During community re-entry, the risk of post-release opioid-related overdose mortality is increased through the intermediate determinants of disrupted social networks/support, poverty, interruptions in health care access, stigma, and an exacerbation of underlying psychiatric and substance use disorders (Fig. 1, Box 2) [54, 55]. Incarceration exposure leads to these intermediate determinants and efforts to successfully mitigate the risk of post-release opioid-related overdose could target these factors to reduce their influence on subsequent proximate and biological determinants.

Disrupted social networks

Social support buffers the negative health effects of stressful events, such as incarceration, and can promote healthy behaviors [56]. The process of incarceration physically removes a person from their family, friends, and community, interrupting social relationships during a period of increased stress. Between 50 and 80% of individuals are in committed relationships at the time of prison entry, but between 30 and 50% of those relationships end during incarceration [57, 58]. The loss of a committed partner during incarceration is linked to increased post-release stress and substance use compared to men who remained with a committed partner. For example, in a sample of African American men recently released in North Carolina, those whose committed relationships ended during incarceration had greater stress associated with re-entry when compared to men who remained in a relationship with a committed partner [59]. Within this population, incarceration-related partnership disruption independently predicted post-release binge drinking. Upon release, criminal justice exposure may continue to indirectly disrupt social supports. Males released from jail or prison in Ohio reported using strategies of “preventative” social withdrawal and secrecy to avoid anticipated discrimination [60]. In addition, individuals with a recent history of justice involvement may avoid reintegration into the community to avoid re-exposure to their prior lifestyle, leading to isolation at home and avoidance of old contacts. Qualitative interviews with PRJP indicate the importance of social support as a protective factor against returning to drug use and overdose during re-entry [61].

Poverty

Incarceration also has the long-term, often unintended, consequence of trapping individuals in poverty upon transitioning to the community. Once released, PRJP—particularly those convicted of felonies and those on sex offender registries—are no longer eligible for specific educational, employment, or housing opportunities [62]. Some housing policies may exclude PRJP, potentially leading to housing instability and homelessness [63.]. In the Fragile Families study, PRJP had four times the odds of homelessness, and incarceration was associated with increased risk of eviction for those living in public housing [63]. Housing insecurity is tied to labor market potential, which is also negatively affected by incarceration [64]. Incarceration limits employment opportunities by limiting access to education and/or eligibility for government jobs and professional licenses [65]. Employers may be less likely to hire those with prior criminal justice exposure. Among generic job applications submitted to low wage jobs in New York city, PRJP were half as likely to be called back or receive a job offer relative to those without a criminal record and this disparity was more pronounced among blacks relative to whites [48, 66]. These barriers make employment difficult to attain after incarceration. In a longitudinal study of PRJP in Ohio, Texas, and Illinois, less than half were currently employed 8 months after release and their median monthly income was approximately $700, which equates to $8.95 per hour [67]. The stress due to unmet financial needs may drive PRJP to use substances to cope. In a sample of individuals with a history of substance use recently released from correctional facilities, those experiencing unstable housing reported the highest levels of drug use [68].

Stigma

The problems of social isolation and poverty are further exacerbated by incarceration-related stigma. Stigma is described as unfavorable attitudes, beliefs, and policies directed toward people perceived to belong to an undesirable group. There are few groups as highly stigmatized as PRJP [69]. PRJP perceive high levels of stigma, which may lead them to internalize the stigma and ultimately self-stigmatize [47, 70]. Among PRJP in New York state, 65.3% reported discrimination due to their prior criminal justice involvement [71]. In comparison to college students, PRJP perceived more stigma in the general public regarding incarceration [70]. Stigma impacts post-release success among PRJP, including gaining employment and risk of recidivism [70]. In a sample of women released from jail or prison with a history of substance use, stigma was highlighted as a factor impacting all aspects of community re-entry, including basic survival, access to treatment, and family reintegration [72]. Stigma is linked to poor psychological functioning, such as increased depressive symptoms and to substance use [73, 74]. Further, individuals who feel stigmatized, especially within health care settings, may avoid treatment and health care except in the case of emergencies. Among adults in the community who are living with HIV and inject drugs, those who reported (versus did not report) internalized HIV or substance use-related stigma had lower odds of health service utilization [75]. In a sample of transgender men in the community, those who experienced stigma from healthcare providers had increased risk of using drugs to cope with the mistreatment [76]. Hence, incarceration-related stigma may exacerbate post-release psychopathology, which in turn, can lead to increased opioid use and overdose mortality risk.

