Sticking points: Incarcerated women's views on barriers to a prison needle exchange program

While prison needle exchange programs, or prison needle and syringe programs, have existed in different parts of the world since the 1990s, little is known about how currently incarcerated people perceive them—particularly in Canada, where such programs have only recently been implemented. This study explores incarcerated women's perceptions of a recently implemented prison needle exchange program using in-depth, semi-structured qualitative interviews with 56 federally incarcerated women in Western Canada. In particular, we explore the barriers that women perceive in accessing the prison needle exchange program. These perceived barriers contributed to our participants’ negative views of the prison needle exchange program as well as their overwhelming lack of support for its implementation. Our participants felt that the prison needle exchange program acts as an obstacle to sobriety and could increase different types of harm—including encouraging injection drug use and contributing to overdoses—within the prison. Participants also identified other barriers to using the prison needle exchange program, including a perceived lack of confidentiality/anonymity for users of the program and that the prison needle exchange program itself is structurally incompatible with the rules and operations of a prison system that continues to criminalize drugs. Using an implementation science framework, we argue that this situation accentuates the need for significant consultations with incarcerated people about the operation of such programs, and for funds to support other programs that target participant-identified root causes of substance misuse, such as programs that address past trauma and victimization. At the same time, we caution that some barriers may be inherent in how prisons are structured.


Introduction
Providing incarcerated individuals with in-prison programming can be particularly challenging in light of the distinctive security, logistical, legal, and population-specific attributes of prison.Such factors can limit or undermine officials' abilities to deliver programming in a way that is effective, accessible, and ethical.One notable policy-relevant attribute of prisons is that incarcerated individuals are disproportionately likely to use illicit drugs or have a history of such use.Many incarcerated people either continue or initiate injecting drugs while in prison (Martin et al., 2005).As such, there is a need for drug-related programming in prison to support individuals who might want to reduce or cease their drug use or to use drugs more safely.At the same time, the drug use practices of incarcerated individuals can also limit the effectiveness or viability of certain programs (Frank et al., 2015;Kothari et al., 2002;McKeganey et al., 2016).
Historically, Correctional Service of Canada (CSC), the government agency responsible for housing individuals sentenced to two or more years of imprisonment, has had a drug policy primarily focused on interdiction and surveillance to try and limit the flow of drugs into and within federal prisons.Such measures continue, but in recent years CSC has paid increased attention to the health risks of intravenous drug use by incarcerated individuals.Such use poses acute risks of fatal and non-fatal overdose (Kerr et al., 2007), transmission of blood-borne diseases such as HIV/AIDS (Wood et al., 2001), and hepatitis C (HCV) (Shephard et al., 2005) and can produce abscesses and cellulitis at the site of injection (Binswanger et al., 2000).In Canada, as elsewhere, infectious diseases are more prevalent among incarcerated than non-incarcerated individuals (CSC, 2018), with a strong correlation between injection drug use, incarceration, and HIV status (Lines et al., 2006).
To address such health concerns, CSC has introduced a suite of harm reduction measures including opioid agonist therapies, bleach kits, and an overdose prevention service (currently available in one men's prison).In 2018, CSC also introduced prison needle exchange programs (PNEP) into some of its federal institutions.Currently, nine of 53 federal prisons house a PNEP (CSC, 2021).
Research conducted in other countries on the efficacy of PNEPs has found that such programs can limit the health risks posed by injection drug use and decrease the spread of infectious diseases (Asl et al., 2013;Dolan et al., 2003;Lines et al., 2006;Stark et al., 2006;Stöver and Nelles, 2003).More specifically, this body of evaluative research finds that, in order for PNEPs to be successful, they should be implemented in prisons with high levels of injection drug use (Dolan et al., 2003) and involve substantial collaboration with incarcerated people prior to implementation in order to identify and address their needs (Asl et al., 2013;Dolan et al., 2003).Anonymity and confidentiality must be assured in order to encourage participation (Lines et al., 2006), and there must be a high level of acceptance of PNEPs by both staff and incarcerated people (Dolan et al., 2003;Stöver and Nelles, 2003).Furthermore, a review of research conducted by the Canadian HIV/AIDS Legal Network suggests that the "method of needle distribution is less important than ensuring the program responds to the needs of the institution, the prisoner populations, and the prison staff," again highlighting the importance of addressing the needs of different stakeholders in different prisons, rather than taking a one-size-fits-all approach to PNEP implementation (Lines et al., 2006: 53).
Unfortunately, uptake of needle and syringe exchange programs in prison is minimal, even in countries where they are widely available (Sander et al., 2019).In Canada, if enrollment numbers are any measure of program success, CSC's PNEP can only be classified as a failure.As of 2020, across the nine institutions that offer this program, only 36 incarcerated individuals had enrolled in the program (Interim Commissioner CSC, 2020 personal communication).We do not have clear insight into why this might be the case, although this situation suggests that environmental factors specific to prison, such as location of prison health services and social factors, can influence the operation and acceptance of harm reduction strategies (Azbel et al., 2018).
As part of a larger research project on incarcerated people's experiences of prison, victimization, and perceptions of prison programming (University of Alberta Prison Project), this article examines the introduction of one needle exchange program in a women's prison in Western Canada.We conducted problem-centered interviews with 56 women incarcerated in a Canadian federal institution, paying particular attention to how such individuals viewed and responded to this program and what barriers they identified to using the program.Contrary to the hopes of health officials and harm-reduction advocates, this program was extremely poorly received, to the point that the majority of women had signed a petition opposing the program and calling for it to be removed.The body of this article examines why the women embraced such a counter-intuitive stance.We pay particular attention to factors that, in the eyes of the incarcerated population, seem to have limited or undermined the value and utility of this program.As such, this article is in part a response to the call from Davis et al. (2017: 12) for more research examining the unique barriers to using clean needles experienced by people who inject drugs.Moreover, individuals interested in the introduction and operation of a wide range of in-prison programming can take this study as an instructive cautionary tale about how institutional and population dynamics of prison need to be anticipated and the affected population needs to be consulted when designing and implementing any in-prison harm reduction measures.If such attributes are not taken into consideration, they can negate the potential benefits of a proven harm reduction measure (McIntosh and Saville, 2006).

