R E S E A R C H
Open Access
Prison sentencing increases the risk of
unemployment among illegal heroin users
in Taiwan
Charles Tzu-Chi Lee
1†, Chiu-Mieh Huang
2†, Li-Chun Chang
3, Shih-Wen Wang
1, Hsiao-Pei Hsu
2, Jung-Yu Liao
4and
Jong-Long Guo
1*Abstract
Background: Previous studies have rarely explored the effect of type of sentencing on employment status among illegal heroin users, therefore, we aims to examine the association of the sentencing types and employment outcomes among illegal heroin users in Taiwan.
Methods: Participants with illegal heroin use were identified through the national prison register system and deferred prosecution system: 2406 with deferred prosecutions, 4741 with observation and rehabilitation, 15 compulsory rehabilitation and 1958 sentenced to prison in calendar 2011. Logistic regression models were built to estimate the effect of sentencing type on unemployment status at 2 years after release. Stratification analysis was conducted to determine the effect of sentencing type based on the offender’s employment status before sentencing.
Results: Illegal heroin users receiving a prison sentence were more than twice as likely to be unemployed 2 years later than those receiving deferred prosecution. The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior drug use criminal records were also higher risk of unemployment. Subgroup analysis by prior employment status revealed that being sentenced to prison, observation and rehabilitation and compulsory rehabilitation affected the subsequent employment status only for those heroin users with a job before sentencing. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment outcomes.
Conclusions: Illegal heroin users who receive a prison sentence have a much higher risk of unemployment than those who receive deferred prosecution after controlling potential confounders, especially those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk of unemployment outcomes. Our study support that illegal heroin user is legally regarded as a patient before being regarded as a criminal, so giving priority to quit addition rather than imprisonment.
Keywords: Deferred prosecution, Observation and rehabilitation, compulsory rehabilitation, Prison sentence, Employment rate, Heroin users
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* Correspondence:jonglong@ntnu.edu.tw
†Charles Tzu-Chi Lee and Chiu-Mieh Huang contributed equally to this work. 1Department of Health Promotion and Health Education, National Taiwan Normal University, 162, Sec. 1, He-ping East Road, Taipei, Taiwan 10610 Full list of author information is available at the end of the article
Background
Illegal drug use and addiction represent a global crisis, creating seriously harm to the addict’s physical and men-tal health [1], social function and employment [2], even endangering the social order by increasing the rates of both crime and violence [3, 4]. For these reasons, nu-merous countries are committed to implementing pro-grams to prevent, control and treat the use of illegal drugs. In 2018, according to the 2020 World Drug Re-port, 269 million people aged 15–64 years used at least one illegal drug in the previous year, an estimated 5.4% of the population; the most used illegal drugs are canna-bis, opioids and opiates [5]. The prevalence of illegal drug use in Taiwan was approximate 1.2%, according to Taiwan’s first national household survey; the top five most used illegal drugs were methamphetamine, ecstasy, ketamine marijuana and heroin [6]. Heroin in particular is one of the world’s most widely used illegal drug [7]. According to the Taiwan Surveillance System of Drug use and Addiction Treatment, heroin is the one of the most commonly used drug in Taiwan; among drugs monitored, heroin accounted for 80.9% of illegal drug users who received treatment in 2002, a rate which rose to 93.8% in 2007, then declined to 83.3% in 2011 [8]. These percentages were more than 80% of illegal drug user received treatment.
Use of heroin and other substances burdens both the in-dividual user and society as a whole, to a greater extent than other mental disorders [9]. Physical and mental dis-orders resulting from illegal heroin use may increase the medical cost, but this represents only be a small portion of the total cost of heroin dependency. For example, one study found that the medical cost of heroin dependency (23% of the total cost) is much smaller than the productiv-ity loss (53% of the total cost) [10]. To this should be added the cost to the individual users (including financial expenses and health risks) as well as the social costs of crime to support the drug behavior [11].
Previous studies have shown that illegal drug use treat-ment reduced substance use and criminal behavior and improved the social functioning, employment, and phys-ical and emotional health of the former user [12, 13]. The drug treatment alternative to prison program in Taiwan started as a deferred sentencing model, assisting illegal drug user into treatment. A 5-year study of the program indicated that the re-arrest rates and reconvic-tion rates of those with deferred sentencing were signifi-cantly lower than those of offenders who received regular processing into the criminal justice system [14]. Taiwan also initiated a deferred prosecution and metha-done maintenance treatment (MMT) pilot project to ad-dress the human immunodeficiency virus (HIV) epidemic. A shift in the official view of illegal drug users from “criminal” to “patient” in Taiwan suggested the
corresponded strategic approach from “punishment” to “treatment.” Before 1998, all illegal drug users in Taiwan were sentenced as“criminals” to criminal penalties. After 1998, the Against Narcotics Act classified illegal drug users as“patients,” eligible for treatment and other non-sentencing interventions. Consequently, there was a de-ferred prosecution policy which did not immediately im-prison the illegal drug users, but prefer to provide treatment [15]. Thus, illegal drug users in Taiwan may receive one of four types of sentence: (1) deferred pros-ecution and complete MMT, (2) observation and re-habilitation, (3) compulsory rehabilitation and (4) prison sentence. This sentencing aim to help illegal heroin users return to society, resume employment and live a normal life. It has replaced imprisonment with medical treatment, offers heroin offenders MMT, improves social interactions, and helps former users transition back into society.
