People in contact with the criminal justice system outside institutional settings have high levels of mental health and substance use problems, contributing to adverse outcomes. Help-seeking behaviour is an important component of optimising access to effective treatment and support that is under-explored in this population. Empirical investigation into the influences on help-seeking for stigmatised health conditions is needed to inform efforts to facilitate help-seeking. This study established the individual, relational, and contextual influences on help-seeking for mental health and substance use problems among people in contact with the criminal justice system living in the community, and examined the applicability of existing models and frameworks for understanding help-seeking behaviour in this population. We applied framework analysis to qualitative data from a mixed-methods social network analysis study. Our framework drew on help-seeking behaviour and healthcare access models to determine initial categories for help-seeking influences (desire, ability, and context). Help-seeking was confirmed to result from an interaction between 'desire to seek help', 'ability to seek help', and 'help-seeking context'. We show that help-seeking is not an individual behaviour, but strongly affected by relational influences that operate between individuals, across social networks, and via cultural norms. High levels of criminal justice involvement, and mental health and substance use problems in the social networks of people in contact with the criminal justice system shape these influences. Optimising help-seeking for mental health and substance use problems among people in contact with the criminal justice system living in the community requires critical engagement with, and application of, existing models to ensure sufficient appreciation of relational and contextual influences. Research is needed to develop and test multi-level policy/practice interventions that go beyond individual factors.
Police officers have long been tasked with translating drug policies into practice; as a key public-facing side of the criminal justice system, they influence how drug policy messages are conveyed to the public through everyday enforcement practices. The government of British Columbia, Canada, received a 3-year exemption from federal drug laws to decriminalize the possession of small amounts of most illicit substances starting January 31, 2023. In this context, we explored what people who use drugs learned from drug policy as it was taken up into policing practice. We use constructs from curriculum theory as a framework to understand what policing explicitly and implicitly communicates to people who use drugs. We analyzed 40 qualitative interviews with people who use drugs in socioeconomically stable positions (housed and employed) in the first year of decriminalization in British Columbia to understand lessons gleaned from policy and policing in this policy context. Findings show that the formal curriculum of drug policy provided a sense of relief for many participants who could ease their fears of being labelled "criminals." However, the way that drug policies were applied by officers in practice, making explicit a hidden curriculum, shaped how participants saw themselves and other people who use drugs in ways that were stigmatizing. Our research shows the value of analyzing the hidden curriculum of drug policy to illuminate how it shapes the way in which people who use drugs construct and position themselves.
Asian and Latina survivors of international criminal sex trafficking often face profound mental health challenges, yet research on this group remains limited. This study examines mental health outcomes and correlates among 94 survivors in New York City using a Community-Based Participatory Research approach. Multivariable logistic regression identified factors associated with depression, posttraumatic stress disorder (PTSD), and comorbid symptoms. Survivors reported high rates of depression (41.9%), PTSD (41.3%), and co-occurring symptoms (26.6%). Pain and forced abortion were significantly associated with PTSD and comorbidity. Findings highlight the need for trauma-informed, culturally appropriate mental health interventions addressing pain and reproductive coercion to support survivor recovery.
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Long-acting injectable buprenorphine (LAIB) is increasingly used in the Criminal Justice System (CJS) for treating people with opioid use disorder; however, little is known about these patients' experiences. We aimed to understand the perspectives of participants commenced on LAIB in prison as a part of the Understanding NSW Long-Active Opioids in Custody-Treatment (UNLOC-T) study. Results of an open-ended survey administered by UNLOC-T researchers underwent analysis. Participants were adults, recruited November 2018-July 2019, with moderate-severe opioid use disorder and ≥ 6 months remaining on their sentence. We conducted a thematic analysis using a pragmatic, descriptive coding approach. Sixty-seven participants were included, of which 82% were male. Five primary themes were identified that described participants' experiences and highlighted issues that can directly inform service delivery: medication effectiveness, social and relational considerations, dosing frequency, financial aspects, and health and wellbeing. There was considerable variation in participant perspectives within themes. Perspectives on LAIB are diverse, suggesting a need to individualise treatment and ensure person-centered care. While LAIB offers benefits to warrant including it as a treatment option, challenges remain. Future research into LAIB in the CJS would allow for triangulation, as well as further exploration of ongoing acceptability in the post-release period. Our findings could help to improve the way LAIB is offered as a treatment option or delivered to people in the CJS. There are also lessons for prescribers in counselling and tailoring treatment, and broader policy considerations around access to treatment formulations and patient autonomy.