PNEPs
The risks of injection drug use are heightened in prison (Long et al., 2004;Stöver and Hariga, 2016) where the research findings indicate that people are more prone to sharing used needles/syringes (Barro et al., 2014;Long et al., 2004), using homemade needles/syringes (Chu and Peddle, 2010), and quickly consuming drugs (Barro et al., 2014).Incarcerated individuals engage in such practices for various reasons, including lack of available sterile equipment (Jürgens et al., 2009) and concerns about being caught with contraband (Barro et al., 2014).
Needle exchanges aim to reduce health-related risks, such as HCV and HIV, associated with sharing or re-using syringes.As their name suggests, needle exchange programs provide people who inject drugs with a new clean syringe when they return an old or used needle.Many of these programs also offer additional prevention materials such as alcohol swabs and information on safe injection practices and treatment programs.The research findings on such programs operating in the community have been mixed.Systematic reviews and meta-analyses of the scientific literature have alternately concluded that community-based needle exchanges have a small positive effect on infection rates, that they have no effect, or that they are correlated with an increase in the rise of HCV infection (Davis et al., 2017;Hagan et al, 2011;MacArthur et al., 2014).Studies of such programs operating in prison have found some evidence that needle exchanges can limit the spread of blood-borne diseases (Stark et al., 2006), reduce risky forms of drug use (Asl et al., 2013), and facilitate referrals to drug treatment programming (Lines et al., 2006), such as opioid agonist therapies (UNODC, 2015).However, while PNEP efficacy research does indicate that PNEPs can contribute to reductions in blood-borne diseases among incarcerated populations and are associated with other benefits, Lazarus et al. (2018) critique the quality of some of this evidence.Specifically, they find that, like efficacy research pertaining to community-based needle and syringe exchange programs, methodological weaknesses such as non-probabilistic sampling and high rates of participant attrition are common in PNEP efficacy studies.While the studies under review demonstrate that PNEPs are associated with at least one health benefit, Lazarus et al. (2018) also conclude that the strength of this evidence is low.Studies of the efficacy of PNEPs have also largely been conducted in prisons with very high levels of injection drug use, 1 meaning that findings cannot be generalized to prisons where injection drug use is low or moderate.With that said, Lazarus et al. (2018) are careful to conclude their review by noting that, in times of public health crises, it is generally justifiable to implement preventative strategies even if those strategies do not meet "…the highest empirical standards in public health research" and that not implementing PNEPs could cause considerable harm to incarcerated people (p.100).Thus, while the quality of evidence in support of PNEPs may be questionable, it appears to be the opinion of experts that such programs do more good for incarcerated populations than bad.
We still, unfortunately, know extremely little about whether currently incarcerated people agree with that assessment.Only a handful of studies explore incarcerated people's perceptions of these programs.This lack of knowledge is troubling because uptake of any harm reduction program can be heavily influenced by the perceptions of potential participants and individuals in the wider community in which such programs are being introduced, including the prison community (Deryabina and El-Sadr, 2017;Sander et al., 2019).Research on incarcerated individuals' perceptions of PNEPs tends to focus primarily on: (a) men rather than women (Chu and Peddle, 2010;Long et al., 2004;Wright et al., 2015); (b) hypothetical rather than operational programs (Chu and Peddle, 2010;Long et al., 2004;van der Meulen et al., 2017;Wright et al., 2015); (c) formerly, rather than currently, incarcerated individuals (Chu and Peddle, 2010 2 ; van der Meulen et al., 2017); and (d) participants who have used drugs intravenously (inside or outside of prison), or otherwise have extensive knowledge of injection drug use (Chu and Peddle, 2010;van der Meulen et al., 2017).
A Swiss study of 10 incarcerated drug users' perceptions of a retractable syringe exchange program found that most participants felt it was useful in limiting the spread of infectious diseases (Barro et al., 2014).However, other research exploring incarcerated people's perceptions of hypothetical PNEPs found mixed support.A Scottish study, for instance, found that 57% of participants opposed the prospect of introducing PNEPs largely due to fears about the program condoning drug use and the weaponization of PNEP needles (Pulford et al., 2011), while participants in an Irish study held mixed views on PNEPs (Long et al., 2004).Research on the prevalence of injection drug use among incarcerated men in a prison in northern England found that one-third of participants indicated they would inject drugs in prison if a PNEP was available (Wright et al., 2015).
Research on women's views of PNEPs is conspicuously lacking, with almost all of the existing studies having been conducted with previously incarcerated men (see: Chu and Peddle, 2010 3 ; Long  et al., 2004).This lack of attention to women's perceptions and needs is in keeping with the longstanding situation in Canada where incarcerated women have often been "correctional afterthoughts" (Hannah-Moffat, 1991: 190).

The Canadian situation
In Canada, 21% of federally incarcerated men and 30% of federally incarcerated women report lifetime injection drug use (Kelly and Farrell-MacDonald, 2015).Canadian data suggest that 17% and 14% of federally incarcerated men and women, respectively, inject drugs behind bars (Zakaria et al., 2010).
CSC began implementing PNEPs in some of their facilities after facing pressure stemming from a constitutional court case from Steven Simons, who contracted HCV after using a contaminated needle in prison (van der Meulen et al., 2016).Since the launch of the constitutional challenge in 2012, CSC has rolled out nine PNEPs across the country-the first of which was implemented in 2018 (CSC, 2021).Before introducing the program at any site, CSC claims that it conducts "extensive consultations with institutional management and operations, the institutional occupational health and safety committee, the inmate committee, and the community advisory committee" (CSC, 2019).
