#158 Medicine and Incarceration

July 1, 2019 | By Nora Taranto

Jails, Prisons, and their Effect on Public Health and Health Disparities

Expand your knowledge about how–and how well–we manage patient’s health during incarceration in the United States, with the expert knowledge of correctional health experts Drs. Aaron Fox @adfoxmd, Jon Giftos @JonGiftosMD, and Emily Wang @ewang422. Correctional medicine is a black box for many providers who do not work in prison and jail settings. But it’s ever more relevant to primary care physicians everywhere, with increasing rates of incarceration the last decade.  In this episode, recorded live at SGIM 2019 #SGIM19, Dr. Fox, Dr. Giftos, and Dr. Wang talk us through the variability of the correctional healthcare systems throughout the country, the challenges to health for patients both while incarcerated and in the transition after release, and some essential nuts and bolts for providers about how to provide better care to this vulnerable population.  

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Credits

• Written and produced by: Justin Berk MD MPH MBA, Nora Taranto MD
• Cover Image: Beth Garbitelli MS2
• Infographic: Beth Garbitelli MS2
• Hosts: Matthew Watto MD, Paul Williams MD, Justin Berk MD MPH MBA
• Edited by: Matthew Watto MD
• Guests: Aaron Fox MD, Jon Giftos MD, Emily Wang MD MAS

Sponsor

This episodes was recorded LIVE at #SGIM19 in Washington DC! Join the Society for General Internal Medicine today!

Time Stamps

• 00:00 Intro, disclaimer and guest bios
• 05:10 One liners, book recommendations, career advice
• 13:00 Why does incarceration matter for healthcare?; Defining terms: jail, prison, probation
• 18:47 What is healthcare like during incarceration? What services are available? Who provides the care? How does it breed “passive patients”?
• 21:10 HIV in incarcerated patients
• 27:02 Opioid use disorder in prisons -MAT is rarely available
• 31:44 Prison is a toxic environment —exposure to solitary confinement, PTSD, self harm
• 34:23 How to ask about incarceration
• 36:49 Trauma informed care and the unique challenges to providing patient care after release from prison
• 43:22 Systemic barriers after release from jail or prison e.g. lifetime ban from public housing or food stamps
• 44:45 Discharge planning and transitioning care after release from prison; community health workers
• 51:32 Resources for learning more and advocacy —AAJH, The Fortune Society, Just Health, Dr Wang’s research —why you should visit and learn more about the correctional settings in your locale
• 57:20 Outro

Medicine and Incarceration Pearls 

Healthcare delivery in jails and prisons is heterogeneous across the United States. 

Correctional health systems are often not well incorporated into larger state healthcare institutions, making transitions of care for patients being released from prison or jail all the harder. (Read: No EHR, folks!) 

Patients in jails and prisons suffer from the same chronic health conditions as patients who are not incarcerated. They will often be newly diagnosed with these conditions when they enter the correctional setting (due to lack of access before). 

The majority of patients are getting treated for health conditions in prison. Adherence to treatment regimens is quite high. BUT, transitions out of incarceration can be difficult. 

One giant missing piece in routine care is the obvious lack of treatment for opioid use disorder in most state prisons and jails.

Upon release, individuals are at a >100x risk of opiate overdose (Binswinger et al. 2007). 

Treatment for OUD in jails / prisons is associated with a 60% decrease in mortality upon discharge (Green et al. 2018).

Being incarcerated, and particularly being placed in solitary confinement, is toxic to health.

Taking care of these patients require knowledge of trauma-informed care in order to maintain longitudinal relationships to address health needs.

The Transition Clinic Network is a model working to address the health needs of patients recently incarcerated.

Medicine and Incarceration Show Notes

First, a few definitions of “correctional control”

Jail: The detainment institution to which you go after arrest–once charged and if you cannot afford bail–but generally before sentencing. You can be detained there, or can serve a short sentence (<1 year). For example: in NYC, median length of stay is around 2 weeks. There is high turnover here.

Prison: Once convicted of a felony, a person will generally be sent to prison to serve out a sentence. Most individuals in prisons in the United States are in state prisons, not federal.

Parole: An extension of a prison sentence in the community, under the supervision of a parole officer

Probation: Instead of incarceration in jail or prison, an individual is placed under community supervision of some sort. The similarity between parole and probation: both are high-risk if an individual has a substance use disorder, and both can lead very quickly, if an individual’s life becomes chaotic, to placement in jail or prison. 

