Care of Incarcerated Patients

Dawn M. Davis, MD, MPH;​Jennifer K. Bello, MD, MS;​and Fred Rottnek, MD

Saint Louis University School of Medicine, St. Louis, Missouri

The United States has the highest incarceration rate of any nation in the world. Approximately 870
of every 100,000 U.S. citizens are currently in jails or prisons. U.S. inmates are disproportionately
young males, racial and ethnic minorities, and persons of low socioeconomic status. Incarcerated per-
sons have high rates of psychiatric conditions, communicable diseases, substance use disorders, and
chronic diseases. The U.S. Preventive Services Task Force recommends that all inmates be screened for
human immunodeficiency virus infection, hepatitis C, syphilis, and latent tuberculosis infection, and
that sexually active female inmates be screened for gonorrhea and chlamydia. Inmates should also be
screened for psychiatric conditions and substance use disorders. Therapy should be continued for all
chronic conditions when indicated. Inmates should be referred to community organizations for fol-
low-up medical care and treatment of substance use disorders before they are released from detention
facilities. A systematic approach to urgent, routine, and preventive care for persons in jails and prisons
creates a healthier correctional environment and a healthier community after release. (Am Fam Physi-
cian. 2018;98(10):577-583. Copyright © 2018 American Academy of Family Physicians.)

Approximately 870 of every 100,000 U.S. adult citizens detention facilities, territorial prisons, military facilities,
are in jail or prison, which represents the highest incarcera- or tribal justice facilities.
tion rate in the world.1 Incarcerated persons are guaranteed a
right to health care by the 1976 U.S. Supreme Court decision Demographics
Estelle v. Gamble.2 Although the type and quality of health In 2015, the U.S. correctional population included more
care services for incarcerated persons differ because of vari- than 2.1 million adults in jails and prisons, and 4.66 mil-
ations in policies, budgets, and staffing across federal, state, lion adults supervised on probation or parole.1 The aver-
and local jurisdictions, such care benefits individuals, their age daily population of jail inmates in 2015 was 721,300,
institutional communities, and their home communities but because of high turnover rates, there were 10.9 million
after release. admissions into jails.3 About 27% of jail inmates are held
For the purposes of this article, the incarcerated popula- for misdemeanor offenses, and 63% have not been convicted
tion refers to persons held in local jails or under the juris- of a crime.3 The U.S. inmate population is heavily skewed
diction of state or federal prisons. Jails, which are under toward young males, racial and ethnic minorities, and per-
county or municipal jurisdiction, house persons awaiting sons of low socioeconomic status.4 Before incarceration,
trial, sentencing, or transfer to another facility;​those who these persons often reside in communities with high rates
have violated parole or probation;​and those who have of poverty, unemployment, family disruption, and racial
been sentenced to less than one year in custody. State and segregation.5
federal facilities house persons who have been sentenced As of 2015, non-Hispanic black males comprised the
to more than one year in custody. This article does not largest population of prisoners (37%) under state or federal
address juveniles in custody or adults in immigration jurisdiction.6 Black and Hispanic persons are incarcerated
in state prisons at 5.1 and 1.4 times the rate of whites, respec-
tively.7 Women and persons older than 55 years account for
CME This clinical content conforms to AAFP criteria for
smaller but increasing percentages of the incarcerated pop-
continuing medical education (CME). See CME Quiz on ulation (7% and 11%, respectively).6 Approximately 10% of
page 568. all jail, state, and federal inmates are military veterans,8
Author disclosure:​​ No relevant financial affiliations. and 12% to 16% were homeless in the past or at the time of
their incarceration.9,10

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 CARE OF INCARCERATED PATIENTS