The incorporation of PNEPs into CSC's broader harm reduction strategy is an encouraging development.However, some harm reduction experts and advocates are critical of the current program because they believe it does not meet accepted standards for such health services and is, thus, unconstitutional (Chu, 2020).PNEPs are also highly controversial with the Canadian public and correctional officers (COs) (Stöver and Hariga, 2016), with the Union of Canadian COs formally opposing them (UCCO/SACC, n.d.).
Despite such concerns, nine Canadian federal institutions currently operate PNEPs.Potential participants must undergo a two-step approval process.First, Health Services evaluate the application and then the Warden conducts a "Threat Risk Assessment" to identify any security issues relating to an applicant's involvement (Zinger, 2019).If eligible, participants are given a PNEP kit consisting of a transparent plastic container that holds one syringe with a safety capped needle, sterile water, cotton filters, a sachet of vitamin C, and a sterile cup for mixing.The program operates using a one-to-one exchange, with program users returning used kits to prison Health Services before receiving a new one (Zinger, 2019).PNEPs appear to operate similarly across all nine federal institutions that have a needle exchange.
Canadian research on the perceptions of PNEPs has found considerable support for such hypothetical programs among selective samples of formerly incarcerated people (Chu and Peddle, 2010;van der Meulen et al., 2017), although study participants also indicated that trust and confidentiality would be major obstacles for successful program operation (van der Meulen et al., 2017).As of 2020, only 36 individuals in the nine institutions that offer the PNEP has enrolled in the program.The lack of uptake among federally incarcerated individuals is cause for concern, as harm reduction programs cannot be effective if the people they are meant to serve do not use them (Zinger, 2019).It is hard to understand the reasons for this lack of uptake without interrogating how currently incarcerated people conceive of operational PNEPs and the pragmatic challenges pertaining to their use.Such perceptions are a key aspect of the organizational context in which PNEPs operate and, as we will demonstrate, without understanding or adjusting to such perceptions, evidence-based practices "may either not be adopted or may be taken up in an adapted form with compromised fidelity" (Bauer et al., 2015: 5).

Analytical framework
Implementation science is especially useful for orienting research into these questions as it starts from the recognition that the success of treatments and programs partially depends on how they are received (or perceived) in a particular context.Consequently, research in this tradition aims to identify disconnects between the clinical effectiveness of treatments or harm reduction measures and how such measures are applied in practice (Proctor et al., 2009;Rubenstein and Pugh, 2006).
Looking to address this gap, implementation science aims to "promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services" (Eccles and Mittman, 2006: 1).Implementation scientists generally gather evidence to maximize positive outcomes by identifying implementation factors limiting the effectiveness of an intervention (and solutions) (Olswang and Prelock, 2015).While relying on a wide variety of methodological approaches, they often deploy qualitative methods to identify consequential local nuances that can easily be overlooked when relying on quantitative methodologies (Berardi et al. 2021;Bucerius and Haggerty, 2019;Campbell et al. 2007).
In terms of the actual implementation process, the Consolidated Framework for Implementation Research (Damschroder and Hagedorn, 2011) identifies 39 different constructs that can serve as moderators or mediators of implementation outcomes.These constructs operate within five domains: (a) intervention characteristics, which might include complexity and cost; (b) outer settings, which refer to features such as patient needs, incentives, and external policies; (c) inner settings, including things like organizational culture, the resources available, and readiness for implementation; (d) characteristics of individuals involved in the implementation process, including their knowledge and beliefs about the intervention, as well as more personal characteristics; and (e) implementation strategies or tactics that might influence implementation, which can include planning and the role of change agents.
A foundational insight of harm reduction practitioners is that social contexts shape the dynamics of substance use (Rhodes, 2009).Our analysis reinforces this point by foregrounding the challenges that limit the appeal and effectiveness of a needle exchange program in a distinctive, carceral environment.Our study examines program implementation at what Fixsen et al. (2009) call the "initial implementation" stage.Specifically, we focus on the "inner settings" of the PNEP, namely how it operates at Prairie Institution (PI) 4 and the prison context within which it is situated.We also highlight characteristics of the incarcerated individuals who use (or might conceivably use) this program, particularly whether participants were practicing sobriety or trying to cease their drug use.We do so because a large subset of participants consistently identified these factors as playing a key role in shaping their attitudes toward the PNEP.
This study provides an on-the-ground understanding of how a broad cross-section of incarcerated people-including those who currently use drugs, previously used drugs, and have never used drugs-perceive the PNEP at their prison.More specifically, we consider how lived experience with problematic substance use, along with the everyday realities of incarceration, converge in ways that not only shape incarcerated women's perceptions of PNEPs, but also influence the uptake and viability of these programs in a carceral setting.

Setting, methods, and participant profile
We conducted the research this article is based on in August 2019 at PI after being approved by CSC and the Research Ethics Board at the University of Alberta.PI is one of six federal women's prisons in Canada.As a multi-level facility, it contains minimum, medium, and maximum-security units, as well as a mother and child unit.It has a capacity of 110 people and detains federally sentenced women from Canada's western provinces.CSC implemented the PNEP at PI in February 2019, seven months before we began collecting data.This timing provided a unique opportunity to capture women's perceptions of the program as it was still relatively new.
Our qualitative data indicate that the most popular drugs at PI at the time of our research were prescription medications.At that time, participants characterized PI as being relatively "dry" (i.e., drug free) compared to other Canadian correctional institutions, although this situation fluctuated and could change quickly.Indeed, on the first day of our research an incarcerated woman overdosed on fentanyl (and was revived).While PI has a PNEP, using and possessing drugs, including heroin, fentanyl, cocaine, methamphetamine, and the non-medical use of prescription drugs, are illegal in Canadian prisons.The women could consequently obtain a PNEP kit but still be charged for possessing these substances.In fact, women who are granted access to PNEP kits must sign a contract acknowledging that "disciplinary measures will continue to be implemented if the inmate is found to be in possession of illicit drugs or drug paraphernalia (except for the needle exchange kit and supplies provided)" (Zinger, 2019: 16).
