Mass incarceration, public health, and widening inequality in the USA

Are we gatekeeping trauma? A conceptual model to expand criterion A for invisible, identity-based, and systemic traumas

Since the inception of the criterion A framework into the posttraumatic stress disorder (PTSD) diagnosis in DSM-III, what qualifies as traumatic has been a fieldwide debate. Historically, social movements coinciding with advances in research have spurred improvements in the definition of criterion A, often by expanding the breadth of experiences that are considered trauma exposure. Contemporary issues of ongoing racial discrimination, ethno-violence, public health pandemics, warfare, oppression, and climate change warrant a re-examination of the criterion A definition. This critical review builds on prior critiques of criterion A and addresses (1) the limitations to the current criterion A definition in DSM-5 in capturing the experience of minoritized individuals; (2) three categories of trauma that are under-recognized in the current criterion A definition; and (3) the implications of expanding criterion A on clinical and research practice. We critically review three trauma categories that disproportionately affect minoritized individuals-invisible traumas, identity-based traumas, and systemic traumas. Evidence to date suggests that several traumatic experiences in these categories rise to the level of being traumatic, are associated with PTSD symptoms, and are prevalent among minoritized individuals. We discuss the implications of these traumas being omitted from criterion A and call for future work to critically examine the definition of criterion A in the PTSD diagnostic framework. Overall, this critical review captures traumas which remain undertreated, underdiagnosed, and under-represented by our current psychiatric nosology.

Providing Equitable Surgical Care to Patients in Law Enforcement Custody: A Review

Importance

Approximately 2 million individuals are incarcerated in the US. Surgical needs increase with age, and an aging prison population means an increasing need for surgical care for incarcerated individuals. Challenges in logistics, privacy, communication, and comorbidities put people in law enforcement custody at risk for suboptimal care and outcomes. Little guidance exists for surgeons seeking to provide equitable care for these patients.

Observations

No national statistics are available on the need for surgery among incarcerated people. Autopsy data suggest that nearly a quarter of deaths among incarcerated individuals were attributable to causes that could have been treated with surgery, yet few received surgical care before death. Across the spectrum of custody, including police detention, jail, prison, probation, and parole, access to consistent preoperative and postoperative care are major challenges, as is sustaining appropriate levels of privacy and communication. Incarcerated people are often accompanied by guards, preventing privacy. Patients are shackled to hospital beds, restricting mobility. For incarcerated individuals, access to postoperative medication may be curtailed when they return to jail or prison. To be effective advocates for patient-centered care and to achieve the best outcomes, surgeons must remain vigilant to specific barriers to care.

Conclusions and Relevance

Individuals in law enforcement custody have particular needs regarding communication, surgical planning, and perioperative and postoperative care. Clinicians must remain alert to these challenges and serve as advocates for these marginalized patients, even adjusting their care practices. Professional societies and health systems can bolster care for this marginalized population by developing and disseminating guidelines and pathways for patient-centered surgical care for individuals in law enforcement custody.

The Intersecting Effects of Lifetime Experiences of Homelessness and Incarceration on Cognitive Aging and Dementia Risk Factors in the United States

BACKGROUND AND OBJECTIVES

Alzheimer's disease and related dementias (ADRD) remain a pressing concern in the United States, which also has one of the highest incarceration rates worldwide. Existing research has analyzed dementia risk and care among currently incarcerated and homeless populations; this paper fills a gap by examining later-life cognitive disparities facing formerly incarcerated and/or homeless individuals.

RESEARCH DESIGN AND METHODS

Using Health and Retirement Study data (1998-2018), we tested whether formerly homeless and/or incarcerated people had earlier onset of cognitive decline, and whether they were more likely to have modifiable risk factors for ADRD than those without such experiences. We estimated prevalence of mild cognitive impairment (MCI), dementia, and self-reported ADRD diagnosis. We also used repeated observations of cognitive functioning coupled with nested nonlinear regression to examine the onset of accelerated cognitive decline.

RESULTS

Adjusting for demographic variables, formerly homeless and/or incarcerated participants have increased odds of having risk factors for dementia, including smoking, drinking alcohol, depression, mental illness, and discrimination from healthcare providers and police. Diagnosis of MCI and ADRD were more common among participants reporting a history of incarceration or homelessness. Nested nonlinear regression revealed that previous experiences of incarceration or homelessness-alone or together-are associated with earlier onset of accelerated cognitive decline compared with those who experienced neither.

DISCUSSION AND IMPLICATIONS

This study suggests that, even if they occur earlier in life, homelessness and incarceration experiences may increase risk of poorer cognitive health in late life. Future work is warranted to understand the lifelong consequences linked to this adversity.

"You can't incarcerate yourself out of the drug problem in America:" A qualitative examination of Colorado's 2022 Fentanyl​ criminalization law

BACKGROUND

In response to the U.S. overdose crisis, many states have increased criminal penalties for drug possession, particularly fentanyl. This study sought to qualitatively explore diverse community perspectives on increasing criminal legal penalties in Colorado for fentanyl possession (House Bill 22-1326) and the broader role of the criminal legal system in addressing substance use and overdose prevention. We conducted 31 semi-structured interviews in 2023 with community leaders directly working with people who use drugs, individuals with lived experience with drug use and the criminal legal system, and law enforcement throughout Colorado. Interviewees were asked about the perceived impact of House Bill 22-1326 on their communities and agencies. After interviews were complete, we created templated summaries and matrix analyses to conduct rapid qualitative analysis, an action-oriented approach to qualitative data analysis.

RESULTS

Respondents included peer support specialists (n = 7), policymakers (n = 6), community behavioral health/harm reduction providers (n = 6), criminal legal program staff (n = 8), and law enforcement (n = 4), with nine participants from rural counties. Analysis revealed that participants found increasing criminal penalties for fentanyl possession to be misguided: "And the felony [of HB-1326] is such a good example of a policy being led by feelings rather than evidence." This was in the context of participants' divergent views on police as conduits to treatment and punishment and perceiving jail as an (in)appropriate response for substance use disorder treatment.

CONCLUSIONS

All participants supported policy efforts to prevent fatal fentanyl overdoses, yet, most thought that increased use of police and incarceration as avenues to prevent overdose was misguided. This study highlights a diverse array of community perspectives that can inform policy decisions concerning criminal penalties for fentanyl possession and distribution and can inform policies that affect people who use drugs broadly.

Addressing social determinants of health in individuals with mental disorders in clinical practice: review and recommendations

Social determinants of health have been shown to have a greater impact on overall health than traditionally considered medical risk factors, especially in people with mental disorders. It is the primary responsibility of healthcare providers to ensure that persons with psychiatric disorders are actively helped in reducing the adverse effects of SDoMH on their health and healthcare. Yet, the current clinical psychiatric practice in the U.S. does not have any standardized guidelines for evaluating or addressing these critical factors even among individuals who are receiving psychiatric and other medical treatment. Although there are several barriers to implementing such interventions, there are also practical approaches to address selected social determinants of mental health and improve the well-being of our patients. In this article, we review the literature on the assessment of relevant social factors and pragmatic psychosocial strategies at the individual, family, and community levels to help reduce their adverse impact. We offer guidelines for psychiatric clinicians and case managers to improve the health and quality of life of persons with mental disorders, using sustained inter-professional collaborative efforts.

The Health and Health-Related Quality of Life Impacts of Having a Sibling on Probation or Parole in the United States: A Focused Ethnography

In this study, we explored the experiences of adult siblings of brothers who have been on probation or parole and the impacts on the participants' health and health-related quality of life. We conducted semi-structured interviews and focused field observations of 8 adult siblings. The major themes were siblings being primary support providers , feelings of existing in a perpetual state of unknown , and perceived needs and resources . These themes reflected the types of support that participants provided; the associated strains and instability perpetuated by the criminal legal system; and the perceived resources needed to mitigate the negative impacts of participants' experiences.

Multiple Disadvantage and Social Networks: Toward an Integrated Theory of Health Care Use During Reentry From Criminal Justice Settings

Research consistently finds the disproportionate negative health impact of the criminal justice system on racial and ethnic minorities. Yet less is known about the underlying mechanisms of health care utilization during community reintegration. We contribute to the literature theoretically by integrating two perspectives: network theory of social capital and multiple disadvantage hypothesis and providing a more nuanced explanation of health service use during reentry. We identify incarceration history as a unique disadvantaged status that precludes people from accessing social networks and social capital. We further elaborate on the phenomenon of racialized reentry and illustrate how multiple disadvantaged statuses are linked to social networks and health care.

A novel use of HIV surveillance and court data to understand and improve care among a population of people with HIV experiencing criminal charges in North Carolina 2017-2020

OBJECTIVES

To enumerate and describe the population of people with HIV (PWH) with criminal charges and to estimate associations between charges and HIV outcomes. We hypothesized that being charged in the court system will be associated with declines in viral suppression.

METHODS

We linked statewide North Carolina (NC) criminal court records to confidential HIV records (both 2017-2020) to identify a population of defendants with diagnosed HIV. We used generalized estimating equations to examine changes in viral suppression (outcome) in the time 12-month periods pre- and post-criminal charges (exposure), adjusting for other demographic and legal system factors.

RESULTS

9,534 PWH experienced criminal charges. Compared to others with charges, PWH were more likely to be male and report Black race. The median duration of unresolved charges was longer for PWH. A slightly larger proportion of PWH experienced viral suppression in the 12-month post-charge period compared to the pre-charge period (72% vs 70%, p < 0.05). Similarly, when adjusting for demographic factors, the 12-month period following resolution of charges was modestly associated with an increased likelihood of viral suppression (aRR 1.03, 95% confidence interval [CI] 1.02-1.04) compared to the pre-charge period.

CONCLUSIONS

A significant portion of PWH in NC had criminal charges during a three-year period, and these charges went unresolved for a longer time than those without HIV. There was a modest statewide increase in viral suppression in the 12-month period after resolution of charges. Considering the exploratory nature of study, the modest association between charges and viral suppression should not be interpreted causally. In contrast to our expectation, we did not find any evidence that charges were associated with a decline in viral suppression. We suggest future lines of research to improve upon this exploratory analysis and area of study.

Health and incarceration research in Australia: a scoping review

Background

People who experience incarceration often have complex healthcare needs and poorer health than the general population. Australia has the eighth-largest custodial population in the Western Pacific. Understanding the breadth and quality of research on this population's health is crucial for advancing health equity both in Australia and across the region. This scoping review synthesised health research involving people in contact with the criminal justice system in Australia.

Methods

We searched eight databases for primary, peer-reviewed research reporting on the health of people incarcerated or previously incarcerated in Australian prisons or youth detention settings.

Findings

Our search identified 11,731 unique records, and 508 met the inclusion criteria. Over half (51%) were published between 2015 and 2024. Relatively few studies provided evidence on cognitive disabilities (16%), non-communicable diseases (14%), or sexual and reproductive health (6%). Few focused on youth detention (15%) or post-release health (24%). Only 27 studies (5%) focused exclusively on the health of First Nations Australians. Most studies (86%) came from Australia's most populous states-New South Wales, Queensland, and Victoria-which account for 68% of people incarcerated each year, and 58% of incarcerated First Nations peoples.

Interpretation

Despite considerable growth in the number of peer-reviewed studies on the health of people who experience incarceration, critical health issues, key populations, and Australian jurisdictions with the highest incarceration rates require urgent attention. Further high-quality research is needed to fill these evidence gaps and translate research into evidence-based strategies that address the complex and diverse health needs of justice-involved people.

Funding

SP was supported by a Australian Government Research Training Program Scholarship.

Neighborhood intergenerational mobility and population health inequality: Spatial dependency and heterogeneity

Health inequity represents a significant social injustice with major policy implications. This study examines the role of neighborhood intergenerational mobility (IM)-defined as the extent to which children within a specific neighborhood can achieve better socioeconomic outcomes than their parents-in shaping population health, addressing widening health inequalities. We propose that neighborhood IM is positively associated with population health, moderated by spatial dependency and heterogeneity. Analyzing over 69,000 census tracts in the contiguous United States using spatially-lagged X models, we find that neighborhood IM is positively associated with health status. The positive relationship weakens in neighborhoods surrounded by neighborhoods with higher levels of IM and strengthens in neighborhoods surrounded by neighborhoods with lower levels of IM. It also weakens in more advantaged environments-characterized by higher socioeconomic indicators, better built environment features, and more favorable natural environment conditions-and strengthens in less advantaged environments with poorer socioeconomic, built, and natural conditions. Our findings underscore the critical role of neighborhood context and heterogeneity in shaping the effects of social determinants on health, suggesting that policymakers should prioritize resources for disadvantaged neighborhoods with lower IM, particularly those surrounded by similarly low-IM areas, to mitigate health disparities more effectively. Our study provides new insights into the role of neighborhood IM in population health and demonstrates the value of geographic approaches for understanding and mitigating health disparities.

Employment and mental health for adults on probation, 2002-2021

BACKGROUND

The 21st century has seen a decline in employment rates in the US at the same time that it has experienced a historically unprecedented rise in the numbers of adults under criminal justice system control. Both low employment and high incarceration have posed serious challenges for public health.

METHODS

Using data from the National Survey on Drug Use and Health from 2002-2021, we estimated employment rates by community supervision status. Variations by sociodemographic subgroups were explored as well as correlations between employment and a range of mental and behavioural health variables.

RESULTS

Those on probation were twice as likely as those not to live in poverty. They experienced higher rates of poor mental and behavioural health, including three times the rate of substance use. Employment rates varied little by community supervision status. Health risk factors were associated with more risk and protective factors did less to mitigate risk for those under community supervision.

CONCLUSIONS

Despite the range of adversities faced by individuals under criminal justice system control, their employment rates are remarkably close to those not. Despite near equivalent involvement in the labour force, this population has substantially poorer health and substantially reduced likelihood of escaping poverty.

Felony disenfranchisement laws and racial inequities in women's self-rated health

Objectives

To determine if more strict state-level felony disenfranchisement laws, which are a form of structural racism, are associated with worse self-rated health, and if this association is stronger for Black women compared to white women.

Methods

Using Behavioral Risk Factor Surveillance System (BRFSS) 2021, American Community Survey 2017-2021, and State Felony Disenfranchisement Laws in 2020 from the "Locked Out Report" by the Sentencing Project, we fit hierarchical linear models to estimate changes in self-rated health with state felony disenfranchisement laws for 185,833 Black and white women, stratified by race, in 49 states (excluding Florida).

Results

We found a significant positive association between more restrictive disenfranchisement and worse self-rated health for Black women (b = 0.08, SE = 0.03, p < 0.01), but not white women, in the fully adjusted model.

Conclusions

Stricter state-level felony disenfranchisement laws were associated with worse self-rated health for Black women but not white women suggesting that policies of disenfranchisement may exacerbate racial inequities in health.

Housing assistance among people who are unstably housed and use drugs in Oregon: a cross-sectional study

BACKGROUND

Unstable housing has tremendous harms on health and well-being and people who use drug experience significant barriers to housing. The objectives of this study were to estimate the prevalence of housing assistance among people who use drugs experiencing unstable housing in Oregon and explore factors associated with obtaining housing assistance.

METHODS

We used cross-sectional survey data collected between March and November 2023 from people who were unstably housed and used drugs across eight counties in Oregon (N = 425). Unstable housing was defined as experiencing unsheltered or sheltered homelessness in the past year. Participants reported whether they obtained housing assistance in the past year. We explored associations between sociodemographic characteristics and housing assistance using multivariable log-binomial models.

RESULTS

There were 133 participants (31.3%) who reported obtaining housing assistance in the past year. There was a lower prevalence of housing assistance for cisgender men (versus cisgender women and gender expansive participants) (PR = 0.73, 95% CI: 0.55-0.98) and those interviewed in non-urban counties (versus urban counties) (PR = 0.72, 95% CI: 0.53-0.98). Using opioids 21 or more days (versus 0-20 days) was associated with a lower prevalence of obtaining housing assistance (PR = 0.67, 95% CI: 0.48-0.94) Community supervision was associated with a higher prevalence of housing assistance (PR = 1.70, 95% CI: 1.27-2.27).

CONCLUSION

We found a large gap in housing assistance for people who use drugs in Oregon and identified several factors associated with obtaining housing assistance. Our findings can inform future interventions to connect people who use drugs with stable housing.

Death and disappearance: Measuring racial disparities in mortality and life expectancy among people in state prisons, United States 2000-2014

BACKGROUND

Research on carceral institutions and mortality finds that people in prisons and jails have a high risk of death immediately following release from custody and that while incarcerated, racial disparities in prisoner mortality counter observed death patterns among similarly situated non-incarcerated, demographic groups. Yet, many of these studies rely on data prior to the millennium, during the COVID-19 pandemic, or are relegated to a small number or select group of states. In this paper, we explore changes in mortality and life-expectancy among different demographic groups, before and after the Great Recession, across forty-four states that reported deaths in custody to the federal government between 2000 and 2014.

METHODS

Drawing on a novel dataset created and curated, we calculate standard, age- specific quantities (death rates and life-expectancy) using period lifetable methods, disaggregated by race and sex, across three different periods (2000-2004, 2005-2009, and 2010-2014) for each state. Ordinary least squares regression models with state and year fixed-effects are included to examine state-level factors that may explain differences in prisoner mortality rates between 2000 and 2014. We also benchmark death counts reported to federal agencies with official state reports to cross-validate general mortality patterns.

RESULTS

Among imprisoned men, age-specific trends in mortality have shifted across the three periods. Following the Great Recession and the push for criminal justice reforms, prisoner mortality dropped significantly and is concentrated at older ages among men during 2010-2014; the shifting pattern of mortality means that men age 30 in 2010-2014 had similar death rates as men in their early 20s during 2000-2004, representing a 7.5 year shift in age-specific mortality rates. Gains in the mortality decline were disproportionately experienced by Non-Hispanic White and Non-Hispanic Black men, with the latter experiencing the greatest gains in life-expectancy of any demographic group. State-level violent crime rates are strongly and positively associated with prison mortality rates across states, net of socioeconomic and political factors. The large and significant disappearance of deaths in prisons from official data reported to federal agencies calls into question the narrowing gap in racial disparities among people in carceral facilities.