perform tuberculosis and

SORT:​KEY RECOMMENDATIONS FOR PRACTICE other health screenings.
Prison and jail facili-
Evidence ties have varying levels of
Clinical recommendation rating References
medical care for inmates.
Incarcerated adults and adolescents benefit from HIV screening. A 19 Clinic visits are held in
prisons and some larger
Incarcerated or formerly incarcerated individuals should be screened B 20
for hepatitis C.
jails to address acute or
chronic medical problems.
Incarcerated or formerly incarcerated individuals should be screened A 21 Some facilities have conti-
for syphilis infection.
nuity clinics for those with
Incarcerated persons are at increased risk of latent tuberculosis infec- B 22 chronic illnesses. An infir-
tion and should be screened. mary is available in most
Because of the high rates of psychiatric conditions and substance use C 29 prisons and many large
disorders in incarcerated persons, inmates should be screened on jails for patients who are
entry to the facility with the Correctional Mental Health Screen or the ill enough to require daily
Brief Jail Mental Health Screen.
nursing care. Infirmary
Incarcerated persons 40 to 70 years of age should be screened for B 38 stays may be provided for
abnormal blood glucose levels if they are overweight or obese. recent transfers from hos-
HIV = human immunodeficiency virus.
pitals, patients undergoing
acute withdrawal symp-
A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality patient-oriented
evidence;​ C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For toms, and those who can-
information about the SORT evidence rating system, go to https://​w ww.aafp.org/afpsort. not perform their own
self-care. Some facilities
have psychiatric infirma-
Initial Approach ries to house patients who are acutely homicidal or sui-
The National Commission on Correctional Health Care cidal, or who are starting a new medication.
and the American Correctional Association provide guide-
lines for the accreditation of jails, prisons, and detention Medical Conditions in Inmates
centers, and processes described in this article are con- Communicable diseases, psychiatric illness, and noncom-
sistent with recommendations from these organizations. municable diseases are common within the U.S. prison
Detention facilities are not considered licensed health care population (Table 1).13-15
entities;​thus, accreditation is not mandatory. Most U.S.
jails, prisons, and detention facilities are not accredited. COMMUNICABLE DISEASES
Intake screening should be performed for all inmates The U.S. inmate population has higher rates of nearly every
on arrival at a facility to ensure that they are healthy infectious disease compared with the general population.
enough for incarceration. This process, termed a fit for In 2015, the rate of human immunodeficiency virus (HIV)
confinement examination, should be done as soon as pos- infection in inmates housed in state and federal facilities was
sible, particularly in a jail setting.11,12 Inmates who are not 1,297 cases per 100,000 persons16;​the rate among the gen-
considered fit for confinement should be transferred to eral U.S. population was 299.5 cases per 100,000 persons.17
an emergency department for further evaluation. Intake In 2013, the annual incidence of tuberculosis in jail inmates
screening usually involves a structured interview and and federal prisoners was eight times that in the overall U.S.
limited examination by a health professional, but it can population.18 Nearly one-half of inmates diagnosed with
be completed by a trained correctional staff member. The tuberculosis while in custody were born outside the United
intake health assessment is a more thorough evaluation States (primarily in Mexico and Central America).18 Because
that includes medical, dental, and mental health histories of the increased risk of infection in the correctional pop-
and a physical examination. It is completed by a physi- ulation, the U.S. Preventive Services Task Force (USPSTF)
cian, nurse practitioner, physician assistant, or specially recommends that inmates be screened for HIV infection,19
trained nurse and should be performed within 14 days of hepatitis C,20 syphilis,21 and latent tuberculosis.22 It also
admission to jail or within seven to 14 days of admission recommends that inmates be given behavioral counseling
to prison. Intake health assessments are opportunities to interventions to prevent sexually transmitted infections.23

