During his incarceration in a prison in Colorado, Scott (a pseudonym) was one of our many patients diagnosed with an addiction to fentanyl. While in prison, he was prescribed buprenorphine, a medication that lessens cravings for opiates and prevents withdrawal symptoms. One week after his release, Scott visited my office for continuation of treatment. As a new NP working in substance use (with individuals both within and outside of the judicial system), I innocently told Scott that he needed to report to my office the following week for our next appointment, and that he should also see a primary care provider for his diabetes and a psychiatric provider for his bipolar disorder. He looked at me with a combination of shock, anger, and helplessness.
After four years of working with recently imprisoned people, I am used to responses like Scott's. They usually go something like, "Between three different doctor's appointments, four drug screens a week, parole officer meetings, group therapy, community service hours, and paying court fees, how am I supposed to hold a job that makes enough to pay rent and feed my family?"
With so many requirements, patients often become distraught at the difficulty in finding their footing. Factors like economic stability, education, health care systems, community, and neighborhoods have an influence on health beyond genetics and behavior. But incarceration is an often-underappreciated social determinant of health. Health disparities between the incarcerated and nonincarcerated populations have been demonstrated not only with the COVID-19 pandemic, but also with chronic conditions and mental health diagnoses. My clinical experience focuses on the high prevalence of substance use in this group, which is a contributing factor to both entering prison and high recidivism, as well as to poor health outcomes and death.
The odds are stacked against patients like Scott reestablishing life after prison. Many employers are unwilling to hire someone with a criminal record. When a person does find employment, they may have difficulty obtaining a driver's license and have to rely on often time-consuming and unreliable public transportation. Missed work due to a three-hour bus ride or having to leave early to complete a drug screen can lead to termination or lost hourly wages. Day labor or temporary placements can be unpredictable and exploitative. And many people released from prison have not had the opportunity to learn the basic skills necessary to find consistent employment. These seemingly never-ending challenges too often push people back into lives of crime and relapse.
If the goal after prison is to allow people to create a dignified and fulfilled life, then it is critical to address the factors related to social determinants of health that hinder this reasonable aspiration. Although nurses can't repair the fragmented judicial system, we can offer kindness to these stigmatized patients. We can be more understanding with "no-shows" and more compassionate toward mental health struggles and relapses. We can be less quick to dismiss and discharge "difficult" patients or "frequent fliers." We can use our networks to access resources for a patient looking to get their high school diploma or find a job-training class. It is imperative that nurses understand that incarceration and other social determinants of health affect a person long after they've been released and strive to always provide patient-centered care of the highest quality-even to patients with active substance use.
Before meeting Scott and patients like him, I had never interacted with recently incarcerated individuals. What I thought would be a monotonous job of endless buprenorphine prescriptions taught me to feel compassion for these vulnerable people and to want to share their situation with my fellow health care workers. Our role is to meet the patient where they are and recognize each person's humanity without judgment. Every person deserves peace, well-being, and good health, and using the framework of social determinants can help us to understand and address these concerns equitably.