Learn to take a trauma-informed criminal legal history, tailor your MOUD prescribing to meet the needs of patients impacted by the criminal legal system, and advocate for high-quality care in the carceral system and the community. We’re joined by Dr. Lisa Puglisi, @pugleesa (Yale University)
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Caring for People with Criminal Legal Involvement and SUDs Pearls
It’s critical that we understand the context of the criminal legal system to best care for our patients. A racist and classist system of mass incarceration has been, and continues to be, policy in the US. This system is built on intentional policies to punish substance use and poverty with long periods of incarceration (Wilderman 2017). Even after release, a criminal record imparts continued stigma and barriers to care and life needs (e.g., housing, employment, etc.) that equates to lifelong punishment.
70-100 million people in the US have a criminal record, so all clinicians will see patients with this history. Mass incarceration disproportionately impacts racialized and minoritized people and their families (The Sentencing Project).
There is debate around universal screening for incarceration. Those in favor argue that screening can provide important context to help tailor healthcare and connection to resources to better meet a patient’s needs. Those against screening argue that documenting incarceration in the medical record can lead to the transmission of stigma between healthcare providers, with tangible consequences.
When asking questions about someone’s history of criminal legal involvement, Dr. Puglisi emphasizes the importance of taking a trauma-informed approach. This means putting power back into the patient’s hands by asking permission to talk about their experience and giving context as to why you’re asking these questions. The set-up of the room can be important too; offer to let them sit near the door if it makes them feel more comfortable.
Taking a history on criminal legal involvement is similar to taking a SUD history. Ask questions about the pattern of periods of incarceration and when it started. Were there precipitating events that led to incarceration? (e.g., the onset of mental health conditions, financial difficulties, increasing substance use, etc.)
Key components are:
While exposure to the criminal legal system is undeniably harmful, It’s important to not only focus on the negative but to discuss some of the positives/their accomplishments too. For example, did they have a job they were good at or did they take classes while incarcerated?
While asking why someone was incarcerated is generally not advisable, discussing the sorts of things that get someone incarcerated can be important. Are their episodes of incarceration related to things they do to make money, substance use, untreated mental health conditions, or something else? Focus on ways we can help with those situations.
Only document things that will be helpful to their care going forward. Avoid documenting reasons for incarceration as it can lead to overt stigma. Stigma is transmitted from provider to provider through the medical chart and has tangible negative consequences (e.g., difficulty placing patients in skilled nursing facilities) (Goddu 2018). As a way to continue building trust, be open with patients about what you’re writing, and also, things you’re deciding not to document.
Criminal legal exposure is associated with higher rates of asthma, COPD, cardiovascular disease, HTN, infectious diseases such as HIV (Wilper 2009) HBV & HCV (Weinbaum 2003), sexually transmitted infections, mental health diseases (Fazel 2002), and substance use disorders. Tobacco use disorder is particularly common, with high rates of return to use upon release (Binswanger 2014).
Solitary confinement, also referred to as restrictive or segregated housing, is a form of extreme social isolation often used as a punishment in the criminal legal system. It is inhumane and yet shockingly common, with nearly 20% of those incarcerated having spent time in solitary. (Beck 2015). It is associated with an increased risk of mortality, particularly from suicide or overdose in the weeks following release (Brinkley-Rubinstein, 2019). In Dr. Puglisi’s experience, she often sees more mental health symptoms (e.g., depression, PTSD, etc.) in people with proximal exposure to solitary and this is something we can help treat with medications, behavioral therapy, and support.
In particular, transitioning from incarceration to the community is an incredibly high-risk time (Binswanger 2007). The risk of death during this period is markedly elevated and partially driven by opioid overdose (Larochelle 2019). Transitioning to the community doesn’t mean the consequences of incarceration end. The American Bar Association documents over 40,000 collateral consequences of a conviction ranging from inability to obtain public housing to inability to get professional licenses (National Institute of Justice 2018). These consequences are hyperlocal, meaning they’re different depending on where you are, so it’s critical to engage with community partners that are doing this work.
It’s also important to know that patients have a very passive role while receiving healthcare while incarcerated (e.g., meds are given to you, appointments are made for you), so significant education may be needed even for chronic problems. For instance, those with diabetes diagnosed while incarcerated may have no experience using a glucometer or injecting insulin.
It’s critical to remember that MOUD, particularly methadone and buprenorphine, are life-saving medications that are the gold standard of care for OUD (National Academies of Sciences, Engineering, and Medicine, 2019).
However, access to MOUD for criminal legal involved people remains poor and inconsistent. (Dunn, 2009, Krawczyk 2018). The experience of forced withdrawal from MOUD is extremely stressful (Aronowitz 2016) and can continue to impact treatment preferences regarding MOUD even after release.
