We can’t ignore the ties binding US deaths of despair and incarceration

Each day in the United States, millions of people cycle through the nation’s jails and prisons. Nearly 85 percent of them either recently used substances or have a substance use disorder, and nearly half of them have been diagnosed with a mental health condition. Yet, far from being a safe haven from overdoses, jails and prisons are adding fuel to the nation’s behavioral health crisis. 

People leaving jails and prisons are at greater risk of an overdose shortly after release, primarily due to a lack of treatment for opioid use disorder. This same population has a greater need for health care generally, with higher rates of death from cancer and heart disease than the general population. Further, almost 77 percent of those who died in local jails in 2019 were not convicted of a crime at the time of their death. 

Research recently released by the O’Neill Institute shows common threads in many deaths in jail custody. We examined civil litigation cases and case summaries involving deaths in jail custody between 2015 and 2020. In the hundreds of cases we looked at, almost a quarter of deaths in custody occurred in the first 24 hours of entry.  We also found that in more than half of the cases (59 percent), deaths were related to behavioral health conditions, which often led to suicide, fatal overdose and complications from substance use withdrawal. Suicide is the leading cause of death in U.S. jails, occurring at a rate twice that of individuals in the community.

Tragically, many of these deaths were avoidable. Based on our research, we make the following recommendations, each of which relies upon action by elected officials and correctional administrators.

• First, establish clear protocols and training for correctional staff to better screen and provide care for persons at risk for suicide, overdose, withdrawal, or other medical issues immediately upon intake, when the bulk of deaths occur. To enable quick access to quality medical and psychological treatment for physical and mental health conditions, including substance use disorder, these steps should take place in the first 24 hours and first seven days of incarceration. Clear intake procedures and connections to healthcare will provide people who are incarcerated with the lifesaving treatment they need.
• Second, Congress should act to eliminate the almost 60-year-old “inmate exclusion,” a provision in the Social Security Act of 1965 prohibiting the expenditure of federal Medicaid funds on health care for people who are incarcerated. The inmate exclusion applies even if an individual is awaiting trial or is incarcerated for a technical violation such as a missed appointment with their parole officer. When the law was enacted in 1965, just over 200,000 people were serving time in U.S. jails and prisons.  Today, more than 2 million people are in various detention facilities across the United States. The sheer number of people involved, and the urgency of today’s mental health and substance use crisis, impels a change. Eliminating the inmate exclusion will not only provide desperately needed resources for necessary medical care it will also clarify standards of care for correctional healthcare and provide an additional layer of oversight through the Centers for Medicare and Medicaid Services.
• Third, governments should scale up diversion and deflection services, including community-based treatment, so individuals with substance use disorder or mental health conditions are provided appropriate care in lieu of incarceration. Even with improved health care services, the correctional system is not well suited to care for people with substance use and mental health conditions. Diverting people to appropriate, community-based care will improve outcomes for individuals with behavioral and other health conditions. Moreover, if people are incarcerated, connecting them with community-based care immediately upon reentry will help save lives. 

Our research demonstrates that deaths in custody often result from untreated mental health conditions and substance use disorder. Governments at every level should use the tools at their disposal to reduce needless deaths in custody, as well as the monetary damages that result and follow through on these recommendations.

Improving training and procedures to address substance use and mental health, investing in correctional and community-based healthcare and promoting diversion programs can reduce the human and financial cost of deaths in jail custody, and allow people involved in the criminal legal system the chance to live full, healthy lives.  

Regina LaBelle, JD is the director of the Addiction and Public Policy Initiative at Georgetown University Law Center’s O’Neill Institute. In 2021, she served as acting director of the White House Office of National Drug Control Policy. Shelly Weizman, JD is the associate director of the Addiction and Public Policy Initiative. She is an adjunct professor at Georgetown Law Center and Georgetown University’s Master of Science in Addiction Policy and Practice program.