578  American Family Physician www.aafp.org/afp Volume 98, Number 10 ◆ November 15, 2018
 CARE OF INCARCERATED PATIENTS

opioid, and benzodiazepine detoxification. Medical treat-

TABLE 1 ment for substance use disorders, including methadone or
buprenorphine, is often unavailable in correctional insti-
Common Medical Conditions in Jail Inmates tutions.32,33 Substance abuse education is most commonly
and State and Federal Prisoners provided to inmates with substance use disorders or addic-
Jail State and federal tion problems.30,32 Because of high relapse rates, inmates
Condition inmates (%) prisoners (%) with opioid use disorders should be referred to appropriate
Drug dependence or 63.3 58.5 community-based medication-assisted therapy on release
abuse 13 from correctional facilities. A recent systematic review
concluded that compared with referral to community treat-
Overweight, obesity, or 62 74
morbid obesity 14 ment for substance use disorder, extended-release naltrex-
one administered before release decreases opioid use in
History of mental health 44.3 36.9 adults under criminal justice supervision. Extended-release
disorder 15
naltrexone can be prescribed by any licensed clinician.34
Hypertension 14 26.3 30.2
CHRONIC CONDITIONS
Asthma 14 20.1 14.9
Chronic diseases are common among inmate populations.
History of infectious 14.3 21 Medical records should be requested from the inmate’s pri-
disease 14 mary care clinician to ensure continuity of care, and ther-
Arthritis or rheumatism 14 12.9 15 apy should be continued for all chronic conditions. Certain
chronic conditions may be exacerbated by excess calories and
Heart conditions 14 10.4 9.8
sodium in prison diets, lack of physical activity, and psycho-
Diabetes mellitus or high 7.2 9 logical stress associated with incarceration.35-37 Physicians
blood glucose levels 14 should screen for obesity and diabetes mellitus in accordance
Information from references 13 through 15.
with USPSTF recommendations for the general population.38
Preventive medications, including statins and aspirin, should
also be provided based on USPSTF recommendations.
The World Health Organization recommends that condoms
be distributed in prisons to decrease the transmission of Special Needs of Incarcerated Females
HIV and other sexually transmitted infections,24 but only The female jail population is the fastest growing correc-
two states (California and Vermont) require condoms to be tional population, increasing by 18% between 2010 and
available to inmates.16,17,25 2014.39 Female inmates have a higher prevalence of chronic
medical conditions, psychiatric conditions, and substance
PSYCHIATRIC ILLNESS AND SUBSTANCE ABUSE use disorders compared with male inmates.40 Incarcerated
The number of U.S. inmates with symptoms or a diagnosis of women have disproportionate rates of chlamydia and gon-
psychiatric illness is significantly higher than in the general orrhea compared with incarcerated males and the general
population;​estimates vary from 37% to 60% of inmates.13,26 population, and females in juvenile correctional facilities
Psychiatric conditions increase the risk of being placed in have the highest rates.41 The USPSTF recommends that all
solitary confinement,27 being assaulted while incarcerated,26 sexually active incarcerated women be screened for gonor-
engaging in self-harming behaviors (including suicide),27 rhea and chlamydia using nucleic acid amplification test-
and of recidivism.28 On arrival to a correctional facility, ing.42 Incarcerated women also have higher rates of cervical
inmates should be screened with the Correctional Men- cancer than women in the general population.43,44 Most have
tal Health Screen or the Brief Jail Mental Health Screen,29 experienced childhood physical or sexual abuse, which is
and those who screen positive should be referred for fur- strongly linked to substance use disorders later in life,45,46 as
ther mental health evaluation.29 Medical records should be well as increased risk of physical and sexual victimization
requested for inmates with known psychiatric diagnoses. by other inmates or staff.47,48
Psychoactive medications should be continued without Addressing the reproductive health needs of incarcerated
interruption once previous prescriptions have been verified. women is an essential component of health care delivery in
Many inmates report substance use disorders.30,31 They adult and juvenile correctional settings. On average, 6% to
should be evaluated on admission for substance use history. 10% of incarcerated women are pregnant, with the high-
Many large urban jails have standing orders for alcohol, est rates in local jails.49 Incarcerated women are at risk of

November 15, 2018 ◆ Volume 98, Number 10 www.aafp.org/afp American Family Physician 579
 CARE OF INCARCERATED PATIENTS
FIGURE 1

On intake, assess all women of childbearing age for

pregnancy risk and history of reproductive health issues
Inquire about sexual activity, menses, contraceptive
poor maternal and infant use, history of sexually transmitted infections, and
health outcomes because of Papanicolaou results

the high rate of comorbid

medical conditions in this Screen for the following in accordance
population. Incarcerated with guidelines from the U.S. Preventive
women are also at high risk Services Task Force:
Cervical and breast cancers
of unintended pregnancy;​
Gonorrhea/chlamydia
in one study, more than
Human immunodeficiency virus
80% of incarcerated women Syphilis
reported that they had had Perform pregnancy test if indicated
an unintended pregnancy.49
All female inmates should
undergo a reproductive
health evaluation and be
Pregnant Not pregnant
provided with any indicated
contraceptive and/or pre-
conception health services Provide pregnancy counseling
(Figure 1).50-52 Preventive
Patient desires Patient does not
health services specific to pregnancy desire pregnancy
women include screening for
gonorrhea and chlamydia,42 Carry pregnancy Patient requests
Optimize physical Provide contraceptives,
cervical cancer,53 and breast to term abortion
and mental health including emergency
cancer.54 These services Counsel about contraception
should be provided based on Screen for and treat substance Refer for
substance use Consider long-acting
reversible contraceptives, if
USPSTF guidelines, which use disorders (if not done abortion Provide folate
available
supplementation
are endorsed by the Amer- previously) services*

ican Academy of Family Pregnant women with opioid

use disorders should be treated
Physicians.55 In a jail setting, with an opiate agonist
Papanicolaou testing and Provide care in accordance with
mammography should be guidelines from the American
College of Obstetricians
ordered only if results will and Gynecologists and the
be obtained before release. American Academy of Pediatrics