Interruptions in care

After incarceration post-release interruptions in health care are common [77,78,79,80]. Therefore, PRJP are less likely than the general population to have a primary care physician and more likely to use emergency departments or experience preventable hospital admissions [79, 81, 82]. Among a group of men released from jail or prison with chronic health conditions, barriers to accessing clinical care included lack of insurance, stigmatization, substance use, being on parole, institutional bureaucracy, and being assigned to the indigent system. These men reported reducing their utilization of the healthcare system due to these barriers [83]. Reduced access to care has implications for screening to identify overdose risk and interruptions in access to medications for opioid use disorder (MOUD). More than 1 in 15 adults released from jail or prison were taking a prescription medication at the time of incarceration and 41.8% stopped taking these medications following incarceration [84]. In addition, psychiatric medication regimens disrupted during incarceration and barriers to care after release hinder the continuity of mental health care [85]. This may result in under-treatment of symptoms in some cases and over-sedation in other cases [86,87,88,89]. Post-release changes in mental health treatment may lead to polypharmacy such as use of opioids with benzodiazepines, especially in the context of treating post-release anxiety disorders; polypharmacy use is a strong overdose risk factor [90, 91].

Non-opioid substance use

Unhealthy alcohol use and injection drug use are prevalent among PRJP. Among PRJP, rates of alcohol use disorder ranged from 18 to 30% among men and 10–24% among women. Rates of drug use disorders among men ranged 10–48% and for women 30–60% [10]. Upon release, the stress of re-entry may exacerbate substance use disorders. Among PRJP, problems with family, friends, and significant others were associated with 3 times the odds of substance use and over 2.5 times the odds of unhealthy alcohol use [92]. Women with a history of justice involvement report drug and incarceration related stigma contributed to substance use relapse and recidivism following re-entry [72]. Non-opioid substance use may increase the risk of post-release opioid-related overdose mortality. Among adults in the community, alcohol was involved in over one-fifth of prescription opioid-related overdose deaths [93].

Depression, anxiety, and post-traumatic stress disorder

PRJP also have high prevalence of psychiatric disorders, including depression, anxiety and post-traumatic stress disorder, which may increase the risk of post-release opioid-related overdose [40]. Estimates suggest 50–60% have a mental health disorder including 20–30% with symptoms of major depression [40, 94, 95], and between 40 and 50% exhibit both psychiatric and substance use disorders [96]. High levels of psychiatric symptoms among PRJP may increase exposure to other risk factors for post-release opioid-related overdose including prescription opioids [97, 98], benzodiazepines [99], and alcohol [98, 100,101,102]. Among adults receiving long-term opioid therapy for chronic pain in the community, those with moderate and severe depression were 1.8 and 2.4 times more likely to report misuse of opioids for non-pain symptoms [98].

Criminal justice exposure itself may exacerbate underlying psychiatric disorders. The stressful and disruptive nature of incarceration and release appear to underlie post-release increases in psychiatric symptoms [103]. PRJP with (vs. without) a history of exposure to solitary confinement had nearly fourfold increased odds of positive post-traumatic stress disorder screen at the time of first post-release primary care contact [104]. People released from the New York City jail system who had been assigned to solitary confinement were 3.2 times more likely to commit an act of self-harm compared to those without solitary confinement exposure. While only 7.3% of people released from jail received any solitary confinement, 53.3% of self-harm and 45.0% of potentially fatal self-harm occurred within this group [105]. While a substantial proportion of PRJP have histories of psychiatric disorders at the time of incarceration, the experiences of detention and release may also exacerbate symptoms; some evidence indicates acute effects immediately following release from prison and other studies suggesting long-term post-release psychiatric symptoms [106]. In a sample of individuals being released from incarceration in Rhode Island, one-third had worse depression symptoms upon return to the community [103]. PRJP may self-medicate with substance use as a means of coping with psychiatric disorder symptoms upon release [61], and post-release anxiety treatment with benzodiazepines can increase polydrug use and risk of opioid-related overdose [85].