In child sexual abuse trials, attorneys often use demonstrative anaphors, such as it, that, this, these, and those, to refer to children's earlier statements, questions, or portions of them. For example, after a child says, "He left the room," an attorney may ask, "What happened after that?" Here, that is an anaphor referring to the multi-word statement "He left the room." To answer such questions, children must identify the intended referent and retrieve the relevant information, increasing cognitive load and potentially leading to brief responses or misunderstanding. We examined how the anaphors it, that, this, these, and those shaped responses from 5- to 10-year-old children in 40 trial testimonies comprising 12,314 question-answer (Q-A) pairs. Prosecuting and defense attorneys frequently used anaphora, appearing in 30% of Q-A pairs. When anaphors replaced multi-word or compound referents rather than single-word referents, children's elaboration decreased. Contrary to expectations and prior studies, children elaborated more when a Q-A pair contained multiple anaphors. Elaboration and misunderstanding also increased when children, rather than attorneys, first introduced an anaphor. We conclude that those questioning children about sexual abuse should avoid using anaphora for multi-word or compound referents and promptly clarify any anaphoric referent to reduce misunderstanding or incomprehension.
There is a long-standing international research interest in how substance use and criminality are intertwined. Research on adolescents in substance use treatment has observed high rates of criminality, but little is known in the international literature about how different types of criminality are patterned among patients. The aim of this study was to identify different criminal profiles, in terms of convictions, among adolescents and young adults in Swedish substance use treatment. The sample included all patients aged 13 to 25 who were in contact with Sweden's largest specialized regional provider of substance use treatment for adolescents and young adults, Maria Ungdom (MU) Stockholm, between 2011 and 2021 (n = 29,960). Data on convictions were gathered from the Swedish National Conviction Register and linked to data from patient journals and other Swedish registers. Latent class analysis was used to identify different subgroups based on 12 different offenses. Differences between these sub-groups on socio-demographic and clinical characteristics were also explored. Over 40% of the patients had been convicted between 2011 and 2021, with drug offenses being the most common. The LCA identified six classes based on offenses included in the convictions, including classes defined by single offense types to a class characterized by multiple offenses. The largest class (47.8%) consisted of patients with primarily drug offenses and the smallest class consisted of patients primarily defined by shoplifting (6.5%). Comprising only about 5% of all patients, the class with multiple offenses accounted for 32.8% of all convictions. Classes differed across socio-demographic and clinical variables, where the class with multiple offenses was the most severe. Patients with no convictions scored more favorably on socio-demographic and clinical variables compared to those who had been convicted. A large share of adolescents and young adults in substance use treatment have been convicted for criminal offenses. However, there is profound heterogeneity in this group related to type of offenses as well as to socio-demographic and clinical characteristics. This heterogeneity should be considered in further research and in the provision of treatment.
The phenomenon of Unfinished Nursing Care raises important questions from theoretical and empirical perspectives, as well as legal and forensic implications that have not been considered in the available literature to date. The analysis of rulings issued in a given country may expand available knowledge by introducing a legal-forensic lens into this field of research, enabling the identification of unlawful behaviors attributed to nurses, the types of omissions recognized by judges, and the judicial reasoning underlying the attribution of individual criminal responsibility. To analyze and synthesize criminal rulings issued by the Italian Supreme Court of Cassation in which registered nurses were convicted for omissions or delays in the provision of nursing care. A qualitative document analysis was conducted. Supreme Court of Cassation rulings involving nurses held responsible for adverse outcomes in patients due to episodes of poor care attributable to Unfinished Nursing Care were considered. The DeJure database was searched. Extracted data were synthesized in narrative form, focusing on the main characteristics of the rulings, their consequences for patients, nurses, and the health care system, the omitted or delayed interventions sanctioned, and the concurrent reasons underlying such omissions. Between December 2004 and October 2022, the Italian Supreme Court of Cassation issued 10 rulings. In eight cases, the patients died; in the remaining cases, the patients suffered permanent consequences. The most reported omissions included failure to monitor vital signs and postoperative care, inadequate patient monitoring, failure to document notes and allergies, neglect of basic care, failure to check surgical sites, and delays in response time. The rulings identified reasons ranging from a single cause to multiple concurrent factors at the individual nurse, unit, and system-wide levels. This is the first document analysis of Italian case law on Unfinished Nursing Care, offering a forensic perspective based on legally documented omissions rather than self-reported data. Omissions leading to criminal convictions most often concerned patient monitoring, postoperative surveillance, documentation, and basic nursing care. Omissions or delays in nursing care may lead to severe patient harm while also exposing individual nurses to criminal liability, despite the inherently multidisciplinary and system-based nature of care delivery.