For the illegal heroin user who was first seized by the police, the illegal drug user indicated to the prosecutor that he / she had the intention to quit addiction. If the prosecutor thought that he / she was suitable to stay in the community to quit addiction he / she was com-manded to receive deferred prosecution and complete MMT. If the illegal drug user does not express his / her intention to quit addiction, the prosecutor will com-mand the illegal heroin user to receive observation and rehabilitation with a period of less than 2 months. If there is no tendency to indicate the user continue using heroin, he / she will not be prosecuted at the end of the observation and rehabilitation. If there is a tendency to continue to use heroin after professional evaluation, he / she will receive a compulsory rehabilitation which is a treatment with a period more than 6 months until there is no need to continue compulsory rehabilitation. How-ever, it may not exceed 1 year. Recidivists within 5 years may be prosecuted or applied for summary judgment, but prosecutors can still give deferred prosecutions and complete MMT if illegal heroin user indicates to the prosecutor that he or she has an intention to quit addition. Illegal heroin user who receives deferred prose-cutions and complete MMT, may be withdrew and pros-ecuted directly by the prosecutor if any criminal case has been committed during the subsequent two-year period of probation [15].
Currently, Taiwan’s prisons have a serious over-population problem. In 2014, the estimated available space for each prisoner was only 15.3 ft2, far below the 24.9 ft2 specified by international human rights regula-tions [16]. Considering the addictive nature of drugs, not immediately prosecuting drug users, but first giving them an opportunity for treatment, perhaps reduce prison over-crowding and increase the space available to prisoners.
Employment status can be a critical indicator of social control, economic conditions, return to society and re-cidivism. Employment is an essential component of healthy social development. Critical to identity formation [17], the accumulation of social capital [18] and per-ceived quality of life [19], employment can enhance physical and mental well-being and overall quality of life [20,21]. Illegal drug use is associated with poor employ-ment outcomes. The unemployemploy-ment problem of heroin users could be caused by both of the drug-abusing itself (i.e. adverse psychosocial outcomes, including disability or impairment and psychiatric comorbidity) and the so-cial discrimination [22, 23]. For example, previous study found that the use of heroin and cocaine, as well as the higher frequency of use, is predictive of membership in a low-employment trajectory group through middle adult-hood [24]. Evidence-based determinants of employment include educational attainment [25], race [26], marital status and family structure [27], socio-economic status [28] and general health status [29]. However, these stud-ies did not explore whether the type of sentence affected subsequent employment status among illegal heroin users. Therefore, this study examines the association of sentencing types and employment status at 2 years after release among illegal heroin users in Taiwan, to deter-mine the long-term effectiveness of alternatives to prison sentencing.
Method
Ethics statement
The Institutional Review Board (IRB) of National Taiwan Normal University approved this study (No. 201606HM002). Written consent from the study participants was waived be-cause the data were collected from a population-based data-base of de-identified secondary data.
Sample
This was a population-based cohort study. Illegal heroin users in the national prison register system and deferred prosecution system were identified who received a sen-tence from January 1, 2011 to December 31, 2011. There were 2406 deferred prosecutions with MMT require-ment, 4741 observation and rehabilitation, 15 compul-sory rehabilitation and 1958 sentences to prison included in this study. All study participants were followed until 2 years after the index date, that is, the date of deferred prosecution, release from prison or release from the treatment centers.
National Health Insurance in Taiwan
In 1995, the National Health Insurance (NHI) program, a government-run, single-payer insurance system, was established in Taiwan. By December 2010, 23.074 mil-lion people were enrolled nationwide, with a coverage
rate of 99.6%. The NHI Research Database (NHIRD) contains patient demographic and insurance premium data. The insurance premium was used as a proxy indi-cator of employment status and was classified as with or without job salary. Those with a fixed premium who were also listed as a dependent on the insurance pre-mium were considered as not having a job salary. The fixed premium group is composed of people receiving social welfare support and includes low-income people and veterans. The dependent insurance premium group is comprised of people with family members with no job or income.
