AAFP Position Paper

FP Experts Offer Perspective on Incarceration and Health

June 12, 2017 03:15 pm Chris Crawford

The United States has the highest incarceration rate in the world.(www.prisonpolicy.org) The U.S. Bureau of Justice Statistics estimated that more than 6.7 million people(www.bjs.gov) were being supervised by the nation's adult correctional systems as of the end of 2015.

Maricopa County Jail System health staff members provide inmates a hands-on health assessment at the intake clinic before they are transported to their assigned jail, where they receive medications as needed.

That higher incarceration rate has not resulted in a significantly safer or crime-free society, however. That's according to a new AAFP position paper titled "Incarceration and Health: A Family Medicine Perspective" that focuses on the health impact incarceration has on inmates and their families.

Kenneth Lin, M.D., M.P.H., of Washington, D.C., led the AAFP Commission on Health of the Public and Science workgroup that developed the position paper. Lin told AAFP News the paper grew out of a resolution adopted by the Academy's National Conference of Constituency Leaders.

"Family physicians are more likely than other clinicians to care for vulnerable populations, and patients who are or have been incarcerated have higher rates of chronic health conditions, mental illness and substance abuse than the general population," Lin said. "But unfortunately, incarcerated patients are less likely to receive appropriate medical services. This is a particular concern in the U.S."

Story highlights
  • The AAFP has released a position paper titled "Incarceration and Health: A Family Medicine Perspective" that focuses on the health impact incarceration has on inmates and their families.
  • Inmates in correctional facilities are more likely than members of the general population to suffer from infectious disease, mental health problems, and substance use and addiction.
  • The paper highlighted five things family physicians can do to help with issues related to incarceration and its effects on patients.

Contributors to U.S. Incarceration Rate

The position paper highlighted two factors as the primary drivers of the United States' increased incarceration rate. The first was an effort to "deinstitutionalize" patients with mental health issues by moving them from inpatient facilities to outpatient care.

But as those inpatient populations dropped, no additional funding was allocated for outpatient treatment. As a result, large numbers of inpatients were released without adequate care, housing provisions or social support. Many remained untreated, became homeless and, thus, were prone to being arrested for substance abuse, petty theft or disruptive behavior, eventually landing in the country's correctional facilities.

The second factor contributing to the growing incarceration rate was the so-called war on drugs instituted in the early 1970s. According to the paper, this campaign led to "harsh, lengthy sentences for possession of even small amounts of illegal drugs."

"Between 1985 and 2000, increased incarceration of drug offenders accounted for two-thirds of the increase in the federal prison population and one-half of the increase in state prison populations."

Health Issues During Incarceration

Inmates in correctional facilities have significantly higher rates of disease than the general population, and these facilities are often ill-equipped to provide for the medically underserved.

"This population tends to suffer in greater numbers from infectious disease, mental health problems, and substance use and addiction; their health can also be affected negatively by factors in their environment, such as violence or overcrowding," the paper's authors said.

Jeffrey Alvarez, M.D., medical director for the Maricopa County Jail System in Phoenix and AAFP liaison to the National Commission on Correctional Health Care Board of Directors, told AAFP News that if tobacco is included as a substance, 85 percent of people who enter the Maricopa County system report substance use or abuse. Without tobacco, substance use is still in the 60 percent to 65 percent range, he said.

"Secondary to substance abuse, mental health is the next significant issue facing corrections facilities," Alvarez said. "You're seeing higher levels of personality disorders and seriously mentally ill patients. With that, you have the mixture of the mental health issues plus the substance use in a population that likely has not used primary care services prior to coming into custody."

Given those factors, the medical staff at Maricopa County Jail System's five facilities have an increased index of suspicion during intake for patients who may have substance abuse or mental health issues. The system processes 250-275 inmates a day and maintains an average daily population of 8,000, including an all-female jail with about 1,000 inmates.

Many of these patients are in the advanced stages of their respective disorders and may be dealing with related health issues, such as cirrhosis or other liver disease from alcohol abuse or hepatitis C infection from injecting heroin, Alvarez said.

Maricopa County health staff members provide inmates a hands-on health assessment at the intake clinic before they are transported to their assigned jail, where they receive needed medications.