CONCLUSIONS

Legal decisions and social policies aimed at reducing mortality may be most effective in the short-run; however, the effects of these policy changes may fadeout over time. Research should clearly discern whether changes in mortality rates across states are due to diminished gains in social policies or increases in the disappearance (or underreporting) of deaths in custody. Understanding how and why gains in survivorship may stall is important for aligning health initiatives with social policy to facilitate maximal and consistent mortality declines for all demographic groups.

A Primer on Carceral Health for Clinicians: Care Delivery, Regulatory Oversight, Legal and Ethical Considerations, and Clinician Responsibilities

The United States has one of the highest incarceration rates in the world, with approximately 1.7 million individuals detained in jails or federal or state prisons. Chronic medical conditions are more prevalent among adults in custody than among their nonincarcerated counterparts, resulting in needs that often surpass the on-site medical treatment capabilities of carceral facilities. For this reason, many community-based health care professionals will encounter incarcerated patients in an ambulatory or inpatient setting. Yet, although carceral status engenders pragmatic and ethical complexities in patient care, health care professionals in academic and community settings receive little or no education about correctional health. This special article seeks to address this knowledge gap by providing demographic and patient characteristics of this population, describing health care delivery in the criminal legal system, summarizing incarcerated patients' health care rights, conveying the current state of oversight and regulation for correctional health care, and presenting the role of health care professionals in advocating for the ethical care of incarcerated patients. By equipping themselves with this knowledge, clinicians may provide holistic and ethical care for persons involved in the criminal legal system.

Using Appreciative Inquiry in Correctional Health Care: An Integrative Review

This integrative review examines the use of appreciative inquiry in correctional health care settings, following the guidelines of Whittemore and Knafl. Using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool, it assessed the level and quality of the evidence. Search terms included appreciative inquiry AND healthcare, appreciative inquiry AND nursing practice, and appreciative inquiry AND criminal justice. Nine of the 92 articles reviewed used steps of the appreciative inquiry process and were selected for the final review and analysis. Most study authors recommended organizational change. In carceral settings, appreciative inquiry was used to reduce bias, increase empowerment, and improve workplace relationships. Wider dissemination of the usefulness of this process is needed to address workforce shortages.

Mandible Fracture Outcome Disparities in the Incarcerated Patient Population

INTRODUCTION

Inmates represent a vulnerable health care population within the United States, with inconsistent access to surgical specialty care. Facial fractures are common among the incarcerated population, comprising approximately 14% of all traumatic injuries. However, few studies have evaluated facial fracture outcomes in this population. The aim of this study is to identify disparities in mandible fracture outcomes in the incarcerated population.

METHODS

A retrospective review of all isolated traumatic mandible fractures at a single academic medical center from 2018 to 2023 was conducted. Mandible fractures were treated by plastic surgery, otolaryngology, or oral and maxillofacial surgery. Outcome measures such as rates of persistent malocclusion, motor deficits, surgical site infection, reoperation, and readmission were compared between inmate and civilian subgroups.

RESULTS

A total of 205 patients (mean age, 33.1 years; 81.5% male) who were treated for isolated traumatic mandible fracture were included. A minority of patients (11.7%; n = 24) were inmates, whereas 88.3% (n = 181) were civilians. The mean time to operative intervention was 10.2 days in the incarcerated group and 4.4 days in the civilian group ( P < 0.05). Persistent subjective malocclusion after surgery was noted in 20.8% (n = 5) of incarcerated patients and 7.2% (n = 13) of civilian patients ( P < 0.05). There were no significant differences in rates of surgical site infection, reoperation, persistent motor deficits, or readmissions within 30 days.

CONCLUSIONS

Incarcerated patients with traumatic mandible fractures have increased time to operative intervention and increased rates of subjective malocclusion postoperatively. Increased time to operative intervention may reflect barriers in access to specialty surgical care, which could adversely affect patient outcomes.

Characterizing Emergency Department Care for Patients With Histories of Incarceration

Objectives

Patients with a history of incarceration experience bias from health care team members, barriers to privacy, and a multitude of health care disparities. We aimed to assess care processes delivered in emergency departments (EDs) for people with histories of incarceration.

Methods

We utilized a fine-tuned large language model to identify patient incarceration status from 480,374 notes from the ED setting. We compared socio-demographic characteristics, comorbidities, and care processes, including disposition, restraint use, and sedation, between individuals with and without a history of incarceration. We then conducted multivariable logistic regression to assess the independent correlation of incarceration history and management in the ED while adjusting for demographic characteristics, health behaviors, presentation, and past medical history.

Results

We found 1734 unique patient encounters with a history of incarceration from a total of 177,987 encounters. Patients with history of incarceration were more likely to be male, Black, Hispanic, or other race/ethnicity, currently unemployed or disabled, and had smoking and substance use histories, compared with those without. This cohort demonstrated higher odds of elopement (OR: 3.59 [95% CI: 2.41-5.12]), leaving against medical advice (OR: 2.39 [95% CI: 1.46-3.67]), and being subjected to sedation (OR: 3.89 [95% CI: 3.19-4.70]) and restraint use (OR: 3.76 [95% CI: 3.06-4.57]). After adjusting for covariates, the association between incarceration and elopement remained significant (adjusted odds ratio: 1.65 [95% CI: 1.08-2.43]), while associations with other dispositions, restraint use, and sedation did not persist.

Conclusion

This study identified differences in patient characteristics and care processes in the ED for patients with histories of incarceration and demonstrated the potential of using natural language processing in measuring care processes in populations that are largely hidden, but highly prevalent and subject to discrimination, in the health care system.

Talking About Incarceration History: Engaging Patients and Healthcare Providers in Communication

BACKGROUND

Incarcerated individuals in carceral facilities demonstrate an elevated prevalence of chronic disease conditions which are likely to persist post-release. Healthcare providers may not be trained on how exposure to incarceration may influence patient health outcomes and patient-provider communication.

OBJECTIVE

To examine the self-perceived preparedness of healthcare providers to interview patients regarding history of incarceration and the potential related health consequences.

DESIGN

This cross-sectional study consisted of a web-based self-administered questionnaire distributed via email to a random sample of healthcare providers in the Department of Medicine at Brigham and Women's Hospital.

PARTICIPANTS

In total, 400 healthcare providers were invited to participate; 114 respondents completed the survey, of which 26% were medical doctors (n=30), 41% were physician assistants (n=47), and 32% were nurse practitioners (n=37).

MAIN MEASURES

Understanding healthcare provider training in caring for formerly incarcerated patients, current treatment practices and confidence caring for patients who have experienced incarceration, and implications for clinical care.

KEY RESULTS

Of 114 respondents, 73% reported that they currently care for formerly incarcerated patients. However, only 8% received specialized training for the care of formerly incarcerated patients. While most respondents did not ask their patients about prior history of incarceration (81%), when asked about comfortability in doing so, 60% reported low levels of comfort. Most providers (77%) reported high agreement that incarceration impacted health, with 54% reporting that it led to significant healthcare access barriers, but 64% reported low confidence levels in addressing the needs of formerly incarcerated patients.

CONCLUSIONS

Healthcare workers recognized incarceration as a detrimental health exposure. However, providers reported low levels of confidence in understanding and addressing the unique needs of patients who experienced incarceration. Findings support the need for further training regarding how to address the needs of formerly incarcerated patients, which would support efforts towards achieving equitable healthcare.

The association between age and functional disability in US adults with lifetime exposure to the criminal legal system, 2015-2019

IMPORTANCE

As the global population ages, the proportion of individuals living with functional disability is increasing. Evidence suggests that functional disability is associated with worse health outcomes and is concentrated in populations with high rates of concurrent social risk factors such as criminal legal involvement (CLI), making it an increasingly important issue for advocates of health equity.

OBJECTIVE

To determine whether age is associated with functional disability in a nationally representative sample of United States adults with lifetime exposure to the criminal legal system.

DESIGN

Cross-sectional survey data from the National Survey of Drug Use and Health, 2015-2019.

SETTING

Nationally representative survey data.

PARTICIPANTS

US adults who reported lifetime history of arrest (N = 37,279).

EXPOSURE

Respondents were categorized into age groups: younger adults (age 18-49); middle-aged adults (age 50-64); and older adults (age ≥ 65).

MAIN OUTCOME MEASURE

Functional disability as measure by the World Health Organization Disability Assessment Score 2.0 (WHO-DAS 2.0). A higher score indicates a greater degree of functional disability.