Main outcome and study variables
Two periods were used to measure the employment status of study participants, the follow-up period and the past period. The follow-up period for monitoring employment status began at the date of deferred prosecution or release from either prison or the treatment centers and continued until 2 years after the index date. The past period for monitoring employment status was retrospective, tracking back 2 years before the index date. The past period of em-ployment status was included in the analysis as a control variable. In our database, the minimal follow-up duration after index date for all study subjects is around 2 years. Therefore, we used 2 years as time window to analyze the employ status after index date.
For controlling potential confounders, social demog-raphy was collected from National Population Register Database, including gender, age, types of residence (rural, urban), insurance premium (with/without job sal-ary), education level (elementary, junior high school, se-nior high school and college) and marital status (single, married, divorced and widowed) [22, 30, 31]. Illicit drug use criminal record collected from National Police Agency in Taiwan [32, 33]. Mental diseases including schizophrenia, depressive disorders, bipolar disorders and general health condition (Charlson comorbidity score) were collected from NHIRD [31, 34, 35]. All of the potential comorbid diseases and Charlson comorbid-ity score were defined using outpatient and inpatient diagnosis before the index date.
Statistical analysis
Chi-square analysis was used to examine the differences in demographic and other characteristics of those with or without a job at 2 years after the index date. The im-pact of the type of sentence was analyzed using logistic regression. The un-adjusted and adjusted odds-ratio (AOR) were reported. The model was tested first using all participants, then according to employment status be-fore sentencing. Dummy variables were created to per-form collinearity diagnosis by using multiple regression, variance inflation factor (VIF) and condition index were
reported. Variables with VIF > 10 or condition index> 30 was considered as collinearity problem in the study model. Analyses were carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).P values < 0.05 were considered statistically significant.
Results
Sample characteristics
Results for the characteristics of illegal heroin users are summarized in Table 1. Of the 1848 participants un-employed at 2 years after the index date, 1524 were male and 324 were female. The unemployment rate was simi-lar between males and females (P = 0.759) and those with rural and urban residence (P = 0.087), schizophrenia (P = 0.321), depression (P = 0.687), bipolar (P = 0.381). The unemployment rate was associated with age, prior employment status, type of sentencing, education level, marital status, illegal drug use criminal record and Charlson comorbidity score (allP < 0.05).
Risk factors associated with unemployment status among illegal heroin users
After controlling for gender, age, type of residence, pre-vious employment status, education level, marital status, illegal drug use criminal record, schizophrenia, depres-sion, bipolar and Charlson comorbidity score, the un-employment rate at 2 years of those sentenced to prison was 2.30 times that of those who received deferred pros-ecution (AOR = 2.30, 95% Confidence Interval [CI]: 1.97–2.65, P < 0.001). The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior illegal drug use criminal records were also higher risk of unemployment. With senior high school educational level was lower significant risk of un-employment. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment out-comes (allP < 0.001, Table2). In this study, the dysfunc-tion of mental (schizophrenia, depression and bipolar) and general health condition (Charlson comorbidity score) were not significantly associated with unemploy-ment rate in illegal heroin users (allp > 0.05, Table2).
Stratified analysis by prior unemployment status
There was a significant interaction between prior em-ployment status and type of sentence (P < 0.001). To de-termine the relationship between type of sentence and the prior employment status of participants, we per-formed stratification analysis. For participants without a job before the index date, the unemployment rate at 2
years after the index date was not significant difference in type of sentencing (Table3). However, at 2 years after sentencing, for those with a job before the index date, the unemployment rate for those who received a prison sentence was higher than for those who received de-ferred prosecution (AOR = 4.63, 95% CI: 1.22–17.57, P = 0.024). In addition, males, participants with divorced or widowed and≥ 3 illegal drug use criminal record were also higher risk of unemployment (P < 0.001), but age and type of residence were not associated with subse-quent employment status (Table4).
Collinearity diagnosis
All the VIFs for models less than 10 (Tables 2,3 and 4) and condition index less than 30 (Table5) in this study, the results showed mild collinearity problem in our study models.
Discussion
In the present study, after controlling potential con-founders (age, insurance premium at 2 years after index date, education level, marital status, illegal drug use criminal record, Charlson comorbidity score), the un-employment rate of illegal heroin users sentenced to prison was higher than that for those who received de-ferred prosecution, observation and rehabilitation and compulsory rehabilitation. These results indicate that, in the 2 years after release from the penal system, senten-cing to prison made it more difficult for illegal heroin users to acquire a job compared to counterparts of the other three types. Employment is a critical component of the reentry process that positively assists illegal drug users to return to the community. The results support the viewpoint that a deferred prosecution policy can de-crease the risk of unemployment and subsequently im-prove offenders’ social control, economic conditions and ability to return to society. Continued implementation of a deferred prosecution and complete MMT treatment therefore benefits the offender and solve the problem of prison overcrowding.
Employment is a fundamental element of social con-trol, providing a daily routine and expectations regarding performance and productivity. Whether illegal substance use disrupts that process and is associated with negative outcomes is therefore a critical social, economic, and criminal justice question, with implications for drug pol-icy. Although the importance of the issue is widely rec-ognized, the strength and direction of the relationship remains unclear. Early research often reported that drug use is unrelated to employment outcomes [36, 37] and, in some instances, that drug use is associated with a higher wages [38]. In contrast, research conducted post-2000 reveals, more often than not, that drug use is asso-ciated with poor employment outcomes. Huang et al.
Table 1 Demographic and other characteristics of study participants, Taiwan, 2011 (n = 9120)
Characteristics Insurance premium at two years after index datea
P value No job salary,n = 1848 With job salary,n = 7272
Gender
Male 1524 (20.20) 6019 (79.80) 0.759
Female 324 (20.55) 1253 (79.45)
Age (years) at index date
18–24 375 (23.32) 1233 (76.68) < 0.001 25–44 1160 (18.44) 5131 (81.56) ≥ 45 313 (25.63) 908 (74.37) Type of residence Rural 539 (21.43) 1976 (78.57) 0.087 Urban 1309 (19.82) 5296 (80.18)
Insurance premium at two years after index date
With job salary 1265 (16.01) 6635 (83.99) < 0.001
Without job salary 583 (47.79) 637 (52.21) Type of sentencing
Deferred prosecution 393 (16.33) 2013 (83.67) < 0.001 Observation and rehabilitation 853 (17.99) 3888 (82.01)
Compulsory rehabilitation 6 (40.00) 9 (60.00) Sentenced to prison 596 (30.44) 1362 (69.56) Education level
Elementary 323 (21.72) 1164 (78.28) < 0.001
Junior high school 1107 (21.47) 4050 (78.53) Senior high school 383 (16.89) 1885 (83.11)
College 35 (16.83) 173 (83.17)
Marital status
Single 1335 (19.30) 5581 (80.70) < 0.001
Married 348 (21.97) 1236 (78.03)
Divorce or widowed 165 (26.61) 455 (73.39) Drug use criminal record
0 236 (18.02) 1074 (81.98) < 0.001 1 559 (15.23) 3111 (84.77) 2 342 (19.94) 1373 (80.06) ≥ 3 711 (29.32) 1714 (70.68) Schizophrenia Yes 1822 (20.31) 7147 (79.69) 0.321 No 26 (17.22) 125 (82.78) Depression Yes 1675 (20.20) 6616 (79.80) 0.687 No 173 (20.87) 656 (79.13) Bipolar Yes 1819 (20.22) 7179 (79.78) 0.381 No 29 (23.77) 93 (76.23)
Charlson comorbidity score
0 915 (21.43) 3354 (78.57) < 0.001
1 446 (18.82) 1924 (81.18)
2 206 (16.78) 1022 (83.22)
≥ 3 281 (22.43) 972 (77.57)
a
Table 2 Logistic regression analysis of odds of unemployment at two years after release following heroin use sentence in Taiwan, 2011 (n = 9120)
Variable Un-adjusted odds-ratio Adjusted odds-ratiob VIFc
Estimate (95% CI) P value Estimate (95% CI) P value Social demographyd Gender Male 1.00 1.00 Female 1.02 (0.89–1.17) 0.758 0.75 (0.64–0.87) < 0.001 1.1
Age (years) at index datea
18–24 1.00 1.00 25–44 0.74 (0.65–0.85) < 0.001 1.41 (1.17–1.70) < 0.001 2.2 ≥ 45 1.13 (0.95–1.35) 0.155 1.55 (1.21–1.98) < 0.001 2.3 Type of residence Rural 1.00 1.00 Urban 0.91 (0.81–1.01) 0.087 0.91 (0.80–1.03) 0.131 1.0
Insurance premium at 2 years before index date
With job salary 1.00 1.00
Without job salary 4.8 (4.23–5.45) < 0.001 6.65 (5.67–7.82) < 0.001 1.2
Education level
Elementary 1.00
Junior high school 0.99 (0.85–1.14) 0.844 1.06 (0.91–1.25) 0.448 2.0
Senior high school 0.73 (0.62–0.87) < 0.001 0.82 (0.68–1.00) 0.049 2.2
College 0.73 (0.49–1.09) 0.122 0.82 (0.54–1.25) 0.358 1.1
Marital status
Single 1.00 1.00
Married 1.18 (1.03–1.35) 0.019 1.06 (0.9–1.24) 0.500 1.2
Divorced or widowed 1.52 (1.25–1.84) < 0.001 1.42 (1.13–1.78) 0.003 1.2
Drug use sentences and criminal recordd Type of sentencing
Deferred prosecution 1.00 1.00