We conducted problem-centered interviews (Witzel and Reiter, 2012) with a total of 67 participants at PI (66 identified as women and 1 identified as a man) 5 ; however, this article relies on data from 56 participants-11 were not asked about PNEPs because interviews were cut short due to institutional factors such as count times and meals (N = 3), participants ending the interviews early to attend to personal matters (N = 4), or interviewers otherwise failing to ask the questions, largely due to time constraints (N = 4).On average, the interviews lasted 80 min, with the shortest being 38 min and the longest just over two hours.We assigned pseudonyms to all participants and audio-recorded and transcribed the interviews verbatim.
We used nonprobability sampling to recruit participants, announcing and explaining the project on each prison unit.We indicated our interest in talking to participants about their life histories and experiences in prison, including their views on in-prison programming, such as harm reduction measures.Interested individuals provided informed consent, and the interviews were conducted in designated, private areas in the prison.COs and other staff members were never present in interview rooms.As per CSC guidelines, participants were not compensated for their participation.
We employed a generalized interview guide that included a subset of prompts related to perceptions and knowledge of the PNEP.However, we also allowed participants to let their experiences shape the direction of the interview (Glaser and Strauss, 1967;Strauss and Corbin, 1990).After our initial round of interviews (N = 6), we compared interview transcripts and modified the interview protocol to explore emergent themes in greater detail.
To ensure analytical rigor, we drew on principles and heuristic devices of grounded theory (Charmaz, 2014) when coding and analyzing our dataset.While coding, most themes and categories related to the PNEP emerged through answers and discussions relating to our research questions and prompts.The first author developed the preliminary coding categories through the transcription process and multiple readings of the interview transcripts.After this initial descriptive stage of analysis, the first author re-read the transcribed interviews, identifying similarities and differences between participants' perceptions.Based off these comparisons, the first author and one principal investigator (fourth author) created a preliminary thematic coding scheme, which was then altered based on subsequent readings of the transcripts, initial attempts at coding the transcripts, and discussion of the coding scheme between the first and fourth authors.
The final coding scheme consisted of nine main thematic codes, with four sub-codes.The first author then coded all data relating to the PNEP using the updated coding scheme.Once finalized, all four authors discussed the coded data and possible explanatory frameworks.We situated the findings within an implementation science framework given how that approach focuses explicitly on the barriers that can compound the challenges of implementing clinically proven harm reduction measures in real-world settings.We combined some thematic codes during the writing process to provide a more intelligible and holistic narrative of the many detailed opinions participants had about the PNEP.The findings section below represents major themes from our analysis.We have carefully chosen excerpts that best represent the themes and have indicated whenever we present minority views.
Our 56 participants ranged in age from 22 to 70, with the average being 39. 56% of participants self-identified as Indigenous, 33% as White, and 11% as either Chinese, Middle Eastern, or "unsure."Almost all participants had extensive personal histories of problematic substance use.85.2% of participants reported a regular pattern of personal drug use outside of prison (with 100% of Indigenous women doing so) and 55% reported using illicit drugs while incarcerated.
While our research was primarily qualitative, we also surveyed participants about their personal experiences with overdosing and fentanyl use while incarcerated: 39.2% reported having personally overdosed at some point in their lifetime and 11.8% reported using fentanyl while incarcerated.Our qualitative data indicate that participants had varying, but often extensive, experiences with different types of drugs and methods of drug use, including "using crack," "shooting dope," "smoking meth," and injecting "Talwin and Ritalin," to name a few.Many participants noted that friends and family members also had substantial histories of problematic substance use.Several mentioned that people close to them had recently died from a fentanyl overdose.Our participants, therefore, were extremely familiar with, and knowledgeable about, illicit drugs, various methods of drug use, and overdosing.
We sought to learn about perceptions of the PNEP from all 56 of our participants, not just those who inject drugs while incarcerated or who use PI's PNEP (only one participant).It is not uncommon for people to have their first experience with injecting drugs while incarcerated (Bird et al., 1995).Thus, PNEPs need to be understood as a potential resource for all incarcerated people, as we can reasonably anticipate that some individuals who currently do not inject drugs will do so while incarcerated.Furthermore, as was made clear to us during the research, many individuals believe they have a stake in the existence and operation of harm reduction measures even if they do not personally (or currently) use drugs.In the community, this is apparent in how needle exchange programs are often resisted by some local residents due to a fear that they will lead to increased crime, disorder, or substance abuse in their neighborhood.Such fears have resulted in programs being significantly modified or terminated (Davidson and Howe, 2014).A prison is itself a distinctive type of community (or subculture) where people live under oppressive conditions shaped by distinctive subcultural norms.It is vital, then, to gain an appreciation for how different groups of incarcerated people relate to the operation and ramifications of PNEPs, as these programs do not exist in a vacuum and can have implications or unintended consequences for the entire prison population.

Findings
Our main finding is that almost all our participants understood and supported the harm reduction aims of needle exchanges, although only a minority of women (18 out of 56) approved of having them in prison.Those in favor characterized the PNEP as "a good thing" for many of the same reasons that justify harm reduction programs outside of prison, including the prospect of reducing the spread of blood-borne diseases.As Nancy, a participant who supported PNEPs, stated: "Somebody shouldn't come out of prison with a death sentence because they've used a dirty needle."For Nancy, and participants like her, the harms PNEPs reduce were justification enough for supporting the program at PI.These women's views, however, tended to be far more ambivalent than those who opposed the program.Even individuals who expressed some support for the PNEP regularly questioned its practicality for the same reasons as its opponents.As Simone, a woman with a history of alcohol and meth addiction, said: It's good [the PNEP], I guess, for those who use it but [pause]… like, I don't know.You'd think you'd be putting yourself in a situation too, like, "Hey, I need needles," you know, "I'm gonna be the one that's using," right?I don't think girls would come forward, 'cause [COs] will probably, like, give 'em a drug test right away and then you'll get in trouble, you know?