RESULTS

The sample included 37,279 US adults with lifetime CLI of whom 60.0 % were younger adults, 28.5 % were middle-aged adults, and 11.5 % were older adults. The mean, unadjusted functional disability score for younger adults was 5.0 (95 % CI, 4.9, 5.1); for middle-aged adults it was 4.2 (95 % CI, 4.0, 4.4); and for older adults it was 3.2 (95 % CI, 2.9, 3.5). In models adjusted for sociodemographic and clinical confounders, differences were attenuated but remained statistically significant, indicating increased functional disability in the younger age groups.

CONCLUSION AND RELEVANCE

Our findings suggest that among adults with CLI, functional disability is distributed by age in a pattern distinct from the general population. A large number of young adults have CLI, and the findings suggest that prevalence of functional disability is exceedingly high in this marginalized group. Future studies should examine if substance use and mental health conditions contribute to these findings, and policy makers should examine if flexible interventions tailored to the needs of those with disability improve reentry outcomes for young adults with CLI.

Family Incarceration and Mental Health Among 101,417 Affected Families: A Systematic Review and Multilevel Meta-Analysis

Most if not all previous evidence focused primarily on psychological disorders of prisoners/ex-prisoners, whereas the secondary trauma symptoms across the whole family await clarification. The present systematic review and meta-analysis aimed to investigate the associations between exposure to family incarceration and psychiatric symptoms and moderators of the associations. This systemic review and meta-analysis followed PRISMA guidelines (CRD42023495095). Studies on the mental health of family incarceration from inception to March 4th, 2024 were searched in PsycINFO, PubMed, and Medline. Methodological quality was assessed. Meta-analysis of correlation coefficients r with the random-effects model was performed using "metafor" package in R. Fifty-three studies (34 non-duplicate samples, 2005-2024) with 101,417 people experiencing family incarceration across eight countries were included in the final synthesis. Participants aged 2 to 99 years. Most (96.23%) were conducted in high-income countries (i.e., Australia, Finland, Ireland, Sweden, the US, and the UK), with 3.77% in Mexico and Poland. Over half were longitudinal studies with follow-up periods from 2 to 53 years. Exposure to family incarceration was positively associated with psychiatric symptoms. Stronger effect sizes were found between incarceration and substance abuse disorder and externalizing disorders. Incarceration relates to secondary trauma symptoms in the long run among the affected families especially for children, African Americans in the US, and middle-income countries. Family-based intervention should be made to target the whole family with priorities on substance abuse disorder and externalizing disorders.

Implementation of carceral medicaid suspension and enrollment programs: perspectives of carceral and medicaid leaders

BACKGROUND

Medicaid expansion via the Affordable Care Act, more recent legislation and Medicaid 1115 waivers offer opportunity to increase health care access among individuals involved in the carceral system. Effective enrollment of new beneficiaries and temporary suspension and reactivation of existing Medicaid benefits upon release is key to the success of these efforts. This study aims to characterize how jails, prisons and Medicaid agencies are implementing Medicaid suspension and enrollment programs and identifies barriers and facilitators to implementation.

METHODS

We conducted 19 semi-structured interviews with 36 multi-state leaders in carceral facilities, Medicaid agencies, local health departments and national policy experts from 2020 to 2021. Interviews covered 4 domains: (1) the role of policy in influencing carceral and reentry Medicaid practices, (2) implementation strategies to suspend and enroll incarcerated individuals into Medicaid, (3) barriers and facilitators to successful implementation, and (4) variation in implementation between jails and prisons.

RESULTS

Participants identified logistical challenges with suspension and enrollment, including limited infrastructure for data sharing between carceral facilities and Medicaid agencies, burdensome bureaucratic requirements, and challenges with Medicaid renewal, particularly in the jail environment. They offered opportunities to overcome barriers, such as the creation of specialized incarcerated Medicaid benefit categories and provision of in-reach services via managed care organizations. Participants also called for improvements to Medicaid reactivation processes, as even when facilities successfully suspended benefits, individuals faced significant challenges and delays reactivating benefits upon release. Participants also called for further loosening of the Medicaid Inmate Exclusion Policy.

DISCUSSION

Findings highlight the need to update data sharing infrastructure, which will be critical to the implementation of the 1115 waivers, as carceral facilities will be subject to Medicaid billing and reporting requirements. In addition to investing in the ability to newly enroll and suspend Medicaid benefits, attention towards improving timely reactivation practices is needed, particularly given the highly elevated risk of mortality immediately after release. Participants calls for further reforms to the Medicaid Inmate Exclusion Policy are consistent with proposed legislation.

CONCLUSIONS

Findings can critically inform the successful implementation of Medicaid-based reforms to improve the health of incarcerated and formerly incarcerated people.

Barriers and Facilitators to Quality Healthcare for African Americans with Incarceration Histories

BACKGROUND

Prior research has shown that African American men and women are more likely to receive lower quality healthcare compared to their white counterparts, which is exacerbated in jail and prison healthcare systems.

OBJECTIVE

The purpose of this study is to explore barriers and facilitators to quality healthcare among African American men and women released from Illinois State Prisons or Cook County Jail by examining their opinions and experiences with overall healthcare and cancer screening during and after incarceration.

DESIGN

Four focus groups (n = 25 "co-researchers") were conducted to understand how formerly incarcerated African American men and women perceive and describe their experience of accessing, understanding, and utilizing healthcare during and after incarceration. Co-researchers' reports on healthcare during incarceration are retrospective.

KEY RESULTS

Multiple facilitators and barriers to accessing healthcare were described. Unique themes from during incarceration included lack of access to adequate and appropriate healthcare, lack of trustworthiness of healthcare systems, excessive and punitive co-pays for questionable and inadequate healthcare, responses to inappropriate or inadequate healthcare motivated by negative attitudes, and actions by correctional staff or healthcare professionals which dis-incentivized medical help-seeking, and gaps in knowledge and understanding about cancer screening and chronic health conditions. Post-release themes included strong motivations to access and routinely utilize healthcare systems, the ability to prioritize health, increased access to healthcare and healthcare systems (though this required structural assistance), good or better-quality healthcare, and on-going support, knowledge, and positive interactions with healthcare professionals.

CONCLUSIONS

This study highlights the need to address barriers to accessing healthcare during and after incarceration, particularly given racial disparities in healthcare treatment and outcomes.

Criminal legal penalties, substance use, and overdose: a concept mapping study examining Colorado's criminal legal penalties

BACKGROUND

In the USA, many states, including Colorado, have increased criminal penalties for illicit opioid possession, which may alter overdose risk. We aimed to evaluate the relationship between Colorado's increased drug-related criminal legal penalties, risk of overdose, and substance use patterns.

METHODS

We used concept mapping - a mixed-methods approach used to develop a conceptual understanding of an issue from a community lens - to engage with people with living and/or lived experience with the criminal legal system, substance use, and/or overdose, their loved ones, and service providers. In facilitated discussion, we used the prompt: "Do you see overdose and substance use, in Colorado, being impacted by an individual's involvement with the criminal legal system?" Participants - recruited from community-based organizations - identified, rated, sorted, and categorized factors affecting criminal legal involvement, substance use, and/or overdose in their community. We used groupwisdom to develop concept maps and to analyze findings.

RESULTS

Twenty-four individuals (ages 18-70) participated; most had living and/or lived experience. Participants identified 100 distinct factors, which were sorted into 9 clusters: societal impacts of criminal legal involvement, lifesaving benefits to decreased criminal legal penalties, environmental barriers of criminal legal involvement, structural barriers to recovery services, essential culturally aware community-based services, strategic allocation of funding, strategies to improve law enforcement's impact, changing policies to keep law enforcement accountable and better educate law enforcement on community culture, and community issues with law enforcement to prioritize. Of the 40 most influential and common factors, most related to structural impacts of criminal legal involvement and barriers to recovery (e.g., long waitlists, job loss).

CONCLUSIONS

Using concept mapping, we worked with community members to identify and prioritize factors associated with substance use and overdose amidst increasing drug-related criminal legal penalties. These insights (e.g., law enforcement's role should be acting as a bridge to mental health and recovery services) are critical for policymakers and service providers, as they speak to the need for investing in re-entry services, harm reduction services, and co-responder models for behavioral health crises.

Duration in Immigration Detention and Health Harms

Importance

Length of custody is a mechanism by which carceral systems can worsen health. However, there are fewer studies examining US immigration detention, in large part because US immigration detention is largely privately operated and opaque by design.

Objectives

To examine the association between duration spent in US immigration detention with subsequent health outcomes.

Design, Setting, and Participants

This cross-sectional study used a referral sample of recently detained immigrants who were released from Immigrations and Customs Enforcement (ICE) under a series of court orders in 2020 and 2021. Data were analyzed from June 2023 to October 2024.

Exposure

Detention duration less than 6 months vs 6 months or longer.

Main Outcomes and Measures

We used multivariable regression analysis to assess the association of detention duration and several variables: (1) self-rated health, (2) mental illness (Kessler 6-item psychological distress scale), and (3) posttraumatic stress disorder (PTSD) (Primary Care-PTSD-5 Screen). We then calculated the likelihood of experiencing each outcome, controlling for covariates. As a robustness check, we conducted sensitivity analyses with detention duration as a continuous measure.