Benzodiazepines have become increasingly prevalent in the unregulated drug supply in Canada. Benzodiazepines are regularly prescribed as anxiety or sleep aids, and typically have strong sedative effects. Despite the influx of benzodiazepines in the unregulated drug supply, the gendered impacts of this change have not been evaluated. To address this gap, our aim was to explore how the increase of benzodiazepines in the unregulated drug supply shaped experiences of gender-based violence (GBV) among women and gender minorities who experience intersecting modes of criminalization in Vancouver, Canada. This analysis draws on 30 in-depth semi-structured interviews with criminalized women and gender minorities between 2022 and 2023. Using a structural violence framework, this analysis seeks to characterize the intersecting and gendered impacts of increased benzodiazepines in the unregulated drug supply. In addition to the desired effects of benzodiazepines, some participants also described experiencing drowsiness, confusion, and memory loss due to benzodiazepine exposure, heightening both experiences and fear of gender-based violence (GBV). Participants' narratives highlight that, despite instituting safety strategies and fostering positive community connections, many felt vulnerable to GBV while either unintentionally using benzodizepines or unknowingly purchasing high potency benzodiazepines, increasing risk of GBV (assault, exploitation, theft) in the context of broader misogony and gender subordination. The fear of being victimized led some participants to use alone, which in turn increased the potential for fatal overdose. This research demonstrates the gendered impacts of prohibition, highlighting how the influx of benzodiazepines shaped participants' experiences of GBV. Our findings underline the importance of a safe, accessible, and regulated drug supply alongside sustained efforts towards gender equity more broadly to better support the safety of criminalized women and gender minorities.
Harm reduction has gained international policy traction and increasing recognition as essential for health equity, while punitive drug control approaches have re-emerged. This study examines Sweden, known for its restrictive drug policy, to explain why harm reduction measures have gained greater acceptance alongside increasingly severe penal responses to drug offences. Furthermore, it explores the role of stakeholders in shaping these policy processes. We analyzed three data sets 2015-2025 (media texts, key informant interviews, stakeholder comments to two commissions of inquiry) by using the Multiple Streams Framework. Two main problem constructions were identified: drug-related mortality and organized criminality controlling illicit drug markets. Both were related to the opening of two policy windows; however, only one led to policy change (stricter penalties), while the other did not, despite broad stakeholder support (evaluating drug use criminalization). The results highlight the role of specific stakeholders as policy entrepreneurs and indicate growing acceptance of harm reduction, although measures perceived as challenging the control-oriented track remain controversial. The results support previous findings of Sweden adopting a dual-track policy structure. However, the control-oriented policy track continues to dominate drug policy formation. This study suggests that harm reduction is likely to remain subordinate to control-oriented approaches, when the policy tracks remain institutionally separate, and when control institutions, conventions, and key stakeholders hold greater authority than human rights frameworks and may act as status quo entrepreneurs. Furthermore, focusing on control measures due to criminal networks and drug trafficking may hinder harm reduction development.
Substance use during pregnancy poses significant risks to maternal and neonatal health, yet less than half of pregnant women with substance use disorders (SUDs) receive appropriate treatment. State-level prenatal substance use policies may influence treatment outcomes, but their impact on treatment completion remain understudied. This study examines how criminal justice, provider reporting, and treatment support policies are associated with substance use treatment completion among pregnant women. We analyzed data from the Treatment Episode Data Set-Discharge (TEDS-D) for pregnant women aged 12 or older who were admitted to publicly funded substance use treatment facilities between 2020 and 2022 in the United States (n = 38,410). Multivariable-adjusted logistic regression models were used to assess associations between state-level prenatal substance use policies and treatment completion, adjusting for other covariates. About 29.5% of pregnant women completed treatment. Women in states with criminal justice policies had a higher likelihood of treatment completion (adjusted odds ratio [AOR], 1.23; 95% confidence interval [CI], 1.13-1.34; p < 0.001), as did those in states with treatment support services (AOR, 1.14; 95% CI, 1.03-1.28; p = 0.014). Conversely, those in states with provider reporting mandates had a lower likelihood of treatment completion (AOR, 0.49; 95% CI, 0.36-0.67; p < 0.001). State-level prenatal substance use policies are associated with treatment completion among pregnant women. While criminal justice and supportive treatment policies may enhance treatment completion, mandatory provider reporting requirements may deter retention. These findings underscore the importance of designing policies that foster trust, reduce stigma, and prioritize access and engagement for pregnant women.
In response to the large number of people who use substances involved in the criminal legal system, various diversion programs have been introduced as an alternative to standard legal proceedings and sanctions. Drug courts operating at trial courts are perhaps the best known example, but other formats have emerged. Opt for Help and Hope is a prosecutor-led diversion program operating at six municipal courts in New Jersey. This study set out to evaluate the implementation of Opt for Help and Hope as a program operating in the novel context of municipal courts. This cross-sectional study drew on semi-structured interviews with participants in two stakeholder groups in the six participating NJ municipalities: (1) professional stakeholders (n = 41), consisting of prosecutors, municipal judges, peer specialist providers, and public defenders, and (2) defendants who had completed the Opt for Help and Hope program (n = 7). Analyses used a hybrid inductive-deductive approach to code and thematically analyze interview transcripts. All program sites followed key elements developed by New Jersey Office of the Attorney General, although some components of program design, such as division of responsibilities between the county and municipal prosecutors, differed to fit local contexts. There was a universally positive view of the program and its objectives across sites and professional stakeholder categories. Interviewees from four sites expressed satisfaction with the program's results, while the remaining two sites reported lower-than-expected numbers of participants and successful completers. Buy-in from implementing stakeholders and interest in participating among eligible defendants were seen as key factors for program success. Lessons during implementation included the need to ensure sufficient administrative capacity, to think through key parameters such as eligibility criteria and definition of compliance, and to pay attention to the potentially conflicting role and responsibilities of peer specialists working with program participants and reporting to the courts. Municipal courts offer a feasible diversion opportunity away from the criminal legal system. Ensuring adequate administrative capacity for program implementation, and sufficient education and support for service providers facing the problem of conflicting duties towards both participants and the court are key implementation considerations.
Safer supply programs (SSPs) have emerged in Canada in a response to the drug toxicity crisis and to the contaminated illicit drug supply. A form of safer supply, injectable opioid agonist treatment (iOAT) programs, provide individuals with access to regulated opioids that are generally self-administered in supervised settings. The implementation of SSPs has been controversial, and gathering additional data on their impact is necessary to inform their future. An iOAT program in New Brunswick, Canada, was evaluated from the perspectives of individuals accessing the program, to better understand program experiences, impacts, and barriers. Semistructured interviews were completed with iOAT participants (N = 21) who had been in the program for approximately six months. An Interpretive Phenomenological Analysis was used to understand the experiences of participants in the program. Participants reported positive experiences that were associated with the program's low-threshold and nonstigmatizing environment. Impacts such as improvements in mental health, increased financial stability, decreased engagement in criminal activities, and reduced use of substances from the illicit market were reported. Challenges associated with program involvement included inadequacies in the strength of available medications, negative impacts from interruptions to safer supply (e.g., from being arrested or hospitalized), and barriers to access (e.g., transportation and daily attendance). The findings from this study demonstrate the importance of SSPs as a vital option in the care of people who use drugs and identify the need for wraparound health services as well as increased continuity of care from SPPs to services available in healthcare and criminal justice settings.
