Research Article: Illicit substance use after release from prison among formerly incarcerated primary care patients: a cross-sectional study

Date Published: February 19, 2019

Publisher: BioMed Central

Author(s): Adam Chamberlain, Sylviah Nyamu, Jenerius Aminawung, Emily A. Wang, Shira Shavit, Aaron D. Fox.


More than 80% of people in jail or prison report having used illicit substances in their lifetimes. After release from incarceration, resumption of substance use carries risks, including parole revocation, exacerbation of mental health conditions, transmission of infectious diseases, and drug overdose.

This cross-sectional study used baseline data from the Transitions Clinic Network (TCN,, a multi-site prospective longitudinal cohort study of post-incarceration medical care. We investigated substance use among adults, with at least one chronic health condition or age ≥ 50 years, who had been recently released from incarceration and initiated care at a TCN site. Our primary outcome was any self-reported illicit substance use (heroin or other opioids, cocaine, cannabis, amphetamines, hallucinogens, MDMA, or illicit use of prescription medications) following release from incarceration. Alcohol use post-release was a secondary outcome. Using multivariable logistic regression, we also explored factors associated with illicit substance use.

Among 751 participants, median age was 47; participants were mostly male (85%), non-white (47% black, 30% Hispanic), and on parole (80%). The proportion of participants reporting any illicit substance use and any alcohol use soon after release from incarceration was 18% and 23%, respectively. In multivariable regression, variables significantly associated with post-release illicit substance use were male gender (aOR = 3.91, 95% CI: 1.73–8.81), housing with friends or family (aOR = 3.33, 95% CI: 1.20–9.28), years incarcerated during latest prison term (aOR = 0.93, 95% CI: 0.89–0.98), weeks elapsed before engagement with TCN (aOR = 1.07, 95% CI: 1.03–1.10), being on parole (aOR = 0.58, 95% CI: 0.34–0.99), and having a drug use disorder (aOR = 2.27, 95% CI: 1.40–3.68).

Among individuals seeking medical care after release from incarceration, self-reported substance use was lower than previously reported estimates of post-incarceration substance use. Known risk factors, such as male gender and having a drug use disorder, were associated with illicit substance use, as were novel risk factors, such as less supervised housing. Though illicit substance use post-incarceration can carry severe consequences, treatment and surveillance interventions should be targeted toward individuals with greatest risk.

Partial Text

The criminal justice system has an exceptionally broad reach in the United States. At any one time, over 2 million people are incarcerated with 1.3 million in state prisons, 630,000 in local jails, nearly 200,000 in federal prison, and 40,000 in immigration detention centers [1]. Problematic substance use is common among this population with more than 80% of people in jail or prison reporting having used illicit substances in their lifetimes [1, 2]. The majority of people in jails (53%), state prisons (56%), or federal prisons (50%) met DSM-IV criteria for a substance use disorder (SUD) at the most recent national surveys [3–5]. Additionally, according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA), 19% of males on probation (i.e. sentenced and serving time in the community) aged 18–49 had a drug use disorder (DUD) and over a quarter had an alcohol use disorder (AUD) in 2012 [6]. However, few incarcerated individuals receive evidence-based SUD treatment, and substance use often continues during and after incarceration [7, 8].

This cross-sectional study utilized baseline data from the Transitions Clinic Network (TCN,, a multi-site prospective longitudinal cohort study of post-incarceration medical care.

Of the 751 participants who completed the TCN baseline survey, the median age was 47, participants were mostly male (85%), non-white (47% black, 30% Hispanic), and had not graduated from high school (59%). Participants were most commonly on parole (80%), lived in institutional housing (39%), and unemployed (92%). The median time incarcerated during participants’ most recent prison term was 4 years (Interquartile range: 2–8 years). The median time from prison release to engagement at a TCN site was 5 weeks (IQR: 2–9 weeks). Among clinical factors, slightly less than half of all participants reported a prior diagnosis with depression (46%) or a drug use disorder (45%) (see Table 1).Table 1Demographic and clinical characteristics of 751 participants who received medical care following release from prisonDemographic characteristicReported any substance use since release (%)(n = 134)Did not report any substance use since release (%)(n = 617)Total n (%)(n = 751)p-valueAge, median (IQ range)45 (35–51)48 (39–54)47 (38–53)< 0.01Male123 (92)517 (84)640 (85)0.02Race/ethnicity Hispanic36 (27)191 (31)227 (30)NS Non-Hispanic black72 (54)280 (45)352 (47)0.08 Non-Hispanic white19 (14)115 (19)134 (18)NS Other7 (5)31 (5)38 (5)NSGraduated high school50 (38)255 (42)305 (41)NSReceive employment earnings7 (5)54 (9)61 (8)NSReceive any income61 (46)316 (51)377 (50)NSHousing Unstable44 (33)148 (24)192 (26)0.04 Institutional25 (19)266 (42)291 (39)< 0.01 “Doubling up”58 (43)152 (25)210 (28)< 0.01 Rent/own7 (5)50 (8)57 (7)NSYears incarcerated during latest prison term, median (IQ)2 (1–4)4 (2–9)4 (2–8)<  0.01Weeks to TCN engagement, median (IQ)7 (3–14)4 (2–9)5 (2–9)<  0.01Current parole95 (72)501 (82)596 (80)<  0.01Reported diagnoses Depression (N = 683)71 (59)240 (43)311 (46)<  0.01 Bipolar (N = 677)42 (36)141 (25)183 (27)0.02 PTSD (N = 680)23 (19)100 (18)123 (18)NS Schizophrenia (N = 684)25 (20)84 (15)109 (16)NS Drug use disorder (N = 689)74 (60)236 (42)310 (45)< 0.01 Alcohol use disorder (N = 695)34 (27)171 (30)205 (30)NSReceived SUD treatment in prison (N = 362)53 (65)201 (72)254 (70)NSItalic = statistically significant In our cohort of individuals recently released from prison who initiated medical care at a transitions clinic, 18% reported illicit substance use between their prison release and first primary care appointment. In multivariable analysis, we found that post-release substance use was associated with expected risk factors such as drug use disorders, male gender, parole status, and time elapsed between release and the first medical encounter. Interestingly, housing status—specifically, living “doubled up” with friends or family members—had among the strongest association with post-release substance use, and this did not change when we excluded participants who were not monitored by parole (data not shown). Also, greater amount of time incarcerated at the latest prison term (in years) was associated with lower odds of post-release illicit substance use. These findings suggest areas, such as post-incarceration aftercare for drug use disorders or structured housing environments, where interventions could reduce the risk of post-release substance use and perhaps consequences of substance use.   Source: