Justin Jones got hooked on painkillers after he flipped his truck as a teenager, put his head through the windshield and fractured his wrist and sternum. When doctors would no longer write prescriptions for him, he began buying — and selling — drugs on the streets of Durham and Hillsborough, N.C. His first arrests occurred before he turned 20.

At first, he used prescription pills such as Oxycodone, but eventually he turned to heroin, consuming as much as $2,000 worth of the drug a day, and selling more to feed his addiction. He has lost count of how many times he has been incarcerated but guesses it’s more than 15.

Each time he was released, says Jones, now 32, he would try to stop but would soon start using again.

But after his last release, in December 2018, Jones decided he had to make a change. Ten friends, most of them recently released inmates, had overdosed and died right after getting out of jail.

Such overdoses are common because while inside, drug-addicted inmates either go through withdrawal or take smuggled drugs — usually Suboxone, a prescription opioid substitute. As a result, when released, Jones says, “your tolerance is so low, you can’t take as much. You get out and, bam, next thing you know you’re dead.”  

What saved Jones was a program known as the Formerly Incarcerated Transition Program (FIT), which helps people coming out of prison access health and social services.

It’s part of a national effort that began with a San Francisco pilot program that started in 2006 and was bolstered by a 2007 study in the New England Journal of Medicine. That research found that in the first two weeks after release, inmates coming out of prison in Washington state were 12 times as likely to die of any cause and 129 times more likely to die of an overdose than other Washington residents matched by age, sex and race.

Shira Shavit, an associate clinical professor of family and community medicine at the University of California at San Francisco, began the pilot program in a San Francisco public health center. Called the Transitions Clinic, it worked to connect former inmates with chronic health conditions to health, social and support services within two weeks of release.

To overcome their potential patients’ distrust of the health-care system, Shavit and her colleagues put people who had been incarcerated at the center of the program to recruit new patients and build relationships with them. They also didn’t segregate the program from other patients because people with a history of incarceration “want to sit in the waiting room with kids and families and the rest of the community,” Shavit says.

The program spread quickly. The Transitions Clinic Network now includes 34 affiliated clinics in 12 states and Puerto Rico that follow the same model, including the FIT Program in North Carolina that helped Jones.

Transitions Clinic co-founders Shavit and Emily Wang are working to expand the network across the country by documenting its effectiveness. One early evaluation found that recently released inmates who got care from San Francisco’s Transitions Clinic made fewer emergency department visits than those offered standard care, resulting in an estimated savings of $912 per patient.  

A more recent study found patients at Transitions Clinic in New Haven, Conn., were as likely to be rearrested as former inmates who weren’t part of the program but spent 45 percent fewer days locked up when they did. Transitions patients also were less likely to be hospitalized for preventable conditions and spent 60 percent less time in the hospital when they were admitted. The authors also speculated that being connected to the clinic helped patients who were rearrested get into drug treatment more quickly or gave them access to advocates who helped them bail out sooner.

“These folks have experienced a lot of discrimination in the health-care system, so they go to that system with a lot of reluctance,” Shavit says. “That’s where the community health workers are able to break through, to bridge that.”

Need, expansion of support

When Jones got out of prison in 2018, his probation officer referred him to another former inmate, a community health worker named Tommy Green who has been working with FIT since last year.

Green served almost 12 years for armed robbery and knows what it’s like to come out of prison and struggle to find housing, health care and employment. He grew up in a middle-class family with two working parents, but he was drawn to trouble early and fell in with the wrong crowd. After he was sent to prison in 2003, he resolved he would never return and would help others avoid the same mistakes.

After his release in 2015, Green landed a job as a parking lot attendant before getting hired last year by the FIT Program to work with released inmates. His prison experience gives him instant entree with his clients. He says it’s also a job prerequisite.

“This is the only profession where being a criminal is a plus,” he says. “You have to be a reformed criminal, of course.” 

Green hooked Jones up for his first appointment with Evan Ashkin, the FIT program’s founder and director. Ashkin is certified by the Drug Enforcement Administration to prescribe Suboxone and began doing so for Jones to keep him from returning to his old drug habit.

Jones says his daily dose of Suboxone “keeps me from withdrawal and makes me able to live a normal life.” The drug, which combines buprenorphine and naloxone, occupies the brain’s opioid receptors, keeping users from getting high from other opiates. “If I go out right now and get some heroin or a pain pill, it’s not going to affect me,” Jones says. He knows this because he has tried, and “it didn’t do nothing. A big waste of money.”

Ashkin, a professor of family medicine at the University of North Carolina at Chapel Hill, saw the need to address the health needs of people coming out of prison when he ran a program that provides care to the underserved and learned that many formerly incarcerated patients had not had access to medical services when they were free.

In fact, prison was “the first time they had a constitutional right to health care,” Ashkin says. While incarcerated, they were often diagnosed with chronic health problems such as high blood pressure, diabetes or kidney disease.

But when they get out, most ex-inmates focus on such immediate issues as housing and jobs. Since health care isn’t a priority, and they can’t afford it anyway, many simply don’t get care — even when they have serious health, mental health or substance use problems.

Ashkin heard about the Transitions Clinic Network in 2015. The following year, he started the first North Carolina site in Durham, and then expanded to Orange County with funding from the Duke Endowment. The FIT program now operates at five sites around the state, tending to 200 released inmates, a number he hopes to boost to 350 within a year. Even if he succeeds, that’s a small fraction of the roughly 25,000 North Carolina inmates who come out of prison each year, says John Bull, a spokesman for the North Carolina Department or Public Safety. 

Navigating 'all the systems'

Green helps his clients navigate a broad range of health and social problems. He once convinced a magistrate to drop charges against a client and often talks to parole officers on his clients’ behalf. He manages a caseload of almost 35.

Warren Levy, 54, was released from prison early this year and has prostate cancer, sickle cell trait, bipolar disorder and a history of substance abuse.

When he met Green last July, Levy  was staying at a shelter for homeless men and working at Burger King, a job that he said is bad for his fragile health. “It’s 100 degrees in there, and it’s killing me,” he said.

Green told Levy about the FIT Program and gave him the number of his personal cellphone. He also told Levy about his own background of incarceration “because I want you to feel comfortable dealing with me and to let you know that I’ve navigated all the systems that you will have to navigate.” 

Levy  was convinced. “Sign me up,” he said. Within two weeks, Ashkin had seen him for a health exam.

Both Levy and Justin Jones continue to get regular care from the FIT program, but Ashkin says the need is enormous.

“Over 2 million people are incarcerated in the U.S., many with significant medical problems, mental illness and substance use disorder,” he says. When they get out, programs like FIT give them a shot to put their lives back together.

“I think we can keep people out of emergency rooms,” he says. “I think we can reduce preventable hospitalizations and I very much think we can reduce recidivism by treating people’s mental illness and substance use disorders.”

Rob Waters is an independent journalist in Oakland, Calif  This report is a shortened version of a story that appeared in the October 2019 issue of Health Affairs.