Results

The study included 200 respondents (mean [SD] age, 40.3 [10.1] years; 175 male [87.5%]; 149 Hispanic or Latino ethnicity [74.5%]). Results revealed a high prevalence of poor self-rated health, mental illness, and PTSD for all respondents, but especially among those who had been detained for 6 months or longer, who had significantly higher likelihood of poor or fair self-rated health (49.1% [95% CI, 40.5%-57.6%] vs 30.4% [95% CI, 21.8%-39.1%]; P < .001), mental illness (37.0% [95% CI, 28.2%-45.8%] vs 20.7% [95% CI, 12.6%-28.7%]; P < .001), and PTSD (59.3% [95% CI, 50.3%-68.3%] vs 34.8% [95% CI, 25.3%-44.3%]; P < .001). Sensitivity analysis confirmed the general robustness of these findings, with longer detention duration significantly associated with mental illness (OR, 1.11 [95% CI, 1.02-1.20]; P = .01) and PTSD (OR, 1.11 [95% CI, 1.03-1.20]; P = .005) in our adjusted models.

Conclusions and Relevance

In this cross-sectional study, detained immigrants experienced a high prevalence of poor health, mental illness, and PTSD, with detention periods of 6 months or more associated with higher rates compared with those detained less than 6 months. Duration of custody is one mechanism by which immigration detention might be a catalyst for worsening health.

"See Me as Human:" Reflections on an Experiential Curriculum Led by People With Lived Experience of Incarceration

Improving physical and mental healthcare delivery to incarcerated patients and people with carceral histories provides an opportunity to improve health equity more broadly. This article provides a medical curriculum perspective led by the firsthand narratives of two women with lived expertise of incarceration in collaboration with interdisciplinary health professions students and faculty. Together we state that recognizing the humanity of individuals with carceral involvement precedes the ability to provide ethical or equitable healthcare: this humanity begins with students and the community sharing places and spaces together. We herein detail our experiences in honoring community educators with lived expertise of incarceration while pioneering a grant-funded, interdisciplinary medical education event offering early exposure to experiential learning in hopes of preparing future clinicians to transcend the status quo of substandard care through individual-level and systems-level advocacy. By sharing humanity and building relationships directly with community experts, we endeavor to offer future clinicians the relational framework to inform their advocacy efforts to improve healthcare systems from the bottom up throughout their clinical training and lifelong careers. Most importantly, we highlight the reasons why we believe medical curricula aiming to dismantle inequities facing people with carceral histories must be taught alongside those with lived expertise.

Addressing Barriers to Implementing and Scaling PrEP in Carceral Settings: Applying Insights From Implementation Science

INTRODUCTION

Within the United States, individuals experiencing incarceration are at higher risk for HIV acquisition than the general population, yet may face additional difficulty engaging in HIV prevention clinical services. HIV preexposure prophylaxis (PrEP) is an effective approach to preventing HIV transmission, and the Centers for Disease Control recommends that PrEP be offered in carceral settings, particularly during the vulnerable community reentry period. However, there have been few efforts to scale PrEP in this setting.

METHODS

Based on our experience implementing PrEP in Rhode Island's state carceral system, we have identified potential approaches to overcoming barriers to PrEP use in this unique practice environment by using the implementation research logic model. We then evaluated specific implementation determinants and barriers as well as strategies used to overcome those barriers to effectively scale PrEP in this setting.

RESULTS

We developed a "toolkit," or 14-step guide, for others in the field to use for implementing PrEP in carceral settings, including the development and use of clinical protocols and community linkage strategies.

DISCUSSION

Our experiences with barriers in the carceral setting, identifying and leveraging implementation strategies, allowed us to develop a "toolkit" to guide other PrEP implementation projects in carceral settings. We encourage others to scale-out our work to other carceral settings to better reach and engage a group of individuals both at elevated risk for HIV and currently underserved by HIV prevention strategies, including PrEP.

Racial Differences in Medications for Opioid Use Disorder Initiation in a Carceral Setting

BACKGROUND

The opioid overdose crisis significantly affects marginalized communities, with people of color experiencing higher rates of overdose and barriers to treatment. The syndemic of opioid use disorder and mass incarceration exacerbates racial health disparities. Some carceral facilities offer medication for addiction treatment, though no significant research explores differences in type of treatment uptake by race in these settings. This study focuses on the racial differences in medications for opioid use disorder (MOUD) preferences among incarcerated individuals.

METHODS

A retrospective cohort study was conducted at the Rhode Island Department of Corrections (RIDOC), examining MOUD-type preferences (buprenorphine or methadone) among incarcerated individuals. The study utilized RIDOC electronic medical records from January 1, 2017 to December 31, 2022, involving 3533 unique incarceration events. Participants were categorized by race (White vs non-White) and MOUD status (new initiation vs community continuation), with logistic regression models.

RESULTS

The study found no direct racial disparity in preferences for MOUD type. However, an interaction between race and MOUD initiation status significantly influenced MOUD-type preference. Among those initiating MOUD during incarceration, non-White individuals were more likely to choose buprenorphine compared to their White counterparts.

CONCLUSIONS

This research provides new insights into the intersection of race, incarceration, and MOUD preferences. While direct racial disparities in MOUD type were not observed, the analysis uncovered a notable interaction effect: race influences the relationship between MOUD initiation status and the selected MOUD treatment during incarceration. Specifically, data demonstrate that the likelihood of choosing buprenorphine varies significantly based on both racial background and whether the treatment was initiated during incarceration or in the community. Further research is needed in different geographic settings to understand the broader implications to help guide equitable healthcare delivery in jails and prisons.

Men's influence of maternal substance use before, during, and after pregnancy: A qualitative study of men with criminal-legal involvement

BACKGROUND

While the adverse effects of substance use during pregnancy are well-established, the impact men with criminal-legal involvement who use substances have on their partner's substance-using behaviors is not well characterized. We aim to understand men's experiences and perspectives about how their substance use impacts romantic partner substance use in the preconception period, before a potential or actual pregnancy.

METHODS

We conducted semi-structured interviews with men residing in a transition center in the Midwestern US with a substance use disorder (SUD) who partnered with women. Interview questions were informed by the Health Belief Model (HBM) and included questions about perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy in relation to substance use and pregnancy. Participants were asked about desired SUD interventions. Transcripts were analyzed using a modified grounded theory approach.

FINDINGS

Thirty participants were interviewed (mean age=37, SD=10.3). Major themes were mapped onto HBM constructs: (1) Partners did not consider the chance of pregnancy while using together; (2) using together can escalate use before/during pregnancy; (3) quitting can strengthen relationships; (4) lack of preconception health knowledge inhibits quitting; (5) having a pregnant partner may promote quitting; and (6) knowledge of potential negative outcomes increases confidence in quitting.

CONCLUSION

Men in carceral settings face multi-factorial barriers to substance use cessation and have differing perspectives on the impact of their use on their partner in relation to potential or actual pregnancy. Clinicians should consider interpersonal relationship factors that may impede or promote substance use when caring for people with SUD.

"Yeah, this is not going to work for me"-The impact of federal policy restrictions on methadone continuation upon release from jail or prison

INTRODUCTION

Individuals impacted by the criminal-legal system face increased risk of opioid overdose. Medications for opioid use disorder (MOUD) provide a life-saving intervention. Multiple barriers prevent access to MOUD, including federal policies regulating opioid treatment programs (OTPs). This study aims to identify how federal policy affects anticipated barriers to methadone treatment access at a high-risk time for opioid mortality: community re-entry after incarceration.

METHODS

The study used standard qualitative methods to conduct 40 in-depth-interviews with incarcerated individuals enrolled in the Rhode Island Department of Corrections MOUD treatment program. Semi-structured interviews took place between June and August 2018 and focused on participants' experiences with MOUD and anticipated treatment barriers upon re-entry. A deductive coding framework incorporating the SAMHSA "8-point" criteria for take-home methadone as the a priori codebook and additional identified barriers informed further inductive analysis.

RESULTS

Four themes emerged: (1) logistical hurdles such as transportation and clinic location impeded clinic access; (2) punitive measures within clinics, like dose reduction for rule infractions, discouraged treatment continuation; (3) the environment of methadone clinics often tempted return to use; (4) while the structured nature of methadone treatment provided accountability, it also posed challenges. Federal policies, particularly around daily dosing and "take-home" regulations, exacerbated barriers for those re-entering the community. State and clinic level policies, however, were also identified as direct or exacerbating barriers to treatment access.

CONCLUSION

Significant hurdles persist for methadone access among individuals released from incarceration. Though the federal 8-point criteria have now been replaced with more flexible take-home policies, our findings highlight critical treatment barriers for individuals during the high-risk period of community re-entry. State and clinic level policies also exacerbate many of the barrier-driven themes identified in this analysis. Future work can explore how to best implement the identified benefits of a structured program without forcing the punitive measures that discourage treatment retention. Additional policy reform can help mitigate the effects of other social determinants of health (including transportation access). Ultimately, the many barriers to community methadone treatment retention also apply to individuals involved in the criminal legal system; they can be exacerbated at the federal, state, and clinic policy level.