Observation and rehabilitation 1.12 (0.99–1.28) 0.081 1.31 (1.13–1.52) < 0.001 1.6
Compulsory rehabilitation 2.24 (1.94–2.59) < 0.001 1.87 (1.59–2.20) < 0.001 1.5
Sentenced to prison 3.41 (1.21–9.65) 0.021 2.30 (1.97–2.65) < 0.001 1.0
Drug use criminal record
0 1.00 1.00
1 0.86 (0.69–1.07) 0.121 0.88 (0.73–1.06) 0.171 2.3
2 1.13 (0.94–1.37) 0.205 1.15 (0.93–1.4) 0.191 1.9
≥ 3 1.88 (1.59–2.23) < 0.001 1.90 (1.56–2.32) < 0.001 2.5
Mental diseases and comorbidityd
Schizophrenia (Yes vs No) 0.80 (0.51–1.24) 0.322 0.86 (0.54–1.39) 0.542 1.1
Depression (Yes vs No) 1.04 (0.87–1.25) 0.684 1.08 (0.87–1.34) 0.509 1.3
Bipolar (Yes vs No) 1.21 (0.79–1.87) 0.381 1.33 (0.82–2.16) 0.242 1.1
Charlson comorbidity score
0 1.00 1.00
1 0.94 (0.85–1.07) 0.115 0.90 (0.79–1.04) 0.153 1.2
2 0.94 (0.82–1.08) 0.111 0.80 (0.66–0.96) 0.017 1.2
≥ 3 1.06 (0.91–1.24) 0.460 0.99 (0.82–1.18) 0.888 1.3
aThe index date was the date of release from prison, treatment centers or deferred prosecution bGlobal model fit Wald test x2
= 807.6, DF = 22, P < 0.001; R-square = 0.154 c
VIF Variance inflation factor
dFor controlling potential confounders, social demography were collected from National Population Register Database, including gender, age, types of residence, insurance premium, education level and marital status [22,30,31] . Illicit drug use criminal record collected from National Police Agency in Taiwan [32,33]. Mental diseases including schizophrenia, depressive disorders, bipolar disorders and general health condition (Charlson comorbidity score) were collected from NHIRD [31,34,35]
Table 3 Logistic regression analysis of odds of unemployment at two years after release following heroin use sentence in Taiwan for those unemployed before sentencing, 2011 (n = 1220)
Variable Un-adjusted odds-ratio Adjusted odds-ratiob
VIFc Estimate (95%CI) P value Estimate (95%CI) P value Social demographyd Gender Male 1.00 1.00 Female 0.94 (0.74–1.19) 0.610 0.97 (0.74–1.26) 0.815 1.1 Age (years) at index datea
18–24 1.00 1.00 25–44 1.79 (1.40–2.3) < 0.001 1.98 (1.40–2.80) < 0.001 1.9 ≥ 45 4.34 (2.9–6.49) < 0.001 5.10 (2.79–9.35) < 0.001 2.3 Type of residence Rural 1.00 1.00 Urban 0.88 (0.68–1.15) 0.345 0.87 (0.65–1.15) 0.331 1.0 Education level Elementary 1.00 1.00
Junior high school 0.87 (0.66–1.14) 0.311 0.87 (0.65–1.16) 0.348 1.4 Senior high school 1.37 (0.92–2.05) 0.118 0.91 (0.57–1.46) 0.706 1.7 College 1.03 (0.40–2.66) 0.956 0.59 (0.21–1.64) 0.312 1.1 Marital status
Single 1.00 1.00
Married 1.89 (1.38–2.59) < 0.001 0.87 (0.57–1.33) 0.529 1.7 Divorced or widowed 2.43 (1.38–4.29) 0.002 0.95 (0.47–1.90) 0.888 1.5 Drug use Sentences and criminal recordd
Type of sentencing
Deferred prosecution 1.00 1.00
Observation and rehabilitation 0.89 (0.67–1.18) 0.414 1.19 (0.86–1.63) 0.287 1.6 Compulsory rehabilitation 0.71 (0.12–4.33) 0.711 0.90 (0.13–6.15) 0.914 1.6 Sentenced to prison 1.34 (0.93–1.94) 0.118 1.04 (0.68–1.60) 0.849 1.0 Drug use criminal record
0 1.00 1.00
1 0.90 (0.65–1.25) 0.534 0.89 (0.63–1.26) 0.513 2.0
2 1.11 (0.76–1.61) 0.595 1.00 (0.67–1.49) 0.984 1.8
≥ 3 1.05 (0.73–1.53) 0.787 0.86 (0.57–1.29) 0.464 2.0 Mental diseases and comorbidityd
Schizophrenia (Yes VS No) 3.22 (0.33–6.00) 0.312 1.17 (0.11–2.09) 0.894 1.1 Depression (Yes VS No) 2.41 (1.51–3.84) < 0.001 2.44 (1.42–4.19) 0.001 1.3 Bipolar (Yes VS No) 1.94 (0.65–5.84) 0.236 0.79 (0.22–2.80) 0.720 1.2 Charlson comorbidity score
0 1.00 1.00
1 1.15 (0.87–1.52) 0.336 1.11 (0.83–1.49) 0.480 1.1
2 1.03 (0.70–1.52) 0.871 0.90 (0.60–1.36) 0.626 1.1
≥ 3 1.87 (1.26–2.79) 0.002 1.14 (0.71–1.84) 0.590 1.4
a
The index date was the date of release from prison, treatment centers or deferred prosecution
b
