Substance use disorders and avoidable mortality after prison
Authors: Sarah E Wakeman, Josiah D Rich
Journal: The Lancet Psychiatry (2015)

Worldwide, more than 30 million people spend time in prison every year.1UNODCILOUNDPWHOUNAIDSHIV prevention, treatment and care in prisons and other closed settings: A comprehensive package of interventions. United Nations Office of Drugs and Crime, Vienna2013Google Scholar The USA incarcerates 25% of these people and one in 31 Americans is currently under correctional control, either in jail, prison, or on probation or parole.2Pew Center on the StatesOne in 31: the long reach of American corrections. The Pew Charitable Trusts, Washington2009Google Scholar Most prisoners will eventually be released, and the 2 weeks after release have been shown to be associated with a substantial increase in mortality, especially from overdose.3Binswanger IA Stern MF Deyo RA et al.Release from prison—a high risk of death for former inmates.N Engl J Med. 2007; 356: 157-165Crossref PubMed Scopus (991) Google Scholar Substance use disorders are highly prevalent among incarcerated populations, with more than half of prisoners in some countries being imprisoned for drug-related convictions.4Bewley-Taylor DHC Allen R The incarceration of drug offenders: an overview. The Beckley Foundation Drug Policy Programme, London2009Google Scholar In the USA, 85% of people in prisons or jails are substance involved, with 1·5 million individuals meeting DSM criteria for a substance use disorder and an additional 458 000 either with a history of substance use, under the influence at the time of arrest, or convicted of a crime committed to obtain money to buy drugs.5CASABehind Bars II: Substance abuse and America's prison population. National Center on Addiction and Substance Abuse at Columbia University, New York2010Google ScholarAddiction is a treatable disease and decades of scientific evidence support the efficacy of treatment to improve clinical outcomes, save lives, and reduce societal costs. Treatment for opioid use disorder during incarceration with agonists such as buprenorphine or methadone has been shown to reduce recidivism, improve treatment retention, reduce illicit drug use, and decrease criminal activity.6Tomasino V Swanson AJ Nolan J Shuman HI The Key Extended Entry Program (KEEP): a methadone treatment program for opiate-dependent inmates.Mt Sinai J Med. 2001; 68: 14-20PubMed Google Scholar, 7Gordon MS Kinlock TW Schwartz RP O'Grady KE A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release.Addiction. 2008; 103: 1333-1342Crossref PubMed Scopus (125) Google Scholar Buprenorphine has also been shown to decrease the risk of overdose death by more than 50%.8Schwartz RP Gryczynski J O'Grady KE et al.Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009.Am J Public Health. 2013; 103: 917-922Crossref PubMed Scopus (181) Google Scholar However, despite the overwhelming evidence, treatment remains variable between correctional facilities and few prisoners receive these life-saving drugs.9Rich JD Boutwell AE Shield DC et al.Attitudes and practices regarding the use of methadone in US state and federal prisons.J Urban Health. 2005; 82: 411-419Crossref PubMed Scopus (92) Google ScholarIn The Lancet Psychiatry, Zheng Chang and colleagues10Chang Z Lichtenstein P Larsson H Fazel S Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study.Lancet Psychiatry. 2015; (published online April 22.)http://dx.doi.org/10.1016/S2215-0366(15)00088-7Google Scholar examined mortality in all people released from prison in Sweden between Jan 1, 2000, and Dec 31, 2009. In this sample of 47 326 individuals and 238 457 person-years of follow-up, the researchers reported that substance use (both alcohol and illicit drug use) was related to a substantial proportion of post-release mortality, even when controlling for other factors using imprisoned siblings as controls. The association between mental illness and post-release mortality disappeared when substance use was controlled for. This well designed study of an entire country offers important and concerning new data on the high risk of death for individuals with substance use disorder who are incarcerated. The results of the study also showed that the period of risk of increased mortality after release from prison is much longer—months to years—than the few weeks previously reported,3Binswanger IA Stern MF Deyo RA et al.Release from prison—a high risk of death for former inmates.N Engl J Med. 2007; 356: 157-165Crossref PubMed Scopus (991) Google Scholar an important finding that is probably true in most places. These findings are even more alarming when considering the magnitude of risk for a country such as the USA, which has a much higher incarceration rate and far more drug-related convictions than does Sweden.Access to effective treatments for addiction, particularly pharmacotherapy, is the single greatest intervention that can reduce the death toll from overdose.11WHOGuidelines for the psychosocially assisted pharmacological treatment of opioid dependence. World Health Organization, Geneva2009Google Scholar The withholding of evidence-based treatment for prisoners is arguably unethical and certainly unwise. In the USA, correctional facilities are mandated by the Supreme Court to provide medical care that meets the community standard.12Allen SA Wakeman SE Cohen RL Rich JD Physicians in US prisons in the era of mass incarceration.Int J Prison Health. 2010; 6: 100-106PubMed Google Scholar And yet, within state prisons people with drug use disorders largely go without care: of these people, only 0·8% receive detoxification services, 0·3% receive maintenance pharmacotherapy, 6·5% receive counselling by a professional, and 9·5% receive treatment in a residential facility.13Mumola CJ Karberg JC Drug use and dependence, state and federal prisoners, 2004. Bureau of Justice Statistics, Washington2006Crossref Google Scholar Even those on treatment in the community are systematically forced off when incarcerated, with detrimental consequences.14Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a US prison: a randomised, open-label, trial. Lancet (in press).Google Scholar The absence of care in this deeply affected population translates into high costs to society and the communities that these individuals return to. As the Article shows, these costs also translate into avoidable deaths from a treatable illness.JDR was supported by NIH grants K24DA022112 and P30AI42853 . JDR is a stockholder in Alkermes. SEW declares no competing interests. Worldwide, more than 30 million people spend time in prison every year.1UNODCILOUNDPWHOUNAIDSHIV