Ingrid Binswanger

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