Case Scenario

D.H., a 24-year-old patient with opioid use disorder, presents to my clinic for care following minor injuries sustained during an altercation with the police. D.H. spent the weekend in a detention center before being able to post bail. During initial screening for mental health and substance use, D.H. reports symptoms of hypervigilance and increased opioid cravings. What specific clinical or medicolegal issues should I, as the treating family physician, consider or be aware of to optimize the quality of care provided to this patient?

Commentary

Justice system involvement is defined as regular interactions with legal, law enforcement, and carceral systems, including detention, incarceration, or community supervision¹; Table 1 outlines common justice system involvement definitions.² In 2020, the Bureau of Justice Statistics stated that around 21% of U.S. residents (nearly 54 million people) 16 years or older had some type of contact with the police.³ More than 50% of those contacts (more than 25 million) were initiated by the police (i.e., traffic stops, arrests).³ Although the number has been decreasing in the past few years, in 2020 an estimated 5.5 million people were under correctional system control, which includes incarceration and community supervision.³

Profound racial disparities are evident in rates of street stops (e.g., traffic, foot patrol), use of force, arrests, pretrial detention, incarceration, and sentencing.^3,4 Overrepresentation of Black and Hispanic individuals in the justice system is a concern, especially given historic and current law enforcement practices, such as overpolicing communities of color.^5,6

BUILDING TRUST AND TRAUMA-INFORMED CARE IN CLINICAL ENCOUNTERS WITH PATIENTS WHO HAVE JUSTICE SYSTEM INVOLVEMENT

Patients with justice system involvement face stigmatization in most areas of society, including health care. To minimize bias, family physicians should first identify and address their own personal biases regarding people with justice system involvement, substance use disorders (SUDs), or mental health disorders. Family physicians should be cognizant of the variety of psychosocial challenges that patients with justice system involvement experience^7,8 and of their patients' potential mistrust of major institutions, including the medical system.⁹ Family physicians should engage in trauma-informed care with this population.¹⁰ Table 2 provides a list of resources for family physicians to reference when caring for a patient who is involved with the justice system.

HISTORY TAKING AND SCREENING DURING CLINICAL ENCOUNTERS

The population involved in the justice system has an increased prevalence of a variety of health-related conditions compared with the general population.^1,11 These conditions include severe mental health disorders (including schizophrenia, bipolar disorder, and posttraumatic stress disorder); SUDs (including alcohol, opioids, and stimulants); and infectious diseases associated with SUDs (e.g., hepatitis C, HIV/AIDS), sexual activity, and congregate settings (e.g., tuberculosis, COVID-19). Other chronic conditions, such as obesity, hypertension, and type 2 diabetes mellitus, are also included.^1,11,12 In addition, individuals with justice system involvement are more likely to experience negative social drivers of health, including financial insecurity, housing instability, poverty, and a history of adverse childhood experiences.^1,11,12

When engaging with patients involved in the justice system, family physicians can focus on exposures related to the four major types of interaction with the justice system: (1) community-based interactions with law enforcement (e.g., during policing activities, crowd-control events during protests, excessive use of force during traffic stops), (2) detention, (3) incarceration, and (4) community reentry, especially if community supervision is required. Table 3 outlines the major conditions associated with exposure type as well as potential actions family physicians might take to address these conditions.^{1,2,10,12–20}