Megan Comfort

Public health and international drug policy.

The Johns Hopkins–Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug-control policy and to inform and encourage a central focus on public health evidence and outcomes in drug-policy debates, such as the important deliberations of the 2016 UNGASS on drugs. n nThe Commission is concerned that drug policies are often coloured by ideas about drug use and dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug misuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, emphasised that drug use “is neither a medical condition, nor does it necessarily lead to drug dependence”. The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, and alcohol, for which the goal of social policy is to reduce potential harms.

Ambiguity, Ambivalence, and Apprehensions of Taking HIV-1 Pre-Exposure Prophylaxis among Male Couples in San Francisco: A Mixed Methods Study

Objective We conducted a mixed-methods study to examine serodiscordant and seroconcordant (HIV-positive/HIV-positive) male couples PrEP awareness, concerns regarding health care providers offering PrEP to the community, and correlates of PrEP uptake by the HIV-negative member of the couple. Design Qualitative sub-study included one-on-one interviews to gain a deeper understanding of participants awareness of and experiences with PrEP and concerns regarding health care providers offering PrEP to men who have sex with men (MSM). Quantitative analyses consisted of a cross-sectional study in which participants were asked about the likelihood of PrEP uptake by the HIV-negative member of the couple and level of agreement with health care providers offering PrEP to anyone requesting it. Methods We used multivariable regression to examine associations between PrEP questions and covariates of interest and employed an inductive approach to identify key qualitative themes. Results Among 328 men (164 couples), 62% had heard about PrEP, but approximately one-quarter were mistaking it with post-exposure prophylaxis. The majority of participants had low endorsement of PrEP uptake and 40% were uncertain if health care providers should offer PrEP to anyone requesting it. Qualitative interviews with 32 men suggest that this uncertainty likely stems from concerns regarding increased risk compensation. Likelihood of future PrEP uptake by the HIV-negative member of the couple was positively associated with unprotected insertive anal intercourse but negatively correlated with unprotected receptive anal intercourse. Conclusions Findings suggest that those at greatest risk may not be receptive of PrEP. Those who engage in moderate risk express more interest in PrEP; however, many voice concerns of increased risk behavior in tandem with PrEP use. Results indicate a need for further education of MSM communities and the need to determine appropriate populations in which PrEP can have the highest impact.

Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: The intersection of policy, drug use, trauma, and urban space

BACKGROUNDnDue to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women.nnnMETHODSnWe report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs.nnnRESULTSnWomen in the study lived in a range of SRO built environments, from publicly funded, newly built SROs to privately owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.s framework of socio-structural vulnerability, we explore how SROs can operate as mental health risk environments in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact womens mental health. The degree to which SRO built environments were trauma-sensitive at the macro level significantly influenced womens mental health at meso- and micro-levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro-level to manage their mental health symptoms.nnnCONCLUSIONnStudy findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

Discrimination and psychological distress among recently released male prisoners.

Though theoretical perspectives suggest experiences of stigma and discrimination after release may be one pathway through which incarceration leads to poor mental health, little research considers the relationship between discrimination and mental health among former inmates. In this article, data from a sample of men recently released from prison to Oakland or San Francisco, California (N = 172), are used to consider how criminal record discrimination and racial/ethnic discrimination are independently and cumulatively associated with psychological distress. Results indicate that (a) the frequency of criminal record discrimination and racial/ethnic discrimination are similar; (b) both forms of discrimination are independently, negatively associated with psychological distress; and (c) the level of racial/ethnic discrimination does not alter the association between criminal record discrimination and psychological distress. The results highlight that criminal record discrimination is an important social stressor with negative implications for the mental health of previously incarcerated individuals.

A New Vulnerable Population? The Health of Female Partners of Men Recently Released from Prison

BACKGROUNDnDespite a growing literature on the consequences of having a romantic partner incarcerated on womens risk of contracting sexually transmitted infections, little research considers the broader health profile of the female partners of ever-imprisoned men.nnnMETHODSnWe use data from the Relate Project (nxa0=xa0332), a unique cross-sectional survey of recently released men and their female partners (2009-2011), to demonstrate that the female partners of recently released men suffer from a variety of health risks and conditions. We also examine the health conditions of females by their own incarceration history.nnnFINDINGSnWe find that these women engage in poor health behaviors including smoking, drug use, and excessive alcohol consumption and have high levels of health conditions including asthma, hypertension, anxiety, and depression. The vulnerability of women who had themselves been incarcerated in jails or prisons was especially acute. The number of risky background characteristics such as dropping out of high school (45%) and spending time in foster care or a group home (36%) were staggeringly high for ever-imprisoned women, as were their rates of anxiety (50%), depression (59%), and posttraumatic stress disorder (45%).nnnCONCLUSIONSnResults reveal that the health of the female partners of recently released men is at least as poor as that of their male partners, suggesting a degree of vulnerability that has yet to be considered in the medical or public health literature and a population that desperately needs medical attention with the full rollout of the Affordable Care Act inxa02014.