Disparities in the Prevalence of Urinary Diseases Among Prisoners in Taiwan: Population-Based Cross-Sectional Study

BACKGROUND

Prisoner health is a major global concern, with prisoners often facing limited access to health care and enduring chronic diseases, infectious diseases, and poor mental health due to unsafe prison environments, unhygienic living conditions, and inadequate medical resources. In Taiwan, prison health is increasingly an issue, particularly concerning urinary diseases such as urinary tract infections. Limited access to health care and unsanitary conditions exacerbate these problems. Urinary disease epidemiology varies by sex and age, yet studies in Asia are scarce, and comprehensive data on urinary diseases in Taiwanese prisons remain limited.

OBJECTIVE

This study aimed to investigate the prevalence of urinary diseases among Taiwanese prisoners and explore the differences in disease prevalence between men and women, as well as across different age groups.

METHODS

This study used data on prisoners from the National Health Insurance Research Database covering the period from January 1 to December 31, 2013. Prisoners covered by National Health Insurance who were diagnosed with urinary diseases, identified by ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes 580-599 based on their medical records, and had more than one medical visit to ambulatory care or inpatient services were included. Sex- and age-stratified analyses were conducted to determine the differences in the prevalence of urinary diseases.

RESULTS

We examined 83,048 prisoners, including 2998 with urinary diseases. The overall prevalence of urinary system diseases among prisoners was 3.61% (n=2998; n=574, 6.64% in men and n=2424, 3.26% in women). The prevalence rate in men was significantly lower than that in women (prevalence ratio: 0.46, P<.001). In age-stratified analysis, the prevalence rate among prisoners aged >40 years was 4.5% (n=1815), compared to 2.77% (n=1183) in prisoners aged ≤40 years. Prisoners aged >40 years had a higher prevalence (prevalence ratio: 1.69, P<.001). Other disorders of the urethra and urinary tract (ICD-9-CM: 599), including urinary tract infection, urinary obstruction, and hematuria, were the most prevalent diseases of the urethra and urinary tract across age and sex groups. Women and older prisoners had a higher prevalence of most urinary tract diseases. There were no significant sex-specific differences in adjusted prevalence ratios for acute glomerulonephritis, nephrotic syndrome, kidney infections, urethritis (nonsexually transmitted), or urethral syndrome. However, based on the age-specific adjusted prevalence ratio analysis, cystitis was more prevalent among younger prisoners (prevalence ratio: 0.69, P=.004).

CONCLUSIONS

Urinary system infections and inflammation are common in prisons. Our findings advocate for policy reforms aimed at improving health care accessibility in prisons, with a particular focus on the needs of high-risk groups such as women and older prisoners. Further research linking claims data with prisoner information is crucial to providing more comprehensive medical services and achieving health equity.

Dignity restored: the power of treatment first

The perspective article explores systemic issues in psychiatric care, particularly the barriers to timely treatment and the ethical dilemmas involved in involuntary interventions. It further examines the impact of anosognosia-lack of disease insight-on treatment, noting the difficulties in managing care for those unaware of their illness, and scrutinizes training materials from international organizations that might mislabel necessary psychiatric practices as human rights violations, thereby complicating the care landscape. The discussion extends to the legal and societal implications of psychiatric interventions, using Massachusetts' Rogers Guardianship as a case study to highlight the consequences of legalistic approaches to mental health treatment.The article calls for destigmatizing psychiatric treatment and integrating robust, evidence-based practices to improve patient outcomes and healthcare equity. The global mental health policy landscape is urged to recognize the critical role of psychiatric care in restoring health and dignity to individuals with serious mental illnesses, advocating for a more nuanced understanding and application of human rights in mental health.

The Rhode Island transitions clinic: connections to social and healthcare services after release from incarceration

BACKGROUND

After release from incarceration, individuals are rarely connected to primary care or to social services despite bearing a disproportionate burden of poor health (e.g., chronic illness) and structural determinants of health (e.g., housing instability). The Rhode Island Transitions Clinic (RITC) works to fill this gap, particularly for patients with complex needs, by linking individuals to primary care and social services. However, prior work has not formally assessed how successful the TCN is at connecting patients to social services. Our objective was to assess the relationship between RITC and connections to healthcare use and services addressing structural determinants of health.

METHODS

This retrospective cohort study utilizes data among those released from the Rhode Island Department of Corrections (RIDOC) from 2018-2020. These data were linked with state agency data (e.g., unemployment, Medicaid medical claims, housing and homelessness services). We estimated 6-month risk differences (RDs) of each outcome, using stabilized inverse probability weights to account for censoring and confounding.

RESULTS

Of 8,694 individuals, the 68 enrolled in RITC are, on average, older, more likely to be Black, and have had more incarcerations. The RITC was associated with higher likelihood of connection to housing and homelessness services (RD: 0.29; 95% CI: 0.17, 0.41), (re)instatement of Supplemental Security Income (RD: 0.17, 95% CI: 0.06, 0.28), Emergency Department (RD: 0.29; 95% CI: 0.17, 0.41), and primary care visits (RD: 0.32; 95% CI: 0.21, 0.43), and lower likelihood of receiving taxable wages (RD: -0.05; 95% CI: -0.14, 0.05) compared to not being in RITC within six-months of release.

CONCLUSIONS

RITC patients have complex healthcare and social service needs. The RITC is an innovative approach that is successful at connecting its patients to primary care and social services.

Addressing Racial and Ethnic Inequities in Opioid Overdose Mortality: Strategies for Equitable Interventions and Structural Change

PURPOSE OF REVIEW

This review synthetizes findings reflecting the increasing racial and ethnic inequities in opioid overdose mortality and emphasizes the necessity for tailored interventions as well as other policy-level and structural strategies to stem this trend.

RECENT FINDINGS

Factors contributing to inequities in overdose mortality include changes in drug supply, persistent social-structural vulnerabilities stemming from structural racism, and inequities in access to medication for opioid use disorder and harm reduction services. Key strategies to address these inequities include the cultural adaptation of evidence-based interventions within an equity-based framework, integrating social determinants of health into addiction treatment, centering anti-racism praxis in addiction research, diversifying the addiction workforce, and integrating structural competency as a tool to restructure education and inform practice. Structural racism must be recognized as a key driver of inequities in substance use outcomes, and this understanding must be integrated into existing models of substance use disorder prevention, treatment, and research.

A Proposal for a Best-evidence Model of Care and Program Logic for Supported Accommodation for People Released From Prison

This paper describes the development of a proposed best-evidence model of care (MoC) and program logic (PL) for supported accommodation (SA) for people released from prison. Evidence from a systematic review, interviews with clients of SA, and consultation with service providers were synthesized to develop a draft MoC that was embedded into a PL. The MoC and PL were refined in a workshop with researchers and SA providers. The MoC comprised five best-evidence core components to be standardized across any SA, operationalized by flexible activities that need to be determined by services to suit their circumstances. The PL comprised client needs that the program targets, a rationale for why core components would be effective and appropriate process and outcome measures. The development and uptake of a best-evidence MoC and clearly defined PL will help engender a larger and more rigorous SA evidence-base, and improve outcomes for people released from prison.

Pediatric Health and System Impacts of Mass Incarceration, 2009-2020: A Matched Cohort Study

OBJECTIVE

The US has the highest incarceration rate in the world; incarceration's direct and indirect toll on the health and health care use of youth is rarely investigated. We sought to compare the health of youth with known personal or family justice involvement and a matched cohort of youth without known personal/family justice involvement.

METHODS

A cross-sectional matched parallel cohort study was conducted. We queried electronic health records on youth (<21 years) with a visit in a large Midwestern pediatric hospital-based institution from January 2009 to December 2020. Youth were located by searching for justice-related (eg, prison, jail) keywords within all clinician notes. Health diagnostic profiles were measured using ICD 9/10 codes. Health care use included total admissions, inpatient days, emergent and urgent visits, and outpatient visits.

RESULTS

Across all youth at one institution over an 11-year period, 2.2% (N = 38,263) were identified as having probable personal or family justice-involvement. Youth with personal or familial justice involvement had 1.5-16.2 times the prevalence of mental health and physical health diagnoses across all domain groupings compared to a matched sample and the total population sample. From 2009-2020, approximately two-thirds of behavioral health care and nearly a quarter of all hospital inpatient days were attributed to the 2.2% of youth with probable personal or familial justice system involvement.

CONCLUSION

The study illuminates the vast disparities between youth with indirect or direct contact with the criminal legal system and matched youth with no documented contact. Better investment in monitoring and prevention efforts are needed.

A Tale of 2 Experiences: Navigating End-of-Life Care With a History of Incarceration

BACKGROUND

The adverse health effects of incarceration are well-documented, affecting individuals throughout their life course. However, the influence of a history of incarceration on end-of-life (EOL) experiences remains unexplored. This study aims to examine how prior incarceration affects individuals' experiences and care needs as they approach the EOL.

