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Analysis of health and prescription data suggests chronic health conditions in U.S. incarcerated people may be severely undertreated
Findings suggest conditions go untreated in prison inmates compared to general population
Peer-Reviewed PublicationChronic conditions such as type 2 diabetes, asthma, HIV infection, and mental illness may be greatly undertreated in the U.S. jail and prison population, suggests a new study from researchers at the Johns Hopkins Bloomberg School of Public Health.
For their analysis, the researchers used national health survey data covering 2018 to 2020 to estimate rates of chronic conditions among recently incarcerated people, and a commercial prescription database to estimate the distribution of medication treatments to the jail and prison population. Their analysis suggests that for many common and serious conditions, incarcerated people are substantially less likely to be treated compared to the general U.S. population.
The study found that recently incarcerated individuals with type 2 diabetes represented about 0.44 percent of the U.S. burden of the condition, but got only 0.15 percent of oral anti-hyperglycemic medications—nearly a threefold difference. Incarcerated individuals with asthma accounted for 0.85 percent of the total U.S. asthma population, but just 0.15 percent of asthma treatment volume, a more than fivefold difference.
The study will be published online April 14 in JAMA Health Forum.
“Our findings raise serious concerns about the access to and quality of pharmacologic care for very common chronic health conditions among the incarcerated,” says study senior author G. Caleb Alexander, MD, professor in the Department of Epidemiology at the Bloomberg School. “We knew going in that the U.S. incarcerated population has a higher prevalence of some chronic diseases. But we were really surprised by the extent of potential undertreatment that we identified.”
Prior studies have found evidence that health care provided to the U.S. incarcerated population—roughly two million individuals—is often understaffed, underfunded, and of poor quality. Yet studying health care issues among the incarcerated involves many challenges. Few studies have examined treatment of common and chronic diseases such as diabetes and asthma.
“Health care provided in jails and prisons is provided by a patchwork of health care providers, most commonly private contractors who do not widely share information about the services they provide to incarcerated people,” says study co-author Brendan Saloner, PhD, an associate professor in the Bloomberg School’s Department of Health Policy and Management. “The lack of transparency means that advocates and policymakers have a very incomplete picture of the medicines that are available during a stay in jail or prison.”
The lack of transparency also makes it difficult to research. For their study, the researchers generated two sets of estimates: one for the prevalence of specific conditions among recently incarcerated inmates, the other on the percentage of common chronic illness prescriptions going to jails and state prisons.
For the disease prevalence estimates, the researchers used recent data from U.S. government-sponsored National Surveys on Drug Use and Health. These annual surveys don’t cover prison and jail populations directly, but the researchers estimated condition prevalence among adult survey respondents who either had or had not reported being on parole or having been arrested and booked in the prior year. They combined these figures with U.S. Census data, and generated population estimates for state prisons and local jails to gauge the approximate numbers of incarcerated and non-incarcerated individuals with different conditions.
To get a sense of prescriptions dispensed to the incarcerated vs. the non-incarcerated populations, the researchers used data from the same time period from the health care technology company IQVIA. Because of the lack of data on federal prison inmates, the incarcerated population for the analysis included only individuals in local jails and state prisons. The authors made adjustments for the possibility of missing data, and note that their numbers may underestimate disparities between incarcerated individuals and their counterparts.
The analysis yielded estimates for the prevalence of chronic conditions that suggested particularly heavy burdens of some illnesses in the incarcerated population—for example, hepatitis (6.08 percent prevalence among the incarcerated vs. 1.41 for the non-incarcerated), HIV infection (0.84 percent vs. 0.28 percent), depression (15.10 percent vs. 7.64 percent), and severe mental illness (13.12 percent vs. 4.89 percent).
As for prevalence-treatment differentials among the incarcerated, the study also found that incarcerated individuals with HIV represented about 2.2 percent of the U.S. burden of the condition, but got only 0.73 percent of HIV antivirals—a threefold difference. Incarcerated individuals with severe mental illness represented an estimated 1.97 percent of disease burden, but only 0.48 percent of treatment volume consisting of antipsychotics and mood stabilizers, a fourfold difference.