“It Was Basically College to Us”: Poverty, Prison, and Emerging Adulthood

With the tremendous rise in the United States incarceration rates over the last four decades, historically high numbers of young African Americans are spending their “emerging adulthood” (as theorized by Arnett) in close contact with the penitentiary. In contrast to the exploration of future possibilities facilitated by academic, military, and professional institutions geared toward people in this life stage, imprisonment typically restricts ones social, occupational, and civic opportunities during and after confinement. In this article, I draw on in-depth interviews with young men who had recently exited state prison and their intimate partners to probe the meanings of incarceration for emerging adults in the neoliberal era. This investigation invokes Merton and Barbers concept of sociological ambivalence, Blankenships discussion of sociological thriving, and Bourdieus notion of amor fati to analyze the paradoxically positive accounts offered by young people when describing their early experiences with the prison. I argue that these narratives must be interpreted in the broader context of diminished social welfare and intensified socioeconomic disadvantage that force poor people to turn to a punitive institution as a “resource” for the social goods distributed through valorized channels to their more privileged peers. This analysis invites further research by highlighting the necessity of developing a thorough understanding of the dominant role of the prison as a shaping institution at a critical juncture in the lives of those born into poverty.

Partner Incarceration and African-American Women’s Sexual Relationships and Risk: A Longitudinal Qualitative Study

Racialized mass incarceration is associated with racial/ethnic disparities in HIV and other sexually transmitted infections (STIs) in the US. The purpose of this longitudinal qualitative study was to learn about the processes through which partner incarceration affects African-American women’s sexual risk. Four waves of in-depth qualitative interviews were conducted in 2010–2011 with 30 women in Atlanta, Georgia (US) who had recently incarcerated partners. Approximately half the sample misused substances at baseline. Transcripts were analyzed using grounded theory. For over half the sample (Nu2009=u200919), partner incarceration resulted in destitution, and half of this group (Nu2009=u20099) developed new partnerships to secure shelter or food; most misused substances. Other women (Nu2009=u20099) initiated casual relationships to meet emotional or sexual needs. When considered with past research, these findings suggest that reducing incarceration rates among African-American men may reduce HIV/STIs among African-American women, particularly among substance-misusing women, as might rapidly linking women with recently incarcerated partners to housing and economic support and drug treatment.

“He Was the Story of My Drug Use Life”: A Longitudinal Qualitative Study of the Impact of Partner Incarceration on Substance Misuse Patterns Among African American Women

This NIH-funded longitudinal qualitative study explored pathways through which partner incarceration affected substance misuse among African American women. Four waves of semi-structured interviews were conducted with 17 substance-misusing African American women whose partners had recently been incarcerated. Data were collected in Atlanta, Georgia, during 2010–2011. Transcripts were analyzed using grounded theory methods. Analyses suggest that partner incarceration initially precipitated multiple crises in womens lives (e.g., homelessness); over time, and with formal and informal support, women got their lives “back on track.” Substance misuse declined over time, though spiked for some women during the crisis period. We discuss implications for research and interventions.

Health service use and social vulnerability in a community-based sample of women on probation and parole, 2011–2013

BackgroundMost women involved in the criminal justice system are not incarcerated, but rather on probation or parole. We examined the receipt of health services and social vulnerability among women on parole or probation in the past year.MethodsIn a community-based sample of 776 women who use crack cocaine or injection drugs, we compared those who had been on probation or parole in the past year with those who had no criminal justice involvement in the past year.ResultsWomen recently on probation or people were no more likely have health insurance, or to receive most health services, than women not in the criminal justice system. In addition, we found social vulnerabilities that contribute to poor health to be significantly more prevalent among women on probation or parole.ConclusionsThere is a missed opportunity to address health and social needs of women on probation or parole.

Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross-sectional study

BACKGROUNDnOver 1.5 million people are incarcerated in state and federal correctional facilities in the United States. Formerly incarcerated men have significantly higher rates of mortality and morbidity than the general population, disparities that have been partially attributed to higher rates of tobacco smoking-related illnesses such as cardiovascular disease, pulmonary disease and cancer.nnnMETHODSnWe compared the prevalence of smoking tobacco in a sample of 172 men who were released from California state prisons to Oakland and San Francisco between 2009 and 2011 to sub-populations of respondents to the 2009 California Health Interview Survey (CHIS). Using logistic regression, we analyzed the association between lifetime history of incarceration and self-reported smoking status.nnnRESULTSnSeventy-four percent of men recently released from prison reported being current tobacco smokers. The prevalence of smoking in a demographically similar group of men in the CHIS was 24%. We found in bivariate analysis that each additional five years of history of incarceration was associated with 1.32 times greater odds of smoking (95% CI 1.02 to 1.71). Illicit substance use was associated with a 2.47 higher adjusted odds of smoking (95% CI 1.29 to 5.39). In the multivariate model adjusting for age, income, substance use and mental health, every five years of incarceration was associated with 1.23 greater odds of smoking (95% CI 0.94 to 1.63) which was not statistically significant.nnnCONCLUSIONSnGiven the high prevalence of smoking tobacco among former prisoners and the underlying high tobacco-related mortality rates, these findings suggest that a history of incarceration may be an important determinant of smoking. Prison and parole systems may be important potential settings for smoking-cessation interventions.