Another important contextual finding concerns the level of confusion surrounding the operation and purpose of the PNEP at PI.For instance, a few participants (N = 3) did not know that the PNEP existed.Other women (N = 4) knew the program existed but were unsure how to access it or how it operated.A few women (N = 3) told us that when they first heard about the PNEP they thought it referred to beading/sewing needles, and a couple of participants (N = 2) asked us, the researchers, for information about how the program worked.Such confusion and lack of knowledge about the specifics of the program may be a sign that an individual has only recently been incarcerated and is yet unaware of the program, or perhaps indicative of insufficient consultation and guidance with the incarcerated population before the program was brought to PI.However, participants who were more knowledgeable about the program identified numerous other difficulties with its implementation and operation.

Participants' criticisms of the PNEP
Unbeknownst to us at the time, several weeks before we began our study the women at PI had organized a petition demanding the PNEP be removed.More than two-thirds of the overall sentenced population (75 women) signed the petition.Most of the women in our sample (38 out of 56) had some form of negative view of the PNEP and were not shy about vocalizing their opposition using forceful language ("fucked up," "ridiculous," "retarded") when describing the program.The overall structure of feeling among most participants was hostile to the PNEP, with participants often raising PNEP-related complaints in our discussion without being prompted and frequently laughing or rolling their eyes when detailing what they characterized as its inherent contradictions.Interestingly, however, most of the same women who opposed the PNEP generally supported needle exchange programs in community and non-carceral settings.
Opposition toward the program, then, was the norm at PI.However, participants' reasons for opposing the PNEP were varied and multifaceted.Generally, opposition fell under two main categories: (a) participant-identified barriers to using the program and (b) perceived harms of the PNEP.With respect to the former, participants often cited the inherent contradiction of CSC introducing a PNEP while continuing to criminalize drug use.They also expressed a distrust of healthcare staff and COs, along with fear of institutional drug interdiction measures that could lead to serious repercussions for program users.With respect to the latter, participants pointed to the PNEP as a potential "trigger" for women trying to maintain their sobriety while incarcerated, along with the potential for the program to result in more violence within the institution.
These themes contain sub-themes.For example, while more than one-quarter of our sample grounded their opposition toward the program in the barriers that exist to using the program, only two women specifically discussed legal/pragmatic barriers to using the program, with other women identifying various other barriers.Consequently, while some of the factors detailed below were only mentioned by a few individuals, participants did not typically oppose the PNEP for any single overriding reason.Instead, opponents tended to dismiss the PNEP out of hand, listing a number of reasons for why having such a program in prison was illogical, unworkable, or risky to themselves or others.
Participant identified barriers to using the PNEP At a basic level, our participants' reservations about the PNEP derived from their assessment of the logic or viability of a needle exchange in prison.One obvious barrier to participation was the inherent tension or contradiction in CSC's policy toward injection drug use.Participants were bewildered by the fact they could acquire a kit to inject drugs but could also be criminally charged if caught with the drugs to be injected.A subset of these women (N = 6) opposed these programs simply because they saw the PNEP as incompatible with a prison environment that criminalizes drugs.As Saba, who has self-described "addiction issues," explained: I think [the PNEP] is absolutely ridiculous.You [CSC] are saying it's illegal and people aren't supposed to have drugs, but yet you have a needle exchange program?It doesn't make sense to me.It really doesn't make sense.Like, you're running this program and it's supposed to be anonymous but if somebody's found with a needle it's contraband and they're gonna get thrown downstairs [segregation].
Similarly, Rayne noted: "They're trying to eradicate the drug use in here, y'know, people cheeking [diverting] pills and all the rest, but… Well, giving them a clean needle to use is only giving them free access to continue doing what [CSC] don't want you to do."This contradiction made it difficult for Rayne and other participants to make practical sense of having a needle exchange in prison.
As noted above, despite not supporting the PNEP, most women supported needle exchange programs outside of prison: Jordan: I'm all for, like… I understand, like, the outs [community] program.Like, I read extensively about it.I understand, like, British Columbia and Calgary and Edmonton, that they do have, uh, opiate places [safe consumption sites] for hardcore addicts to go and get their fix three times a day.I totally get that.And that they have needle exchange for people.But that's on the outs.
Interviewer: So, you don't think it belongs here?Jordan: I don't think so.But I'm not a real opiate user, right?But I don't think the needle exchange-for the risk to the rest of the population-I don't agree with it whatsoever.
Jordan, and those like her, did not disapprove of needle exchange programs in principle.These women supported needle exchanges in the community and harm reduction more generally.However, they were skeptical of the viability of the existing program and concerned about risks they identified with having a needle exchange operating within the prison's closed setting.
A related barrier participants identified was their distrust of healthcare staff and COs.Such distrust or hostility between incarcerated individuals and COs is a well-documented aspect of prison both in Canada and internationally (Haggerty and Bucerius, 2020;Ricciardelli, 2019;Schultz, 2022).In relation to the PNEP, these concerns were particularly acute in relation to privacy and confidentiality.While people could obtain a syringe kit anonymously, participants believed that the realities of the prison's security protocols and subcultural dynamics made it nearly impossible to keep program involvement a secret from staff or other incarcerated individuals.As Shannon reminded us, everything prisoners do at PI is recorded "in a report."Almost a quarter of participants believed that enrolling in the PNEP would result in some form of increased or unwanted attention by staff.As Chantel, a recovered alcoholic with mixed feelings about the PNEP, explained: …a lot of people, apparently, are not too keen on stepping forward to do that [needle] exchange because then [staff] know, right?So, I'm not quite sure how it's done here…But I'm assuming you're gonna have to get [a needle] from healthcare, or somebody, and they're gonna know who's doin' it.And does healthcare not talk to [correctional officers]?Yeah, they do, you know?