Reentry to the *–Ability to refer for abortion services varies by state and correctional facility.

Community
Reproductive health assessment for female correctional inmates.
Persons recently released
from incarceration have Information from references 50 through 52.

high levels of poverty,

unemployment, and home-
lessness.56 Former inmates with medical or psychiatric most inmates are discharged from correctional facilities
conditions or substance use disorders face distinct chal- without a supply of medications or referrals to primary care,
lenges in finding housing and employment, reconnecting mental health services, or substance abuse treatment.59-61
with family members, abstaining from substance use, and Lack of care coordination directly affects the health of for-
avoiding a return to prison.57 The American Correctional mer inmates. In the two weeks following release, former
Association recommends that health professionals encour- inmates are 129 times more likely to die of a drug overdose
age continuity of care from admission to facility transfer or and 12 times more likely to die of any cause than members
discharge.58 Discharge planning for inmates with serious of the general public.56
health needs should include providing linkages between Many local reentry programs have been established. The
the facility and community-based organizations, assisting Transitions Clinic Network, a primary care–based com-
with scheduling appointments, and arranging medications plex care management program serving formerly incarcer-
for the patient at release.12 Despite these recommendations, ated persons with chronic health problems, has been well

580  American Family Physician www.aafp.org/afp Volume 98, Number 10 ◆ November 15, 2018
 TABLE 2

Evidence-Based Correctional Health Care Resources

for Physicians
studied.62,63 Transitions clinics, which Resource Website
are embedded into preexisting com- American Academy of Family Physicians
munity health centers, offer primary Incarceration and Health:​A Family https://​w ww.aafp.org/about/policies/all/
care services from clinicians who have Medicine Perspective incarcerationandhealth.html
experience working with corrections
American College of Correctional http://​accpmed.org/links.php
populations and case management Physicians
from community health workers
with a personal history of incarcer- American College of Obstetricians and
ation.63 Transitions clinics are cur- Gynecologists

rently located in 11 states and Puerto Health Care for Pregnant and Post- https://​w ww.acog.org/Clinical-
partum Incarcerated Women and Guidance-and-Publications/
Rico. A 2012 study demonstrated that Adolescent Females Committee-Opinions/Committee-
chronically ill persons leaving cor- on-Health-Care-for-Underserved-
rectional facilities will engage with Women/Health-Care-for-Pregnant-
primary care via these clinics when and-Postpartum-Incarcerated-
Women-and-Adolescent-Females
they are provided access, which leads
Reproductive Health Care for Incarcer- https://​www.acog.org/Clinical-Guidance-
to a decrease in emergency depart- ated Women and Adolescent Females and-Publications/Committee-Opinions/
ment utilization.62 Other studies have Committee-on-Health-Care-for-
shown excellent six-month retention Underserved-Women/Reproductive-
rates for patients with HIV infection, Health-Care-for-Incarcerated-Women-
and-Adolescent-Females
but lower rates among patients with
hypertension, diabetes, and opioid use American Correctional Association http://​w ww.aca.org
disorders.64
Center for Prisoner Health and Human http://​w ww.prisonerhealth.org/
Rights
Model for Provision of Care:​
An Opportunity for Family Centers for Disease Control and Prevention
Physicians Correctional Health (includes links to https://​w ww.cdc.gov/
A consistent approach is recom- state resources) correctionalhealth/
mended for providing health services Federal Bureau of Prisons Health Man- https://​w ww.bop.gov/resources/health_
that address urgent, chronic, and agement Resources (includes guidelines care_mngmt.jsp
infectious conditions in incarcerated for management of 35 conditions)
persons. An ideal model for delivering
National Commission on Correctional https://​ncchc.org
health services in a correctional facil- Health Care
ity includes:​ Guide to Developing and Revising Alco- https://​w ww.ncchc.org/filebin/
• Intake services that screen for phys- hol and Opioid Detoxification Protocols Resources/Detoxification-
ical and behavioral health conditions, Protocols-2015.pdf
as well as common infectious diseases Managing Opiate Withdrawal:​The https://​w ww.ncchc.org/filebin/Correct
WOWs Method (opioid withdrawal scale Care/30-3-WOWS.pdf
• Interprofessional health services
and management recommendations)
that include acute and chronic care,
behavioral and substance abuse care, Substance Abuse and Mental Health
dental care, and social services Services Administration
• Reentry services that optimize Guidelines for Successful Transition of https://​store.samhsa.gov/shin/content/
People with Mental or Substance Use SMA16-4998/SMA16-4998.pdf
continuity of care, patient self-man- Disorders from Jail and Prison:​Imple-
agement, and connecting patients with mentation Guide
health services in their community. Medications for Opioid Use Disorder https://​store.samhsa.gov/product/
The care of incarcerated popula- (reviews pharmacotherapy for opioid TIP-63-Medications-for-Opioid-
tions requires judicious use of limited use disorder and provides resources for Use-Disorder-Executive-Summary/
clinicians and patients) SMA18-5063EXSUMM
resources and creative collaborations.
Table 2 lists evidence-based resources World Health Organization
that can assist physicians in providing Health in Prisons:​A WHO Guide to the http://​w ww.euro.who.int/__data/assets/
high-quality care for incarcerated indi- Essentials in Prison Health pdf_file/0009/99018/E90174.pdf
viduals and their communities.

