Participants included 29 men (69%) and nine women (31%) with a mean age of 39 years (range, 22-57 years). Eleven participants (38%) described themselves as African American, 10 (34%) as Caucasian, 5 (17%) as Latino, and 3 (10%) as American Indian. The mean length of time since release was 42 days (range, 5-82). Over half of the participants (16/29) knew of someone who overdosed soon after release from prison, and three had personally overdosed during previous releases from prison. In the course of their interviews, 16 participants described living in shelters. The substances used by our participants included cocaine/crack, heroin, methamphetamine, marijuana, opioid-containing pain medications, benzodiazepines, alcohol, and tobacco.
The re-entry context: social support, financial needs, and other re-entry challenges
After release, return to drug and alcohol use occurred in a context of poor social support and inadequate economic resources to support integration into the community. Social isolation was a particular problem for former inmates who were trying to stay away from drugs and alcohol. For instance, one former inmate explained:
"I just don't go around nobody. It's kind of hard 'cause my whole family gets high."
One participant described the need for social support to avoid drug use after release from prison:
"They just don't know what they're really doing to their body cause they killing themselves slowly but surely and they need somebody to help them, you know, the courage, and to tell them not to mess around with it."
Nearly all participants struggled with financial problems, and several participants described poor finances as contributing to drug use and relapse:
"Most people relapse in the first six months because it's so stressful because they have no help. There's no financial help to even get housing or to... buy clothes for work or a bus pass to even try to look for a job."
Additionally, drug trafficking in the environment where former inmates returned was considered a major problem for participants, whether they used drugs after release or not:
"With the mix of the people that have mental problems and the homeless, people that are, you know, doing drugs and it's just a mess down there [at the shelter].... They stand out there and sell drugs all day long on the corners and it's like a safe zone down there.... It's totally out of control."
In addition to the direct risk to former inmates of using drugs, many participants described the risk of violence and theft related to drug trafficking as major threats to their health and safety after release from prison. Participants perceived themselves as at substantial risk for assault and violence related to drugs and alcohol:
"The biggest threat to my safety was the area that the shelter is located in... I saw several very bad beatings. Some guy got stabbed and almost killed for a pint of vodka 'cause he had it in his pocket and the drug deals and just... it's a very dangerous area."
Overall, the multiple contextual challenges during re-entry had a strong influence on the return to drugs and alcohol after release from prison.
Medical and mental health conditions among drug- and alcohol-involved former inmates
For some former inmates, medical and mental health needs in the re-entry context were closely linked with their drug and alcohol use disorders. Participants identified multiple comorbidities, such as diabetes, epilepsy, hypertension, chronic pain, anxiety, and depression, combined with limited access to care and medications. One woman explained that the biggest threat to her health after release was having diabetes related to alcohol use combined with poor medication continuity:
"[The biggest threat] to my health [after release]? Drinking like the way I did, 'cause I'm a diabetic and I shouldn't be drinking like that.... I almost went into a diabetic coma. My sugar was so high 'cause... the Department of Corrections didn't release me with my insulin."
Another participant with a history of oxycodone and heroin dependence described her difficulties obtaining mental-health medications as contributing to strong feelings of frustration after her release:
"The biggest threat to my health is the issue of trying to get that medication and stuff taken care of and I am really frustrated.... They'll pay for so much of your mental-health care after you get out and stuff like that, and none of that's happened yet, you know, so I'm still without a psychiatrist at this point, you know? And I have a month worth of [mental health] medicine before that runs out...."
Another participant explained the effect of frustration in the context on her drug and alcohol use:
"My biggest challenge [after release] is to not use [drugs and alcohol] and not let... all of the frustration and stuff that you feel build up...."
Later in the interview, this same participant explained that the contextual challenges she faced required that she avoid drugs and alcohol:
"The challenges that I am facing right now in my life cannot be handled without a clear mind. You know, even if [I]drink, it affects me the next day."
For the participants in this study, medical and mental-health problems interacted with poor continuity in health care, drug and alcohol use, and strong emotional reactions including frustration.
