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Transitions between the Criminal Justice System and the Community:
Implications for Health
Ingrid Binswanger, MD, MPHAssistant Professor, Division of General Internal Medicine
and Division of Substance DependenceUniversity of Colorado Denver School of Medicine
University of PennsylvaniaMay 8, 2009
Goals
1) Understand the scope of the criminal justice system in the US
2) Examine death rates and causes of death among former inmates
3) Describe risk factors for death after release from prison
4) From 30,000 to 30: Preliminary qualitative data on health needs of former inmates
5) Implications for public health
1) Scope of the Criminal Justice System
3% US adults in jail, prison, probation or parole
1.5 million children with a parent in prison - 7% of African American children
Bureau of Justice Statistics, 2007, 2008
General Population
Communities/families affected by
incarceration
Previously incarcerated Probationers
and parolees
Current jail and prison
inmates
The ecology of incarceration and health
Growth in the criminal justice system
Number of prisonersYear-end 1980: 300,000Year-end 2006: 1.3 million
Spending on corrections1987: $12 billion2007: $47 billion
The PEW Center on the States, 2008
High Disparities: Projected Percent of Men who will go to Prison
6%
17%
32%
05
10152025303540
African American Latino White
95% will be released
Perc
ent
Bureau of Justice Statistics, 2003
2) Mortality after release from prison:Aims
1. What are the death rates after release from prison?
2. What are the major causes of death after release?
3. How do the death rates among former inmates compare to those of the general population?
Binswanger, Stern, Deyo, et al., NEJM 356:157-65, 2007
Study methods
Retrospective cohort study
Participants
All released inmates from Washington State Department of Corrections
30,257 followed for 57,049 person-years
July 1999-December 2003Binswanger, Stern, Deyo, et al., NEJM 356:157-65, 2007
Data sources
1. Washington State Dept. of Corrections
2. National Death Index-Plus, CDC
3. CDC Wonder
Data analysis
1. Mortality rates Deaths/person-time at risk out of prison after
release Data censored at date of death, end of study, or
date of re-incarceration if not released again If re-incarcerated, time back in prison did not
count towards person-time at risk2. Relative risks
Compare mortality rates among released inmates to other WA state residents
Poisson regression adjusted for age, gender and race
30,257 followed for 57,049 person-years
30,636
150 Incomplete data
Ineligible and excluded: 1%
Deaths excluded:144 Prison deaths & executions 30 Death & prison dates inconsistent 5 Releases for grave medical illness
50 Age<18
Demographic characteristics N=30,257
Age, mean years (SD) 33 (10)
Male 87%
Race/ethnicity White, non-Hispanic African American, non-Hispanic Latino/Hispanic Native American/Alaska Native Asian/Pacific Islander
61% 20%
13%4% 2%
Deaths after release N=30,257
443 deaths
Mean time at risk out of prison: 2 years
Mean age at death: 42
Mortality rates
Deaths/100,000 person-years
Released inmates 777
In WA prison 201
Other Washington residents* 223
*Adjusted for age, gender and race
Elevated mortality rates in first 2 weeks after release
0
1000
2000
3000
0 - 2
3 - 4 5-6 7-8 9+
Overal
l
Weeks since release
Deaths/100,000 person years
Adj. WA state=223
Leading causes of death n=443
*Compared to other Washington State residents, adjusted for age, gender and race
No. Relative Risk*
Drug overdose 103 12.2
CV disease 57 2.1
Homicide 55 10.4
Suicide 41 3.4
Drug overdose deaths (n=103)
0 10 20 30 40 50 60
MultipleOther opioids
Other narcoticsBenzodiazepines
TricyclicsAlcohol
MethadoneHeroin
PsychostimulantsCocaine
Number of deaths
Other causes of death n=443
No. Relative risk
Cancer 39 1.7
Motor vehicle accident 35 3.4
Liver disease 23 4.7
*Compared to other WA residents, adjusted for age, gender and race
Cancer deaths after release (n=39)
0 5 10 15 20
Stomach
Renal
Prostate
Liver
Pancreatic
Lung
Number of deaths
Limitations
Matching individuals with deaths Criteria for rejecting uncertain matches for
death Excluded some known deaths
Cause of death data from death certificates Could not adjust for all socio-economic factors Single prison system in single state
11.5 million releases from jails & prisons/ year
Rates and Causes of Death: Conclusions
Former inmates at high risk for death after release
Risk greatest in first 2 weeks after release Released inmates were at highest risk from
overdose, cardiovascular disease, homicide and suicide
Increased risk of death has also been shown in European, Australia and confirmed in subsequent US studies
Bird SM, 200; Hobbs M, 2006; Pritchard C, 1997; Verger P, 2003; Rosen DL, 2008
Examining Risk Factors: Methods
Data on demographic factors, chemical dependency and mental health characteristics identified from administrative data of DOC
Cox proportional hazards regression used for analysis
All releases treated as independent
Collaborators: MF Stern, P Blatchford
Conceptual model:Prisoner Re-entry and Health
Pre- incarceration factors
Reentry conditions
Incarceration experience
Health Outcomes
Modified from Gelberg L, 2000
Prisoner re-entry and health: Non-modifiable Factors
Pre- incarceration factorsRace, age, gender, education, neighborhood, drug and alcohol dependence, mental health disorders, risk behavior, exposure to violence, access to health care
Reentry conditionsTransitional challenges, type of release, re-entry policies, physiologic changes, access to health care, prescriptions, drug treatment
Incarceration experienceLength of incarceration, quality of care, preventive services, chemical dependency treatment, psychiatric treatment
Health OutcomesMortality
Characteristics (n=38,803) HR (95% CI)
Gender Men Women
1.00.8 (0.6, 1.1)
Age Each decade increase, <50 Each decade increase, >50
1.6 (1.4, 1.7)1.8 (1.4, 2.4)
Race Non-Hispanic White Non-Hispanic Black Other
1.00.9 (0.7, 1.2)1.0 (0.7, 1.4)
Hispanic 0.5 (0.3, 0.7)Length of incarceration, years 1.0 (0.9, 1.0)Release Status Release without supervision Release with supervision/ parole Other
1.00.7 (0.6, 1.0)1.4 (0.8, 2.5)
Characteristics % or median HR (95% CI)
Drug Dependence No Yes Missing
25%48%27%
1.01.4 (1.1, 1.8)2.3 (1.8, 3.1)
Serious Mental Health Problem No Yes Missing
49%7%44%
1.01.2 (0.9, 1.7)0.3 (0.2, 0.4)
Risk Factors for Death: Conclusions
Older individuals at higher risk for death Low mortality rates in Latinos
Deaths that outside of the US?Socio-cultural factors?Different reasons for incarceration?