METHODS

Leveraging the Health and Retirement Study, we conducted secondary analyses on 1 710 individuals who participated between 2012 and 2018. Through retrospective cohort analysis, we explored the association between incarceration history and EOL care, focusing on pain and symptom burden.

RESULTS

Analyses showed that individuals with a history of incarceration experienced significantly higher levels of pain (65% reported "moderate" or "severe" pain) compared to nonincarcerated individuals (50%; adjusted odds ratio = 1.45, 95% confidence interval [CI]: 1.22-1.71, p < .001). Additionally, the symptom burden index revealed that formerly incarcerated individuals had a higher average symptom score (2.8 vs 2.1; β = 0.7, 95% CI: 0.5-0.9, p < .001), indicating a greater range of symptoms in their final year of life. These disparities persisted after adjusting for demographic, health, and socioeconomic variables.

CONCLUSIONS

This study reveals that a history of incarceration significantly affects EOL experiences, with formerly incarcerated individuals facing higher levels of pain and a greater symptom burden compared to nonincarcerated individuals. This underscores the need for tailored palliative care to address the unique needs of this vulnerable population. This research highlights a critical area for intervention and calls for healthcare systems to adapt their practices to better serve those with incarceration histories.

Is Discrimination Widespread or Concentrated? Evaluating the Distribution of Anti-Black Discrimination in Judicial, Hiring, and Housing Decisions

Is anti-Black discrimination concentrated among a discriminatory few, or widespread across many decision-makers? The handful of studies that have addressed this question have reached divergent conclusions, with some suggesting that discrimination follows the 80/20 rule (i.e., a Pareto distribution) and others suggesting that discrimination is normally distributed. This paper explores the distribution of discrimination in hiring, housing, and judicial decisions. Study 1 examined the distribution of anti-Black discrimination in judges' repeated sentencing decisions. The distribution of discrimination was more consistent with a normal distribution than a Pareto distribution. In Study 2, meta-analyses of hiring and housing field experiments revealed anti-Black discrimination in more than 80% of studies. Simulations of widespread discrimination using a normal distribution were more consistent with these experimental data than were simulations of concentrated discrimination using a Pareto distribution. These findings suggest that discrimination is not concentrated in the behaviors of a few highly biased individuals.

Primary care need and engagement by people with criminal legal involvement: Descriptive and associational analysis using retrospective data on the entire population ever detained in one southeastern U.S. county jail 2014-2020

More than 7 million people are released each year from U.S. jails or prisons, many with chronic diseases that would benefit from primary care in their returning communities. The objective of this study was to provide an in-depth, payer-agnostic description and associational analysis of primary care need and utilization by all individuals ever detained in one county detention facility over a 7-year period. Detention records 2014-2020 were merged with data from an electronic health record with excellent coverage of local primary care, emergency, and hospital services. We found low primary care participation for the group as a whole, with under three quarters of those with serious chronic diseases ever seeing a primary care provider over a 7-year period and less than half ever having a year with more than one visit. Multivariable regression models estimated associations between individual characteristics (demographic, detention-related, and clinical) and ever having access to primary care (logistic) and the number of primary care visits (zero-inflated negative binomial). We found that having more jail bookings was associated with fewer primary care visits, but not one-time access, even controlling for time out of community, age, insurance, and other demographic characteristics. This finding was driven by subgroups with chronic disease such as hypertension, obstructive lung disease, and diabetes, who most need regular primary care. Being Black retained an independent effect, even controlling for bookings and other variables, and was also associated with fewer primary care visits, though not one-time access. To promote primary care utilization among individuals who have the combined challenges of repeated jail involvement and chronic disease, it is crucial to focus on engagement, as much as formal access. Access to health insurance alone will not resolve the problem; Medicaid expansion should be coupled with specialized, tailored support to promote engagement in primary care.

The Distribution of Carceral Harm: County-Level Jail Incarceration and Mortality by Race, Sex, and Age

Jail incarceration remains an overlooked yet crucial component of the U.S. carceral system. Although a growing literature has examined the mortality costs associated with residing in areas with high levels of incarceration, far less is known about how local jails shape this burden at the intersection of race, sex, and age. In this study, I examine the relationship between county-level jail incarceration and age-specific mortality for non-Hispanic Black and White men and women, uniquely leveraging race-specific jail rates to account for the unequal racial distribution of jail exposures. This study finds evidence of positive associations between mortality and jail incarceration: this association peaks in late adulthood (ages 50-64), when increases in jail rates are associated with roughly 3% increases in mortality across all race-sex groups. However, patterns vary at the intersection of race, sex, and age. In particular, I find more marked and consistent penalties among women than among men. Additionally, a distinctly divergent age pattern emerges among Black men, who face insignificant but negative associations at younger ages but steep penalties at older ages-significantly larger among those aged 65 or older relative to their White male and Black female counterparts. Evidence further suggests that the use of race-neutral incarceration measures in prior work may mask the degree of harm associated with carceral contexts, because the jail rate for the total population underestimates the association between jail rates and mortality across nearly all race-age-sex combinations. These findings highlight the need for future ecological research to differentiate between jail and prison incarceration, consider the demographic distribution of incarceration's harms, and incorporate racialized measures of exposure so that we may better capture the magnitude of harm associated with America's carceral state.

Police officer Perspectives on a Pre-booking Diversion Program for People who use Drugs in Philadelphia

Pre-booking diversion enables police officers to divert individuals to supportive services in lieu of prosecution for minor crimes related to substance use. We surveyed 204 Philadelphia Police Department officers authorized to initiate pre-booking diversions. We used bivariate x2 tests and multivariate logistic regression to examine differences in respondent perspectives. 78% agreed that pre-booking diversion provides important services to people who use drugs, 69% wanted to expand the geographic score of programming, and 52% wanted to expand eligibility. Yet 59% questioned whether diversion is "what police should be doing", and only 27% believed that it will improve public safety. In logistic regression, the perceived value that the police department places on referrals correlated with agreement that PAD improves safety, provides important services for people who use drugs, and fits within officers' role. Tension between beliefs that the program provides important services but may not improve safety reflects both potential value and inherent challenges of pre-booking diversion models.

"You Have to Be a Doctor First": Trauma Surgeons' Perspectives on Police Interactions in the Hospital

BACKGROUND

Police activity in emergency medical settings has been shown to complicate the care of patients and impact patient-provider relationships. Recent scholarship has called for clear hospital policy outlining the terms of police access to patients and the role of clinicians. Despite regular contact between trauma surgeons and police, research on the impact of police activity on trauma care has been limited.

METHODS

Semi-structured interviews were conducted with attending trauma surgeons and general surgery residents (N = 13) at 3 urban hospitals about their interactions with police in clinical settings. Participants were recruited using snowball sampling. Interviews were audio-recorded, transcribed, and analyzed for recurrent themes using an iterative grounded theory process.

RESULTS

Participants reported routine contact with police that required active negotiation of the scope of clinical and police authority in the hospital. These negotiations were shaped by prior experiences, perceptions of police, officer behavior, and institutional culture. Surgeons felt compelled to advocate for patients, but reported intimidation in moments of conflict. Participants noted uncertainty around the legal dimensions of their relationship to police and a lack of universal guidance on appropriate responses.

DISCUSSION

This data points to the need for improvements in both policy and workflow to regulate and reduce the burden of these interactions and protect clinicians' priorities from being subordinated to those of police. Further research is needed to understand how police presence impacts patient outcomes, and to guide best practices for regulating and mitigating potential negative impact.

Carjacking and homicide in Minneapolis after the police killing of George Floyd: Evidence from an interrupted time series analysis

There is abundant research showing the disproportionate impacts of violence on health in disadvantaged neighborhoods, making an understanding of recent violent crime trends essential for promoting health equity. Carjackings have been of particular interest in the media, although little research has been undertaken on this violent crime. We use interrupted time series models to examine the impact of the police killing of George Floyd on the spatiotemporal patterns of carjacking in Minneapolis in relation to neighborhood disadvantage. To provide grounding, we compare our results to the well-studied patterns of homicides. Results indicate that carjackings both increased and dispersed spatially after the murder of George Floyd and subsequent social unrest, more so than homicides. Socially disadvantaged neighborhoods experienced the greatest absolute increase while more advantaged neighborhoods saw a greater relative increase. The challenge ahead is to identify policy responses that will effectively curb such violence without resorting to harsh and inequitable policing and sentencing practices.

