US Prisoners Being Undertreated for Common Chronic Health Conditions

G. Caleb Alexander, MD, MS
Credit: Johns Hopkins Bloomberg School of Public Health

As national headlines are being dominated by claims of inhumane conditions contributing to the death of LaShawn Johnson inside of a Fulton County justice facility¹, a new study in the Journal of the American Medical Association is outlining the undertreatment of chronic health conditions among incarcerated individuals in the US.²

The study, which was led by a team at Johns Hopkins Bloomberg School of Public Health, suggested use of prescription medications for chronic conditions was consistently lower in jails and state prisons compared with community settings, including prescriptions for diabetes, asthma, hypertension, depression, and more.²

“Our findings raise serious concerns about the access to and quality of pharmacologic care for very common chronic health conditions among the incarcerated,” said senior investigator G. Caleb Alexander, MD, MS, professor in the Department of Epidemiology at the Bloomberg School.³“We knew going in that the US incarcerated population has a higher prevalence of some chronic diseases. But we were really surprised by the extent of potential undertreatment that we identified.”

Citing an interest in developing a greater understanding of treatment among incarcerated individuals in the US, the current study was launched by Alexander and colleagues with the intent of exploring differences in treatment with prescription medications using data from the IQVIA’s National Sales Perspective, which includes data related to prescriptions at state prisons, county and city jails, and juvenile detention centers. Using 2018-2020 as a time period of interest, investigators combined NSP data with information from the National Survey on Drug Use and Health to estimate condition prevalence among the incarcerated population.²

The study investigators identified 7 conditions of interest for their cross-sectional analysis. These conditions were diabetes, asthma, hypertension, hepatitis B and C, human immunodeficiency virus (HIV), depression, and severe mental illness. Investigators pointed out further analysis was planned to examine whether there was evidence of using older products among incarcerated individuals relative to their counterparts who were not incarcerated for diabetes medications specifically.²

Upon analysis, results indicated the proportion of pharmaceuticals distributed to jails and state prisons to treat type 2 diabetes (0.15%), asthma (0.15%), hypertension (0.18%), hepatitis B or C (1.68%), HIV (0.73%), depression (0.36%), and severe mental illness (0.48%) was much lower compared with the relative burden of disease among this population. Relative to the general population, incarcerated populations had a greater prevalence of hepatitis (6.08% [95% confidence interval [CI], 4.32-8.49] vs 1.41% [95% CI, 1.25-1.59]), HIV (0.84% [95% CI, 0.43-1.61] vs 0.28% [95% CI, 0.21-0.37]), depression (15.10% [95% CI, 13.36-17.01] vs 7.64% [95% CI, 7.40-7.88]), and severe mental illness (13.12% [95% CI, 11.59-14.82] vs 4.89% [95% CI, 4.70-5.08]). Investigators determined the magnitude of difference between burden of dais compared to proportion of total NSP extended units distributed to the incarcerated population was 2.86 (95% CI, 2.22-3.65) for diabetes, 5.45 (95% CI, 4.32-6.83) for asthma, 2.40 (95% CI, 1.98-2.89),1.87 (1.51-2.29) for hepatitis B or C, 3.01 (95% CI, 2.06-4.37) for HIV, 4.08 (95% CI, 3.73-4.45) for depression, and 4.11 (95% CI, 3.78-4.46) for severe mental illness.²

In regard to products used in people with diabetes, results suggested 87.1% were of the oldest vintage, 11.1% were of moderate vintage, and 1.8% were of the most recent vintage. In comparison, among the nonincarcerated populations, 76.5% of therapies were of the oldest vintage, 11.2% were of moderate vintage, and 12.3% were of the most recent vintage.²

“Health care provided in jails and prisons is provided by a patchwork of health care providers, most commonly private contractors who do not widely share information about the services they provide to incarcerated people,” added study investigator Brendan Saloner, PhD, an associate professor in the Bloomberg School’s Department of Health Policy and Management.³ “The lack of transparency means that advocates and policymakers have a very incomplete picture of the medicines that are available during a stay in jail or prison.”

References

1. Youd C. Family says deplorable conditions and insect bites in Atlanta Jail contributed to Inmate's death. CNN. https://www.cnn.com/2023/04/13/us/atlanta-inmate-dies-jail-conditions-family/index.html. Published April 14, 2023. Accessed April 17, 2023.
2. Curran J, Saloner B, Winkelman TN, Alexander GC. Estimated Use of Prescription Medications Among Individuals Incarcerated in Jails and State Prisons in the US. JAMA Health Forum. 2023;4(4):e230482. doi:10.1001/jamahealthforum.2023.0482
3. Analysis of health and prescription data suggests chronic health conditions in U.S. incarcerated people may be severely undertreated. Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2023/analysis-of-health-and-prescription-data-suggests-chronic-health-conditions-in-us-incarcerated-people-may-be-severely-undertreated. Published April 14, 2023. Accessed April 17, 2023.