Dr. Puglisi emphasizes the importance of understanding a person’s prior experience with MOUD, how this has been impacted by the criminal legal system, and always returning to the principle of treating the person in front of you. A plan that works for them may need to take into account concerns about being forced to stop MOUD while incarcerated. For example, a patient who was forced to rapidly taper from methadone while incarcerated may prefer to avoid methadone upon release because of how uncomfortable their taper experience was.
It’s also critical not to overlook someone’s history of opioid use if they haven’t used while incarcerated. Even if someone doesn’t classically meet current OUD criteria (with use in the last 12 months), if they’ve only had periods of remission while incarcerated or are currently having cravings or concerns about return to use, MOUD MUST be offered! As mentioned above, people released from incarceration are at particularly elevated risk of overdose, at least in part due to loss of tolerance (Binswanger 2007,Larochelle 2019).
For initiation of buprenorphine in someone without recent use, Dr. Puglisi’s approach is low and slow initiation of MOUD given the loss of tolerance. Her expert opinion is to start buprenorphine at 2mg BID with weekly follow-up. Clinicians can uptitrate more quickly with shorter interval follow-ups (telehealth can be helpful here) if they have a history of rapid return to use upon release.
Overdose education is critical as well. The current drug supply is incredibly toxic, with fentanyl and other adulterants incredibly prevalent, but this may not have been the case when the person was incarcerated. Ensure access to naloxone and encourage patients to avoid using substances alone.
Some brief definitions:
Probation – an alternative to incarceration in which someone is placed under community supervision.
Parole – after completion of a period of incarceration, an extension of a sentence through a form of community supervision. Parole is more strict than probation.
In both instances of community supervision, even small violations (including drug or alcohol use) can lead to revocation of community supervision and immediate incarceration (Human Rights Watch, 2020).
With permission, probation/parole is an opportunity to advocate for your patient, particularly in the setting of substance use. Substance use is one of the most frequent reasons for revocation of parole/probation (Human Rights Watch, 2020). Informing the officer that the patient is engaging in treatment may help!
It’s worth acknowledging that for someone currently in custody in the hospital, the officer at their bedside is a stranger in their room overhearing and seeing all of their medical care. It should be the standard of care to ask the officer to leave the room when discussing medical care or doing a physical exam. Persons in custody are still protected by HIPAA and for discussion/treatment of substance use disorders, even more strict disclosure rules are applicable (Haber 2019). There are some rare HIPPA exceptions to hospitalized individuals in custody such as disclosing information if necessary for the health and safety of the patient or others at the correctional institution. Exceptions are described in this article: Haber 2019.
As Dr. Puglisi notes, it’s worth going in with the mindset that the officer in the room is a person doing their job. She often starts with some chit-chat with the officer and patient, to ease a bit of tension. Then she transitions to letting the officer know that HIPAA-protected medical care will be conducted and asks the officer to leave the room.
Shackling while in the hospital should also be addressed. There are real health risks of shackling (e.g., reduced mobility, difficulty with positioning during a seizure, etc.) and it is within our scope to request that they are removed (ideal), or at least minimized (Haber 2019). The hospital is a difficult enough place for people and particularly people who use drugs. Ensuring patient safety, comfort, and privacy are important steps in creating a more healing environment.
It’s important to understand where the patient will be discharged to (e.g., jail, prison, police lockup, getting bailed out, etc.) and how long they’ll be there. This is particularly true in the setting of treatment with MOUD as medications may not be available in all discharge locations. For instance, if methadone isn’t available where they’re going, uptitrating it isn’t a feasible treatment plan. The officer may be a resource to know what forms of MOUD are available where the patient is going, but patient privacy rules apply, and it is best practice to ask the patient if it is okay to ask the officer these questions. If they’re being treated with buprenorphine and that isn’t available, consider using XR-buprenorphine, 1-month injectable form, prior to discharge.
Lastly, it’s our responsibility to communicate with the carceral health system to ensure management of the patient’s health conditions continues just as it would be with any other transfer of medical care. As Dr. Puglisi notes, we should be reaching out to the carceral health system to ensure the best possible care for the patient.
Listeners will become comfortable with the unique elements of history-taking, care, and advocacy for patients with criminal legal involvement
After listening to this episode listeners will…
Dr. Puglisi reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Cohen SM, Puglisi L, Leyde S, Chan, CA. “#17 Caring for People with Criminal Legal Involvement and SUDs with Dr. Lisa Puglisi”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/episode-list August 10, 2023.
Producer, writer, show notes, infographic, cover art: Shawn Cohen MD
Hosts: Carolyn Chan, MD and Shawn Cohen MD
Reviewer: Sarah Leyde MD
Showrunner: Carolyn Chan, MD
Technical Production: Podpaste
Guest: Lisa Puglisi MD
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