"Because a jail has a rapid transition of people in and out, I tell my medical providers and nurses to always consider discharge planning because inmates can leave at any time," Alvarez said. "Prisons have an easier time with discharge planning because you have a sentence date and you know when they're going to leave."

When the Maricopa County system releases inmates, they are required to sign a form saying whether they want their medications, and then the jail clinic gives them what was received from the pharmacy -- typically, a 30-day supply.

"It's up to them to decide if they want to take the medication we provided with them that day, but we offer them that 30-day supply," he said.

The release paperwork also includes names and phone numbers of local community health centers so inmates can follow up with a primary care health professional if they don't have one.

"It's amazing the difference you see (in inmates) when the drugs aren't onboard any longer," Alvarez said. "A lot of them are more engaged about their health. So if you want to make a difference, that's the time to talk with them."

Unfortunately, however, like many correctional facilities, Maricopa County has a high rate of recidivism, with some inmates returning several times a year.

"We have an electronic record so we're able to see previous bookings. We might know from (a patient's) prior stay what his medications were and that he didn't take them with him when he left," said Alvarez. "Last time he was here, we had him on metformin and lisinopril, so we go ahead and start those drugs again."

Health Issues After Incarceration

The AAFP's position paper said that for some inmates, incarceration positively impacts their short-term health by providing housing and regular meals; reducing access to drugs, alcohol and cigarettes; and giving them additional access to health care.

More than 650,000 individuals were released from prison in 2015. This transition, or re-entry, may be a very stressful period for the former inmates, their families and communities.

The paper notes that one in 12 former inmates is hospitalized for an acute condition within 90 days of release, said Lin, and adjusted mortality risk in the first two weeks after prison release is almost 13 times the risk of never-incarcerated individuals, with drug overdose, cardiovascular disease, homicide and suicide being the leading causes of death.

"In addition, common chronic conditions such as hypertension, diabetes and asthma can worsen if former inmates have problems obtaining health insurance and timely primary care during the transition back to their communities," he said.

Incarceration also affects inmates' families. Lin said children and adolescents with an incarcerated parent are more likely to use illicit drugs and have higher rates of antisocial behavior than their peers whose parents have not been incarcerated.

"Some children struggle with school performance and mental health issues," he said. "Having an incarcerated parent increases financial burdens on families and negatively affects social cohesion in communities."

Positive Actions FPs Can Take

The paper highlighted five things family physicians can do to help with issues surrounding incarceration and its effects on patients.

  1. Learn about the unique needs of incarcerated or formerly incarcerated individuals and their families via CME activities and journal articles. Recommended resources include the American College of Correctional Physicians,(societyofcorrectionalphysicians.org) the National Commission on Correctional Health Care,(www.ncchc.org) and the Center for Prisoner Health and Human Rights.(www.prisonerhealth.org)
  2. Consider working in the prison system or volunteering to work with individuals in this population during or after their incarceration.
  3. Advocate that prisoners, former prisoners and their families have adequate access to mental health and substance abuse treatment services.
  4. Advocate that unnecessary jail and prison stays be prevented by diverting eligible people from the justice system to substance abuse and/or mental health treatment.
  5. Work with legislators on other policy issues related to prisoner health, such as eliminating racial disparities in sentencing, commuting sentences of nonviolent drug offenders and facilitating health insurance enrollment after prisoner release.

"We can work to improve our knowledge of the health needs of this patient population; provide direct clinical care; and advocate to prevent unnecessary incarceration, racial disparities in incarceration and for adequate medical, mental health and substance abuse treatment resources in prisons and jails," Lin said.

Alvarez agreed with the above calls to action, and added a simple request.

"We need to get back to the point where our primary care providers ask the difficult questions when they are doing a social history," he said. "They need to ask about drug use, jail stays, STDs and mental health. I think many times you concentrate on the diabetes and hypertension and you neglect to ask, 'Well, where were you the past six months?' … 'Oh, you were in jail.'

"I can't tell you how much information that gives you," Alvarez noted.

"If providers do this, that will be the link back to the jail and they'll know to reach out to the jail system to get medical records and use this information to better integrate the patient's care."

Maricopa County Correctional Health Services received the R. Scott Chavez Facility of the Year Award for 2015.