Background on Incarceration

The United States incarcerates more people than any other country in the world. In the past 3 decades, the rates of incarceration has increased despite a decrease in violence. Racial minorities are disproportionately affected. Example: 1 in 3 lifetime risk of being in prison for black males (Wang et al. 2017). Women are the fasting growing population behind bars. 

What does the prison system have to do with healthcare? 

Experiences interacting with the correctional system are overwhelmingly common in many patient populations. 

Every chronic health condition is common, or even overrepresented, in jail and prison. HIV and Hepatitis C are three to five times more common in the incarcerated population (Dolan et al. 2016) Almost ⅔ of the jailed population meet criteria for having a substance use disorder. 

Exposure to the criminal justice system is toxic and contributes to health problems through violence, social isolation, and trauma it can inflict upon incarcerated and formerly-incarcerated individuals (Wang et al. 2017).

What does the correctional health model look like?

There is a constitutional right to healthcare (Estelle v. Gamble; Brown v. Plata) , so there will be healthcare delivered across the country–but it can vary dramatically in quality. These systems are generally quite isolated from community healthcare delivery. 

Correctional health systems vary widely across municipalities because they are municipally and regionally funded. Many determinations of what services are offered are driven by litigation about denial of services. (Example: some parts of the country may not screen for HCV as the systems may not have the funding to treat the condition they have diagnosed.)

Dr. Giftos highlights a Case Study: In New York City, the city public hospital system provides healthcare delivery in the prison system. This allows for better incorporation into the statewide medicaid system, including regarding the electronic medical record (the lack of EMR–and even internet access–in many other correctional settings can be a huge problem for transitioning individuals to outside clinics) 

There’s generally no billing of insurance by correctional systems so there is less oversight and regulation than there would be out in the community. 

The Passive Patient

Healthcare delivery in prisons does not require individuals to engage with their health in the same way as receiving care in the community requires patient activation. Incarcerated individuals are taken to the pill line, told exactly what to do and take, and observed doing it in the moment by nurses and correctional officers. Adherence is very high, but their involvement is incredibly passive.  

What are we treating in correctional settings? 

Epidemiology: The incarcerated population has high rates of substance use disorder, chronic infectious diseases (e.g. HIV and Hepatitis C), and mental health disorders, as well as all other chronic diseases including diabetes, hypertension, and cardiovascular disease (Dolan et al. 2016).

Statistics from the Bureau of Justice suggest the majority of individuals do see a physician and are started on some medication as needed (Wilper et al. 2009). (Dr. Wang advises that this does not mean all health needs are met). Some data suggests that chronic issues are addressed well, An example is HIV: viral loads are suppressed and CD4 improve (though the data is more robust in prisons than in jails.) (Meyer et al. 2014).

Around 40% individuals coming into contact with correctional health are newly diagnosed once incarcerated (because they are often young and often uninsured patients who have not had prior access to healthcare) (Wang et al. 2012) 

But this doesn’t mean that all of a patient’s health needs are actually met…. 

A Giant Missing Piece: Treatment for Opioid Use Disorder  

There are very few states in which the gold standard treatment (methadone, XR naltrexone, buprenorphine) for opioid use disorder is offered to patients in prison.  

Even if an individual were taking methadone or buprenorphine through a program, in many cases these medications would be taken away from them during incarceration, and this patient would undergo “detox”, or a rapid period of managed withdrawal. 

Dr. Fox argues: The sense that it’s better for incarcerated patients be taken off of all opioids, or to undergo a cleanse that will “get it out of their system,” and that this period of incarceration will cure an addiction–is False.  

Why ignoring OUD in prisons is dangerous 

When people are released from jail or prison, their risk of opioid resumption is more dangerous than at other times. Individuals have lost physical tolerance while incarcerated because of more inconsistent use, so if they return to their previous dose of opioids, the risk of overdose is dramatically higher. 

When individuals are released, their risk of substance resumption is high and their risk of death in the two weeks following incarceration is 12 times elevated, with their risk of drug overdose over 100 times elevated (Binswinger et al. 2007).

The few places that have incorporated treatment for opioid use disorder in correctional settings have seen much lower rates of relapse, and much higher chances of maintaining treatment. 

Data out of Rhode Island has shown that exposure to agonist therapy in correctional settings was associated with a 60% reduction in post-release mortality (Green et al. 2018). Of course, access to maintenance treatment once out of the correctional setting can be just as challenging.