Global model fit Wald test x2
= 72.28, DF = 21, P < 0.001; R-square = 0.093
c
VIF Variance inflation factor
d
For controlling potential confounders, social demography were collected from National Population Register Database, including gender, age, types of residence, insurance premium, education level and marital status [22,30,31]. Illicit drug use criminal record collected from National Police Agency in Taiwan [32,33]. Mental diseases including schizophrenia, depressive disorders, bipolar disorders and general health condition (Charlson comorbidity score) were collected from NHIRD [31,34,35]
Table 4 Logistic regression analysis of risk of unemployment at two years after release following heroin use sentence in Taiwan among those employed before sentence, 2011 (n = 7900)
Variable Un-adjusted odds-ratio Adjusted odds-ratiob
VIF c Estimate (95%CI) P value Estimate (95%CI) P value Social demographyd Gender Male 1.00 1.00 Female 0.61 (0.5–0.74) < 0.001 0.63 (0.51–0.77) < 0.001 1.1 Age (year) at index datea
18–24 1.00 1.00 25–44 1.36 (1.1–1.67) 0.004 1.11 (0.88–1.40) 0.364 2.2 ≥ 45 1.7 (1.33–2.18) < 0.001 1.05 (0.78–1.41) 0.752 2.5 Type of residence Rural 1.00 1.00 Urban 0.85 (0.75–0.97) 0.018 0.91 (0.77–1.12) 0.208 1.0 Education level Elementary 1.00 1.00
Junior high school 1.29 (1.07–1.56) 0.007 1.22 (1–1.48) 0.051 2.2 Senior high school 0.98 (0.80–1.22) 0.888 0.90 (0.71–1.12) 0.339 2.3 College 0.95 (0.60–1.51) 0.825 0.94 (0.58–1.51) 0.791 1.2 Marital status
Single 1.00 1.00
Married 1.07 (0.90–1.26) 0.452 1.06 (0.89–1.27) 0.517 1.2 Divorced or widowed 1.60 (1.29–1.98) < 0.001 1.51 (1.19–1.94) 0.001 1.2 Drug use Sentences and criminal recordd
Type of sentencing
Deferred prosecution 1.00 1.00
Observation and rehabilitation 1.02 (0.87–1.19) 0.841 1.38 (1.16–1.65) < 0.001 1.5 Compulsory rehabilitation 2.61 (2.22–3.08) < 0.001 2.07 (1.73–2.47) < 0.001 1.5 Sentenced to prison 4.62 (1.29–16.47) 0.018 4.63 (1.22–17.57) 0.024 1.0 Drug use criminal record
0 1.00 1.00
1 0.87 (0.70–1.08) 0.211 0.87 (0.70–1.09) 0.237 2.3
2 1.25 (0.98–1.59) 0.070 1.19 (0.93–1.52) 0.161 1.9
≥ 3 2.67 (2.16–3.03) < 0.001 2.30 (1.82–2.90) < 0.001 2.6 Mental diseases and comorbidityd
Schizophrenia (Yes VS No) 0.95 (0.59–1.51) 0.816 0.92 (0.56–1.52) 0.750 1.1 Depression (Yes VS No) 0.91 (0.73–1.14) 0.413 0.88 (0.68–1.13) 0.313 1.3 Bipolar (Yes VS No) 1.15 (0.69–1.91) 0.605 1.38 (0.79–2.41) 0.254 1.1 Charlson comorbidity score
0 1.00 1.00
1 0.81 (0.69–0.95) 0.008 0.84 (0.71–0.98) 0.031 1.2
2 0.73 (0.59–0.89) 0.002 0.77 (0.62–0.94) 0.013 1.2
≥ 3 1.06 (0.88–1.27) 0.529 0.94 (0.77–1.15) 0.569 1.3
a
The index date was the date of release from prison, treatment centers or deferred prosecution
b
Global model fit Wald test x2
= 368.5, DF = 21, P < 0.001; R-square = 0.085
c
VIF Variance inflation factor
d
For controlling potential confounders, social demography were collected from National Population Register Database, including gender, age, types of residence, insurance premium, education level and marital status [22,30,31]. Illicit drug use criminal record collected from National Police Agency in Taiwan [32,33]. Mental diseases including schizophrenia, depressive disorders, bipolar disorders and general health condition (Charlson comorbidity score) were collected from NHIRD [31,34,35]
[24] find that use of heroin as well as higher frequency use is predictive of membership in a low-employment trajectory group through middle adulthood. The present study extended these findings and further showed that higher illegal drug use criminal record (> 3 times) was associated with a risk of unemployment after controlling potential confounders, especially those who had a job before sentencing.
