Opioid use disorder, infectious diseases, and the criminal justice system

Background on criminal justice in the United States

In the United States, the rate of incarceration has skyrocketed over the last 50 years, ignited by the “Tough on Crime” as well as the “War on Drugs” political pushes of the 1970s and disproportionately affecting people of color and people with mental health illnesses. The lifetime likelihood of incarceration for black men in the United States is 1 in 3, compared 1 in 17 for white men (Bonczar, 2013). Of the 2.2 million people incarcerated in the United States at any given time, over half have been diagnosed with a substance use disorder, with or without a serious mental illness. 12% of jail inmates report using opioids regularly, more than six times higher than the general population [ , ].

The specifics of mass incarceration based on location, medical care, and jurisdiction should also be highlighted. 1.2 million sentenced individuals are incarcerated in state prisons, while approximately 600,000 people reside in local jails in the United States. Jail stays are generally shorter, tend to be a pretrial population, and are more likely to consist of time served for misdemeanors. Prisons stays, on the other hand, are longer, for sentenced individuals, and generally sentences that involve more serious crimes. In terms of jurisdiction, jails mostly are managed under local governing bodies, while prisons are managed at the state or federal level. Within federal prisons, run by the federal Bureau of Prisons or utilizing private prisons in some places, approximately 200,000 people are currently incarcerated. Drug offense charges comprise 14.8% of sentences at a state level and 47.3% at a federal level [ ]. With more states interested in implementing diversion for low-level offenses like drug possession, these statistics will hopefully change, but again, in the scope of the ongoing “War on Drugs” and the opioid epidemic, there is a real concern that this could continue to worsen.

Prisoners are the only group of people in the United States who have a constitutional right to healthcare. The federal case Estelle v Gamble (1976) determined that prisoners should be guaranteed three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment. Any lack of these rights for prisoners constituted a violation of the 8th Amendment, “cruel and unusual punishment” [ ]. Despite a federal ruling, many prisoners still have incomprehensibly poor access to healthcare, and the variability in quality of care is wide.

Bloodborne illnesses in criminal justice settings

As other chapters in this book will delve into the details of bloodborne illnesses in the setting of opioid use disorder, we will focus specifically on the criminal justice setting.