Relapse and exposure to drugs and alcohol
Former inmates described ubiquitous exposure to alcohol, drugs, and drug trafficking in their living environments. In particular, former inmates who stayed in homeless shelters found that it took substantial effort to stay away from drugs and alcohol after release from prison. One man in his mid-forties struggling to stay abstinent from drugs after his release:
"You get asked 50 times if you want some coke before you get into the [shelter] door."
One 46-year-old man who had a place to live also described frequent exposure to drugs:
"Well, when I first got out, peoples come around asking me do you want this. Hey man, I remember you, man you used to look out for me, here, here you go. I said man, no I don't want it. I been there. I done it."
Several participants with a history of addiction described exposure to drugs as the major challenge they faced, requiring avoidant behaviors and new skills to prevent relapse. For instance, one man, whose drug involvement led to his incarceration, had successfully averted relapse since his release. He was motivated by a desire to preserve a relationship with his son, born while he was in prison. He practiced avoidant behaviors at his shelter:
"There's a lot of drug activity, kind of drug users and stuff like that at the shelter, and it's kind-of hard there.... I mean, people will walk up to me and ask me, oh, you want to buy some weed...? What are you looking for? I try and avoid those situations, those people; I said, no I'm not looking and just kind of walk away and go to a different area or something like that.... I'm really not tempted to use any drugs right now because I'm trying to get my life on a straight path but... people have offered to get me high for free, hey you want to smoke, you want to hit this pipe? You want to smoke a joint? You know, stuff like that and just avoiding it, trying to, you know, keep myself out of those situations is really the only way I've been, you know, I focus.... I think about my son, and drugs is really what took me into prison, so I don't want to use drugs 'cause they will probably take me back to prison, so I'm trying to stop myself from going in a circle."
Several participants described a return to drug use within a short period of time after release from prison. Participants described an overwhelming urge to use drugs and alcohol to cope with frustration, "numb out," and "forget about" the daily stresses of the transition period, citing easy availability combined with pressure from old friends and new acquaintances to "party." One participant explained her use of cocaine, crack, alcohol, and nonmedical benzodiazepines within one week of release as follows:
"What led me to [use] this last time... was... frustration and wanting to feel released.... [I]t was something also that I didn't go look for, that was right in the house with me, and I don't blame them for that, but it's just... I don't think I would have sought it out had it not been there."
Similarly, a young woman who had resumed intravenous methamphetamine and cocaine use after a prior release described why she relapsed:
"If you don't go to [a therapeutic community] in prison, then you never really stopped using. You just stopped intaking it, so your body still wants it, your mind still wants it, and it's all you think about while you're in prison, but if you go to rehab and people show you a different way of life, then you start thinking maybe I don't want it. But most people who are in prison are just waiting for their next hit."
For a participant who had used drugs after prior releases, the most significant challenge he faced was staying away from individuals with whom he had previously used drugs:
"[The biggest problem is] not going back to the same lifestyle that got me in prison, 'cause I have seen some of the old people that I used to hang out with, and some of them are clean and sober and doing good and some of them are still up to the same, but you know, I still care about them. They're my friends, but I just... it was hard for me to like say 'I need to go,' you know, cause I had spent so much time with them over the years that now that some of them are still getting high and still doing the things that they do, it was hard for me to just say, 'Hey, I can't not be your friend, but I just can't be around you at this time, because that's just too much of a trigger for me cause it's just one little slip up and I go back'.... [T]he hardest thing is not going back into the lifestyle that got me put in prison and finding a job."
In summary, the environments to which participants returned immediately following prison made it difficult to avoid relapse due to ubiquitous triggers to use. Despite these risks, former inmates described protective factors and responses such as strengthening family relationships, changing social networks, and avoiding former lifestyles to mitigate the risks of relapse and return to prison.
Perceptions of overdose after release from prison
We specifically sought to learn more from former inmates about post-release overdose. Three participants had personally experienced a post-release overdose, and 16 had either witnessed or known people who had such overdoses. Most participants were aware of the dangers of post-release overdose. The reasons most frequently mentioned for overdose were the lack of knowledge about lowered tolerance levels after limited access to drugs during incarceration, the increase in potency level of street drugs over years of incarceration, and intentional overdose as a means of coping with stress and anxiety that seemed unbearable.