prevention, treatment and care in prisons and other closed settings: A comprehensive package of interventions. United Nations Office of Drugs and Crime, Vienna2013Google Scholar The USA incarcerates 25% of these people and one in 31 Americans is currently under correctional control, either in jail, prison, or on probation or parole.2Pew Center on the StatesOne in 31: the long reach of American corrections. The Pew Charitable Trusts, Washington2009Google Scholar Most prisoners will eventually be released, and the 2 weeks after release have been shown to be associated with a substantial increase in mortality, especially from overdose.3Binswanger IA Stern MF Deyo RA et al.Release from prison—a high risk of death for former inmates.N Engl J Med. 2007; 356: 157-165Crossref PubMed Scopus (991) Google Scholar Substance use disorders are highly prevalent among incarcerated populations, with more than half of prisoners in some countries being imprisoned for drug-related convictions.4Bewley-Taylor DHC Allen R The incarceration of drug offenders: an overview. The Beckley Foundation Drug Policy Programme, London2009Google Scholar In the USA, 85% of people in prisons or jails are substance involved, with 1·5 million individuals meeting DSM criteria for a substance use disorder and an additional 458 000 either with a history of substance use, under the influence at the time of arrest, or convicted of a crime committed to obtain money to buy drugs.5CASABehind Bars II: Substance abuse and America's prison population. National Center on Addiction and Substance Abuse at Columbia University, New York2010Google Scholar Addiction is a treatable disease and decades of scientific evidence support the efficacy of treatment to improve clinical outcomes, save lives, and reduce societal costs. Treatment for opioid use disorder during incarceration with agonists such as buprenorphine or methadone has been shown to reduce recidivism, improve treatment retention, reduce illicit drug use, and decrease criminal activity.6Tomasino V Swanson AJ Nolan J Shuman HI The Key Extended Entry Program (KEEP): a methadone treatment program for opiate-dependent inmates.Mt Sinai J Med. 2001; 68: 14-20PubMed Google Scholar, 7Gordon MS Kinlock TW Schwartz RP O'Grady KE A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release.Addiction. 2008; 103: 1333-1342Crossref PubMed Scopus (125) Google Scholar Buprenorphine has also been shown to decrease the risk of overdose death by more than 50%.8Schwartz RP Gryczynski J O'Grady KE et al.Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009.Am J Public Health. 2013; 103: 917-922Crossref PubMed Scopus (181) Google Scholar However, despite the overwhelming evidence, treatment remains variable between correctional facilities and few prisoners receive these life-saving drugs.9Rich JD Boutwell AE Shield DC et al.Attitudes and practices regarding the use of methadone in US state and federal prisons.J Urban Health. 2005; 82: 411-419Crossref PubMed Scopus (92) Google Scholar In The Lancet Psychiatry, Zheng Chang and colleagues10Chang Z Lichtenstein P Larsson H Fazel S Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study.Lancet Psychiatry. 2015; (published online April 22.)http://dx.doi.org/10.1016/S2215-0366(15)00088-7Google Scholar examined mortality in all people released from prison in Sweden between Jan 1, 2000, and Dec 31, 2009. In this sample of 47 326 individuals and 238 457 person-years of follow-up, the researchers reported that substance use (both alcohol and illicit drug use) was related to a substantial proportion of post-release mortality, even when controlling for other factors using imprisoned siblings as controls. The association between mental illness and post-release mortality disappeared when substance use was controlled for. This well designed study of an entire country offers important and concerning new data on the high risk of death for individuals with substance use disorder who are incarcerated. The results of the study also showed that the period of risk of increased mortality after release from prison is much longer—months to years—than the few weeks previously reported,3Binswanger IA Stern MF Deyo RA et al.Release from prison—a high risk of death for former inmates.N Engl J Med. 2007; 356: 157-165Crossref PubMed Scopus (991) Google Scholar an important finding that is probably true in most places. These findings are even more alarming when considering the magnitude of risk for a country such as the USA, which has a much higher incarceration rate and far more drug-related convictions than does Sweden. Access to effective treatments for addiction, particularly pharmacotherapy, is the single greatest intervention that can reduce the death toll from overdose.11WHOGuidelines for the psychosocially assisted pharmacological treatment of opioid dependence. World Health Organization, Geneva2009Google Scholar The withholding of evidence-based treatment for prisoners is arguably unethical and certainly unwise. In the USA, correctional facilities are mandated by the Supreme Court to provide medical care that meets the community standard.12Allen SA Wakeman SE Cohen RL Rich JD Physicians in US prisons in the era of mass incarceration.Int J Prison Health. 2010; 6: 100-106PubMed Google Scholar And yet, within state prisons people with drug use disorders largely go without care: of these people, only 0·8% receive detoxification services, 0·3% receive maintenance pharmacotherapy, 6·5% receive counselling by a professional, and 9·5% receive treatment in a residential facility.13Mumola CJ Karberg JC Drug use and dependence, state and federal prisoners, 2004. Bureau of Justice Statistics, Washington2006Crossref Google Scholar Even those on treatment in the community are systematically forced off when incarcerated, with detrimental consequences.14Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a US prison: a randomised, open-label, trial. Lancet (in press).Google Scholar The absence of care in this deeply affected population translates into high costs to society and the communities that these individuals return to. As the Article shows, these costs also translate into avoidable deaths from a treatable illness. JDR was supported by NIH grants K24DA022112 and P30AI42853 . JDR is a stockholder in Alkermes. SEW declares no competing interests. Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort studyInterventions to address substance use disorders could substantially decrease the burden of excess mortality in people released from prison, but might need to be provided beyond the immediate period after release. Full-Text PDF Open Access