Another participant, Yasmin, who has an extensive history of opioid addiction, laughed at the prospect of incarcerated people trusting COs with any information about drug use, saying, "Even if you are using, who's gonna go tell the staff they need clean equipment to use drugs?"Another participant, Roxane, who also has an extensive history with problematic substance use, shared a similar concern, highlighting the implications of participating in a program that results in increased scrutiny by COs: Everybody was against [the PNEP], but they still gave it out here.And some of the girls are getting the safe needle kits given to them on their persons.And from the stories I've heard about people who have them, they're just a hassle.So, it gives [the COs] more reason to watch you and more reason to try to charge you, or try to get at [you], or test you, or whatever.
Here, Chantel, Yasmin, and Roxane all spoke to an underlying distrust of prison staff who they believe will either gossip about who is using the PNEP or otherwise scrutinize and harass known program users.
Connected to this distrust of staff was the belief that using the PNEP would increase the likelihood of being drug tested (i.e., through urinalysis), which could result in institutional charges and/or fines.Eva, a self-identified alcoholic, believed that women enrolled in the program inevitably become targets for testing, despite reassurances by COs and the institution that these tests are random: Eva: They're saying they can't target you.They can't pick on you, they can't search your room all the time, they can't drug test you all the time just because you're on it.
Interviewer: My question is: is it random?Eva: I get targeted all the time…I feel it's not random.And the… the one girl that I know that's, that's on it, she gets targeted quite a bit.
In this way, many of the women concerned about the potential harms of the PNEP perceived participating in the program as putting a target on their back for unwelcome attention from COs.
As they saw it, participation would inevitably lead to increased disciplinary action, particularly from "random" drug testing.Victoria, who has a history of injecting heroin and meth and who was the only participant in our sample who disclosed having enrolled in the PNEP, was frustrated by exactly this scenario: [The COs] pushed me to go on to that needle exchange program.I was on it for two weeks.I got charged for the stupidest things.The whole [living unit] knew within a day 'cuz the guards were so, like, loud about it."Let me see the needle!Take the tube off, I wanna see the tip of the needle!"Oh my god.
Two participants who supported the harm reduction aspect of the PNEP nonetheless worried about COs, confidentiality, potential disciplinary measures, or the prospect of being denied parole.One woman told us that nobody she knows uses the program, because anyone who uses it is "…just asking to get harassed all the time."This underlying distrust of prison staff, and the perception that involvement in the PNEP would lead to increased harassment and institutional charges from COs, contributes to participants' negative views of the PNEP at PI.
A few other women believed that being involved in the PNEP would negatively influence one's chances of early release.Given the dynamics of prison gossip, these individuals had no faith in the prospect of keeping their enrollment in the PNEP a secret.Moreover, the fact that women had to formally enroll in the program meant that prison authorities knew of their involvement.COs could further publicize women's participation in the PNEP when searching living units, demanding, as Victoria noted above, that individuals display the syringe from the kit.Consequently, there was a general belief that discussions among staff and COs would result in women's parole officers learning of their participation in the PNEP, which they anticipated would be interpreted negatively and hinder their likelihood of being granted parole.Given these fears, it is ironic that Victoria enrolled in the program because she thought that participation would "look good" on her parole file: Victoria: …I thought it would look good on me to have [the PNEP kit] and, you know, keep it a whileand I'd never use it.I thought it'd just look… I just wanted to look good on the paperwork.
Interviewer: You're participating in something.
Victoria: Yeah.Um, and then, it just…complete other way.It was…it was way worse.
Victoria explained that being on the program was "worse" than she imagined because, in her view, it led to her receiving institutional charges within two weeks of enrolling.She feared that this would be detrimental to her parole outcome given that such decisions are based, in part, on demonstrated behavior while incarcerated (Government of Canada, 2021).
Yet another institutional barrier to use was the process of enrolling in the program itself.One participant told us, "You have to be a known drug user to have those [PNEP] kits," while another described wanting to participate but being denied because she had been recently charged with assault.In this way, the formal requirements for participating could be a barrier for women who might want to use it.These requirements, coupled with the perceptions that enrolling would lead to increased surveillance, harassment by COs, and potential disciplinary consequences, ultimately made our research participants extremely skeptical that the PNEP could "work." The perceived harms of PNEPs While prison harm reduction initiatives aim to reduce harms related to substance use, almost half of our participants (24 out of 56) criticized PNEPs for the prospect that they could produce different types of physical or psychological harms.This included worries that the program could: (a) "trigger" women who were trying to maintain their sobriety or using prison as an opportunity to stop using drugs and (b) result in PNEP needles being used as weapons or be implicated in other forms of physical harm.
With respect to the former, Amaya, who does not inject drugs but is nonetheless trying to get sober in prison, explained: I think [the PNEP is] kind of useless to have here because it just makes girls want to do drugs.You know, especially for the girls that have triggers with injecting and that was their main way of doing drugs on the outside.It's just gonna make them wanna do drugs.
Another five participants, all of whom have histories of self-identified problematic substance use, worried about the potential consequences of the PNEP for themselves and/or other women trying to maintain their sobriety.For example, Mallary, who has a history of smoking and injecting drugs, told us PNEPs "…make you wanna use when you haven't used for a long, long time."Alex, who has a history of injection drug use, described how the needle itself could be a trigger for women trying to stay sober, saying "I don't approve of [the PNEP].I don't like it.Being an IV user [myself], yeah, 'cuz I was addicted to the needle itself."Fatema, who is now sober but first started injecting cocaine and speed at the age of 14, believed, "[The PNEP is] promoting drug use within this facility.That's what it's doing."The result of bringing a PNEP to PI, in these participants' opinion, would be more drug use among the prison population, even for those who were previously sober.Here, it is important to note that many of the women we interviewed approached their incarceration as an opportunity to break from their prolonged patterns of drug use and to seek treatment for their substance dependency (Bucerius et al., 2021).Consequently, many women presented the introduction of needles into the institution as a threat to their sobriety.
