Living with addiction in the shadow of punishment: a qualitative study of prison drug use and harm reduction in Iceland.

This qualitative study explored how people with experience of imprisonment and injecting drug use in Iceland understand drug-related harm in prison and the role of harm reduction. It adds qualitative evidence from a small prison system where social proximity, limited anonymity and concerns about trust and confidentiality shape understandings of harm, safety and support. Six participants aged 25-35 were interviewed, and the data were analysed thematically within an interpretive description framework. Participants described prison drug use as continuing dependence under hidden, unsafe and degrading conditions. Four themes were identified: (a) You always find a way; (b) Pushed into hiding; (c) Deepened suffering and shame; and (d) Seeking safety under surveillance. Together, these form the overarching interpretation, "Living with addiction in the shadow of punishment". Harm reduction went beyond access to sterile equipment. It was seen as humane, health-oriented care that could reduce injury and preserve dignity. The findings suggest that unmet harm reduction needs in prison may increase risk by pushing drug use further into secrecy and distancing people from care. In Iceland, where prisons are few, social worlds overlap and anonymity is limited, participants identified trust, confidentiality and independence from punitive authority as key conditions for harm reduction.