U.S. physicians call for new approach to address national 'epidemic of mass incarceration'

In a Perspective article to appear in the June 2 issue of the New England Journal of Medicine (NEJM), the authors argue that much of this epidemic is due to inadequate treatment of addiction and mental illness in the community, which they say can be linked to policy changes over the last 30 years, such as severe punishment for drug users as a result of the nation's "War on Drugs."

"More than half of all inmates have a history of substance use and dependence or mental illness, yet they are often released to the community without health insurance or access to appropriate medical care and treatment," says Josiah D. Rich, M.D., M.P.H., director of the Center for Prisoner Health and Human Rights, which is based at The Miriam Hospital.

"Sadly, without these linkages to transitional care in the community, the majority of these individuals will re-enter the revolving door of the criminal justice system, which already costs our county $50 billion annually," he adds.

Rich and co-authors Sarah E. Wakeman, M.D., of Massachusetts General Hospital, and Samuel L. Dickman, A.B., of Harvard Medical School (formerly with Brown University), point out that over the past 40 years, the number of people in U.S. prisons has increased by more than 600 percent. With 1 in 100 Americans currently in prison or jail, no other country comes close to imprisoning as many of its citizens as the U.S. Low-income and minority populations are disproportionately affected by this epidemic of mass incarceration, further exacerbating racial and socioeconomic health disparities.

The largest facilities housing psychiatric patients in the U.S. are not hospitals but jails, the authors write. Major depression and psychotic disorders are four to eight times as prevalent among inmates as in the general population. However, only 22 percent of state prisoners and 7 percent of jail inmates receive mental health care while incarcerated.

With growing numbers of drug users in correctional facilities, the prevalence of infectious diseases has also increased. As many as a quarter of all HIV-positive Americans and one in three individuals with hepatitis C pass through a correctional facility each year. Similarly, inmates are also disproportionately affected by chronic diseases, such as hypertension and diabetes.

Meanwhile, re-entry into the community for former inmates is a vulnerable time -- especially for those with mental illness -- and is marked by increased drug use. In the two weeks after release, former inmates are 129 times more likely to die from a drug overdose than members of the general public.

There are tremendous medical and public health opportunities that can be created by addressing the health care needs of prisoners and former prisoners, the authors note. "For some inmates, incarceration may represent their first intersection with the medical community, offering an invaluable opportunity to diagnose and treat the overrepresented rates of infectious and chronic diseases, addiction and mental illness," says Wakeman.

Partnerships between correctional facilities and community health care providers -- especially community health centers and academic medical centers -- also can capitalize on health gains made during incarceration and improve the continuity of care for former inmates during the critical post-release period.

"Health care reform, with the Affordable Care Act, has the potential to improve access to much needed health care, which in turn, could redirect many people with serious illnesses away from the revolving door of the criminal justice system," the authors write, adding that this could avoid costs, re-incarceration and other adverse outcomes related to untreated addiction and mental illness.

"Physician awareness and involvement with this public health crisis will benefit not just the millions of Americans who cycle through corrections each year, but also the communities to which they return," adds Wakeman.

"In light of the recent US Supreme Court decision that California's prisons are unconstitutionally overcrowded and fail to deliver minimal care to prisoners with serious medical and mental health problems, this call by physicians to address the national epidemic of incarceration is timely," adds T. Stephen Jones, M.D., U.S. Public Health Service, Commissioned Corps (ret) and the Centers for Disease Control and Prevention (CDC).

Rich concludes that a new evidence-based approach is desperately needed. "Locking up millions of people for drug-related crimes has failed as a public-safety strategy and has harmed public health in the communities to which these men and women return," he says. "The medical community and policymakers must advocate for alternatives to imprisonment, drug-policy reform and increased public awareness in order to reduce the consequences of mass incarceration."

Rich is a funded investigator of the National Institute on Drug Abuse (NIDA).