Relatedly, other participants were anxious about the method of drug use that PNEPs might facilitate.These individuals felt the program encouraged injection drug use-a more direct and dangerous form of consumption compared to other methods, such as snorting, smoking, or ingesting (CDC, 2021).This included six women who said that having needles/syringes more readily available would result in more women injecting over-the-counter medications as well as the prescription medications that incarcerated people regularly divert and sell to other incarcerated individuals.For example, Alex, who used to inject drugs, was certain that the presence of more needles would lead to women "smashing" (i.e., injecting) Tylenol.Other participants believed that the PNEP would inadvertently, but inevitably, encourage people who had never used drugs intravenously to start doing so, with Casey-a former opioid user-saying "…there's always those people that never tried [injecting drugs] n' wanna try it.What…what's gonna happen if they wanna try [injecting drugs] in jail and maybe shoot-up some Suboxone and then they overdose?"Another participant, Olivia, who has a history of using opioids intravenously, further elaborated on the risk of overdose that could be exacerbated by the presence of PNEP needles: …for me, personally, the needle program is pretty stupid.Well, it's…it's stupid and it's not, right?It's, like, encouraging them to use intravenous drugs, but yet, it's…encouraging them to use clean needles too, right?But, like, I guess it's just the fact that there is drugs coming in and [incarcerated people] would rather use clean needles than dirty needles.But, […] it's more potent when you use it intravenously and that's why people overdose so much.
While Olivia, and others, recognized the importance of the harm reduction elements of the PNEP, she was one of several individuals who feared it could also lead to women taking more risks -particularly a greater proclivity to using drugs intravenously, which may increase overdose risk.This concern is perhaps unsurprising considering that 36% of our sample have personally witnessed an overdose, 39% have overdosed themselves, and that PI does not provide the overdose reversing drug naloxone to incarcerated individuals (only COs can access it) (McKendy et al., 2019).
While a minority view, a number of women (three of 56) also anticipated that the PNEP would contribute to an escalation in interpersonal violence emanating from several sources.For example, in light of their belief that the PNEP would lead to more drug use, a couple of participants concluded that this, in turn, would make the prison population more volatile and the interpersonal dynamics more unpredictable.One participant, Xiu, who herself used to inject hydromorphone and "speedballs" (i.e., a mix of cocaine and heroin), presented a hypothetical scenario about how having a needle kit could instigate violence: I guess [people who inject drugs] can get a needle?Like I know diabetics… that's why I was like, "You mean, like, diabetics?"and they were like, "No."Cuz diabetics, they can have their own kit in the house, with needles, right.Which I don't agree with either.They have their own [needles], so they could get beat up for that, like, easily.
Although Xiu had never witnessed someone assault another person to obtain her diabetes syringes, other women identified comparable scenarios.One participant expected that those who were wary of the possible institutional repercussions of enrolling in the PNEP would pressure or assault other women to force them to enroll in the program and give them their kit.Here, then, a small grouping of participants feared that the barriers to formally using the PNEP or perceived risks of formally being enrolled in the program would encourage some women to use violence or intimidation to obtain needle exchange kits in a clandestine manner.
Another minority view held by a couple of women concerned a fear that an incarcerated person would use a needle to assault someone else.In a correctional environment where women had seen weapons ingeniously crafted from scraps of wire, wood, and plastic, it seemed inevitable to them that someone would eventually use a needle as a weapon too.One woman with a history of problematic substance use said that PI housed some "crazy bitches" and felt uneasy about these women having access to needles, saying "How do I know you're not gonna stick me with your needle?"Another participant, also with a history of problematic substance use, argued that providing needles to incarcerated people who inject drugs was akin to handing them a "murder weapon" that could also be used to commit suicide.

Discussion and conclusion
Prisons detain populations of individuals with distinctive and often acute needs pertaining to mental and physical health, education, problematic substance use, personal trauma, and much more (Bucerius and Sandberg, 2022).Providing effective in-prison programming is consequently a pressing concern.However, the prison environment can profoundly shape the form and content of such services in ways that reduce their utility and viability (Frank et al., 2015;Kothari et al., 2002;McKeganey et al., 2016).Our analysis of the needle exchange at PI is both a demonstration and cautionary tale about how otherwise beneficial programs can be compromised if such prison-related attributes are not (or cannot be) prospectively addressed and incorporated into the delivery of such programing.
Our participants routinely identified several factors relating to the prison's inner settings that they saw as being in tension with or entirely antithetical to the uptake or success of the PNEP.Such issues included the legal prohibition on possessing drugs, concerns that participants would be tested for drugs in a more targeted manner, and that their involvement would count against them in parole decisions.Of particular concern was the fear that COs and staff would harass and subject those enrolled in the program to greater surveillance, something that corresponds with fears articulated by formerly incarcerated individuals about hypothetical PNEPs (van der Meulen et al., 2017).Participants also regularly referenced their personal histories of drug use, arguing that the PNEP put their sobriety at risk and portraying it as a psychological trigger for those trying to avoid using drugs intravenously.Such concerns about triggering have also been identified in European studies of individuals' views about hypothetical PNEPs (Pulford et al., 2011).The totality of these concerns should be of interest to researchers internationally as they offer possible insights into why PNEPs in Canada and elsewhere tend to be under-utilized (Sander et al., 2019) and also the types of challenges any in-prison programming might encounter.
Given that the Union of Canadian COs has opposed introducing PNEPs (UCCO/SACC, n.d.), some readers may interpret these women's hostility to the program as resulting from officer intimidation or manipulation.However, these women explicitly identified and resented the insinuation that their stance on this issue was influenced by COs-a group whose preferences and interests incarcerated women are often happy to subvert as they deem appropriate.However, the fact that many COs across Canada are against the implementation of PNEPs into federal institutions, coupled with our finding that many women at PI also do not want the program, does present a problem.Efficacy studies find that buy-in from both incarcerated people and prison staff is vital for the successful implementation of PNEPs (Dolan et al., 2003;Stöver and Nelles, 2003).This buy-in is clearly lacking at PI.If both COs and incarcerated individuals are hostile toward PNEPs, these programs are unlikely to be successfully implemented at PI or any other federal prison in Canada.