Alexander says that the findings may reflect not only institutional neglect but also factors such as the temporary nature of many local jail stays, and the high prevalence of mental illness—which tends to complicate treatment of other conditions—in the incarcerated population.
“We hope our results will motivate further investigations that continue to explore these vital matters using a variety of data sources,” he says.
“Estimated Use of Prescription Medications Among Individuals Incarcerated in Jails and State Prisons in the US” was co-authored by Jill Curran, Brendan Saloner, Tyler Winkelman, and G. Caleb Alexander.
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JOURNAL
JAMA Health Forum
ARTICLE TITLE
Estimated Use of Prescription Medications Among Individuals Incarcerated in Jails and State Prisons in the US
ARTICLE PUBLICATION DATE
14-Apr-2023
Offering medications for opioid addiction to incarcerated individuals leads to decrease in overdose deaths
BOSTON – New research from Boston Medical Center concluded that offering medications to treat opioid addiction in jails and prisons leads to a decrease in overdose deaths. Published in JAMA Network Open, the study also found that treating opioid addiction during incarceration is cost-effective in terms of healthcare costs, incarceration costs, and deaths avoided.
Overdoses kill more than 100,000 people per year in America and this number continues to increase every year. People with addiction are more likely to be incarcerated than treated, with those from communities of color who use drugs more likely to be incarcerated than White people. Most prisons and jails in the United States discontinue medications for opioid use disorder (MOUD) upon incarceration, even if taken stably prior to incarceration, and do not initiate MOUD prior to release. Patients often suffer withdrawal symptoms while incarcerated and the post incarceration period is a time of very high-risk for overdose death.
“Offering medications for opioid addiction for incarcerated individuals saves lives. Specifically, offering all three medications—buprenorphine, methadone, and naltrexone—is the most effective at saving lives and is more cost-effective,” said lead author Avik Chatterjee, MD, primary care and addiction medicine physician at Boston Medical Center and Boston Healthcare for the Homeless and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine. “We hope our study supports policy change at the state and federal level, requiring treating opioid use disorder with medications among people who are incarcerated.”
The study modeled the impact of MOUD access during and upon release from incarceration on population-level overdose mortality and OUD-related treatment costs in Massachusetts using three different strategies: 1) no MOUD provided during incarceration or upon release, 2) offer only extended-release naltrexone (XR-NTX) upon release from incarceration, and 3) offer all three MOUD at intake.
Among 30,000 incarcerated people with OUD, offering no MOUD was associated with 40,927 MOUD treatment starts over a 5-year period and 1,259 overdose deaths after 5 years. Over 5 years, offering XR-NTX at release led to 10,466 additional treatment starts and 40 fewer overdose deaths. In comparison, offering all three MOUD at intake led to 11,923 additional treatment starts, compared to offering no MOUD, and 83 fewer overdose deaths. Among everyone with OUD in MA, “XR-NTX only” averted 95 overdose deaths over 5 years—a 0.9% decrease in state-level overdose mortality, while the all-MOUD strategy averted 192 overdose deaths—a 1.8% decrease.
In this simulation modeling study, researchers found that offering any MOUD to incarcerated individuals with OUD would prevent overdose deaths and offering all three MOUD would prevent more deaths and save money.
Researchers believe that a treatment-based approach is more appropriate than an incarceration-based one for treating addiction. Proactively offering treatment during incarceration can save lives and is a cost-effective health intervention, while also supporting the dignity of people who are incarcerated.
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About Boston Medical Center
Boston Medical Center is a leading academic medical center with a deep commitment to health equity and a proud history of serving all who come to us for care. BMC provides high-quality healthcare and wrap around support that treats the whole person, extending beyond our physical campus into our vibrant and diverse communities. BMC is advancing medicine, while training the next generation of healthcare providers and researchers as the primary teaching affiliate of Boston University Chobanian & Avedisian School of Medicine. BMC is a founding member of Boston Medical Center Health System, which supports patients and health plan members through a value based, coordinated continuum of care.
JOURNAL
JAMA Network Open
ARTICLE TITLE
Associated With Use and Nonuse of Medications for Opioid Use Disorder During Incarceration and at Release in Massachusetts
ARTICLE PUBLICATION DATE
14-Apr-2023
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