The interdependence of caring, safety, and health in correctional settings: Analysis of a survey of security staff in a large county jail system

The health of incarcerated populations is intertwined with the health of security staff, but the social mechanisms, and especially the specific interventions, that might mitigate these health harms are underexplored. We examine one possible mechanism of interrelated health harms: whether and how jail security staff are willing and able to care for mentally ill detainees. We hypothesize that the attitudes of security staff towards care affect the well-being of everyone in a jail setting-staff, as well as detainees. Analyzing 539 anonymous respondent surveys administered to a stratified cluster sample of security staff working in a large U.S. county jail system, we (1) describe the prevalence of a perceived duty to care and availability of caring resources among security staff and (2) analyze whether variations in a duty to care and caring resources predict outcomes associated with staff and detainee well-being. Across five maximum likelihood models estimated, both perceived duty to care and availability of caring resources are significantly associated with collaborative relationships with medical staff, increased perceptions of personal safety, decreased frequency of hostile encounters, and better self-reported health outcomes. Our models explain 20 percent of the variation in self-reported health outcomes (R2 = .20), a meaningful effect of care on security personnel's well-being. Our findings suggest security staff have an often-overlooked duty to care akin to that experienced by healthcare staff. Among healthcare staff, dual loyalty trainings have successfully amplified caring duties relative to security duties; similar trainings for security staff might better leverage their caring duties to improve both staff and detainee well-being.

Decrease in injection and rise in smoking and snorting of heroin and synthetic opioids, 2000-2021

BACKGROUND

Injecting, smoking, and snorting heroin/synthetic opioids is each associated with unique health risks. It is unclear how route of administration (ROA) preferences have shifted during the opioid epidemic.

METHODS

Using 2000-2021 admissions data from SAMHSA TEDS-A, we analyzed trends in heroin/synthetic opioid ROA preferences and factors associated with these preferences.

RESULTS

7,881,318 heroin/synthetic opioid admissions reported injection, smoking, or snorting preference. Nationally, injection peaked in 2014 (69.9 %) and nadired in 2021(52.2 %), snorting nadired in 2014 (24.9 %) and peaked in 2021 (36.4 %), and smoking rose steadily from 2.5 % in 2005 to a peak of 11.4 % in 2021. From 2000-2021, the number of states with ≥10 % smoking rates grew from 2 to 27 (highest: 57.0 % in Arizona in 2021). In 2021, increased adjusted prevalence ratios (APR) of non-injection versus injection use were associated with older age at first opioid use (APR 1.52 [95 % CI: 1.51, 1.54] for those 30+ relative to ≤20), and all race/ethnicities relative to non-Latino White individuals (highest: Black individuals, APR 1.77 [1.75, 1.78]). Geography strongly predicted smoking versus snorting (Mountain APR 6.91 [6.64, 7.19], Pacific APR 6.61 [6.35, 6.88], reference: New England).

CONCLUSIONS

ROA preferences of heroin/synthetic opioids have changed substantially since 2000, with: 1) recent decreases in injection nationally; 2) increased smoking, particularly in the western US; and, 3) recent increased snorting in the eastern US. Smoking is now prevalent and growing. Public health implications include an increasing number of smoking-related fatal overdoses and the probable reduction of injection-specific morbidity and increase in smoking-specific morbidity.

National and state-level trends in the availability of mental health treatment services tailored to individuals ordered to treatment by a court: United States, 2016, 2018, and 2020

PURPOSE

We sought to identify trends and characteristics associated with the availability of tailored mental health services for individuals involved in the criminal justice system and ordered to treatment by a court, nationally in the US and by state.

METHODS

We used National Mental Health Services Survey to identify outpatient mental health treatment facilities in the US (2016 n = 4744; 2018 n = 4626; 2020 n = 4869). We used clustered multiple logistic regression to identify changes over time as well as facility- and state-level factors associated with the availability of specialty court-ordered services.

RESULTS

Slightly more than half of the outpatient mental health treatment facilities offered specialized services for individuals ordered to treatment by a court, with wide variation between states. Nationally, there was a significant increase in the odds of offering court-ordered treatment in 2020 compared to 2016 (aOR = 1.16, 95% CI = 1.06-1.27, p < 0.01). Notable associations included offering integrated substance use treatment (versus none, aOR = 2.95, 95% CI = 2.70-3.22, p < 0.0001) and offering trauma therapy (versus none, aOR = 2.05, 95% CI = 1.85-2.27, p < 0.0001).

CONCLUSION

The availability of mental health services for individuals ordered to treatment by a court is growing nationally but several states are lagging behind. Court ordered treatment is a promising strategy to improve health and reduce reliance on the carceral system as a healthcare provider. At the same time, we express caution around disparities within behavioral health courts and advocate for equity in access to incarceration alternatives.

Medicaid Expansion and Mortality Among Persons Who Were Formerly Incarcerated

Importance

Since 2014, Medicaid expansion has been implemented in many states across the US, increasing health care access among vulnerable populations, including formerly incarcerated people who experience higher mortality rates than the general population.

Objective

To examine population-level association of Medicaid expansion with postrelease mortality from all causes, unintentional drug overdoses, opioid overdoses, polydrug overdoses, suicides, and homicides among formerly incarcerated people in Rhode Island (RI), which expanded Medicaid, compared with North Carolina (NC), which did not expand Medicaid during the study period.

Design, Setting, and Participants

A cohort study was conducted using incarceration release data from January 1, 2009, to December 31, 2018, linked to death records from January 1, 2009, to December 31, 2019, on individuals released from incarceration in RI and NC. Data analysis was performed from August 20, 2022, to February 15, 2024. Participants included those aged 18 years or older who were released from incarceration. Individuals who were temporarily held during ongoing judicial proceedings, died during incarceration, or not released from incarceration during the study period were excluded.

Exposure

Full Medicaid expansion in RI effective January 1, 2014.

Main Outcomes and Measures

Mortality from all causes, unintentional drug overdoses, unintentional opioid and polydrug overdoses, suicides, and homicides.

Results

Between 2009 and 2018, 17 824 individuals were released from RI prisons (mean [SD] age, 38.39 [10.85] years; 31 512 [89.1%] male) and 160 861 were released from NC prisons (mean [SD] age, 38.28 [10.84] years; 209 021 [87.5%] male). Compared with NC, people who were formerly incarcerated in RI experienced a sustained decrease of 72 per 100 000 person-years (95% CI, -108 to -36 per 100 000 person-years) in all-cause mortality per quarter after Medicaid expansion. Similar decreases were observed in RI in drug overdose deaths (-172 per 100 000 person-years per 6 months; 95% CI, -226 to -117 per 100 000 person-years), including opioid and polydrug overdoses, and homicide deaths (-23 per 100 000 person-years per year; 95% CI, -50 to 4 per 100 000 person-years) after Medicaid expansion. Suicide mortality did not change after Medicaid expansion. After Medicaid expansion in RI, non-Hispanic White individuals experienced 3 times greater sustained decreases in all-cause mortality than all racially minoritized individuals combined, while non-Hispanic Black individuals did not experience any substantial benefits. There was no modification by sex. Individuals aged 30 years or older experienced greater all-cause mortality reduction after Medicaid expansion than those younger than 30 years.

Conclusions and Relevance

Medicaid expansion in RI was associated with a decrease in all-cause, overdose, and homicide mortality among formerly incarcerated people. However, these decreases were most observed among White individuals, while racially minoritized individuals received little to no benefits in the studied outcomes.

Perceptions of incarcerated people: prison conditions, public health, and justice in the United States

Carceral conditions in the United States may serve as a proxy for crises within justice and health systems. This study seeks to consider and measure prison climate from the perspective of incarcerated people. By examining within-facility differences in carceral experiences, results shed light on the complex nexus between the carceral context, health, and justice. We administered the Prison Climate Questionnaire (PCQ) to the complete population of incarcerated men in a correctional facility located in the Eastern United States. In this facility, housing units hold distinct populations, fulfill different functions, and can offer unique programming. We regress select items from the PCQ on a set of dummies corresponding to different residential units within the facility. Responses indicate low but relatively uniform perceptions of overall personal health, as well as access to, and satisfaction with, medical care. Between-unit differences emerge regarding staff relationships, experiences of discrimination, and levels of isolation. The perspectives of incarcerated people can, and should, play a role in understanding and conceptualizing the nature of the prison environment. Policy responses, especially those that impact the health and well-being of currently and formerly incarcerated people, can be informed by these perspectives.

Generational and Gender Patterns of Prescription Opioid Misuse Among Black Adults

INTRODUCTION

Opioid-related overdose mortality disproportionally affects Black adults in Kentucky, particularly overdoses associated with prescription opioid misuse (POM). Black adults also face other consequences of POM, such as disparate health and legal outcomes. While several factors effect POM, such as generational factors and gender, these risk factors are understudied among Black adults with a history of POM. Current literature primarily focuses on White individuals who use opioids.

METHOD

The present study qualitatively examined reasons for POM, prescription opioids misused, how prescription opioids are obtained, and initiation of POM among Black adults using thematic analysis. Participants included a sample (n = 39) of Black adults from a southern state, stratified by gender and age across four cohorts: born (1) 1995-2001, (2) 1980-1994, (3) 1970-1979, and (4) 1955-1969.

RESULTS

Results revealed similarities and differences in these themes across age cohorts and gender.

CONCLUSIONS

Implications for findings include the importance of culturally responsive interventions that utilize dual diagnosis treatment and idiographic approaches due to heterogeneous experiences with POM among Black adults.