Release with supervision mildly protective
Risk Factors for Death: Conclusions
Chemical dependency is an independent risk factor for death Missing chemical dependency screen
even more strongly associated Not having a mental health record is
protective factor Administrative correctional data have
substantial missing data on clinical factors
Risk Factors for Death: Conclusions
The subset of inmates who were not screened for chemical dependency deserves closer attention
If failure to be screened is a contributor to increased death, greater screening for chemical dependency in prison settings may reduce the risk of death among former inmates by increasing access to treatment
4) From 30,000 to 30: Assessing the health needs of former inmates
Known challenges faced by former inmates Legal identification Housing Employment Health care Parole conditions Drugs & alcohol Re-integration with families & communities
La Vigne, Castro, Vicher, 2004, Burgess-Allen, 2006, Freundenberg, 2005
4) From 30,000 to 30: Assessing the health needs of former inmates
Aim: Describe health-seeking experiences, perceptions of risk, and health needs of former prisoners during the transition from prison to the community
Goal: Learn how to reduce the risk of death from former inmates
Health needs of former inmates: Methods
Qualitative key informant interviews with 30 former prisoners within 60 days of release
Recruitment: 2 medical clinics at Denver Health with snowball sampling
Interview topics Perceptions of risk to health and safety Gaining access to medical care How could health needs/safety be better
addressed Analysis: Team approach with member checking
Preliminary Results
19 interviews completed X% white, Y% African American, X% Latino, Z
% American Indian X% female
Preliminary Results
Early themes: Prison as a healthier environment than the
community Gaining access to health care after
release is high priority Direct experiences with friends who
overdosed after release from prison
Prison as a healthier environment than the community
In all actuality, and a lot of people may take this the wrong way, but prison can actually preserve you. It can actually save you. I mean if you were doing drugs – not to say that there are not drugs in there, but they are not in abundance, you know what I mean? So what are you going to do if you can’t get them you know? So you either quit or go crazy.
Prison as a healthier environment than the community
[about prison] You exercise. You use your mind. You read. You work. You do everything to improve your health. There’s no down side to being in prison except for one thing. You are isolated from women. Add women to that, women in prison, and every man who got a prison sentence I swear to god would stay there. Do every day of his time.
Gaining access to health care after release is high priority
[about priorities after release] You know you get food stamps, you get other things when you get out. But healthcare is one of the main things you know? Your health is everything. If you don’t have your health you don’t have anything. If you don’t have your health you can’t do nothing.
Experiences with overdose after release
[Respondent] …I’ve lost quite a few friends that have came out [of prison] and were very fresh to this street life and they OD’d on heroin you know. Just a sad thing. Of course they had only been out a couple weeks.
[Interviewer] And how many times have you seen or heard about that happening would you say?
[Respondent] Um…maybe 6 times...and then there’s been others who have OD’d but not died you know.
5) Implications of for Public Health
Detrimental impact of transitions on individual healthMorbidity and mortality after releaseMultiple transitions in careSecondary health effects of social and economic factors related to conviction
Blankenship, et al., J Health Care Poor Underserved, 2005; Freudenberg, AJPH, 2002; Iguchi, Public Health Reports, 2002.
5) Implications for Public Health
Detrimental effects on family/community healthDisruption of family, social and sexual networks“Forced migration” Transmission of sexually transmitted infectionsInter-generational health effects
Thomas, 2008; Clear in Greifinger, 2007
Recommendations
1. Measure health outcomes in criminal justice populations
2. Include criminal justice involvement in broader health research
3. Provide preventive care in criminal justice settings
4. Reduce health disparities through interventions in criminal justice system
5. Including correctional care in comprehensive efforts at health care reform
Acknowledgements
John Steiner, MD, MPHJean Kutner, MD, MSPH
Marc Stern, MD, MPHPatrick Blatchford, PhD
Susanne Felton, MACarolyn Nowels, MA
Robert Wood Johnson Foundation Physician Faculty Scholars Program
Division of General Internal Medicine, University of Colorado Denver School of Medicine
Washington Department of Corrections