"The last time I OD'd, I was on parole. I did too much. I went back to my normal dosage, what I was doing before I went in and that didn't work.... I wound up in intensive care three days later from a coma.... I know that when you come out of [the Department of Corrections] your body is clean so... you need to be careful and know what you're doing... and you never know what you get."
One participant in his mid-fifties experienced fatal overdose among six of his friends and acquaintances. He described the trend of early deaths after release from prison as follows:
"I've lost quite a few friends that have came out and were very fresh to this street life, and they OD'd on heroin you know. Just a sad thing. Of course they had only been out a couple weeks."
Several described the overdoses of friends or acquaintances as being related to the stress of release, difficulty adhering to parole conditions, a sense of hopelessness, and a lack of ability to cope with the transition:
"It [overdose] would have to be on purpose, because parole makes it so difficult to make it."
As a result, overdose was considered by other several participants to be a mechanism for committing suicide to end such stress. One man who was interviewed five weeks after release described overdose as choosing death over going back to prison:
"It's like they purposely want you to screw up so you go back.... If I foul up, they're going to file escape charges on me... that's 48 years off the top. I'm going back for the rest of my life. I would... rather die than go back and give them 48 years of my life. So, it's like... you got a choice. Go back to prison for the rest of your life or die. They going to choose death."
Thus, overdose was considered a physiologically driven phenomena--a coping mechanism (albeit poor) for the seemingly insurmountable challenges faced by former inmates and a "way out" if the challenges became too great.
Available services and other strategies employed by former inmates
The most commonly cited substance-abuse services available to participants after release from prison were drug and alcohol classes. Many participants also had to undergo urine toxicology screens through their case-management programs or parole offices. The parole office was perceived as structured around enforcement rather than assistance but, nonetheless, some participants obtained services and support from their parole officer. Participants also described re-entry services and community-based case management services as helpful in general. For instance, one participant identified his parole officer and Treatment Accountability for Safer Communities (TASC) case manager as helpful:
"Staying in touch with my parole and with my TASC lady, staying in touch with her."
Participants identified factors that protected them from returning to drug use, including avoidance of old neighborhoods, strong family relationships, religion and spirituality, housing, support from friends, a highly structured residential treatment program, a patient navigator, community-based organizations and programs, and self-help groups such as Alcoholics Anonymous (AA) and Narcotic Anonymous (NA). In response to a question about what has helped her avoid using drugs since release, a woman with a history of opioid dependence described the following community resources:
"[I] got involved, like, with Empowerment [a community-based organization], gone to church, been to some meetings like AA, NA, and talked to, like, my mom and stuff about it... been more open with people and not hiding it, except from my parole officer, of course (laughing), you know."
Housing away from shelters, with their associated drug use and trafficking, was of foremost importance to our participants.
"There's a lot of drugs, there's a lot of alcohol in those shelters and there should be some statutes pertaining to individuals like myself that had to parole homeless... to get housing somewhere once we're released."
One 26-year-old woman explained that a highly structured transitional residential program, paid for by the Department of Corrections, prevented her relapse.
"If I'd been in the real world, I probably would have relapsed already, but being because I am in this structured environment [residential drug treatment facility] and I have the support I need, I haven't relapsed; but if anybody is an addict and they are out there without the support, it's a probably nine-to-one chance that they're going to relapse."
Participants described learning from prior releases, which helped them through the re-entry period in their most recent release. One young woman described a long process of re-learning how she dressed and presented herself to others in order to avoid relapse after release from prison, with the assistance of a structured program:
"It's the way you act, the way you present yourself, [your] perception, you know? And it all has to be re-learned cause it's not... that you say one day, 'I want to be a dope dealer' (laughing), you know? It's something that happens with time, and everything has to be re-learned."
Despite the tremendous challenges faced by former inmates, a number of participants expressed hope about their prospects and willingness to work to maintain their sobriety and avoid relapse:
"I haven't been sober this long for a long time, so now then I'm back out and re-integrating into the community, it's kind of weird, because I didn't know how to have sober fun. I didn't know how to communicate with people without being high on drugs or drunk or... so, it's a new experience and it's kind of hard, but then at the same time, it's just... it's another challenge that I'm willing to take on."