As well, DeSimone [39], adopting a sophisticated econometric model that addresses simultaneity, reports a negative relationship between illegal drug use, employ-ment, and labor force participation [40]. Problematic substance use increases the likelihood of unemployment and decreases the chance of finding and holding down a job. Unemployment is also a significant risk factor for substance use and the subsequent development of sub-stance use disorders. Unemployment and subsub-stance use have a bidirectional correlation [41]; in other words, im-proving the employment rate in the illegal drug use population contribute to reduce the recurrence of drug use. Moreover, employment is highly associated with treatment retention [42, 43]. Thus, the deferred
sentencing model can decrease the unemployment rate and assist former drug users continue to receive treat-ment. Employment helps users maintain their treatment and recover better.
A previous study revealed that former employment and work experiences are protective factors that increase the likelihood of employment after release [44]. Similarly, our data showed that the unemployment rate for illegal heroin users without a job before the index date was higher than that for those with a job before the index data. Interest-ingly, those sentenced to prison had a higher risk of un-employment than those who received deferred prosecution, observation and rehabilitation and compul-sory rehabilitation, even if they were employed before be-ing arrested (Tables 3 and 4). This result suggests that illegal heroin use treatment for those with prior employ-ment might be superior in the criminal justice settings to sentencing only, but not for those previously were un-employed. Reducing the number of people incarcerated for illegal drug use can net huge savings in economic and social costs [45]. The finding support that the policy of prioritizing treatment for illegal heroin user over impris-onment deserves continued promotion.
Previous studies have indicated that gender and age are associated with employment status in illegal heroin user [24,46]. At ages 23–25, the low-employment trajec-tory group was employed in approximately 21 of 52 workweeks, followed by a rapid decline to 10 or fewer by age 40 [24]. Similarly, we also found that being male and being older increased the risk of unemployment in illegal heroin users at 2 years after release. Furthermore, we found that the association of gender and employment status remained significant for those previously were employed, while the association of age and employment status was still significant for those previously were employed. This difference suggests that previously un-employed older heroin users and previously un-employed male users were more likely to be jobless after arrest, in-creasing their likelihood of unemployment after their re-lease from the system.
A illegal drug use crime refers to a detrimental behav-ior or an illness, society has a obligation to expect that an effective public policy or approach to the“illegal drug use problem” that will reduce drug-related crime, un-employment, family dysfunction and disproportionate use of heath care [47]. However, although half of pris-oners need treatment, approximately 14.8–17.4% re-ported having received drug treatment since admission in a survey of US State and Federal prisoners, according to the Bureau of Justice Statistics (BJS) [48]. Another study was conducted to compare rates of employment before, during, and after employment at the therapeutic workplace [49]. The researchers found that unemployed chronic drug users will attend work at higher rates at
Table 5 Condition index to check collinearity for the models of Tables2,3and4in this study
Number Condition Index
Model of Table2 Model of Table3 Model of Table4
1 1.0 1.0 1.0 2 2.0 1.9 2.0 3 2.3 2.1 2.3 4 2.5 2.2 2.5 5 2.6 2.4 2.7 6 2.7 2.5 2.7 7 2.7 2.6 2.7 8 2.7 2.6 2.7 9 2.8 2.6 2.8 10 2.8 2.7 2.8 11 2.8 2.8 2.8 12 2.9 2.9 2.9 13 3.0 3.0 3.0 14 3.0 3.2 3.1 15 3.1 3.4 3.7 16 3.7 3.6 3.8 17 3.8 3.8 3.9 18 3.9 4.1 4.4 19 4.4 5.4 5.3 20 5.4 7.3 8.9 21 8.4 9.3 10.5 22 10.3 19.4 21.8 23 21.4 – –
the therapeutic workplace than in the community when paid modest wages. Thus, after receiving treatment, a successful mechanism that can transfer the illegal drug user to the therapeutic workplace contribute to improve their employment rate. Providing vocational training as part of drug abstinence-oriented treatment has the po-tential to improve employment-seeking behaviors, in-crease the chances of securing employment, improve the employment rate and lead to higher paying jobs [48]. Consequently, a high quality treatment program is ne-cessary and should produce positive results.