November 15, 2018 ◆ Volume 98, Number 10 www.aafp.org/afp American Family Physician 581
 CARE OF INCARCERATED PATIENTS

Data Sources:​ The following data sources were searched in the 1 1. National Commission on Correctional Health Care. Standards for Health
preparation of this manuscript:​the Cochrane database, Agency Services in Prisons. Chicago, Ill.:​National Commission on Correctional
for Healthcare Research and Quality evidence reports, the Health Care;​2014.
Bureau of Justice Statistics website, the U.S. Preventive Services 1 2. National Commission on Correctional Health Care. Standards for
Task Force, and PubMed. The search terms included care of Health Services in Jails:​2014. Chicago, Ill.:​National Commission on
Correctional Health Care;​2014.
inmates and prisoners. The initial search took place on April 15,
13. Bronson J, Stroop J, Zimmer S, Berzofsky M. Drug use, dependence,
2017. Additional PubMed searches were done in July and August
and abuse among state prisoners and jail inmates, 2007-2009. U.S.
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Department of Justice. June 2017. https://​w ww.bjs.gov/content/pub/
pdf/dudaspji0709.pdf. Accessed June 22, 2018.
The Authors 14. Maruschak LM, Berzofsky M, Unangst J. Medical problems of state and
federal prisoners and jail inmates, 2011-12. U.S. Department of Jus-
DAWN M. DAVIS, MD, MPH, is an assistant professor in the tice. Revised October 4, 2016. https://​w ww.bjs.gov/content/pub/pdf/
Department of Family and Community Medicine at Saint mpsfpji1112.pdf. Accessed June 22, 2018.
Louis (Mo.) University School of Medicine. 15. Bronson J, Berzofsky M. Indicators of mental health problems reported
by prisoners and jail inmates, 2011-12. U.S. Department of Justice. June
JENNIFER K. BELLO, MD, MS, is an assistant professor in the 2017. https://​w ww.bjs.gov/content/pub/pdf/imhprpji1112.pdf. Accessed
June 22, 2018.
Department of Family and Community Medicine at Saint
Louis University School of Medicine. 16. Maruschak LM, Bronson J. HIV in prisons, 2015 - statistical tables. U.S.
Department of Justice. August 2017. https://​w ww.bjs.gov/content/pub/
pdf/hivp15st.pdf. Accessed June 22, 2018.
FRED ROTTNEK, MD, is a professor in the Department of
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Family and Community Medicine at Saint Louis University
tion in the United States and dependent areas, 2015. HIV Surveillance
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582  American Family Physician www.aafp.org/afp Volume 98, Number 10 ◆ November 15, 2018
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