At the same time, some of the women's fears about the PNEP were not supported by science and involved misunderstandings about how the program worked in practice (Bucerius et al., 2022).For example, despite research showing that needles distributed by PNEPs have not been used as weapons (Dolan et al., 2003;Stöver and Nelles, 2003;UNODC, 2015), some women saw this as a likely and perhaps inevitable outcome.This suggests that more effort is needed to educate the population about the risks and realities of PNEPs.Such an educational strategy would be in keeping with how advocates and officials often address concerns about harm reduction programming.That said, it would seem to be a mistake to conclude from our findings that the women only need to be offered more education and information for them to support the PNEP.That is because many of the barriers to using the PNEP they identified are inherent in the day-to-day operational structure of PI and are not easily amenable to change.Concerns about heightened surveillance, legal prohibitions against substances, conflictual or distrusting relationships with staff, and concerns about parole decisions are structural attributes of PI identified by participants.Moreover, as their fears that a needle exchange might put their sobriety at risk were grounded in their highly personalized experiences of drug use, it seems unlikely that such concerns will be easily alleviated by pointing to research that does not support that conclusion (WHO, 2007).
If the PNEP is to be maintained or comparable programs introduced elsewhere, our findings suggest that, at a minimum, all affected parties need to be consulted to determine if it will be supported within a specific prison community and, if so, how incarcerated people at any given institution want the program to be implemented.Indeed, consultations to determine the needs of different groups impacted by PNEPs, as well as how to tailor harm reduction interventions to these specific populations' needs, have been determined to be a prerequisite for successful PNEP implementation (Asl et al., 2013;Dolan et al., 2003) Consideration, then, has to be given to the possible structural impediments to program success identified by incarcerated people themselves.If these factors are not or cannot be addressed, then the PNEP at PI, and other yet to be implemented PNEPs, will likely remain an under-used initiative and target of animosity or ridicule for a considerable subset of incarcerated individuals.
Relatedly, our findings raise practical and ethical questions about implementing a PNEP in a prison where incarcerated people do not want it.As indicated by the inmate-led petition against the implementation of the PNEP, the majority of incarcerated people at PI opposed the program.The majority of participants in our study also were against the program or otherwise held negative views about it.While we recommend that pre-PNEP implementation consultations be conducted to identify incarcerated people's opinions and needs (Asl et al., 2013;Dolan et al., 2003), the question of what to do when such consultations find that these individuals simply do not want such a program is a difficulty that has yet to be addressed in the literature.How can the needs of incarcerated people who inject drugs be balanced with the needs of incarcerated people who want to become, or continue being, sober?What happens when the scientific facts and human rights arguments supporting prison-based harm reduction strategies like PNEPs appear to clash or be in tension with the experientially grounded beliefs of affected parties?How can this tension be addressed without dismissing or trivializing incarcerated people's concerns?These are not easy questions to answer and, in our view, they deserve far greater scholarly attention.
Finally, our study raises methodological issues about studying in-prison harm reduction programming.In contrast with our findings, other empirical research in Canada has found considerable support for PNEPs (Chu and Peddle, 2010;van der Meulen et al., 2017).However, that research has exclusively focused on convenience samples of individuals who have injected drugs in prison drawn from the personal or professional networks of harm reduction researchers or advocates.Almost all this research is conducted in community settings after participants have been released from detention.Our findings suggest that future research on this topic should pay greater attention to interrogating how the structural dynamics of prison itself shape or limit the value of otherwise beneficial programs.It also seems clear that studies of people's perceptions of PNEPs should incorporate a broader and more representative range of currently incarcerated individuals, including people who do not currently use drugs.Such inclusiveness is vital because an extensive crosssection of incarcerated individuals sees themselves as having a legitimate stake in the operation of harm-reduction programming, including a considerable subset of people who may not currently use or inject drugs but will do so for the first time in prison and those who might otherwise be affected by such programs (Stöver and Hariga, 2016).

Limitations
We interviewed participants about their perceptions of the PNEP at one point in time.While gaining research access to the prison shortly after the PNEP was implemented gave us unique insights into the women's perceptions as the program was being implemented, it is possible that the resistance toward the PNEP demonstrated in our data is related to the fact that the program was new and perhaps unfamiliar.Longitudinal research is warranted to explore how perceptions of PNEPs may, or may not, change over time.
Further, while we did ask participants to indicate, generally, if they had ever used drugs while in prison, including if they had ever used fentanyl, we did not ask participants to divulge the specifics of their drug use.Namely, we did not explicitly ask participants to disclose their method of drug use while incarcerated or if they were currently using drugs.While it would have been beneficial to cross-reference our participants' opinions with their current drug use, for both methodological and ethical reasons, we felt it was in the best interest of our participants not to directly ask about this, as such drug use remains illegal in CSC institutions.
Lastly, we did not compare the opinions of incarcerated people who use, or have used, drugs with those who have never used drugs.As more than 85% of our sample admitted to having a history of illicit drug use, it was difficult to make meaningful comparisons between drug-using and non-drug using participants.In future research conducted in prisons where such drug histories are less extensive it would be useful to investigate if there are meaningful differences in perceptions of PNEPs among these groups.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/ or publication of this article: This work was supported by the Centre for Addiction and Mental Health (grant number RES0042706) and the Social Sciences and Humanities Research Council (grant number 895-2022-1011).

ORCID iDs
Lorielle Giffin https://orcid.org/0000-0002-5166-1787Luca Berardi https://orcid.org/0000-0002-4734-9168Notes 1.For example, a review by Dolan et al. (2003) found that, of the six efficacy studies under review, the percentage of injection drug users ranged from 39% to 60% of the total incarcerated population at these six prisons.2. Only eight out of 50 participants in Chu and Peddle's (2010) study were currently incarcerated.3.Only 12 out of 50 participants in Chu and Peddle's (2010) report were women.Only eight of these individuals were incarcerated at the time of the study.4. Prairie Institution (PI) is a pseudonym.5.For readability purposes, we have chosen to use the term "women" and "participants" interchangeably when referring to our participants as a group, recognizing that this women's prison also houses transgender men.