To our knowledge, this is the first national population-based study to investigate the association of type of sen-tencing and the subsequent employment status among illegal heroin users in Taiwan. The major strength of this study is its population-based study design. Because this study was conducted using the population-based data-base, the findings can be applied to the general popula-tion. However, this study has several limitations. Several crucial confounding factors could not be included in this study, including severity of the substance use disorder, family income and social support system since our study database did not contain this information. Second, we only track the employment status of illegal heroin users at 2 years after release, if more time points of employ-ment status can be included in the analyses, generalizability of study findings will be warrant. Third, for drug users, three factors associated with unemployed were lower education, the personal willing of discour-aged workers, and social discrimination. As Webster et al. (2007) addressed that all of the employers surveyed were willing to hire someone having no criminal record before hiring a released prisoner [33]. However, there is no relevant survey variable in the database, the in-fluences of these three factors did not include in this analyses. Interpretation of the study results should be with caution.
Conclusion
Basically, illegal heroin users are legally regarded as a pa-tient before being regarded as a criminal, so giving prior-ity to quit addition rather than imprisonment. This study supports this viewpoint that staying in the com-munity to receive methadone maintenance treatment (MMT) may increase the odds ratio of illegal heroin users who keep their jobs. But for illegal heroin users who were unemployed before their arrest would not be significantly different because of four different senten-cing types. Illegal heroin users sent to prison may be at greater risk for subsequent unemployment than those receiving deferred prosecution, observation and rehabili-tation, and compulsory rehabilirehabili-tation, especially among those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk
of unemployment outcomes. In addition, males, older of-fenders, those without a job before sentencing, divorced or widowed, those have ≥3 illegal drug use criminal re-cords are also at higher risk of unemployment at 2 years after release. Effective public policy should strive to in-crease the employability of this population, in order to reduce both illegal drug use and prison sentencing in so-ciety as a whole. However, such a conclusion of the causal relationship between the deferred prosecution policy and the risk of unemployment should be proved by the social experiments or other methods for further research.
Abbreviations
BJS:Bureau of Justice Statistics; HIV: Human immunodeficiency virus; IRB: Institutional Review Board; MMT: Methadone maintenance treatment; NHI: National Health Insurance; NHIRD: NHI Research Database
Acknowledgments
This research was supported by the Taiwan Food and Drug Administration (105TFDA-N-005). Dr. Charles Tzu Chi Lee had full access to all the data in the study and takes responsibility for the data integrity and the accuracy of the data analysis.
Authors’ contributions
Charles Tzu Chi Lee, Chiu-Mieh Huang and Jong-Long Guo contributed to the study concept and design, and analysis and interpretation of data; Charles Tzu Chi Lee, Chiu-Mieh Huang, Shih-Wen Wang, Hsiao-Pei Hsu and Jong-Long Guo drafted of the manuscript; Li-Chun Chang, Shih-Wen Wang, Jung-Yu Liao and Hsiao-Pei Hsu contributed to data acquisition; Charles Tzu Chi Lee, Chiu-Mieh Huang, Li-Chun Chang, and Jong-Long Guo performed the critical revision of the manuscript; all authors agreed with the final manuscript.
Funding
This research was supported by the Taiwan Food and Drug Administration (105TFDA-N-005).
Availability of data and materials
The data used to support the findings of this study are included within the article.
Ethics approval and consent to participate
The Institutional Review Board (IRB) of National Taiwan Normal University approved this study (No. 201606HM002). Written consent from the study participants was waived because the data were collected from a population-based database of de-identified secondary data.
Consent for publication Not applicable.
Competing interests
The authors declare that they have no competing interests. Author details
1
Department of Health Promotion and Health Education, National Taiwan Normal University, 162, Sec. 1, He-ping East Road, Taipei, Taiwan 10610. 2Institute of Clinical Nursing, School of Nursing, National Yang-Ming University, 155, Sec. 2, Li-Nong Street, Taipei, Taiwan 11221.3Department of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hua 1st Rd, Tao-Yuan, Taiwan 33303.4Institute of Population Health Sciences, National Health Research Institutes (NHRI), 35 Keyan Road, Zhunan, Miaoli County 35053, Taiwan.
Accepted: 2 October 2020
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