Disruptions to the US criminal legal system during the SARS-CoV-2 pandemic temporarily reduced the numbers of people in prisons while exacerbating racial disparities in their populations, increasing the percentage of incarcerated people who are Black. Less is known about jail populations, including disparate impacts by race. We used web-scraped data from the publicly available rosters of North Carolina (NC) jails to examine their population sizes, admission and release rates, and racial composition during 2020-2022. Data were available from 45 jails (of 93 total in NC) representing 194,230 incarcerations. Relative to pre-pandemic (January-February 2020) sizes, populations decreased to a median of 66% (IQR = 60%-72%) in March-April 2020 as releases outpaced admissions (median 124 releases per 100 admissions per week) and rebounded to a median of 86% (IQR = 81%-97%) by March 2022. Black, Indigenous, and People of Color (BIPOC) were over-represented in jail incarcerations (44%) relative to the general population (26%), with the rate of incarceration for BIPOC increasing from 2.4 to 3.0 times the rate for White people in the early pandemic period. Overall, the initial decreases to jail populations resulted from high release rates and were not sustained. Consistent with observations in prison populations, pandemic-related disruptions to the criminal legal system may have worsened racial disparities in jail incarceration rates and the resulting percentage of BIPOC in jail populations.
Policy Points The liberalization of medical and recreational cannabis policies may increase cannabis initiation across age groups, with increased prevalence of cannabis use among young adults and adults and weaker effects among youth. Evidence also suggests increases in cannabis-related health care utilization among adults. Alcohol use may decrease following medical legalization (suggesting use of cannabis in place of alcohol), but it may increase among young adults following recreational legalization (suggesting co-consumption). Evidence suggests a potential decrease in tobacco use across age groups and cannabis policy changes, and most studies found no change or a decrease in opioid-related outcomes, although evidence was less consistent for opioid-related mortality specifically. Substantial changes in cannabis policies are occurring globally; however, the impacts of these reforms on cannabis use, as well as downstream effects on other substance use, remain unclear. We conducted a systematic review to identify studies examining the impact of a cannabis policy change on substance use. We searched Embase, Medline, PsycINFO, the Web of Science Core Collection, and the Criminal Justice Database, as well as gray literature sources including the Social Science Research Network. The included studies employed a quasi-experimental approach and were assessed for risk of bias using a modified version of ROBINS-I to facilitate the assessment of these designs. The findings were synthesized using a descriptive, analytical approach. The included reports (N = 176) were published between 1993 and 2024, with approximately two-thirds published after 2019. Most were peer-reviewed publications (n = 148) applying a difference-in-differences (n = 129) or interrupted time series (n = 42) approach to data from the United States (n = 141). Medical and recreational cannabis legalization may increase cannabis initiation across age groups, with increased prevalence of cannabis use among young adults and adults and inconsistent evidence among youth. The impacts on alcohol use were differential by policy and age group, with potential decreases following medical legalization and potential increases following recreational legalization among young adults. Evidence from a limited number of studies suggested potential decreases in tobacco use among all age groups. Most studies found no change or a decrease in opioid-related outcomes, although evidence was less consistent for opioid-related mortality. We found few studies examining cannabis decriminalization, with no clear evidence of changes in cannabis or other substance use. Overall, these findings suggest that medical and recreational legalization increase cannabis use, with weaker effects among youth. In addition, potential substitution effects were identified for other substances (e.g., alcohol, tobacco, opioids), excepting complementary alcohol use among young adults following recreational cannabis legalization.
This essay examines human enhancement drugs - particularly anabolic-androgenic steroids - through the lens of public health theory from the Global South. It critiques prohibitionist policies, which criminalize users while disregarding social determinants, as well as extreme relativism, which reduces consumption to individual autonomy alone. In contrast, harm reduction emerges as an evidence-based, user-centered approach that rejects criminalization, upholds human rights, and provides contextualized health responses. By reframing anabolic-androgenic steroids as human enhancement drugs, the analysis promotes a less moralistic perspective shifting the focus from individual behavior to broader societal pressures. Allied with Global South public health frameworks, harm reduction addresses the health needs of people who use drugs, prioritizing societal transformation over punishment.
