Criminal Justice System and Addiction Treatment

Smoking

Smoking is the leading preventable cause of death in the United States, resulting in over 480,000 premature deaths each year and is implicated as a causal agent in an increasing range of cancers. Prisoners, as a class, are especially vulnerable to the negative health consequences of smoking. Smoking rates are 3–4 times higher among prisoners than among individuals in the general population, and smoking is normative and nonstigmatized within the correctional environment. Among male prisoners, smoking prevalence is 70%–80%. Smoking rates among incarcerated women range from 42% to 91%—2–4 times greater than among women in the general population.

Ninety percent of prisons prohibit smoking in medical, chapel, and vocational and educational areas; however, about 40% allow unrestricted smoking in common areas, housing units and cells, or in prison yards. Due to a 2006 policy, cigarettes and other tobacco products are readily available in prison and tobacco products were banned from being sold in prison commissaries. In 2012, 30 states prohibited the use of tobacco inside state correctional facilities to reduce secondhand smoke. [CR] Due to the increase in smoke-free policies in prisons and jails, there has been an increase in tobacco contraband sold among prisoners. Tobacco products are bartered among prisoners and employees and function as a form of prison currency.

In an attempt to return nicotine products for sale in commissaries, electronic cigarettes have recently been developed specifically for use in correctional facilities. If successful, electronic cigarettes will be sold in prisons across all 50 states, with calculated sales of nearly $330,000 per 100 inmates annually. However, because of the high cost of cigarettes in prison, many prisoners purchase loose tobacco that they roll into nonfiltered cigarettes. Thus smoking inside a correctional environment may present a higher risk for tobacco-related diseases than smoking in the community.

In contrast to the enormous literature focusing on smoking prevalence, prevention, cessation, and policies in other populations, smoking among prisoners remains virtually ignored, despite the enormous human, health, and economic costs. Only five published studies have examined smoking interventions for prisoners. All five suggest that prisoners are interested in smoking cessation and able to achieve smoking abstinence, despite pressures within the correctional environment to continue smoking. In the largest study to date of smoking cessation in a correctional setting, Cropsey and colleagues conducted a randomized controlled trial of a combined nicotine replacement and 10-week group smoking cessation intervention for female prisoners. Sustained cessation rates were comparable to cessation rates following smoking cessation interventions in the community.

Psychiatric Disorders

According to a recent Report to Congress by the National Commission on Correctional Healthcare and National Institute on Justice on the health status of soon-to-be released inmates, rates of psychiatric disorders in US prisons and jails dramatically exceed general population rates. A meta-analysis of 62 studies from 12 Western countries estimated that one in seven prisoners has a psychotic or major depressive disorder. Prevalence estimates for psychiatric disorders among state prison inmates are schizophrenia (2%–4%), major depression (13%–19%), bipolar disorder (2%–5%), dysthymia (8%–14%), anxiety disorder (22%–30%), and posttraumatic stress disorder (6%–12%). Prevalence estimates for psychiatric disorders among jail inmates are similar: schizophrenia (1%), major depression (8%–15%), bipolar disorder (1%–3%), dysthymia (2%–5%), anxiety disorder (14%–20%), and posttraumatic stress disorder (4%–9%). Approximately 50% of female inmates have mental illness. A national study estimated rates of mental illness ranging from 3% to 23% for probationers and 1%–11% for parolees. Finally, 6% of male and 15% of female jail inmates have acute psychiatric symptoms in need of treatment at the time of initial booking.

Inmates with comorbid substance use and mental health problems report more numerous and serious past year and lifetime medical conditions and consume more medical services during incarceration and in the community —underscoring the importance of psychiatric treatment in correctional settings. With the number of prisoners with serious psychiatric disorders exceeding the number of patients in psychiatric hospitals, jails and prisons have become “America’s new mental hospitals” (p. 1612). For many individuals with severe mental illness, most psychiatric care is provided in jails and prisons. The high prevalence of psychiatric disorders in correctional populations is due, in part, to the deinstitutionalization of mentally ill persons, lack of access to community mental health services and the criminalization of the mentally ill. Unfortunately, most prisoners with psychiatric and substance use disorders do not receive adequate care during incarceration and are expected to serve 4 months longer than prisoners without a mental health problem. Although data are limited, most prisons and jails fail to conform to community standards for screening and treatment of mental disorders. For example, 83% of jails offer screening, 60% offer mental health evaluations, 42% provide psychiatric medications, 43% offer crisis intervention, and 72% offer access to inpatient psychiatric treatment. Jails and prisons differ in the type and range of mental health services; jails may provide management of acute symptoms and suicide prevention, whereas prisons may offer a range of services including long-term support and treatment. After incarceration, 34% of state prisoners received treatment, followed by 24% of federal prisoners and 17% of jail inmates. [CR] Medical and psychiatric treatment in criminal justice systems varies from state to state; some contract with independent companies to provide psychiatric and medical services for their populations. Often facilities offer specialized services such psychiatric or sex offender treatment units, although little is known about the types and effectiveness of treatment programs offered.