Solitary Confinement is Toxic

Exposure to solitary confinement leads to worsening of mental health disorders (Wang et al. 2017) in addition to higher rates of self-harm and suicide attempts (Kaba et al. 2014). When you have patients who are coming out of an incarcerated setting, it is worthwhile to screen for PTSD and mood disorders.   

The Traumas of Prison, and Trauma-informed Care 

When you have a recently released individual in clinic, it is important to remember: Patients who are transitioning out will have likely experienced trauma. This includes high levels of interpersonal violence (witnessed or experienced), experiences of abandonment and neglect, and even high rates of history of sexual abuse (especially among women in prison).  

Dr. Giftos quotes Nelson Mandela: “It is said that no one truly knows a nation until one has been inside its jails… A nation should not be judged by how it treats its highest citizens, but its lowest ones.”

Dr. Fox highlights: As providers, we (and our whole clinic staff!) need to be aware of this, and to be able to provide better trauma-informed care–from our wording about certain things, to talking before touch, to screening for PTSD and other mental health conditions.  

Having an uncaring demeanor can send a message that you don’t care about your patient. Patients notice this, and this affects outcomes.  

The Transition Out

The transition out of incarceration is a vulnerable time. 

Individuals may not have been exposed to how the current community health system functions if they have been incarcerated for an extended period of time. The label of incarceration also affects social determinants of health. In some states, this includes restrictions on employment, lifetime bans on public housing and lifetime bans on voting. 

Dr. Wang argues these restrictions suggest to the person transitioning that their world is not welcoming them back into the fold with open arms. And, since social needs typically take a high priority, picking up a medical prescriptions or making it to an office visit may fall to the wayside. 

Dr. Wang argues the expansion of Medicaid in many states through the Affordable Care Act to include young adult men without children has made a huge difference in supporting the healthcare of the formerly incarcerated (Cueller et al 2014). In some states, individuals have a “discharge plan” when they leave prison to enroll in a clinic, and a voucher for 1 month of medications.  Different states have differing discharge structures.

Transitions Clinics

The Transitions Clinic Network is a series of clinics that have interdisciplinary partnerships to holistically address the needs of the transitioning community. A key part of these clinics is the presence of the community health workers. These clinics all partner with community organizations and attempt to address the needs of the community in which they operate by constantly re-evaluating.

Dr. Giftos recommends looking at the Osborne Clinic.

How to ask about incarceration

Incarceration is a very common experience of patients in primary care. 

Dr. Wang recommends that we ask about incarceration in a tactful way:  “Have you or any family member every spent any time in jail or prisons? I ask this to all of my patients.”  You do not need to ask about why the patient went to jail or prison. 

Recommended Resources: 

1. Academic Consortium for Criminal Justice Health (ACCJH): Good curricular materials on criminal justice and best practices 
2. The Fortune Society: Great pamphlets on providing trauma-informed care (including one on caring for women within the criminal justice system with HIV) 
3. Epidemiology research by Dr. Emily Wang et al (check out Lancet paper: Mass Incarceration, public health, and widening inequality in the USA, to start, which focuses on the epidemiology of mass incarceration and its impact on health 
4. Just Health: Monthly Digest (by medical students!) about key articles on criminal justice and health  
5. Follow our guests on Twitter: @Adfoxmd, @jongiftosmd, and @ewang422

Goals

Listeners will develop an understanding to the provision of health care in correctional facilities and the unique challenges to patients’ health during incarceration and upon release. 

Learning objectives 

After listening to this episode listeners will…

1. Define jail, prison, probation, parole
2. Describe the epidemiology of chronic conditions in correctional facilities
3. Appreciate the role of incarceration in public health and health disparities
4. Identify risk factors during and after incarceration that have negative health consequences

Disclosures

Doctors Wang, Fox and Giftos report no financial disclosures. The Curbsiders report no financial disclosures.

Links

1. Life and Death at Rikers by Homer Venters
2. The Gruffalo by Julia Donaldson
3. The Power Broker by Robert Moses
4. Just Mercy by Bryan Stephenson
5. The Herlihy Boy (SNL clip) with Adam Sandler and Chris Farley

Citation

Fox, Aaron; Giftos, Jon; Wang, Emily. Guest, expert. “#158 Medicine and Incarceration.” The Curbsiders Internal Medicine Podcast http://thecurbsiders.com. July 1, 2019.