recovery is impossible without addressing these underlying causes.

Several programs have been proposed for drug-dependent prisoners, including opioid substitution treatment (OST), therapeutic communities, drug-free units, and cognitive behavioral therapy (Dolan et al., 2018). However, treatment efforts that remain confined to correctional facilities are unlikely to produce lasting outcomes. Effective responses to addiction require structured, evidence-based, and culturally responsive interventions delivered outside prison settings. Such programs should support recovery not only physically and psychologically, but also socially, addressing housing instability, economic insecurity, and community reintegration.

From an implementation science perspective, the success of drug-related multicomponent interventions depends on careful planning informed by community needs, inclusive stakeholder engagement, context-specific adaptation, ongoing evaluation, and strategies to ensure long-term sustainability. Rather than placing individuals with substance use issues in prisons or prison-like alternatives, genuine solutions must offer—not impose—holistic, human-centered care. These approaches should address not only individual behavior, but also the broader social conditions that fuel addiction.

This study in no way represents a formal evaluation of prisons or prison-based programs; however, it highlights how the realities of incarceration often diverge from the intended goals of both punishment and rehabilitation, revealing significant barriers to meaningful recovery within prison environments.

Footnotes

Acknowledgements

The author used ChatGPT (OpenAI) in a limited capacity to assist with style editing and improving sentence clarity. All intellectual content, analysis, and interpretation are solely the responsibility of the author.

ORCID iD

Nahid Rahimipour Anaraki

Ethical Approval

The field work was approved by Memorial's Research Ethics Board and was performed in accordance with TCSP (Canada's Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans). ICEHR Number: 20172118-AR.

Informed Consent

Informed consent was obtained from all subjects involved in the study.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data from this study are not accessible to the public to safeguard confidentiality and privacy of participants.

Notes

Author Biography

Nahid Rahimipour Anaraki holds a PhD in Sociology and was a Postdoctoral Fellow in Health Sciences at Memorial University of Newfoundland (MUN). Her research program focuses on the social and health dimensions of substance use, prison subculture, implementation science, and qualitative research methodologies.

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