The Dobbs v. Jackson Supreme Court decision overturned Roe v. Wade and federal abortion protections, resulting in nearly half of U.S. states banning or significantly restricting abortion. Qualitative data are needed to understand how abortion restrictions influence pregnancy perceptions and experiences. This study describes pregnancy perceptions and experiences before and after Dobbs, across states with abortion restrictions and protections, and across individual-level differences in income and age. We conducted in-depth interviews with people during pregnancy (n = 31, 28 pre-Dobbs) and a subset of those individuals again during the postpregnancy period (n = 14, all post-Dobbs) from October 2021 to August 2023. All interviews were recorded, transcribed, concept mapped, and coded using MAXQDA 2022. We also conducted across-group comparisons by state abortion policy, income, and age. Before Dobbs, participants described how abortion accessibility was already compromised in some states. After abortion was banned in restrictive states, participants described feeling dehumanized, criminalized, that their reproductive autonomy was constrained, and that pregnancy carried real risks to their lives. In protective states, participants were grateful they had abortion access but lacked awareness and knowledge about abortion access in other states. Participants explained that Dobbs and abortion restrictions are harming perinatal wellbeing, even for wanted pregnancies. Group comparisons demonstrated that lower income and younger people described greater impacts related to abortion availability. Post-Dobbs abortion restrictions are negatively impacting the mental and physical well-being of pregnant people, even those with wanted pregnancies. Dobbs could exacerbate existing health inequities for younger and lower-income people.
This retrospective descriptive study examined firearm-related fatalities during (April-December 2020; n = 241) and after (April-December 2023; n = 299) COVID-19 lockdowns using 540 cases from the Diepkloof Forensic Pathology Service, Soweto, South Africa. Data was obtained from autopsy reports, forensic records, police statements, and death scene documentation. Firearm violence affected young adult Black males (22-43 years), with only minor demographic shifts post-pandemic. The overall burden and core patterns of violence remained stable, with criminal activity - primarily robbery and interpersonal violence - persisting as the leading contexts, and homicide the dominant manner of death. Post-COVID-19 findings demonstrated contextual shifts, including increased incidents in public and social environments, reflecting greater mobility and resumption of social activity. A significant rise in mean blood alcohol concentration (0.09 g/100 mL vs 0.14 g/100 mL; p < 0.0001) suggests increased alcohol involvement following easing of restrictions. Unfortunately, persistent information gaps, noted particularly in circumstantial history, incident location, firearm type, highlighting the need for improved data provision and capture systems. While the epidemiology of firearm-related fatalities remained unchanged, the post-COVID-19 period was characterised by increased alcohol involvement, shifts toward public-space violence, and fewer gunshot wounds per victim, suggesting changes in situational and behavioural dynamics rather than underlying drivers of violence.
Artificial intelligence (AI) is reshaping healthcare, and forensic medicine and nursing are no exception. From automated wound pattern analysis to natural language processing (NLP) in medicolegal documentation, AI tools are entering a field situated at the intersection of clinical care, legal accountability, and human rights. This systematic review with narrative synthesizes contemporary clinical, forensic, and AI ethics literature to examine current and emerging applications of AI in forensic practice, with particular attention to injury interpretation, postmortem interval estimation, forensic imaging, survivor documentation, and medicolegal reporting. Forensic nursing practice, including sexual assault nurse examiner (SANE) programs, domestic violence assessment, and paediatric abuse evaluation, is a central focus. The review critically evaluates ethical risks associated with deploying algorithmic decision-making in high-stakes forensic contexts where outputs may influence criminal outcomes and judicial proceedings. Issues of algorithmic bias, chain-of-custody integrity, explainability, and the potential displacement of clinical judgment are examined alongside practical considerations for implementation. Given the still-emerging forensic-specific evidence base, this review draws selectively on adjacent clinical disciplines while emphasizing the distinct medicolegal demands of forensic practice. Responsible integration of AI, the review concludes, requires interdisciplinary governance, equity-stratified validation, and preservation of the clinician-examiner's primary interpretive authority.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, scalable public health intervention designed to identify and address alcohol, prescription, and illicit drug use in primary care. By combining validated screening tools, brief behavioral interventions, and referral to treatment, SBIRT reduces risky substance use, prevents progression to substance use disorders, and improves health outcomes. Evidence supports its effectiveness in adults, adolescents, and older adults, with additional benefits including cost savings through reduced health care utilization, criminal justice involvement, and productivity losses. Implementation requires integration into workflows, staff training, and interprofessional collaboration.